Running head: QUALITY IMPROVEMENT PREVENTION OF PRESSURE ULCERS IN 1

Quality Improvement Prevention of Pressure Ulcers in the Operating Room

Charito Ward

Bon Secours Memorial College of Nursing

Quality and Safety in Nursing Practice II

NUR 3207

Ms. Connie Garrett

November 27, 2016

I Pledge.

Quality Improvement Prevention of Pressure Ulcers in the Operating Room

The nursing practice issue in the Operating Room (OR) that I feel needs to be addressed

and or given additional attention is pressure ulcer development in the surgical suite. It is

especially important for nurses to be patient advocates during surgery by preforming a proper

skin assessment, as well as padding body prominences of the body for their procedure. Pressure

ulcers have always been a concern with articles dating back to the 1990s.
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More recently hospital acquired pressure ulcers have become more of a concern due to

Medicare/Medicaid not giving reimbursement for issues that are hospital acquired such as

pressure ulcers and infections as examples. In the Untied States, approximately 1.6 billion

patients develop health care-associated pressure ulcers at an annual cost of $2.2 billion to #3.6

billion. Twenty-three percent are acquired intra-operatively during surgeries that last longer than

three hours (Primiano et al., 2011, p. 3). With a large percentage of pressure ulcers acquired in

the operating room, it is an issue that needs to be addressed; interventions can save facilities

money, decrease health case cost across the country, as well as eliminating other risks for patients

undergoing surgery.

Prevention of pressure ulcers need diligent practice in the OR due to surgical positioning,

duration of surgical procedures, positioning devices and anesthesia technique, these all play a

role in development of pressure ulcers. Typically, patients are asleep for surgery and covered

completely by necessary surgical drapes to prevent infection. However, having the patient

positioned and draped in surgery makes them at risk for developing pressure ulcers due to no

movement, pressure on bony prominences, patient core temperate running lower than normal,

and low blood perfusion to the extremities, nurses cannot see how the patient is underneath the

drapes. During surgery patients are usually asleep, paralyzed or relaxed and cannot speak up for

themselves or move into a more comfortable position.

Pressure ulcer development in the operating room can be difficult to track. Signs of ulcer

development sometimes may seen as early as a few hours after surgery, but more commonly a

pressure ulcer develops three days post-operatively; this most likely indicates the ulcer occurred

during surgery, these are caused by intense or prolonged pressure that is unrelieved for a long

period of time, resulting in skin and underlying tissue damage (Primiano et al., 2011, p. 3).
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Background Information

Pressure ulcers are not limited to the operating room, they occur in assisted living

facilities, on nursing floors in the hospital, and even at the patients own home. There are certain

risk factors that make people more susceptible to developing pressure ulcers. Patients at risk for

developing pressure ulcers are typically malnourished, extremely young such as a neonate, or

elderly, morbidly obese, patients who have chronic diseases, paralyzed or immobile. Pressure

ulcers effect nursing practice because they negatively impact patient outcomes by increasing the

risk of hospital acquired infections and exposing patients to more invasive treatment and

procedures for the pressure ulcer. Additional care needs to be given to the patient by staff in

treating the pressure ulcer causing nursing staff to fall behind in other patients care and possible

medication administration. Pressure ulcers developed in a hospital may cause the healthcare

facility to incur financial and legal ramifications for these injuries (Shoemake & Stoessel, no

date, p. 1).

Pressure ulcers may impact hospital organizations by increasing hospital stays for

patients from days to weeks or months, and almost doubles the cost of patient care with minimal

or no reimbursement for treatment. Unfortunately, the average reimbursement rate per patient

from insurance and Medicare/Medicaid was less than $1,600 causing hospitals to lose more than

$10,000 per pressure ulcer incident (Shoemake & Stoessel, no date, p. 2). Pressure ulcers cause

more health complications in patients who may be more susceptible to other complications such

as pneumonia, osteomyelitis, and sepsis and in some cases cause death.

Patient outcomes become affected negatively outside of the patients health, effects could

be seen financially due to not being able to return to work in a timely manner; this can cause

emotional distress for the patient worrying about providing for their family. Emotional distress
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could be formed from feeling have a deformity directly caused from the pressure ulcer even after

it is healed. Family members of the patient also feel the negative effects of a pressure ulcer on a

financial and emotionally basis as well.

Implementation of QI project

There should be one perioperative skin champion/team member/liaison with clear roles,

expectations, and dedicated time to serve in that role should be designated from the perioperative

nursing staff (Minnesota Hospital Association, 2013, p. 1). The skin champion/liaison would be

the point of contact for education, questions, concerns, and training. The skin champion/liaison

will also implement a standard skin assessment form for all OR nurses to follow for each patient.

The first thing I would like to do for implementation is education to the staff on the

importance of padding and positioning to prevent pressure ulcers. An in-service would be the

method of education. If the staff understands the etiology of how a pressure ulcer begins they can

prevent them from occurring all together. Fact sheets stating hospital cost and patient stay times

would be used to back the purpose of education and what it means to them as health care

workers. The AORN suggests that education on prevention of pressure ulcers should be done

annually.

In line with the education portion, stressing the importance of the OR Nurse preforming a

through head-to-toe skin assessment would be addressed. A paper with a template of a body front

and back will be on a sheet as well as a key for different stages of pressure ulcers. Nurses will

circle the part of the body on the diagram where they may notice an area of concern, and what

stage the pressure ulcer or lesion the wound may be. A head-to-toe assessment right before going

to the OR will alert staff to areas of each patients body need more attention to reduce or

eliminate risk of pressure ulcers.

