The cardiothoracic ICU (CICU) at our facility is a 26-bed unit with high-risk cardiac surgery patients (adults and children). The facility offers a full range of cardiac procedures including coronary revascularization, valve replacement, congenital heart defect repair, ventricular assist device implantation (for bridge to transplant and destination therapy), and heart and lung transplants. In 2008–2009, hospital-acquired pressure ulcers (HAPUs) in the facility's adult cardiac surgery population frequently exceeded the national benchmarks of 6.2% to 8.1% for patients in comparable ICUs in other hospitals across the country.1 These data spurred the nursing staff to plan and implement a quality improvement program that helped us reduce the incidence of HAPUs in adult cardiac surgery patients to under 2%.
About pressure ulcers
The National Pressure Ulcer Advisory Panel defines pressure ulcers as an area of localized injury of the skin and/or underlying tissue caused by external pressure alone or in combination with shearing and/or friction.2 Most pressure ulcers develop over bony prominences, typically the sacrum and heels. Pressure ulcers are classified according to the extent of tissue injury (see Pressure ulcer staging).
Duration and intensity of pressure are crucial to the development of pressure ulcers; low-intensity pressure of long duration can be as damaging to tissues as high-intensity pressure experienced for a briefer period of time. The result of this pressure is an interruption in blood flow, capillary collapse and/or thrombus formation, and a localized accumulation of cellular waste products, all of which can cause tissue necrosis.3,4 (See How the skin is structured.)
Suspected deep tissue injury (DTI), the most common type of intraoperative pressure injury, develops in the underlying soft tissue spreading outward to the skin, unlike other types of pressure ulcers that form in the skin and may progress to deeper tissues.5 The initial appearance of DTIs tends to be very different from the first visible signs of other pressure ulcers. You'll notice a localized maroon or purple discoloration of intact skin or blood-filled blister that can be mistaken for a burn injury or bruising. The DTI may be painful, feel boggy to the touch, and be warmer or cooler than the surrounding tissue. Within 2 to 4 days after surgery, the DTI can rapidly progress to necrosis of all affected tissue layers.6,7 The discoloration associated with DTIs may be visible shortly after the surgical procedure or might not appear for several days, making it difficult for caregivers to determine the etiology of the injury.4
A nursing sensitive condition
All cardiac surgery patients should be considered at risk for developing HAPUs (see Risk factors for HAPUs). Although HAPUs are considered preventable in most cases, an estimated 3% to 12.7% of patients hospitalized in acute care facilities develop HAPUs.3
The quality of nursing care in healthcare facilities is considered to directly influence the incidence and severity of HAPUs, earning this type of pressure injury the classification of a “nurse sensitive” condition. Pressure ulcers are associated with significant pain, increased infection risk, delayed recovery, and increased length of hospital stay.8 HAPUs also contribute to increased healthcare costs; treatment and increased length of stay (the average is 8 days) can cost $15,000.3
Hospital-acquired Stage III and IV pressure ulcers are “never events” to the Centers for Medicare and Medicaid Services, which no longer reimburses hospitals for the costs of caring for these HAPUs. This is a powerful financial incentive for hospitals to develop effective HAPU prevention strategies.9
Information on the incidence of HAPUs, including DTIs, in our facility's adult cardiac surgery patient population was obtained during biweekly skin care rounds conducted by the CICU's skin care team, led by the unit's clinical nurse specialist (CNS). Data collected included patient age and comorbidities, preoperative prealbumin level, surgical case length, and special circumstances such as an open sternum or presence of mechanical circulatory support devices (intra-aortic balloon pump or ventricular assist device). A thorough review of the data collected revealed that the only common factor for all adult cardiac surgery patients who developed HAPUs was use of vasopressors during the intraoperative and early postoperative period. These data were shared with the hospital's wound care specialist nurses, who were consulted for any patients with skin breakdown other than a minor break in skin integrity (such as a small skin tear). The wound care nurses identified 35% of the unit's hospital-acquired sacral pressure ulcers as DTIs. Because most of the DTIs developed within 24 to 48 hours of CICU admission, the wound nurses concluded that these pressure injuries occurred during surgery. The remaining 65% of the HAPUs that weren't classified as DTIs were identified as Stages I through IV or unstageable pressure ulcers that developed on the sacral, occipital, and/or heel areas.
