Pressure injury prevention for surgery: Results from a prospective, observational study in a tertiary hospital

This Article is brought to you for free and open access by Journal of Perioperative Nursing. It has been accepted for inclusion in Journal of Perioperative Nursing by an authorized editor of Journal of Perioperative Nursing. Recommended Citation Wang, Isabel; Walker, Rachel; and Gillespie, Brigid M. (2018) "Pressure injury prevention for surgery: Results from a prospective, observational study in a tertiary hospital," Journal of Perioperative Nursing: Vol. 31 : Iss. 3 , Article 4. Available at: https://doi.org/10.26550/2209-1092.1035


Background
Hospital acquired pressure injury (HAPI) refers to the development of pressure injury (PI) during hospitalisation.Prevalence rates of HAPI among all PI cases in acute health settings vary widely in different regions and countries, ranging from three to 18 per cent [1][2][3][4][5][6][7][8][9][10][11][12] .While patients with limited mobility are at greater risk of developing a PI, anaesthetised patients are particularly vulnerable due to limited mobility.Perioperative HAPI remains problematic, with current prevalence rates varying from 5. 1 to 64. 1 per cent 13 .Through the literature review component of this study, we identified five categories of pressure injury prevention (PIP) strategies that comply with current clinical practice guidelines 14 .There has been considerable research undertaken on PIP in medical-surgical wards but research undertaken in the perioperative environment is scarce 15 .

Study aim
The aim of this study was to report on the PIP strategies used by perioperative health professionals at a large tertiary hospital in southeast Queensland.

Method
This is an observational study of the use of PIP strategies by health care professionals across a selected range of surgical procedures in a tertiary hospital.A structured data collection tool was developed, tested and used to collect patients' demographic and clinical data, and health care professionals' implementation of PIP strategies, as well as data from skin inspection on day two after surgery.Observations occurred during the preoperative, intra-operative and post-operative periods, i.e. in the induction room, in the operating room and during the first half hour after the patient was admitted to the Post Anaesthesia Care Unit (PACU) respectively.The study was conducted in 2016.

Setting and sample
The study setting was a 750-bed tertiary hospital in Queensland.Surgical procedures were purposively selected across seven specialties.Adult patients whose length of surgery exceeded 60 minutes and who were anticipated to be an inpatient for a minimum of 48 hours after surgery were included in the study.All perioperative practitioners working in the operating room department were invited to participate.Patients who were unable to provide informed consent and who could not speak, read or understand English in the absence of an interpreter were excluded from the study.

Results
In total, this study recruited and observed 278 staff during surgical procedures of 73 recruited patients.Table 1 presents patients' characteristics by surgical specialty.Each specialty group had at least ten Peer-reviewed article patients, and their age, comorbidities, Waterlow risk assessment scores, length of surgery, and temperature upon PACU admission are reported using the median and IQR.
Data about selected PIP strategies were derived through observation or documentation; as shown in Table 2, most data was derived from direct observation.Data for three selected categories of PIP strategies -skin inspection, positioning aids and medical devices or/and equipmentwere collected from direct observation, and data for selected interprofessional communication strategies were collected from both observation and documentation when communication was related to skin inspection, positioning and medical devices or/and equipment (n = 10/90, 55.6 per cent).Data for selected communication strategies where communication was related to  thermal regulation was drawn from documentation when it was related to patients' temperature measured upon PACU admission (n = 2/90, 14.3%).
Figure 1 is a box plot that illustrates the number of PIP strategies implemented, based on patients' PI risk.Of the 36 patients deemed to be at risk of developing PI using the Waterlow risk assessments, the median number of PIP strategies implemented intra-operatively ranged from 39 to 40 strategies for the three risk groups -at risk, moderate risk, high risk (IQR = 11.5, 6.5 and 3, respectively).The results suggest that the highest number of PIP strategies was implemented for patients in the at-risk category.The minimum total number of PIP strategies implemented for patients in the moderate and high-risk groups was higher than for patients in the at-risk group, although the difference was not statistically significant (p = 0.819).

Sub-analysis
A high incidence rate of PI on day two after surgery has been reported in the literature 16,17 .Hence, the decision to inspect patients' skin on the second post-operative day was made.
In this study, skin inspection on the second day after surgery revealed that four male cardiac surgical patients had developed a postoperative Stage 1 PI on the ear, due to pressure from oxygen tubing.
As shown in Table 3

Key messages
The total number of PIP strategies used intra-operatively and Waterlow risk assessment scores suggests that patient deemed to be at risk (using the Waterlow risk assessment tool) have a higher number of PIP strategies implemented intraoperatively.
Patients having prolonged surgeries, i.e. greater than two hours, are at greater risk of developing a PI.
Post-operative PIs that occur as a result of using medical devices or equipment should not be overlooked.Perioperative professionals should be vigilant and monitor the use of devices and equipment during the intra-operative period.

Figure 1 :
Figure 1: Box plots of the total number of PIP strategies implemented during the intraoperative period with whiskers from minimum to maximum for the three Waterlow risk categories (n = 36)

Table 1 :
Patient characteristics by surgical specialty (n = 73) * n reports only the dominant gender per specialty group.† 18 incomplete Waterlow risk assessments were excluded, as only 15 per cent of the items were complete, on average.† † 1 to 3 refers to at-risk, moderate-risk and high-risk groups, respectively; 0 refers to not-at-risk group; 4 refers to unavailable or incomplete Waterlow assessment.^ In 11 cases data for temperature upon PACU admission was missing, as this was not recorded when the patients arrived at the PACU.

Table 2 :
Sources of data for each key PIP strategy category (n = 90) *Each category includes a number of PIP strategies.For instance, preoperative, intraoperative and post-operative skin integrity screening are three strategies in the skin inspection category.

Table 3 :
Sub-analysis for patients who had PI on day two after surgery (n = 4)