Volume 40 Number 3

Introduction

Hospital-acquired pressure injuries (HAPIs) are one of the major challenges encountered by any healthcare facility, particularly in the critical care setting¹. This significant problem highlights the increasing incidence of morbidity and mortality, including lengthening of hospital stays, and contributes a substantial financial burden to any healthcare system¹. As defined by the National Pressure Ulcer Advisory Panel (NPUAP)², a PI is “a localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device due to intense and/or prolonged pressure or pressure in combination with shear”. Evidence shows that 95% of these PIs are preventable, and reduction of these is considered an eminent priority for any healthcare organisation¹.

One of the high-risk clinical areas of PI development for an ambulatory patient is in the operating theatre (OT). It was emphasised that patients undergoing an operation which lasts for more than 3 hours are at high risk of PI occurence³. In addition, any injuries over a bony prominence in the body that developed within 72 hours after prolonged and direct pressure during and/or after any surgical procedure are considered a PI incident. Furthermore, a medical device-related PI is a “Pressure injury that results from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally closely conforms to the pattern or shape of the device”³. If this pattern of injury occurs during the surgical procedure, it is considered a PI as well⁴. Studies reveal that the incidence and prevalence rates of HAPIs secondary to prolonged surgical procedures range from 5–53.4% and 9–21% respectively⁴.

This incidence rate is likely related to the intraoperative fixed position, type of anaesthesia, length of surgery, and patient factors such as age, gender, and history of diseases such as diabetes and heart failure⁵. The risk of skin damage is much higher in surgical patients than in non-surgical patients due to being immobile during the procedures and lacking awareness of pressure sensation during anaesthesia⁶. Also, anaesthesia decreases autonomic nervous system function which, in turn, enlarges vessels and decreases tissue perfusion, especially over bony prominences; this increases with longer surgery time and the use of general anaesthesia⁷.

At the same time, there is no validated risk assessment measures for surgical patients which has been formally established⁸. Several instruments are available to screen patients at high risk. However, according to an analysis of the predictive validity of the Braden Scale applied to surgical patients, the absence of risk factors related to surgery in this scale – i.e. surgery time or the position of the patient – makes its predictive validity to be low^6–8. Other instruments include the Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients – Adults (the Munro Scale) and the Scott Triggers tool. The Munro Scale includes 15 items to comprehensively assess the risk factors for PIs during the pre-, intra- and postoperative phases^9–10. The Scott Triggers tool includes four items of age, serum albumin level, estimated surgery time, and the American Society of Anesthesiologists (ASA) score¹¹.

One component of electronic health records (EHRs) is the pre-anaesthesia evaluation of the condition of a surgical patient written by the anaesthesiologist which is used to formulate an effective anaesthetic plan. This evaluation typically includes the type of surgery, serum albumin level and ASA score, which are also items on the Scott Triggers tool. Other data in the pre-anaesthesia evaluation are type of anaesthesia, laboratory test results such as haemoglobin and creatinine levels, and comorbidities such as hypertension and diabetes which are important to establish the profile, or model of risk factors, for predicting the development of PIs in surgical patients.

Although researchers have scrutinised individual prevention methods – e.g. repositioning, type of OT mattress used – the effectiveness of implementing a multidimensional approach has not been extensively evaluated⁸. Hence, it is essential for an institution to prevent and reduce the incidence of HAPIs, especially in the OT, and be able to provide safe and effective quality of care that is comparable to local and international benchmarks. Proper padding and pressure-relieving devices should be utilised. A support surface is required to redistribute pressure. The use of foam pads has not been as effective as protective devices, as they easily compress under heavy body areas and result in ‘bottoming out’.

