A Change in Focus: Shifting From Treatment to Prevention of Perioperative Pressure Injuries

Nurses' experiences of hospital-acquired pressure injury prevention in acute healthcare services in Victoria, Australia: A qualitative study using the Theoretical Domains Framework

We investigated nurses' experiences of hospital-acquired pressure injury (PI) prevention in acute care services to better understand how PI prevention may be optimised. We used the Theoretical Domains Framework to systematically identify barriers and enablers to evidence-based preventive practices as required by the International Guideline. This study was one element of a complex capacity building project on PI surveillance and prevention within the acute health service partners of Monash Partners Academic Health Science Centre, an accredited academic health partnership located in Melbourne, Australia. We adopted a qualitative descriptive design. We interviewed 32 nurses that provided care in intensive care units, general wards and COVID wards of four acute care services. Nurses were recruited from four large acute care services (three public, one private) located in Melbourne. Most of them worked with patients who were at high risk of hospital-acquired PI on a daily basis. Interview transcripts were coded and analysed using thematic analysis guided by the Theoretical Domains Framework. The domains referred to most frequently by all participants included: Knowledge, Skills, Social/Professional Role and Identity, Beliefs about Capabilities, and Environmental Context and Resources. The key barriers discussed by nurses included gaps in nurses' knowledge and skills related to identification and staging of PI, heavy nursing workload and inadequate staffing levels, stigma and self-blame related to PI identification, and exacerbating impacts of the COVID-19 pandemic. Main facilitators discussed were training programmes, nursing audits and feedback, and teamwork. Participants suggested improvements including accessible and tailored training, visual reminders, and addressing heavy workloads and emotional barriers nurses face. Investing in tailored training initiatives to improve nurses' knowledge and organisational changes to address low level staffing and heavy workloads are urgently needed to support nurses in delivering optimal care and preventing hospital-acquired PI.

Positioning the surgical patient - roles, responsibilities and challenges. A qualitative study

AIMS

The aim was to explore how representatives from the different professions in the surgical team experience roles, responsibilities and challenges in positioning the surgical patient.

BACKGROUND

Appropriate patient positioning on the operating table during surgery is vital for optimal anatomical exposure, access to essential equipment, patient comfort and to minimize the risk of injuries. Patient positioning has been described as a shared responsibility of the entire surgical team. The research on roles and responsibilities in patient positioning during surgery is sparse.

DESIGN

The study had a qualitative design, including 16 individual, semi-structured interviews, conducted in November and December 2023.

METHODS

Participants included surgeons (n = 4), anaesthetists (n = 4), operating room nurses (n = 4) and nurse anaesthetists (n = 4) in a hospital in Southeastern Norway. The data were analysed using Braun and Clarke's six-step Reflexive Thematic Analysis.

RESULTS

Three main themes with subthemes were identified, namely (1) A teamwork approach, with subthemes (a) facilitating surgery and (b) health professionals' roles and responsibilities. (2) A patient safety issue, with subthemes (a) risk patients and (b) procedural challenges. (3) Absence of a systematic approach, with subthemes (a) various approach to second time-out and (b) documentation and feedback issues.

CONCLUSION

Appropriate and safe positioning during surgery is a common responsibility of all members of the surgical team. Despite the common assumption that surgeons hold the primary responsibility, the operating room nurses seemed to hold the hands-on responsibility. Different health professionals emphasized different risk patients, risk procedures and perceived challenges. This suggests a connection between the specific focus of distinct professional domains, their tasks and expertise within the surgical context.

IMPACT

There is a lack of clear guidelines outlining roles and the distribution of responsibility in patient positioning, which may be a safety concern. A need for reviewing responsibilities and defining roles is identified. Systematic follow-up of documentation of post-operative observation and documentation of skin status and the "second time-out" procedure is crucial to establish measures rooted in guidelines supported by both professional and administrative management. This dual commitment may ensure a comprehensive strategy for systematic follow-up, fostering a culture of continuous improvement.

PATIENT CONTRIBUTION

Not applicable.

Risk Factors of Intraoperative Pressure Injury in Adult Patients Undergoing Neurologic Surgery

GENERAL PURPOSE

To present research investigating the incidence of and risk factors associated with intraoperative pressure injury in patients undergoing neurologic surgery at Xiangya Hospital, Central South University in China.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Identify the incidence of intraoperative pressure injuries (PIs) in patients undergoing neurologic surgery at Xiangya Hospital, Central South University in China.2. Describe risk factors for intraoperative PI.3. Outline strategies to help mitigate intraoperative PI risk.

