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Operating Room Ulcers: Who is at Risk? Can They be Prevented? Joyce Black, PhD, RN, CWCN, FAAN Susan M. Scott, MSN, RN, CWOCN Debra Fawcett, PhD, RN

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The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research.

©2015 National Pressure Ulcer Advisory Panel | www.npuap.org

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NPUAP – in collaboration with the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) – has worked to develop a NEW pressure ulcer prevention and treatment Clinical Practice Guideline and a companion Quick Reference Guide.

Purchase your copy today at www.npuap.org


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Released in November 2012, the 254-page, 24 chapter monograph, Pressure Ulcers: Prevalence, Incidence and Implications for the Future was authored by 27 experts from NPUAP and invited authorities and edited by NPUAP Alumna Dr. Barbara Pieper.

The monograph focuses on pressure ulcer rates from all clinical settings and populations; rates in special populations; a review of pressure ulcer prevention programs; and a discussion of the state of pressure ulcers in America over the last decade.

Purchase the monograph today at www.npuap.org   Hard Copy $75   E-version $49   Individual Chapters $19


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NPUAP’s Next Live Webinar! October 1, 2015 1:00 PM ET Prevention of Pressure Ulcers in Vulnerable People Aimee Garcia, MD Steven Antokal, MSN, RN, WOCN


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25 – 29 September

www.wuwhs2016.com

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  Discuss how to identify OR acquired ulcers in your facility

  Identify the risk factors for pressure ulcer development in OR

  Describe interventions to reduce risk during surgery

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Joyce Black: Consultant/Speaker’s Bureau for Celleration, Coloplast, Hill-Rom, Mölnlycke, Roho, Sage Products Suzy Scott: Sage Products Speaker Bureau Debra Fawcett: None No conflicts exist for any of the webinar speakers.

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  Pressure ulcers that appear within the first 72 hours after surgery in tissues that were subjected to pressure during the operation

  Incidence ◦  5-53.4%

  Prevalence ◦  9-21%

Ganos, Siddiqui, 2012

©2015 National Pressure Ulcer Advisory Panel | www.npuap.org 11!


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  Determining what is “an OR acquired ulcer” ◦  Seldom visible at

end of case   Cautery, device and

prep solution burns visible early

  How many of your PrU start in OR?

This burn occurred in the OR; visible at end of case

Prep solution burn

  Pressure ulcer in loaded body area during case ◦  Need to know position for

surgery ◦  Supine = buttocks in

normal weighted patients, heels and occiput ◦  Lithotomy = lower pelvis ◦  Prone = face, shoulders,

ribs, knees This patient had a 12 hour Whipple done 2 days prior to the onset of purple buttocks tissue

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Susan M. Scott, MSN, RN, CWOCN University of Tennessee College of Medicine

Office of Graduate Medical Education Memphis, Tennessee

Facebook #scotttriggers Twitter @scotttriggers

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Surgery is one of the

few times when someone

not normally at high-risk

for pressure ulcer

development is

placed at risk (Gendron 1988)

30 min

+ 20 min

2 hrs

A 2 Hour Surgery is really much longer = Time sedated + surgical procedure + recovery period

2 hrs

Created by Kathy Carlson

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•  1999 Aronovitch study (1,128 pt.) •  Rate 4%-45%

•  2012 Chen review of 17 studies (5,451 pt.) •  Rate 0.3% to 57% •  Pooled incidence of 15%

“Incidence over past 5 years has NOT decreased, but increased” (Chen 2012)

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Consider trauma cases, bariactric, and re-operations

Cardiac

Orthopedic

General/Thoracic

Urology

Vascular

•  29.5%

•  20%-55%

•  13%-29.3%

•  14.4%-17%

•  9.8%-16%

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  Total number of procedures: 51.4 million   19.2 million 65 years and older

