Operating Room Ulcers: Who is at Risk? Can They be Prevented?

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 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. npuap.org 2015 National Pressure Ulcer Advisory Panel www.npuap.org 1

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 npuap.org 2015 National Pressure Ulcer Advisory Panel www.npuap.org 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 npuap.org 2015 National Pressure Ulcer Advisory Panel www.npuap.org 2

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 npuap.org npuap.org 2015 National Pressure Ulcer Advisory Panel www.npuap.org 3

8/11/15 25 29 September www.wuwhs2016.com 4

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 9 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. 10 5

8/11/15 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! 2015 National Pressure Ulcer Advisory Panel www.npuap.org 12! 6

8/11/15 Determining what is an OR acquired ulcer Prep solution burn 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 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 7

Susan M. Scott, MSN, RN, CWOCN University of Tennessee College of Medicine Office of Graduate Medical Education Memphis, Tennessee Facebook #scotttriggers Twitter @scotttriggers 8

8/11/15 Surgery is one of the few times when someone not normally at high-risk for pressure ulcer development is placed at risk (Gendron 1988) A 2 Hour Surgery is really much longer = Time sedated + surgical procedure + recovery period + 20 min 30 min 2 hrs 2 hrs Created by Kathy Carlson 9

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) Cardiac Orthopedic General/Thoracic Urology Vascular 29.5% 20%-55% 13%-29.3% 14.4%-17% 9.8%-16% Consider trauma cases, bariactric, and re-operations 11 10

Total number of procedures: 51.4 million 19.2 million 65 years and older Cardiac Cardiac catheterizations: 1.0 million Balloon angioplasty or artherectomy: 500,000 Insertion of coronary artery stent: 454,000 Coronary artery bypass graft: 395,000 Orthopedic Reduction of fracture: 671,000 Total knee replacement: 719,000 Total hip replacement: 332,000 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) 22 11

Preoperative (Intrinsic) Intraoperative (Extrinsic) Postoperative *Statistically Significant Factors in Multiple Studies 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 12

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 4 th, 2015 at http://www.asahq.org/resources/clinical-information/asaphysical-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 13

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. 14

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 15

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 31 32 16

Real Time Concurrent Trigger System (AHRQ) Scott Triggers Age >62 Albumin <3.5 ASA Score 3 Time on the table 3 hr Score 2 or more = HIGH RISK 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 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.. 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 34 Infection Society 34 th Annual Meeting 2014 Baltimore, MD May 1-3, 2-14. 17

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. 35 Universal Pressure Precautions OR Skin Bundles Lean the OR Structured standardized handoff communication Teamwork investigations including Root Cause Analysis (RCA) 18

Debra L. Fawcett PhD, RN Assessment Skin/Risk Pharmacology Factors Intrinsic/extrinsic Positioning 19

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) 20

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 21

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 22

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 23

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 24

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 25

Preoperative team should communicate risk to the intraop team and intraop should report to PACU and PACU to unit. Intraop Unit Preop PACU 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. 26

Communication of PU development should also be reported to all staff /all units for their understanding and review. 2015 National Pressure Ulcer Advisory Panel www.npuap.org 54! 27

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. 28

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. 57 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. 09 0003. 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 34 th 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 56 th Annual Conference March 14-19, 2009. 58 29

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. 09 0003. 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. https://blueq.co1.qualtrics.com/ SE/?SID=SV_9T5LsV2pLZGqgzH npuap.org 30