Nurses Work Together to Reduce Rate of Pressure Injuries in Cancer-Related Surgeries

Nurses Work Together to Reduce Rate of Pressure Injuries in Cancer-Related Surgeries

A nurse-led quality improvement project significantly reduced the amount of operating room [OR]-related pressure injuries at a New York Cancer Institution, elevating patient safety and improving the quality of care.

Kizzie Charles, MS, APRN, AGCNS-BC, CNOR, who is a clinical nurse specialist with Memorial Sloan Kettering Cancer Center, and who has been working in an OR for 17 years, helped lead this project. In an interview with Oncology Nursing News, she walked through the design of this project and underscored the impact that nurses can have on their patient’s safety and quality of life.

Behind The Project

“We are a magnet institution,” Charles said. “We are always looking to improve our nurse sensitive indicators.”

In 2020, the perioperative nursing department at her institution set a goal to reduce the number of acquired pressure injuries. As she explained, Memorial Sloan Kettering is a cancer institution, so the surgeries performed are very complex. Surgeries can involve multi-organ resections, chemotherapy administration, and even radiation oncology (external radiation or implantation of radioactive implants). Some of these surgeries require that the perioperative team pause and reposition the patient altogether, and some of these surgeries can be very long. There are surgeries that last up to 24 hours.

Because of that, patients are at risk for pressure injuries, or injury to the skin and underlying tissue because of the prolonged pressure on the skin.

“During that time, the patients are anesthetized, they're paralyzed, they're unable to move, they can't voice if they are uncomfortable, and they can't make the body adjustments that you would normally do to improve comfort,” Charles said. “So, they are at an extremely high risk for developing pressure injuries.”

“Pressure injuries develop within 72 hours of the actual injury itself, so that we needed to have some sort of process in place to identify which patients were developing these injuries,” she added.

Leveraging the Plan-Do-Study-Act Framework

The Plan-Do-Study-Act method is an implementation framework that can be used for quality improvement projects. It outlines a cyclical process for going through the phases of a project.

Charles and her team used this framework to design their quality improvement project.

“The plan phase happens before you implement your project,” Charles explained. “In this phase, you decide what your interventions are going to be; for our plan phase, we conducted a literature review and formed a multidisciplinary team with surgery, nursing, and anesthesia stakeholders to help us establish patient criteria for the project.”

During the plan phase, her team also modified their nursing documentation—including the intraoperative documentation and the postoperative documentation to reflect the skin assessments, and the application of prophylactic dressings.

They developed a daily “At-Risk Report” that would be emailed to the charge nurse and nursing leadership team. This lists all of the patients who are on the schedule for the day that met the criteria, and developed an anatomical chart that would guide the OR nurses in the placement on application of the dressings based on the patient's surgical position.

Charles noted that a key part of the planning phase was ensuring that all the necessary inventory was available to the nursing team.

“The prophylactic dressings that we used were already used in other areas in the institution but just not in the OR, so we acquired them,” she explained. “Then we did staff education on the dressings and the documentation changes.”

This prepared the team to move for the next phase, the “do phase,” which is when the project goes live. All of the interventions were implemented. "The wound care team would assess the patients when they [are] in the inpatient units after surgery and stage any injuries," she said.

Assessing the Findings

Charles’ team monitored the results, which is considered the beginning of the "study phase." For this project, this meant monitoring the number of injuries that occurred in the OR. "We evaluated the results, determined any opportunities for improvement to the process, and decided whether we needed additional cycles." The decision to include additional cycles is considered the "act phase."

She shared that the team ultimately implemented multiple cycles to adjust. They changed the workflow so that patients were getting their dressings placed in the OR instead of the presurgical area, and updated the electronic health record to allow for documentation of a comprehensive skin assessment.

The project ultimately led to a 50.5% reduction in OR-related hospital acquired pressure injuries (HAPIs).

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.

During the postintervention period, 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.

Takeaways for Nurses

“Nurse driven initiatives, [and] collaboration with perioperative nurses, clinical nurse specialists, wound care nurses, and informatics nurses can have a profound impact on the quality and safety of patient care,” Charles concluded, noting that these projects can also yield financial implications for the institution.

“We were able to save $80,000 based off the reduction in injuries,” she said.

She concluded that having the support of the Executive Nursing Leadership also helps move a project along.

“We had our director of perioperative services as an active member of our implementation team,” she said. “It opened up doors for us and ensured that the initiative remained a priority for the department.”

Reference

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