• Cardiac catheterizations: 1.0 million • Balloon angioplasty or artherectomy: 500,000 • Insertion of coronary artery stent: 454,000 • Coronary artery bypass graft: 395,000

Cardiac

• Reduction of fracture: 671,000 • Total knee replacement: 719,000 • Total hip replacement: 332,000

Orthopedic

NCHS 2010 National Hospital Discharge Survey http://www.cdc.gov/nchs/data/nhds/4procedures/2010p+ro4_numberprocedureage.pdf

+

•  Location of Ulcers

•  Heels 14% - 52% •  Sacral 22% - 41%

•  Buttocks 11%-47% •  Elbow 5% •  Occiput 4% (Pediatric)

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Pre-operative (Intrinsic)

Intra-operative (Extrinsic)

Post-operative

Age* >62 • Age & co-morbidity • Low Albumin level* • Body mass index <19 or >40 • Recent significant weight loss • Race • ASA Scores* • Diabetes* • Cardiac disease* • Vascular disease* • Pulmonary disease* • Renal Insufficiency • Time to surgery *Statistically Significant Factors

in Multiple Studies

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  Category I ◦  Normal Healthy

  Category II ◦  Mild systemic disease without functional limitations

  Category III ◦  One or more moderate to severe diseases. I.e. poorly

controlled DM or HTN, COPD, morbid obesity (BMI ≥40).   Category IV ◦  Severe systemic disease that is a constant threat to life.

I.e. (<3 mo.) MI, CVA, TIA, or CAD/stents.   Category V ◦  Moribund not expected to survive without the operation

  Category VI ◦  A declared brain-dead patient whose organs are being

removed for donor purposes.

American Society of Anesthesiologist Physical Status Classification. Retrieved August 4th, 2015 at http://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system

Time on the table* •  Type of Surgery* •  Surgical position & devices •  Negativity – layers •  Warming blanket •  Hypotensive episodes •  Heat - Hypothermia •  Decreased H&H* •  Cardiopulmonary Circulation •  Table pad construction* •  Shear/Friction •  Lateral transfers •  Anesthesia (General/spinal) •  Medications •  Moisture - Maceration

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Post-operative • Days in the bed* • Total time of immobility • Success of Recovery

• Early mobilization • Hemodynamic status • Respiratory (Hypoxia)

• Nutrition* • Skin assessment • Pressure redistribution • Pain Control • Device related ulcers

• Cervical Collars • Tubing

NPUAP, EPUAP, PPPIA 2014 Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines Individuals in the Operating Room

1. Consider additional risk factors specific to individuals undergoing surgery (C)

2. Use a high specification mattress on the OR table for at risk individuals (B)

3. Position patient to reduce risk of PrU development during surgery (C) 4. Ensure that the heels are free of the surface of the operating table (C) 5. Position the knees in slight flexion when offloading the heels (C) 6. Pay attention to pressure redistribution prior to and after surgery (C) Strength of Evidence (A,B,C) Strength of Recommendations (Definitely do it)

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.

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1. Consider additional risk factors specific to individuals undergoing surgery including:

  Duration of time immobilized before surgery   Length of surgery   Increased hypotensive episodes during surgery   Low core temperature   Reduced mobility on day on post-op.

NOTE: •  Braden Scale has limitations in the surgical

population •  Braden Q Scale – Pediatric populations •  Munro Scale is undergoing validation studies •  Scott Triggers is a concurrent systematic

trigger tool National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.

  The Munro Scale has under gone 3 rounds of a Delphi Study and is currently in implementation studies in seven sites.

  This Study is funded by Cardinal Health E3 Foundation Grants and AORN.

  Undergoing validity and reliability   The Munro Pressure Ulcer Risk Assessment

Scale for Perioperative Patients ~ Adults developed by Cassendra A. Munro MSN, RN CNOR

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In General Trigger Systems • Target adverse events that are both prevalent and preventable • Should fill a need and add value • Trigger notifications should be actionable • Should have a good “signal-to-noise” ratio and cost-benefit ratio.

