Nursing Research
In Our Unit
The Virginia Commonwealth University Medical Center (VCUMC) is a quaternary urban academic medical center located in Richmond, Virginia. Our 865-bed facility is the only
level I verified adult and pediatric trauma center in Richmond, host- ing a state-of-the-art critical care tower, where our 14-bed cardiac sur- gery intensive care unit (CSICU) resides. We provide intensive care nursing for adult and geriatric patients who require surgical treat- ment of cardiac, thoracic, and vascular conditions. Our mechanical circulatory assist program serves as a referral center for patients in the region who require advanced cardiac and respiratory life support interventions. Patients with such complex problems are often trans- ported to us by the VCUMC mobile intensive care unit (ICU) team.
Patients in the CSICU are at high risk for development of hospital- acquired pressure ulcers as a result of their extensive cardiopul- monary bypass times, hemodynamic instability, and vasopressor requirements. Additionally, many cardiac surgery patients are dif- ficult to turn because they have delayed sternal closures and large amounts of blood being rerouted outside of the body for cardiac
and pulmonary support. Although our unit has routinely managed these high-risk patients aggres- sively, medical device–related pressure ulcers were increasing in frequency. The CSICU nursing staff implemented preventative measures to decrease rates of all hospital-acquired pressure ulcers, with a goal of 0 preventable pres- sure ulcers.
Pressure Ulcer Prevalence Data and Education
Midway through 2011, VCUMC progressed from quarterly to monthly pressure ulcer surveys, revealing opportunities for improve- ment. Several months into the sur- veys, it was evident that our reactive approach to pressure ulcer man- agement was no longer providing patients with optimal outcomes. Two CSICU bedside nurses serve as representatives on the organi- zation’s Champions of Skin Integ- rity (CSI) team, which consists of unit representatives who dissemi- nate best practices in pressure ulcer prevention.1 They collaborated with the hospital’s wound ostomy continence team and empowered
Danielle Nicole Cooper, RN, BSN, CCRN-CSC
Sarah Layton Jones, RN, BSN, CCRN
Linda Ann Currie, RN, MSN, ACNS-BC, CCRN-CSC
Against All Odds: Preventing Pressure Ulcers in High-Risk Cardiac Surgery Patients
Authors Danielle N. Cooper is a critical care certified staff nurse and unit representative for the Champions of Skin Integrity Pressure Ulcer Prevention Team in the cardiac surgery intensive care unit at Virginia Commonwealth University Medical Center, Richmond, Virginia.
Sarah L. Jones is a critical care certified staff nurse and unit representative for the Champions of Skin Integrity Pressure Ulcer Prevention Team in the cardiac surgery intensive care unit at Virginia Commonwealth University Medical Center.
Linda A. Currie is a critical care certified clinical nurse specialist in the cardiac surgery intensive care unit at Virginia Commonwealth University Medical Center. Corresponding author: Linda A. Currie, RN, MSN, ACNS-BC, CCRN-CSC, Virginia Commonwealth University Medical Center, 1250 East Marshall St, Richmond, VA 23298 (e-mail: linda.currie@vcuhealth.org).
To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
©2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2015434
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their peers to effect change through development of a proactive approach to pressure ulcer prevention.
Developing this proactive cul- ture began with augmentation of current knowledge. The CSICU’s CSI team provided small-group education for staff, covering the content of the hospital’s pressure ulcer prevention program. This content included reviewing cur- rent pressure ulcer rates, causes of pressure ulcer formation, and Braden scoring. Pressure ulcer prevention topics such as proper turning and positioning, device- related pressure ulcers, nutrition, and moisture-associated skin damage were included. Our care partners participated in this edu- cation and also attended a 4-hour specialized class on pressure ulcer prevention hosted by the organiza- tional wound care team. Education was translated into bedside prac- tice with return demonstration of proper turning and pressure- offloading techniques.
The members of the CSI team, in collaboration with our unit’s nurse clinician, implemented pro- active daily bedside rounding, evaluating practice and providing real-time education. During pro- active rounds, the CSI and bedside nurse collaboratively visualize the patient to ensure that all pressure points are relieved and discuss risk factors, anticipating potential problems.
To identify pressure ulcers accurately and treat them prop- erly, communication between patient care areas is imperative. The CSICU’s CSI team members
correspond with the champions in the cardiac surgery progressive care unit to communicate findings and subsequent interventions via e-mail before a patient is trans- ferred. Existing pressure ulcers are discussed daily during intershift safety huddles. Monthly preva- lence survey results are posted on the unit to promote awareness and foster accountability.
