Intraoperative Pressure Ulcer Prevention: Strategies for Success

Nearly half of all hospital- acquired pressure ulcers originate in the surgical environment costing $750 million to 1.5 billion annually (Wadlund, 2010). The unique environment during surgery involves many of the known risk factors in pressure ulcer formation. These include immobility, patient positioning dependent upon procedure, intensity and duration of pressure, as well as moisture and temperature variances. A patient’s risk of pressure ulcer development is also influenced by co morbidities and hemodynamic issues, presenting challenges for the entire surgical team to consider.

A performance improvement team committed to reducing intraoperative pressure ulcers, proceeded with a quality improvement project.  Stakeholders included perioperative staff, OR management, and the wound care nurse.  A Plan, Do, Study, Act methodology was used to guide development and implementation of this 36-month project. Project components included: 1) synthesis of scientific evidence; 2) adoption of a new best practice; 3) staff education; 4) phased implementation of practice changes; and 5) measurement of project-related outcomes.

The higher risk services targeted were cardiovascular, transplant, neurosurgery and complex general surgery. The changes in practice included, new therapeutic support surfaces, different positioning techniques, addition of heel suspension boots, removal of cooling and heating blankets, (when possible) and finally the addition of a soft silicone dressing over the patient’s sacrum.

Following this staged implementation over three years, pressure ulcer development dropped to zero in 3 of the 4 specialties. Overall, the incidence of pressure ulcers decreased from 1.51/1000 procedures in 2009 to 0.16/1000 by 2011 and 0.55/1000 in 2012, with sustained downward trending in 2013. This resulted in an estimated savings of $890K annually based on pre project incidence and treatment cost estimates by Johnson et al. (2010).  The success of this multipronged approach resulted in positive outcomes for intraoperative patients at greatest risk for pressure ulcer development and significant healthcare savings.