The Development of a Pressure Ulcer Risk-Assessment Scale for Perioperative Patients

Comparison of the predictive validity of the Braden, Munro and 3S scales in surgical patients

AIM OF THE STUDY

This research is a descriptive and cross-sectional study aimed at examining the use of three different scales to assess the risk of pressure injury (PI) in surgical patients.

MATERIALS AND METHODS

This study was conducted between February 1 and July 1, 2022. The study included patients who had planned surgery in general surgery clinic. The sample size was 388 patients. Patients who agreed to participate in the study were asked to fill out the " Introductory Information Form " and perform a risk assessment using the Braden, Munro and 3S Scales. The statistics program IBM SPSS Statistics 25.0 packaged software was used in the analyses of data.

RESULTS

It is evident that the relationship between the scales and the diagnosis of PI, as well as the strength of this relationship, are statistically significant (p < 0.05). The Munro Scale exhibited the highest value of Phi value and validity coefficient c, indicating a stronger association with the diagnosis of PI, thus suggesting its greater effectiveness in discrimination. According to the validity coefficients found, it can be stated that the correct classification percentages for Munro, Braden, and 3S Scales were 91 %, 71 %, and 66 %, respectively.

CONCLUSION

The findings of this study indicate that both the Braden, Munro, and 3S Scales can be used for PI risk assessment in surgical patients, but the Munro Scale exhibits superior predictive validity compared to the Braden and 3S Scales in terms of overall sensitivity and specificity.

Validity and Reliability Evidence of the Munro Scale for Perioperative Patients Part II: Construct Validity

Background and Purpose: The Munro Pressure Injury Risk Assessment Scale for Perioperative Patients (Munro Scale) is the first three-phase risk instrument designed specifically for perioperative patients. The purpose of this study was to establish validity and reliability evidence for the Munro Scale. This study also had a goal to reduce the data into more manageable constructs with fewer items. Methods: Exploratory and confirmatory factor analyses were used to test the hypothesized model for risk assessment using the Munro Scale to identify latent variables. A retrospective review of charts from 630 risk assessments was analyzed from two community acute care hospital settings. Results: The model explained 95% of the variance in the cumulative final risk level, R2 = .95, F(20, 588) = 501.88, p < .001. Six latent variables emerged in the model with a cumulative contribution rate of 56% of the variance. Similar results were obtained in studies with Chinese and Turkish translations of the Munro Scale. Conclusions: The validity and reliability evidence obtained in this study supports the implementation of the Munro Scale for clinical practice in the perioperative setting.

Validity and Reliability Evidence of the Munro Scale for Perioperative Patients, Part I: Correlation, Multiple Regression, and Reliability

Background and Purpose: Patients undergoing surgery are at risk of pressure injury development and should be assessed to ensure measures are taken for prevention. The study's purpose was to examine the causal relationships and reliability of the Munro Pressure Injury Risk Assessment Scale for Perioperative Patients (Munro Scale). The Munro Scale is the first dynamic risk scale available for this patient population in the acute clinical setting. Methods: This study was a retrospective review to explore the relationships of the variables in the Munro Scale, identify the strongest predictors, and measure the reliability of previously collected data from two northeastern community hospitals. A total of 630 risk assessments were analyzed to obtain regression, correlation, and reliability evidence for the Munro Scale. Results: The correlation analysis among the 15 risk variables and combined comorbidities revealed commonalities among the variables and significant relationships to the final postoperative injury score. The model as a whole is significant to predict the final level of risk. Coefficient alpha revealed a lower than anticipated reliability when compared to the Chinese, Turkish, and Brazilian versions of the Munro Scale. Conclusions: There are significant relationships among the variables, and the scale is acceptable for use in the acute perioperative practice setting. This study has both clinical and statistical significance.

Evaluation of perioperative pressure injury in adults 65 years and older: A prospective cohort study

INTRODUCTION

Old age is an important risk factor for the formation of pressure injury (PI). The aim of this study was to investigate the incidence, risk factors, characteristics of PI and suitability of risk assessment tools for patients aged 65 years and older.

METHOD

This prospective monocentric cohort study was conducted in Turkey between September 2022 and March 2023. Data were collected from a total of 240 surgical patients aged 65 years and older using a skin assessment form and the Braden and Munro scales for PI risk assessment.

RESULTS

The patients had a mean age of 72.90 ± 5.53 years, 123 (51 %) were male, 203 (85 %) had chronic diseases, and the mean operative time was 194.83 ± 99.45 min. PI occurred in 45 patients (18.8 %). PIs were most commonly stage I and located in the coccyx region. Postoperative Munro score, postoperative Braden score, and operative time were significant in univariate analyses (p < 0.001). According to the multiple logistic regression model, a postoperative Munro score ≥26 and postoperative Braden score ≤20 were independent factors associated with increased risk of PI.

