By Susan M. Scott, BSN, MSN, RN, WOC
Over the past five years, the incidence of perioperative hospital-acquired pressure injuries (HAPI) has increased (Chen, Chen, & Wu, 2012), causing patients pain and suffering and costing the U.S. healthcare system $11 billion per year (Brem et al., 2010).
Pressure injuries (previously referred to as pressure ulcers) result in substantial patient harm and can lead to sepsis, osteomyelitis, disfigurement, disability, and death. Patients who develop pressure injuries are more likely to die while in the hospital, to have longer hospital stays, and to be readmitted within 30 days after discharge (Lyder et al., 2012). Healthcare costs for a Stage 4 pressure injury are estimated to be between $44,000 and $128,000 (Brem et al., 2010). The Centers for Medicare & Medicaid Services considers Stage 3 and 4 pressure injuries to be hospital-acquired conditions and does not pay for them.
Pressure injuries can develop while patients are undergoing surgery because of a physiological reaction to immobility. Blood vessels become compressed, creating poor circulation, which leads to oxygen and nutrient deficiencies and accumulation of acidic metabolism products. The body reacts by enlarging the blood vessels, resulting in a loss of fluid and eventually blister formation. Including preoperative preparations, waiting time, and the postoperative recovery period, even a relatively short, two-hour surgery can mean six or more hours of immobility for the patient. Because pressure injuries often do not show up until hours or days following surgery, many operating room (OR) staff members and surgeons do not even think about preventing these lesions. According to a 2014 publication from the National Pressure Ulcer Advisory Panel (NPUAP), the incidence of pressure injury attributed to the OR varies among specialties and procedures from 5% to 53.4% (NPUAP, 2014).
Fortunately, hospital staff can reduce the incidence of perioperative pressure injuries and their associated costs by using risk assessment tools and implementing evidence-based programs.
Who is at risk?
More than 100 risk factors for pressure injury have been identified in the literature (Chen, Chen, & Wu, 2012; Cox, 2013; Fred, Ford, Wagner, & Vanbrackle, 2012; Lindgren, Unosson, Krantz, & Ek, 2005; Lyder & Ayello, 2008; Man & Au-Yeung, 2013; Minnesota Hospital Association, 2013; Wake, 2010). Physiologic (intrinsic) and non-physiologic (extrinsic) risk factors for adults include:
Intrinsic risk factors
Extrinsic risk factors
- Age greater than 60 years
- Albumin levels lower than 3.5 g/dL
- American Society of Anesthesiologists (ASA) score greater than 3
- Body mass index (BMI) less than 19 or greater than 40
- Peripheral vascular disease
- Cerebrovascular accident
- Pulmonary disease
- Renal insufficiency
- Low core temperature
- Duration of time immobilized before surgery
- Operation planned for three hours or longer
- Prone positioning
- Cardiac, orthopedic, vascular, transplant, or bariatric procedure
- Increased hypotensive episodes
- Use or continued use of vasopressors
- Reduced mobility on the first day postop
Additional risk factors have been correlated with pressure injury development outside the OR: current smoking history, dry skin, impaired mobility, altered mental status (i.e., confusion), urinary and fecal incontinence, malnutrition, physical restraints, malignancy, history of pressure injury, existing skin breakdown, and impaired sensation, as well as being bedbound, chairbound, or unable to reposition oneself (Lyder & Ayello, 2008; Minnesota Hospital Association, 2013).
Evaluating patients with risk assessment tools
[caption id="attachment_2836" align="alignright" width="450"]
Figure 1. Scott Triggers Tool[/caption]
Several steps can be taken to decrease the incidence of pressure injury among surgical patients. They include understanding the epidemiology and presentation of pressure injury development, identifying patients at high risk, and assessing patients’ skin. These steps may require educating staff and physicians and familiarizing them with certain screening tools, such as the Scott Triggers Tool (Figure 1).
The Scott Triggers Tool identifies high-risk patients preoperatively by evaluating four evidence-based predictors of perioperative pressure injury—age, serum albumin or BMI, ASA physical status classification score, and estimated time of surgery. These nurse-designed, evidence-based predictors were identified in a study conducted at the VA Medical Center in Memphis, Tennessee (Scott, 2015). The tool prompts care providers to implement additional interventions to reduce the patient’s risk. It provides rapid, real-time identification of potential problems and enables timely, productive intervention at the patient level.
Other screening tools include the Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients (Munro, 2010) and the Braden Scale for Predicting Pressure Sore Risk (Braden, Bergstrom, & Ball, 2016). The Munro Scale is used to identify adult general surgery patients at risk for pressure injury development. It is not a skin assessment tool. The patient’s risk level is scored for each phase of surgery (pre-, intra-, and postoperative), and the cumulative score is communicated to the inpatient unit for continuation of care. The Braden Scale is used to evaluate a patient’s risk of developing a pressure injury by examining six criteria: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score can range from 6 to 23, with a lower score indicating a higher risk. The level of risk indicates the intervention strategies that should be used.