Wound Care Service: an identified need

The Wound Care Service (WCS) at our medical city was initiated in early 2017 by two nurses. In 2018, three additional nurses joined the team to address and further enhance wound management delivered in the inpatient clinical areas. As mandated by SEHA – the Abu Dhabi Health Services Company, the owner/operator of all public hospitals and clinics across the United Arab Emirates, UAE – and the Department of Health (DOH), PI prevention and management are the primary goal of our team. Specific guidelines and key performance indicators (KPIs) known as Jawda (the Arabic word for quality) were published to serve as a guide in data collection and monitoring processes¹².

In the first quarter (Q1) of 2018, three HAPI cases were reported after undergoing oral and maxillofacial (OMF) surgeries which lasted from 8–14 hours. This led to an in-depth inter-professional team investigation and initiation of root cause analysis (RCA) to determine contributing factors of these incidences. A retrospective data analysis was conducted from our institutional incident reporting system, Safety Intelligence (SI), between 2016 and 2017 to gather baseline information of all skin injuries – including rashes, irritation, ecchymosis, lacerations, burns, abrasions, skin tears – and PIs reported in the OT.

In 2016, there were 21 reported cases of impaired skin integrity, of which 13 were reported PI cases, while 11 incidents of skin injury, two of which were PIs, were logged in the SI reporting system in 2017 (Figure 1). Furthermore, from 2016 to Q1 of 2018, a total of 18 PI incidents were reported in the OT (Figure 2).

Figure 1. OT SI report 2016 versus 2017

Figure 2. PI incident as raw data reported in SI – Q1 2016 to Q1 2018 in the OT

In conjunction with the extensive effort towards patient safety and quality of care at our institution, this quality improvement initiative was chosen to increase PI risk awareness, particularly in the OT. We aimed to identify common contributing factors and evaluate current practice and procedures in coordination with members of the inter-professional OT team – OT nurse leaders/staff/ surgeons – and higher hospital management with representation from nursing, quality and education departments.

Quality improvement goals and objectives

The goal was to reduce the incidence of PIs secondary to prolonged surgery. The following objectives were formulated in order to address the rising HAPI incidence secondary to prolonged surgeries in the OT. Specifically, this study aimed to:

• Identify factors contributing to the development of PIs in the perioperative phase of the surgical population.
• Implement PI preventive measures through:
• Early identification of high-risk patients and adoption of specific and appropriate risk assessment tools.
• Initiation of in-service education and training to all OT staff regarding PI prevention and management.
• Formulation of guidelines and policies related to PI prevention and management specific to perioperative patients.
• Empowerment of OT staff who will serve as resource individuals, and monitoring improvements/progress related to PI incidences.

Project methods

Planning and implementation

After completion of a needs analysis, the Plan-Do-Check-Act (PDCA) methodology was applied. This four-step quality improvement and management process is typically used for continuous advancement of people and systems within an organisation^13–15. PDCA is a successive cycle which starts off small to test potential effects on processes, then gradually leads to larger and more targeted changes¹³. This framework has been utilised in most of SEHA as a quality program for continuous quality improvement activities (Figure 3).

Figure 3. PDCA cycle

Resources

Human resources: several department meetings and consultations with hospital stakeholders were conducted to identify their respective roles and responsibilities for improving the process of preventing PI incidents for all prolonged surgery cases (Figure 4).

Figure 4. Human resources involved

Devices/tool utilised: during the incidence review and data collection period, the approved online incidence reporting tool – the UHC Safety Intelligence (UHC-SI), a real-time, web-based event reporting system – was utilised¹⁶ (Figure 5).

Figure 5. The UHC-SI tool

Implementation process

PI prevention is vital and is often neglected in the perioperative setting⁵. A questionnaire was conducted for OT staff to identify the main gaps. Results of RCA from Q1 2018 SI incidences revealed alarming deficits in terms of staff knowledge (PI risk assessment, staging and prevention), system/process (lack of guidelines, risk assessment tool, documentation and resources), appropriate OT table surface, and preventive dressings.

