Pressure Injury Prevention

Purpose

This document provides guidance to perioperative team members for the prevention of perioperative pressure injury (PI) in patients undergoing operative and other invasive procedures in the perioperative practice setting. Guidance is provided for

• developing a perioperative PI prevention program;

• conducting a PI risk assessment and incorporating tools for assessing adult and pediatric patients;

• selecting support surfaces;

• using prophylactic dressings to prevent PI;

• implementing intraoperative interventions to prevent PI;

• providing hand-over communication;

• conducting a postoperative assessment; and

• developing policies and procedures, quality improvement initiatives, and education programs.

A PI is defined as an area of localized injury to the skin or underlying soft tissue that usually occurs over a bony prominence or is related to the use of a medical or other device and is the result of pressure or pressure combined with shear.¹  The primary cause of PIs is sustained cell and tissue deformation. The inability of the tissue to expand in volume leads to an increase in interstitial pressure, causing further cell and tissue deformation and distortion. This means that even if the pressure on the body part is offloaded after the initial deformation injury, the damage will continue while that inflammation persists.

Prevention of PI is an important aspect of perioperative patient care. Among the different care settings associated with increased PI risk, the operating room (OR) is known to be one of the most high-risk environments. Surgical patients are at a high risk for developing PIs because of immobility and the lack of sensation during the course of surgery and initial recovery from surgery.

The incidence of PI varies significantly according to the clinical environment (ie, extrinsic factors)^2-7  and the individual and clinical characteristics of the patient such as co-morbidities and health status (ie, intrinsic factors) (Figure 1).^1-29 

Figure 1. Intrinsic and Extrinsic Risk Factors for Pressure Injury

The Centers for Medicare & Medicaid Services (CMS) no longer pays for high-cost, high-volume conditions that develop during a hospital admission, such as a hospital-acquired PI (HAPI), for which the hospital must give the patient a diagnosis-related group assignment that carries a higher payment if the condition is secondary to the principal diagnosis and reasonably could have been prevented by using evidence-based practice.³⁰  Incremental costs to hospitals for treatment of a HAPI could be approximately $500 to $152,000 per patient.²  These costs amount to $26.8 billion yearly in the United States, most of which is represented by the extensive cost of treating Stage 3 and Stage 4 HAPIs.²¹  Decreasing the probability of HAPI progression across stages has been demonstrated to have the greatest effect on lowering costs.²¹  Prevention efforts and early interventions may be the most cost-effective strategies for hospitals.

Surgical positioning creates a risk for skin breakdown and PI development. Specific surgical positioning guidance is not provided in this guideline. Perioperative nurses should follow the recommendations in the Guideline for Positioning the Patient²⁸  in conjunction with the recommendations provided in this guideline.

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2000 through January 2021. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until November 2021. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included accidental falls, ambulatory surgery, cephalad slide, deep Trendelenburg, falling, falls, friction, head-down tilt (adverse effects), head holders, head positioners, hernia, inclined position*, injur*, intraocular pressure, intraoperative complications, intraoperative complications (prevention & control), laparoscopy (adverse effects), move*, movement, nerve injuries, neurosurgical head holders, neurosurgical head positioners, operating rooms, operating theater, operating theatre, patient positioning (adverse effects), patient positioning arms, patient positioning upper extremities, panniculus adhesive, panniculus adhesive tape, panniculus positioning, panniculus positioning device, panniculus retraction, panniculus retraction device, panniculus taping, pannus adhesive, pannus positioning, pannus positioning device, pannus retraction, pannus retraction device, postoperative complications, postoperative complications (prevention & control), ramped position*, redness, retraction of pannus, retraction of pannus adhesive tape, retraction of pannus taping, shear, shift*, shoulder brace, shoulder positioning device, slid*, surgical suite, Trendelenburg, Trendelenburg position*, trocar, tuck* arms, and tuck* upper extremities.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 2).

Figure 2. Flow Diagram of Literature Search Results

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The lead author and the appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.