Reduce, Relieve, and Redistribute: Implementing a ...



Reduce, Relieve, and Redistribute: Implementing a Perioperative Pressure Ulcer ProgramMarcie ChenetteAbstractPerioperative pressure ulcers are the leading hospital acquired pressure ulcer (Black, Fawcett, & Scott, 2014). MidMichigan Health will be introducing a perioperative risk assessment using Scotts Triggers to identify patients who are at high risk for developing a pressure ulcer during surgery. If patients meet 2 or more of the 4 criteria identified they will be considered at high risk. The risk assessment will be built in MidMichigan’s Epic documentation and an alert will fire at each level of care to notify staff that the patient is at higher risk and additional precautions should be applied.Keywords: perioperative, pressure ulcer, Scotts Triggers, prevention, documentation.Author DescriptionMarcie Chenette is a registered nurse who is completing the accelerated RN-MSN informatics track at Ferris State University. She is an Epic analyst and principal trainer in Optime and Anesthesia for MidMichigan Health. Marcie has been employed by MidMichigan Health for 17 years. Marcie Chenette has no conflicts of interest.Reduce, Relieve, and Redistribute: Implementing a Perioperative Pressure Ulcer ProgramPressure ulcers in the operating room contribute to up to 45% of hospital-acquired ulcers (Black, Fawcett, & Scott, 2014). Perioperative nurses currently are not identifying patients that are at risk for developing a perioperative pressure ulcer during surgery or completing a pre-operative skin assessment. Pressure ulcers can be devastating for patients and can financially impact the hospital (Bollinger, Postlewaite, Denslow, & Hooper, 2017). Working with the Director of Perioperative Services, MidMichigan Health perioperative nurses will be implementing a quality improvement project to establish criteria to identify patients at risk for developing a perioperative pressure ulcer and incorporating a skin assessment to identify breakdown prior to surgery. This project will identify patients at higher risk for developing a pressure ulcer during surgery using Scott Triggers. The purpose of this project is to alert the perioperative nurse that the patient is at a higher risk for developing a pressure ulcer during surgery. Identifying patients at a higher risk for developing a pressure ulcer during surgery allows perioperative nurses to proactively initiate precautions for the best possible outcome for the patient during their perioperative experience. The goal is to decrease the incidence of patients who acquire an ulcer during their surgical procedure.Literature ReviewCenters for Medicare and Medicaid Services (CMS, 2016) have created a pay for performance initiative for hospital acquired conditions, including pressure ulcers, which have become a major health issue. Pressure ulcers are created by pressure, friction, and shear force (Chen, Chen, & Wu, 2012). Surgical related pressure ulcers represent the most common hospital acquired ulcers (Chen, Chen, & Wu). According to Spruce (2017), hospital acquired pressure ulcers are considered an event that should never happen. Hospitals are not reimbursed for the care provided for those patients who acquire a pressure ulcer during hospitalization (Spruce, 2017).Rao et al. (2016), completes a systematic review that showed many risk factors associated with developing pressure ulcers. The amount of time the patient spends on the operating room table was one of the most significant risks. Other common risk factors included co-morbid condition, age, severe illness, malnourished, and over/underweight (Rao et al., 2016).Surgical patients are at risk for many reasons. The most notable is the patient is under anesthesia and unable to reposition themselves or voice pain. This means that they rely on the perioperative team members to protect them from harm. Identifying patients at a higher risk pre-operatively is important to begin the process of protecting the patient. Currently the hospital only utilizes the Braden Scale to identify patients at risk for developing a pressure ulcer. The Braden Scale is an effective tool for the inpatient setting, however it lacks appropriate risk criteria for surgical patients. Every patient would accumulate the lowest score for sensory perception and mobility, ultimately identifying every patient as high risk while under anesthesia utilizing the Braden Scale (Munro, 2010). MethodsPlanningMidMichigan Health nursing units were struggling with identification, documentation at point of entry to the hospital, and wound care consultations on patients who were identified as having an ulcer. A review of process discovered that in addition to the deficiency on the nursing units, the perioperative department was not completing a risk assessment or skin assessment on patients whose point of entry to the hospital was through the perioperative area. This