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Use of an OR skin bundle to prevent pressure injury
PERIOP BRIEFING
IN FOCUS
Use of an OR skin bundle to prevent pressure injury Susan M. Scott, MSN, BSN, RN, WOC Nurse
P
ressure injuries (PIs) can occur in any surgical patient, during any procedure, and in any surgical position.1-3 Damage may not be immediately visible postoperatively, but it can quickly evolve to include deep red or purple discoloration, blistering, and necrosis, resulting in full-thickness wounds.1-3 Lack of communication about incidence combined with the unique presentation of PIs can affect staff member awareness about the actual incidence of PIs.2,4 AORN recommends that risk and skin assessments be performed in all patients and communicated in all hand overs.5 In addition, perioperative RNs must anticipate, obtain, and verify appropriate positioning and pressure redistribution equipment before every procedure.6,7
Risk and the OR skin bundle For preoperative PI risk assessment, nurses should use the Braden Scale combined with other surgeryspecific tools, such as the Scott Triggers tool.2,6,8 After determining risk, the nurse should implement an OR skin bundle, which is a set of evidence-based interventions used to define standard care.4 The bundle may include • assessing skin preoperatively and immediately postoperatively; • safe patient handling; • standardizing high-specification OR bed pads;9 • redistributing pressure or padding bony prominences; • offloading pressure on heels while maintaining knees in slight flexion; • considering prophylactic dressings for bony prominences or under medical devices; • avoiding use of unapproved positioning devices; • maintaining normothermia and microclimate (excessive perspiration, moisture, or heat at the skin level that can lead to maceration and weaken the epidermis); • using hand-over communication; http://dx.doi.org/10.1016/S0001-2092(17)30847-5
P18 | Periop Briefing
• instituting early movement, daily skin assessment, and pressure management; and • reporting PIs that develop within 72 hours after the procedure. Skin assessment should include a head-to-toe, front-and-back visual inspection and palpation of bony prominences that may contact surface or devices.6,10 Documenting skin integrity preoperatively will establish a baseline for comparison postoperatively, and is necessary to evaluate effectiveness of prevention practices. Patients can have six or more lateral transfers per procedure, increasing tissue shear and friction risk; therefore, safe patient handling practices should be used. AORN recommends that patients weighing more than 157 pounds be moved with assistive devices,11 and Baptiste et al12 found that air-assisted lateral transfer devices were more effective and safer than traditional devices. Typical OR bed pads are 2-inch elastic foam covered with conductive laminated vinyl, which may contribute to PI development.2 Standardizing these pads to a high-specification reactive foam surface that accommodates the patient population weight limits can reduce PIs.2,4,6,9 Nurses should understand the difference between weight capacity of the table (which can be found in the manufacturer’s instructions for use) and the therapeutic weight limit of the OR surface to ensure effectiveness.6 To reduce extremes of pressure, shear, and friction, strategies such as offloading, pressure redistribution padding, and prophylactic dressings can be used.2,4,6,10 When possible, heels should be offloaded using devices that elevate the heel and distribute leg weight.2,4,6 It should be noted that prophylactic dressings are not a substitute for these other strategies.6,10 Items commonly used for positioning, such as IV bags, towels, and rolled sheets, can cause
harm during long procedures; therefore, their use should be avoided.6 Fred et al13 found that a 1° F (1.8° C) body temperature decrease was linked to a higher risk of PIs, and Yoshimura et al14 indicated that excessive perspiration and body temperature greater than 100.6° F (38.1° C) were risk factors in the parkbench position. Sheets or drapes that wick moisture away from the skin may help manage microclimate. Hand-over communication should include PI risk factors, abnormal skin assessment results, and an action list. Early movement or progressive mobility, as identified in the UP Campaign, helps to improve outcomes.15 Skin assessments should occur at least daily, tracking all PIs within 72 hours and providing real-time reporting for follow-up and analysis.
Conclusion Mitigating risk using such tools as the OR skin bundle can help prevent PIs. Evidence-based practices, appropriate equipment, and technology can be integrated into routines to create a sustainable program promoting patient safety.16 Editor’s note: Scott Triggers is a registered trademark of Susan Scott Williams, Memphis, TN. References 1. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury [news release]. Washington, DC: NPUAP; April 13, 2016. http://www.npuap.org/ national-pressure-ulcer-advisory-panel-npuapannounces-a-change-in-terminology-frompressure-ulcer-to-pressure-injury-and-updatesthe-stages-of-pressure-injury/. Accessed August 29, 2017. 2. Scott SM. Progress and challenges in perioperative pressure ulcer prevention. J Wound Ostomy Continence Nurs. 2015;42(5):480-485. 3. Preston A, Rao A, Strauss R, Stamm R, Zalman D. Deep tissue pressure injury: a clinical review. Am J Nurs. 2017;117(5):50-57. 4. Scott SM. Perioperative pressure injuries: protocols and evidence-based programs for reducing risk. PSQH. 2016;13(4):20-28.
