Best Practices in Pressure Injury Prevention

Staff Training and Education Patient Safety

By: Joe Paone | Senior Editor

Published: 8/3/2022

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It takes a team effort to successfully address the risks — and the collective initiative should never end.


Pressure injury prevention isn’t just about using the right positioning aids. It’s an ever-continuing process of monitoring, documentation, education, investigation, risk assessment and process improvement. A dedicated, interdisciplinary team at Ochsner Health in New Orleans hit all those notes, and the results were impressive. Ochsner’s perioperative nursing leaders joined forces with supply chain managers, nursing informatics experts and wound care nurses to identity and address skin injury risks. After implementing its changes, the team achieved an impressive 40% reduction in pressure injuries. The steps they took provide an excellent template for any surgical facility that wants to get its arms firmly around effective prevention strategies.

• Assess the issue. Pressure injuries occur because of prolonged immobility, friction and shearing forces, poorly applied positioning devices and non-modifiable patient risk factors. They can have numerous negative effects on a facility and the patient by increasing the cost of care and length of stay, including possible readmission, and they can happen at any phase of care. “There is a need to improve identifying skin injury risks in the perioperative area, prevention measures and capturing the occurrence of injuries,” says Nattie Leger, MSN, RN, vice president of supply chain, value and clinical performance at Ochsner Health. “Capturing the rates of pressure injuries can be challenging because they may not show up until days after the surgery.”

Perioperative pressure injury prevention has come under sharper focus at Ochsner and other surgical facilities over the last decade as research shone a stronger light on the issue. For many experienced perioperative nurses, pressure injuries weren’t something they learned about in school, as the complication was considered more of an inpatient issue or something to be concerned about in nursing homes. As a result, data about perioperative pressure injuries wasn’t being captured.

Two years ago, Ochsner transitioned to evidence-based risk management strategies based on AORN recommendations to decrease the relatively few perioperative pressure injuries it was logging and implement appropriate clinical practices in this care area. After launching its investigation, the Ochsner team found that OR-acquired pressure injuries were due to several underlying issues: a lack of standardized positioning products and documentation, and a need for an evidence-based risk assessment tool. Andrea Thibodeaux, BSN, RN-BC, manager of nursing informatics with the Center for Quality Excellence at Ochsner Health, says identifying best practices and risks helps the surgical team better understand which patients are at higher risk and what their risk factors are.

Mary Anne Toledano, MSN, BSN, RN, CNOR, RN, clinical educator of perioperative services at Ochsner Health, guided the team to upgrade from the Braden Score tool to the more appropriate AORN-approved Scott Triggers injury risk assessment, which they integrated with Ochsner’s EHR system. “Scott Triggers is an evidence-based tool that gives a more accurate pressure injury risk assessment,” says Ms. Toledano. “Perioperative nurses can easily identify patients at high risk and, thanks to the EHR integration, they can customize and document the care plan.”

The team created Scott Triggers templates in the EHR based on AORN evidence-based practice for supine, prone, lateral and lithotomy positions. “If you select a template, the EHR displays the information that needs to be documented if the patient is at risk,” explains Ms. Thibodeaux. These templates ensure that all providers are on the same page, she notes.

TAKE A LOAD OFF Relieving pressure on the heels when patients are placed in the supine position protects the skin in a sensitive area.  |  Ochsner Health

The integration of patient positioning standards within the EHR also better enables a surgical team to audit compliance with positioning practices and, if an injury occurs, identify the root cause. The integration also eliminates variability in practice as well as the need for nurses to “free text” every aspect of the positioning documentation, a benefit that makes data analysis and reporting much easier.

Ms. Leger says 96% of Ochsner’s nurses now document using the Scott Triggers risk assessment. She believes that capturing data about the few injuries that have occurred has enabled the team to further identify and eliminate issues and scenarios regarding when and where pressure injuries can occur. “Plan, do, study, act,” says Ms. Leger, referring to the time-honored change management philosophy, noting that by doing so you can tweak whatever is needed as you go along.

It’s also important to focus on improving the communication during patient handoffs from the surgical team to members of the PACU staff. “If the patient has been identified as high risk, the OR nurse should include it in the handoff report to the next nurse to ensure preventative measures remain in place,” says Susan Overman, BSN, RN, CNOR, a perioperative nurse at Ochsner Medical Center - New Orleans. During these handoffs, nurses should note skin abnormalities and breakdowns so they can focus on prevention and treatment during the surgical episode.

• Investigate injuries. If a pressure injury should occur, complete a root cause analysis and utilize the information generated to prevent further injuries. In some cases, a trend might be noted that can lead to practice changes. “Through our project, the team improved communication not only between perioperative nurses, but also among the entire interdisciplinary team,” says Tara Clesi, BS, BSN, RN, WCC, operations coordinator in the Wound Ostomy Department at Ochsner Medical Center - New Orleans. “We built a professional collaborative network for wound care nurses, surgery nurses and supply chain representatives who work toward the same goal. If a wound care nurse is consulted to see a postoperative surgical patient with a pressure injury, we reach out to our surgery contact to perform a root cause analysis.”

Ms. Overman says interactions with providers who make errors that lead to pressure injuries should be nonpunitive and constructive. Ochsner Health’s journey to become a highly reliable organization includes numerous “target zero” goals for patient safety measures, including pressure injuries. “Our ‘just culture’ policy plays a part in creating an environment where employees feel secure and are encouraged to report errors when they occur,” says Ms. Overman. The idea is to learn about the “why” rather than the “who” behind errors — to create opportunities for learning, design safe systems, manage behavioral choices and create a workplace that encourages individuals to report mistakes.

• Protect pressure points. Trial and approve evidence-based and AORN-recommended positioning products, both reusable and disposable. At Ochsner, once-popular “egg crate” pads have been replaced with foams and gels. It’s important to make sure you always have enough of these positioning aids available. “Stocking up on the recommended supplies in advance of and throughout implementation of patient positioning protocols is key to ensuring product availability due to global supply chain disruptions,” says Ms. Leger, who adds that facilities could benefit from reusable or disposable positioning devices depending on their needs. At Ochsner Medical Center - New Orleans, a major teaching academic center that performs more than 75 surgeries a day, disposables made more sense. However, at Ochsner’s community hospitals that perform 10 to 15 surgeries a day, reusables were the right choice.

Helping the team understand the risk factors really has a positive impact. They embrace and champion change.
— Andrea Thibodeaux, BSN, RN-BC

• Conduct continuing education. The coaching of providers on proper patient positioning and pressure injury prevention is an ongoing need — especially considering the volatile staffing situations right now at many facilities — and is vital to consistently reinforce. Ochsner nurses completed training on advanced technology and upgraded AORN guidelines outlining best practices for patient positioning. “Helping the team understand the risk factors really has a positive impact,” says Ms. Thibodeaux. “They embrace and champion change.”

Perioperative professionals need to keep up with the latest guidelines and the newest research and undergo yearly education because the underlying causes of pressure injuries are not going away, notes Ms. Overman. Her advice to surgical leaders is to keep educating, assessing and making sure that the prevention protocols in place are working properly. In addition, new positioning aids that might be less expensive, easier to use or more effective in preventing injuries could arrive on the marketplace and should be investigated.

“You need to evolve and strive for improvement by evaluating evidence-based practices that impact the reduction of pressure injuries,” says Ms. Leger. “Our goal is zero pressure injuries.”
If you employ the education, vigilance and flexibility displayed by the Ochsner team, you’re more likely to join them on that satisfying and valuable journey to zero. OSM

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