CONCLUSION

Measures to prevent PI in surgical patients should begin in the preoperative period. Age alone may not be a risk factor in geriatric surgical patients. The Munro and Braden PI risk assessment scales can be used in geriatric surgical patients, but changes in cut-off score calculations may be required and additional age-related risk factors should be evaluated.

Using a Decision Tree Approach to Analyze Key Factors Influencing Intraoperative-Acquired Pressure Injury

OBJECTIVE

To determine the key factors influencing intraoperative-acquired pressure injury (IAPI).

METHODS

Researchers assessed 413 surgical patients in a Shanghai tertiary hospital using an information collection form and an IAPI occurrence record form. Analysis took place using the classification and regression tree algorithm and multiple logistic regression.

RESULTS

A total of 43 surgical patients (10.4%) had IAPI, including 32 stage 1 cases (74.4%), and 11 stage 2 cases (25.6%). The multiple logistic regression analysis indicated that operation duration, surgical position, preoperative hypertension, and preoperative Braden Scale risk score were independently associated with IAPI development. The decision tree showed that preoperative Braden Scale score, surgical position, operation grade, operation duration, age, prealbumin level, and body mass index were important factors and that preoperative Braden Scale score was the most critical decision variable. The cross-validation method was used to indicate a model accuracy of 91.8%.

CONCLUSIONS

The decision tree effectively identified key factors for IAPI, complementing the logistic regression analysis and providing a scientific basis for the further development of structural risk assessment, prevention, and treatment strategies for IAPI.

Comparison of four risk assessment scales in predicting the risk of intraoperative acquired pressure injury in adult surgical patients: a prospective study

OBJECTIVE

To develop and compare four predictive models for intraoperative acquired pressure injury (IAPI) in surgical patients.

METHODS

One hundred patients undergoing various surgeries (hepatobiliary, pancreas, spleen, gastrointestinal, and cardiac surgeries) at Ruijin Hospital from November 2021 to September 2022 were included in this prospective cohort study. Four pressure injury risk assessment scales were used to measure the pressure injury risk: the Braden scale, Munro Pressure Injury Risk Assessment Scale, Scott Triggers tool, and CORN Intraoperative Acquired Pressure Injury Risk Assessment Scale. The patients were divided into the IAPI group and non-IAPI group.

RESULTS

In total, 37% of patients (37/100) developed class I/stage pressure injury (erythema) after surgery, which resolved within 2 hours after surgery in 86.49% of cases and further progressed to class II/stage or higher pressure injury within 6 days in 15.63% of cases. The application effects of the four commonly used risk assessment tools were compared with the sensitivity, specificity, and area under the receiver operating characteristic curve. The Munro Scale showed the best sensitivity and area under the receiver operating characteristic curve among the four tools for postoperative assessment, but its specificity was only 20.63.

CONCLUSIONS

More appropriate assessment tools are required for IAPI risk evaluation.

Perioperative Risk Assessment for Skin Injury

Hospital-acquired pressure injuries create a tremendous cost to health care organizations and negatively affect quality and patient safety. Surgical patients are at an increased risk for skin injury, particularly a pressure injury, because of a lack of sensation and immobility during a procedure. An interprofessional team at our facility identified factors that place surgical patients at risk for skin injury. We developed a risk assessment protocol in March 2021 using the Six Sigma DMAIC (define, measure, analyze, improve, and control) method. After data review and analysis, we identified age of 65 years or older, existence of a skin condition, and procedural duration greater than four hours as significant predictors for postoperative skin injury. Our findings reinforce the benefit of using an appropriate risk assessment protocol that alerts the perioperative team members to at-risk patients.

Assessment of the risk factors for intraoperative pressure injuries in patients

AIM

This study was conducted to assess the risk factors for pressure injuries in patients during surgery.

METHODS

In this descriptive cross-sectional study, the risk of pressure injuries during surgery was evaluated in 250 patients in a university hospital. Data were collected through a Patient Descriptive Information Form (PDIF) and the 3S Intraoperative Pressure Injury Risk Assessment Scale (IPIRAS).

RESULTS

The mean age of the patients was 44.15 ± 17.00, and 52.4% were female. In addition, it was determined that the mean 3S IPIRAS score was higher in patients who were male, were aged ≥60 years, were obese, had a chronic disease, and had low serum albumin and hemoglobin levels (p < .05). During the surgery of the patients included in the study, support surfaces were used in 67.6%, positioning aids were used in 82.4%, and 55.6% had normal skin. Patients who underwent CVS procedures for more than 6 h, did not use support surfaces during surgery, had moist skin, or used vasopressors had higher and significantly different mean 3S IPIRAS scores (p < .05).

