Pressure Ulcers: Factors Contributing to Their Development in the OR DAWN ENGELS, MSN, RN, CNS, CWOCN, CWCN-AP; MELODY AUSTIN, BSN, RN, CWOCN; LAURIE McNICHOL, MSN, RN, CNS, GNP, CWOCN, CWON-AP; JENNIFER FENCL, DNP, RN, CNS-BC, CNOR; SAT GUPTA, PhD; HASEEB KAZI, MD

ABSTRACT The prevention of health care-associated pressure ulcers (HAPUs) is an important quality measure because HAPUs are considered a never event. The literature suggests that the prevalence rate of pressure ulcers is 8.5% or higher among patients who undergo surgical procedures that last longer than three hours. We performed a retrospective chart review to determine what factors contribute to the development of pressure ulcers in patients who undergo surgical procedures. The sample population included patients who acquired a pressure ulcer that was not present at admission and developed during their postoperative hospital stay. The project revealed consistent risk factors that may contribute to the development of pressure ulcers in patients who have undergone surgical procedures. These findings can drive the implementation of preventive measures to reduce the occurrence of HAPUs associated with surgical procedures. AORN J 103 (March 2016) 271-281. ª AORN, Inc, 2016. http://dx.doi.org/10.1016/j.aorn.2016.01.008 Key words: pressure ulcer, risk factors, HAPU, never event.

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ressure ulcers are referred to by many names, including decubitus ulcers, bed sores, and pressure sores. The National Pressure Ulcer Advisory Panel (NPUAP) defines pressure ulcers as a “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.”1(p41) Health care organizations are placing an emphasis on the delivery of safe patient care and challenging health care providers to develop effective, evidence-based prevention strategies to eliminate the occurrence of health careassociated pressure ulcers (HAPUs). Surgical patients are uniquely susceptible to the development of pressure ulcers as a result of multiple complex risk factors that only occur in the perioperative environment.

DESCRIPTION OF THE PROBLEM Identifying patients who are at the highest risk for developing intraoperative pressure ulcers is the first step toward preventing HAPUs.2 An estimated 2.5 million patients in US health care facilities develop pressure ulcers every year.3 According to the NPUAP, pressure ulcers that originate in the OR may account for up to 45% of all HAPUs.4 In October 2008, the Centers for Medicare & Medicaid Services (CMS) ceased reimbursing health care facilities for the treatment of HAPUs.5,6 The average estimated cost of pressure ulcer treatment is $750 million to $1.5 billion per year.7 The occurrence of a pressure ulcer can add an estimated $43,180 to the cost of a patient’s hospital stay.8

http://dx.doi.org/10.1016/j.aorn.2016.01.008 ª AORN, Inc, 2016

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BACKGROUND The high incidence of pressure ulcer development in the perioperative setting indicates opportunities for improved patient risk assessment and implementation of preventive measures. For example, Munro9 states that half of the patients who develop a HAPU have previously undergone a surgical procedure. AORN’s “Guideline for positioning the patient” notes that the incidence of pressure ulcers occurring as a result of surgery may be as high as 66%.10 Nurses have the opportunity to refine the risk assessment of individuals undergoing surgery by identifying factors that are likely to contribute to the development of an ulcer. Although validated HAPU risk assessment scales are available, the majority of these tools do not focus on pressure-related skin injuries specifically acquired in the OR; however, Munro9 created an assessment tool in 2010 that addresses perioperative-related risk factors. Our review of risk assessment scales in the literature revealed that the Braden Scale is considered to have the highest validity and reliability.11 However, the Braden Scale has limited use for patients undergoing surgery because it does not capture critical risk factors that only occur in the OR.12 Munro’s assessment tool is undergoing an implementation study but has not been validated and was not used for this project.13

DRIVING FORCE FOR CHANGE Recognizing the opportunity for improved prevention of perioperative pressure ulcers, we reviewed retrospective quality data from our facility’s previous fiscal year (2012) to determine the incidence of pressure ulcer development in OR patients. The findings revealed that care providers discovered 11 of 12 HAPUs within 72 hours of the perioperative period. Based on this finding, an interprofessional group that included perioperative and wound ostomy continence nurses, clinical nurse specialists, anesthesia personnel, and members of nursing leadership gathered to investigate how to reduce factors that might contribute to intraoperative-associated pressure ulcers. Our team discussed possible systemic and environmental factors that typically occur during the perioperative period. This meeting launched the development of a quality improvement project with the following primary question: “What factors may contribute toward the development of pressure ulcers in patients that have been to the OR?”

