PERIOP BRIEFING
IN FOCUS
Creating a strategic plan for perioperative
pressure ulcer prevention
Susan M. Scott, BSN, MSN, RN, WOCN
T
he incidence of perioperative pressure ulcers
(PPUs) during the past five years has increased.1
In a systematic review, the pooled incident
rate for PPUs was 15 percent; with more than 50
million surgical procedures performed annually in
the United States, seven million patients could be at
risk for PPUs.1,2 Pressure ulcers result in substantial
patient harm and can lead to sepsis, osteomyelitis,
disfigurement, disability, and death.3 In 2015, AORN
chartered a task force including subject matter experts
among the AORN members and representatives from
the Wound, Ostomy, Continence Nurses Society
(WOCN) to develop the “Prevention of Perioperative
Pressure Ulcers Tool Kit.”
Identifying aspects of care that need
improvement
Keys to PPU prevention include developing a
strategic plan to address factors in all phases of
perioperative care. To guide the quality improvement
process, an interprofessional team should track
the PPU incidence at their facility, determine the
root causes of these events, identify any barriers to
providing optimal patient safety, and investigate
possible interventions to reduce PPU incidence.
The tool kit contains the “Scott Trigger Gap
Analysis Template” to facilitate the development of
a Perioperative Pressure Ulcer Prevention Program;
this document provides a detailed gap analysis
checklist and a model for evaluating the strengths,
weaknesses, opportunities, and threats of the current
program.4
The culture of quality dictates reporting of adverse
events that have caused harm and near misses that
may cause patient harm. Tracking pressure ulcer
incidence related to surgical cases and performing
a root cause analysis frames the event as a failure in
the system and not a result of any one individual.
Evaluating trends in data over time can help identify
gaps in the current process and lay the foundation
for a corrective action plan to mitigate future harm.
http://dx.doi.org/10.1016/S0001-2092(16)30017-5
© AORN, Inc, 2016
Performing a gap assessment
The tool kit provides a checklist to assess the
current state of a facility’s PPU prevention program
and the perioperative work environment. Patient
population, staffing, and access to equipment needed
for preventive measures are key factors to assess. Task
or process factors include adherence to evidence-
based protocols (e.g., head to toe and front to back
skin inspections). Team factors include collaboration,
communication, documentation, and competency.
Prioritizing actions
Conducting an analysis of the strengths, weaknesses,
opportunities, and threats (SWOT) of the
current program can help prioritize interventions.
Traditionally used in business, health care facilities
can apply this high-level strategic analysis to assess
the quality of their program and propose a new
program.5 The first step is to identify the current
program’s internal strengths and weaknesses.
Strengths may include experienced and competent
staff, strong leaders, WOC nurse collaboration, and
protected education time. Weaknesses may include
inconsistencies in assessment and documentation of
risk and skin integrity or lack of notification of OR
personnel regarding PPU incidents.
Opportunities and threats are generally external
factors to consider. Opportunities may include
investing in new positioning aids, creating new
policies and procedures for patient assessment,
introducing the use of a PPU assessment scale, and
ensuring staff member competency and compliance
with its use. Threats may include high numbers
of hospital-acquired pressure ulcers (HAPUs),
non-payment or penalties from the U.S. Centers
for Medicare & Medicaid Services (CMS), recent
litigation, and high staff turnover.
When the SWOT analysis is complete, personnel
can develop an action plan using a Six Sigma impact/
effort matrix to prioritize solutions according to
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PERIOP BRIEFING
PREVENTION PROGRAMS
the expected effort required to implement the
change and the magnitude of the expected effect
on outcomes.6 Valuable interventions significantly
improve outcomes and can be accomplished
with minimal effort; these may include checklist
use, policy/procedure changes, or enhanced
communication. High-effect and high-effort actions
require planning and strategy. Personnel should
consider total cost and expected benefit in terms
of reducing patient harm, delivering on customer
needs, eliminating rework, and improving efficiency.6
Using this framework can help personnel avoid low-
effect solutions that may be a waste of time.