CONCLUSIONS

According to the results, all surgical patients were at risk for pressure injury in the intraoperative period. In addition, it was found that male gender was associated with risk factors and that being aged ≥60 years, obesity, chronic disease, low serum hemoglobin and albumin levels, CVS, operations lasting more than 6 h, moist skin, vasopressor drugs, and not using support surfaces during surgery increased the risk of pressure injuries significantly.

The prediction model for intraoperatively acquired pressure injuries in orthopedics based on the new risk factors: a real-world prospective observational, cross-sectional study

Introduction: Orthopedic patients are at high risk for intraoperatively acquired pressure injuries (IAPI), which cause a serious issue and lead to high-expense burden in patient care. However, there are currently no clinically available scales or models to assess IAPI associated with orthopedic surgery. Methods: In this real-world, prospective observational, cross-sectional study, we identified pressure injuries (PI)-related risk factors using a systematic review approach and clinical practice experience. We then prepared a real-world cohort to identify and confirm risk factors using multiple modalities. We successfully identified new risk factors while constructing a predictive model for PI in orthopedic surgery. Results: We included 28 orthopedic intraoperative PI risk factors from previous studies and clinical practice. A total of 422 real-world cases were also included, and three independent risk factors-preoperative limb activity, intraoperative wetting of the compressed tissue, and duration of surgery-were successfully identified using chi-squared tests and logistic regression. Finally, the three independent risk factors were successfully used to construct a nomogram clinical prediction model with good predictive validity (area under the ROC curve = 0.77), which is expected to benefit clinical patients. Conclusion: In conclusion, we successfully identified new independent risk factors for IAPI-related injury in orthopedic patients and developed a clinical prediction model to serve as an important complement to existing scales and provide additional benefits to patients. Our study also suggests that a single measure is not sufficient for the prevention of IAPI in orthopedic surgery patients and that a combination of measures may be required for the effective prevention of IAPI.

Determining the Risk of Intraoperative Pressure Injury in Patients Undergoing Elective Cranial Surgery

Purpose: Neurosurgical interventions are long and complex, and additional difficulties are encountered in positioning in the operating room.The aim of the study is to determine the risk of pressure injury development in the intraoperative period of patients undergoing elective cranial surgery. Methods: This descriptive cross-sectional study was conducted with 127 patients who met the inclusion criteria and underwent elective cranial surgery in a city hospital between September and October 2021. 3S Operating Room Pressure Injury Risk Diagnostic Scale were used to collect data. Results: It was determined that 55.1% of the patients were female, their mean age was 53.22±13.47 years, and 61.4% had at least one chronic disease. It was determined that 71.7% of the patients were operated with the diagnosis of cerebellar tumor. Stage 1 pressure ulcers were observed in 37% of the patients. It was determined that the total score obtained from the scale was 14.87±2.83 and the patients were at low risk for pressure injury. Age, body mass index and duration of the surgical procedure were found to be independent factors affecting the patients' operating room pressure ulcer risk assessment scale score. Conclusion:It was determined that the risk of pressure injury in patients who underwent cranial surgery was low level.

Prevention of Pressure Injury in Patients Hospitalized with Heart Failure

Hospital-acquired pressure injuries are problematic within organizations. The Centers for Medicare and Medicaid Services counts hospital-acquired pressure injuries as a patient safety event and encourages hospitals to reduce or eliminate them in part by reducing payments to the hospital. Individuals who are admitted to hospitals with acute heart failure are usually elderly with comorbidities that increase their risk of developing a pressure injury. Therefore, evidence-based protocols should be made, implemented, and analyzed by an interprofessional team to combat the development of pressure injuries to maintain the best quality of life for patients hospitalized with heart failure.

Pressure Injury Risk Assessment and the Use of Intraoperative Polyurethane Foams to Prevent the Pressure Injuries

BACKGROUND: Patients undergoing surgery are at risk of developing pressure sores up to 72 h after surgery. The incidence of pressure injury can affect patient outcomes and quality of care. Pressure injuries have many risk factors and causes. The Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients was used to assess risk factors for developing a pressure injury. One of the interventions to prevent pressure injuries during and after surgery is polyurethane foams. AIM: The study aimed to describe the risk of pre-operative pressure injury, the use of intraoperative polyurethane foams, and the incidence of post-operative pressure injury in a private hospital in western Indonesia. METHODS: A cross-sectional quantitative descriptive study was conducted among 81 patients undergoing surgery using purposive sampling. The pre-operative risk assessment was conducted with the Munro scale for the pre-operative phase. The use of polyurethane foams during surgery and pressure injury incidence was observed. RESULTS: The results showed that 62 (76.5%) respondents were at moderate risk for pressure injury. 42 (51.9%) respondents used polyurethane foams in the intraoperative phase. Based on observation 72 h postoperatively, there was no pressure injury incidence. CONCLUSION: Pressure injuries can be prevented by identifying risk factors before the surgery. Nurses and surgeons need to be aware of the risk of pressure ulcers in the pre-, inter-, and post-operative phases. The use of polyurethane foams during surgery can be considered an intervention to prevent pressure injury.

