AMBULATORY SURGERY

Pressure Ulcer Prevention: Bringing It Hometo the Perianesthesia World

Margaret Johnson, MSN, RN, Guest Columnist

AS WE ARE ALL AWARE, the cost of providing health

care is rising at a dramatic rate; the cost of medications,

new equipment, and supplies rises daily.1 Unfortunately,

part of the increased cost is because of care-related com-

plications (eg, surgical wound infections, nosocomial

deep vein thrombosis, nosocomial pressure ulcers). Asa result of these increased costs, third-party payers are

beginning to place the treatment cost for care-related

complications back on the hospital by denying payment

for treatment of these complications. One goal of this

strategy is to make it more profitable to provide a higher

quality of care aimed toward preventing care-related

complications.2

Pressure Ulcers—A Complicated Part of CostDeferral

One of the first areas evaluated for treatment cost deferral

by Medicare was the development of nosocomial pressure

ulcers.2 In April of 2008, the Centers for Medicare and

Medicaid Services issued a statement that for all discharges

after October 1, 2008, ‘‘Medicare will no longer pay hospi-

tals at a higher rate for the increased costs of care that result

when a patient is harmed by one of several conditions they

didn’t have when they were first admitted to the hospitaland that have been determined to be reasonably prevent-

able by following generally accepted guidelines.’’2 Nosoco-

mial pressure ulcers were among the selected conditions.

In evaluating the situation, MCGHealth in Augusta,

Georgia, came to the conclusion that identification and

documentation related to pressure ulcers present on

arrival to the facility would be an important factor in treat-ment reimbursement for pressure ulcers. MCGHealth is

a tertiary care center receiving patients from across the

Margaret Johnson, MSN, RN, is the perioperative nurse educator for

perianesthesia nursing at MCGHealth, Augusta, GA.

Address correspondence to Margaret Johnson, MCGHealth, Perio-

perative Services, 1120 15th Street, BAN 2453, Augusta, GA 30912;

e-mail address: mmjohnso@mcg.edu.

� 2010 by American Society of PeriAnesthesia Nurses

1089-9472/10/2502-0007$36.00/0

doi:10.1016/j.jopan.2010.01.016

104

state of Georgia as well as within the Augusta area.

Because of the nature of our patient population, it is likely

that some of our patients will come to the hospital for

treatment unrelated to a pressure ulcer, but will have

one or more pressure ulcers that require treatment

when they arrive. It is not unusual for the admitting phy-sician to have no knowledge of the pressure ulcer before

the patient’s arrival because the patient’s admission is for

a different reason.

MCGHealth’s response to this issue was to enact a proto-

col designed to identify, stage, and document all pressure

ulcers, both those existent upon entry to the system as

well as nosocomial pressure ulcers. As a part of the pres-sure ulcer prevention effort, all patients are evaluated for

their risk of developing a pressure ulcer during hospitali-

zation and precautions are instituted to protect the at-risk

patient.

MCGHealth is comprised of an adult inpatient hospital,

a children’s inpatient hospital, and an extensive ambula-

tory care center. All areas were included in the protocol.The protocol requires all patients to have a head-to-toe vi-

sual inspection of all skin surfaces and a Braden Risk Assess-

ment completed upon admission, at transfer, and upon any

change of condition. To facilitate communication between

care providers, including the wound and skin nurse, as

soon as a pressure ulcer is identified, it is documented in

the patient’s medical record, included in our patient hand-

off report, and entered into our variance reporting system(Patient Safety Net [PSN]). This includes all pressure ulcers

identified on admission as well as pressure ulcers identified

later in the hospital stay.

Implementation of the protocol included provision of

education for all direct patient care providers on pressure

ulcer identification, staging, prevention, treatment, and

the Braden Risk Assessment tool. To remain consistentwith hospital policy and promote a single standard of

care for all MCGHealth patients, the Perioperative

Services department participated in all aspects of the pro-

tocol. The Perioperative Nurse Educator provided educa-

tion via unit in-services and one-on-one sessions in all

Journal of PeriAnesthesia Nursing, Vol 25, No 2 (April), 2010: pp 104-107

Perioperative Pressure Ulcer Prevention

Program

Pre-op Evaluation Clinic

•Braden Risk Scale

•Ask patient/family if patient has any skin issues at time of appointment

•Notify Surgeon of any identified skin issues.

Day Surgery – admission

•Braden Risk Scale

•Visual inspection

•Report Risk assessment and skin assessment in handoff to Holding

•Notify Surgeon of any identified skin issues.

OR Holding -

•Reports Braden Risk Number and presence of any skin issues to OR

•Ensure that Surgeon has been notified of any skin issues

OR –

•Takes appropriate actions to prevent skin issues

•Protects any current skin problems

•Evaluates skin in pressure areas specific to OR Position

•Include Braden Risk Number and OR Position to PACU nurse in Hand off report

•Notify Surgeon of any identified skin issues

PACU –

•Assess skin in Pressure Point areas specific to Surgical Position for potential issues

•Review Braden Risk Score from Day Surgery for any changes that the surgical procedure may have made.