The best practice framework developed by Nelson et al.¹⁷ was adopted in the implementation stage of Q1 to achieve the required outcomes in the prevention of HAPIs. This best practice framework was further utilised as a model for Q1 interventions that targets the process of development in four areas – leadership, staff, information, and information technology (IT) – to support the clinician in the process of changing the old practice and adopting best practice of PI prevention and general performance improvement¹⁷.

Perioperative nurses should be educated about the risk factors of PI development and safety measures that can be implemented to prevent this injury from occurring¹⁸. An appropriate and validated risk assessment tool should be utilised by perioperative nurses to identify patients who are at high risk for developing a PI^18–19. All perioperative team members are responsible for the safe positioning of surgical patients. Circulating nurses coordinate the positioning of patients during intraoperative periods of care at our hospital^18–20.

In order to respond to gaps identified, our team focused on establishing awareness through assessments of staff knowledge of PI prevention and management^21–25. A patient trace was conducted in one of the elective cases undergoing OMF surgery. This allowed us to follow and understand the processes in the pre-, intra- and postoperative care provided to all surgical patients. In addition, accurate assessment, referral in the electronic documentation platform Malaffi – an Abu Dhabi innovative and unified health information exchange platform that facilitates a more patient-centric approach to healthcare provision – and efficient incident reporting were reinforced during the morning huddle, staff meetings and mandatory training. Coordination with the Nursing Education Department (NED) involved the clinical resource nurse (CRN) and application specialist investigating and formulating a risk assessment tool specific to the OT that could be incorporated in Malaffi. Detailed implementation processes were laid out as follows:

Knowledge assessment and mandatory PI education

Initial evaluations of PI knowledge among OT staff were completed using the Pieper Pressure Injury Knowledge Assessment Survey^22–23. Discrepancies in terms of the concepts of PI prevention – use of rings/doughnuts, massaging bony prominences areas – and inaccurate staging were observed²⁴. These gaps were addressed during the two mandatory education sessions conducted in the months of April and May 2018. An additional communication huddle guide was prepared emphasising the Surface/Skin assessment, Keep moving, Incontinence and Nutrition management (SKIN bundle), and the use of preventative dressings was communicated during daily pre-meetings.

Patient tracer and process evaluation

Prior to implementation, the actual process of the perioperative journey was observed by conducting a patient tracer. One patient under OMF who was electively admitted and booked for more than 10 hours of surgery was followed initially from the day surgery unit. Observation was continued from the pre-holding area in the OT until the patient reached surgical ICU postoperatively. Major findings included the lack of a standardised PI risk assessment tool, inconsistent implementation of referral system/consultation to the WCS, and inadequate pressure relieving equipment and supplies available in the OT. These findings were incorporated into the major action plan and communicated with the respective departments.

Early identification of high-risk patients and referral process

Clinical staff are requested to refer all patients to the WCS who are at risk of developing a PI – using risk assessment scores – and who are undergoing surgical procedures of more than 3 hours. These patients can be referred at any time or immediately after their surgery via the Malaffi. Through this system, OT staff are encouraged to complete accurate skin assessment/re-assessment prior to, during and after surgery by using a newly developed risk assessment tool with an emphasis on clear documentation which is to be reflected in the electronic documentation, the Surginet – MQM Nurse Assess Skin.

Risk assessment tool and recruitment of unit resources

Performing early risk assessment and appropriate interventions can prevent PI development^18–25. Due to the lack of a specific PI risk assessment tool to identify the risk status of patients undergoing prolonged surgery in our institution, the project team – in coordination with the OT CRNs – reviewed the possibility of adopting an existing risk assessment scale relevant to the operative period. Multiple discussions and meetings were held to review any existing PI risk assessment tools for the OT.