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Proper positioning equipment and necessary padding for positioning will be easily and

readily available for each surgical procedure. Egg-crate, soft roll, gel pads, axillary rolls, and

pillows will be easy to locate and use for patient use. Extra attention will be made in eliminating

wrinkles in the sheets on the surgical bed. According to the Association of perioperative

Registered Nurses (AORN) the OR surfaces should be evaluated prior to each use and use

pressure redistribution surfaces for surgeries lasting longer than two-and-a-half hours (Fleck,

2011, p. 48).

Although surgical time is not an easily modifiable factor, when surgical cases run longer

than two hours patients are at higher risk of developing pressure ulcers. Nurses should pay

additional attention to bony prominences and readjusting body parts that do not interfere with the

surgical procedure such as anesthesia turning patients head from side to side or repositioning

arms and legs on the surgical bed. Repositioning should be a team effort, communicating with

the surgeon on the importance to adjusting devices, extremities, and head can be crucial to the

patients skin, recovery time, and overall outcome. Other actions that alleviate pressure ulcers

that are in the nurses control would be to ensure the patients stay dry and warm, during surgery.

Professional Practice Implications

Implications for nurses in preventing pressure ulcers according to the AORN would be

implementing risk and skin assessments for each patient a standardized risk assessment allows

for the identification of persons susceptible to the development of a pressure ulcer during a

surgical procedure. The risk assessment and skin assessment allows the perioperative team to

plan interventions to prevent pressure ulcers from occurring (AORN, 2016, para. 6).

Patient education on their risk of developing pressure ulcers can increase patient

participation in obtaining information necessary to provide feedback for quality improvement on

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actions taken. Protocol requires each unit to do a follow-up for each department that was

involved in the patients care during their stay, a two-minute questionnaire is part of the follow up

questions regarding the patients skin condition should be evaluated then for information. A

check-off sheet should be placed in the patients chart for tracking to serve as a means to follow

up with the patient and as a reminder to the perioperative nurse on actions took to pad bony

prominences, keep the patient dry and warm, as well as necessary repositioning. The patient

follow-ups should be evaluated monthly and compared over the next several years to indicate the

goal to prevent pressure ulcers are met. Currently my facility has not implemented any way of

monitoring pressure ulcers in the OR. The suggested table for monitoring pressure ulcers should

look something like this:

Month Patient reports of 2017 2018 2019 Intervention Education

skin abnormality s done given

January

February

March

April

May

June

July

August

September

October
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November

December

The follow-ups will have information the patient was asked including any blanching or

openings of skin, the year, what interventions were done intraoperatively and was education

given that year on proper prevention of ulcers.

Outcome Improvement

With perioperative nurses and a collaborative team effort in the operating room to prevent

pressure ulcers patient follow-ups will show improvement with intraoperative pressure ulcer

development. If all units in the hospital are mandated to do a follow up pressure ulcer skin

assessment this should eliminate most development of patients getting hospital acquired pressure

ulcers. Educating the patients on what to look for or signs of pressure ulcers also give them

knowledge to notice what is not normal and report it as soon as possible. Eliminating pressure

ulcers in the surgical suite will save the facility money and prevent additional complications to

each patient.

Although it may take additional time for perioperative nurses to preform a risk and skin

assessment prior to bringing patients back for surgery, it is worth having to wait an extra 10-15

minutes than for the patient to stay an extra three to four weeks in unplanned hospital stays.

Properly assessing, padding, positioning and repositioning patients in the OR in the long run the

United States, preoperatively acquired pressure ulcers cost $750 million to $1.5 billion per year

on average (Shoemake & Stoessel, no date, p. 2). Each patient is different, detailing

interventions individually depending on risk and predisposition not only allows for a patient to
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have a positive experience despite having surgery, it will allow for them to return to their homes,

normal lives and families much sooner.

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References

AORN. (2016, November 1). AORN Position statement on perioperative pressure ulcer

prevention in the care of the surgical patient. AORN Journal, 104, 437-438.

http://dx.doi.org/10.1016/j.aorn.2016.08.011

Fleck, C. A. (2011). Healthy skin magazine [Supplemental material Magazine]. Theyre lurking

in... The Operating Room and Beyond!, 9(2), 47-50. Retrieved from

https://www.scribd.com/document/57234801/Healthy-Skin-Magazine-Volume-9-Issue-2

Minnesota Hospital Association. (2013). Pressure ulcer prevention in the O.R. recommendations

and guidance. Retrieved from Minnesota Hospital Association Patient Safety a Call to

Action: https://www.mnhospitals.org/Portals/0/Documents/ptsafety/skin/OR-pressure-

ulcer-recommendations.pdf

Primiano, M., Friend, M., McClure, C., Nardi, S., Fix, L., Schafer, M., & Savochka, K. (2011).

Pressure ulcer prevalence and risk factors among prolonged surgical procedures in the

OR (AORN Journal 94-6). Retrieved from AORN Journal:

http://www.aornjournal.org/article/S0001-2092(11)00972-0/pdf

Shoemake, S., & Stoessel, K. (no date). Pressure ulcers in the surgical patient [Supplemental

material Journal]. Kimberly-Clark The Clinical Issue, 1-10. Retrieved from

http://es.halyardhealth.com/media/1513/h0277-0701_ci_pressure_ulcer.pdf