Hospital-acquired pressure ulcers are costing hospitals billions of dollars in treatment.1 For major surgeries, HAPUs are adding 44 percent to the hospital costs. More research is being done, but research shows per patient, the cost of treatment is running $20,000 to $70,000. To learn more about focusing on the operating room to reduce the number of pressure injuries I spoke with Debra Fawcett. Fawcett is a registered nurse and Director of Infection Prevention at Eskenazi Health. For years, she has been researching and educating nurses on pressure injuries in the operating room.
Martie: What challenges are today’s nurses and OR teams dealing with that are contributing to these high numbers in pressure injuries?
Debra: There are multiple issues and barriers, but the number one issue is lack of knowledge. This is an area of the OR that is really just beginning to get its feet on the ground. A lot of people will come in and say we had no idea. I will be inundated with questions about how come no one has told us about this before. Many anesthetists did not believe that pressure injuries began in the OR, but we’re now starting to see a change in that belief because they’re now experiencing them and root cause analysis is being brought back to the OR. They are now seeing it makes sense, especially when you can see the injury is the exact shape of the piece of equipment.
Martie: You mentioned root cause analysis? Why is it so critical in the OR and really any healthcare setting in achieving better outcomes?
Debra: It gives you a roadmap back. It tracks where you’ve been, what you’ve done and what the risks were when the patient arrived. There’s a bit of a grey area in the pre-op clinic. Patients may sit not just in the pre-op clinic, but in a pre-op holding area for four, five, even six hours waiting for their turn in surgery. Those patients are laying on beds not made for pressure reduction, relief or redistribution. Those beds were made to temporarily hold someone before their surgery. So one patient could be sitting in pre-op for six hours, then another 10 hours in surgery and finally in the post-anesthesia care unit (PACU.) All of that pressure is built up, and there’s no communication about these two areas between the different teams. Then add that there are no risk assessments for the patient.
In 2014, I conducted a survey and communication was one of the biggest issues for perioperative nurses, units and WOCNs. If the nurses aren’t looking back far enough and they’re not adding that root cause analysis to track it back to the OR, they’ll blame it on whatever unit they’re on.
On the plus side, I will add one reason we are seeing higher numbers of pressure injuries in the OR because teams are starting to conduct more root cause analyses.
Martie: What are the common complaints and issues you’re hearing about from nurses when it comes to positioning and pressure injuries?
This is an interesting question. There is some great education on positioning out there, including from AORN and the hospitals themselves. One problem we have though is our beds are made for utility, not for comfort or even the size of the patient. We need to do these three things:
- Get the OR team up to the bed.
- Get the team good visibility.
- Get the patient stable.
Another big complaint I’m hearing is doctors don’t believe the injuries are coming from the OR. Even my own team tells me they’re dealing with this issue. Finally, many nurses are complaining they don’t have as much help as they should, that it can be difficult getting the patient positioned correctly and there is equipment to position patients safely, but it’s really expensive.
Debra: How can clinicians make an impact?
I think the first part is awareness. They need to be aware before they can change any behavior. If they’re experienced, and are aware then they need to communicate. I was absolutely amazed during that survey in 2014 how many people said once that patient leaves the OR, they never know whether that patient has had a pressure injury. It never comes back to the OR. On the other side of the coin, they don’t necessarily report to the unit staff what position the patient was in, for how long and any equipment or devices used to move or hold them. When you have a nurse who knows what they’re doing and they communicate to staff that leads to an awareness to all team members. I’m now seeing perioperative nurses are now being included in the review process and they’re coming back to the OR and talking to the other staff nurses.
We can decrease the prevalence of pressure injuries by using an assigned champion, someone who has the advanced knowledge and then shares it. The other staff can see there’s weight in what that nurse has to say. Word spreads and there’s increased awareness, cutting into the lack of knowledge. It’s happened with me where I’ve talked about pressure injuries, made people aware of the issues and my colleagues started to listen and make changes.
Continuing education can help your OR team learn best practices for preventing pressure injuries.
1. High Cost of Stage IV Pressure Ulcers. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950802/. The American Journal of Surgery. October 2010.