• Cost of implementation vs. cost of harm to patient • Good sensitivity and positive predictive value

• Trigger systems should be easy to implement

Concurrent Trigger System* • Identify real-time problems during the clinical episode in which the

problem occurs • Allow productive intervention at the patient level • Prevent or mitigate adverse event • *Does not have inherent criteria for clinical specificity

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Real Time Concurrent Trigger System (AHRQ)

• Age >62 • Albumin

<3.5 • ASA Score ≥3 • Time on the

table ≥3 hr

Scott Triggers

OR Skin Bundle • Use high specification OR

table pads • Offload heels • Use special padding for high

risk body areas • Use only approved

positioning devices • Safe patient handling • Handoff communication • Post op:

• Early movement • Daily skin assessment • Pressure management

Score 2 or more = HIGH RISK

Black J, Fawcett D. Scott S Ten top tips: Preventing pressure ulcers in the surgical patient. Wounds International 2014:5(4). http://www.woundsinternational.com/pdf/content_11478.pdf. Accessed February 10, 2015.

  Michael E. DeBakey VA Medical Center, and Baylor College of Medicine in Houston, TX

  21,377 surgical patients screened with Scott Triggers ◦  (Age >62, Albumin <3.5, ASA ≥ 3, Surgery >3 hrs)

  7,000 high risk (≥2 triggers)   High risk protocol   HAPU dropped from 3.37% to 0.89% (P=.004) and

sustained over 18 months.

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. Martinez S, Braxton C, Helmick R, Awad S, Lara-Smalling, A, Baylor College of Medicine. Sustainability of a hospital acquired pressure ulcer prevention bundle in surgical patients. Paper presented at Surgical Infection Society 34th Annual Meeting 2014 Baltimore, MD May 1-3, 2-14.

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Risk Assessment Scale specific to surgical population

Incidence and prevalence perioperative pressure ulcers

RCT of surfaces and positioning devices

Role of hypothermia, anesthesia and medications in microcirculation.

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Universal Pressure Precautions

OR Skin Bundles

Lean the OR

Structured standardized handoff communication

Teamwork

investigations including Root Cause Analysis (RCA)

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Debra L. Fawcett PhD, RN

 Assessment  Skin/Risk  Pharmacology Factors   Intrinsic/extrinsic  Positioning

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 Knowledge/Education  Technology  Appropriate staffing  Positioning  Communication

Knowledge and the application of knowledge is the key to the prevention of pressure ulcer in the OR.   Educate up front, part of orientation, annual

education  Do a journal club with a focus on PU’s in the OR  Report on PU during morning reports  Toilet talk  Posters  Stories of PU acquired in the OR (powerful)

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 Know the AORN Standards and Guidelines  Have an assigned champion that follows all

patients with extended surgeries or increased risk factors

 Attend conferences with NPUAP, WOCN, webinars

  Isn’t it great   In 1994 when I started   Pressure mapping systems   Research on devices   Low air loss   Dynamic surfaces   Gel –vs- foam   Viscoelastic   Overlays

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 Powered or non powered  Look at your patient population, choose

surfaces that are compatible with your care setting

 Alternating pressure (not recommended for the OR)

 Advance planning (time to get supplies adds to time on OR bed)

 Correct functioning of all devices to be used should be checked in advance

 Know the pressure points  Type of anesthesia

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 During positioning it is imperative the team have a solid understanding of the position to be used

 How long will the patient will be in that positon

 How will it affect the airways (decreased oxygen)

 What devices will be used  Are the heels off loaded  Are pressure points protected

  Supine   Lateral   Prone   Lithotomy

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 What devices are used, have in room  Make sure working correctly  Do not use IV bags to position  Linens do not redistribute pressure  Bariatric devices – make sure they are

correctly attached  Do devices help control the microclimate

(wick)  Know the expectations of the surgical team

 Check for correct placement after the patient is positioned

 Anesthesia- general/ spinal  Use pressure redistributing surfaces on all

carts/gurney before the procedure starts

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 Must have the correct amount of staff in each operating room during positioning to protect the patient from injury.

