Abstract

Purpose:Thepurposeofthisresearchistoexploretheuseofpressureredistributionsurfacesto
reducetheoccurrenceofHospitalacquiredpressureulcers(HAPUs)intheoperatingroom
(O.R.).Additionally,thenursesroleinHAPUpreventionthroughriskassessmentandhandoff
communicationintheperioperativesettingwillbeexamined.
Rationale
PatientsundergoingsurgeryareatuniqueriskfordevelopingHAPUs.Limitedresearchhasbeen
conductedonaddressingpressureulcerscausedduringsurgerybecausemostresearchhasbeen
limitedtolongtermpatients.
Methods
ALiteraturereviewwasconductedusingCINAHL,PUBMED,GoogleScholarandHealWA
databases.Thearticlesinthisliteraturereviewincludefiveexpertopinions,threerandomized
controlledtrialsandtwometaanalyses,specificallyfocusingontheperioperativesettingandthe
useofdistributionsurfacesduringsurgery,riskassessmentsandcommunicationhandoff.
Results/Implications:
Theliteraturereviewrevealedthatoperatingtableoverlaysmayreducetheoccurrenceof
HAPUscomparedtostandardoperatingtables.Nursesmusttaketheleadindevelopingpressure
ulcerriskassessmenttoolsthatspecificallyaddresssurgicalpatients.Perioperativeteamsmust
participateineffectivehandoffcommunication.Amultifacetedapproachusingrisk
assessments,pressureredistributionsurfaces,andgoodhandoffcommunication,allownursesto
tackletheburdenofHAPUsuniquetothesurgicalpopulation.
keyterms:
pressureulcerprevention,riskassessments,handoff,perioperative,communication

Introduction
In2006,MedicareestimatedthatoneHAPUcostsover$43,000totreat.Accordingtothe
NationalPressureUlcerAdvisoryPanel...45%ofHAPUsdevelopinthe[operatingroom](OR)
(ascitedbyBlack,2014,p14).Thereviewofliteraturerevealedthatitisimportanttoregardthe
perioperativeperiodand
surgicalpatientsashavinguniqueriskfactorsindevelopingHAPUs
(Gonzales&Picket,2011Munro,2010).Itisessentialthattheperioperativenurseandsurgical
teamidentifyrisksandimplementstrategiesthataideinreducingtheoccurrenceofHAPUs
(Munro,2010).
DevelopmentofHAPUandtissuedamageisntapparentintraoperatively,anddamage
maynotbevisibleforseveralhoursandcaneventakeafewdaystobecomeevident(McCance,
2010).
Theperioperativenursecarriestheburdenofreducingsurgicalpressureulcer
development.The
AORNholdsconferenceswithavarietyofspecialistsfordiscussionof
pressureulcerdevelopmentandreviewoftreatmentmodalities.Duringa2014conferencethere
wasconsensusthatevenwithbestpracticeapressureulcermaynotbecompletelyavoidable
(
Baharestanietal.,2014).
WhetherHAPUsarepreventableornot,theyhavenegativeimpactson
patientsandmedicalcareproviders.

Pressureulcersarecausedbypressureappliedtoanarea(McCance,2010).P
atients

undergoingsurgeryundergoauniqueprocesssuchasundergoing
hoursimmobileonanOR
surface,anexternallyappliedforce,bloodloss,anesthesiaandsurgicalremovaloralterationto
organs.
Patientswhospendhoursunmovedonthesurgicaltable,areatriskfortissuebreakdown
tovulnerablepressurepointssuchasthesacrum,heel,forehead,althoughthesespecificareas
dependonpatientpositioningduringsurgery
(WaltonGeer,2009)
.Onceshiftedfromaposition,

reperfusionensueswhichoftencausesinjuryandmayresultinfurthertissuedamage(McCance,
2010).ThetrajectoryofapatientthatdevelopsaHAPUisoneofpain,longerhospitalization,
andpossiblyevendeathinseverecases(Munro,2010).Thepurposeofthisliteraturereviewwas
toanswerthequestion:Whattypesofoperatingroomstrategiescanbeusedtoreducethe
occurrenceofHAPUsinthesurgicalpatient?

SynthesisoftheLiterature

HAPUpreventionresearchhasbeenconductedinlongtermcare,intensivecare,and
rehabilitationsettingswithlittlefocusonacutecaresettingsorthesurgicalenvironment
(WaltonGeer,2009,p.53839).AccordingtoBlack,Fawcett,&Scott(2014)moreresearchis
needstobeconductedontheincidenceofpressureulcersthatoriginateintheO.R.
Inreviewing
researchspecifictotheperioperativesetting,therewerethreethemesthatrelatedtoHAPU
developmentanditsrelationshiptodistributionsurfaces,riskassessmentsandcommunication
handoff.

