INTRODUCTION
Millions of Americans undergo surgical procedures each year, and the rate of surgical procedures is increasing annually, with 7.3 million inpatient invasive surgical procedures performed in 2014.1 Commonly reported complications for all types of surgery include adverse reactions to anesthesia such as respiratory issues, rash, low blood pressure, confusion, and agitation. Other prevalent complications are surgical site wound infections, urinary tract infections, and blood clots.2 Readmissions, returns to the operating room (OR), and sepsis are also counted as complications. Pressure injuries (PIs) are rarely considered in the surgical literature as a postoperative complication, even though skin damage from anesthetically induced immobility and positioning is a reality. Chen and colleagues3 reported incidence rates of perioperative-acquired PI ranging from 0.3% to 57%, with a pooled incidence of 15%. McKenzie and Ramirez4 reported a PI incidence of 12% to 66% in patients undergoing surgery. Ganos and Siddiqui5 reported OR PI incidence rates dropped to a range of 0% to 17.6% in studies where prevention interventions were present.
Operating room-associated hospital-acquired pressure injuries (HAPIs) are typically classified as "positioning injuries"; however, before the recent attention given to HAPIs, neurophysiological injuries were the only "positioning injuries" recognized by the OR team (D. Boling RN, PhD, personal communication, January 11, 2017). Nerves in the brachial plexus can become compressed, stretched, entrapped, or ischemic from pressure, subluxation, or dislocation. Culprit practices include poor positioning or suboptimal design of arm boards, blood pressure cuffs, taping shoulders, arm tucking, application of countertraction, and hyperextension of the neck.6
Neurophysiological positioning injuries have decreased with the use of monitoring equipment such as somatosensory-evoked potential (SSEP), or transcranial electrical motor-evoked potential monitoring (TCeMEP).7 Guidelines from the American Operating Room Nurses (AORN) association indicate that OR staff responsibilities include monitoring patient positioning during surgery and making any necessary changes.6 When an SSEP or TCeMEP indicates altered neural function secondary to surgical positioning, the OR staff then modifies the patient's position to mitigate neural damage. We assert that the same attention be given to positioning that could potentially cause a HAPI
Tissue damage caused by pressure and shear associated with a surgical procedure may be visible within the perioperative period or may take as long as 3 to 5 days to become visible.8 Because of this potential delay, OR staff and surgeons may be less engaged in efforts to prevent PIs or recognize PI as a surgical complication. Also, the OR culture may lend itself to a more isolated type of mindset, assuming the patient is under their care for a fraction of time compared with an inpatient unit that provides care for a significant portion of the patient's length of stay. Nevertheless, a comprehensive pressure injury prevention (PIP) program encompasses implementation of evidence-based prevention strategies in all hospital areas for inpatient care, including the OR.9
Although our experience clearly demonstrates that OR colleagues want to provide high-quality perioperative evidence-based care in the area of PI prevention, this desire is mitigated by a history of isolating PI prevention practices outside of the surgical suite. Given changes in pay for performance by the Centers for Medicare & Medicaid Services and other insurers, hospital services that traditionally functioned in isolation (such as the OR) are now being included in facility-wide PI prevention programs.10 The following cases provide a context for the need for collaboration between WOC and OR nurses in order to design and implement PIP practices for patients undergoing surgical procedures in the acute care setting.
CASE 1
Mrs F was a 70-year-old female admitted to hospital for an elective laminectomy and transforaminal lumbar interbody fusion of L3-4 and L5-S1. Her body mass index (BMI) was 42 (Obesity Class 3). She had a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and lumbar spinal stenosis. During surgery, she was placed in a prone position on a Jackson table. Documentation indicated her arms were secured on a padded arm board, abducted less than 90[degrees], her palms were facing downward, and she had eggcrate padding for her arms and axilla. Pillows offloaded her bilateral legs with toes hanging free, and a safety strap was placed across her thighs. A 5-layer silicone foam dressing was applied prophylactically on the sternum and bilateral iliac crests. Prone positioning pillows, constructed of both contour ethane and support ethane, cradled her head.
