Running head: REDUCING HOSPITAL ACQUIRED PRESSURE ULCERS

Reducing Hospital Acquired Pressure Ulcers in Surgical Patients

Christen Bowman, Michelle Carrillo, Amy Ellsworth
Western Washington University

REDUCING HOSPITAL ACQUIRED PRESSURE ULCERS

Abstract
Purpose: The purpose of this research is to explore the use of pressure redistribution surfaces to
reduce the occurrence of hospital acquired pressure ulcers in the operating room. Additionally,
the nurses role in HAPU prevention through risk assessment and handoff communication in the
perioperative setting will be examined.
Rationale: Patients undergoing surgery are at unique risk for developing HAPUs. Limited
research has been conducted on addressing pressure ulcers caused during surgery because most
research has been limited to long term patients.
Methods: A Literature review was conducted using CINAHL, PUB-MED, Google Scholar and
Heal-WA databases. The articles in this literature review include five expert opinions, three
randomized controlled trials and two meta-analyses, specifically focusing on the perioperative
setting and the use of distribution surfaces during surgery, risk assessments and communication
handoff.
Results/ Implications: The literature review revealed that operating table overlays may reduce the
occurrence of HAPUs compared to standard operating tables. Nurses must take the lead in
developing pressure ulcer risk assessment tools that specifically address surgical patients.
Perioperative teams must participate in effective hand-off communication. A multi-faceted
approach using risk assessments, pressure redistribution surfaces, and good handoff
communication, allow nurses to tackle the burden of HAPUs unique to the surgical population.
Key words: pressure ulcer prevention, risk assessments, handoff, perioperative, communication

REDUCING HOSPITAL ACQUIRED PRESSURE ULCERS

Reducing Hospital Acquired Pressure Ulcers in Surgical Patients

In 2006, Medicare estimated that one hospital acquired pressure ulcer (HAPU) costs over
$43,000 to treat and according to the National Pressure Ulcer Advisory Panel...45% of HAPUs
develop in the [operating room] (OR) (as cited by Black, 2014, p. 14). The review of literature
revealed that it is important to regard the perioperative period and surgical patients as having
unique risk factors in developing HAPUs (Gonzales & Picket, 2011; Munro, 2010). It is
essential that the perioperative nurse and surgical team identify risks and implement strategies
that aid in reducing the occurrence of HAPUs (Munro, 2010).
Development of HAPU and tissue damage isnt necessarily apparent intraoperatively and
damage may not be visible for several hours and can even take a few days to become evident
(Walton-Geer, 2009). The perioperative nurse carries the burden of reducing pressure ulcer
occurrence in the surgical setting. The Association of perioperative Registered Nurses (AORN)
holds conferences with a variety of specialists for discussion of pressure ulcer development and
to review current treatment modalities. During a 2014 AORN conference, there was consensus
that even with the implementation of best practices a pressure ulcer may not be completely
avoidable (Baharestani et al., 2014). Whether HAPUs are preventable or not, they have negative
impacts on patients and medical care providers.
Pressure ulcers are caused by pressure applied to an area (McCance, Huether, Brashers,
& Rote, 2010). Patients undergoing surgery experience unique processes such as hours of being
immobile on an OR surface, externally applied force, blood loss, anesthesia and surgical removal
or alteration to organs (Walton-Geer, 2009). Patients who spend hours unmoved on the surgical
table are at an increased risk for tissue breakdown due to vulnerable pressure points such as the

REDUCING HOSPITAL ACQUIRED PRESSURE ULCERS

sacrum, heel and forehead, although these specific areas depend on patient positioning during
surgery (Walton-Geer, 2009). Once shifted from a position, reperfusion ensues which often
causes injury and may result in further tissue damage (McCance, et al., 2010). The trajectory of a
patient that develops a HAPU is one of pain, longer hospitalization, and possibly even death in
severe cases (Munro, 2010). The purpose of this literature review was to answer the question:
What types of operating room strategies can be used to reduce the occurrence of HAPUs in the
surgical patient?
Synthesis of the Literature
Pressure ulcer prevention research has been conducted in long-term care, intensive care,
and rehabilitation settings with little focus on acute care settings or the surgical environment
(Walton-Geer, 2009, p. 538-39). According to Black, Fawcett, & Scott (2014) more research
needs to be conducted to determine the incidence of pressure ulcers that originate in the OR. In
reviewing research specific to the perioperative setting, there were three themes that related to
HAPU development and its relationship to distribution surfaces, risk assessments and
communication handoff.
Risk assessment
Risk assessments are commonly used by nurses in the perioperative setting to determine
the amount of risk that a patient has in developing a HAPU. These assessments are performed by
the Registered nurse (RN) and include a thorough head to toe skin assessment and the use of the
Braden scale. The purpose of the skin assessment is to detect alterations in skin integrity
including lacerations, bruising and redness. An alteration in skin integrity can increase a patients
risk for developing a HAPU and early detection will assist nurses in instituting interventions to