Pathophysiology of Pressure Ulcers
Prevention of pressure ulcers is heavily reliant upon redistribu- tion of pressure and shear along with microclimate management. Pressure ulcers develop when tis- sue damage occurs, either from ischemia induced by capillary occlusion, reperfusion injury, accumulated metabolites from impaired lymphatic drainage, or prolonged deformation of the tis- sues from shear. Risk factors for decubitus ulcers include mechan- ical ventilation, immobility, use of vasopressors, multiple comor- bid conditions, spinal cord injury, severe illness, increased length of hospital stay, impaired nutrition, older age, low body mass index, diabetes, and renal insufficiency.2,3
Medical device–related pressure ulcers are injuries associated with therapeutic or diagnostic devices. These pressure ulcers are most fre- quently found in ICUs, where con- tinuous and invasive monitoring is essential. It is recommended that pressure redistributive dressings be placed around medical devices. The applied dressings should be inspected and repositioned every
shift, to ensure that pressure relief is successfully maintained.4
Use of Prophylactic Dressings
Our unit participated in a research study approved by the institutional review board that used prophylactic sacral dressings for prevention of pressure ulcers. Patients were randomly assigned to a standard of care group that used the current bundle for pre- vention used in the ICU, or to an intervention group consist- ing of the same standards of care, with the addition of a prophylac- tic sacral dressing both during the operation and in the ICU (Mepilex Sacrum, Mölnlycke Healthcare).
The results (8 pressure ulcers in the standard care group, 1 in the intervention group) led to a change in practice not only in the unit, but in the hospital as a whole, and now globally. Since the results were published in early 2012,5 2 randomized controlled trials, multiple peer-reviewed manu- scripts, and more than 70 clini- cal posters have been completed validating results of that study, including the cost-effectiveness of this intervention.6-10 All patients in the CSICU have a prophylac- tic sacral dressing for their entire hospital stay. Application of the dressing is initiated preopera- tively and continues through their progressive care recovery. Nurses inspect under the dressing daily and as needed to assess for new pressure ulcer development and optimal dressing placement for pressure reduction.
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Turning and Positioning Occasionally patients return
from the operating room with delayed sternal closure or “open chest.” Delayed sternal closure is used to manage reperfusion myo- cardial edema, hemodynamic instability, refractory bleeding, and malignant arrhythmias. This approach facilitates surgical reen- try for bleeding control, clot evac- uation, and cardiac massage.11 Slowikowski and Funk12 state that being “too unstable to turn” is a major indicator for pressure ulcer development. Labeling a patient “too unstable to turn” perpetu- ates the notion that turning will result in hemodynamic instabil- ity. According to Winslow and col- leagues,13 changes in heart rate and mixed venous oxygen satu- ration following lateral turning of intensive care patients is transient and expected, and most patients return to baseline within 5 minutes of completion of the repositioning.
Vollman14 suggests that failing to turn patients in the early days after cardiac surgery can cause less adaptability to gravitational changes from turning; thus the body may become hemodynami- cally stable, solely dependent on the supine position. In critically ill patients who are already com- promised from poor vascular cir- culation and low cardiovascular reserve, turning patients who can recover within 10 minutes after being repositioned, despite hav- ing a delayed sternal closure, can prevent development of hospital- associated pressure ulcers.14
Following a grand rounds pre- sentation on suspected deep tis- sue injury, an internationally recognized expert in pressure ulcer prevention and member of the National Pressure Ulcer Advi- sory Panel visited the CSICU on walking rounds. The consultant was immediately intrigued with our use of prophylactic dressings, as well as the unit’s culture and approach to repositioning hemo- dynamically unstable patients, which she witnessed when a patient with an open chest undergoing extracorporeal mem- brane oxygenation (ECMO) was being turned.
She remarked that our low rates of pressure ulcers, compared with other CSICUs she had visited, may be related to the aggressive bed- side management of postopera- tive patients to include turning all patients, especially those with open chests and those undergo- ing ECMO. To minimize hemo- dynamic changes, CSICU nurses elicit the help of several colleagues to monitor the patient, manage equipment, and monitor patients’ responses, while turning the patient very slowly. Parameters such as life-threatening arrhyth- mias, refractory hypotension, acute hemorrhage, or the inabil- ity to recover within 10 minutes of turning were used to classify patients as “too unstable to turn.” If a patient meets the definition for “too unstable to turn,” our nurses reassess at least every 8 hours to determine whether frequent turn- ing (every 2 hours) may resume.
