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Best Practices Can Prevent Pressure Ulcers in Perioperative Setting

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For more than 20 years, Susan Scott, MSN, RN, WOCN, patient safety educator at the University of Tennessee Health Science Center in Memphis, has conducted extensive research examining the incidence of pressure ulcers in surgical patients and how they can be prevented.

Now, Scott is working to teach other nurses her findings in the hopes of decreasing the incidence of hospital-acquired pressure ulcers directly related to time spent in the operating room.

?Pressure ulcers, damages to the skin or underlying tissue caused by unrelieved pressure, are painful and potentially life-threatening injuries that increase risk of infection and other complications,? Scott said.

?It?s much easier to work on preventing the development of pressure ulcers than to treat them after the fact.?

Scott?s research found that certain patient populations are at an increased risk of developing pressure ulcers during surgery. Rather than having her research languish on a shelf, Scott wanted to incorporate her findings into the nursing practice. She developed the Perioperative Pressure Ulcer Prevention Program (PPUPP), aimed at drastically reducing the incidence of pressure ulcers in surgical patients through aggressive prevention methods.

In the past, Scott offered the onsite workshops detailing PPUPP strategies, and is now designing an online curriculum.

Despite Scott?s research, and the work of others, preventing pressure ulcers in surgical patients is still an evolving field.

?We?ve seen pockets of excellence emerge across the country ? both the Minnesota Hospital Association and the Ascension Health Network have embraced best practice recommendations for preventing pressure ulcers in the operating room,? Scott said.

?We know that hospitals who emphasize that pressure ulcer prevention is everyone?s job, and who train staff on how to assess and perform pressure ulcer skin inspections, are successful at positively impacting patient outcomes.?

Scott developed a surgical risk assessment tool for pressure ulcers called ?Scott Triggers? that serve as predictors for those at highest risk of developing pressure ulcers. While all patients can be at risk for pressure ulcers because of length of surgeries, and the effects of anesthesia, along with the use of vasoactive medications that affect blood pressure and heart rate during surgery, Scott said some patients have an increased risk.

These include patients who are ages 62 or older, have an albumin (blood serum) level below 3.5, and an ASA score of 3 or greater (the grading system developed by the American Society of Anesthesiologists that assesses the degree of a patient?s health prior to surgery), and who undergo a surgical procedure that takes longer than two to three hours.

Scott said it?s critical for training in pressure ulcer prevention to extend beyond traditional wound care nurses, and to address the unique challenges faced by perioperative nurses including prolonged patient immobility, and patient transfer processes that prevent shearing of a patient?s skin.

?Many OR nurses report they have never witnessed a pressure injury in their patients, but a pressure ulcer can take 24-48 hours to appear,? Scott said. ?Pre-operative nurses need to be trained to recognize the risk factors and mechanisms contributing to pressure ulcer formation and to identify them accurately if they do occur.?

Scott said PPUPP covers staff education and awareness of pressure ulcers and teaches skin and risk assessment, equipment selection, best positioning for patients and best care plans based on research. Nurses also are taught strategies for repositioning patients every two hours during lengthy procedures, and to reposition devices such as face masks and nasal/oral tubes when possible. If repositioning isn?t possible, solutions such as gel pads with a foam base custom fit for an operating room table, have been shown to reduce the rate of acquired pressure ulcers.

At Mercy Medical Center in Baltimore, Lisa Owens, MSN, RN, CWOCN, program manager of the WOC department, said nurses who work in Mercy?s perioperative setting are keyed in to perform thorough skin inspections prior to surgery, and how to prevent device-related pressure ulcers.

?Pre- and post-operative skin assessments, as well as thoughtful positioning and preventive measures in the OR are the foundation to keeping skin safe,? Owens said. ?Effective prevention interventions such as gel-padded OR tables, protective pads and sleeves are also used to reduce device-related pressure ulcers.?

While the treatment for pressure ulcers has remained the same, Scott said the tools used to prevent pressure ulcers have changed. She points to evidence illustrating how changes such as using a multilayered pad for a patient in the OR can make a big difference.

?In a study involving over 323 patients over a four-year period, 38% of patients who had the standard pad during surgery developed sores, but only 7% of patients who had a pressure-relieving pad developed pressure ulcers,? Scott said. ?A pressure-redistributing pad should be used on the operating table for all patients identified as being at risk for pressure ulcer development, since the standard 2? elastic foam pad with a laminate cover is an increased risk factor for pressure ulcer development.?

At Mercy, Owens said, the hospital?s electronic medical record is customized to capture thorough and detailed assessments.