REDUCING HOSPITAL ACQUIRED PRESSURE ULCERS

prevent further skin damage. In the perioperative setting, nurses are responsible for assessing
patients risks for pressure ulcer development and implementing preventative measures (Munro,
2010). The Braden scale focuses on the following subscale categories which are: sensory
perception, moisture, activity, mobility, nutrition, friction and shear (Gonzales & Pickett, 2011).
Currently, there are no proven risk assessment scales that are designed specifically for use
in the perioperative setting. Research by Gonzales and Pickett (2011) suggest that a new
approach is needed in the OR that captures this populations risk for HAPU development. It is
necessary to make a scale that can reduce the incidence of HAPUs in the surgical setting; a risk
assessment scale that includes the use of the Braden scale, surgical risks factors and pre-existing
conditions (Gonzales & Pickett, 2011; Munro, 2010). Munro (2010) suggests that a perioperative
risk assessment scale will assist nurses in planning care and implementing interventions at a
much earlier phase of care; all of which can potentially reduce the occurrence of HAPUs in the
surgical setting. Assessing patients prior to surgery is a vital first step and should be performed
before the surgery begins; high risk patients not properly identified in the preoperative period
will not receive proper preventative measures for pressure ulcer prevention (Black et al., 2014;
Munro, 2010).
Communication
The perioperative setting involves different phases and includes the preoperative,
intraoperative and postoperative settings. In each of these phases, nurses are given patients to
care for and the nurse who is previously working with that patient is responsible to provide the
next nurse with a thorough informative report for care of that patient during the time of care
handoff (Black et al., 2014; Gonzales & Picket, 2011; Munro, 2010; Robins & Dai, 2015). The

REDUCING HOSPITAL ACQUIRED PRESSURE ULCERS

rationale for this is that the continuum of care will be provided and will specifically address the
needs of patients that the health care team is caring for. Gonzales and Pickett (2011) report that a
team approach can greatly decrease the incidence of HAPU occurrence in surgical patients, part
of this approach is understanding the present risk factors that the preoperative nurse identifies
through the risk assessment, and reporting these findings to the intraoperative nurse, at the time
of care handoff.
The perioperative team consists of healthcare team members from different settings who
work together and includes the wound care team, ostomy and continence nurses, surgeons,
anesthesiologists and postoperative nurses (Black et al., 2014; Gonzales & Picket, 2011; Robins
& Dai, 2015). Communication and collaboration at each of these phases needs to be accurate,
timely and efficient, as this is a cohesive approach to the continuum of care and helps to reduce
the incidence of pressure ulcers in surgical patients (Black et al., 2014; Gonzales & Picket,
2011). Likewise, Munro (2010) agrees that nurses and anesthesia care providers need to
implement a collaborative approach in formulating an assessment and plan of care specific to
surgical patients to aid in implementing best practices and to reduce the occurrence of pressure
ulcer development in the perioperative setting.
Intraoperative Pressure Redistribution Surface
Overall, the evidence from three randomized controlled trials (RCT), a Cochrane metaanalysis and expert opinion revealed that using an OR table overlay redistributes pressure more
effectively than the standard OR table ( Black et al., 2015; Gul & Karadag, 2015; Keller, 2006;
McInnes, Jammali-Blasi, Bell-Syer, Dumville, & Cullum, 2012; Shelanski et al., 2009; Walton-

REDUCING HOSPITAL ACQUIRED PRESSURE ULCERS

Geer, 2009). Implementing this intervention has the potential to reduce HAPUs in the surgical
patient. In reviewing causes of surgical HAPU the literature revealed several things.
Many intrinsic factors such as age, nutrition, body mass index (BMI), and medications
place patients at a greater risk for developing a HAPU. Extrinsic risk factors including shear,
moisture, and friction contribute to HAPU development. During surgery, skin is pulled, pressure
is applied and the patient remains in the same position for long hours and this causes tissue
damage to occur (Black et al., 2015; Gul, & Karadag, 2015; McInnes et al., 2012; Shelanski &
Holley, 2009; Walton-Geer, 2009) Repositioning a surgical patient, except for the heels, arms,
and head, is rarely possible intraoperatively (Walton-Geer, 2009, p. 543). Healthy patients can
also be at risk for developing tissue damage if a surgical procedure lasts a long time. Using a
redistribution surface for all surgical patients is a technical intervention that addresses extrinsic
factors (Black et al., 2015; Walton-Geer, 2009).
With a focus on extrinsic risk factors, we decided to continue our research on
understanding if there was a specific surface that could effectively redistribute the pressure and
potentially reduce the prevalence of HAPUs in the perioperative setting. Three RCTs and one
Cochrane review compared overlays used in the OR. Researchers compared a variety of
redistribution surfaces to the standard OR mattress. The variety of product types evaluated
include polyurethane, fluid filled mattress, high density foam, and gel mattresses. (Gul &
Karadag, 2015; Keller, 2006; McInnes et al., 2012; Shelanski et al., 2009). One of the common
finding of the articles was that having a polyurethane mattress is better at distributing the
pressures than the standard OR mattress (Defloor, 2000; Keller, 2006; McInnes, et al., 2012;
Shelanski et al., 2009). The contact surface on the polyurethane mattress was significantly
higher than on the standard hospital mattress (Defloor, 2000, p. 10).

