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O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E | N O V E M B E R 2 0 1 4
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Educate, educate, educate
Once we identified the main problems, we knew we had to
continue to educate staff on proper practices. We re-educated
staff on the risk factors (elderly, low Braden score, in surgery for
more than 2 hours, high BMIs) contributing to pressure ulcers. We
made sure to re-introduce these basics to staff, and held classes on
pressure ulcer prevention techniques, such as patient positioning, to
be sure that everyone followed the same practices. Additionally, it
was crucial that staff were using the new products properly. Members
of the committee went around to ORs and monitored the products
being used. We also created a "Skin Is In" tip. Each month the com-
mittee comes up with a tip to prevent skin injuries, such as reminding
staff to float patients' heels or accurately document patients' skin
before and after surgery. Staff see them everywhere, from the lounge
to locker rooms, which make sure that skin integrity is in the fore-
front of our minds while in the OR.
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Check your progress
Audit your progress. The safety nurse in our committee
reviews charts and checks out skin issues that arise. This lets
us pinpoint certain practices or devices that were exacerbating or
causing skin injuries. For example, we realized that the pillow we
were using for patients in the prone position — which was square
with a softer, covered area where the patient's face would go — could
cause friction and tearing of the skin. We decided to change to a prod-
uct that instead cradled the patient's face, with a mirror underneath
that let the anesthesia providers see the patient's reflection.
Anesthesia ended up liking the new product much more, plus the
switch solved a skin injury problem.
P R E S S U R E U L C E R S