The pressure ulcer prevention bundle
CICU leadership (the unit nurse manager and CNS) approached the manager and clinical educator in the cardiothoracic OR (CVOR) with their concerns about the incidence of HAPUs in the two units' shared patient population. The overall incidence of HAPUs in CICU patients continued to exceed the desired benchmark of less than 11% despite the application of pressure ulcer prevention strategies (including skin assessment and the use of pressure-reduction mattresses and positioning wedges) by nurses in the CICU and CVOR.
A comprehensive preventive approach was needed to significantly reduce HAPUs in cardiac surgery patients. The CICU CNS and OR educator searched for information on successful HAPU prevention initiatives in other acute care hospitals. They found a few reports in the literature of hospitals whose nurses had successfully reduced HAPUs via a pressure ulcer prevention bundle. Care bundles combine interventions that improve patient outcomes when used in isolation but are most effective at preventing complications when used consistently and in combination with other preventive measures.10 Although bundle components varied among the facilities, common measures included skin and pressure ulcer risk assessment, use of pressure-relieving surfaces and devices, and regular repositioning.11 No current reports specifically focused on a cardiac surgery patient population, which led our team to design a bundle for this population.
The concept of the care bundle was first developed by the Institute for Healthcare Improvement as a way to promote the consistent use of preventive measures to reduce the risk of certain complications.11 Many hospitals have successfully used care bundles to reduce the incidence of catheter-related bloodstream infections and ventilator-associated pneumonia.11 The application of a bundle approach to clinical care reduces the possibility that one or more care recommendations aren't consistently applied. Care bundles typically consist of a set of three to five interventions that are supported by evidence from current research.12
Planning and implementation
The first step in developing a pressure ulcer prevention bundle was to review current research to determine the most effective interventions for preventing pressure ulcers in the perioperative and intensive care settings. The major limitation was the lack of published research focused on preventing HAPUs in surgical patients. We accessed 108 research articles on HAPUs; only seven specifically addressed surgical patients, and only one discussed prevention of HAPUs in cardiac surgery patients. DTIs were first classified as a separate pressure ulcer stage in 2007, so we couldn't find any published research with a specific focus on DTI prevention at the time of our initial project planning.1 The consistent recommendations found in the literature outlined risk assessment, pressure redistribution, and avoidance of friction and shearing forces as the crucial components of any HAPU prevention initiative.
- Risk assessment. A thorough skin assessment, including a visual inspection of all potential pressure points, should be conducted immediately before and at the completion of surgery. To promote interrater consistency, facilities should adopt a single standardized skin assessment tool (such as the Braden Scale or Norton risk assessment scale). Include relevant skin assessment findings in the hand-off communication at any transfer of patient care.13
- Pressure redistribution. Pressure redistribution surfaces and padding materials prevent pressure injuries by reducing or redistributing pressure. Pressure-reducing mattresses play an important role in the CVOR and CICU. OR and ICU mattresses should be inspected on a regular schedule because a worn or damaged mattress won't provide effective pressure reduction.6
- Minimize shear and friction. Patient-handling techniques using low-friction slide sheets and air-assisted transfer devices for all lateral transfers can reduce the risk of skin injuries caused by friction and shearing. Prophylactic use of a soft silicone sacral dressing can prevent or reduce the incidence of sacral pressure injuries by minimizing friction and shearing forces.14
The hospital's wound care nurses recommended initiating the pressure ulcer prevention bundle in the OR and continuing the preventive interventions throughout the patient's stay in CICU. The nursing leadership of both CICU and CVOR agreed with this recommendation. The complete care bundle is outlined in Preventing pressure injuries.