REDUCING HOSPITAL ACQUIRED PRESSURE ULCERS

Another common finding was that continued research is needed on surgical support
surfaces in reducing HAPUs. Pressure mapping technology is a research modality that is used to
determine how well a surface distributes pressure (Gul & Karadag, 2015). Pressure mapping
technology provides researchers with insight as to how well a support surface redistributes
pressure. A common finding among our literature review was that fluid mattresses have been
proven by pressure mapping to reduce HAPUs and effectively redistribute pressure; the fluid
mattress has been proven to nearly eliminate HAPUs according to several RCTs, and a metaanalysis (Gul & Karadag, 2015; Keller, 2006; McInnes et al., 2012). Research further suggests
that if a surface is able to distribute pressure evenly, it may reduce HAPUs (Gul & Karadag,
2015; Keller, 2006).
Conflicting Findings
The Braden scale is widely used to detect patient risks for pressure ulcer development in
surgical and non-surgical settings (Gonzales & Picket, 2011; Munro, 2010). Although the
Braden scale is useful for determining a patients risk for developing a HAPU, it is not tailored to
surgical patients and lacks surgical risk factors (Black, et al., 2014; Munro, 2010). Risk factors
that contribute to pressure ulcer development in the perioperative setting include age, weight,
metabolic and circulatory changes, heat, friction, shear, comorbidities such as diabetes or
vascular disease, length of surgery, anesthesia, blood loss, position, immobility and the use of
surgical positioning devices (Black et al., 2014; Gonzales & Picket, 2011; Munro, 2010).
Munro, (2010) decided to create a risk assessment tool that is designed to capture risk
factors specific to the preoperative, intraoperative and postoperative settings. Munros risk
assessment scale includes intrinsic factors such as age, body mass index, comorbidities, body
temperature, American Society of Anesthesiologists pre-anesthesia evaluation score, nutrition,

REDUCING HOSPITAL ACQUIRED PRESSURE ULCERS

and mobility; extrinsic factors include maintained body temperature, friction and shearing forces,
and moisture (Munro, 2010). Specific factors addressing the intraoperative setting include
support surfaces, type of anesthesia given to the patient, blood loss, position and length of
surgery (Munro, 2010). Munro gave this scale accompanied with a survey to twelve experts in
the perioperative field who were RNs and doctors with four to thirty years of experience (Munro,
2010). The purpose of this was to obtain expert opinion about the risk assessment scales ease of
use and the survey was given to provide feedback about each risk factor included and its
relevance to pressure ulcer development in the perioperative setting. Upon collecting the risk
assessment scales and surveys, the results were reviewed and revealed that the Munros scale
was moderately easy to use and that the risk factors included were notable; additional factors that
experts agreed needed to be on Munros scale were diabetes and pre-existing skin conditions
(Munro, 2010). Munro (2010) acknowledges that this scale is currently being refined based on
the expert feedback that was provided.
Communication is extremely important in the perioperative setting; Robins and Dai
(2015) report that information loss can occur during the transfer of patient care, at the time of
handoff; an increasingly susceptible time of miscommunication happens when patients are being
transferred from the OR to the post anesthesia care unit (PACU). A national goal of the Joint
Commission (2006) is to improve care handoffs which will increase patient safety (as cited in
Robins & Dai, 2015, p. 6). According to Robins and Dai (2015) in the hospital setting, nursing
shifts, resident hours worked, and OR schedules require multiple care handoffs and although
hospitals may attempt to decrease the number of handoffs, it is difficult to accomplish.
Due to the frequency of handoffs in the perioperative setting, information is susceptible
to being left out or miscommunicated (Robins & Dai, 2015). Robins and Dai (2015) report that