 Many patients go sleep on a gurney and then are moved to the operating room bed.

 Need the correct number of people to place all devices and to prevent damage to the skin and boney prominences

 Communication should begin when the patient is scheduled for surgery.

 Preoperatively, the risk assessment should be completed and then relayed to the intraoperative team, include items such as albumin if available, weight, mobility, past PU, co-morbidities

 All of the items that Susie spoke of in her risk section

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 Preoperative team should communicate risk to the intraop team and intraop should report to PACU and PACU to unit.

Preop

Intraop

PACU

Unit

  Include time on OR bed, any special devices used, what the skin looked like at the end of the procedure, type of anesthesia, any reddened areas, decreased O2 levels, by-pass machines, how long in PACU

 Communication should also return to the OR team if the patient develops a PU so the OR team can investigate as well.

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 Communication of PU development should also be reported to all staff /all units for their understanding and review.


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  AORN (2015). Guidelines for Perioperative Practice. Denver, CO. 563-580.

  Baron, S. and Mc Farlane, G. (2009). Reducing pressure ulcer risk in the operating room.

  Black J, Fawcett D. Scott S Ten top tips: Preventing pressure ulcers in the surgical patient. Wounds International 2014:5(4). http://www.woundsinternational.com/pdf/content_11478.pdf. Accessed February 10, 2015.

  Fawcett, D. (2011). Prevention of positioning injuries. Perioperative Safety. St. Louis, Missouri. 167-178.

  Giachetta-Ryan, D. (2015). Perioperative pressure ulcers: How can they be prevented? OR Nurse, July, 22-28.

  National Pressure Ulcer Advisory Panel (NPUAP) (2014). Prevention and Treatment of pressure ulcers: Clinical Practice Guidelines. 73-75.

  Primiano, M. Friend, M., McClure, C., Scott, N., Fix, L., Schafer, M., Savochka, K., and McNett, M. (2011). Pressure ulcer prevalence and risk factors during prolonged surgical procedures. AORN Journal (94)6, 555-566.

  Reddy, M., Gill, S., & Rochon, P. (2006). Preventing pressure ulcers: a systematic review. Journal of the American Medical Association, (296)8, 978-974-982

  Walton-Greer, P. (2009). Prevention of pressure ulcers in the surgical patient. AORN Journal, (89)3. 538-548.

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1.  Scott SM, Mayhew PA, Harris EA. Pressure ulcer development in the operating room. Nursing implications. AORN J. 1992; 56 (2):242-250.

2.  Aronovitch SA. Intraoperatively acquired pressure ulcer prevalence: a national study. J Wound Ostomy Continence Nurs. 1999;26:130-136.

3.  Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison of costs in medical vs. surgical patients. Nurs Econ. 1999;17:263-271.

4.  Cowan LJ, Stechmiller JK, Rowe M, Kairalla JA. Enhancing Braden pressure ulcer risk assessment in acutely ill adult veterans. Wound Rep Regen. 2012;20:137-148

5.  Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomized controlled trial comparing a dry viscoelastic polymer pad and standard operating table mattress in the prevention of post-operative pressure sores. In J Nurs Stud. 1999; 35:193-203

6.  Aronovitch S, Wilber M, Slezak S. Martin T. Utter D. A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients. Ostomy Wound Management. 1999;45(3):34-44.

7.  Russell J, Lichtenstein S. Randomized controlled trial to determine the safety and efficacy of a multi-cell pulsating dynamic mattress system in the prevention of pressure ulcers in patients undergoing cardiovascular surgery. Ostomy Wound Management. 2000;46(2):46-5.