Effect of "micromovement" in preventing intraoperative acquired pressure injuries among patients undergoing surgery in supine position

To explore the clinical effect of "micromovement" in preventing intraoperative acquired pressure injures (IAPIs) among patients experiencing surgery in supine position. A total of 200 patients accepting elective surgery in supine position from 10 May 2023 to 4 July 2023 at Shulan (Hangzhou) Hospital were selected and randomized into two groups (experimental group, n = 100; control group, n = 100). For control group patients, soft silicone foam dressing was applied to the sacrococcygeal region. On the basis of the treatment for control group patients, "micromovement" was implemented among experimental group patients. During this process, the operating table was tilted for 15° leftwards and rightwards alternately every 1 h, and the tilt angle was maintained for 5 min to prevent IAPIs. Finally, comparisons between the two groups were made in terms of the sacrococcygeal IAPI incidence, relative temperature differences (ΔT) on sacrococcygeal skin, and job satisfaction of nurses. Compared with control group patients, patients from the experimental group exhibited lower IAPI incidence (2% vs. 10%), reduced ΔT between the sacrococcygeal skin and surrounding normal skin [0 (-0.1, 0.1) vs. 0.2 (-0.2, 0.4)], and elevated job satisfaction of nurses (80% vs. 66%). All the differences were statistically significant (p < 0.05). "Micromovement" implemented intraoperatively among patients receiving surgery in supine position is able to lower the IAPI incidence by five times and elevate job satisfaction of nurses.

Knowledge translation for nursing care for patients with Risk of perioperative positioning injury: A case report

PURPOSE

The aim was to apply the Advanced Nursing Process and demonstrating procedures of surgical positioning, as well as to show the participating the Nursing Outcomes Classification findings in order to translate the knowledge on specific preventive perioperative positioning into practice, the review of clinical protocols and nursing care plan.

METHODS

The methods used include case report about knowledge translation by applying training modalities, review and adaptation of clinical protocols and examination of nursing care plans.

FINDINGS

One hundred and nine healthcare providers attended the training, including nurses and nursing technicians working in the surgical center and the outpatient surgical center of the hospital chosen for this study. The surgical positioning protocols were revised based on the evidence described in the literature and the main surgical guidelines. The review of care registered in the institution's electronic system for the nursing prescription stage of the diagnosis Risk of perioperative positioning injury was based on the review on evidence on risk factors, the main guidelines in the area and the interventions suggested by Nursing Intervention Classification. The electronic system had registered 14 cares for this diagnosis, and after the review, one care was excluded and eight new cares were included, totaling 21 cares.

CONCLUSION

Nursing teams play a prominent role in positioning patients for surgery, protecting them in a moment of extreme vulnerability, thus making knowledge about the fundamental elements of surgical positioning essential. This emphasizes the importance of training, and of reviewing protocols and records of procedures that promote safety to patients and care teams.

IMPLICATION FOR NURSING PRACTICE

The translation of knowledge about the Advanced Nursing Process in the perioperative area contributes to the refinement of classifications and standardization of language in this scenario, subsidizing an evidence-based clinical practice.

Evaluation of pressure ulcer risk and development in operating rooms

AIM

This study aimed to determine the risk and development of pressure ulcers in operating rooms.

MATERIALS AND METHODS

The sample of the study included a total of 250 patients. In the study, the risk of pressure ulcers was assessed before the operation, and the development of pressure ulcers was evaluated within 24 h after the operation.