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communication variances among staff such as tone and speed, culture and productivity of the
hospital, and time allotted for handoff coupled with the lack of standardized handoff checklists
during transfer of patient care, further contributes to the loss of vital information. Robins and Dai
(2015) performed a pilot study using two checklists they created for handoff transfer of care from
the OR to the PACU. One was for use by the certified registered nurse anesthetist (CRNA) and
the other for the PACU RN. According to Robins and Dai (2015) the use of the checklist during
handoff from the OR to the PACU improved accurate reporting between CRNAs and PACU
RNs. Robins and Dai (2015) also found that all of the elements of the checklist were successfully
recalled by the PACU RNs. It did not require additional time for handoff and lessened the need
for clarification of callback information received and also showed that the use of a checklist
during handoff improves communication amongst staff (Robins & Dai, 2015). Robert and Dai
(2015) did not specify if this was done in one setting.
Conflicting evidence suggests that the air-fluidized mattress provides the best
redistribution capabilities when compared to the polyurethane mattress in the intraoperative
setting (Keller, 2006; McInnes, 2011). Even so, air-fluidized mattresses often cannot be used
intraoperatively because of the possibility of movement, electrical problems, and the potential for
asepsis (Walton-Geer, 2009, p. 546). The air fluidized bed reduced the average contact pressure
registered by pressure mapping sensors when in the lithotomy and supine position (Keller,
2006).The findings in both studies by Gul and Karadag (2015) and Keller (2006) are that the
experimental group with the fluid mattress had a reduced incidence of stage I pressure ulcer
development. Granted, this finding is significant to intraoperative nurses for implementation of a
mattress suggestion postoperatively for patients assessed at high risk for development of a
HAPU.

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Perspective and Gaps

There needs to be a tool that is designed specifically for use in the perioperative setting
that is greater than the usual risk assessments; by bringing the Braden scale, pre-existing patient
conditions and intraoperative factors together to aid in the reduction of HAPU development in
surgical patients (Black et al., 2014; Gonzales & Picket, 2011; Munro, 2010). It is critical to
develop a proper assessment tool designed for use in the perioperative setting that will work to
meet patient care needs and decrease the occurrence of pressure ulcer development. The
checklist created by Robins and Dai (2015) appears to have clinical significance for its
implementation in the perioperative setting. More current and unbiased research is needed to
address the effectiveness and deficiencies of surgical pressure redistribution support surfaces
(Walton-Geer, 2009, p. 546). Along with the intraoperative period, the postoperative period
carries risks for development of a HAPU and could be an area where pressure redistribution
mattresses can be implemented.
Suggestions for change in the perioperative setting
Understand that there are additional risk factors contributing to pressure ulcer
development in the surgical population that arent readily captured with the use of the Braden
scale alone. Additional risk factors to consider in this population were several that go beyond the
Braden scales ability to detect HAPU development. There were gaps in research that warrant a
risk assessment scale that is designed for use in the perioperative setting. The perioperative
healthcare team can improve patient outcomes and decrease the incidence of HAPUs with the
implementation of a risk assessment scale and effective communication at handoff (Black et al.,
2014; Gonzales & Picket, 2011; Munro, 2010). Nurses can empower patients by encouraging

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them to disclose any information that they have relating to pain and altered skin integrity as well
as medications and comorbidities; all of which can aid in reducing the occurrence of a HAPU
developing in the perioperative setting. Nurses can implement preventative measures to reduce
pressure ulcer occurrence based on the information that patients provide early on and throughout
their course of care.
Evaluation Plan
Recommendations for Peace Health St. Josephs hospital (PHSJH) are to perform a pilot
study using Munros risk assessment scale and the checklist created by Robins and Dai (2015),
and compare the rates of HAPU development before and after the pilot study. Both of these are
cost effective strategies that can potentially aid in reducing HAPU development in the
perioperative setting. In 2012, The Joint Commission estimates that 80% of medical errors are
due to communication failure during the handoff process (as cited in Robins & Dai, 2015, p. 1).
Care handoffs are subjective and widely vary by the style of communication an RN uses, by
using checklists, subjectivity is nearly eliminated and necessary information is communicated.
The use of a checklist also eliminates the nurses need to recall information about a patient from
memory alone. In regards to redistribution surfaces, PHSJH could consider analyzing their
current surgical surfaces by taking into consideration the condition, availability, and quality of
the current overlays, tables or mattresses.
Implication of Change
Before PHSJH spends money on implementing a solution for HAPUs, there needs to be
research on what is specifically needed at PHSJH in the perioperative setting. Due to the
prevalence of pressure ulcer development originating in the perioperative period, it is evident

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that prevention of perioperative HAPUs is needed and is something that is well worth investing
in (Black, 2014). With the use of both Munros scale and the checkoff list for handoff during
transfer of care, it may detect HAPU development in patients earlier on while they are in the
perioperative setting. It may be beneficial to contact the researcher Munro to learn about other
pilot studies. Specific strategies that the perioperative team can implement without changing
institutional policy that has an effect on pressure ulcer prevention may include: implementation
of redistribution surfaces, implementing a risk assessment tool that is designed to capture
specific risks of HAPU development in the perioperative setting and effective communication
with the use of a checklist during handoffs.

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