review led to further research better directed to surgical patients.Research showed the Association of periOperative Room Nurses (AORN) had begun an initiative called Prevent Perioperative Pressure Ulcers. AORN published toolkits to help assist in the design for implementing the prevention initiative (Fawcett, D.L., 2016). AORN recommends using a standardized method for evaluating a risk for developing pressure ulcers (Spruce, 2017). Perioperative nurses only had the Braden Scale available to document patients at risk for developing a pressure ulcer, which although a good tool, does not address the unique circumstances related to surgery. Two suggested assessments from AORN were Scott Triggers and the Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients (Spruce, 2017). Scott Triggers risk assessment is based on four criteria. The Munro assessment includes many of the criteria in Scott Triggers along with several additional criteria including body temperature and blood loss. Due to the length of the assessment and risk for compliance with the Munro Scale it was decided that Scott Triggers would be more appropriate for the perioperative setting. The Munro scale also was rejected because some of the data was unable to be collected until surgery was complete (ex. blood loss), eliminating the identification of being at risk prior to surgery. Identifying patients preoperatively allows perioperative staff to act proactively and initiate preventative interventions as opposed to a reactive response once the harm is already completed (Bollinger et al., 2017).Scott Triggers address four criteria that predict a higher risk for developing a pressure ulcer during surgery (Spruce, 2017). The criteria included in Scott Triggers are; age 62 or older, albumin level <3.5 g/L or body mass index (BMI) <19 or >40, American Society of Anesthesiologists (ASA) score 3 or greater, and estimated surgery time over 3 hours (this time is considered patient in room to patient out of room) (Spruce, 2017). If the patient is identified in 2 or more of these areas they are considered at an increased risk of developing a perioperative pressure ulcer (Spruce, 2017).Development of electronic documentation and a best practice advisory within Epic will help communicate that a patient is at a high risk for developing a pressure ulcer during surgery. If the patient meets 2 or more of the criteria listed in Scott Triggers, a best practice advisory will fire when the perioperative staff open the chart. The precautions listed in the best practice advisory should be initiated to prevent the patient from injury and documented in the electronic medical record. According to Spruce (2017), it is important that all perioperative staff understand the risk for injury to patients. This includes completing a complete skin assessment, identifying pressure injuries, proper positioning and padding of patients, and transferring patients appropriately. In addition to the implementation of this project all operating room pads currently being used will be evaluated to make sure proper pressure redistribution pads are being used.Evaluation and predicted results. The evaluation of this project due to limited time frame will be based on percent of perioperative pressure ulcer risk assessments completed. According to Meehan & Beinlich (2014), a 77% reduction rate was obtained in surgical acquired pressure ulcers after a pre-assessment program was initiated. Further evaluations will be conducted on reporting of perioperative acquired pressure ulcers with the goal to see a decrease of 50% from current reporting. Last year MMC-Midland reported two perioperative acquired pressure ulcers.Setting. The perioperative pressure ulcer prevention quality improvement project will take place at MidMichigan Health in the perioperative setting, beginning in Midland. MidMichigan Medical Center-Midland is a tertiary hospital, Level 2 trauma center. MidMichigan Medical Center-Midland has approximately 90 surgeons, 10 operating rooms; including robotics, open heart, and a hybrid room. In 2016, 13,537 cases were completed at MMC-Midland.DoCreation of the best practice advisory in the electronic medical record Epic, including when and where it will open, is in cooperation with the Epic Orders and Epic ClinDoc teams. Orders owns the best practice advisory and ClinDoc owns the interdisciplinary flowsheets used in documentation. After meeting with the Orders team, it was identified that the information within the best practice advisory is definitive data. This means the best practice advisory can be created to fire without abstracting the information into an assessment. This is a significant find, this means that nurses do not have to duplicate documentation and 100% of patients will be assessed. It was decided that the skin assessment can be completed utilizing the current documentation for skin breakdown in Epic.Creating the best practice advisory to fire automatically required a lengthy build in Epic to configure and combine the criteria. Height and weight will be pulled from the required pre-operative documentation which calculates BMI. Length of surgery will be pulled from the preference cards. Albumin (if drawn) can be pulled from the lab. Age will be pulled from the patient’s date of birth. ASA will be pulled from the anesthesia pre-assessment.The best practice advisory will alert the nurse that the patient is at a high risk for developing an ulcer during surgery. It also notifies the nurse that the following initiatives should be taken; 1. Padding the heels. 