Riskassessment

Riskassessmentsarecommonlyusedbynursesintheperioperativesettingto
determinetheamountofriskthatapatienthasfordevelopingaHAPU.Theseassessmentsare
performedbytheRegisterednurse(RN)andincludeathoroughheadtotoeskinassessment
withtheuseoftheBradenscale.TheBradenscalefocusesonthefollowingsubscale
categorieswhichare:sensoryperception,moisture,activity,mobility,nutrition,frictionandshear
(Gonzales&Pickett,2011).Thepurposeoftheskinassessmentistodetectalterationsinskin
integrityincluding

lacerations,bruisingandrednessthatmayincreaseapatient'sriskfor
developingaHAPU
.
Earlydetectionofalterationsinskinintegrityallowsthenursetoimplement
interventionstopreventfurtherskindamage.
Intheperioperativesetting,nursesareresponsibleforassessingapatientsrisksfor
pressureulcerdevelopmentandimplementingpreventativemeasures(Munro,2010).Currently,
thereisnoprovenriskassessmentscalethatisdesignedspecificallyforuseinthe
perioperativesetting.ResearchbyGonzalesandPickett(2011)suggestthatanewapproachis

neededintheO.R.thatcapturesthispopulationsriskforHAPUdevelopment.Itisnecessaryto
makeascalethatcanreducetheincidenceofHAPUsinthesurgicalsettingariskassessment
scalethatincludestheuseoftheBradenscale,surgicalrisksfactorsandpreexistingconditions
(Gonzales&Pickett,2011Munro,2010).Munro(2010)suggeststhataperioperativerisk
assessmentscalewillassistnursesinplanningcareandimplementinginterventionsatamuch
earlierphaseofcareallofwhichcanpotentiallyreducetheoccurrenceofHAPUsinthe
surgicalsetting.Assessingpatientspriortosurgeryisavitalfirststepandshouldbeperformed
beforethesurgerybeginshighriskpatientsnotproperlyidentifiedinthepreoperativeperiodwill
notreceiveproperpreventativemeasuresforpressureulcerprevention(Blacketal.,2014
Munro,2010).
Communication

Theperioperativesettinginvolvesdifferentphasesandincludesthepreoperative,
intraoperativeandpostoperativesettings.Ineachofthesephases,nursesaregivenpatientsto
careforandthenursewhoispreviouslyworkingwiththatpatientisresponsibletoprovidethe
nextnursewithathoroughinformativereportforcareofthatpatientduringthetimeofcare
handoff(Blacketal.,2014Gonzales&Picket,2011Munro,2010Robins&Dai,2015).The
rationaleforthisisthatthecontinuumofcarewillbeprovidedandwillspecificallyaddressthe
needsofpatientsthatthehealthcareteamiscaringfor.GonzalesandPickett(2011)reportthata
teamapproachcangreatlydecreasetheincidenceofHAPUoccurrenceinsurgicalpatients,part
ofthisapproachisunderstandingthepresentriskfactorsthatthepreoperativenurseidentifies
throughtheriskassessment,andreportingthesefindingstotheintraoperativenurse,atthetime
ofcarehandoff.

Theperioperativeteamconsistsofhealthcareteammembersfromdifferentsettingswho
worktogetherandincludesthewoundcareteam,ostomyandcontinencenurses,surgeons,
anesthesiologistsandpostoperativenurses(Blacketal,2014Gonzales&Picket,2011Robins
&Dai,2015).Communicationandcollaborationateachofthesephasesneedstobeaccurate,
timelyandefficient,asthisisacohesiveapproachtothecontinuumofcareandhelpstoreduce
theincidenceofpressureulcersinsurgicalpatients(Blacketal.,2014Gonzales&Picket,
2011).Likewise,Munro(2010)agreesthatnursesandanesthesiacareprovidersneedto
implementacollaborativeapproachinformulatinganassessmentandplanofcarespecificto
surgicalpatientstoaidinimplementingbestpracticeandtoreducetheoccurrenceofpressure
ulcerdevelopment.

