Preventing pressure ulcers: new lessons from Minnesota.

pressure ulcers during long surgical procedures. Data collected through the state’s adverse event reporting system in 2009 found 13% of the 122 Stage 3, Stage 4, and unstageable pressure ulcers reported were related to long surgical procedures. Attention to this potentially devastating complication has ramped up since Medicare announced it will no longer pay for Stage 3 and Stage 4 pressure ulcers that develop during a patient’s hospital stay. A statewide advisory group of wound care and perioperative nursing experts came together to analyze the reports and develop recommendations. The group found 2 primary contributing factors: • a lack of awareness of risk of skin breakdown by OR teams and a lack of communication of the risk during handoffs • a lack of guidance for determining the types of surgical cases that increase the risk of skin breakdown. They also found confusion about support surfaces and other practices for preventing pressure ulcers during surgery. “Patients under anesthesia are among our highest risk patients because they cannot move,” says Denise Nix, RN, MS, CWOCN, a member of the advisory group and an ostomy and wound care expert. She is an advisor to the Minnesota Hospital Association and coauthor of Acute and Chronic Wounds: Current Management Concepts (Mosby Elsevier, 2007). The advisory group began by consulting professional guidelines, including those of AORN and an international body, and then developed recommendations to address issues they were seeing in Minnesota (sidebar).