Her spinal procedure lasted 7 hours and 33 minutes. The postoperative skin assessment was not consistent with the preoperative assessment. Specifically, Mrs F developed a nonblanchable brownish-red lesion on her chin. The WOC nurse consult occurred on postoperative day 1. On initial assessment the affected skin was maroon colored and the epidermis was intact; her injury measured 4.0 x 4.5 cm. The site was indurated and painful to palpation. It was determined to be an OR-associated deep tissue pressure injury (DTPI). The care plan included leaving it open to air. A plastic surgery consultation was ordered as part of standard hospital practice for any facial injuries. By postoperative day 4, the DTPI began to evolve with expected epidermal sloughing and appearance of necrotic tissue. A new treatment plan was initiated using an enzymatic debriding agent and a silicone foam dressing. The DTPI did not extend her length of stay in the hospital but required a plastic surgery follow-up as an outpatient (Figures 1 and 2).
CASE 2
Mr C was a 65-year-old male with a history of kidney stones, benign prostatic hyperplasia, diabetes mellitus, and a BMI of 31 (Obesity Class 1). He was admitted for surgical replantation of both ureters for severe bilateral hydroureteronephrosis with tortuous ureters. He was positioned supine on the OR table for an abdominal approach. Documentation indicated his right and left arms were secured to a padded arm board, abducted less than 90[degrees], his palms were facing upward, and he had eggcrate padding for his arms and axilla. The position of his legs on the table was not specified. No prophylactic dressings were applied. During the case, the patient needed to be positioned onto his right side to allow the surgeon access to the left kidney. The surgical procedure lasted 4 hours and 45 minutes. Forty-eight hours later, a DTPI was evident on his right buttock. In addition, there was a smaller, 1.0 x 0.7-cm area of slough on the left buttock within a 3.2 x 1.9-cm area of blanching erythema, which healed with conservative treatment. The WOC nurse team was consulted and assessed the right buttock as 7.7 x 5.1 cm of deep red, firmly indurated, painful injury. Within this location was a 4.2 x 3.0-cm area of necrosis. This unstageable OR-associated PI continued to necrose and required surgical debridement and negative pressure wound therapy over the following 9 months (Figure 3).
We queried whether, in either of the 2 cases illustrated earlier, the surgical consent form included developing a PI as a potential complication? The answer is no. We also considered the likelihood that the surgeon discussed PI development as a risk the OR team would mitigate via prevention strategies. We believe this unlikely, and postulate that most hospitals have not yet implemented intraoperative PIP strategies. The following discussion highlights similarities among published PIP professional guidelines. Our intent is to encourage and assist WOC nurses to collaborate with OR colleagues to create and implement an OR-specific PIP program.
DISCUSSION
The 2018 AORN is the most recent version of Guidelines for Perioperative Practice; it is the first to incorporate guidance on PIP.6 Specifically, the chapter provides 22 practice recommendations on proper positioning of patients during surgical procedures; this guidance is supported by 529 sources of evidence. The guideline indicates that positioning patients during surgical procedures is one of the most critical tasks performed by perioperative personnel.9 Responsibility for proper positioning extends beyond the perioperative nurse's role to the entire team, including surgeon, anesthesia professionals, first assistants, and other personnel.9 An introductory statement in the guideline implies that each recommended step is achievable within a hospital system and essential to high quality and safe patient care.9 We assert this guideline is a call to action for every OR to engage in HAPI prevention.
The National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA) released updated clinical practice guidelines for PIP in 2019.11 Specific OR-associated HAPI prevention recommendations are noted throughout the document; they include a risk assessment tool, guidance on positioning in the OR, and use of pressure redistributing surfaces. The equipment used, time spent immobilized before surgery, duration of surgery, and the patient's comorbidities, often measured by the American Society of Anesthesiologists (ASA) physical status classification score, are identified as risks for PI development.12 The guidelines provide diagrams of the 9 most common surgical positions, illustrating pressure points of concern. Use of prophylactic dressings, positioning equipment, heel offloading, pressure redistribution surfaces, and medical device-related injury prevention are also covered in the 2019 clinical practice guideline.