© AORN, Inc, 2017
5. AORN position statement on perioperative pressure ulcer prevention in the care of the surgical patient. AORN J. 2016;104(5):437-438. 6. Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017:691-710. 7. Pressure ulcer prevention in the O.R. Minnesota Hospital Association. http://www.mnhospitals. org/Portals/0/Documents/ptsafety/skin/ORpressure-ulcer-recommendations.pdf. Published March 2013. Accessed August 29, 2017. 8. Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Nurs Res. 1998;47(5):261-269. 9. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines. Perth, Australia: Cambridge Media; 2014. 10. Stechmiller JK, Cowan LJ, Oomens CW. Bottom-up (pressure shear) injuries. In: Doughty DB, McNichols LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:313-332. 11. Safe Patient Handling Tool Kit. AORN. https:// www.aorn.org/guidelines/clinical-resources/ tool-kits/safe-patient-handling-tool-kit. Accessed August 29, 2017. 12. Baptiste A, Boda SV, Nelson AL, Lloyd JD, Lee WE III. Friction-reducing devices for lateral patient transfers. AAOHN J. 2006;54(4):173-180. 13. Fred C, Ford S, Wagner D, VanBrackle L. Intraoperatively acquired pressure ulcers and perioperative normothermia: a look at relationships. AORN J. 2012;96(3):251-260. 14. Yoshimura M, Nakagami G, Iizaka S, et al. Microclimate is an independent risk factor for the development of intraoperatively acquired pressure ulcers in the park-bench position. Wound Repair Regen. 2015;23(6):939-947. 15. The Up Campaign: Brief. Health Research & Educational Trust. http://www.hret-hiin.org/ Resources/up_campaign/17/up_campaign_brief. pdf. Accessed August 29, 2017. 16. Scott SM. Creating a strategic plan for perioperative pressure ulcer prevention. AORN J. 2016;103(4):P13-P14.
October 2017 Vol 106 No 4 • Periop Briefing | P19
PERIOP BRIEFING
PRESSURE INJURY PREVENTION
IN FOCUS
Use of an OR skin bundle to prevent pressure injury Susan M. Scott, MSN, BSN, RN, WOC Nurse
P
ressure injuries (PIs) can occur in any surgical patient, during any procedure, and in any surgical position.1-3 Damage may not be immediately visible postoperatively, but it can quickly evolve to include deep red or purple discoloration, blistering, and necrosis, resulting in full-thickness wounds.1-3 Lack of communication about incidence combined with the unique presentation of PIs can affect staff member awareness about the actual incidence of PIs.2,4 AORN recommends that risk and skin assessments be performed in all patients and communicated in all hand overs.5 In addition, perioperative RNs must anticipate, obtain, and verify appropriate positioning and pressure redistribution equipment before every procedure.6,7
Risk and the OR skin bundle For preoperative PI risk assessment, nurses should use the Braden Scale combined with other surgeryspecific tools, such as the Scott Triggers tool.2,6,8 After determining risk, the nurse should implement an OR skin bundle, which is a set of evidence-based interventions used to define standard care.4 The bundle may include • assessing skin preoperatively and immediately postoperatively; • safe patient handling; • standardizing high-specification OR bed pads;9 • redistributing pressure or padding bony prominences; • offloading pressure on heels while maintaining knees in slight flexion; • considering prophylactic dressings for bony prominences or under medical devices; • avoiding use of unapproved positioning devices; • maintaining normothermia and microclimate (excessive perspiration, moisture, or heat at the skin level that can lead to maceration and weaken the epidermis); • using hand-over communication; http://dx.doi.org/10.1016/S0001-2092(17)30847-5
P18 | Periop Briefing
• instituting early movement, daily skin assessment, and pressure management; and • reporting PIs that develop within 72 hours after the procedure. Skin assessment should include a head-to-toe, front-and-back visual inspection and palpation of bony prominences that may contact surface or devices.6,10 Documenting skin integrity preoperatively will establish a baseline for comparison postoperatively, and is necessary to evaluate effectiveness of prevention practices. Patients can have six or more lateral transfers per procedure, increasing tissue shear and friction risk; therefore, safe patient handling practices should be used. AORN recommends that patients weighing more than 157 pounds be moved with assistive devices,11 and Baptiste et al12 found that air-assisted lateral transfer devices were more effective and safer than traditional devices. Typical OR bed pads are 2-inch elastic foam