RESULTS

The risk of pressure ulcers was low before the operation, and Stage I pressure ulcer developed in 12.8% of the patients within 24 h after the operation. The patients had pressure ulcers mostly in their sacrum. Their mean 3S Intraoperative Risk Assessment Scale of Pressure Sore score was 15.68 ± 4.84, suggesting that they were not at risk of developing pressure ulcers. Having a chronic disease (OR = 8.986; 95% CI = 3.697-21.845), undergoing general anesthesia (OR = 3.084; 95% CI = 1.323-7.194), and orthopedic surgery (OR = 10.172; 95% CI = 3.121-33.155) were statistically significant risk factors for pressure ulcers (p < 0.001). Additionally, moderately edematous skin (OR = 3.838; 95% CI = 1.024-14.386), overweight/underweight (OR = 16.333; 95% CI = 3.779-70.602), intraoperative bleeding greater than 800 ml (OR = 13.000; 95% CI = 3.451-48.969), operation time longer than 5 h (OR = 21.667; 95% CI = 2.122-221.223), moderate intraoperative stress (OR = 4.917; 95% CI = 0.425-56.916), body temperature higher than 38.3 °C or lower than 36.1 °C (OR = 5.462; 95% CI = 2.161-13.805), and intraoperative prone position (OR = 3.354; 95% CI = 1.386-8.115) were statistically significant risk factors for the development of pressure ulcers.

CONCLUSION

According to our preoperative pressure ulcer risk assessment, it is very important to take additional protective measures both during and after surgical operations to prevent pressure ulcers.

Relationship between predisposing and facilitating factors: Does it influence the risk of developing peri-operative pressure injuries?

This study examined the relationship between the personal predisposing factors of patients and the severity of pressure injuries (PIs) developed during surgery. This retrospective cohort study collected 439 cases of peri-operative PIs. Using binary logistic regression to identify the variables associated with PI severity, the effects of interactions between associated variables were then tested. The results of this study revealed that among the personal predisposing factors, only higher patient age (P = .001) and higher body mass index (P < .001) posed a greater risk of stage 2 PIs or higher. Among the surgery-related facilitating factors, only patients who were placed in the prone position during surgery and patients who lost ≥1000 mL of blood during surgery were at greater risk of stage 2 PIs or higher, compared, respectively, to those placed in the supine position and those who lost ≤100 mL of blood. Furthermore, the amount of blood lost during surgery moderated the influence of age on PI severity. For elderly patients who are expected to lose a large blood volume during surgery or lose an immeasurable amount of blood due to the use of cardiopulmonary bypass, taking more precautionary measures to prevent PIs is recommended.

Establishment and Application of Pressure Injury Assessment Module in Operating Room Based on Information Management System

A pressure injury is a common and painful health condition, particularly among people who are elderly or surgical patients. In order to explore how to use the information management system to optimize the pressure injury management process of surgical patients, this work establishes an integrated pressure injury management information platform for surgical patients, which can effectively control the key links in the process and realize the multistep full-process monitoring of surgical patients from admission to discharge. A total of 578 patients before the operation of the information platform were selected as the control group (CG), and after the operation of the information platform, 662 cases became the observation group (OG). Various evaluation metrics are employed to evaluate pressure injury in terms of single-pass rate, high-risk pressure injury, transfer skin condition description matching rate, hospital pressure injury incidence, and incidence of pressure injury in surgical patients at various stages. The results showed that the qualified rate of the pressure injury assessment in the OG was 99.2%, the accuracy rate of high-risk pressure injury screening and reporting was 100.0%, and the matching rate of the transfer skin description was 100.0%, which was higher than that of the CG. The integrated pressure injury management information platform for surgical patients based on the information management system realizes the full, continuous, accurate, and dynamic evaluation and monitoring of patients' skin. Furthermore, it can effectively improve the quality of pressure injury care and facilitate care management.

The Swedish version of the attitude towards pressure ulcer prevention instrument for use in an operating room context (APUP-OR): A nationwide psychometric evaluation

INTRODUCTION

To assess operating room (OR) nurses' attitudes towards pressure ulcer prevention, the Attitude towards Pressure Ulcer Prevention (APuP) instrument was developed.

AIM

The aim of this study was to psychometrically evaluate the Attitude towards Pressure Ulcer Prevention (APuP) instrument in a Swedish OR context.

MATERIALS AND METHODS

A psychometric evaluation study was conducted, using a convenience sample, between February and August 2020. Validity (content, construct, discriminatory power) and reliability (stability and internal consistency) were evaluated.

RESULTS

The first survey (test) was completed by 284 Swedish OR nurses, of whom n = 50 (17.6%) completed the second survey (retest). A Principal Component Analysis was conducted for the 13-item instrument. The KMO value for this model was 0.62. Bartlett's test for sphericity was statistically significant (p 0.001). Five factors were identified which accounted for 56% of the variance in responses related to attitudes toward pressure ulcer prevention. The Cronbach's α for the instrument "attitude towards Pressure Ulcer Prevention" was 0.66. The intraclass correlation coefficient was 0.49 (95% CI = 0.25-0.67).