The initial draft of the bundle was submitted to a panel of specialty experts (including hospital wound care nurses, the CICU CNS, and the CVOR educator) for review and recommendations. Before the final bundle was implemented, a pressure ulcer education needs assessment was administered to all CVOR adult cardiac surgery nurses in order to identify their baseline knowledge of HAPUs. The survey found that most nurses weren't aware that intraoperatively acquired pressure ulcers aren't evident at the end of surgery, and most OR nurses were unable to identify DTI as the most common intraoperative pressure injury. The survey findings were used to plan education materials for the CVOR nurses.
Education sessions were provided for CVOR and CICU nurses on all shifts beginning 2 weeks before the bundle implementation. These sessions provided information about pressure ulcer development, pressure ulcer prevention, and the specific details of the pressure ulcer prevention bundle. After the initial education sessions, supplemental information on pressure ulcer prevention, skin care, and project progress was provided in monthly updates at each staff meeting and postings on the employee lounge bulletin boards.
Following the implementation date, the CICU skin care team continued biweekly skin audits to collect data on the presence or absence of skin breakdowns in the unit's patients.
From October 2009 through the first week of July 2010, before the bundle implementation, the CICU skin care team audited 153 postoperative adult cardiac surgery patients in the CICU for skin breakdown and confirmed 19 incidents of new skin breakdown. The overall incidence of HAPUs and DTIs during this time was 13%. The bundle measures were implemented in mid-July 2010. Biweekly skin audits continued in the CICU. Thirty-six patients were audited from mid-July 2010 through August 2010, and no new HAPUs were found in the unit's patients.
From September 2010 to June 2012, the overall incidence of HAPUs has ranged from zero to 8.1% (see Incidence of postoperative sacral breakdown in adult cardiovascular surgery patients). During this period, two patients were identified as having hospital-acquired sacral DTIs; one of these patients was found to have an incorrectly applied sacral dressing on the first postoperative day.
A major limitation of this initiative is the authors included all adult cardiac patients in data collection and analysis. The study should be repeated to either include or exclude patients with certain comorbidities and to classify patients according to the number and type of vasopressors received during the intraoperative and early postoperative periods. An important variable to consider in any future study would be nurse-staffing ratios in the CICU in relation to patient acuity. Data are insufficient to determine if the pressure ulcer prevention bundle would be equally effective in other patient populations and in other hospital nursing units.
Continued application of the bundle and monitoring will be necessary to validate efficacy of this approach to HAPU prevention. However, our facility achieved its goal of reducing the incidence of HAPUs and DTIs in adult cardiac surgery patients by using this bundle, and we'll continue to monitor HAPU incidence and the bundle's effectiveness for our patients.
Pressure ulcer staging2
Suspected DTI—localized area of discolored (usually maroon or purple) skin or blood-filled blister due to pressure or shearing injury of subcutaneous tissues.
Stage I—intact skin with nonblanching erythema of a localized area, usually over a bony prominence.
Stage II—partial-thickness loss of dermis appearing as a shallow open ulcer with a red-pink wound bed, without slough, or an intact or ruptured serum-filled blister.
Stage III—full-thickness tissue loss accompanied by damage to subcutaneous tissue; doesn't penetrate the fascia.
Stage IV—full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. The wound also may have undermining or tunneling.
Unstageable—full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
Risk factors for HAPUs3,5–7
- Preexisting skin conditions such as fragile skin in older adults
- Comorbidities including diabetes, heart disease, peripheral vascular disease, and obesity
- Poor preoperative nutritional status, especially protein deficiency
- Low preoperative hemoglobin
- Tobacco use
- Transfer from another facility
Surgical patient risks
- Immobility during the surgical procedure, particularly if the procedure lasts more than 2.5 hours
- General and regional anesthesia, which suspend the normal protective mechanisms that let patients feel pressure and reposition themselves to relieve pressure
- Anesthetic agents, which may reduce BP, causing peripheral hypoperfusion
- Use of vasoactive drugs (especially vasopressin) during the surgical procedure
Cardiac surgery patient-specific risks
- Altered tissue perfusion due to extracorporeal circulation and intentional hypothermia during surgery
- Potential for hemodynamic instability during the immediate postoperative period
- Use of mechanical circulatory assist devices such as intra-aortic balloon pumps and ventricular assist devices
Preventing pressure injuries
This protocol was developed to prevent HAPUs in adult cardiac surgery patients. The bundle has six key components:
- Assessing the patient's skin and risk for HAPUs.
