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By: Daniel Cook
Published: 2/3/2021
The two-inch red circle on the patient's sacrum was unmistakable. A PACU nurse noticed the deep tissue injury during a post-op assessment and called over to pre-op to see if one of her colleagues had documented the patient's skin condition before surgery. No one had. The 51-year-old male patient with a BMI of 44 had undergone a left distal open reduction and internal fixation, an outpatient procedure that typically takes 90 minutes to complete, but this case had unexpectedly lasted more than three hours. All told, including time spent in pre-op, the patient was supine on a stretcher for five hours.
"We didn't have a pressure injury prevention program in place at our on-campus surgery center, so a pre-op baseline skin assessment wasn't done," says Diane Kimsey, MSN, MHA, RN, CNOR, CMLSO, WTA, perioperative educator at Einstein Medical Center Montgomery in East Norriton, Pa. "At the time, we weren't sure if the patient presented with the injury or had acquired it during surgery."
Many surgical nurses float between Einstein's inpatient ORs and its ASC, so they're familiar with the comprehensive pressure injury prevention program in place at the main hospital. "We had to determine what protocols could provide the same level of protection for patients in the ambulatory setting," says Ms. Kimsey.
She huddled with Bryan Panetta, RN, manager of the hospital's short procedure unit and operating room, and developed a straightforward pressure injury risk-reduction strategy based on a three-hour limit because "evidence shows skin can break down on patients who remain in a static position for that long," says Mr. Panetta.
Mr. Panetta knows how long scheduled procedures should last, but also taps into his working knowledge of how the surgery center runs to help make the decision. For example, he knows cases with surgeons who are more — ahem — deliberate than their colleagues have a chance to go over the allotted time on the schedule. He's aware that distal open reduction and internal fixations —the procedure that launched the hospital's risk-reduction bundle — require instrumentation that takes a long time to set up and complex foot reconstructions can last longer than expected.
If there is little to no possibility that a patient will be on a table or stretcher chair for more than three hours, no action is taken. Patients who are expected to remain on either surface beyond the three-hour limit are placed in the risk-reduction bundle, and the perioperative team is notified about the added protection these patients require.
The risk-reduction bundle's guidelines do not include thresholds for how long patients remain on stretchers in pre-op due to delayed start times. "Patients are typically in and out of that area in a timely fashion," explains Ms. Kinsley. "However, nurses are vigilant about monitoring how long patients remain in pre-op and alert us if a case's start time is delayed significantly to find out if they should shift the patient into the bundle."
You might think your staff doesn't need to be overly concerned with pressure injury prevention because patients who undergo outpatient procedures are relatively healthy and have fairly normal BMIs and low ASA scores. Think again. "Pressure injury risk in the outpatient setting is an underreported and underrated problem," says Diane Kimsey, MSN, MHA, RN, CNOR, CMLSO, WTA, perioperative educator at Einstein Medical Center Montgomery in East Norriton, Pa. "Your entire care team must ensure appropriate skin assessments take place, and follow protocols to identify high-risk patients and apply extra protection to their skin to protect it from harm."
Be sure to pay extra attention to these high-risk areas, based on AORN's Pressure Injury Prevention Toolkit, when positioning and padding patients before surgery.
A similar pressure injury prevention program was launched in Einstein's main hospital in 2015. "Every staff member is fully aware of the importance of preventing skin injuries," says Ms. Kimsey.
Einstein's staff has flagged more than 100 patients since the bundle was put in place in April 2019, and 16 patients have gone through the program. "We've had zero injuries," says Mr. Panetta. "That's a great number." OSM
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