An initiative led by nurses helped reduce operating-room pressure injuries and saved their institution an estimated $80,210 per year.
A nursing enhancement project conducted out of Memorial Sloan Kettering Cancer Center reduced the rate of inpatient operating room–related hospital-acquired pressure injuries (OR-HAPIs) by 50.5% and helped the institution save a projected $80,000 in costs.
Specific interventions included preoperative skin assessments, identifying risk factors for surgical patients, and providing early consultation by wound experts to those at-risk. Through these practice changes, the team was able to address OR-HAPI prevention in a more comprehensive way than merely applying prophylactic multilayer foam dressing (PMFD).
“By shifting the focus of pressure injury prevention from inpatient care to perioperative care and by establishing an interprofessional team, perioperative nurses can lead quality improvement initiatives to reduce OR-HAPIs, promote a culture of safety, and improve quality of care,” Kizzie Charles, MS, APRN, AGCNS-BC, CNOR, a clinical nurse specialist for the operating room at Memorial Sloan Kettering Cancer Center, and co-investigators wrote in the study published in the Clinical Journal of Oncology Nursing.
Before the intervention, between July 2020 and June 2021, a total of 4,470 patients met the criteria to be identified as at high-risk for an OR-HAPI. Among them, 8 had an OR-HAPI, and there were 10 total documented OR-HAPI cases. Patients who developed OR-HAPIs had been in lateral, prone, and supine positions during surgery, and their operation time lengths ranged from 115 to 1,607 minutes.
Postintervention, between July 2021 and June 2022, a total of 4,308 patients were identified as being high-risk for OR-HAPIs. At this point, the rate of PMFD application for high-risk patients was 95.9% and among this population, only 3 had documented had OR-HAPIs. Later, a total of 5 OR-HAPIs occurred while patients were in prone or lateral positions. Their operation time lengths ranged from 484 to 1,590 minutes.
According to the authors, for each prevented pressure injury, there was an estimated $43,180 in savings. The intervention itself costs $135,689. When considering the 5 prevented injuries, the estimated total cost avoidance was $80,210.
As Charles explained, OR-HAPIs can result in debilitating pain and infections for the patients. They can therefore lower a patient’s quality of life and even result in death.
Patients usually develop an OR-HAPI within 48 to 72 hours of their operation. Patients in certain anatomical positions during surgery are at higher risk, as well as those with impaired body temperature regulation, reduced perfusion, and a surgery time of 3 or more hours. Patients with cancer are also more likely to develop OR-HAPIs because chemotherapy, radiation therapy, nutritional deficits, and low body mass indexes make them more susceptible to injuries.
Memorial Sloan Kettering Cancer Center, which is a Magnet-designated comprehensive facility, has over 514 inpatient beds. The main cancer has 28 operating rooms and 100 perianesthesia beds. As with many surgical oncology centers, the surgeries performed are complex. Often, surgeons are resecting large or multiorgan tumors, and the average operating time is 4 or more hours. Some of these surgeries last for longer than 24 hours.
In 2020, 10 patients experienced OR-HAPIs. The most common locations for these injuries were the patient’s chest, ilium, or sacrum. Consequently, the perioperative nursing team chose to design a quality improve project to identify the unique risk factors for OR-HAPIs and reduce the risk of occurrence in their center. Of note, they chose to focus on inpatient care, because patients in the ambulatory setting could not be assessed within the 48-to-72-hour time frame because of different follow-up protocols.
Three aspects of oncology nursing practice were enhanced. First, for patients who were flagged as high-risk, a prophylactic multilayer foam dressing was applied to bony prominences. High-risk patients were those scheduled for a surgery longer than 4 hours or whose body mass index was less than 19.
Second, the electronic health record (EHR) was optimized to include the operating room skin assessment. Specifically, the new EHR allowed nurses to note where exactly the skin condition occurred, and, if there had been nurse intervention, when documenting intraoperative and postoperative skin assessments. Also, for patients suspected as having an OR-HAPI, the EHR would prompt the user to ensure the patient received a nurse-driven wound care consultation.
Finally, an in-service education was held with all the nursing staff in the presurgical center, OR, and postanesthesia care unit. During this meeting, nurses practiced comprehensive skin assessments and applying PMFDs. Further, the team developed an anatomic chart which shows where a patient should receive PMFD depending on their surgical position.
As Charles noted, this projected was guided by an interprofessional team of nurses. By working together, they were able to enhance their practice, improve patient outcomes, and reduce hospital costs.
Charles K, Forlizzi B, Salgado YV, Rosado M. Reducing pressure injuries within the perioperative oncology setting using an evidence-based quality improvement initiative. Clin J. Oncol Nurs. 2023;27(5):548-552. DOI: 10.1188/23.CJON.548-552