215 - Reducing Harm Through Standardized OR Pressure Injury Prevention Protocols

Description: Background Information and Study Question: Pressure injuries (PIs) in the perioperative setting pose a significant and preventable challenge to patient safety. Despite AORN guidelines, inconsistent implementation in PI prevention leads to preventable harm. At our institution, an alarming increase in PIs identified within 72 hours postoperatively was observed, 9 PIs (Q1-Q2 2024) to 14 PIs (Q3-Q4 2024), with operating room procedures. This critical trend highlighted an urgent need to standardize and enhance frontline staff education and practices in perioperative PI prevention. An interdepartmental team was formed, led by two main OR clinical nurses. This team will work together to develop sustainable, evidence-based perioperative PI prevention guidelines and education aligned with AORN standards, specifically addressing high-risk areas and intervention techniques. This project is guided by the question: Does the creation of perioperative pressure injury prevention guidelines and standardized education reduce pressure injuries associated with operating room procedures?

Design: A pretest/posttest quasi-experimental design to evaluate the effect of a comprehensive perioperative PI prevention program.

Methodology: The project comprises three core, interconnected components: enhanced education, standardized practice implementation, and continuous data monitoring. First, the team will create evidence-based guidelines outlining specific steps for comprehensive preoperative skin assessments, standardized intraoperative repositioning protocols, and improved communication strategies during handoffs to ensure continuity of care. Second, along with implementation of the guidelines, nurses will complete education hosted on our organization's e-learning platform (May-June 2025). Complementing the e-learning, staff will also complete hands-on check-off sessions to validate clinical competency in proper positioning, padding techniques, and identifying high-risk body areas. Third, key metrics will be continuously tracked via organizational dashboards for data monitoring on the incidence of new PIs identified within 72 hours of procedures lasting over two hours (July 2025-January 2026). Process measures include staff knowledge improvement, assessed April 2025, through same day pre- and post-intervention surveys integrated into the e-learning platform, and compliance with new guidelines.

Results: This nine-month project is expected to demonstrate a reduction in perioperative pressure injuries and a significant improvement in staff knowledge and adherence to best practices. By implementing a standardized, interdepartmental approach, our organization anticipates enhancing patient safety outcomes and establishing a scalable model for PI prevention within complex surgical environments, contributing valuable insights for similar institutions.

Conclusion: Will share at AORN 2026 Conference.