DESCRIPTION OF SETTING We performed a retrospective data collection within our integrated, tertiary health care network located in the southeastern United States. Our system includes four community 272 j AORN Journal

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hospitals in multiple locations with a total of 600 acute care beds. A review of the annual OR statistics for our health care system revealed that personnel performed approximately 25,300 surgical procedures per year and that 2,093 of these procedures lasted longer than three hours.

INTENDED OUTCOMES We agreed that tracking possible contributing factors through retrospective data collection could improve preventive care measures by identifying patients who are at risk for perioperative pressure ulcers. The goal was to reduce the occurrence of pressure ulcers in patients during the perioperative period by 20% compared with the previous year. Including nurses from the perioperative team in this quality improvement process was a priority because these nurses play a pivotal role in the pressure ulcer prevention process in this high-risk setting.14

REVIEW OF RELEVANT EVIDENCE We performed a literature review using the databases CINAHL and PubMed that focused on pressure ulcers specifically occurring in the OR setting. We used the key words pressure ulcer and ORs and targeted studies published in English from January 2009 to December 2013. The search of CINAHL revealed 30 journal articles, and we found 23 articles using the same key words in the PubMed database. The search results included a variety of studies, such as meta-analyses, randomized controlled trials, prospective trials, retrospective studies, and systematic reviews that addressed any subject pertinent to pressure ulcer development in the OR setting. A limited amount of current research is available regarding HAPUs acquired in the OR; of the 23 articles located in PubMed, only 10 were published in the past five years.

The OR Environment and HAPUs The OR creates a high-risk environment for pressure ulcer development related to many intrinsic and extrinsic variables; however, the ultimate cause is pressure.15 Intrinsic risk factors that affect the ability of the skin to respond to pressure and shear forces include
advanced age;
medications (eg, corticosteroids, vasoactive agents);
the presence of comorbid diseases such as o cancer, o cardiovascular and peripheral vascular disease, and o diabetes mellitus;
low hemoglobin and hematocrit levels;
low systemic blood pressure;
low body mass index;

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poor nutritional status;
low albumin levels; and
decreased blood pressure.16 Extrinsic factors relate to physical and environmental factors and can include shear, friction, and moisture.16 Shear is the applied force that can cause an opposite, parallel sliding motion in the planes of an object, such as pulling the dermis in one direction while the bone slides in an opposing manner beneath the skin.17 Friction is a superficial, mechanical force directed against skin that results in increased susceptibility to ulceration, such as when a patient is pulled across a sheet.18 Additional risk factors identified in the search include









length and type of surgery, positioning, anesthetic agents, blood loss, low arterial pressure, shear, moisture, and body temperature.19

A patient’s skin is at increased risk for formation of a pressure ulcer when body weight is not evenly distributed on a support surface or if there is poor tissue perfusion.20 AORN’s positioning guideline suggests that a patient should be repositioned every two hours to prevent continuous pressure on pressure points.10 This recommendation can be difficult to accomplish. Patient positioning during surgical procedures is limited by many factors, such as the surgeon’s preference, the anesthesia professional’s needs, the type of procedure, and the necessary exposure of the surgical site; in some instances, repositioning the patient may not be possible.16 Further research may reveal techniques, supplies, and equipment that can prevent skin damage during surgical procedures, such as pressure mapping surfaces to alert caregivers to decreased tissue tolerance. For example, Allegretti et al21 conducted a study indicating that measuring interface pressure and body temperature using monitoring mats placed under patients is a feasible way to quantify interface pressure and temperature during surgery; however, additional studies are necessary to validate the methodology. Pressure ulcers that begin in the perioperative setting appear to have a more complex etiology related to circulatory and metabolic changes.4 The primary risk factors for development of a pressure ulcer in the perioperative patient are immobility and the inability to perceive pain from unrelieved pressure when under anesthesia, in addition to shearing forces.22

