Running head: PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 1 Perioperative Risk Factors Associated with Post Operative Pressure Ulcer Development Ana Carla Pena University of Florida
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 2 Abstract The incidence of p ressure ulcers (PUs) is continuing to trend upwards. Literature review reveals that the operating room (OR) shares responsibility for the d evelopment of PUs because of potential high risk factors in surgical patients The main objective of this quantitative retrospective study is to ident ify and validate perioperative factors that contribute to the development of pressure ulcers in the OR in order to create a perioperative tool that identifies at risk patients and provides intraoperative interventions. Data collected from 41 patients revea led that factors such as the time of the procedure, a high American Society of Anesthesiologist (ASA ) score and comorbidities including vascular disease, diabetes, and hypothyroidism are highly associated with the development of PUs in the OR. Currently, the results of the study are being analyzed for statistical significance and validation. Future implications include the development of the Shands at UF Pres s ure Ulcer Risk Asses sment Scale for Peri Operative p atients and the validation of perioperative in terventions. These interventions will be analyzed by utilizing the Nursing Quality Database to track PUs with the OR as site of origin and to decide whether the incidence of pressure ulcers increas e or decrease in the surgical population Keywords : pressu re ulcer, operating room, assessme nt tool, perioperative, nursing
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 3 The main purpose s of this research paper were to determine perioperative risk factors that contribute to the development of pressure ulcers in the operating room (OR) in order to develop a tool that would indicate patients at high risk; and to explore the journey and the role of three honors nursing students while working in this investigation. What is a pressure ulcer? In the attempt to comprehend perioperative risk factors leading to the development of pressure ulcers postoperatively, an understanding of the pathophysiology of pressu re ulcers is required. A pressure ulcer is defined as t issue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period of time ( Ignatavicious & Workman, 2010) This tissue damaged can occur anywhere in the body. five regions have been identified as the most prone to develop pressure ulcers : t he sacrum and calcaneus during supine position, the lateral malleolus and greater troch anter when the patient is in lateral position, the ischium while sitting, and the occiput and elbow during prone position (Prekumar, 2005 ). Pressure ulcers have been divided into four stages, each stage having different prognosis and treatment. S tage I i s identified as a nonblanchable erythema of an intact localized area of skin (Ignatavicious & Workman, 2010) In stage II, there is pa r tial thickness loss of the epidermis and some of the dermis. This stage is characterized as an abrasion, blister, or a shallow crater; yet, bruising is not present (Ignatavicious & Workman, 2010) In a stage III pressure ulcer, there is full thickness loss of the skin and necrosis of subcutaneous tissue. The depth of the injured can vary depending on the anatomical positio n. Areas of thin epidermis may show a shallow crater; however, areas with larger amounts of subcutaneous fat may show a deep crater like appearance (Ignatavicious & Workman, 2010) During stage IV, there is full thickness loss
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 4 with exposed or palpable musc le, tendon, or bone. Undermining, tunneling, slough and eschar are often present on the wound Moreover, there are two other categories of pressure ulcers, Deep Tissue Injury (DTI) and an unstageable pressure ulcer A DTI is defined as a localized area of discolored skin that is purple or maroon in color due to damage of underly ing soft tissue. T he skin is intact and the injury occurs to deeper tissues as opposed to superficial skin commonly associated with pressure sores In a n unstageable pressure ulcer, extensive necrotic tissue covers the area, obscuring the true depth of the wound; it is usually covered by either eschar or slough (Ignatavicious & Workman, 2010) Once the tissue has been damaged and a pressure ulcer has dev eloped, patients often experience a significant amount of pain and discomfort. In addition, the injured site is at high discomfort ( Prekumar, 2005). After doing an extensive review of literature, patients who develop pressure ulcers while being hospitalized tend to share the following risk factors: Immobilization : this includes prolon ged bed rest, being bedridden, the use of w heelchair s and /or being affected by illness or injuries that result in limited range of motion ( Baumgarten et al., 2012; Ignatavicious & Workman, 2010; Schouchoff 2002) Age : a thinner, drier, and more fragile epidermis is part of the normal process of aging that increases the risk of skin breakdown ( Feuchtinge Halfens, & Dassen, 2005; Ignatavicious & Workman, 2010 ; Price, Whitney, & King, 2005; Schouchoff 2002) Comorbidities such as d iabetes m ellitus (DM), spinal cord injuries, and neurological disorders often cause a loss of sensation. This makes patients unable