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.

Defining Practices to Avoid Hospital-Acquired Pressure Injuries in the Operating Room

BACKGROUND

Data from the Agency for Healthcare Research and Quality indicate that hospital-acquired pressure injuries (HAPIs) and surgical site infections are the only 2 hospital-acquired conditions that have not improved. Consequently, health systems around the nation are struggling to lower HAPI rates and avoid penalties. All patient care areas of the hospital play a part in pressure injury (PI) development. Analysis of real-time PI data and completion of root cause analysis related to HAPIs can guide organizational leaders to specific clinical areas in need of improvement. Surgical patients are high risk for development of a PI due to their unique vulnerability from multiple transfers and induced immobility. Operating room (OR) nursing organizations and wound care professional organizations have published evidence-based clinical practice guidelines addressing prevention of PIs in the OR.

CASES

This article discusses 2 surgical patients from 2 different academic medical centers who experienced OR-associated HAPIs. Operating room HAPI prevention measures should include current evidence-based practice recommendations. Each hospital should take a critical look at their OR HAPI prevention procedures and measure them against the current published guidelines, changing and updating them to reflect best practices for avoiding PI development. Clinicians from both the OR and WOC nurse team can provide expertise to develop confluent nursing practice standards for OR-associated HAPI reduction.

CONCLUSION

This article highlights the commonalities found in the guidelines and encourages collaboration between WOC nurses and OR nurses in building and implementing pressure injury prevention practices associated with the OR.

Knowledge and practices of operating room nurses in the prevention of pressure injuries

BACKGROUND

Operating room (OR) nurses play an important role in preventing the pressure injuries (PIs) that may develop during the perioperative process. This study was conducted to determine OR nurses' level of knowledge about PIs, and how they manage them.

METHODS

This is a cross-sectional, quantitative and descriptive study. The sample of the study consisted of 234 OR nurses working in eight different public hospitals in Ankara. The questionnaire applied in this study was prepared in accordance with the guidelines. This questionnaire consisted of three sections: demographic profiling, common preventive practices, and the knowledge of OR nurses about intraoperative PI prevention.

FINDINGS

66.7% of the participants had received education about PIs during their basic nursing training, and 41.5% had received education after graduation. 97.4% of OR nurses did not follow international guidelines about PIs. The mean total score of the OR nurses for the questions about PIs was 52.0 ± 13.7 out of a possible score of 100. The lowest mean score was obtained for the topic of 'staging pressure injuries', and the highest score was obtained from 'interventions to prevent pressure injuries'. In addition, 81.5% of the OR nurses stated that they were not given information about patients with a high PI risk by clinical nurses. 97.9% of the OR nurses did not use a scale to assess intraoperative PI risks. Fewer than half of the nurses said that they assessed the risk of PIs during surgery. 90.8% the nurses did not record risk assessment and interventions to prevent PIs.

CONCLUSION

There is a need to incorporate basic operating room PI (ORPI) training into both the basic nursing and in-service training to improve the knowledge of OR nurses about how to prevent and manage ORPIs. In addition, measures to assess PI risk and prevent ORPI should be included in institutional policies and procedures.

Assessment of the risk of pressure ulcer during the perioperative period: Adaptation of the Munro scale to Turkish

AIM OF THE STUDY

This study was conducted to adapt the Munro Pressure Ulcer Risk Assessment Scale (Munro Scale) to Turkish and to test its validity and reliability.

MATERIALS AND METHODS

In the methodological study, the data were collected using the patient identification form, the Braden Scale, and the Munro Scale. A total of 188 patients were diagnosed for the risk of preoperative and intraoperative pressure ulcer, and then re-evaluated in the recovery room and in their bed.

RESULTS

The study group consisted of 81 (43.1%) males and 107 (56.9%) females with a mean age of 51.98 ± 16.87. The Kaiser-Meyer-Olkin sampling adequacy test was 0.588 and the Bartlett's test was 430.471. The results of goodness of fit indices were not as expected value in the confirmatory factor analysis. In the exploratory factor analysis, it was determined that the factor loadings of the Munro Scale varied between 0.336 and 0.873 and explained 62% of the total variance. In the parallel-form method performed for the reliability of the scale, it was observed that there was a weak and negative correlation between the total scores of the Munro Scale and Braden Scales before the surgery and a negative and moderate correlation between the total scores after the surgery. The total Cronbach's alpha value was found to be 0.504. In the reliability analysis of the scale, interrater correlation coefficients were found to be 0.865-0.998.