Implementing an OR skin bundle
Once a patient has been identified as being at high risk for developing a pressure injury, an OR skin bundle protocol should be implemented to mitigate harm. A bundle is a set of evidence-based interventions to help standardize care and reduce complications in the healthcare setting. Other successful evidence-based bundles include those for ventilator-acquired pneumonia and for central line infections (Waters et al., 2015).
An OR skin bundle may include the following interventions:
- Assessment of the patient’s skin preop and immediately postop
- Safe patient handling
- Standardization of high-specification* OR table pads
- Redistribution and offloading of pressure, particularly to heel and occiput
- Use of protective dressings
- Use of approved positioning devices
- Maintenance of normothermia and microclimate
- Handoff communication
- Early movement
- Daily skin assessment
- Pressure management
A study of 21,377 surgical patients screened with the Scott Triggers Tool found that more than 7,000 patients had two or more triggers and were considered to be at high risk for pressure injury (Martinez et al., 2014). For these patients, an OR skin bundle was implemented that included skin assessment on admission, transfer, and discharge; standardization of high-specification OR table pads; interprofessional education; careful positioning; redistribution and offloading of pressure; protective dressings; frequent assessments; turns scheduled every two hours using wedges; and real-time reporting of pressure injuries. Results showed the rate of HAPI decreased from 3.37% to 0.89% (p=0.004), with the reduction sustained over a 14-month period. The facility also lowered costs by nearly $1.4 million over a one-year period (Martinez et al., 2014).
[caption id="attachment_2837" align="alignleft" width="300"]
Figure 2. Deep Tissue Pressure Injury 48 Hours After Coronary Artery Bypass Graft[/caption]
High-specification OR table pads
To more effectively redistribute pressure on the bony prominences of the body, the surface of the OR table should allow for immersion of the body into the material. Standard OR table pads are comprised of a 2-inch elastic foam covered with black, conductive, laminated vinyl fabric. While this type of pad is great for stability, several studies have demonstrated that it contributes to pressure injury development during surgery (Aronovitch, Wilber, Slezak, Martin, & Utter, 1999; Feuchtinger, Bie, Dassen, & Halfens, 2006; NPUAP, 2014; Nixon, McElvenny, Mason, Brown, & Bond, 1999; Russell & Lichtenstein, 2000; Schoonhoven, Deﬂoor, & Grypdonck, 2002; Scott, 2013).
High-specification foam mattresses, on the other hand, have been shown to reduce the development of pressure injury (McInnes et al., 2015; Scott, 2015). Soft, multi-layer cushions allow patients to sink into the underlay, with the cushion molding around the patient’s body to increase surface contact by up to 60%. This helps distribute pressure across a greater area. Bi-elastic covers also reduce creases and shear forces on the skin. While installing new OR table pads is an added expense, intraoperative prevention may be more cost-effective than the current practice (Pham et al., 2011). At the VA Medical Center in Memphis, replacement of all OR table pads resulted in a reduction in the cost of extra foam positioning devices by $250,000 over two years.
Implementing a Perioperative Pressure Injury Prevention Program
Implementing a Perioperative Pressure Injury Prevention Program (PPIPP)—previously known as a Perioperative Pressure Ulcer Prevention Program or PPUPP—is another strategic way to reduce HAPI in the acute care setting. After a PPIPP was instituted at the VA Medical Center in Memphis, the incidence of HAPI fell 60% over a four-year period, with a cost avoidance of $3.1 million (Scott & Hector, 2001). Recognized by the American Academy of Nursing (2016) as an innovative approach to improving healthcare through nursing leadership, a PPIPP has been used successfully in the Veterans Integrated Service Network, where it reduced costs by $2.4 million in a single fiscal year.
PPIPP includes a 10-step strategy to strengthen HAPI prevention efforts:
- Quality improvement. Using the DMAIC improvement model (define, measure, analyze, improve, control), bring together an interprofessional team of stakeholders to develop a strategy that addresses barriers to providing optimal patient safety. Determine the facility’s incidence of HAPI by tracking occurrences of pressure injuries and conducting patient safety investigations, including root cause analysis.
- Assessment. Perform a gap analysis and assess the environment. Use the SWOT analysis format (strengths, weaknesses, opportunities, and threats) to set priorities and create an action plan for improvement.
- Staff education and awareness. Develop educational programs for all perioperative staff. Improve awareness by posting the incidence and prevalence of HAPI. Include PPIPP in orientation, staff meetings, and in-service time.
- Evidence-based practice. Incorporate evidence-based national guidelines such as those from the NPUAP (2014) and the Wound, Ostomy and Continence Nurses Society (www.wocn.org) into clinical practice routines.
