Introduction
My first encounter with a perioperative pressure ulcer (PPU) occurred in 1985 when I observed a large ecchymotic lesion in the sacral area of an abdominal aortic aneurysm patient on the second day after surgery. However, it was the use of pressure ulcer (PU) incidence data that drove my interest to study prevention in surgical patients. After becoming a WOC nurse in 1989, I began tracking hospital-acquired PUs. I observed higher incidence rates of PUs in surgical patients than in the medical or long-term care area where the patients were at a much higher risk. I searched the literature in 1992, which was limited to 25 articles on PPU. Based on that search, I consulted with colleagues and we concluded: (1) accurate and timely skin assessments and interventions by perioperative nurses may help to reduce incidence and mitigate severity, (2) research is needed to document PPU incidence and risk factors and evaluate the efficacy of support surfaces for surgical tables, and (3) a risk assessment instrument sensitive to PPU was needed.1 Now it is 2015 and I was asked to revisit these questions and determine whether we are doing a better job today of preventing PUs in surgical patients than we were 23 years ago.
Historical Perspective
In order to answer this question, I began with a literature search from 1992 to present. This search led me to several observations. Surgery is now recognized as a legitimate risk factor for PU development. The Aronovitch landmark study and reports in 1999 demonstrated incidence, cost, and impact of PPU.2,3 Cowan and colleagues4 found that 4 medical factors (malnutrition, pneumonia/pneumonitis, candidiasis, and surgery) have stronger predictive value (sensitivity 83%, specificity 72%, area under receiver operating characteristic curve 0.82) for predicting PUs in acutely ill veterans than Braden Scale total scores alone (sensitivity 65%, specificity 70%, area under receiver operating characteristic curve 0.70). I also observed that research now suggests that the "conventional/standard" OR table pad (2 inches/5.08-cm-thick, elastic foam covered with black conductive laminate vinyl fabric) may be a potential hazard for high-risk patients.5-10 Feuchtinger and colleagues9 recommended a thicker pad of at least 7 cm than the standard 4 cm pad. Nevertheless, there is insufficient evidence to conclude which surface is most effective for prevention.5-10
My literature search also led to a realization that the true incidence of PPUs is difficult to discern. Several studies and surveys have evaluated PU incidence and surgical case mix. The most prevalent case types include cardiac, thoracic, orthopedic, general, and vascular surgery.2,8,9,11,12 A systematic review of 17 studies completed within the past 5 years that enrolled 5451 patients reported variable incidence rates varying from 0.3% to 57.4%; the pooled incidence rate was 15%.11 Finally, I noted that while I identified multiple studies that identified risk factors associated with surgical patients,13-15 I found no validated risk assessment tool for determining PPU risk. Several studies evaluated the Braden Scale13 for use in surgical patients with mixed results.14,15 A meta-analysis conducted by He and colleagues15 suggests that the Braden Scale cannot be used alone in surgical patients because of its low predictive validity for assessing PU risk.
Defining the Problem
I believe clearly defining a problem is essential. In the context of a study evaluating the efficacy of a multilayer pressure-redistribution pad, our research team defined the PPU as any pressure-related tissue injury (ie, nonblanchable erythema, purple discoloration, or blistering) associated with the surgical position within 48 to 72 hours postoperatively (Box 1 and Figure 1). I have observed that PPUs occur as a result of factors that occur during 3 distinct periods of operative care, the preoperative, intraoperative, and postoperative periods. The preoperative begins once the decision is made to undergo surgery. Preoperative factors relevant to PPU risk including age, comorbid conditions, and nutritional status are frequently out of our immediate control. Intraoperative factors associated with PPU risk include time on the table, hypothermia, blood loss, hypotension, anesthesia type, draping, device use, pooled fluid, and surgical position. Postoperative factors affecting PPU development include how well we recover the patient relative to mobilization, nutrition, respiratory, skin status, pain control, pressure redistribution, and hemodynamic status.