The Wound, Ostomy and Continence Nurses (WOCN) Society published a Guideline for the Prevention and Management of PIs in 2016.13 Although there are no specific OR practice recommendations in this document, there is an inherent generalizable theme of prevention applicable throughout a patient's length of stay, including the OR
We have found that evidence-based guidelines for PIP from the NPIAP, AORN, and WOCN, provide a common ground between wound clinicians (generally responsible for the organization's overall PIP efforts) and OR staff to discuss and develop a specific OR PIP program. The 3 published guidelines are synergist; we found no conflicts in recommendations (Table 1). Based on all 3 guidelines, we assert the following recommendations form a foundation for PIP in the OR: (1) validated risk assessment tool with associated interventions, (2) preoperative and postoperative skin assessments, (3) environmental considerations, and (4) participation in OR-associated PI root cause analysis.
Risk Assessment
Using a standardized risk assessment tool throughout a health care system may drive consistency in documentation and enhance communication between shifts and departments. However, we have found that no one tool captures all risk factors in all areas within the acute care setting (emergency department, intensive care units, procedural areas, medical/surgical units, and OR) and for all levels of illness severity. As a result, we have observed a lack of consensus regarding which tool best predicts PI risk in the perioperative patient. Potential validated instruments include the Braden Scale for Pressure Sore Risk (Braden Scale), Munro Scale, Scott Triggers, and the Perioperative Risk Assessment Measure for Skin (PRAMS) Scale.14
The Braden Scale was not developed for evaluation of risk during surgical procedures and has a low predictive validity for this population.15 However, Meehan and colleagues16 found that a Braden Scale score of less than 16 emerged as an independent risk factor for PI development-based multiple logistic regression analysis. For purposes of this study, Meehan's group used the Braden Scale score recorded most recently before surgery.
The Munro Pressure Risk and Scott Triggers were developed specifically for the perioperative patient.17 The Munro Scale identifies adult general surgery at-risk patients. The patient's risk scores as low, medium, or high during each surgery phase-preoperative, intraoperative, and postoperative-and the nurse communicates the cumulative score to the receiving unit.17 The preoperative assessment includes checking the patient's mobility, nutritional status, BMI, weight loss patterns, age, and comorbidities. The intraoperative assessment includes the ASA classification,19 type of anesthesia, temperature, hypotensive events, moisture, surface, and patient position. Finally, the postoperative assessment takes blood loss and the total length of perioperative time into account.17 However, a risk assessment tool aims to identify high-risk patients, and trigger prevention strategies to avoid harm. Those variables considered after surgery help explain causation but cannot be predictive. The Scott Triggers include 4 factors: age over 62 years, serum albumin less than 3.5 g/L, ASA of 3 or 4, and estimated time of surgery to be over 180 minutes. Patients with 2 or more triggers are considered high risk for OR-associated PI development.18 A potential limitation of the Scott Triggers is the lack of consistent serum albumin measurement before elective surgery.
The PRAMS has been revalidated to increase its generalizability; however, the validation study tested only patients in supine or lateral decubitus positions.20 The PRAMS instrument identifies surgical patients at risk for OR-associated PI development using 6 criteria: age over 70 years, diabetes mellitus, preexisting PI, previous surgery during the same admission, Braden score less than 6, and surgical time 5 hours or longer.16 The user must also complete a Braden Scale, increasing the time required for completion of the instrument.
The value of a risk assessment score lies not in its completion but in triggering evidence-based interventions matching the risk level. Before adopting a risk tool, a collaborative team of OR and wound care clinicians should determine individual interventions associated with each risk level to ensure buy-in from all disciplines involved. We assert that agreeing on a valid risk assessment instrument and associated prevention interventions creates a new PIP standard in the OR.
Preoperative and Postoperative Skin Assessment
The skin assessment comprises a head-to-toe, front-to-back inspection of the skin, including under and around medical devices.9 The preoperative skin assessment is performed, documented in the preoperative holding area, and findings are documented and communicated by an RN.9 Padding, positioning, and prophylactic dressings should be initiated and customized based on skin assessment findings. For example, a nurse identifies a Stage 2 PI on the left hip, and the required surgical position is supine should trigger appropriate PIP interventions including application of a prophylactic dressing on the sacrum and a 5-layered adhesive foam dressing on the left hip.
