Perioperative Pressure Injuries: Protocols and Evidence-Based Programs for Reducing Risk

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

  • Age greater than 60 years
  • Albumin levels lower than 3.5 g/dL
  • American Society of Anesthesiologists (ASA) score greater than 3
  • Diabetes
  • Body mass index (BMI) less than 19 or greater than 40
  • Peripheral vascular disease
  • Cerebrovascular accident
  • Sepsis
  • Hypotension
  • Pulmonary disease
  • Renal insufficiency
  • Low core temperature