•Include Braden Risk Number and OR Position to receiving nurse in Hand off report

•Notify Surgeon of any identified skin issues

Day Surgery – Post Op

•Reevaluates Braden Risk Scale for significant changes

•Assesses Pressure Point areas specific to Surgical Position for potential issues

•Provides patient education to patient/family related to skin care as appropriate

•Notify Surgeon of any identified skin issues

Perioperative Pressure Ulcer Prevention

Program

Pre-op Evaluation Clinic

•Braden Risk Scale

•Ask patient/family if patient has any skin issues at time of appointment

•Notify Surgeon of any identified skin issues.

Day Surgery – admission

•Braden Risk Scale

•Visual inspection

•Report Risk assessment and skin assessment in handoff to Holding

•Notify Surgeon of any identified skin issues.

OR Holding -

•Reports Braden Risk Number and presence of any skin issues to OR

•Ensure that Surgeon has been notified of any skin issues

OR –

•Takes appropriate actions to prevent skin issues

•Protects any current skin problems

•Evaluates skin in pressure areas specific to OR Position

•Include Braden Risk Number and OR Position to PACU nurse in Hand off report

•Notify Surgeon of any identified skin issues

PACU –

•Assess skin in Pressure Point areas specific to Surgical Position for potential issues

•Review Braden Risk Score from Day Surgery for any changes that the surgical procedure may have made.

•Include Braden Risk Number and OR Position to receiving nurse in Hand off report

•Notify Surgeon of any identified skin issues

Day Surgery – Post Op

•Reevaluates Braden Risk Scale for significant changes

•Assesses Pressure Point areas specific to Surgical Position for potential issues

•Provides patient education to patient/family related to skin care as appropriate

•Notify Surgeon of any identified skin issues

Figure 1. MCGHealth perioperative services PUP program. This figure is available in color online at www.jopan.org.

AMBULATORY SURGERY 105

Perioperative Services areas (Preoperative EvaluationClinic, Day Surgery Center, and the PACU [postanesthesia

care unit]) using the same material used throughout the

rest of the hospital. The operating room (OR) Nurse

Educator provided the same education for the OR holding

area and the OR staff.

Complications in Implementing the Protocolin Perioperative Services

As soon as we began implementation of the protocol, it

became obvious that the protocol had been written

around an inpatient scenario and was not a ‘‘good fit’’

for the ambulatory surgical arena, including the OR and

PACU. According to the protocol, each change of location

and condition requires the head-to-toe visualization and

completion of the Braden Risk Assessment. The perioper-ative patients are seen in the Preoperative Evaluation

Clinic, and later they arrive in the Day Surgery Center;

from there they go to OR Holding, from Holding they

go to the OR suite, then to the PACU. After the PACU,

the patient either returns to the Day Surgery Center for

discharge home or to an inpatient unit. Therefore, a pa-

tient in the perioperative arena changes location and care-

givers approximately five to six times. Strictly adhering tothe protocol would require each area to perform the head-

to-toe assessment and complete the Braden Risk Assess-ment, most within the same day.

From the beginning, the nurses voiced their concerns

about following the protocol exactly as written. In the

Preoperative Evaluation Clinic, patients are not undressed

for their visit. Even if the nurse became aware that

a patient had a pressure ulcer during the patient inter-

view, he or she could not visualize the pressure ulcerand stage it because the Preoperative Evaluation Clinic

does not maintain a stock of dressings appropriate for re-

dressing a pressure ulcer, especially if special dressings

are used.

The nurses in Day Surgery were resistant to performing

head-to-toe visual assessments on all of their patients.

Their practice included visualizing the surgical area forskin issues that could interfere with the surgical proce-

dure or possibly cause postoperative complications. For

instance, if the patient was scheduled for an implanted

port placement, they examined the chest area where

the port would be placed but they did not inspect the pa-

tient’s back and buttock areas (common areas for pres-

sure ulcers). Also, some patients, specifically the

ophthalmology patients, do not completely undress fortheir procedures. The nurses felt that the patients would

106 JOHNSON

feel it was an invasion of privacy if the nurse had to ask

them to undress and be evaluated for a pressure ulcer

when they would go to the OR with their lower clothing

in place.

The OR staff and the PACU staff found it difficult to use the

Braden Risk Assessment tool. The Braden Risk Assess-

ment Tool evaluates the patient in six areas: sensoryperception (ability of the patient to respond to

pressure-related discomfort), moisture, activity, mobility,

nutrition, friction, and shear.3 Much of the assessment is

performed either by observing the patient or asking for

the patient’s input on the patient’s abilities. In the OR,

all patients are considered at high risk for pressure ulcer

development. In the PACU, the patient is still sedated

and the nurse is unable to ascertain the patient’s normalstatus related to such items as nutrition, activity, and

mobility.

The Plan

With the input of staff members and the Perioperative

Services management team, it was decided to develop

a Perioperative Pressure Ulcer Program that would be inline with the intent of the MCGHealth Pressure Ulcer Pre-

vention Program while still being relevant to the staff. A

360� evaluation and reporting system was developed

(Fig 1). At each step in the process, any pressure ulcers

identified are entered into the variance reporting system

as per the hospital protocol.

