Can We Predict and Prevent Pressure Injuries?

Patient Experience

By: Susan Scott

Published: 5/16/2019

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Match redistribution and relief devices with the level of susceptibility.


The only hospital-acquired condition that increased in volume between 2014 and 2017? Pressure injuries, which rose by 6%. By point of comparison, surgical site infection rates were actually neutral during that period. I've been tracking pressure injuries over 3 decades, and I fear the problem is even worse than those statistics suggest.

Helpful Resources From AORN

True, it's difficult to determine how many pressure injuries occur perioperatively because they usually don't present for hours or days after surgery. Plus, your staff is likely unaware that there's been an injury — it's not something they can always ID on the spot. But even though they can't see them, your team plays a key role in pressure injury prevention.

Fortunately, easy-to-use tools can help you determine a patient's level of susceptibility before surgery. I developed the AORN-endorsed Scott Triggers (osmag.net/Qou5QQ), a concurrent trigger tool that identifies at-risk individuals for perioperative pressure injuries. It evaluates 5 factors — age, serum albumin level, BMI, ASA score and estimated surgery time — to determine the patient's level of risk.

Other pre-op risk assessment tools include the Braden Scale for Predicting Pressure Sore Risk (osmag.net/KAenF3) and the Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients (osmag.net/GTGaa3). Whichever tool you use, instruct your team to transfer it to the OR staff during handoff and to the post-op staff after surgery.

While these tools can help staff determine how likely a patient is to develop a pressure injury, every patient, no matter how healthy, is in fact at risk.

Underweight or thinner patients have a higher risk of injury to bony prominences. Other considerations include a patient's current physical state, nutritional status, and comorbidities like vascular disease, diabetes, immobility, advanced age and severe illness.

Skin assessment

Is your team engaged when they perform a skin assessment, or do they simply ask a patient if her skin is intact? They need to visualize the pressure points and bony prominences, and document what they see. They should report any redness, blanchable or not, in the handoff, along with concerns such as the patient's position, the length of surgery and any devices that might contribute to injuries.

Monitoring (and documentation) should continue during the surgery itself, with staff checking for temperature, edema, redness and change in skin consistency. Post-op, ongoing skin assessment is just as key. Absence of skin damage immediately post-op doesn't mean the patient is out of the woods. What we communicate in the handoff can set the stage for an aggressive care plan post-op whether the patient goes to a post-op bed or home. Family members can play an important role in assessing for unusual pain or skin changes that they should report to the physician and in follow-up clinic visits.

The duration of a surgery is a factor in the development of pressure injuries — the longer the procedure, the more likely they are to develop because of the progressive prolongation of pressure on the skin. If it's possible to reposition the patient during a lengthier surgery, staff should do so.

As an outpatient facility, you might not think your procedures are lengthy enough to result in pressure injuries; indeed, the Scott Triggers tool uses 3 hours as the standard for high risk. But sub-epidermal moisture (SEM) scanners, which measure SEM values and can detect pressure injuries long before visual signs are present, have presented emerging evidence that tissue damage may occur in surgical procedures of less than 1 hour.

Horizontal approach

I champion a "horizontal approach" to pressure management and risk mitigation. By that, I mean we should address our surfaces and pressure redistribution and relief devices in all settings where a patient can be subject to unrelieved pressure. That includes pre-op and post-op settings as well as the OR.

The most important surface, of course, is the OR table. The low-hanging fruit here includes standardization of high specification OR table pads. These pads, which absorb the patient's weight through immersion and envelopment, and redistribute pressure in specific areas commonly associated with perioperative pressure injuries, are designed to reduce pressure by distributing load away from high-pressure points.

So-called dynamic support surfaces can compensate for an inability to reposition a patient during a longer case. You're probably familiar with such non-dynamic overlays and positioners as water, foam and gel. Prophylactic dressings such as 5-layer silicone foam dressings are an emerging prevention approach — researchers are currently evaluating them for their effectiveness in high-risk patients and positions. These dressings have a silicone backing that lets you assess the skin under the dressing and reseal.

What procedures do you perform at your facility, and what patient positions are used most frequently? The answers will determine what types of support surfaces and other preventative measures you should research and use.

AORN reports the overwhelmingly most common site for a pressure injury is the sacrum, followed by the heels, chin, sternum and trochanters. Sacral and heel injuries are associated with the supine position, while chin, sternum and trochanter injuries are associated with the prone position, says AORN. Any time sustained pressure is applied to a bony prominence, no matter what position the patient is in, it's an area of concern and staff should pay close attention.

Some other positioning tips from AORN:

  • Don't use sheets and blankets to position patients, as they can decrease the effectiveness of support surfaces and may cause additional pressure.
  • Ensure linens under the patient aren't wrinkled.
  • Ensure no fluid or moisture is under the patient.
  • Use a lateral transfer device like a slider board to transfer or reposition the patient — sliding or pulling can cause shear or friction.

Extended post-op monitoring

Soon after surgery, perform another skin assessment and compare it to the pre-op assessment. You're not done yet. Because symptoms might not appear for several days after surgery, extended post-op monitoring is vital. Instruct patients about what to look for, and what to report. During post-op follow-up calls, always ask patients about their skin.

When a pressure injury occurs, notify all staff. Awareness can lead to improvements in detection and more vigilant prevention. There's a plethora of education material, guidelines and research on pressure injuries. Your perioperative staff should receive pressure injury education when they join your facility, and then at least every year thereafter. OSM