To prevent supine dependency, a number of weight distribution measures are implemented; for example, slow incremental turning (starting at 10º and increasing by 10º increments as tolerated), shift- ing hips every 30 minutes, and use of air redistribution mattress modes. A description of our tech- niques for turning high-risk ICU patients and consensus recom- mendations from a panel of crit- ical care–certified clinicians has been published.3 Efforts to pro- tect other pressure points require equal attention during times of hemodynamic instability. Fluidized positioners are used to protect the occiput, repositioning the head at regular intervals. Standard pillows are positioned to float heels and elbows. In cachectic patients, soft silicone dressings (Mepilex Border, Mölnlycke Healthcare) should be placed prophylactically to protect elbows. An extended-frame bed should be considered for tall patients whose feet consistently rest against the footboard, as they are at high risk for pressure ulcers developing on the soles of the feet.
Cardiac Assist Devices A unique challenge specific to
cardiac surgery patients is pre- vention of pressure ulcers related to cardiac assist devices. Patients being supported with ECMO or Centrimag (Thoratec Corpora- tion) are often cannulated through the internal jugular vein, requir- ing a polyurethane foam dress- ing to be placed between the cannula tubing and the ear to
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relieve pressure. Likewise, cannu- lation tubing placed in the groin requires the same pressure- offloading techniques when metal clamps are used for stabilization against the lower extremities. Placement of these prophylactic dressings immediately after cannu- lation is imperative for preventing such ulcers.
Drivelines associated with mechanical circulatory assist devices, such as HeartMate II (Thoratec Corporation), Heart- Ware (HeartWare Inc), and the Syncardia Total Artificial Heart, place patients at risk for both pressure ulcers and subsequent infection. To prevent the develop- ment of pressure ulcers related to the driveline for a left ventricular assist device, the driveline must be stabilized to the patient’s skin with a tubing anchor. Stabilization pro- motes skin adherence to the drive- line while suspending it above the skin, preventing erosion and tun- neling, while providing pressure relief to the surrounding tissue. Skin is assessed under the anchor every 5 days, with anchor replace- ment as needed. The Total Arti- ficial Heart has 2 larger driveline exit sites, making them more chal- lenging to stabilize. Wrapping the driveline with gauze and securing with tape prevents twisting and skin irritation.
Tracheostomy Nursing standards of care
related to tracheostomy manage- ment and pressure ulcer preven- tion are often impeded by surgical techniques. Providers often use sutures to secure the tracheostomy
phalange to the patient’s neck, with the intention of preventing poten- tial dislodgment of the tracheos- tomy tube. However, sutures make it difficult for nurses to relieve pressure by preventing adequate barrier placement between the tracheostomy plate and the skin. This is especially a problem fol- lowing fluid resuscitation or in patients with fluid volume over- load. The combination of direct pressure on the skin, with poten- tial additive effects of tracheal secretions, creates pressure ulcers that are often accompanied by maceration at the suture sites.12
An exhaustive literature search was conducted to ensure that eliminating tracheostomy phalange sutures would not compromise patients’ airways. A multi-institutional analysis of tracheostomy complications revealed no difference in rates of accidental decannulation based on the presence or absence of outer phalange sutures.15 Most publica- tions related to tracheostomy pro- cedures indicate that differences in suture placement practices are related to provider preference as opposed to evidence.15-18 Most of our tracheostomy procedures are bedside percutaneous placements, performed by our interventional pulmonology team. We engaged in collaborative discussion regard- ing the lack of evidence to support the use of sutures to secure trache- ostomy phalanges for airway pro- tection. The discussion resulted in the decision to change practice. Sutures are no longer routinely used to secure bedside percutaneous tracheostomy phalanges. Velcro
(hook and loop fastener) tracheos- tomy holders continue to be used for safe airway securement for all tracheostomy patients. Reducing the use of sutures with routine per- cutaneous tracheostomy patients has allowed our nurses to deliver pressure-relief interventions.
Our interventions for the prevention of medical device– related pressure ulcers in respiratory devices include the collaborative development of educational mod- ules created by the wound ostomy and continence team and the respiratory therapy department as annual competencies, which specify repositioning of devices and the use of prophylactic thin foams (Mep- ilex Lite, Mölnlycke Healthcare LLC), which have been described in published reports.3,16 These efforts have resulted in our ability to nearly eradicate these injuries.