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 5 to feel pain thus making them unaware of the need for changing positions. In addition, peripheral vascular d isease (PVD) and hypertension cause a decrease in blood flow and circulation, which also incr ease the risk for tissue damage ( Feuchtinge Halfens, & Dassen, 2005; Ignatavicious & Workman, 2010; Price, Whitney, & King, 2005; Schouchoff 2002). Incontinence : patients who are constantly exposed to bowel and urine incontinence have extra skin moisture that can lead to maceration of the epidermis, thus making the effects of s hear and friction more damaging ( Baumgarten et al., 2012; Ignatavicious & Workman, 2010). Malnutrition : patients with a low Body Mass Index (BMI) and poor nutritional status have less fat an d muscle, leaving less cushioning between bony prominences and surfaces ( Feuchtinge Halfens, & Dassen, 2005; Ignatavicious & Workman, 2010; Price, Whitney, & King, 2005; Schouchoff 2002). Medications such as immunosuppressant s and steroids cause thinning of the skin in addition of delay woun d healing and tissue synthesis ( Baumgarten et al., 2012; Ignatavicious & Workman, 2010). Facts and Statistics The treatment to cure pressure ulcers is long, painful, and very expensive. In fact, the monetary cost of the treatment is over 41 billion dollars annually just in the United States (Armstrong et al., 2008). Since October 1 st 2008, the Center for Medicare and Medicaid services (CMS) introduced various plans to reduce the cost of pressure ulcers. It wa s decided that hospitals will not receive additional payment for cases in which one of the selected Hospital Acquired Conditions (HACs) was not present on admission. In return, hospitals will not obtain
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 6 reimbursement to care for a patient who has received an acquired pressure ulcer while in the hospital (Armstrong et al, 20008). Yet, statistics show that in the United States, the prevalence of pressure ulcers ranges from 4 38% among hospitalized patients (Feutchinger, Halfens & Dassen, 2005). In addition, of the overall hospital population that developed pressure ulcers, 4.6 to 66% were surgical patients whose procedures lasted more than four hours (Schouchoff, 2002). Therefore, there is an immediate need of new interventions to decrease the prevalence of p ressure ulcers in this vulnerable population. T he effectiveness of the interventions in the OR in order to prevent pressure ulcers h as been examined A research trial conducted by Nixon, McElvenny, Mason, Brown, & Bond (1998) showed that the use of dry viscoelastic polymer pad intraoperatively reduced the probability of pressure sore development by half. However, a randomized study showed that patients who were positioned over a 4 cm thermoactive viscoelastic foam pad suffered more pressure ulcers (17.6%) than patients positioned on an OR table with the warming source but no pressure reducing device (11.1%) (Feuchtinger, De Bie, Dassen, & Halfends, 2006). PU Assessment Tools The American Agency for Heal th Care Rese arch and Quality recommended the use of three major pressure ulcer assessment scales: the Norton scale, the Braden scale, and the Braden Q scale. The Norton scale was developed in 1962 and it was the first tool developed to assess for the potential of deve loping pressure ulcers (Defloor, 2005). This scale includes five main categories: general physical condition, mental status, activity, mobility, and incontinence (Norton et al. 1975). Each item is scored on a four point scale, in which a score lower than 12 points is indicative of high risk for pressure ulcers (Defloor, 2005). Currently, most hospitals including Shands at University of Florida (UF) prefer the Braden scale. This scale utilizes six categories to
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 7 evaluate factors such as sensory perception, m oisture, activity, mobility, friction/shear, and nutrition. The score varies between six and 23, in which patients with a score lower than 16 tend to develop pressure ulcers (Bergstrom et al. 1987). Similarly, the Braden Q scale was created in 1996 to pre dict the development of pressure ulcers in the pediatric population. It consists of seven subscales: mobility, activity, sensory perception, moisture, friction/shear, nutrition, and tissue perfusion/oxygenation. The score ranges from seven to 28, with a sc ore lower than 16 identifying patients at risk (Curley et al., 2003). While these tools have been known to be ef fective, currently, there is no scale exclusively designed for the use in OR, an area with a definite need for a pressure ulcer perioperative as sessment scale. The Study Currently, the majority of research and interventions to prevent the development of pressure ulcers is focus o n patient care in nursing homes Only few studies attempted to investigate factors associated with pressure ulcer develo pment among surgical patients ( Aronovitch, 1999 ; Lindgren, et al., 2005). Twenty three percent of the total number of pressure ulcers developed in the US was from surgical procedures ( Aronovitch, 1999 ) Therefore, the focus of this researc h project i s to determine, validate, and develop a tool in which patients with specific risk factors can be identified in order to allow for early interventions before, during and after surgery thus decreasing occurrence of pressure ulcers from the OR. This research project was a retrospective and quantitative study. A convenience sample of 41 subjects was used for review The only inclusion criterion was that the subject had to have develope d a pressure ulcer during surgery at Shan ds at UF from July 2008 to 2011 The two main databases utilized to retrieve data were the Nursing Quality Database and the Shands Pressure Ulcer Quality Database for July 2008 July 2011 At the time t he honors nursing
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 8 students joined the project, the principal investigator (PI) had obtained approval from the institutional review board (IRB) to start the investigation. The IRB revision was submitted for the honors students to access the database. The hono rs nursing students were approved within a month after the submission of IRB revision This allowed the honor students to review charts from the Nursing Quality Database and the Shands Pressure Ulcer Quality Database and to review the r ecords of patients who developed pressure ulcers at the OR as the poin t of origin. H onors students reviewed the sections of history and physical, anesthesia records, surgical operative records, nursing perioperative records, patient progress notes, nursing flow sheets and progress notes, laboratory results, and medication administration records. Data re trieved from the chart included patient diagnosis, comorbidities, nutritional status, BMI, age, race, ethnicity, Society of Anesthesiologist (ASA) pre anesthesia evaluation score, functional capaci ty, skin condition preoperatively, skin evaluation postoperatively, length of surgery, cardio pulmonary bypass, plans of care, postoperative progress, total length of stay, time and stage of first notation of PU, stage of PU at discharge, and discharge dis position. In addition, the statistical significance of the s e specific risk factors were analyze d as well as their correlation with an increase in t he prevalence of pressure ulcers. Discussion The main goal of this study was to identify and validate factors in the perioperative period that may be associated with the development of pressure ulcers. The data obtained from this sample will then be used as part of a preliminary study to develop a Shands at UF Pres s ure Ulcer Risk Assessment Sca le for Peri Operative Patients (refer to Figure 1) This scale will be