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Pressure Ulcer Development in the OR

Suspected Deep Tissue Injury Tissue breakdown can appear in a variety of ways, and NPUAP classifies it according to stages (Table 1). In 1980, the ECRI Institute noted burn-like injuries that occurred in the OR and were initially attributed to underlying warming blankets. However, upon further investigation, the ECRI Institute determined that these injuries were actually pressure ulcers that developed intraoperatively.23 To describe this unique form of pressure ulcer, which is frequently noted after the perioperative period, NPUAP added suspected deep tissue injury (sDTI) as a new definition in 2007.24 A suspected deep tissue injury (Figure 1) is defined as a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.1(p41) An sDTI may quickly evolve into full-thickness tissue loss despite optimal postoperative treatment; the rapid deterioration is attributed to the combination of direct ischemic damage and reperfusion injury to the microvascular endothelium.25 Many at-risk patients can appear to be free from the signs of a pressure ulcer immediately after surgery, only to develop a pressure ulcer later (eg, one to three days after surgery).26,27 Pressure ulcers also may appear within hours or as long as seven days after a surgical procedure has occurred.28 Armstrong and Bortz26 determined that patients with diabetes are at increased risk for development of intraoperative pressure ulcers because of their compromised baseline circulation. Liu et al29 conducted a meta-analysis indicating that patients with diabetes have a two-fold increased risk of surgery-related development of pressure ulcers, and careful control of intraoperative glucose levels in these patients can be an important preventive measure. AORN guidelines refer to inadvertent perioperative hypothermia as the most frequently preventable complication of surgery.30 Experiencing a 1 F (0.6 C) rise in skin temperature causes a 10% increase in tissue metabolism.31 This evidence suggests that avoiding perioperative hypothermia might decrease the incidence of intraoperative pressure ulcers. In another study, Armstrong and Bortz26 discussed how the use of anesthesia blocks a patient’s sensitivity to pain and pressure, predisposing tissue to damage. In addition, agents used in the administration of anesthesia can depress the autonomic nervous system and this leads to vasodilation, which results in decreased blood pressure and tissue perfusion.

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Table 1. National Pressure Ulcer Advisory Panel Pressure Ulcer Stages/Categories Stage I/Category Nonblanchable erythema

Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Stage II/Category Partial thickness

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.a

Stage III/Category Full-thickness skin loss

Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Bone/tendon is not visible or directly palpable.

Stage IV/Category Full-thickness tissue loss

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. Category/Stage IV ulcers can extend into muscle and/or supporting structures. Exposed bone/muscle is visible or palpable.

Unstageable/Unclassified Full-thickness skin or tissue loss; depth unknown

Full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined but it will be either a Category/Stage III or IV.

Suspected deep tissue injury e depth unknown

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

a

Bruising indicates suspected deep tissue injury. Reprinted with permission from the National Pressure Ulcer Advisory Panel (NPUAP), Washington, DC. http://www.npuap.org/resources/educational -and-clinical-resources/npuap-pressure-ulcer-stagescategories/. Accessed October 29, 2015.

The implementation of the CMS policy of no reimbursement for never events has resulted in the creation of many guidelines for prevention of pressure ulcers.6 Many agencies have created evidence-based guidelines or recommendations for prevention of HAPUs that are specifically targeted toward the perioperative patient population, including the following:
Healthy People 2020 recommends reducing the rate of pressure ulcererelated hospitalizations as a quality of care goal.32
The Institute for Healthcare Improvement identified prevention of pressure ulcers in its evidence-based guidelines for the “5 Million Lives campaign.”33
The Wound, Ostomy and Continence Nurses Society (WOCN) provides guidelines that are frequently referenced when developing HAPU preventive practices and implementing educational programs.34
AORN’s Guidelines for Perioperative Practice10 provide specific guidelines for the prevention of hypothermia and for positioning, pressure redistribution, types of support 274 j AORN Journal

surfaces, and skin assessments for the perioperative population.