CONCLUSIONS

The Munro Scale can be used to assess the risk of pressure injuries in perioperative patients and may help nurses to identify high-risk patients.

Comparison of interface pressures on three operating table support surfaces during surgery

AIM OF THE STUDY

To investigate the effect of support surface usage and positions on interface pressure during surgery.

MATERIALS AND METHODS

This randomized controlled experimental study was conducted between October 2018 and June 2019. The study included patients who had planned surgery in supine and prone positions. The sample size was 72 patients. Patients were assigned to three groups (gel support surface, viscoelastic support surface and standard operating table) according to the determined randomization table. During the surgery, the pressure in the patients' body was recorded. The statistics program IBM SPSS Statistics 25.0 packaged software was used in the analyses of data.

RESULTS

There was no statistically significant difference between the total body average interface pressure (mmHg) values between the supporting surfaces in the prone position. There was a statistically significant difference between the total body average interface pressure (mmHg) values between the support surfaces in the supine position, and the average interface pressure measured on the viscoelastic foam support surface was significantly lower than the gel support surface and the standard operating table.

CONCLUSION

In the study, the use of viscoelastic foam support surface was found to be more effective than the use of a standard operating table and gel support surface. Viscoelastic foam support surface is recommended for patients at risk for pressure injury in the operating room.

Adding a Visual Communication Tool to the Electronic Health Record to Prevent Pressure Injuries

Health care organizations no longer receive reimbursement for stage 3, stage 4, and unstageable hospital-acquired pressure injuries, which are never events that require interdisciplinary collaboration to treat and prevent. Perioperative patients are at risk for developing pressure injuries that may not manifest until five or more days after surgery. This quality improvement project aimed to inform inpatient nursing and health care professionals of the potential areas of skin breakdown after surgery using an annotated image (AI) depicting intraoperative patient positioning. To gauge OR nurses' use of the AI, we tracked image addition to the patient records weekly from May 2018 to May 2019 and found an overall average participation rate of 80% to 90%. Adding the AI of surgical positioning and pressure points raised awareness of the potential for skin breakdown and became a valuable communication tool for the inpatient nurses who were providing postoperative care to prevent pressure injuries.

An exploratory study of risk factors for pressure injury in patients undergoing spine surgery

Background

Perioperative patients are potentially at risk for pressure injuries due to anesthetic agents and surgical positioning. Pressure injury increases discomfort and pain in patients and causes complications, which lead to an increase in mortality and hospitalization duration. Most previous studies did not focus on specific types of surgery or surgical positioning. We tried to identify the incidence of perioperative pressure injury during spinal surgery and perioperative risk factors that contribute to pressure injury.

Methods

We retrospectively analyzed electronic medical records of 663 patients who underwent spinal surgery between March 2016 and May 2018. The primary outcome was occurrence of pressure injury. Potential risk factors of pressure injury were selected based on previous studies and expert opinion, and divided into two sub-categories: preoperative and intraoperative risk factors. We compared the clinical characteristics of patients in the pressure injury and non-injury groups. Perioperative risk factors for pressure injury were analyzed by logistic regression.

Results

Among 663 patients, the incidence of all stages of pressure injury was 5.9%. The face and inguinal regions were the most injured sites (both 28.6%). The pressure injury group showed a 13% longer hospitalization period. Preoperative plasma concentration of protein was associated with 0.5-fold lower pressure injury (OR: 0.50; 95% CI: 0.27 to 0.95; P = 0.034).

Conclusions

The incidence of pressure injury was similar to that previously reported and occurred in the direct weight-bearing areas, which led to longer hospitalization. We found that a lower preoperative serum protein level is significantly associated with intraoperative pressure injury occurrence during spinal surgery.

Incidence and Variables Predictive of Pressure Injuries in Patients Undergoing Ventricular Assist Device and Total Artificial Heart Surgeries: An 8-Year Retrospective Cohort Study

OBJECTIVE

To investigate the incidence and risk factors of pressure injury (PI) development after ventricular assist device (VAD) or total artificial heart (TAH) surgery.

METHODS

The investigator reviewed all VAD-TAH surgeries performed between 2010 and 2018 in a large academic health system. The PIs were reported by case incidence, patient incidence, and incidence density for each of the respective 1,000 patient days during the study period. Statistics on four different VAD-TAH devices were assessed; variables significant in bivariate analysis were entered into a stepwise logistic regression model to identify significant predictors of PI.