2. Use pressure redistribution services. 3. Manage moisture, friction, and shear. The alert will fire when the perioperative staff opens the chart. It will remain open until the clinician accepts the alert. Training was completed to perioperative nurses that included proper completion of a skin assessment, what criteria was included in the risk assessment, and what the initiatives meant for the perioperative nurse. Training materials included a Power Point and handouts for presentation to perioperative nurses. Education is crucial in knowledge and compliance in the success of implementing the perioperative pressure ulcer prevention plan. Perioperative nurses must be knowledgeable about the risk factors and what the proper initiatives are to prevent injury (Primiano et al., 2011).Pre-operative nurses are the first line of communication with the patient. The pre-operative nurse will be trained on proper skin assessment on admission. Having a base skin assessment is important for several reasons. If the patient has the beginning of breakdown, additional precautions can be added. It also helps identify whether a pressure ulcer is hospital acquired or if it existed upon admission, which is imperative for payment of services. Intra-operative nurses are important in preventing injury during the operation. Surgical patients are at an increased risk due to being under anesthesia (Chen, Chen, & Wu, 2012). The role of the intra-operative nurse is to use proper positioning and preventing moisture, shear, and friction. Positioning of a patient for surgery should not result in injury (Spruce & Van Wicklin, 2014). Pressure redistribution overlays, at a cost of $1.66 per patient, were found to be overall more cost effective for the hospital by reducing pressure ulcers (Ba et al., 2011). Moisture should be monitored to avoid pooling of prep agents and/or irrigation fluids. Friction and shear should have special monitoring during positioning and transfer of patients (Burlingame, 2017). Patients identified at high risk should be shared during the pre-operative briefing which includes the surgeon, anesthesia, circulator, and scrubs that are participating in the patient’s surgery. Post-operative nurses will monitor the patient after surgery is completed. For those patients who were identified as a high risk for developing a pressure ulcer, the post-operative nurse will re-assess the patient’s skin condition. Inspecting areas that are pressure points or areas that may have been exposed to friction post-operatively can be identified in an early stage. Proper documentation and consult to the wound specialist can also help prevent injury.StudyOnce build was complete, testing started to verify that the best practice advisory fired appropriately. Testing was completed on each area that could make the alert fire. The testing was completed with the following equation: 1 = age, 2 = BMI>40, 3 = BMI<19, 4 = albumin, 5 = ASA, 6 = length of surgery; (1 and ((2 or 3 or 4)) or (1 and 5) or (1 and 6) or ((2 or 3 or 4) and 5) or ((2 or 3 or 4) and 6) or (5 and 6).Issues were noted during testing that identified 5 = ASA and 6 = length of surgery were hitting the surgical encounter, but not the hospital encounter. For the best practice advisory to open when the chart opens the criteria must hit the hospital encounter. Further research was completed with Epic and issues were corrected using admission rule criteria that associated with the hospital encounter. Testing was completed again and the best practice advisory worked appropriately. Meaning 100% of patients will automatically have the risk assessment completed and notify nurses if a patient is considered at a higher risk for developing a pressure ulcer during surgery.The testing of the risk assessment is vastly different than the planned phase. The plan was to have the nurse complete the assessment by checking yes/no for the criteria listed in Scott Triggers. This build would have been much easier and less time consuming. Although it was more in depth and required more time building and testing, seeing the alert fire automatically when opening the chart is very substantial. Lippitt (1958), concentrates on the role and responsibility of the change agent other than the process of the change. Using Lippitt’s