Preventing Operating Room Acquired Pressure Ulcers: Taking it Down to Zero

Recent attention to adverse events in healthcare facilities has required that nursing staff in every department become aware of the circumstances in each specific area which contribute to hospital acquired conditions. We were notified that some of the hospital acquired pressure ulcers in our facility were directly related to time spent in the operating room. Patients are often required to spend several hours without repositioning during surgical procedures. Many times this lack of repositioning cannot be prevented. If repositioning is difficult and sometimes impossible, we needed to identify an alternative method to redistribute pressure and thus aid in the prevention of hospital acquired pressure ulcers. One easy solution was to look at different pads for the operating room table.  We trialed a radiolucent gel pad with a foam base for the operating room tables in our facility. The gel pad consisted of five (5) pieces which permitted multiple configurations for patient positioning. In addition the radiolucent quality allowed x-rays to be taken without additional transfer of the patient. Because the gel pad we trialed tolerated up to 500 pounds, we felt that it would accommodate most of our patient population. We reviewed and revised our protocols to include the use of the gel pad. During the month long gel pad trial period we experienced a decline in the rate of operating room acquired pressure ulcers. We continued to monitor the operating room patients following the purchase of the gel pads. Our rate of operating room acquired pressure ulcers declined to zero per cent (0%) for one full year. It became apparent to us that the use of a gel based operating room table pad could have extremely beneficial results for our patients, reduce the amount of operating room acquired pressure ulcers and result in better outcomes for our patients.