METHODS After obtaining approval from the hospital system’s institutional review board, we conducted a retrospective chart review to identify any patient who experienced a HAPU within one week of undergoing a procedure in the OR. We used an audit tool (Table 2) that we developed to guide patient assessments. This tool reflected specific risk factors identified in the literature that contribute to the development of perioperative pressure ulcers. In addition, we used the tool to assess 45 randomly selected surgical patients who did not develop a pressure ulcer during their postoperative stay to serve as control subjects. The study period consisted of eight months of data collection or the enrollment of 20 patients, whichever came first. We included only individuals 18 years of age or older who had

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Table 2. Audit Tool for Perioperative Pressure Ulcers Patient identifier Date pressure ulcer first noted Date patient went to OR Pressure ulcer stage/category Location Type of surgery Albumin, if available Pre-albumin, if available Height Weight

Figure 1. Photograph of a suspected deep tissue injury. Reprinted with permission of the National Pressure Ulcer Advisory Panel, October 29, 2015, all rights reserved.

Type of support surface used on nursing unit Preoperative Braden Scale score Braden Scale score when pressure ulcer noted Comorbidities (enter yes if applicable)

undergone a surgical procedure and met the inclusion criteria. We collected data through a secure network and accessed medical records via online chart reviews; we treated all information collected as protected health information and omitted identifiers to maintain participant confidentiality. After entering these data into PASW Statistics Version 18.0, formerly known as SPSS, a member of the department of statistics verified the data for accuracy. We calculated descriptive statistics for all variables, including mean, standard deviation, range, and frequencies.

Diabetes Hypertension Vascular disease Obesity Malnutrition Incontinence Vasopressors Sepsis Coronary artery disease Congestive heart failure

RESULTS

Hemodialysis

Between January 2013 and September 2013, we identified 15 patients who underwent surgical procedures in our hospital system and developed a pressure ulcer that was identified within one week of a perioperative stay. The information revealed that caregivers discovered 11 of the HAPUs within 72 hours of a procedure performed in the OR. The documentation on most of the patients we identified indicated that they had been transferred to the intensive care unit postoperatively, where they were immediately placed on a low air loss sleep support surface (eg, air mattress or specialty bed for pressure reduction) and turned every two hours. We compared this study group with a randomized control group of 45 patients who underwent OR procedures performed during the same time frame but did not develop a pressure ulcer. The final sample size consisted of 60 patients, reflecting both patients who developed a pressure ulcer (n ¼ 15) and patients who did not develop a pressure ulcer (n ¼ 45). The surgeries that were performed represented a variety of specialties, including cardiac, orthopedic, neurosurgical, abdominal, and urologic procedures.

Cardiac disease

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Device related, other Length of OR time in minutes Blood glucose, intraoperative (highest) Blood glucose, intraoperative (lowest) Type of anesthesia Type of skin prep Oxygen saturation, intraoperative (highest) Oxygen saturation, intraoperative (lowest) Patient temperature, intraoperative (highest) Patient temperature, intraoperative (lowest) Positioning devices used Type of OR support surface (eg, foam, gel) Type of warming measure, if used

The data did not reveal a significantly increased risk of pressure ulcer formation as a result of various types of support surfaces used in the OR (eg, gel or foam mattresses), the AORN Journal j 275

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varieties of skin prep, or the types of warming or positioning devices used. Of the patients who acquired intraoperative pressure ulcers directly after the perioperative period (n ¼ 15), three were female (20%) and 12 were male (80%). We tested the significance of various predictors using binary logistic regression, which is commonly used to model binary response. The Braden Scale score displayed a relative risk of 0.421 (P ¼ .001), indicating that the risk of pressure ulcer occurrence increases 58% with each decreasing unit of this risk assessment scale. Several other significant predictors of pressure ulcers were revealed (Table 3). The risk of pressure ulcers for patients with incontinence is 56 times that of those without incontinence (P ¼ .033). The risk of pressure ulcers for patients with sepsis is 44 times that of those who are not diagnosed as septic (P ¼ .038). The risk of pressure ulcers increases by 48% with each additional hour of time spent in the OR beyond the initial 60 minutes (P ¼ .056), and the risk decreases by 94% with each additional degree of temperature increase (P ¼ .039). Table 4 shows a comprehensive comparison of data collection averages between the study and control groups. Caregivers documented the use of pillows or foam pads for intraoperative patient positioning for 86.2% of the patients who developed pressure ulcers. These were placed to reduce pressure points depending on the patient’s position for the surgery, including under the patient’s knees, heels, arms, and legs. Previous quality improvement projects have discussed the importance of using pillows under the patient’s knees to decrease pressure when in the supine position, using egg crate foam padding of the heels to reduce calcaneal ulcers, and using prone pillows to reduce pressure on the bony prominences.35 We found that care providers placed 73.3% of the patients who had a postoperative HAPU on some type of low air loss sleep surface directly upon transfer to the intensive care unit. An average of 4.67 days passed before the bedside nurses noted the pressure ulcers. The locations of the