covered with conductive laminated vinyl, which may contribute to PI development.2 Standardizing these pads to a high-specification reactive foam surface that accommodates the patient population weight limits can reduce PIs.2,4,6,9 Nurses should understand the difference between weight capacity of the table (which can be found in the manufacturer’s instructions for use) and the therapeutic weight limit of the OR surface to ensure effectiveness.6 To reduce extremes of pressure, shear, and friction, strategies such as offloading, pressure redistribution padding, and prophylactic dressings can be used.2,4,6,10 When possible, heels should be offloaded using devices that elevate the heel and distribute leg weight.2,4,6 It should be noted that prophylactic dressings are not a substitute for these other strategies.6,10 Items commonly used for positioning, such as IV bags, towels, and rolled sheets, can cause
harm during long procedures; therefore, their use should be avoided.6 Fred et al13 found that a 1° F (1.8° C) body temperature decrease was linked to a higher risk of PIs, and Yoshimura et al14 indicated that excessive perspiration and body temperature greater than 100.6° F (38.1° C) were risk factors in the parkbench position. Sheets or drapes that wick moisture away from the skin may help manage microclimate. Hand-over communication should include PI risk factors, abnormal skin assessment results, and an action list. Early movement or progressive mobility, as identified in the UP Campaign, helps to improve outcomes.15 Skin assessments should occur at least daily, tracking all PIs within 72 hours and providing real-time reporting for follow-up and analysis.
Conclusion Mitigating risk using such tools as the OR skin bundle can help prevent PIs. Evidence-based practices, appropriate equipment, and technology can be integrated into routines to create a sustainable program promoting patient safety.16 Editor’s note: Scott Triggers is a registered trademark of Susan Scott Williams, Memphis, TN. References 1. National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury [news release]. Washington, DC: NPUAP; April 13, 2016. http://www.npuap.org/ national-pressure-ulcer-advisory-panel-npuapannounces-a-change-in-terminology-frompressure-ulcer-to-pressure-injury-and-updatesthe-stages-of-pressure-injury/. Accessed August 29, 2017. 2. Scott SM. Progress and challenges in perioperative pressure ulcer prevention. J Wound Ostomy Continence Nurs. 2015;42(5):480-485. 3. Preston A, Rao A, Strauss R, Stamm R, Zalman D. Deep tissue pressure injury: a clinical review. Am J Nurs. 2017;117(5):50-57. 4. Scott SM. Perioperative pressure injuries: protocols and evidence-based programs for reducing risk. PSQH. 2016;13(4):20-28.
© AORN, Inc, 2017
5. AORN position statement on perioperative pressure ulcer prevention in the care of the surgical patient. AORN J. 2016;104(5):437-438. 6. Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017:691-710. 7. Pressure ulcer prevention in the O.R. Minnesota Hospital Association. http://www.mnhospitals. org/Portals/0/Documents/ptsafety/skin/ORpressure-ulcer-recommendations.pdf. Published March 2013. Accessed August 29, 2017. 8. Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Nurs Res. 1998;47(5):261-269. 9. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines. Perth, Australia: Cambridge Media; 2014. 10. Stechmiller JK, Cowan LJ, Oomens CW. Bottom-up (pressure shear) injuries. In: Doughty DB, McNichols LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:313-332. 11. Safe Patient Handling Tool Kit. AORN. https:// www.aorn.org/guidelines/clinical-resources/ tool-kits/safe-patient-handling-tool-kit. Accessed August 29, 2017. 12. Baptiste A, Boda SV, Nelson AL, Lloyd JD, Lee WE III. Friction-reducing devices for lateral patient transfers. AAOHN J. 2006;54(4):173-180. 13. Fred C, Ford S, Wagner D, VanBrackle L. Intraoperatively acquired pressure ulcers and perioperative normothermia: a look at relationships. AORN J. 2012;96(3):251-260. 14. Yoshimura M, Nakagami G, Iizaka S, et al. Microclimate is an independent risk factor for the development of intraoperatively acquired pressure ulcers in the park-bench position. Wound Repair Regen. 2015;23(6):939-947. 15. The Up Campaign: Brief. Health Research & Educational Trust. http://www.hret-hiin.org/ Resources/up_campaign/17/up_campaign_brief. pdf. Accessed August 29, 2017. 16. Scott SM. Creating a strategic plan for perioperative pressure ulcer prevention. AORN J. 2016;103(4):P13-P14.
October 2017 Vol 106 No 4 • Periop Briefing | P19
PERIOP BRIEFING
PRESSURE INJURY PREVENTION