Determining PPU Risk
The Agency for Healthcare Research and Quality recommends development of "trigger tools" to easily identify preventable adverse events.16 These tools should be easy to implement, add value, and lead to meaningful actions. I developed the Scott Triggers tool to help identify potential surgical patients at risk for PPUs (Figure 2). The tool was developed from findings in the secondary analysis of variables linked with PPU development in the "Perioperative Pressure Ulcer Assessment and Prevention: Efficacy Study of a Multilayer Pressure-Redistribution Pad in the Operating Room" (Table 1).17,18
The Scott Triggers include >62 years of age, American Society of Anesthesiology score (ASA) >3, serum albumin < 3.5 mg/dL (<35 g/L), and time on the table over 180 minutes was added later based on results from multiple studies.2,3,6,8,9,23 Although the Scott Triggers have not been validated for sensitivity and positive predictive value to date, other facilities have incorporated them into research studies and quality improvement projects (Table 1).19-22
After developing the Scott Triggers, I formatted the "Perioperative Pressure Ulcer Prevention Program (PPUPP)," which addresses critical focus areas for consideration when developing a strategic plan for prevention (Table 2). In 2009, I was recognized by the American Academy of Nurses as an "Edge Runner" in the Raise the Voice Campaign for the PPUPP. The AAN looks for new care models and interventions that demonstrate significant clinical and financial outcomes.24
PPU Prevention: Challenges and Opportunities
Despite progress since I first became aware of issues surrounding PPU, research concerning the epidemiology of these lesions, and clinical evidence concerning effective strategies for risk assessment and prevention remains limited. Additional research is urgently needed to more precisely determine the incidence and prevalence of PPU and the effects of multiple associated factors including type of surgery, and positions during a procedure (lateral, prone, and supine). A risk assessment instrument specific to surgical patients should be developed and validated; I further propose using the Scott-Triggers as a basis for developing this instrument. Additional evidence concerning the efficacy of table surfaces or devices for prevention of PPU is needed. I believe that devices designed to prevent pressure and nerve injuries of the sacrum, heels, and occipital ulcers are especially needed. I also believe that these trials should focus on prevention of PPU in patients who must be placed in the supine, lateral, lithotomy, and prone positions in particular. Future study should include both powered and nonpowered devices incorporating fluid immersion, alternating air, various configurations of viscoelastic foam, and gel features. Finally I propose additional research focusing on postanesthesia nursing care to include revising standards of practice for the surgical patient to mitigate PPU risk.
I applaud the development of evidence-based clinical practice guidelines by the Association of Perioperative Registered Nurses and the National Pressure Ulcer Advisory Panel (NPUAP), but I also recognize gaps in collaboration and communication among the interprofessional teams persist that influence PPU prevention efforts. For example, awareness of the role of surgery and the operating room as a cause of PPUs is not widely understood since the injury may not be detected until hours or days after surgery. Critical care and front-line staff nurses are too often blamed for development of PU that may be related to a surgical procedure while perioperative nurses express frustration concerning their limited role in PU prevention. I have cared for numerous patients who have suffered from PPU and they are shocked that an ulcer could occur from a routine elective surgery. I propose that if PU is a known adverse event after surgery we should include the discussion of this possibility in the informed consent.
My personal focus has shifted from device testing to identifying barriers to practice integration. My original research considered the efficacy of OR table pads (Box 1). The strength of evidence for this recommendation is now a B; however, the standardization of high specification support surfaces for all operating rooms has not occurred.10,25 According to the Institute for Healthcare Improvement (IHI), Always Events are aspects of patient care that are so important healthcare providers must do this for every patient every time.26,27 I believe a list of "Always Events" should be implemented to prevent PPU (Box 2).
Conclusions
Perioperative pressure ulcers are costly and devastating to our patients. As long as we are not aware of the "cause and effect" of the operating room on PPU development that is a barrier to consistently implement prevention practices across the continuum, our patients remain at risk for developing these avoidable adverse events. The Centers for Medicare & Medicaid Services value-based purchasing (VBP) reimbursement schema is shifting their focus from process measures to clinical outcomes.28 In 2016, PU development, along with surgical site infections, will be added to the priority list of never events. Financial incentives will rest on the improvement of quality and patient safety. I too will not be satisfied until we have zero patient harm from perioperative PU.
ACKNOWLEDGMENT
The study was funded by a grant from Allen Medical, A Hill-Rom Company, Acton, Massachusetts, in 2004.
References