Teamwork for prevention: Reducing HAPUs in cardiac surgery patients
The National Pressure Ulcer Advisory Panel defines pressure injury as an area of localized damage to the skin and/or underlying soft tissue caused by intense or prolonged pressure alone or in combination with shear.1,2 Hospital-acquired pressure injury (HAPU) is a preventable complication, causing pain and suffering, contributing to morbidity, and increasing length of stay.3 The National Quality Forum defines never events as errors in medical care that are clearly identifiable and preventable. Stage 3 and 4 pressure injuries acquired during hospitalization meet the criteria for a never event and aren't reimbursed.4 According to the Centers for Medicare and Medicaid Services, the cost of Stage 3 or 4 pressure injuries in an acute care hospital is approximately $43,180. HAPUs are painful, and the emotional turmoil patients and families experience decreases satisfaction and increases litigation risk. The average settlement for HAPUs in the United States is around $250,000, with the largest settlement currently reported as $84,000,000.5 HAPUs often result in poor outcomes and can negatively impact the hospital's financial bottom line.
Cardiac surgery patients are at a high risk for developing pressure injuries. During the operative procedure, cardiac surgery patients remain on a firm OR table for a lengthy period of time, with periods of hypotension, paralysis, and heavy sedation due to anesthesia.3,6 Intraoperatively, manipulation of body temperature and metabolic changes to the tissues caused by prolonged immobility, inability to reposition, extracorporeal circulation, and anesthesia impact circulation to the skin.7,8 In the postoperative period, cardiac assistive devices also interfere with effective patient turning and repositioning because immobilization is required for an extended period of time.7 Cardiac surgery patients have rates of HAPUs reported to be as high as 29.5%.9 Older age and comorbidities, such as poor nutritional condition, aberrant body mass index, low levels of albumin or hematocrit, and complicated conditions, predispose and increase the risk of skin breakdown in these patients.