Reducing facility costs by improving
outcomes
The Affordable Care Act of 2008 mandated that
CMS no longer pay for hospital-acquired conditions,
such as HAPUs. Furthermore, the group of hospitals
with the highest HAPU rates will be penalized by a
one percent pay reduction for all Medicare patients.7
A study conducted by Waters, et al8 found that the
new CMS rules did not improve the rate of HAPUs,
indicating that our current practice is ineffective,
despite non-payment from the government.
Health care costs for HAPUs are estimated to be
between $44,000 and $128,000 per pressure ulcer,
with a total U.S. cost of 11 billion dollars per year.9
A study of 21,377 surgical patients used the Scott
Trigger Tool to identify high-risk surgical patients,
and those with at least two triggers were assessed
for PPU after implementing an OR “skin bundle”
(i.e., standardization of high-specification OR
table pads, interprofessional education, pressure
redistribution and offloading, protective dressings,
frequent assessments, and real-time reporting of
PPU). The incidence rate of HAPUs decreased from
3.37 percent to 0.89 percent and the reduced rate
was sustained over a 14-month period; the facility
reduced costs by $1,364,000 for a one-year period.10
Conclusion
Pressure ulcers are a serious threat to perioperative
patients. This threat can be significantly reduced
through understanding the root causes of quality
issues, performing perioperative patient assessment,
and altering care as needed. The AORN tool kit
contains the tools necessary to develop a strategic
P14 | Periop Briefing
plan to raise awareness, educate personnel, and
improve communication to prevent PPUs.
Editor’s note: The Wound, Ostomy and Continence
Nurses Society is a trademark and WOCN is a registered
trademark of the Wound, Ostomy and Continence Nurses
Society, Mt Laurel, NJ. Scott Triggers Tool is a registered
trademark of Susan Scott Williams, Memphis, TN.
References
1. Chen H, Chen X, Wu J. The incidence of pressure
ulcers in surgical patients of the last 5 years. Wounds.
2012;24(9):234-241
2. 2010 National Hospital Discharge Survey. National
Center for Health Statistics. http://www.cdc.
gov/nchs/data/nhds/4procedures/2010pro4_
numberprocedureage.pdf. Accessed March 7, 2016.
3. National Pressure Ulcer Advisory Panel, European
Pressure Ulcer Advisory Panel and Pan Pacific
Pressure Injury Alliance. Prevention and Treatment
of Pressure Ulcers: Clinical Practice Guidelines. Emily
Haesler (Ed.). Cambridge Media: Perth, Australia;
2014.
4. Scott S. Progress and challenges in perioperative
pressure ulcer prevention. J Wound Ostomy
Continence Nurs. 2015;42(5):480-5.
5. Helms M, Nixon J. Exploring SWOT analysis—
where are we now? A review of academic research
from the last decade. J Strat Manage. 2010;3(3):215-
251.
6. George M, Rowlands D, Price M, Maxey J. The Lean
Six Sigma Pocket Toolbook. New York, NY: McGraw-
Hill; 2005.
7. The financial impact of pressure ulcers. Leaf
Healthcare. http://www.leafhealthcare.com/
pdfs/LH_WP_FinancialOverview_1563AA_
PDF_100514.pdf. Accessed March 7, 2016.
8. Waters TM, Daniels MJ, Bazzoli GJ, et al. Effect
of Medicare’s nonpayment for hospital-acquired
conditions: lessons for future policy. JAMA Intern
Med. 2015:175(3):347-354.
9. Brem H, Maggi J, Nierman D, et al. High
cost of stage IV pressure ulcers. Am J Surg.
2010;200(4):473-477.
10. Martinez S, Braxton C, Helmick R, Awad S, Lara-
Smalling A. Sustainability of a hospital acquired
pressure ulcer prevention bundle in surgical patients.
Presented at: Surgical Infection Society 34th Annual
Meeting; May 1-3, 2014; Baltimore, MD.