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 9 used for early detection of PU and to develop the effective interventions that can be used to reduce the risk of develo ping pressure ulcers in the OR settings. The Pre s sur e Ulcer Risk Assessment Scale for Peri Operative Patients will be used by perioperative nurses to gather including comorbidities such as asthma, hypertension, PVD, and DM Each comorbidity weights one point. Also, factors such as BMI, physical status, their American ASA pre anesthesia evaluation score, and the length of the surgery will be coll ected. Each of those items will be scored from one to three, where one equals li ttle risk, two equals moderate risk, and three equals high risk. The final score will determine the type o f interventions they needy based on the category in which each patient falls. The following are items from the Assessment Scale for periope rative patients. Low risk, total score is less than six. The nurse would assess the patient for any preoperative pressure ulcer At risk, total score is between six and eight. The nurse would assess for pressure ulcers pad all bony prominences, assess ski n integrity every two hours, and assess fo r alignment and pressure points. High risk, total score is higher than eight. The nurse would implement all the previous interventions and the surgical team would be asked to stop the surgery once 4 hours have pass ed by in order to reposition the patient as long as the movement does not compromise the surgical procedure or sterile field. In addition, the use of specialty beds such as the Pressure Relieving Air Mattress and wou l d be enc ouraged.
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 10 If a fter t he Shands at UF Pre s sure Ulcer Risk Assessment Sc ale for Peri appears to be effective, it will be implemented in the OR for six months to one year. During that period of time, t he effectiveness of this tool will be measure d by utilizing the nursing quality database to track PUs with the OR as site of origin and to determine whether the incidence of PUs increased or decreased in the surgical population (Avigne, 2011) Role As one of the h onor nursing student s for this project the role of the author and her teammates throughout this project was very significant. The students immersed themselves into an extended review of literature in which they investigated interventions that are curren tly being implemented in the OR. They analyzed different intraoperative patient positions that assist in reducing friction/sheer forces, and they also looked at new technological devices that are being studied to help reduce pressure such as the different pressure r elieving air mattresses. Subsequently the students contributed in the develop ment of a risk factor checklist. They hypothesized various factors that may cause patients be at risk for developing pressure ulcers. The factors were preoperative, perioperati ve, as well as postoperative. These factors included nutritional status, pre surgical medications, pre surgical skin assessment, pre surgical ASA evaluation, func tional capacity, co morbidities surgical procedure, OR position, skin preparation, OR bed surface, body t emperature ( pre surgery, peri surgery, and post surgery), cardio pulmonary bypass/tim e use, cross clamp time, ejection fraction, moisture potential in OR, and patient census history (see Tables 1 and 2) T he students created a patient profile for all the
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 11 anesthesia assessment, operative consent, operative reco rd, anesthesia record, nursing perioperative records, physician progress notes, nursing flow sheets and nursing notes After data collection, each student had the opportunity to observe differen t surgical procedures in the OR including mitral valve repla cement, catheter directed thrombolysis, Abdominal Aortic Aneurism (AAA) repair, and Inferior Vena Cava (IVC) filter placement among others. During the observations, students focused their analysis on noting how vigilant the OR team was in completing the pr eoperative skin assessment, how often patients were repositioned, the type of bed being used, and their body tem perature especially if patients were under the cardio pulmonary bypass machine Challenges and Suggestions Conducting an honors research study was not an easy task. As the students worked in the project they faced multiple challenges mainly involving the charting system. The students were not currently doing clinical rotations at Shands at UF ; and consequently they did not have direct access to the computer system. They were therefore dependent on Shands employees to sign them in every time they needed access to the system. In addition, the students reviewed the charts and notes f rom multiple interdisciplinary professions including nursing, physicians, dietitian, and physical therapy. Each charting system had its own design and model, which added to the difficulty of data collection since there was not an established pattern Moreo ver, the inconsistency and lack of data added more stress to the data collection process and made it extremely time consuming. Finally, the lack of a fully computerized record sharing system made chart reviewing very complicated especially when students h ad to look at scans and handwritten notes by physicians and nurses.