change theory, the best practice advisory becomes the change agent since a perioperative nurse is not needed to complete the assessment. This helped promote a successful implementation of the project. ActInitial evaluation of the project was originally going to access percentage of risk assessments completed. Upon build of the best practice advisory, as stated previously, it was found the best practice advisory could fire from other definitive documentation and the nurse would not need to complete the assessment. Since this eliminates this evaluation tool, project evaluation will be conducted in 6 months to identify if a decrease in perioperative ulcers is determined.The project for identifying patients at risk was successful. Additional affiliates will be included at a rate of one affiliate per month for the next four months. Allowing time for training and implementation of the project. Statistical data for perioperative pressure ulcers will only be collected from MidMichigan Medical Center-Midland for the initial 6 months and will include all five affiliates at 12 months. Plans to include a sixth affiliate will be completed when finalization of acquisition and implementation of Epic is completed at the affiliate. Moving forward training will be added to onboarding training materials for pre-operative, intra-operative and post anesthesia care nursing material. Discussion and ConclusionThis project was important to identify patients at risk for developing a pressure ulcer during surgery. A big win was being able to create a risk assessment that is able to be completed by definitive documentation and the perioperative nurse would not need to re-document in a specific assessment. Since perioperative nurses did not need to complete additional documentation or have additional work to complete, the response to this project was very successful. The conclusions drawn on this project are 100% of patients entering the perioperative area will have a risk assessment automatically completed. This will identify 100% of patients considered at a higher risk for developing a pressure ulcer during surgery based on Scott Triggers. Identification of high risk patients will allow nurses to act on initiatives to help protect the patient from developing a pressure ulcer during surgery. Limited time for the project failed to allow follow-up on surgical outcomes. Additional collection of data will need to be completed to detect if a decrease in perioperative pressure ulcers is obtained. ReferencesBa, P., Teague, L., Mahoney, J., Goodman, L., Paulden, M., Poss, J., Jianli, L.,…Krahn, M. (2011). Support surfaces for intraoperative prevention of pressure ulcers in patients undergoing surgery: A cost-effectiveness analysis. Surgery 150(1), 122-132. , J., Fawcett, D., & Scott, S. (2014). Ten top tips: preventing pressure ulcers in the surgical patient.?Wounds Int J, 5(4), 14-18.Bollinger, J., Postlewaite, C., Denslow, S., & Hooper, V. (2017). Exploration of the Scott triggers instrument in predicting postoperative pressure ulcer risk. Journal of PeriAnesthesia Nursing 32(4), 45-46. , B.L. (2017). Guideline implementation: Positioning the patient. AORN Journal 106(3), 227-237. , H., Chen, X., & Wu, J. (2012). The incidence of pressure ulcers in surgical patients of the last 5 years. Wounds 24(9), 234-241. Retrieved from for Medicare & Medicaid Services [CMS] (2016). Fiscal year 2016 results for the CMS hospital-acquired conditions reduction program. Centers for Medicare & Medicaid Services. Retrieved from: , D.L. (2016). New collaboration for pressure injury prevention. AORN Journal 104(4), 17-18. (16)30632-9Lippitt, R. (1958). The dynamics of planned change. New York, NY: Harcourt and BraceMeehan, A., & Beinlich, N. (2014). Peer-to-peer learning/teaching: An effective strategy for changing practice and preventing pressure ulcers in the surgical patient. International Journal of Orthopedic and Trauma Nursing 18(3), 122-128. , C.A. (2010) The development of a pressure ulcer risk-assessment scale for perioperative patients. AORN Journal 92(3), 272-287. , M., Friend, M., McClure, C., Nardi, S., Fix, L., Schafer, M…McNett, M. (2011). Pressure ulcer prevalence and risk factors during prolonged surgical procedures. AORN Journal 94(6), 555-566. , L., & VanWicklin, S.A. (2014). Back to basics: Positioning the patient. AORN Journal 100(3), 299-303. , A.D., Preston, A.M., Strauss, R., Stamm,R., Zalman, D.C. (2016) Risk factors associate with pressure ulcer formation in critically ill cardiac surgery patients: a systematic review. Journal of Wound Ostomy Continence Nursing 43(3), 242-247. , S.M. (2015). Progress and challenges in perioperative pressure ulcer prevention. Journal of Wound Ostomy Continence Nursing 42(5), 480-485. , L. (2017) Back to basics: Preventing perioperative pressure injuries. AORN Journal 105(1), 92-98. ................
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