It is well known that immobility leads to pressure injuries. There is no setting in health care where immobility for extended periods of time occurs comparable to the operating room (OR). While immobility is necessary to accomplish surgical procedures, it should not surprise clinicians that pressure injuries occur in the perioperative area. We would argue that these are "unavoidable pressure injuries" borne of necessity.
The primary author polled 7 RNs in the perioperative holding area of an academic medical center, and not one had ever seen a pressure injury listed as a possible complication on a preoperative consent form. These nurses represented a total of 85 years of nursing experience and work in an academic medical center that performs organ transplants and complex cardiac and oncologic procedures, among others. Despite pressure redistributing surfaces on OR tables and various positioning devices used, the inability to provide intraoperative repositioning sets the stage for pressure damage.
According to information from Cleveland Clinic, informed consents help "prevent misunderstandings" and ensure understanding that includes "the chances of less-than-optimal outcomes."1 The information further elaborates on disclosure of potential risks; it states that risks considered remote or common knowledge may not be included. In our experience, pressure injuries acquired in the OR are not remote, nor is this risk common knowledge.
A 2016 article from Black et al2 describes 2 clinical presentations of deep tissue pressure injuries associated with patients who have undergone surgery. In addition to describing clinical hallmarks of perioperative-associated pressure injuries, the authors discuss the time from pressure injury to overt signs of damage commonly ranging 24 to 72 hours after the surgical event. Typically, 24 hours is the time frame used in determining where a pressure injury may have originated. Based on this standard, a pressure injury may be attributed to a nursing unit that may have actually occurred in the OR suite.
According to Engels et al,3 there is at least an 8.5% increase in pressure injury prevalence in patients who have undergone procedures greater than 3 hours in duration. A relevant 2017 article from Spruce4 regarding prevention of perioperative pressure injuries states pressure injuries that occur within 72 hours of surgery may be attributed to the perioperative area. In addition, the author suggests that high-risk ambulatory surgery patients should be instructed in signs of pressure injuries that they should report and the follow-up phone call should also include a skin check. This suggestion further supports our premise that informed consent should include pressure injuries as a potential risk.
A recent article from Schaffer et al5 focuses on the incidence and treatment of pressure injuries associated with patients dependent on left ventricular assist devices (LVADs) and raises some interesting points regarding not only intrinsic risks from the underlying clinical condition but also unique issues created by the LVAD. While providing life-sustaining improvement in central circulation, the LVAD also worsens peripheral flow via endothelial dysfunction and increased inflammation that impedes healing. The authors discuss risk factors associated with intensive care unit stays including bedridden status, inadequate repositioning, use of inotropic agents, ventilatory support, and prolonged sedation, all of which are also applicable to the OR setting. These patients are already compromised and at high risk going into the procedure. Why would we not inform them of the risk of pressure injury along with other known risks?
If the intent of informed consent is to educate patients and their caregivers not only of the procedure to be performed but also of complications that may reasonably arise including death, it is surprising that pressure injuries are not included. This is particularly unexpected, given poor health literacy, the litigious nature of Americans, and the increasing acuity and complexity of patients. We would submit to the readership that if patients and their caregivers were informed of the risk of pressure injuries prior to surgery, perioperative-acquired pressure injury lawsuits would decrease.
In addition, it is our belief that patients and caregivers would be more invested in participating in their care to avoid such events. At present, patients commonly refuse turning and other preventive interventions in the interest of comfort and sleep. While these are both important to recovery, it is also essential to preserve the integrity of the largest organ, the skin. To further compound the problem, staff frequently fail to document such refusals due to lack of time or poor understanding of the importance of documentation in defending care when litigation arises, generally several years later. As trust in the health care system declines and litigation of hospital-acquired pressure injuries increases, documentation of education and interventions becomes even more important. Adding risk of pressure injury to informed consent addresses one aspect of the avoidable versus unavoidable argument for hospital-acquired pressure injury.
As wound care specialists, we are aware of the lack of consistent science behind staging of pressure injuries and the intricacies of pressure injury development. The LVAD article3 highlights our lack of understanding of events at a cellular level, which complicates the issue independent of prevention efforts. It may be time to look at the informed consent process from a pressure injury perspective. The risk is real. If patients and caregivers were better informed, it should follow that resistance to turning would be encountered less often as the consequence of refusal would be more apparent. To put it plainly, perioperative patients would literally have more skin in the game.
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