IntraoperativePressureRedistributionSurface
Overall,theevidencefromthreerandomizedcontrolledtrials(RCT)and
acochrane
metaanalysis,andexpertopinionrevealedthat
usinganO.R.tableoverlayredistributes
pressuremoreeffectivelythanthestandardoperatingroomtable
(Blacketal.,2015Gul&
Karadag,2015Keller,2006McInnes,JammaliBlasi,BellSyer,Dumville,&Cullum,2012
Shelanskiet.al,2009WaltonGeer,2009).
Implementingthisinterventionhasthepotentialto
reduceHAPUinthesurgicalpatient.InreviewingcausesofsurgicalHAPUtheliterature
revealedseveralthings.
Manyintrinsicfactorssuchasage,nutrition,BMI,andmedicationsplacepatientsata
greaterriskfordevelopingaHAPU.Extrinsicriskfactorsincludingshear,moisture,andfriction

contributetoHAPUdevelopment.Duringsurgery,skinispulled,pressureisapplied,thepatient
remainsinthesamepositionlonghoursandthiscausestissuedamagetooccur

(Blacketal.,
2015Gul,&Karadag,2015McInnes,etal.,2012Shelanski&Holley,2009WaltonGeer,
2009)Repositioningasurgicalpatient,exceptfortheheels,arms,andhead,israrelypossible
intraoperatively(WaltonGeer,2009,p.543).Healthypatientscanalsobeatriskfordeveloping
tissuedamageifasurgicalprocedurelastsalongtime.Usingaredistributionsurfaceforall
surgicalpatientsisatechnicalinterventionthataddressesextrinsicfactors.(Blacketal.,2015
WaltonGeer,2009)

Withafocusonextrinsicriskfactors,wedecidedtocontinueourresearchon
understandingiftherewasaspecificsurfacethatcouldeffectivelyredistributethepressureand
potentiallyreduceprevalenceofHAPU.
Three
RCTsandonecochranereviewcompared
overlaysusedintheOR.Researcherscomparedavarietyofredistributionsurfacestothe
standardORmattress.Thevarietyofproducttypesevaluatedincluded:polyurethane,fluidfilled
mattress,highdensityfoam,andgelmattresses.
(Gul&Karadag,2015Keller,2006Shelanski
et.al,2009McInnesetal.,2012).
Oneofthecommonfindingofthe
articleswasthathavingapolyurethanemattressis
betteratdistributingthepressuresthanthestandardORmattress.(Defloor,2000Keller,2006
McInnes,etal.,2012Shelanskietal.,2009)Thecontactsurfaceonthepolyurethanemattress
wassignificantlyhigherthanonthestandardhospitalmattress(Defloor,2000,p.10).
Anothercommonfindingwasthatcontinuedresearchisneededonsurgicalsupport
surfacesinreducingHAPUs.Pressuremappingtechnologyisaresearchmodalitythatisusedto

fordeterminehowwellasurfacedistributespressure(
Gul&Karadag,2015).
Pressuremapping
technologyprovidesresearcherswithinsightastohowwellasupportsurfaceredistributes
pressure.Acommonfindingamongourliteraturereviewwasthatfluidmattresseshavebeen
provenbypressuremappingtoreduceHAPUsandeffectivelyredistributepressure.Thefluid
mattresshasbeenproventonearlyeliminateHAPUsaccordingtoseveralRCTs,anda
metaanalysis(
Gul&Karadag,2015Keller,2006McInnesetal.,2012).
Researchfurther
suggeststhatifasurfaceisabletodistributepressureevenly,itmayreduceHAPUs(
Gul&
Karadag,2015Keller,2006)
.
ConflictingFindings
RiskAssessment
TheBradenscaleiswidelyusedtodetectpatientsrisksforpressureulcerdevelopment
insurgicalandnonsurgicalsettings(Gonzales&Picket,2011Munro,2010).Althoughthe
Bradenscaleisusefulfordeterminingapatient'sriskfordevelopingaHAPU,itisnottailoredto
surgicalpatientsandlackssurgicalriskfactors(Blacketal.,2014Munro,2010).Riskfactors
thatcontributetopressureulcerdevelopmentinthesurgicalpatientincludeage,weight,
metabolicandcirculatorychanges,heat,frictionandshear,comorbiditiessuchasdiabetesor
vasculardisease,lengthofsurgery,anesthesia,bloodloss,position,immobility,andtheuseof
surgicalpositioningdevices(Blacketal.,2014Gonzales&Picket,2011Munro,2010).
Munro,(2010)developedariskassessmenttoolthatcapturesriskfactorsspecificto
thepreoperative,intraoperativeandpostoperativepatient.SimilartotheBradenscale,Munros
riskassessmentscaleincludesintrinsicandextrinsicfactors.Munrosriskassessmentscale
identifiesintrinsicandextrinsicfactorsspecifictotheperioperativepatient:age,BMI,
comorbidities,bodytemperature,AmericanSocietyofAnesthesiologistspreanesthesia