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 12 Nonetheless, the honors research process was very gratifying and filled with learning experiences. The students learned that every population is at risk for developing pressure ulcers, not just older adults. Data collection revealed that patients as young as 16 years old were at risk of develop ing pressure ulcers after having surgical procedures lasting at least four hours. More over, the importance of post operative skin assessment was a major discovery. In multiple occasions, skin was not fully assessed until 24 hours after surgery. This clearly delays diagnosis Most important the students learned that research is an on going, multi step process. Their research study is only a small contribution to all the work the ir preceptors are involved i n. As of now, the data is being analyzed by a statistician and the following steps val idating the interventions and publishing the findings. As previously discussed, working in an honors research project requires a lot of effort and it could become overwhelming if students do not know how to approach it. This is the reason why t he author w ould like to share three main suggestions for future students who decide to join the honors journey: Fixed Schedule: even though working on research requires investigators to be flexible about potential changes and unexpected outcomes, having a fixed schedule would help students incorporate research to their regular school calendar; t hus helping to avoid major sche duling conflicts in the future. Deadlines: by setting deadlines, students are able to set timelines for themselves, track their progress, m ake sure assignments are completed, and make the research process a lot smoother. Pro active : students must use the research experience to their own advantage. They need to ask questions, stay involve in the research process as muc h as their
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 13 scope allows them to and start building professional relationships with their team members because this could represent future career opportunities. Summary T he honors research project is a great learning opportunity that every student should take Although it is stressful and it adds more work to their study plan, the end r esult is astounding It helps students feel more comfortable working on intimidating topics such as research and it gives them the possibility to increase their knowledge in their particular are a of interest. In this particular case, the incidence of pressure ulcers in the OR population caught t attention. After conducting an extensive literature review, it was revealed that there is an immediate need for an adequate perioperative pre ssure ulcer risk assessment tool because the predictive value of existing tools is unsatisfactory (Nonnemacher et al., 2008). In this different risk factors that could h ave contributed to the development of pressure ulcers such as length of surgery, position during surgery, and comorbidities among others. In addition, they participated in different surgical procedures to observe the current interventions that are been taken in order to prevent pressure ulcers from occurring. The results of the study, which are currently being analyzed by a statistician, will be used as evidence in order to create a pressure ulcer risk assessment scale that will allow nurses in Shands at UF recognize patients at high risk. By using evidence based practice, health care providers can guarantee they are using the highest their outcomes.
