Put a Stop to Pressure Injuries From the Start

Early assessments, preemptive positioning plans and awareness of potential problem spots are a recipe for success.

Your surgeon and OR team perform a textbook surgery that leaves the patient with only the tiniest of incisions at the surgical site. Unfortunately, that same patient also walks away with a gaping, painful pressure injury (PI) that wasn’t there when they walked through your doors in the morning.

This is the type of worst-case scenario that can often be avoided altogether when safety-centered OR teams take all the necessary PI-prevention steps at their disposal.

Not only an inpatient concern

Pressure-injury prevention in the outpatient space starts by having the right culture in place and quashing the misconception that PIs are only an inpatient problem. “Pressure injuries can start in the OR on any patient, and it’s our job to do everything we can to prevent them down the road because there are major ramifications,” says Dawn Yost, MSN, RN, CNOR, CSSM, business manager of perioperative services at West Virginia University Hospitals in Morgantown, W.V. Ms. Yost would know, as her own husband experienced a pressure injury that took nearly a year to heal.

Indeed, with longer, more complex procedures migrating to outpatient centers, viewing PIs as an inpatient issue is a recipe for disaster. “A lot of surgery has moved to the outpatient setting, including orthopedic procedures,” says Lisa Gould, MD, PhD, FACS, a plastic and reconstructive surgeon from Warwick, R.I. “Now we have patients getting their hips and knees done, and these patients were probably fairly immobile before surgery because of pain. Now they’re getting discharged directly home and if they’re not moving due to pain, it’s a major problem.” For Dr. Gould, mobility is a key component of prevention because if you can get people to move, they tend to be a lot less susceptible to PIs.

While providers can’t control what patients do or don’t do in the comfort of their own homes after surgery, they can do a lot pre-, intra- and in the immediate post-op period to keep patients safe. This is especially important for surgical patients because OR-acquired pressure injuries are extra difficult to track because of delayed presentation.

Accurate, efficient assessments

PREVENTABLE PAIN Areas like the heel are especially susceptible to pressure injuries, so it’s critical to provide proper padding and monitor often.

“Preoperative skin assessments allow staff to spot those high-risk patients early on,” says Ms. Yost, adding that elderly patients, thin skin texture and extremely heavy or extremely thin patients tend to be more at risk for PIs.

At Dr. Gould’s facility, they’ve implemented a specialized prevention protocol with an OR skin bundle that is applicable to both inpatient and outpatient surgeries (See Proven Protocols below) — one that places a premium on the preoperative assessment. The OR team uses the Scott Triggers assessment tool, which determines patients at a high risk for pressure injuries based on whether they have two or more “Yes” responses to four evidence-based predictors:

• Age (62 or older)
• Serum albumin or BMI (less than 3.5 g/L for albumin and less than 19 or greater than 40 for BMI)
• ASA score (score of three or greater), and
• Estimated time of surgery (surgery time over three hours or 180 minutes).

Scott Triggers is but one of several effective assessment tools out there. There’s the widely used Munro Pressure Ulcer Risk Assessment Scale, a tool that addresses the many factors that can cause skin breakdown along the entire perioperative pathway. There’s also the Pressure Injury Predictive Model, a tool created by Outpatient Surgery Magazine contributors Christine Anderson, PhD, RN, and Dana Tschannen, PhD, RN.

For Dr. Gould, the efficiency factor of the Scott Triggers tool is key. “We had to have something that would be easy to use, and that’s been the case,” she says. “It’s been very durable. It’s in the EMR, so that then communicates to the OR and continues across the different phases of care — from the operating room to the task queue to home or wherever the next destination is,” she says.

Plan, position and pad accordingly

Once you’ve determined the patient’s risk status, there are plenty of proven precautionary measures you can take to decrease the likelihood of a PI — starting with the stretchers and OR table you use to transport and position the patient. For instance, there are high-specification foam mattresses for both pre- and post-op stretchers and OR tables that manage pressure and reduce the risk of injury. When it comes to positioning patients, Dr. Gould urges OR teams to plan well in advance, checking the functionality of all relevant devices and positioning aids, and paying extra attention to patients’ pressure points. “I position a lot of my patients prone or on their side in lateral decubitus, and we are very careful with them,” she says, “We use gel pads and different foams for padding, and there’s also been a heightened awareness among staff about positioning and protecting people because of our skin bundle.”

Pressure injuries can start in the OR on any patient, and it’s our job to do everything we can to prevent them down the road because there are major ramifications.
Dawn Yost, MSN, RN, CNOR, CSSM

Dr. Gould also cites AORN educational material as a critical resource in preventing PIs. “AORN has a really good pictorial guide for positioning patients in different, awkward positions,” she says. In addition to a wealth of tools on its website (aorn.org), AORN’s new portable Pocket Positioning Cards feature step-by-step instructions, tips and illustrations for each major surgical position: lateral, lithotomy, prone, reverse Trendelenburg, Trendelenburg, sitting/semi-sitting and supine as well as a card for general best practices in all positions.

For Ms. Yost, proper education of perioperative staff should result in PI prevention becoming second nature among nurses. One way to get staff there: Have them feel exactly what the patients feel. How? By placing new staff in the same positions in which they will be placing their patients and asking, “What did you feel?” That’s a tactic Ms. Yost has seen help new nurses who haven’t been in surgery understand firsthand the importance of proper positioning. “If you make it real, they won’t forget when they’re positioning the actual patient,” she says. This type of hands-on education creates an ever-vigilant staff that is always looking to pad and protect. “OR nurses are always looking for methods that might cause shearing and injury to patients and responding accordingly,” says Ms. Yost. “For instance, in lithotomy, patients need padding in the sacral area.”

While pressure injury prevention involves an array of critical steps beginning in the preoperative phase of care, Dr. Gould says beneath all the details the overall strategy is fairly clear-cut. “It comes down to looking at the skin, head to toe, and then emphasizing mobility,” she says. “In pre- and post-op, anything that can increase mobility — whether it’s turning or actually getting somebody up — is going to be the best strategy in the prevention efforts.” OSM