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KCI RIK fluid operating table pad

"Awareness of OR-acquired pressure sores has increased over the last few years," said Dan Allen, a consultant for STERIS Corporation, Mentor, OH. "Longer surgeries are being performed on higher risk patients. The risks of developing a pressure ulcer as the result of an OR experience is increasing every year."

"Time is one of the biggest issues in pressure ulcer development," explained Allen, who specializes in surgical table accessories, patient posturing, pressure management and pressure sore prevention. The developer of the Allen Stirrup, he has spent the last 25 years devoted to developing posturing devices that protect patients from injuries that may occur as a result of lengthy surgical procedures.

The Association of periOperative Registered Nurses (AORN) 2006 Recommended Practices for Positioning the Patient in the Perioperative Setting, state that "procedures longer than two and one-half to three hours significantly increase the patient’s risk for pressure ulcer formation."¹

While AORN guidelines recommend pressure relief surfaces for surgeries lasting longer than two hours, "pressure sores can start to form in as few as 20 minutes," acknowledged Michael Bredal, vice president, sales for Action Products Inc., Hagerstown, MD. "It‘s important to think about how quickly they can form."

Complicating the matter, said Allen, "When a patient’s under anesthesia, they can’t tell you what hurts. The highest level of risk occurs when the patient is least able to provide feedback to deal with it."

Therefore, "Vigilance and making sure they’re using products that are appropriate is key to pressure ulcer prevention", said Bredal.

"Pressure sores develop from a combination of intrinsic and environmental causes," said Allen. Patients are at greatest risk for pressure sore development as the result of pressures created at the bone-tissue interface. Bony prominences (heels, sacrum, shoulder blades, back of the head and elbows) are the most susceptible sites. Allen calls these sites "the landing gear" because they are the primary support structures interfacing with the table surface. "The goal of posturing a patient to achieve pressure relief is accomplished when pressure is redistributed away from the bone-tissue interface to areas where the bone is no longer pressing into tissue," he said.

Vertical and horizontal shear also contribute to the formation of pressure sores. Capillaries allow only one blood cell to pass through at a time. If you stretch or elongate the capillary enough, it can become so thin as to be occlusive. If that occurs, blood cells can’t get through and tissue can die. According to early studies, it takes only 32 mm/Hg interface pressure to close a capillary, Allen noted. AORN guidelines state "studies suggest that positioning devices should maintain normal capillary interface pressure of 32 mm/Hg or less."1

Cincinnati Sub-Zero’s Gelli-Roll combines pressure and temperature management in one pad.

If you’ve ever shopped for pressure management devices, or even a new mattress for your home, you’ve probably seen a pressure map. With areas that are considered to be high pressure marked in red, and low pressure areas marked in shades of white and blue, pressure maps are often used in an attempt to compare interface pressures to represent the efficacy of patient surfaces, but manufacturers cautioned against using them as the sole measure of a product’s pressure-relieving performance. Looks can be deceiving, they agreed.

For one, the scales representing pressure can be set for favorable results. Allen explained, "A number of comparative pressure maps utilize a scale of 0 (white) to 125 (red) to represent the quality of their pressure management surface. It would be better science for manufacturers to supply pressure mapping using a much lower scale range. Since interface pressures greater than 32 mm/Hg close capillaries, the pressure maps should be set at 0-50 with any interface pressure greater than 50mm/Hg being depicted in red. Unless lower scales are applied to this mapping, it will continue to be difficult to evaluate patient surfaces."

Action’s Bredal pointed out another nuance related to pressure maps that buyers should be aware of. "The way that pressure maps are conducted is that you do an average of all of the sensors that are activated. There are pressure points that would go beyond 32 mm/Hg, but on average they are below. That is the industry standard for measuring pressure."

Added Michael Brown, senior programs manager for therapeutic surfaces, Kinetic Concepts Inc. (KCI), San Antonio, TX, "An individual pressure map really only represents how a surface performed for the patient being measured, by the technology (equipment) used to measure, and dependent on how the equipment was set up and calibrated. Bottom line, pressure maps can be misleading."

What’s more, 32 mm/Hg may be too much pressure for patients at higher risk for pressure ulcers, including elderly patients with thinner and less elastic skin, he said.

Cindy Miller-Mikolajczyk, RN, director of wound market development for KCI, and a former OR nurse, noted that blood volume loss and shunting are other contributing factors to pressure ulcer development in surgery and trauma patients. "In a cold environment like the OR, the body will shunt blood away from the skin into the trunk of the body to protect the vital organs. In the OR these patients are susceptible to pressure ulcer formation. These patients are just so vulnerable without aggressive intervention before the surgery starts."