Surgical Bra A rare, yet equally trouble-
some pressure ulcer occurred in the CSICU with the use of a post- surgical compression brassiere, which is reserved for female car- diac surgery patients who are larger in both chest circumfer- ence and breast size. Published reports19-21 are focused on the use of these garments for stabilization of the sternum, improved approx- imation of sternal wounds, and comfort. The Women’s Recovery from Sternotomy-Extension Study determined that female patients experience postoperative pain for up to a year after their cardiac surgery, and a larger chest cir- cumference is a risk factor.20 The postsurgical brassiere offered at
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our hospital was not constructed to accommodate forward breast expansion. The fabric did not stretch, and most importantly, the edges were abrasive, minimally elastic, and constrictive. A patient who required the use of this post- operative brassiere had pressure ulcers develop above and below the breast and on the left lateral aspect of her rib cage along the bra line. The ulcer was painful and difficult to heal.
Frustrated with this pressure ulcer, our CSICU’s CSI team inves- tigated alternative products in collaboration with the plastic sur- gery team. Multiple products were evaluated, and the Carefix Mary Bra (Tytex, Inc) was selected for a trial. This product was ranked favorably by both our nurses and our patients. The Carefix Mary Bra is constructed of a soft, flexi- ble fabric with built-in compres- sion areas and soft, flexible edges that do not cut into patients’ skin. Since implementation of this prod- uct, we have not experienced any pressure ulcers related to the use of postoperative surgical brassieres.
Without a proper supportive garment, the failure to separate the skin fold under the breast may lead to more cutaneous compli- cations. Moisture, friction, and pathogenic organisms have been described to cause a form of breakdown referred to as inter- triginous dermatitis—a form of moisture-associated skin dam- age.22 Therefore, care must be taken to cleanse the skin prop- erly with a pH-balanced foaming cleanser, while drying the skin well and avoiding placing inappropriate
moisture management devices (eg, sheets, towels, washcloths, or gauze) between the folds. Proper support of the breasts in addition to appropriate moisture and anti- microbial wicking products (Inter- dry AG, Coloplast) are used to prevent these injuries.
Endotracheal Tubes Endotracheal tube (ETT) muco-
sal injuries comprised the major- ity of our device-related pressure ulcers, prompting the CSI team to add surveillance of ETT repo- sitioning to their daily rounds. Best-practice recommendations for ETT management include ETT rotation every 24 hours when tape is being used as the securement method. The barrier to maintaining this best practice was the absence of a date being written on the ETT tape. The Hollister Anchor Fast Oral ETT Holder (Hollister Inc) was introduced as an additional securement device option. This device requires staff to rotate the ETT every 2 hours and change the device every 3 days. When applied properly, the device alleviates oral mucosal pressure points. Retrain- ing and surveillance of ETT rota- tion frequency and timing nearly resolved this problem.
Feeding Tubes and Heel-Offloading Devices
Although we did not initiate formal practice changes for off- loading pressure from feeding tubes or patients’ heels, the educa- tion and increased focus on pres- sure ulcer prevention in general resulted in a decrease in pressure ulcers related to feeding tubes to 0
for the past 14 months. Our nurses continue to rotate nasogastric tubes every 24 hours to prevent mucosal injuries. Repositioning requires the nurse to inspect, remove and reap- ply, and note the date and time on the securement adhesive tape.
We participated in the trial of a feeding tube securement device that secured to the patient’s cheek. How- ever, the product was not strong enough to hold the feeding tubes in place. Cloth tape continues to be the securement method of choice in the CSICU. Heels continue to be floated, using pillows placed verti- cally underneath the lower extremi- ties. Prevalon boots (Sage Products) are our method of choice when heel pressure cannot be properly offloaded with pillows because of edema or leg circumference.
Results The journey to improved out-
comes began in 2012, with a total of 28 pressure ulcers attributed to our unit over the course of 12 sur- veys (Figure 1). Twelve of these pressure ulcers were related to medical devices (Figure 2).
In 2013, our total pressure ulcer rate decreased by 56%, with an 83% decrease in medical device–related pressure ulcers and a 27% decrease in pressure ulcers that were not related to medical devices (see Table). This reduction is particularly noteworthy because the acuity of the patients had increased (see Table).