- Risk assessment. Numerous risk factors have been linked to pressure injury development in surgery. Decide which tool or tools best fit your setting. The Braden Scale should be used in conjunction with other “surgical-specific” tools such as the Scott Triggers Tool or Munro Scale for identification of at-risk individuals (Putnam, 2016). Consider additional factors such as surgical case type, position, trauma, and reoperations.
- Perioperative nursing care plan. Use an OR skin bundle tailored to your surgical setting. Incorporate a system redesign to standardize care for all patients. Develop or refine structured, standardized handoff communication to include surgical position, time on the table, and skin assessment in your SBAR (situation, background, assessment, recommendation) tools and verbal reports. Documentation should be clear and concise and include nursing interventions and assessments. Complete documentation may also help protect against litigation.
- Positioning competencies. Integrate guidelines for perioperative positioning from the Association of periOperative Registered Nurses (AORN) (2015) into clinical practice.
- Universal pressure precautions. Incorporate pressure redistribution and relief devices into all perioperative care. Start by standardizing high-specification support surfaces in all functioning ORs and on beds/stretchers prior to and after surgery. Use of a high-specification support surface on the operating table for at-risk individuals is recommended (NPUAP, 2014). Devices used for positioning and padding should be consistent with principles of pressure redistribution, as this is the cornerstone for success (Black, Fawcett, & Scott, 2014; Scott, 2015).
- Product specification and selection. There is insufficient evidence to conclude which surfaces and devices are most effective for prevention; however, review of available clinical research and outcome studies on all positioning devices is recommended (Scott, 2015). Prior to purchasing a product, consult with a team to develop specific criteria for product selection consistent with your environment: safety features, fire standards, biomedical requirements, infection prevention, decontamination, resuscitation, radiolucency, weight limits, and efficacy. Is the product compatible with tables and positioning requirements? Consider the initial and replacement costs, disposable vs. reusable products, applicable warranty, and manufacturer reputation.
- Specialty nurse collaboration. Improve handoff communication and collaboration between the interprofessional team of perioperative staff: post-anesthesia; wound, ostomy, and continence nurses; and nursing.
In 2010, over 51 million surgeries were performed in the United States (Centers for Disease Control and Prevention, 2015). If the rate of surgical pressure injuries is assumed to be 15% (the average of incidence rates found in the literature) (Chen, Chen, & Wu, 2012), more than 7 million individuals could acquire a pressure injury during a surgical procedure in 2016 alone.
Reducing HAPI in the OR begins with educating staff and improving communication. A strategic plan that addresses the challenges and barriers to strengthening outcomes can reduce waste, conserve valuable resources, and mitigate patient harm. By implementing the strategic protocols and programs described above—including identifying at-risk patients, implementing the interventions in the OR skin bundle, and putting in place a PPIPP—organizations can help improve patient safety and strive for the ultimate goal of zero patient harm.
Editorial support was provided by Jani Bergan, MA, of W2O Group, on behalf of Getinge Group, a leading global provider of innovative solutions for operating rooms, ICUs, hospital wards, and sterilization departments, as well as for elder care and life science companies.
Susan M. Scott is the patient safety quality improvement educator at the University of Tennessee Health Science Center, College of Medicine, Office of Graduate Medical Education in Memphis. At the university, she serves as an affiliated staff member at the Center for Health Systems Improvement, College of Medicine, and as a clinical instructor in the College of Nursing. Scott is also a clinical consultant and speaker for Sage Products, Inc. She may be contacted at email@example.com, firstname.lastname@example.org, and @scotttriggers on Twitter.
American Academy of Nursing. (2016). The Perioperative Pressure Injury Prevention Program. [Raise the Voice]. Retrieved June 16, 2016, from http://www.aannet.org/edge-runners--perioperative-pressure-ulcer-prevention-program.
Aronovitch, S., Wilber, M., Slezak, S., Martin, T., & Utter, D. (1999). A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients. Ostomy Wound Management, 45
Association of periOperative Registered Nurses. (2015). Guideline for positioning the patient. In Guidelines for perioperative practice.
Denver, CO: Author.
Association of periOperative Registered Nurses. (2016). Prevention of perioperative pressure ulcers tool kit. Retrieved from https://www.aorn.org/guidelines/clinical-resources/tool-kits/prevention-of-perioperative-pressure-ulcers-tool-kit
Black, J., Fawcett, D., & Scott, S. (2014). Ten top tips: Preventing pressure ulcers in the surgical patient. Wounds International Journal, 5
Braden, B., Bergstrom N., & Ball J. (2016). Prevention Plus: Home of the Braden Scale. Retrieved from http://www.bradenscale.com/index.htm.
