You know that surgery makes patients more vulnerable to pressure ulcers, but you might not realize just how big the problem is. It's estimated that up to 45% of the 1.6 billion healthcare associated pressure ulcers that patients develop each year originate in the OR. And 23% are acquired intraoperatively during surgeries that last more than 3 hours. What makes the OR a likely place for skin breakdown and pressure ulcer formation? Prolonged pressure, friction and shearing — the perfect storm for decubitus ulcers (from Latin decumbere, "to lie down").

And the longer patients are lying down for surgery, the greater their chance of acquiring pressure ulcers on the skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. Studies have shown that nearly 1 out of every 10 patients who undergoes surgical procedures that last more than 3 hours will develop a pressure ulcer. Here are a 7 ways you can offload the pressure of pressure injuries. Remember, like most things, it's more cost-effective to prevent pressure ulcers than to treat them.

1. Identify high-risk patients

You can reduce the number of pressure injuries by creating a standardized assessment and implementing specific interventions for patients at the most risk. Here are some of the patient-specific factors that increase the likelihood a patient will develop a pressure injury:

• over 65 years old
• taking certain medications such as corticosteroids or vasoactive agents
• diagnosed with certain diseases such as cancer, cardiovascular disease and diabetes mellitus
• low hemoglobin and hematocrit levels, systemic blood pressure and BMI
• poor nutrition
• low albumin levels

Nurses at Cone Health in Greensboro, N.C., apply a soft silicone foam dressing to the sacrum of patients that fall in the high-risk category for developing pressure injuries. Their skin assessment also provides a baseline for post-op comparison to monitor for any changes in skin condition.

Nurses involved in each perioperative stage at the Robert Wood Johnson Memorial Hospital in Somerset, N.J., developed a "perioperative pressure ulcer protocol" that includes guidelines on how to assess patients' skin at every phase of surgery. After its implementation, there have been no identifiable pressure ulcers from the OR.

2. Deploy positioning devices

Using proper positioning devices like gel pads and thermo-active foam pads reduces pressure injuries, but you should avoid rolled-up blankets and IV bags. Straighten wrinkles or bunching in linens to avoid unwanted pressure. AORN recommends using prophylactic dressings over bony areas such as the sacrum. But don't stack them on top of each other or use them in lieu of other positioning devices. Using them in tandem with other aids is acceptable as long as you consult the manufacturer's IFU for compatibility. AORN also recommends that you "float" the patient's heels by using a boot-like heel-suspension device to raise the patient's heels off the operating surface instead of a pad or piece of egg crate foam. This redistributes the patient's leg weight along the calf without placing pressure on the Achilles tendon.

Researchers at the University of Pittsburgh found that blood flow increased to the skin over the sacral area in patients with a normal BMI who were placed on an alternating pressure (AP) overlay instead of just the OR pad. Combining AP overlays with sacral dressings may provide complete off-loading at the sacrum, according to research done at the Cleveland (Ohio) Clinic.

Store your positioning equipment so it's easily accessible and organized. This ensures you always have the proper roller or pad for the procedure. Nurses at Virtua Health in Voorhees, N.J., created a "positioning cart" that they keep in each sub-sterile room for easy access to positioning aides.

3. Keep 'em dry

Moisture also increases the likelihood of pressure injuries. You should monitor fluids to make sure they aren't pooling near the patient and identify other sources of moisture. For instance, the use of prophylactic dressings can increase the humidity and temperature of a patient's skin according to AORN's Guideline for Positioning the Patient. So you should be aware of any moisture trapped between the dressing and the skin.

4. Maintain normothermia

Studies have shown that the lower a patient's body temperature, the higher the chances she will develop a pressure injury. A 2016 study published in the AORN Journal found that the average temperature of patients that developed pressure injuries was 95.7 ?F. In another study, for every 1 ?F that a patient's temperature dropped, their risk for pressure injury increased by 20%. Yet another reason to actively warm your patients.

5. Monitor length of surgery

Pressure ulcers can develop during surgeries of any length, but the length of surgery is a significant risk factor for pressure ulcers. The longer a patient is in the OR the more likely she is to develop a pressure injury. And it's not just OR time. A patient who undergoes a 90-minute procedure could be immobile for considerably longer when you consider the time he spent on pre-op and post-op stretchers. If unrelieved, that prolonged pressure will cause skin and underlying tissue damage. AORN recommends making time during procedures to assess a patient's position and intervene if it looks like there is potential for a pressure injury. This gives the nursing team the chance to speak up if there are any concerns about patient positioning.

6. Document

A good documentation system lets you keep track of which procedures and patients are at higher risk for pressure injuries. The Children's Hospital of Colorado worked with its IT department to standardize data collection and improve the charting process for staff. This let them follow up with specific surgical services when pressure ulcers occurred to counsel them and offer evidence-based suggestions for improvement. After implementing this and other protocols, their pressure injuries dropped from 20 cases in 2010 to 6 in 2013. Tip for success: Creating a link to their documentation procedure in their electronic charting system made it easier for staff at another facility to implement their new process.

7. Educate your staff

Sometimes a refresher course for your staff or re-education is necessary to improve awareness. The Boston (Mass.) Children's Hospital found that re-education and simulation training of positioning for all their staff helped improve outcomes A team at Rhode Island Hospital in Provi-dence, R.I. created a hands-on clinic in the OR for nurses. A major component of the training involved placing the nurses in the positions their patients would be in so they could feel the points of pressure for themselves. They also developed laminated posters demonstrating the common pressure points associated with the four most common positions. The posters were placed on their education boards as a reminder to PACU nurses and used in trainings.

Many facilities implement testing once or twice a year to see if staff are retaining the knowledge learned during training. Nurses at the Memorial Sloan-Kettering Cancer Center used the AORN Perioperative Mastery Program to assess their staff's knowledge of positioning protocols — and to measure the nurses' confidence in their answers. They found it to be a quick, easy and reliable way to assess their staff's knowledge and improve it.

Out of sight, out of mind?

Treat surgery-related pressure ulcers like the important problem they are. Patients don't develop ulcers until hours or days after surgery, so your OR team might not be overly concerned about preventing patients from developing pressure ulcers. It's your job to drive this point home to your team. OSM