instead of waiting for guidance to come from the top. After all, we
were the ones in the trenches dealing with the patients. We felt we
should be the ones looking more closely at the situation and finding
ways to implement better practices. Of course, we knew we'd eventu-
ally have to get buy-in from physicians and from administration, but
our nursing shared governance council got the initiative off the
ground, and now, almost 2 years later, we've seen dramatic results. In
the first 4 months of 2017, before we implemented our new proce-
dures, we had 9 documented or related pressure injuries. In the first 4
months after implementation, we had 2. We're still collecting data, but
in the first 6 months of 2018, we had just 1.
2-inch mattresses too thin
One of the first lights to go on was the realization that this was a pre-
operative issue, not just an operating room issue. The pre-op nurses
had an important role to play, as did the PACU nurses. Our wound-osto-
my-continence (WOC) nurses also helped in several ways, as they tend
to be well-versed in this issue. Their first contribution was to help us
identify the best evidence-based practices.
In fact, the WOC nurses had recently returned from a conference
with some important resources. As a result, the first thing we identi-
fied was that the 2-inch-thick mattresses in our ORs were too thin.
The recommendation they came back with was that table mattresses
be at least 3-inches thick. We'd never thought about that, and proba-
bly never would have, but it made sense once it was said out loud.
The revelation also underscored one of the challenges we'd face. We
were going to have to justify spending some money. More on that
later, but it was unrealistic to think we could immediately buy 35 new
mattresses (for our 35 ORs). So, instead, we immediately brought in
thicker mattresses where they were most needed. For example, some
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