RESULTS

The sample included 292 independent VAD-TAH surgeries among 265 patients. Thirty-two patients developed 45 PIs. The PI incidence was 11% (32/292), with a PI incidence per patient of 12% (32/265). Incidence density was 10 per 1,000 patient days (1%) for 2010-2012, 12 per 1,000 patient days (1.2%) for 2013-2015, and 10 per 920 patient days (1.1%) for 2016-2018. Logistic regression revealed that significant predictor variables for PI were age, mechanical ventilation time, and preoperative Braden Scale score. The mean time to PI was 23 days after admission and over 14 days after surgery, indicating a low rate of intraoperative and ICU-associated PI.

CONCLUSIONS

The incidence of PI was lower than anticipated given historic rates. Potential mechanisms by which these patients were protected from PI are discussed. Prospective studies to further investigate significant risk factors and effective prevention measures are warranted.

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

Hospital-acquired pressure injuries are a patient safety concern and can be costly for health care organizations. A multidisciplinary team of senior leaders, managers, nurses, and educators from departments that care for perioperative patients created an evidence-based perioperative pressure injury prevention bundle that includes skin and risk assessments, visual and electronic health record cues, prophylactic protection of at-risk skin, communication among providers and leaders regarding patient risk and injury throughout hospitalization, staff member education, compliance audits, root cause analyses, and wound care team follow-up. The prevention bundle resulted in a 50% reduction in perioperative pressure injuries the first calendar year after implementation and a zero-incidence rate for perioperative pressure injuries for at least a two-year period. This article discusses hospital-acquired pressure injuries related to the perioperative setting and outlines the full perioperative pressure injury prevention bundle.

The Effect of Selected Risk Factors on Perioperative Pressure Injury Development

Patients undergoing operative and other invasive procedures are at high risk for developing pressure injuries. This study aimed to determine the incidence of perioperative pressure injuries in patients who underwent procedures lasting two hours or more in Turkey and the risk factors that affect the development of pressure injuries. Data were collected during the perioperative period. The incidence of perioperative pressure injuries was 40.4%. The results of univariate logistic regression analysis showed that intraoperative vasopressor use, skin turgor, and diastolic blood pressure less than or equal to 60 mm Hg were significantly related to the development of pressure injuries. There was no significant difference between patients who developed pressure injuries and patients who did not when comparing their preoperative Braden Scale scores. Perioperative nurses should assess each patient for pressure injury risk and perform interventions to prevent pressure injuries during each stage of the patient's perioperative course.

Estratégias de enfermagem para prevenção de lesão por pressão em pacientes cirúrgicos

Objetivo: Identificar na literatura as estratégias utilizadas pela equipe de enfermagem para prevenção de lesão por pressão em pacientes cirúrgicos. Métodos: Revisão integrativa, utilizando a estratégia PICo, tendo como questão norteadora: “quais as estratégias utilizadas pela equipe de enfermagem para prevenção de lesão por pressão em pacientes cirúrgicos?” As buscas foram realizadas nas bases de dados Web of Science, MEDLINE via PubMed, CINAHL, Cochrane, Scopus e no índice bibliográfico LILACS via BVS, sendo analisados 12 estudos. Resultados: O Brasil se destacou com quatro publicações e os estudos de coorte, com nível de evidência IV, prevaleceram em seis artigos. As intervenções tecnológicas para prevenção de lesão por pressão no centro cirúrgico foram colchões para distribuição de pressão, dispositivo para redução de pressão no calcâneo, instrumentos validados específicos para a classificação do risco de lesão por pressão em pacientes cirúrgicos, além de superfícies de apoio contendo polímero viscoelástico e outros utensílios para alívio da pressão decorrente do peso e de dispositivos médicos. Com relação às intervenções educativas, destacaram-se os protocolos, os treinamentos e a simulação realística. Conclusão: Observou-se que essas estratégias reduziram a incidência de lesão por pressão, além de diminuírem os custos e garantirem a satisfação dos pacientes.

Nursing strategies for pressure injury prevention in surgical patients

Objective: To identify in the literature the strategies used by nursing teams to prevent pressure injury in surgical patients. Methods: Integrative review, using the PICo strategy, with the guiding question: “What are the strategies used by the nursing team to prevent pressure injury in surgical patients?” The searches were performed in the Web of Science, MEDLINE via PubMed, CINAHL, Cochrane, Scopus and LILACS bibliographic index via VHL, from where 12 studies were analyzed. Results: Brazil stood out with four publications and cohort studies, with level of evidence IV, prevailed in six articles. Technological interventions for the prevention of Pressure Injury in the operating room were pressure distribution mattresses, a device to reduce pressure on the calcaneus, specific validated instruments for the classification of the risk of Pressure Injury in surgical patients, in addition to support surfaces containing polymer viscoelastic and other tools to relieve pressure from weight and medical devices. Regarding educational interventions, protocols, training and realistic simulation stood out. Conclusion: It was observed that these strategies reduced the incidence of pressure injury, in addition to reducing costs and ensuring patient satisfaction.