After surgery, the RN circulator is responsible for completing the postoperative visual skin assessment, followed by documentation and communication of findings. The RN circulator should assess locations where safety restraints, monitoring devices, positioning equipment, adhesives, and any other equipment were placed during the surgical procedure potentially causing injury. Identification of an OR associated PI triggers initiation of measures to offload and protect the area, documentation in the electronic medical record, and communication with the surgeon and RN at hand-off.9
Environmental Considerations: Pressure Redistribution Surfaces and Positioning Equipment
The OR team must ensure proper anatomical positioning to spare nerve damage and prevent PIs; both are crucial and hold equal weight in terms of patient safety. Prevention strategies should decrease pressure and shear forces on the skin and soft tissue, thereby minimizing ischemia and tissue deformation. High-volume, time-stamped case efficiency, and staffing limitations may make it difficult for OR staff to prepare each room with an operating table surface specific to a patient's risk. Since all patients are immobile during surgery, replacing all OR table mattresses to pressure redistributing surfaces may be the best way to ensure compliance. Surfaces that increase immersion and envelopment of the body provide the best form of protection; a high-specification reactive foam surface is a preferred mattress.21,22 Alternating pressure and gel mattresses are available for at-risk cases, especially those that will last over 3 hours. Lupe and colleagues23 assert that reducing the rates of OR-acquired PIs to zero was partly due to a concentrated effort at using the proper overlays. Limited evidence also suggests that an alternating pressure support surface may be used to reduce HAPI in the OR setting.24 Challenges exists between the need to keep the patient stabilized during the OR procedure, prevent falls, radiograph through the table, and provide pressure redistribution. These challenges present a call to action to biomedical engineers to design OR table surface products that meet each need.
We have observed that multiple items are used to position patients on the OR table including pillows, rolled and stacked towels, rolled sheets, blankets, intravenous fluid bags, foam wedges, gel pads, eggcrate foam, and bean bags. None of these items provide perfect conformity, immersion, or envelopment for the body contours, and none are designed to maintain shape over time. Instead, they tend to flatten under body weight impairing their potential for pressure redistribution. Fluidized positioners made of viscoelastic composite material are available that can be molded to the body; these devices can maintain their shape even with continuous bodyweight forces.25 We urge development of additional positioning products to provide effective positioning and promote safe skin during surgical procedures.
Occiput and Heel Protection
An informal survey of anesthesiologists practicing at the Virginia Commonwealth University Medical Center indicated the most common practice for head positioning is a stack of folded towels or the use of a gel donut. According to this same anesthesiologist group, during a lengthy surgery, the head may be lifted and repositioned approximately every 20 to 30 minutes. We assert that stacking folded towels does not redistribute pressures in a manner likely to prevent PIs and it does not provide envelopment. Instead, it leaves the entire weight of the head on the occiput. Gel donuts cause a phenomenon known as venous congestion within the center hole and exert maximum pressure and tissue distortion where the gel contacts the head.26 Donut-shaped head positioners concentrate the head-weight forces to transfer through a relatively narrow ring of scalp tissues, increasing the risk of developing occipital PIs during supine surgery.26 Therefore, these donut-shaped devices should not be used for head positioning during surgery, as well as in other settings.26 As an alternative, fluidized head positioners expose the head to more surface area, lowering the overall tissue deformation and the point pressure, mitigating injury.24
Heels are the second most common anatomic site for PI development27 If the foot is not part of the surgical field, floating the heel with specifically designed heel suspension devices or a pillow/foam cushion will provide 100% offloading. The proper heel offloading technique using a pillow or foam cushion is to lay the device lengthwise under the calf distributing the leg's weight without placing pressure on the Achilles tendon or the popliteal vein. Heel suspension boots or offloading techniques are crucial for each at-risk OR patient because there is no pressure redistribution surface available to provide heel protection. Prophylactic heel dressings may be used as an adjunct to heel offloading.6,11,13
Prophylactic Dressings