pressure ulcers correlated with the patient positions required during the procedures. The most common location was the sacrum; 70% of the patients studied had an ulcer in this location, and other sites included the heels (12%) and chin, sternum, and bilateral trochanters (6%). The sacrum and heel pressure ulcers correlated with supine positioning in the OR, whereas the pressure ulcers on the chin, sternum, and trochanters were the result of patients being in the prone position during surgery. Table 5 compares the presence of comorbid conditions between the study and control groups and shows that many of the patients we reviewed had several comorbid conditions that increased their risk of developing pressure ulcers.

DISCUSSION During our initial interprofessional team meeting, the group hypothesized that the occurrence of pressure ulcers in our system might be related to outdated intraoperative support surfaces. We reviewed the qualities of the various support surfaces in the ORs to determine if they met current NPUAP practice guidelines. The team reviewed the following issues to determine their effects on this group of patients.

Support Surfaces Gel pad overlays or thermo-active foam pads significantly reduce the probability of pressure ulcers compared with some standard OR mattresses.36 Perioperative personnel should minimize use of pads or blankets when positioning patients; rolled sheets or blankets should not be used because they cause additional pressure and decrease the effectiveness of the support surface.16 Monitoring to avoid wrinkles in the linen on the OR bed and identifying and removing any fluid that might be pooling under the patient or other sources of moisture are important preventive measures.37 We tracked patients who sustained HAPUs to determine if the ulcers were related to our specific OR beds; however, the data did

Table 3. Significant Predictors Based on Logistic Regression Model B

SE

Wald

Degree of Freedom

Significance

Exp(B)

Incontinence

4.037

1.894

4.542

1

.033

56.662

Sepsis

3.781

1.827

4.284

1

.038

43.871

OR time in hours

0.392

0.205

3.640

1

.056

1.480

2.782

1.351

4.242

1

.039

0.062

265.815

130.871

4.125

1

.042

2.767  10115

Temperature in Celsius Constant

Constant ¼ the intercept term in the regression model; B ¼ regression coefficients; SE ¼ standard error of the estimate; Wald ¼ Wald test statistic; Exp(B) ¼ relative risk.

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Table 4. Comparison of Data Averages Between Study and Control Groups Indicator

Study Group

98.1 F (36.7 C)

OR time in minutes

355.0

158.2

Braden Scale score

12.9

18.1

Body mass index

29.6

31.8

Percent oxygen saturation

98.0

98.5

Glucose in mg/dL



Control Group

95.7 F (35.4 C)

OR temperature



145.0

110.0

not reveal any significant association between various types of support surfaces used in the perioperative setting.

Assessment The mean preoperative Braden Scale score of 12.9 in our sample is consistent with a score that is determined to be high risk on the Braden Scale. According to this risk assessment tool, in which a low score indicates a lower level of functioning and higher risk for HAPUs, a score of nine or lower indicates severe risk, 10 to 12 indicates high risk, and 13 to 14 indicates moderate risk for development of HAPUs.38 One criteria that determines whether a patient is at risk for a HAPU is a body mass index (BMI) of < 19 or > 40. The patients we reviewed had an average BMI of 29.6. The patient’s BMI is important for nurses to consider when choosing perioperative positioning and padding. Most positioning aids provide adequate pressure reduction for thin patients but may not provide adequate protection for the bariatric population.39

