Against All Odds: Preventing Pressure Ulcers in High-Risk Cardiac Surgery Patients

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, hosting a state-of-the-art critical care tower, where our 14-bed cardiac surgery intensive care unit (CSICU) resides. We provide intensive care nursing for adult and geriatric patients who require surgical treatment 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 transported 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 cardiopulmonary bypass times, hemodynamic instability, and vasopressor requirements. Additionally, many cardiac surgery patients are difficult 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 aggressively, 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 pressure ulcers.Midway through 2011, VCUMC progressed from quarterly to monthly pressure ulcer surveys, revealing opportunities for improvement. Several months into the surveys, it was evident that our reactive approach to pressure ulcer management was no longer providing patients with optimal outcomes. Two CSICU bedside nurses serve as representatives on the organization’s Champions of Skin Integrity (CSI) team, which consists of unit representatives who disseminate best practices in pressure ulcer prevention.1 They collaborated with the hospital’s wound ostomy continence team and empowered their peers to effect change through development of a proactive approach to pressure ulcer prevention.Developing this proactive culture 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 current 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 education and also attended a 4-hour specialized class on pressure ulcer prevention hosted by the organizational wound care team. Education was translated into bedside practice 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 proactive daily bedside rounding, evaluating practice and providing real-time education. During proactive 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 properly, 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 transferred. Existing pressure ulcers are discussed daily during intershift safety huddles. Monthly prevalence survey results are posted on the unit to promote awareness and foster accountability.Prevention of pressure ulcers is heavily reliant upon redistribution of pressure and shear along with microclimate management. Pressure ulcers develop when tissue damage occurs, either from ischemia induced by capillary occlusion, reperfusion injury, accumulated metabolites from impaired lymphatic drainage, or prolonged deformation of the tissues from shear. Risk factors for decubitus ulcers include mechanical ventilation, immobility, use of vasopressors, multiple comorbid conditions, spinal cord injury, severe illness, increased length of hospital stay, impaired nutrition, older age, low body mass index, diabetes, and renal insufficiency.2,3Medical device–related pressure ulcers are injuries associated with therapeutic or diagnostic devices. These pressure ulcers are most frequently found in ICUs, where continuous 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.4Our 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 prevention used in the ICU, or to an intervention group consisting of the same standards of care, with the addition of a prophylactic 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 manuscripts, and more than 70 clinical 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 prophylactic sacral dressing for their entire hospital stay. Application of the dressing is initiated preoperatively 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.Occasionally patients return from the operating room with delayed sternal closure or “open chest.” Delayed sternal closure is used to manage reperfusion myocardial edema, hemodynamic instability, refractory bleeding, and malignant arrhythmias. This approach facilitates surgical reentry for bleeding control, clot evacuation, 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” perpetuates the notion that turning will result in hemodynamic instability. According to Winslow and colleagues,13 changes in heart rate and mixed venous oxygen saturation 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 hemodynamically stable, solely dependent on the supine position. In critically ill patients who are already compromised from poor vascular circulation and low cardiovascular reserve, turning patients who can recover within 10 minutes after being repositioned, despite having a delayed sternal closure, can prevent development of hospital- associated pressure ulcers.14Following a grand rounds presentation on suspected deep tissue injury, an internationally recognized expert in pressure ulcer prevention and member of the National Pressure Ulcer Advisory 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 hemodynamically unstable patients, which she witnessed when a patient with an open chest undergoing extracorporeal membrane 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 bedside management of postoperative patients to include turning all patients, especially those with open chests and those undergoing ECMO. To minimize hemodynamic 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 arrhythmias, refractory hypotension, acute hemorrhage, or the inability 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 turning (every 2 hours) may resume.To prevent supine dependency, a number of weight distribution measures are implemented; for example, slow incremental turning (starting at 10° and increasing by 10° increments as tolerated), shifting hips every 30 minutes, and use of air redistribution mattress modes. A description of our techniques for turning high-risk ICU patients and consensus recommendations from a panel of critical care–certified clinicians has been published.3 Efforts to protect 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.A unique challenge specific to cardiac surgery patients is prevention of pressure ulcers related to cardiac assist devices. Patients being supported with ECMO or Centrimag (Thoratec Corporation) are often cannulated through the internal jugular vein, requiring a polyurethane foam dressing to be placed between the cannula tubing and the ear to relieve pressure. Likewise, cannulation 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 cannulation 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 development 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 promotes skin adherence to the driveline while suspending it above the skin, preventing erosion and tunneling, while providing pressure relief to the surrounding tissue. Skin is assessed under the anchor every 5 days, with anchor replacement as needed. The Total Artificial Heart has 2 larger driveline exit sites, making them more challenging to stabilize. Wrapping the driveline with gauze and securing with tape prevents twisting and skin irritation.Nursing standards of care related to tracheostomy management and pressure ulcer prevention 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 potential dislodgment of the tracheostomy 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 following fluid resuscitation or in patients with fluid volume overload. The combination of direct pressure on the skin, with potential additive effects of tracheal secretions, creates pressure ulcers that are often accompanied by maceration at the suture sites.12An 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 publications related to tracheostomy procedures 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 regarding the lack of evidence to support the use of sutures to secure tracheostomy phalanges for airway protection. 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) tracheostomy holders continue to be used for safe airway securement for all tracheostomy patients. Reducing the use of sutures with routine percutaneous 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 modules 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 (Mepilex 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.A rare, yet equally troublesome pressure ulcer occurred in the CSICU with the use of a post-surgical compression brassiere, which is reserved for female cardiac surgery patients who are larger in both chest circumference and breast size. Published reports19–21 are focused on the use of these garments for stabilization of the sternum, improved approximation 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 circumference is a risk factor.20 The postsurgical brassiere offered at 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 postoperative 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 investigated alternative products in collaboration with the plastic surgery 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, flexible fabric with built-in compression areas and soft, flexible edges that do not cut into patients’ skin. Since implementation of this product, 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 complications. Moisture, friction, and pathogenic organisms have been described to cause a form of breakdown referred to as intertriginous dermatitis—a form of moisture-associated skin damage.22 Therefore, care must be taken to cleanse the skin properly 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 antimicrobial wicking products (Interdry AG, Coloplast) are used to prevent these injuries.Endotracheal tube (ETT) mucosal injuries comprised the majority of our device-related pressure ulcers, prompting the CSI team to add surveillance of ETT repositioning 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. Retraining and surveillance of ETT rotation frequency and timing nearly resolved this problem.Although we did not initiate formal practice changes for offloading pressure from feeding tubes or patients’ heels, the education and increased focus on pressure 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 reapply, 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. However, 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 vertically underneath the lower extremities. Prevalon boots (Sage Products) are our method of choice when heel pressure cannot be properly offloaded with pillows because of edema or leg circumference.The journey to improved outcomes began in 2012, with a total of 28 pressure ulcers attributed to our unit over the course of 12 surveys (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 Quality, the cost of treating a stage II pressure ulcer is estimated at $7000.18 The cost savings from 2012 to 2013 (at $7000 per ulcer) was $84 000, $70 000 for medical device–related pressure ulcers and $14 000 for pressure ulcers not related to medical devices.The CSICU’s theory that pressure ulcer surveillance is not a once-a-month event has been the cornerstone of professional practice related to the reduction of the number of pressure ulcers in our unit. Peer-to-peer feedback 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 maintaining such low rates.The the entire nursing team from the cardiac surgery intensive care unit and the Virginia Commonwealth University Medical wound care team for their to providing proactive care to our cardiac surgery patients. We for in the review of this

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