evaluationscore,nutrition,andmobility,frictionandshearingforces,andmoistureareall
includedinMunrosscale(Munro,2010).Specificfactorsaddressingtheintraoperativesetting
areincludedonthescaleandinclude:supportsurfaces,typeofanesthesiagiventothepatient,
bloodloss,positionandlengthofsurgery(Munro,2010).
Munrogavethisscaleaccompaniedwithasurveytotwelveexpertsintheperioperative
fieldwhowereRNsanddoctorswithfourtothirtyyearsofexperience(Munro,2010).The
purposeofthiswastoobtainexpertopinionabouttheriskassessmentscaleseaseofuseand
thesurveywasgiventoprovidefeedbackabouteachriskfactorincludedanditsrelevanceto
pressureulcerdevelopmentintheperioperativesetting.ResultsrevealedthattheMunroscale
wasmoderatelyeasytouseandthattheriskfactorsincludedinthescalewererelevanttothe
perioperativesetting.AdditionalfactorsthatexpertsagreedneededtobeonMunrosscalewere
diabetesandpreexistingskinconditions(Munro,2010).Munro(2010)acknowledgesthatthis
scaleiscurrentlybeingrefinedbasedontheexpertfeedbackthatwasprovided.
Communication

CommunicationisextremelyimportantintheperioperativesettingRobinsandDai
(2015)reportthatinformationlosscanoccurduringthetransferofpatientcare,atthetimeof
handoffanincreasinglysusceptibletimeofmiscommunicationhappenswhenpatientsarebeing
transferredfromtheO.R.tothepostanesthesiacareunit(PACU).AnationalgoaloftheJoint
Commision(2006)istoimprovecarehandoffswhichwillincreasepatientsafety(ascitedin
Robins&Dai,2015,p.6).AccordingtoRobinsandDai(2015)inthehospitalsetting,nursing
shifts,residenthoursworked,andO.R.schedulesrequiremultiplecarehandoffsandalthough
hospitalsmayattempttodecreasethenumberofhandoffs,itisdifficulttoaccomplish.

Duetothefrequencyofhandoffsintheperioperativesetting,informationissusceptible
tobeingleftoutormiscommunicated(Robins&Dai,2015).RobinsandDai(2015)reportthat
communicationvariancesamongstaffsuchastoneandspeed,cultureandproductivityofthe
hospital,andtimeallottedforhandoffcoupledwiththelackofstandardizedhandoffchecklists
duringtransferofpatientcare,furthercontributestothelossofvitalinformation.RobinsandDai
(2015)performedapilotstudyusingtwocheckliststheycreatedforhandofftransferofcare
fromtheO.R.tothePACU.Onewasforusebythecertifiedregisterednurseanesthetist
(CRNA)andtheotherforthePACURN.RobinsandDai(2015)reportthattheuseofthe
checklistduringhandofffromtheO.R.tothePACUimprovedaccuratereportingbetween
CRNAsandPACURNsandalsofoundthatalloftheelementsofthechecklistwere
successfullyrecalledbythePACURNs.Itdidnotrequireadditionaltimeforhandoffand
lessenedtheneedforclarificationofcallbackinformationreceivedandalsoshowedthattheuse
ofachecklistduringhandoffimprovescommunicationamongststaff(Robins&Dai,2015).
RobertandDai(2015)didnotspecifyifthiswasdoneinonesetting.
IntraoperativePressureRedistributionSurface
Conflictingevidencesuggeststhattheairfluidizedmattressprovidesthebest
redistributioncapabilities
whencomparedtothepolyurethanemattressintheintraoperative
setting(
Keller,2006McInnes,2011).
Evenso,airfluidizedmattressesoftencannotbeused
intraoperativelybecauseofthepossibilityofmovement,electricalproblems,andpotentialfor
asepsis(
WaltonGeer,2009,
p.546).

Theairfluidizedbedreducedtheaveragecontactpressure
registeredbypressuremappingsensorswheninthelithotomyandsupineposition(Keller,
2006).Thefindingsinbothstudies(Gul&Karadag,2015Keller,2006)arethatthe

experimentalgroupwiththefluidmattresshadareducedincidenceofstageIpressureulcer
development.
Granted
,thisfindingissignificanttointraoperativenursesforimplementationofa
mattresssuggestionpostoperativelyforpatientsassessedathighriskfordevelopmentofa
HAPU.