Time in the OR The average time spent in the OR of 365 minutes for the sample set that experienced pressure ulcers is consistent with

Table 5. Comparison of Comorbid Conditions Between Study and Control Groups Study Group (n ¼ 15) Comorbidity

n

Percent

Percent

Dialysis

4

26.0

6

13.3

Diabetes

6

40.0

17

37.7

Incontinence

6

40.0

6

13.3

Sepsis

8

53.3

7

15.5

12

80.0

37

82.2

Cardiac disease

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Temperature Our review showed that development of a pressure ulcer is also related to the patient’s temperature during the perioperative period. We found an average temperature of 95.7 F (35.4 C) in patients with HAPUs in our sample population. This finding is in agreement with previous studies showing that perioperative hypothermia is significantly correlated with development of intraoperative pressure ulcers.41 Fred et al4 conducted a study that revealed a 1 F (0.6 C) decrease in temperature increased the odds of pressure ulcer development by 20.2%.

IMPLEMENTATION After reviewing the evidence, personnel at our facility created a sacral dressing protocol to reduce the occurrence of HAPUs (Figure 2). The protocol guides nursing personnel in the application of a soft silicone foam dressing to patients during the preoperative period if they meet the high-risk criteria for development of a pressure ulcer. Best practices for correct assessment and documentation are also provided in the protocol. We demonstrated the product and protocol at our system-wide shared governance committee meeting before its implementation to allow nurses to ask questions and disseminate the information to their various units. We provided intensive in-service education on the nursing units regarding use of the new product. We optimized facilitation of the change by creating a link in our computer charting system to simplify the documentation process for staff nurses.

LESSONS LEARNED

Control Group (n ¼ 45) n

findings from multiple previous studies.40 The prevalence rate of pressure ulcers is reported to be 8.5% or higher among patients who undergo surgical procedures that last longer than three hours.20 The duration of the surgical procedure is a significant contributor to the risk of tissue damage. As the length of surgery increases, the percentage of patients with pressure ulcers also rises.22

Perioperative nurses should understand their role in skin protection and the effect they can have on patient outcomes. Nurses should perform skin assessments to establish a preoperative baseline against which to compare the patient’s postoperative status. This should include details of the patient’s skin and whether the patient is at high risk for development of a pressure ulcer. Hand-over reporting should include the patient’s intraoperative risk factors (eg, extended length of surgery, an occurrence during the perioperative period that could contribute to potential development of a pressure ulcer).42 AORN Journal j 277

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Figure 2. Cone Health sacral dressing protocol. Reprinted with permission of Cone Health, Greensboro, NC. Assessing the effectiveness of OR support surfaces or upgrading to evidence-based pressure-reducing surfaces is an important step toward prevention of intraoperative pressure ulcers. Personnel at some hospitals have implemented preventive measures that include sacral dressings applied preoperatively to patients who are at high risk for skin breakdown or who are scheduled for procedures expected to last longer than four hours.43 A consensus panel of experts on prevention of pressure ulcers recommended use of a silicone foam dressing for high-risk patients in the OR.44 278 j AORN Journal

There is currently no validated, recognized risk assessment scale for the preoperative patient.45 Recognizing the need for a risk assessment scale specific for the perioperative patient, AORN has partnered with Munro to create a task force to validate her assessment tool.9,13 The results of our review confirm that a relationship exists between several risk factors and the development of intraoperative pressure ulcers. The findings of our review require further exploration at other hospital locations with larger sample sizes to be considered generalizable to the entire OR population. Similar studies

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and quality improvement projects in different OR settings would be informative because facilities have a variety of support surfaces, risk assessment procedures, and hand-over communication styles.

LIMITATIONS Conducting a retrospective chart review was a limitation of this project because this type of review does not provide the same strength of data as a prospective or randomized clinical trial. All the patients in our review were enrolled after the occurrence of a pressure ulcer was noted, and the data could only be reviewed at a later time. A further limitation of the data collected during this project and our conclusions is the complex relationship of risk factors that can contribute to the development of intraoperative pressure ulcers. For example, many patients undergo the same surgical procedures for similar amounts of time but relatively few patients develop a pressure ulcer. It is difficult to isolate specific variables that might not have a confounding relationship with other systemic factors. Focusing on the population of a specific type of surgery or controlling the type of pressure-reducing surface, patient positioning, and padding might provide a better understanding of the occurrence of intraoperative pressure ulcers.