"Individual patient conditions, the overall environment within the OR, and the length of surgery can have a cumulative effect on the risk of pressure ulcer formation," said Brown.

There are a variety of pressure-relieving positioning devices on the market that are designed to help prevent pressure sores from forming in the OR. According to AORN, "selection criteria for positioning equipment and devices, include, but are not limited to: availability in a variety of appropriate sizes and shapes; durable material and design; ability to maintain normal capillary interface pressure; resistance to moisture and microorganisms; radiolucency; fire resistance; nonallergenic to the patient; ease of use; easily cleaned/disinfected if not disposable; easily stored, handled, and retrieved; and cost effectiveness."1

AquaGel pressure management positioners from STERIS feature three-dimensional contouring that conforms to anatomical characteristics and cradles the skin. This contoured pressure redistribution disperses pressure away from bony prominences to areas where there is no bone to push against the fascia and the muscle. A dual-density construction helps protect against skin shear with a top layer that replicates skin and an inner layer that is similar to fatty tissue.

The RIK Fluid Operating Table Pad from KCI helps relieve pressure by conforming to body contours and distributing pressure evenly across the entire body using a proprietary fluid material that is neither gel nor foam.

Action Products’ positioners are filled with a visco-elastic polymer called Akton that will not leak, flow or bottom out, even with patients up to 1,000 lbs. The pads are covered with a stretchy, ultra-thin polyurethane film that is similar to skin, provides shear-reducing capabilities and brings the protective properties of the polymer through to the skin. Action’s extensive line includes specialty frame pads, pediatric positioners and custom designs.

Cardinal Health has a variety of Private Brand disposable foam positioning and cushioning products. These include heel and elbow protectors, foot cradles, abduction pillows, body aligners, head cradles, wheelchair cushions and mattress pads. "These products offer protection to patients while in bed, in a wheelchair or on the operating room table and allow air to circulate and minimize pressure during recovery," said Stephanie DeGroot, associate product manager, Cardinal Health, Dublin, OH.

New from Cincinnati Sub-Zero is the Gelli-Roll which combines pressure management with warming and cooling capabilities in one pad. A CSZ Plasti-Pad warming blanket is encapsulated within Akton gel. This reusable combination product can be used with CSZ‘s Norm-O-Temp, Blanketrol, or Hemotherm before, during or after surgery to help provide temperature management and pressure reduction for infants to bariatric patients.

"There are so many factors that go into forming pressure ulcers," said Bredal.

STERIS AquaGel contoured sacral protector

That’s part of the reason why it’s so hard to pin pressure sores to the point at which they started. Complicating the issue further, while
a Stage I or Stage II pressure sore appears in the first 24 to 48 hours after surgery, explained Allen, what had been called a Stage III or Stage IV pressure sore is really a deep tissue injury that starts at the bone/fascia/muscle interface. "Sometimes these terrible injuries don’t appear until 5 to 7 days post-op," said Allen. "These injuries take so long to present because they start from the inside and work their way out. In most instances the protocol for following patients stops after 72 hours. When patients are discharged within hours of their procedure, there is little or no follow-up communication. So a lot of the most serious pressure sores that are showing up in nursing homes and in ambulatory care facilities could very well have started with the patient’s experience in the operating room."

"There’s also a continuity of care issue," Allen remarked. "Pressure sores do not necessarily start in the OR. They are also a function of cumulative time. The kind of pressure required to create a pressure sore often starts the moment the patient becomes immobile or unable to react to ischemic pain. The clock starts ticking when the patient gets hit by a car, or when they fall and they can’t get up."

He explains a common scenario in which a patient is put on a hard surface in the ambulance, placed on a cheap stretcher mattress in the ER, and left on the stretcher to wait several hours for a room. "Then they take the patient to the OR, and what happens? Amazing! This 85 year-old woman develops a pressure sore," lamented Allen. "The damage is caused by the cumulative time spent placing pressure on the vascular system."

KCI AtmosAir stretcher MRS

"If we’re going to point fingers at the OR, let’s remember that patients tend to be put on a two inch or three inch thick pad on the stretcher either in the ER, and/or on the way to the OR," said Brown. "And then they’re returned to that two inch or three inch stretcher pad to go to recovery where they may stay for potentially hours, if not longer, especially if there’s no room in the ICU."

"All that damage that you’re thinking happened in the OR or ICU, could have happened starting out at the accident site," said Miller-Mikolajczyk. "There’s so much research that’s starting to percolate up about where pressure ulcers are really happening. The OR is a phenomenal focus, it’s an area with a great chance for quality improvement, but there are other areas that need to be addressed as well."