- Reducing and redistributing pressure.
- Avoiding friction and shear.
- Managing moisture.
- Assessing the patient's nutrition.
- Intervening early if breaks in skin integrity are found.
- Perform a skin and pressure ulcer risk assessment on admission.
- Perform a skin assessment before the procedure.
- Reduce pressure by using a viscoelastic gel OR mattress overlay, and gel pads to pad pressure points
- Perform a skin assessment at the end of the procedure. Evaluate major pressure points for reddened areas (especially nonblanching erythema or maroon or purple discoloration).
- Reduce friction and shearing by using a friction-reducing slide sheet for lateral transfers, and applying a prophylactic soft silicone sacral dressing on adult patients whose procedures require a sternotomy or cardiopulmonary bypass.
- Inspect OR mattresses regularly and replace when damaged or worn.
- Perform a skin assessment (including assessment of pressure ulcer risk) on admission
- Reposition patients regularly (at least every 2 hours).
- Elevate the patient's heels.
- Follow hospital protocols to manage any breaks in skin integrity.
- Monitor unit HAPU incidence on an ongoing basis.
1. VanGilder C, Amlung S, Harrison P, Meyer S. Results of the 2008–2009 International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage
2. National Pressure Ulcer Advisory Panel (NPUAP). Updated staging system. Pressure ulcer stages revised by NPAUP. 2007. http://www.npuap.org/pr2.htm
3. Alderden J, Whitney JD, Taylor SM, Zaratkiewicz S. Risk profile associated with outcomes of hospital-acquired pressure ulcers: a retrospective review. Crit Care Nurse
4. Idemoto BK, Kresevic DM. “Emerging nurse-sensitive outcomes and evidence-based practice in postoperative cardiac patients.” Crit Care Nurse Clin North Am
. 2007;19(4):371–384, v-vi.
5. Aronovitch SA. Intraoperatively acquired pressure ulcers: are there common risk factors? Ostomy Wound Manage
6. Walton-Geer PS. Prevention of pressure ulcers in the surgical patient. AORN J
7. Primiano M, Friend M, McClure C, et al. Pressure ulcer prevalence and risk factors during prolonged surgical procedures. AORN J
8. Pieper B, Langemo D, Cuddigan J. Pressure ulcer pain: a systematic literature review and National Pressure Ulcer Advisory Panel white paper. Ostomy Wound Manage
9. Centers for Medicare and Medicaid Services (CMS). Hospital-acquired conditions (present on admission indicator). https://www.cms.gov/hospitalacqcond/06_hospital-acquired_conditions.asp
10. Joint Commission on Accreditation of Healthcare Organizations. Raising the bar with bundles: treating patients with an all-or-nothing standard. Jt Comm Perspect Patient Saf
11. Baldelli P, Paciella M. Creation and implementation of a pressure ulcer prevention bundle improves patient outcomes. Am J Med Qual
12. Resar R, Pronovost P, Haraden C, Simmonds T, Rainey T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf
13. Fulbrook P, Mooney S. Care bundles in critical care: a practical approach to evidence-based practice. Nurs Crit Care
14. King CA, Bridges E. Comparison of pressure ulcer relief properties of operating room surfaces. Periop Nurs Clin
15. Brindle CT. Outliers to the Braden Scale: identifying high-risk ICU patients and the results of prophylactic dressing use. World Council Enterostomal Ther J