Brem, H., Maggi. J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., … Vladeck, R. (2010). High cost of stage IV pressure ulcers. American Journal of Surgery, 200
Centers for Disease Control and Prevention (2015). National Hospital Discharge Survey. Retrieved from http://www.cdc.gov/nchs/nhds.htm.
Chen, H., Chen, X., & Wu, J. (2012). The incidence of pressure ulcers in surgical patients of the last 5 years. Wounds, 24
Cox, J. (2013). Pressure ulcer development and vasopressor agents in adult critical care patients: A literature review. Ostomy Wound Management, 59
(4), 50–54, 56–60.
Feuchtinger, J., Bie, R. D., Dassen, T., & Halfens, R. (2006). A 4 cm thermoactive viscoelastic foam pad on the operating room table to prevent pressure ulcer during cardiac surgery. Journal of Clinical Nursing, 15
Fred, C., Ford, S., Wagner, D., & Vanbrackle, L. (2012). Intraoperatively acquired pressure ulcers and perioperative normothermia: A look at relationships. AORN Journal, 96
Lindgren, M., Unosson, M., Krantz, A. M., & Ek, A. C. (2005). Pressure ulcer risk factors in patients undergoing surgery. Journal of Advanced Nursing, 50
Lyder, C. H., & Ayello, E. A. (2008). Pressure ulcers: A patient safety issue. In Patient safety and quality: An evidence-based handbook for nurses
(Chapter 12). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2650/.
Lyder, C. H., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N. R., & Hunt, D. R. (2012). Hospital-acquired pressure ulcers: Results from the National Medicare Patient Safety Monitoring System Study. Journal of the American Geriatrics Society, 60
Man, S. P., & Au-Yeung, T. W. (2013). Hypotension is a risk factor for new pressure ulcer occurrence in older patients after admission to an acute hospital. Journal of the American Medical Directors Association, 14
Martinez, S., Braxton, C., Helmick, R., Awad, S., & Lara-Smalling, A. (2014, May). Sustainability of a hospital acquired pressure ulcer prevention bundle in surgical patients. Presented at the Surgical Infection Society 34th Annual Meeting, Baltimore, MD.
McInnes, E., Jammali-Blasi, A., Bell-Syer, S. E. M., Dumville, J. C., Middleton, V., & Cullum, N. (2015). Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews.
Minnesota Hospital Association. (2013, March). Pressure ulcer prevention in the O.R. Recommendations and guidance. Retrieved from https://www.mnhospitals.org/Portals/0/Documents/ptsafety/skin/OR-pressure-ulcer-recommendations.pdf.
Munro, C. A. (2010). The development of a pressure ulcer risk-assessment scale for perioperative patients. AORN Journal, 92
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2014). Prevention and treatment of pressure ulcers. Clinical practice guidelines. Perth, Australia: Cambridge Media.
Nixon, J., McElvenny, D., Mason, S., Brown, J., & Bond, S. (1999). A sequential randomized controlled trial comparing a dry viscoelastic polymer pad and standard operating table mattress in the prevention of post-operative pressure sores. Journal of Nursing Studies, 35,
Pham, B., Teague, L., Mahoney, J., Goodman, L., Paulden, M., Poss, J., … Krahn, M. (2011). Support surfaces for intraoperative prevention of pressure ulcers in patients undergoing surgery: A cost-effectiveness analysis. Surgery, 150
Putnam, K. (2016). Minimizing pressure ulcer risk for surgical patients. AORN Journal, 103
Russell, J., & Lichtenstein, S. (2000). Randomized controlled trial to determine the safety and efﬁcacy of a multi-cell pulsating dynamic mattress system in the prevention of pressure ulcers in patients undergoing cardiovascular surgery. Ostomy Wound Management, 46
Schoonhoven, L., Deﬂoor, T., & Grypdonck, M. H. (2002). Incidence of pressure ulcers due to surgery. Journal of Clinical Nursing, 11
Scott, S. (2015). Progress and challenges in perioperative pressure ulcer prevention. Journal of Wound, Ostomy and Continence Nursing, 42
Scott, S. (2016). Creating a strategic plan for perioperative pressure ulcer prevention. AORN Journal,
Scott, S., & Hector, M. (2001, February). A Certified Wound, Ostomy, and Continence Nurse (CWOCN) approach to pressure ulcer, prevention and treatment: Complication and cost reduction. Poster presented at National Pressure Ulcer Advisory Panel 7th National Conference, Pressure Ulcer Prevention: From Research to Practice, Washington, D.C.
Wake, W. T. (2010). Pressure ulcers: What clinicians need to know. The Permanente Journal, 14
(2), 56–60. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912087/.
Waters, T., Daniels, M., Bazzoli, G., Perencevich, E., Dunton, N., Staggs, V., … Shorr, R. I. (2015). Effect of Medicare’s nonpayment for hospital-acquired conditions: Lessons for future policy. JAMA Internal Medicine, 175,