New from KCI, the AtmosAir Stretcher MRS with "open pressurized", Self Adjusting Technology (SAT) addresses a potential gap in a hospital’s overall wound care program by helping to prevent and treat facility acquired pressure ulcers on patients who spend time on ER, Recovery/OR and Transportation Stretchers.

Clearly pressure management is the enitre hospital’s responsibility.

"Another important issue is the general absence of a protocol for intra-departmental reporting of post operative pain unrelated to the incision site," said Allen. "As a result the OR staff, who are genuinely dedicated to protecting patients from harm, continue to posture patients with old methods, with no knowledge that patients are being injured and no understanding of what they need to guard against."

He continued: "I can’t tell you how many major hospitals I’ve walked into where OR staffs have said, ‘We know that other hospitals have problems with pressure sores, but we’ve never had a single one in 25 years. We must be doing something right.’ Then you walk down to the wound care people, and they say, ‘are you kidding me? At least 20 percent of our pressure sores are on surgical patients."

Statistically, 25 percent of all nosocomial pressure sores come out of the OR, noted Allen. "Some procedures have risk factors that are inordinate, such as vascular, re-implantation, and cardiac procedures that can last 11, 12, or even 15 hours. For these types of surgeries, the pressure related wound incidence in some areas is as high as 60 percent," he said.

"I went into a post-operative care unit (PACU), and the first question was, ‘why do we have so many patients complaining about pain that’s not related to the incision site?’ If someone had an abdominal procedure, why do their legs ache? Why does the patient feel like he jammed the funny bone in his arm? It’s all because of patient posturing injuries. I asked the staff if they report these incidents to the OR, and they said, ‘there’s really no procedure to do that’", related Allen. "If a wound care specialist doesn’t tell an OR nurse that they’ve had pressure sores from surgical patients, how would a surgical nurse know to guard against or prevent surgical-induced pressure sores? It’s not their fault if they don’t know about it. We’re finding time and time again that the only way to get through the lack of communication is to discuss this issue at the risk manager, CFO, corporate council, vice president of nursing and director of OR levels."

According to Bredal, patient posturing devices are no longer the sole concern of the OR nurse. "Lately we’ve had to increase the number of people we approach. We no longer speak only to the OR nurse. We speak to the risk manager, purchasing manager; it’s a multi-pronged sale."

"They need to cut holes in their management silos," Allen emphasized. "They need to share concerns and tell each other what’s going on."

Action donut head pad and pediatric chest rolls

Cost justifications

The cost savings potential for avoiding pressure ulcers is huge. Allen noted that the literature states that a Stage II pressure sore can cost upwards of $15,000 to treat, a stage III can cost up to $30,000 and a stage IV up to $90,000.

And litigation raises the stakes even higher. "Let’s consider the case of a nosocomial pressure sore," said Allen. "Some patients who developed a single pressure wound have been awarded hundreds of millions of dollars in compensation for their serious injuries."

"Both the prevention and aggressive treatment of pressure ulcers are potential savings opportunities when managed properly," said Brown.

"While the cost of treating an OR-acquired pressure ulcer does not come out of the OR budget, it does come out of the institution’s revenue," commented Allen. "A study was performed by the National Decubitus Foundation that shows that, based on the costs of therapy for OR-acquired pressure sores, a hospital has to budget at least $350 from every surgery lasting over three hours to pay for the therapy necessary to treat a potential OR-acquired pressure sore."

Pressure related OR-acquired injuries do not just come from the table surface; improper patient posturing devices can also be a source of postoperative pain and suffering, Allen explained. "There is not a single literature reference suggesting the use of towels and blankets to posture patients; however makeshift use of hard towels and blankets is commonplace even though they can cause skin and nerve damage. There may be a misconception that using towels and blankets is more economical than judicious use of reusable posturing equipment. Facilities using towels and blankets should be aware that there is a significant cost associated with those linens, they aren’t free. They can cost from seventy-five cents to a dollar and a half to process and transport. Sometimes 10 or 15 are used for a single case. So they’re looking at $10 or $15 in laundry charges for each case, rather than buying a reusable product with a very low cost per use," he offered. "Sometimes we think that we are saving money by using on-hand items, but what we’re doing is wasting money. Even worse, these time-worn positioning methods can hurt patients."

Action Products provides a Return on Investment (ROI) model on the company’s web site, www.actionproducts.com, that can help buyers build a business case for reusable patient posturing products.