It was decided to incorporate the Scott Triggers tool as part of the skin risk assessment tool. The elements of the Scott Triggers¹¹ tool are: age >62; an ASA score >3; albumin <3.5g/dl; and prolonged surgery time >3 hours. The ASA score is a “global score that assesses the physical status of patients before surgery”¹⁰. The CRNs initiated and submitted a proposal to trial the Scott Trigger tool to the Perioperative Nursing Advisory Council Committee. An aim was to investigate the possibility of integrating the tool in the electronic clinical documentation system Surginet, with a further goal of standardising to all other SEHA business entities (see Appendix 3A & 3B). Upon identification of risk using the Scott Triggers tool, a bundled preventive approach or POP program (Prophylactic/Prevention dressing, Offloading devices/equipment and Position changing) would be initiated by OT staff. Completion of the process included accurate hand over between OT or post-anaesthesia care unit (PACU) staff to the receiving unit, with continued referral to the WCS as necessary. Furthermore, two staff from the OT department were nominated to be active members of the tissue viability link nurses group. These individuals will serve as a resource for information in promoting, reinforcing and monitoring PI preventive practices in the OT.

Introduction of preventive dressings and requisition of OT table mattresses

In addition to existing preventative protocols, the project team extended the use of preventive dressings for identified high-risk individuals in the OT. Although wound dressings are not routinely used to prevent PIs, evidence demonstrates that a non-woven, multilayer, polyurethane foam dressing may reduce the effect of shear forces¹⁸. Process guidelines were initiated in the OT (see Appendix 4) to keep the preventive dressing materials in a designated cabinet in the pre-holding area. Prophylactic dressing application over bony prominences such as the sacrum and trochanters can be applied in the pre-holding area or prior to sedation and positioning in the OT table to prevent the development of PIs (see Appendix 5).

Inadequate access to pressure relieving equipment and devices was one of the major findings during the tracer exercise. As observed, the operating table, with its hard surface, is only cushioned by gel padding and toppers. Pressure relieving and redistributing devices are widely accepted methods of preventing the development of PIs for people considered at risk²⁶. This equipment may be used in a variety of ways in the OT. Custom-made cushions for the OT tables are necessary to provide adequate support during extended surgeries. These issues have been raised with our facilities’ nurse leaders and cordially communicated with the materials management department for the provision of appropriate foam mattress and additional gel paddings.

Data analysis

The data collected from the SI between 2016 and Q1 2018 were used as a benchmark for the OT improvement project. After initiating the various strategies and methodologies, the team recognised there was a gradual improvement in the incident reports received from Q2–Q4 2018. These outcomes were achieved with the commitment and consistency of all departments adhering to the new system and practices, which included:

• Proper hand over and concurrent skin assessment.
• Identification of high-risk patients.
• Implementation of appropriate prevention measures.
• Earlier referral to the WCS.

Barriers identified by the group

Changing clinical practice can be a challenging process. Throughout the process of the improvement project, the team encountered important barriers and implemented activities to address these. These are outlined in detail in Table 1.

Table 1. Barriers and activities implemented

Project tools

The tools and processes used for the successful completion of quality improvement initiatives are outlined in the appendices:

• Appendix 1 displays the tool used for assessing OT staff knowledge.
• Appendix 2 (A & B) outlines the referral system to the WCS in the Mafraq Hospital.
• Appendix 3 (A & B) outlines the proposed pre-operative skin risk assessment form.
• Appendix 4 shows the pre-operative skin risk assessment flow chart utilised in the OT.
• Appendix 5 outlines the communication huddle regarding the appropriate use of prophylactic dressings in clinical settings.

Evaluation and Outcomes

Evaluation of the process

In accordance with the sudden increase of PIs reported in the OT from UHC-SI, the WCS decided to reduce these preventable cases of HAPIs. Both quantitative and qualitative data were evaluated to determine the impact of implementing system and process changes in our institution.

Qualitative outcomes

Valuable feedback was received from OT staff and nurse leaders following implementation of this quality improvement initiative. The focus was on the efficiency of the prophylactic dressing, the effectiveness of posters on the OT communication board in alerting staff, and the usefulness of education sessions to reinforce knowledge of all OT staff. Moreover, the reduction of PIs in the OT showed great achievement that positively affected the total number of HAPIs.