8.  Schoonhoven L., Defloor T, Grypdonck MH. Incidence of pressure ulcers due to surgery. J Clin Nurs. 2002;11(4):479-487

9.  Feuchtinger J, Bie RD, Dassen T, Halfens R. A 4 cm thermoactive viscoelastic foam pad on the operating room table to prevent pressure ulcer during cardiac surgery. J Clin Nurs. 2006;15(2):162-7.

10.  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. Emily Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

11.  Chen H, Chen X, Wu J. The incidence of Pressure Ulcers in Surgical Patients of the Last 5 years. Wounds. 2012;24(9):234-241.

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11. Lumbley, J, Ali S, Tchokouani L. Retrospective review of predisposing factors for intraoperative pressure ulcer development. Journal of Clinical Anesthesia. 2014; 26:368-374. 12. 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;47:261-269. 13.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):116-124. 14. He W, Liu P, Chen H. The Braden Scale cannot be used alone for assessing pressure ulcer risk in surgical patients: A meta-analysis. Ostomy Wound Manage. 2012;58(2):34-40

15. Agency for Healthcare Research and Quality. Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting: Conference Summary. Rockville, MD. AHRQ Pub. No. 090003. Feb. 2009 16. Martinez S, Braxton C, Helmick R, Awad S, Lara-Smalling, A, Baylor College of Medicine. Sustainability of a hospital acquired pressure ulcer prevention bundle in surgical patients. Paper presented at Surgical Infection Society 34th Annual Meeting 2014 Baltimore, MD May 1-3, 2-14. 17. Dunlap L, Baker D. Correlation of Scott Triggers and Perioperative Homeostasis Indicators (PHI): Arthroplasty (total hip and total knee) and Spinal Fusion Surgery. Poster presented at the 2012 Tennessee Hospital Association Annual meeting. 18. Esch D. Scott Triggers: A Screening Tool for Pressure Ulcer Prevention in Surgical Patients. J PeriAnesthesia Nurs. 2010; 25(3):186 19. Fawcett D, Scott S, Thompson L. CSI (Common Surgical Injury) Investigation. Poster presented at AORN 56th Annual Conference March 14-19, 2009.

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  21. Lindgren M, Unosson, M, Krantz, AM, Ek, A. Pressure ulcer risk factors in patients undergoing surgery. J of Adv Nurs. 2005;50(6):605-612.

  22. American Academy of Nurses. Raise the Voice 2014. http://www.aannet.org/edge-runners--perioperative-pressure-ulcer-prevention-program

  23. Pham B, Teague L, Mahoney J, Goodman L, Paulden M, Poss, J. “et al.” Support surfaces for intraoperative prevention of pressure ulcers in patients undergoing surgery: A cost-effectiveness analysis. Surgery. 2011;150(1):122-32.

  24. Institute for Healthcare Improvement. Always Events. 1 January 2013 http://www.ihi.org/engage/Initiatives/PatientFamilyCenteredCare/Pages/AlwaysEvents.aspx. Accessed December 7, 2014.

  25. Agency for Healthcare Research and Quality. Triggers and Targeted Injury Detection Systems (TIDS) Expert Panel Meeting: Conference Summary. Rockville, MD. AHRQ Pub. No. 090003. Feb. 2009

  26. Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on www.IHI.org) Accessed December 7, 2014.

  27. Center for Medicare & Medicaid Services (CMS) Hospital Value Based Purchasing. 21 October 2014. (Available on www.CMS.gov) Accessed December 7, 2014.

  28. Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015. In press   29. Black J, Fawcett D. Scott S Ten top tips: Preventing pressure ulcers in the

surgical patient. Wounds International 2014:5(4). http://www.woundsinternational.com/pdf/content_11478.pdf. Accessed February 10, 2015.

To earn the 1.0 continuing education credit from today’s webinar please visit the link below.

This information will also be emailed out to participants at the conclusion of the webinar.

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