Bredal commented that about three years ago, group purchasing organizations began establishing contracts for reusable pads and positioners in the OR. "Also, the orders are bigger now and lately we see whole hospital systems that are converting because they see the benefit of our product," he said.

Long-lasting performance and low-maintenance use are both key features for getting the most value from your reusable positioning devices. "The OR is a very tough environment," said Bredal. Action pads have been known to survive over 10 years in the OR, he noted. "It may not look pretty after all that time, but it’s amazing how it holds up."

X-ray translucency is also a major selling point in positioning devices and pressure relief pads, added Bredal. "There are a lot of pictures taken in the OR and you can’t have anything that degrades the picture to the extent where they have to take the patient out of the room to have them photographed."

"Hospitals are spending enormous amounts of money to treat OR-acquired pressure sores, but they’re not investing in technologies to prevent the pressure sores," Allen remarked. "Medicare currently doesn’t pay for prevention; they pay for wound therapy after the ulcer is formed. Now Medicare is saying, if the hospital doesn’t invest in pressure sore prevention, Medicare won’t pay for therapy because the hospital caused the pressure sore."

"Many times in healthcare, the only thing they’ve had on the shelf for positioning patients has become the hospital’s standard of care," said Allen. "You know, we used to rewash surgical gloves. We used to re-sharpen the needle that we used to take blood. We don’t do that anymore. A hospital’s standard of care must adapt to what we now know are the best practices for promoting patient safety."

That standard of care is rising across the board as public scrutiny builds. "CMS is looking at pressure ulcers as a quality of care measure, hospitals will be faced with a challenge, no matter where in the facility the wound is generated," said Brown. "From an acute care perspective, if a pressure ulcer is not documented upon admission then it’s the facility’s problem. They own it. So it becomes incredibly important for a hospital to improve documentation, to identify patients who have pressure ulcers on admission, identify by direct observation those patients who broke down on their watch, because ultimately those are the ones that will cause the most trouble."

"The public at large, not to mention JCAHO, CMS and any other certifying body is going to be looking for signs of the quality of care," he continued. "Facilities that have a high number of facility acquired pressure ulcers will not fare as well under any of that scrutiny."

Noted Miller-Mikolajczyk, "We do see a high incidence of nosocomial pressure ulcers in the ICU, the transplant units, the geriatric wards. It doesn’t mean that those nurses don’t care or aren’t turning these patients on a regular basis. These are the patients that are at such a high risk, or the procedures performed were so dramatic or any one of another of things coming all together. Pressure ulcer formation can happen so quickly in the high risk population."

"It’s about taking care of people and utilizing the latest technology to improve patient outcomes. In many cases the technology to prevent OR-acquired pressure sores and OR-acquired patient injuries actually exists," concluded Allen. "Pressure sores are an avoidable tragedy, for the people who get them, their families and the community. People lose their lives, livelihood, jobs, and houses because of pressure ulcers that could have been avoided."

1. AORN 2006 Standards, Recommended Practices and Guidelines, "Recommended Practices for Positioning the Patient in the Perioperative Practice Setting."

Pressure Ulcer or Burn: How to Tell the Difference Courtesy of Kimberly-Clark Pressure ulcers and burns are often difficult for clinicians to differentiate upon inspection; however, they differ in several ways. A burn is a tissue injury caused by direct contact with thermal, chemical or other agents that initiates directly at the skin surface, is visible immediately at the end of the surgical procedure and penetrates as it advances. Because they originate at the surface, a burn typically presents itself much earlier than a pressure ulcer. Pressure ulcers are caused by localized unrelieved pressure exacerbated by factors such as compression, shear, friction, and moisture. These typically propagate from the sub-dermal point where the tissue is compressed against a bony prominence, and as such may present within hours following the surgical procedure or as long as seven days after the injury has occurred. Burn Classification Burn injuries have three primary classification levels: 1st, 2nd, and 3rd degree burns. These classification levels are based primarily on the skin layers affected by the burn. The skin layers include the epidermis, the thin, outermost layer; the dermis, which provides strength, support, blood and oxygen to the skin; and the hypodermis or subcutaneous layer, located beneath the dermis, which provides blood supply to the dermis for regeneration. Click image to view full size. The table to the right describes differences between thermal burns and pressure ulcers. To avoid burns or pressure ulcers from patient temperature regulators, consider additional criteria such as thermostat settings, heat exposure temperature (both direct and indirect), temperature probe placement, system and patient monitoring, and patient pressure avoidance, especially on bony prominences such as the heels and the tailbone. It’s also essential that only approved pressure-relieving products be used, because rolled towels and other make-shift devices are known to exacerbate the problem.