PerspectiveandGaps
Thereneedstobeatoolthatisdesignedspecificallyforuseintheperioperativesetting
thatisgreaterthantheusualriskassessmentsbybringingtheBradenscale,preexisting
patientconditionsandintraoperativefactorstogethertoaidinthereductionofHAPU
developmentinsurgicalpatients(Blacketal.,2014Gonzales&Picket,2011Munro,2010).It
iscriticaltodevelopaproperassessmenttooldesignedforuseintheperioperativesettingthat
willworktomeetpatientcareneedsanddecreasetheoccurrenceofpressureulcer
development.
ThechecklistcreatedbyRobinsandDai(2015)appearstohaveclinical

significanceforitsimplementationintheperioperativesetting.
Morecurrentandunbiased
researchisneededtoaddresstheeffectivenessanddeficienciesofsurgicalpressureredistribution
supportsurfaces(
WaltonGeer,2009,p.546).
Alongwiththeintraoperativeperiod,the
postoperativeperiodcarriesrisksfordevelopmentofaHAPUandcouldbeanareawhere
pressureredistributionmattressescanbeimplemented.

Suggestionsforchangeintheperioperativesetting
Understandthatthereareadditionalriskfactorscontributingtopressureulcer
developmentinthesurgicalpopulationthatarentreadilycapturedwiththeuseoftheBraden
scalealone.Additionalriskfactorstoconsiderinthispopulationwereseveralthatgobeyond

theBradenscalesabilitytodetectHAPUdevelopment.Thereweregapsinresearchthat

warrantariskassessmentscaleanddesignedforuseintheperioperativesetting.The
perioperativehealthcareteamcanimprovepatientoutcomesanddecreasetheincidenceof
HAPUswiththeimplementationofariskassessmentscaleandeffectivecommunicationat
handoff(Blacketal.,2014Gonzales&Picket,2011Munro,2010).Nursescanempower
patientsbyencouragingthemtodiscloseanyinformationthattheyhaverelatingtopainand
alteredskinintegrityaswellasmedicationsandcomorbiditiesallofwhichcanaidinreducing
theoccurrenceofaHAPUdevelopingintheperioperativesetting.Nursescanimplement
preventativemeasurestoreducepressureulceroccurrencebasedontheinformationthat
patientsprovideearlyonandthroughouttheircourseofcare.

EvaluationPlan
Recommendationsfor
PeaceHealthSt.Josephshospital(
PHSJH)aretoperformapilot
studyusingMunrosriskassessmentscaleandtheperioperativechecklistcreatedbyRobinsand
Dai(2015)andcomparetheratesofHAPUdevelopmentbeforeandafterthepilotstudy.Both
ofthesearecosteffectivestrategiesthatcanpotentiallyaidinreducingHAPUdevelopmentin

theperioperativesetting.In2012,TheJointCommissionestimatesthat80%ofmedicalerrors
areduetocommunicationfailureduringthehandoffprocess(
ascitedinRobins&Dai,2015,p.
1).Nursecarehandoffisasubjectivestyleofcommunication,byusingachecklistsubjectivityis
nearlyeliminatedandnecessaryinformationiscommunicated.Theuseofachecklistalso
eliminatesthenursesneedtorecallinformationaboutapatientfrommemoryalone.
Inregards
toredistributionsurfaces,PHSJHcouldconsideranalyzingtheircurrentsurgicalsurfacesby
takingintoconsiderationthecondition,availability,andqualityofthecurrentoverlays,tablesor
mattresses.
ImplicationofChange

BeforePHSJHspendsmoneyonimplementingasolutionforHAPUs,thereneedstobe
researchonwhatisspecificallyneededatPHSJHintheperioperativesetting.Duetothe
prevalenceofpressureulcerdevelopmentoriginatingintheperioperativeperiod,itisevident
thatpreventionofperioperativeHAPUisneededandissomethingthatiswellworthinvestingin
(Black,J,2014).
WiththeuseofbothMunrosscaleandthecheckofflistforhandoffduring
transferofcare,itmaydetectHAPUdevelopmentinpatientsearlieronwhiletheyareinthe
perioperativesetting.ItmaybebeneficialtocontacttheresearcherMunrotolearnaboutother
pilotstudies.Specificstrategiesthattheperioperativeteamcanimplementwithoutchanging
institutionalpolicythathasaneffectonpressureulcerpreventionmayinclude:implementation
ofredistributionsurfaces,developmentofariskassessmenttoolthatisdesignedtocapture
specificrisksofHAPUdevelopmentintheperioperativesettingandeffectivecommunicationat
handoff.

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