Prophylactic dressings reduce the forces of pressure, friction, and shear through multiple layer construction, protect fragile skin from shear with specially designed adhesives, and influence microclimate.28 Five-layer silicone adhesive foam dressings are clinically and financially effective when used in tandem with other evidence-based PIP strategies.29 The 2019 NPIAP-EPUAP-PPPIA guidelines endorse applying a prophylactic dressing as early as possible in the OR care pathway.11
A 2018 study by Haggard and colleagues30 examined PI development in neurosurgical patients undergoing surgery in the prone or park bench position. Baseline data on Stage 1 and 2 PI incidence were 8.5% when the operation was over 3 hours. After introducing positioning workshops for staff and 5-layer foam dressings for patients with planned procedures over 1.5 hours, the incidence dropped to less than 2%. In addition, if the patient was positioned prone or placed in a park bench position, all high-risk body areas were dressed in foam dressings. A total of 4310 patients were studied. The incidence fell to zero and remained nearly zero, except for PI development in 4 patients who were obese.30
Brindle31 examined the rate of PI development in an extremely high-risk group of cardiac patients-those undergoing left ventricular assist device (VAD) total artificial heart (TAH) surgery. Two hundred sixty-five patients met the inclusion criteria and had a usual OR time of 7.8 to 8.2 hours, and length of stay ranging from 19.3 to 108.6 days. The incidence of PIs was 11%. Despite long OR and long total immobility times, the mean time to PI occurrence was 23 days after admission and over 14 days after surgery, indicating a low rate of intraoperative and intensive care unit-associated PIs. Interventions at the medical center included 5-layer foam dressings and viscoelastic OR mattresses. Intraoperative PIs occurred in none of the TAH patients and 2.1% of the VAD patients.34 Considered collectively, this evidence indicates that the use of pressure distributing mattresses capable of envelopment and immersion, fluidized positioners to position a patient anatomically and appropriately, and prophylactic dressings targeting at-risk sites are recommendations to reduce OR-associated PI.31
Culture Change
Historically, OR teams operated in a silo; their culture rewarded volume and efficiency, and valued precision and surgical skill. As a result, some OR teams may be resistant to HAPI prevention strategies primarily because they do not see HAPIs as an issue once a patient leaves the postanesthesia recovery unit. However, HAPIs are an organizational issue and effective prevention requires involvement of the entire health system. Given this history and persistent tradition, engagement in HAPI prevention may require changes in the culture of the OR.
Out experiences strongly indicate that a small group dedicated to change cannot lead change the culture of the OR alone. A 2008 study found that a guiding coalition is the most important factor in culture change program success.32 This team is often referred to as a unit-based champion model. The champions are formal and informal clinical practice influential leaders infused with a sense of direction and vision to provide an emotional foundation to the needed change. These unit-based champions minimize their coworker's fear of the unknown and provide a better understanding of what behaviors employees need to achieve the desired future (in this case active dedication to implementing a PIP in the OR). Therefore, we assert that identifying and engaging key OR clinicians is necessary for building a guiding coalition within the OR to effectively reduce operative-related HAPIs. We further recommend, rather than working in isolation, an OR representative should be involved with the hospital's skin champion program, quality improvement projects for HAPI prevention, PIP education, risk assessment evaluation, and product acquisition.
If an OR-associated HAPI does occur, each perioperative team member responsible for this patient's care should be involved in the hospital's formal root cause analysis process. Identifying care gaps and system failures is the first step in mitigating further harm.
The 3 guidelines featured in Table 1 are designed to help teams create new or revise existing protocols to match current evidence. Table 2 is an example of a standardized prevention protocol.
CONCLUSION
The WOCN Society, AORN, and NPIAP provide evidence-based PIP recommendations applicable to the OR. All WOC nurses responsible for their facility's HAPI reduction should become familiar with the new AORN patient positioning guidelines and use this as a common ground to dialog and build healthy collaborative relationships with OR staff. OR staff must recognize this call to action and work in teams to choose a valid and reliable risk assessment tool, match evidence-based interventions to reduce risk, and engage in root cause analysis to determine how they might improve care during the entire intraoperative stay.
KEY POINTS
* The WOCN, AORN, and NPIAP professional organization's published guidelines are evidence-based, confluent resources for developing current PI prevention standards for the surgical patient.
* All WOC nurses and OR nurses should collaborate and review/revise PI standards for surgical patients.
REFERENCES