Our reduction in pressure ulcers provided substantial cost savings. According to the Agency for Healthcare Research and Qual- ity, the cost of treating a stage II
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Table Sustained decrease in prevalence of pressure ulcers in relation to level of patient acuity in the cardiac surgery intensive care unita
2012
2013
Change from 2012 to 2013
2013
2014
Change from 2013 to 2014
All 23
10
56%
10
6
40%
MDRPU 12
2
83%
2
2
Maintained
Non-MDRPU 11
8
27%
8
4
50%
No. of pressure ulcers Patient acuity
No. of patients cannulated with ECMO
34
42
24%
42
46
10%
No. of patients implanted with MCADb
42
46
10%
46
38
17% Abbreviations: ECMO, extracorporeal membrane oxygenation; MCAD, mechanical circulatory assist device; MDRPU, medical device–related pressure ulcer. a Unresolved pressure ulcers are accounted for only once. b Total artifi cial heart, HeartMate II, or HeartWare.
Figure 2 Breakdown of devices associated with all pressure ulcers related to medical devices that the cardiac surgery intensive care unit at Virginia Commonwealth University Medical Center was responsible for, regardless of patient location, on the day of the monthly pressure ulcer survey. In 2012, 134 patients were surveyed; in 2013, 135 patients were surveyed; in 2014, 141 patients were surveyed; through May 2015, 53 patients had been surveyed. Abbreviations: CPAP, continuous positive airway pressure; ETT, endotracheal tube; FMS, fecal management system; SCD, sequential compression device; Trach, tracheostomy.
Ye ar
No. of pressure ulcers
2015 2014 2013 2012
121086420
CPAP Nasal cannula Salem sump FMS ETT Surgical bra Trach fl ange SCD bar Urinary catheter
Figure 1 All pressure ulcers that were attributed to the cardiac surgery intensive care unit at Virginia Commonwealth University Medical Center, regardless of patient location, on the day of the monthly pressure ulcer survey. The blue line represents the point at which implementation of the educational intervention was complete. The data include unresolved pressure ulcers accounted for in more than 1 survey.
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20 12
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20 15
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5
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pressure ulcer is estimated at $7000.18 The cost savings from 2012 to 2013 (at $7000 per ulcer) was $84 000, $70 000 for medi- cal device–related pressure ulcers and $14 000 for pressure ulcers not related to medical devices.
Conclusion The CSICU’s theory that pres-
sure ulcer surveillance is not a once-a-month event has been the cornerstone of professional prac- tice related to the reduction of the number of pressure ulcers in our unit. Peer-to-peer feed- back promotes a culture of shared governance and accountability, improving quality measures and patients’ outcomes. A proactive approach, practice surveillance, evidence-based practice, new products, and hypervigilance of all staff are instrumental in main- taining such low rates.
Acknowledgments The authors recognize the entire nursing team from the cardiac surgery intensive care unit and the Virginia Commonwealth University Medical Center’s wound care team for their steadfast com- mitment to providing outstanding, proactive care to our cardiac surgery patients. We thank Christo- pher Tod Brindle for his generous assistance in the review of this manuscript.
Financial Disclosures None reported.
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14. Vollman K. Introduction to progressive mobility. Crit Care Nurse. 2010;30:3-5.
15. Dennis-Rouse M, Davidson J. An evidence- based evaluation of tracheostomy care prac- tices. Crit Care Nurse Q. 2008;31(2):150-160.
16. Halum S, Ting J, Plowman E, et al. A multi- institutional analysis of tracheotomy com- plications. The Larnygoscope. 2012;122:38-45.
17. Boesch RP, Myeres C, Garrett T, et al. Preven- tion of tracheostomy-related pressure ulcers in children. Pediatrics. 2012;129:e792-e797.
18. Schaetzel S, Juern J, Kiehl K, et al. The effect of suturing on force from dislodgement of tracheostomy tubes: medial versus lat- eral sutures. J Trauma Acute Care Surg. 2013;75(3):492-495.
19. El-Ansary E, Adams R, Toms L, Elkins M. Sternal instability following coronary artery bypass grafting. Physiother Theory Pract. 2011;16:27-33.
20. Naismith C, Street A. Introducing the cardi- bra: a randomized pilot study of a purpose
designed support bra for women having car- diac surgery. Eur J Cardiovasc Nurs. 2005;4: 220-226.
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