CONCLUSION

This Swedish version of the APuP- OR is the first step in the development of an instrument to measure OR nurses' attitudes towards PU prevention in a Swedish OR context. The reliability of the instrument was low and the validity moderate. A larger sample and the revision or addition of items related to the context of the operating room should be considered in order to confirm aspects of the psychometric properties.

Pressure ulcer prevention dressing design and biomechanical efficacy

The objective of this educational article is to explain in non-technical terms how the engineering considerations in the design of prophylactic dressings for pressure ulcer (PU, also known as pressure injury) prevention eventually determine the associated clinical and cost-benefit outcomes. The article specifically describes a bioengineering algorithm for quantitative evaluation of the biomechanical efficacy of different prophylactic dressing designs, which is exemplified for two fundamentally different dressing technologies, one based on superabsorbent cellulose core versus the conventional silicone-foam dressing design. A set of three biomechanical indices is described and employed for the above comparative evaluation, namely, the protective efficacy index, the protective endurance and the prophylactic trade-off design parameter. It is demonstrated that the dressing with the superabsorbent cellulose core is at least as good as silicone-foams but, importantly, provides a good balance between its protective performance in its ‘new’ condition, as opposed to its ‘used’ condition, i.e., after being exposed to moisture. Most notably, we show that preventative dressings are never equal in their performances; the underlying structure and the dressing ingredients together determine the extent of the delivered tissue protection and its durability.

Protecting prone positioned patients from facial pressure ulcers using prophylactic dressings: A timely biomechanical analysis in the context of the COVID-19 pandemic

Prone positioning is used for surgical access and recently in exponentially growing numbers of coronavirus disease 2019 patients who are ventilated prone. To reduce their facial pressure ulcer risk, prophylactic dressings can be used; however, the biomechanical efficacy of this intervention has not been studied yet. We, therefore, evaluated facial soft tissue exposures to sustained mechanical loads in a prone position, with versus without multi‐layered silicone foam dressings applied as tissue protectors at the forehead and chin. We used an anatomically realistic validated finite element model of an adult male head to determine the contribution of the dressings to the alleviation of the sustained tissue loads. The application of the dressings considerably relieved the tissue exposures to loading. Specifically, with respect to the forehead, the application of a dressing resulted in 52% and 71% reductions in soft tissue exposures to effective stresses and strain energy densities, respectively. Likewise, a chin dressing lowered the soft tissue exposures to stresses and strain energy densities by 78% and 92%, respectively. While the surgical context is clear and there is a solid, relevant need for biomechanical information regarding prophylaxis for the prone positions, the projected consequences of the coronavirus pandemic make the present work more relevant than ever before.

Critical biomechanical and clinical insights concerning tissue protection when positioning patients in the operating room: A scoping review

An optimal position of the patient during operation may require a compromise between the best position for surgical access and the position a patient and his or her tissues can tolerate without sustaining injury. This scoping review analysed the existing, contemporary evidence regarding surgical positioning-related tissue damage risks, from both biomechanical and clinical perspectives, focusing on the challenges in preventing tissue damage in the constraining operating room environment, which does not allow repositioning and limits the use of dynamic or thick and soft support surfaces. Deep and multidisciplinary aetiological understanding is required for effective prevention of intraoperatively acquired tissue damage, primarily including pressure ulcers (injuries) and neural injuries. Lack of such understanding typically leads to misconceptions and increased risk to patients. This article therefore provides a comprehensive aetiological description concerning the types of potential tissue damage, vulnerable anatomical locations, the risk factors specific to the operative setting (eg, the effects of anaesthetics and instruments), the complex interactions between the tissue damage risk and the pathophysiology of the surgery itself (eg, the inflammatory response to the surgical incisions), risk assessments for surgical patients and their limitations, and available (including emerging) technologies for positioning. The present multidisciplinary and integrated approach, which holistically joins the bioengineering and clinical perspectives, is unique to this work and has not been taken before. Close collaboration between bioengineers and clinicians, such as demonstrated here, is required to revisit the design of operating tables, support surfaces for surgery, surgical instruments for patient stabilisation, and for surgical access. Each type of equipment and its combined use should be evaluated and improved where needed with regard to the two major threats to tissue health in the operative setting: pressure ulcers and neural damage.