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 14 References Avigne, G. (2011). Evidence based practice presentation [PowerPoint slides]. Armstrong, D., Ayello E., Capitulo K., Fowler, E., Krasner D., Levine J. (2008). New opportunities to improve pressure ulcer prevention and treatment. Journal of Woun d Ostomy Continence Nursing, 35, 485 492. Magaziner, J. (2012). Care related risk factors for hospital acquired pressure ulcers in elderly adults with hip fracture. Journal of the American Geriatrics Society 60 (2), 277 283. Retrieved from http://uh7qf6fd4h.search.serialssolutions.com.lp.hscl.ufl.edu/?genre=article&isbn=&issn =00028614&title=Journal of the American Geriatrics Society&volume=60&issue=2&date=20120201&ati tle=Care Related Risk Factors for Hospital Acquired Pressure Ulcers in Elderly Adults with Hip Fracture.&aulast=Baumgarten, Mona&pages=277 283&sid=EBSCO:CINAHL&pid= Beckrich, K., & Aronovitch, S. (1999). Hospital acquired pressure ulcers: A comparison of c osts in medical vs. surgical patients. Retrieved from http://findarticles.com/p/articles/mi_m0FSW/is_5_17/ai_n18609011/pg_5/ s Bergstrom N, Braden BJ, Laguzza A & Holman V (1987) The Braden scale for predicting pressure sore risk. Nursing Research 36 205 210. Curley, M., Razmus, I., Roberts, K., & Wypij, D. (2003). Predicting pressure ulcer risk in pediatric patients: the Braden Q Scale. Nursing Research 52 (1), 22 33. Defloor, T., & Grypdonck, M. (2005). Pressure ulcers: validation of two risk assess ment scales. Journal Of Clinical Nursing 14 (3), 373 382
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 15 Feuchtinger, J., Halfens, R., & Dassen, T. (2007). Pressure ulcer risk assessment immediately after cardiac surgery does it make a difference? a comparison of three pressure ulcer risk assessment i nstruments within a cardiac surgery population. Nursing In Critical Care 1.2 (1), 42 49. Feuchtinger, J., de Bie, R., Dassen, T., & Halfens, R. 2006). A (4 cm thermoactive viscoelastic foam pad on the operating room table to prevent pressure ulcer during cardiac surgery. Journal Of Clinical Nursing 15 (2), 162 167. Feuchtinge, J., Halfens, G., & Dassen, T. (2005). Pressure ulcer risk factors in cardiac surgery: A review of the research literature. Heart & Lung 34 (6), 375 385 Ignatavicious D., & Workman, L. (2010). Medical surgical nursing: patient centered collaborative care (6th ed.). Missouri: Elsevier. Nixon, J., McElvenny, D., Mason, S., Brown, J., & Bond, S. (1998). A sequential randomized controlled trial comparing a dry visco elastic polymer pad and standard operating table mattress in the prevention of post operative pressure sores. International Jo urnal Of Nursing Studies 35 (4) 193 203. Norton D, McLare n R & Exton Smith (1975) An investigation of geriatric nursing problems in h ospital. Churchill Livingstone, New York, pp. 1 235. Premkumar, K. (2005). Pathology perspectives. Decubitus ulcers: pathophysiology and the role of massage therapists. Massage & Bodywork 20 (5), 100. Price, M., Whitney, J., & King, C. (2005). Wound care. Development of a risk assessment tool for intraoperative pressure ulcers. Journal of Wound, Ostomy & Continence Nursing 32 (1), 19 32.
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 16 Schouchoff, B. (2002). Pressure ulcer development in the operating room. Critical Care Nursing Quarterly 25 (1), 76 82.
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 17 Appendix Table 1 Patient Checklist
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 18 Table 2 Patient Checklist (Continued)
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 19 Risk Score 1 2 3 Total Comorbidity Identify and add 1 point for each Smoking Asthma Hypertension Diabetes Vascular Disease Respiratory Disease Nutritional Status Length of NPO status 12 hours or < >12 hours but <24 hours >24 hours Body Mass Index or weight Choose one description <30 Kg/ 30Kg/ 35Kg/ 35Kg/ <18.5 Kg/ Normal Underweight/obese Morbidity obese/underweight Age Years 39 or < 40 59 60 or > Body temperature ( ) Celsius 36.1 37.8 Pre op >37.8 or <36.1 (+ or 2) in OR >37.8 OR <36.1 (+ or 2) in OR Body temperature maintained Fluctuated + or >2 Maintained + or 2 Preoperative mobility/activity Not or slightly limited Very limited Completely immobile Physical status/American ASA I ASA II, III ASA IV Shands @ UF Pressure Ulcer Risk Assessment Scale for Peri operative Patients Patient Name: Date: Medical Record:
PERIOPERATIVE RISK FACTORS AND PRESSURE ULCER DEVELOPMENT 20 Figure 1 Shands at UF Pressure Ulcer Risk Assessment Scale for Peri operative patients. This figure illustrates the data nurses would be collecting from patients before going to surgery Society of Anesthesiologist pre anesthesia evaluation score Healthy and mild systemic disease, no functional limitations Moderate to severe systemic disease, some function limitation Moderate to severe systemic disease, constant threat to life and functionally incapacitating Functional capacity Moves independently, high functional capacity Requires transfer assistance, medium functional capacity Requires full assistance position intraoperatively changed and use of traction, low functional capacity