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.

Revalidation of a Perioperative Risk Assessment Measure for Skin

BACKGROUND

Validated perioperative pressure injury (PI) risk assessment measures are few and often cumbersome to complete, leading to missed opportunities to identify and target prevention interventions to those patients at increased risk for developing a postsurgical PI.

OBJECTIVES

Previous validation of a six-item perioperative risk assessment measure for skin (PRAMS) was conducted in our community hospital with positive findings. The purpose of this study was to increase generalizability by revalidating the PRAMS in a larger sample.

METHODS

This was a retrospective chart review of all surgical patients aged ≥18 years positioned in the supine or lateral position in a Midwest quaternary care, multispecialty, 1,500-bed hospital during a 6-month period (n = 1,526). The intent of the study was to revalidate the PRAMS. The main outcome of interest was the development of PI after surgery. Risk indicators of interest included diabetes, age, surgical time, Braden score, previous surgery, and preexisting PI. The diagnostic ability of any of the risk indicators on the development of a postsurgical PI was evaluated using sensitivity, specificity, and predictive values.

RESULTS

Postsurgical PIs occurred in 121 patients. Comparing current to previous study results, the PRAMS was effective in identifying surgical patients at risk for PI (sensitivity = .98). Those patients with a postsurgical PI had a lower mean Braden score, were more likely to have a preexisting PI, and were more likely to have a previous surgery during the same admission (p < .001 for all risk indicators), comparing favorably to the original study. Patients without risk indicators were unlikely to develop a postsurgical PI (negative predictive value = .98).

DISCUSSION

Results of this validation study demonstrate that the PRAMS is effective in identifying patients who developed a postsurgical PI using information readily available to the perioperative staff.

The effectiveness of curvilinear supine position on the incidence of pressure injuries and interface pressure among surgical patients

BACKGROUND

Intraoperative pressure injury is still a major problem of perioperative nursing. Reducing the peak interface pressure is a valid clinical intervention for reducing the incidence of intraoperative pressure injuries. However, studies of repositioning and pressure-redistributing for surgical patients are still lacking. In this context we aimed to evaluate the effect of a curvilinear supine position on incidence of pressure injury with surgical patients in a hospital setting.

METHODS

This was a prospective, randomized, controlled study, carried out from May to December 2016, included 104 surgical patients from a university hospital in China (experimental group, n = 52; control group, n = 52). Incidence of pressure injury, interface pressure, comfort and satisfaction scores from surgeons, anesthesiologists, OR nurses were recorded. Mann-Whitney U Chi-square test was used for difference of pressure injury's incidence and mixed linear model was used for interface pressure.

RESULTS

Overall the intervention group had significant fewer intraoperative pressure injuries than the control group (0 patients [0%] vs. 9 patients [17.65%], p = 0.002). Compared with control group, the experimental group had significantly lower interface pressures in the sacrum and heel regions (F = 23.81, p < 0.001; F = 60.71, p < 0.001). The subjects felt comfortable in two groups were 40(80%) vs. 3(5.88%) (experimental group vs. control group), respectively (p < 0.001).

CONCLUSIONS

Curvilinear supine position could significantly decrease the incidence of perioperative pressure injuries in surgical patients with surgery duration more than three hours. Considering these results, we recommend that curvilinear supine position use as effective interventions to inform perioperative care delivery, reducing perioperative pressure injuries. These findings may serve to guide the application of pressure redistribution in the surgical positioning of patients during prolonged surgery.

Risk assessment for perioperative pressure injuries

Objectives:

to evaluate and classify patients according to the Risk Assessment Scale for Perioperative Pressure Injuries; verify the association between sociodemographic and clinical variables and the risk score; and identify the occurrence of pressure injuries due to surgical positioning.

Method:

observational, longitudinal, prospective and quantitative study carried out in a teaching hospital with 278 patients submitted to elective surgeries. A sociodemographic and clinical characterization questionnaire and the Risk Assessment Scale for Perioperative Pressure Injuries were used. Descriptive, bivariate and logistic regression analyses were applied.

Results:

the majority of patients (56.5%) presented a high risk for perioperative pressure injury. Female sex, elderly group, and altered body mass index values were statistically significant (p < 0.05) for a higher risk of pressure injuries. In 77% of the patients, there were perioperative pressure injuries.

Conclusion:

most of the participants presented a high risk for development of perioperative decubitus ulcers. The female sex, elderly group, and altered body mass index were significant factors for increased risk. The Risk Assessment Scale for Perioperative Pressure Injuries allows the early identification of risk of injury, subsidizing the adoption of preventive strategies to ensure the quality of perioperative care.

