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Archive April 2020 XXI, No. 4

Make Pressure Injuries Never Events

Be proactive in protecting skin to prevent avoidable patient harm.

Heather Kooiker

Heather Kooiker, MSN, RN, CNL, CNOR, CRNFA


Lehigh Valley Health Network
PRONE TO PRESSURE Using molded foam inserts for the head of prone patients — as opposed to regular square foam inserts — relieves pressure on the forehead and chin.

The patient came in for a cystoscopy, a common outpatient procedure that only requires a person to be on the table for about 25 minutes. But the procedure does include slight Trendelenburg positioning, and this patient happened to be at risk for a pressure injury.

On top of the injury risk inherent to the position, he had shearing forces and moisture, which wound up being a perfect storm of injury-inducing factors. In the end, this patient came out of surgery with a Stage 2 pressure injury (PI) as well as a deep tissue injury because there was no intervention when intervention was needed. This example was a real wake-up call for the periop nurses who were in the OR that day because it revealed something most staff — especially outpatient staff who generally don't see pressure and skin injuries as something they need to worry about — often aren't aware of: You can cause great damage to your patients simply by not properly assessing them for pressure injury risks and intervening when necessary.

I'm very passionate about pressure injury prevention, and I truly believe we can create a culture that sees PIs — occurrences that in extreme cases lead to infection, sepsis and even death — as "never events." But getting there depends on breaking down the silos that exist in the care continuum and following a critical three-step PI process for every single patient who comes through our doors: Identify, intervene and prevent. At my previous facility, I combined a thorough, standardized risk assessment with a PI prevention bundle to reduce what we were seeing in far too many patients. Here's how you can do the same at your HOPD or ASC.

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