As we’ve mentioned on this blog before, beyond the hurdles of surgery itself, there is a lot that has to go right post-surgery in order to assure a patient leaves the hospital better than when they entered. One very real concern, particularly in the perioperative process, is hospital-acquired pressure injuries (HAPIs). Though HAPIs are considered never events, about 2.5 million patients develop them annually in the U.S.[1] Additionally, HAPIs are the second most common claim for wrongful death, resulting in 17,000 lawsuits filed each year.[2] Whether you’re representing a client who’s suffered a HAPI or is being charged with the development of one, here’s a basic overview of the most important things to know:
What is a HAPI?
Also referred to as a pressure ulcer or bedsore, a HAPI is a localized injury to the skin or underlying tissue that often occurs when soft tissue is compressed between bone and the external surface for a prolonged period of time.[3] It is the unrelieved pressure which causes the ulcer to develop.[4] HAPIS can develop during lengthy surgical procedures, when skin is exposed to friction or shear during transfer, or when the body is not repositioned frequently.[5]
What are the dangers of HAPIs?
Pressure ulcers are painful and potentially life-threatening.[6] They can result in cellulitis (a skin and connected soft tissues infection), bone and joint infections, and increase the risk of cancer and sepsis.[7]
Risk factors
Though there are many causes of pressure ulcers, here is a list of some of the most common HAPI risk factors during the surgical procedure and postoperative care:
- Sedation
- Vasoconstrictive medications
- Instrumentation
- Multiple surgeries
- Type of surgery
- Extended length of time in the OR
- Use of vasopressors
- Mechanical ventilation
- Postoperative corticosteroid use
- Extended hours spent in the intensive care unit[8]
Beyond negligence, improper use of tools, or environmental factors, conditions that may predispose a patient to develop a HAPIs include the following:
- Comorbid conditions such as vascular disease or diabetes
- Immobility
- Advanced age
- Severe illness
- Nutritional deficiencies
- Impaired regulation of body temperature
- Obesity
- Previous pressure injuries
- Skin problems[9]
Screening and prevention methods
Since patients are unable to change position or voice discomfort during surgery, they depend upon surgical team members to be their advocates.[10] Medical staff members need to be trained to conduct pre- and post-operative skin assessments to identify temperature, redness, edema, and pain and determine if any additional steps need to be taken.[11]
The last few years have seen the development of preventative assessment tools that can greatly reduce the number of HAPIs when implemented. Susan Scott, patient safety educator at the university of Tennessee Health Science Center in Memphis, has developed the “Scott Triggers” as one such surgical assessment tool that has proven useful for both detecting risk and preventing pressure ulcers.[12] Beyond training, being attentive to the position of the patient, utilizing padding and pressure-relieving devices properly, and consistent and frequent communication between medical team members can also help lower HAPIs.[13]
Each year, the cost to treat hospital-acquired pressure injuries ranges from $9.1 billion to $11 billion.[14] Striving to prevent HAPIs is beneficial to all: hospitals, medical staff, and patients alike.
[1] Spruce, Lisa, “Back to Basics: Preventing Perioperative Pressure Injuries,” AORN Journal, no. 105 (Jan. 2017): 93, accessed Oct. 28, 2017, https://www.aorn.org/websitedata/cearticle/pdf_file/CEA17502-0001.pdf
[2] Ibid: 93
[3] Giachetta-Ryan, Denise, “Perioperative pressure ulcers: How can they be prevented?”, Lippincott Nursing Center, July 2015, http://www.nursingcenter.com/cearticle?an=01271211-201507000-00005&Journal_ID=682710&Issue_ID=3142036
[4] Ibid
[5] Spruce, “Back to Basics”: 93
[6] “Best practices can prevent pressure ulcers in perioperative setting,” Nurse.com, Dec. 14, 2014, https://www.nurse.com/blog/2014/12/14/best-practices-can-prevent-pressure-ulcers-in-perioperative-setting/
[7] “Bedsores (pressure ulcers),” Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/bed-sores/symptoms-causes/syc-20355893
[8] Spruce, “Back to Basics”: 94
[9] Ibid, Giachetta-Ryan, “Perioperative pressure ulcers”
[10] Spruce, “Back to Basics”: 93-94
[11] Ibid: 94
[12] “Best practices can prevent pressure ulcers”
[13] Giachetta-Ryan, “Perioperative pressure ulcers”
[14] Spruce, “Back to Basics”: 93