A prediction tool for hospital-acquired pressure ulcers among surgical patients: Surgical pressure ulcer risk score

Surgical patients are prone to developing hospital-acquired pressure ulcers (HAPU). Therefore, a better prediction tool is needed to predict risk using preoperative data. This study aimed to determine, from previously published HAPU risk factors, which factors are significant among our surgical population and to develop a prediction tool that identifies pressure ulcer risk before the operation. A literature review was first performed to elicit all the published HAPU risk factors before conducting a retrospective case-control study using medical records. The known HAPU risks were compared between patients with HAPU and without HAPU who underwent operations during the same period (July 2015-December 2016). A total of 80 HAPU cases and 189 controls were analysed. Multivariate logistic regression analyses identified eight significant risk factors: age ≥ 75 years, female gender, American Society of Anaesthesiologists ≥ 3, body mass index < 23, preoperative Braden score ≤ 14, anaemia, respiratory disease, and hypertension. The model had bootstrap-corrected c-statistic 0.78 indicating good discrimination. A cut-off score of ≥6 is strongly predictive, with a positive predictive value of 73.2% (confidence interval [CI]: 59.7%-84.2%) and a negative predictive value of 80.7% (CI: 74.3%-86.1%). SPURS contributes to the preoperative identification of pressure ulcer risk that could help nurses implement preventive measures earlier.

Pressure Ulcers: Factors Contributing to Their Development in the OR

The prevention of health care-associated pressure ulcers (HAPUs) is an important quality measure because HAPUs are considered a never event. The literature suggests that the prevalence rate of pressure ulcers is 8.5% or higher among patients who undergo surgical procedures that last longer than three hours. We performed a retrospective chart review to determine what factors contribute to the development of pressure ulcers in patients who undergo surgical procedures. The sample population included patients who acquired a pressure ulcer that was not present at admission and developed during their postoperative hospital stay. The project revealed consistent risk factors that may contribute to the development of pressure ulcers in patients who have undergone surgical procedures. These findings can drive the implementation of preventive measures to reduce the occurrence of HAPUs associated with surgical procedures.

Assessment scale of risk for surgical positioning injuries

OBJECTIVE

to build and validate a scale to assess the risk of surgical positioning injuries in adult patients.

METHOD

methodological research, conducted in two phases: construction and face and content validation of the scale and field research, involving 115 patients.

RESULTS

the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning contains seven items, each of which presents five subitems. The scale score ranges between seven and 35 points in which, the higher the score, the higher the patient's risk. The Content Validity Index of the scale corresponded to 0.88. The application of Student's t-test for equality of means revealed the concurrent criterion validity between the scores on the Braden scale and the constructed scale. To assess the predictive criterion validity, the association was tested between the presence of pain deriving from surgical positioning and the development of pressure ulcer, using the score on the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning (p<0.001). The interrater reliability was verified using the intraclass correlation coefficient, equal to 0.99 (p<0.001).

CONCLUSION

the scale is a valid and reliable tool, but further research is needed to assess its use in clinical practice.

Whole-lung lavage for pediatric patients with pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis (PAP) is a chronic disorder of surfactant clearance from the alveoli. Its prevalence is rare, especially in the pediatric population. Although there is no cure for this condition, symptoms of PAP are managed most effectively through whole-lung lavage (WLL). Perioperative RNs caring for children with PAP undergoing WLL in the OR should implement patient interventions to maintain vital signs and normothermia and preserve skin integrity. Additionally, perioperative RNs often are responsible for assembling closed-drainage systems for WLL. Detailed procedural preference cards, targeted education sessions, and multidisciplinary collaboration are crucial for establishing a comprehensive plan of care for the pediatric patient with PAP undergoing WLL in the OR.

Expanded resources through utilization of a primary care giver extracorporeal membrane oxygenation model

Extracorporeal membrane oxygenation (ECMO) is a long-term extracorporeal support for critically ill patients with life-threatening compromises in cardiac and/or respiratory function. The unpredictability of ECMO resources for a large pediatric and adult population prompted a need for the ability to respond to significant fluctuations in the volume of patients on ECMO. Through multidisciplinary collaboration, the Primary Care Giver (PCG) ECMO Staffing Model was developed to accommodate unpredictable fluctuations in ECMO activity and to maintain flexibility and fiscal responsibility in turbulent economic times. Advancements in extracorporeal technology supported the opportunity to develop a safe and extended staffing model for ECMO. Combining the use of a centrifugal pump system with specialized and experienced cardiovascular intensive care nurses and the ECMO specialist team provided a milieu for education and training to support the new staffing model. The PCG ECMO model provides a safe, flexible, and fiscally responsible staffing model for variable ECMO activity.