CONCLUSION All surgical patients are at risk for the development of pressure ulcers as a result of a complex combination of systemic and environmental factors. Early identification of risk factors is the first step toward implementing a preventive care bundle that could help decrease the occurrence of HAPUs. We will review the results and outcomes of our new care process in the upcoming year to determine if the occurrence of perioperative HAPUs decreases in our health care system. Nurses across the continuum of patient care need to develop an improved communication system during hand-over reports to positively affect patient care. Ongoing educational efforts regarding pressure ulcer staging and appearance and appropriate padding, positioning, and documentation of assessment and care should be a multidisciplinary process and are critical components to include in an intraoperative pressure ulcer prevention plan.




Editor’s notes: CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. PubMed is a registered trademark of the US National Library of Medicine, Bethesda, MD. The Wound, Ostomy and Continence Nurses Society is a trademark and WOCN is a registered trademark of the Wound, Ostomy and Continence Nurses Society, Mt Laurel, NJ. PASW Statistics Version 18.0, formerly SPSS, is a registered trademark of SPSS, Inc, Chicago, IL.

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March 2016, Vol. 103, No. 3 36. Mackey D. Support surfaces: beds, mattresses, overlays-oh my! Nurs Clin North Am. 2005;40(2):251-265. 37. Tschannen D, Bates O, Talsma A, Guo Y. Patient-specific and surgical characteristics in the development of pressure ulcers. Am J Crit Care. 2012;21(2):116-125. 38. Braden BB. Braden Scale for predicting pressure ulcer risk. 1988. http://www.bradenscale.com/images/bradenscale.pdf. Accessed November 15, 2015. 39. Cherry C, Moss J. Best practices for preventing hospital-acquired pressure ulcer injuries in surgical patients. Can Oper Room Nurs J. 2011;29(1):6-26. 40. Chen H, Chen X, Wu J. The incidence of pressure ulcers in surgical patients of the last 5 years: a systemic review. Wounds. 2012;24(9):234-241. 41. Scott EM, Buckland R. A systematic review of intraoperative warming to prevent postoperative complications. AORN J. 2006; 83(5):1090-1104, 1107-1113. 42. Black J, Fawcett D, Scott S. Ten top tips: preventing pressure ulcers in the surgical patient. Wounds Int J. 2014; 5(4):14-18. 43. Brindle CT, Wegelin J. Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients. J Wound Ostomy Continence Nurs. 2012;39(2):133-142. 44. Black J, Clark M, Dealey C, et al. Dressings as an adjunct to pressure ulcer prevention: consensus panel recommendations. Int Wound J. 2015;12(4):484-488. 45. Mathias JM. Use of refined protocols reduces pressure ulcer rates. OR Manager. 2013;29(12):1-4.

Dawn Engels, MSN, RN, CNS, CWOCN, CWCN-AP, is a clinical nurse specialist and wound ostomy continence nurse at Cone Health, Greensboro, NC. Ms Engels has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Melody Austin, BSN, RN, CWOCN, is a wound ostomy continence nurse at Cone Health, Greensboro, NC. Ms Austin has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Laurie McNichol, MSN, RN, CNS, GNP, CWOCN, CWON-AP, is a clinical nurse specialist and wound ostomy continence nurse at Cone Health, Greensboro, NC. Ms McNichol has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Jennifer Fencl, DNP, RN, CNS-BC, CNOR, is a clinical nurse specialist in Operative Service at Cone Health, Greensboro, NC. Dr Fencl has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

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March 2016, Vol. 103, No. 3

Pressure Ulcer Development in the OR

Sat Gupta, PhD, is a professor of statistics and

Haseeb Kazi, MD, is an assistant professor in the

the associate head of the Department of Mathematics and Statistics at the University of North Carolina, Greensboro, NC. Dr Gupta has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Division of Hospital Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX. Dr Kazi has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

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