Outpatient Surgery Magazine

dressings," says Ms. Kooiker. "We'd rather go overboard on prevention for any patient that's at risk, no matter how seemingly slight." In the OR, the CMunro Scale prompts nurses to assess systolic blood pressure, the surface the patient is on, core body tempera- ture, anesthesia type/ASA physical classification, positioning and presence of moisture underneath the patient. They implement posi- tion-specific protective measures: • Supine. Float heels without hyperextending the knee; apply foam dressing to heels and sacrum. • Prone. Put protective helmet on patient; apply foam dressing/gel pad to chest, knees, iliac crest and other bony prominences. • Lateral. Place pillow between legs; apply foam dressing/gel pad under knee, ankle, foot of depend- ent leg, axillary gel roll, other areas of pressure; ensure dependent ear is well-padded and not folded. They also coordinate with the rest of the OR team to offload pressure points throughout the case, usu- ally every 2 hours. If an intervention is needed, they float the heels without hyperextending the knee and maintain normothermia. PACU nurses note the length of surgery and estimated blood loss as part of the CMunro Scale process, says Ms. Kooiker. Handoff communication between nurses at each stage of the surgical process is vital. Nurses enter the skin assessment results into the patient's EMR, and verbally communicate and document skin assessments at handoffs throughout the surgical process, says Ms. Kooiker. They can send electronic Best Practice Alerts to inpatient nurses regarding the patient's PI risk. In addition, they perform dual- nurse skin assessments upon transfers of care, says Ms. Kooiker. The hospital's outpatient surgical center also par- ticipates in the safe skin initiative. "There's this idea out there that PIs aren't an issue in the outpatient world, but knowing what we know, and knowing surgeries in outpatient centers can still be complex, lengthy and stressful for the patient's body, we feel it's really important for our program to be imple- mented both at our inpatient and outpatient ORs," says Ms. Kooiker. Focus on the prone position In 2013, Vanderbilt University Medical Center in Nashville, Tenn., implemented a practice change to address PIs that developed in surgical patients who were in the prone position, particularly in specialties that were high areas of prevalence for PIs: neurolo- gy, ortho, spine and cardiac. Candi Haggard, RN, CWOCN, a wound, ostomy and continence nurse, explains why they focused on the prone position: • nationally, PIs related to the prone position in surgery are at 36%; • pressure for prolonged periods leads to ischemia-induced damage; • length of surgery and drooling during surgery put neurosurgical patients in particular at increased risk (Vanderbilt's baseline monthly PI rate in the neurosurgical population for 2015 was 8% to 10%). There were numerous problems with their exist- ing process, says Ms. Haggard. They had no consis- tent method for tracking — or providing feedback to providers — when a patient developed a PI. And they had variations in their positioning practices A U G U S T 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 2 5 • DRESS UP Preventing pressure injuries during surgery requires a careful application of protective materials, as well as precise patient positioning, by the OR team. Pamela Bevelhymer, RN, BSN, CNOR

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