The program begins in the Preoperative Evaluation Clinic.The nurse performing the preoperative assessment com-

pletes the Braden Risk Assessment with the assistance

of the patient and/or the family. The nurse also asks about

any skin issues that the patient/family know about. If

issues are identified, the nurse notifies the surgeon and

enters it into the PSN system.

When the patient arrives at Day Surgery, another BradenRisk Assessment is performed, unless the patient is

a Day of Surgery Pre-op, in which case the Preoperative

Evaluation Clinic nurse’s Braden Risk Assessment is

used. The Day Surgery Nurse performs a head-to-toe as-

sessment. He or she reports the risk assessment and

skin assessment to the Holding Room nurse during the

handoff report. If any pressure ulcers are identified, it is

staged (I-IV) and entered into the PSN system. The sur-geon is also notified of any identified skin issues just as

any other issues would be handled.

The OR Holding nurse reports the Braden Risk Assess-

ment to the OR staff. He or she also ensures that the sur-

geon has been notified of any skin issues. The OR staff

follow the Association of periOperative Registered

Nurses standards4 related to positioning the patient forsurgery. They also take extra care to protect any areas

of current skin breakdown to prevent further damage.

Before patient transport to the PACU, they evaluate the

patient’s skin for breakdown at pressure points specific

to the surgical positioning and any issues identified are

reported to the surgeon, entered into the PSN system,

and included in the handoff report to the PACU nurse.

The Braden Risk Assessment done in Day Surgery and

any impact that the surgery might have on the assess-ment score are also related to the PACU staff during

handoff. For instance, any potential surgical impact on

an oral surgery patient’s nutritional score would be

included in the handoff report.

During an assessment of the patient, the PACU nurse pays

special attention to the pressure points specific to the sur-

gical position. The nurse reviews the Braden Risk Assess-ment from Day Surgery along with changes indicated by

the OR personnel and considers any additional impact

he or she feels may occur postoperatively. If necessary,

he or she notifies the surgeon about skin issues. All of

this information is included in the handoff report given ei-

ther to the Day Surgery staff or to the inpatient unit nurse.

If the patient is going home after surgery he or she returnsto Day Surgery postoperatively. The Phase II postopera-

tive nurse, considering the input from both the OR nurse

and the PACU nurse, reevaluates the Braden Risk Assess-

ment for significant changes. He or she also assesses key

pressure points specific to the surgical positioning for

signs of skin issues. As appropriate, the nurse provides

patient education to the patient and the family related

to skin care and protection. If any skin issues are identi-fied that have not been reported to the surgeon, the nurse

reports these and enters a PSN.

Implementation

Before beginning the Perioperative Services Pressure Ul-

cer Prevention Program, the staff in all areas were in-

serviced on the revised process. A space for the BradenRisk Assessment score was added to the Day Surgery

Pre-Op Nursing Note form during the initial program

start-up. This area is being expanded to include the

score for each section to facilitate the reevaluation re-

lated to the surgical intervention. The PACU nurses re-

ceived training on the various operative positions and

pressure points related to each position. Scripting was

developed to facilitate both the Day Surgery nurse’scomfort in performing the head-to-toe assessment and

so the patient understands the need for the visual skin

assessment. The scripting is focused on patient safety.

Patient education tools related to skin care, nutrition,

and other important aspects of care were identified

and made available to the staff.

Because of the small number of patients entering with pres-sure ulcers, it is important to promote continued

AMBULATORY SURGERY 107

awareness of pressure ulcer prevention strategies, en-

hance the nurses’ ability to stage pressure ulcers, and the

ability to enter data correctly into the variance system.

Therefore, pressure ulcer staging and variance data entry

were added to the annual competency assessment

program.

Conclusion

Although diligence in program follow-up is necessary forcontinued success, the nurses have accepted the modi-

fied program as sensible and usable. We feel that we

have met our goal of providing our patients with as safe

an environment as possible, providing quality care and

meeting hospital requirements.

Acknowledgments

This article would not have been possible without the support of the

MCGHI Perioperative Services Management team: Perioperative Man-

ager Susan Andrews, MA, BAN, RN, CAPA; Day Surgery Charge Nurse

Karen Catchings, BSN, RN, CAPA; PACU Charge Nurse Leslie Edney,

BSN, RN, CAPA; and Pre-Op Evaluation Clinic Charge Nurse Sarah Gillen,

AAS, BA, RN, CAPA. I wish to express my thanks for their input into the

Perioperative Services Pressure Ulcer Prevention project and this article.

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3. Braden BI, Bergstrom N. Clinical utility of the Braden Scale for

Predicting Pressure Sore Risk. Decubitus. 1989;2:44-51.

4. AORN. Recommended practices for positioning patients in the

perioperative setting. In: Conner R, ed. AORN Perioperative Standards

and Recommended Practices, 2009 edition. Denver, CO: AORN

Publications; 2009:525-548.