Quantitative outcomes

Quantitative data were gathered through incident reports via the SI unit. In addition, the total number of patients who underwent extended surgery time (>3 hours) were gathered through daily referrals. All data were compared between 2016 to Q1 2018 versus Q2–Q4 2018 data to evaluate the effectiveness of the initiative and to be able to identify significant changes between the two data sets.

After collecting all reported skin integrity incidence data from 2016 to Q1 2018, monthly data of referrals related to prolonged surgery were generated at the beginning of April 2018. An average of 9–11 patients were initially referred monthly to the WCS for follow-up. A total incidence of two cases were reported; one in the month of June 2018 and one in November 2018 which were in addition to the three cases reported from Q1 2018 (Figures 6 & 7).

Figure 6. Monthly referrals versus OT PI incidents 2018

Figure 7. Quarterly referrals versus OT PI incidents 2018

Within a 9-month period, 99 patients were referred to the WCS. Each of these patients, on average, had spent 7 hours on the operating table. Two cases of PI were reported – in Q2 and Q4 2018. The contributing factors discovered through RCA were poor nutrition, immobilisation, prolonged surgery time (more than 17 hours), presence of multiple comorbidities (chronic renal failure, diabetes), hypoalbuminaemia, haemodynamic instability, and inadequate skin assessment.

Reflection on lessons learned and stimulus for future work

On reflection of the initiation, implementation and outcomes of the quality improvement project, it would be important to:

• Ensure the availability and utilisation of a validated perioperative risk assessment tool is incorporated in the clinical documentation system in all public hospital facilities.
• Include more surgeons and allied healthcare staff from other disciplines in the mandatory education sessions related to the prevention of PIs.
• Conduct regular monthly audits for OT staff to evaluate and ensure continuous implementation of strategies related to the prevention of PIs.

Conclusion

The goal of any healthcare improvement project is to implement realistic action plans that can lead to measurable outcomes and enrich healthcare services offered to patients. As a team, our aim was to decrease HAPI, which required collaboration and commitment with various stakeholders – higher management, patients and healthcare practitioners – through proper communication of common challenges and pressing needs in the clinical setting. At our organisation, the support of key nurses in the perioperative area resulted in a new perspective and attitude towards PI prevention.

In summary, the prevention of HAPIs entails increasing awareness among stakeholders about the importance of early identification of at-risk patients and initiation of preventive measures. Engagement of an inter-professional approach towards quality improvements will ensure a long-lasting impact to both the patient and healthcare system.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

The authors received no funding for this study.

Author(s)

Asha Ali Abdi
RN, BSN, MSc Healthcare Management, IIWCC
Mafraq Hospital, Abu Dhabi, UAE
Emailashaaliabdi22@gmail.com ashaaliabdi22@gmail.com

Ashwaq Ali*
RN, Diploma, IIWCC
Mafraq Hospital, Abu Dhabi, UAE
Email ashwaqalinuuh@gmail.com

Fatima El-Ahmed
RN, BSN, IIWCC
Mafraq Hospital, Abu Dhabi, UAE
Email fatimekasem2018@gmail.com

* Corresponding author

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Appendix 1. Knowledge Assessment Tool

Appendix 2A. Wound Care service referral workflow

Appendix 2b. Wound care service patient assessment and workflow

Appendix 3A. OT Pre-operative skin risk assessment

Appendix 3b. Proposed modification in pre-operative checklist with addition of skin risk assessment in malaffi

Appendix 4. Preoperative skin risk assessment flow chart

Appendix 5. Communication huddle regarding the use of prophylactic dressing

附录1. 知识评估工具

附录2A. 伤口护理服务转诊工作流

附录2B. 伤口护理服务患者评估和工作流

附录3A. OT术前皮肤风险评估

附录3B.对术前检查表的建议修改以及MALAFFI中皮肤风险评估的增加

附录4. 术前皮肤风险评估流程图

附录5. 关于预防性敷料使用的交流会议