146 - Pressure Injury Prevention in Cardiothoracic Transplant Patients

Description: Clinical Problem: Pressure injuries lead to higher rates of morbidity, longer hospital stays, and increased health care costs. Treatment costs range from $20,900 to $151,700 per injury, contributing to an annual total of $27 billion to the health care system, and approximately 60,000 deaths each year. Our surgical institution is facing issues with deep tissue injuries among our cardiothoracic transplant patients, with four identified cases of injury to the intergluteal cleft.

Team: To improve patient outcomes, a collaborative team has been formed, consisting of two nursing practice development practitioners (NPDPs), the perioperative clinical nurse specialist (CNS), and the wound care CNS.

Assessment: The specialized team first assessed the operative positioning of cardiothoracic transplant patients, noting that they are positioned supine on a fluid immersion pad with a sacral silicone-bordered foam dressing, which is marked with a P for protecting intact skin or T for treating a pre-existing pressure injury. Collaborating with a wound care CNS and an extensive review of literature, we determined that additional dressings were needed to offset pressure within the intergluteal cleft. The ideal dressing should be easily applied, fit the intergluteal cleft, remain in place until repositioning is possible, and be skin-friendly.

Planning and Preparation: After evaluating several products, we concluded that the 2x5 silicone-bordered foam dressing meets all our criteria. Since this dressing is already available in our institution's inventory, product analysis and supply ordering were not necessary. To ensure its availability for all transplant cases, the 2x5 dressing was added to the operating room's central core inventory and included in the surgeon's preference card.

On May 19, 2025, the cardiothoracic nursing team and the cardiac ICU received training on the proper placement and application of the 2x5 silicone-bordered foam dressing. This carefully established process begins pre-intubation, with the operating room nurse applying a sacral silicone-bordered foam dressing to the sacrum and a 2x5 silicone-bordered foam dressing to both sides of the intergluteal cleft. At the end of the surgical procedure, the operating room nurse assesses the patient's skin under the dressing and documents the skin findings, along with the type and location of the dressing. The dressings will remain in place until the patient meets criteria for safe repositioning.

Implementation and Outcome: The initiative launched on May 28, 2025. As of July 14, 2025, there have been zero sacral or intergluteal cleft pressure injuries, compared to four injuries recorded between January and May 2025. To monitor the initiative, the specialized team, along with the cardiothoracic operating room and cardiac ICU staff, met weekly for one month to analyze the project, provide feedback, review dressing applications, and the skin assessment process. These meetings have since transitioned to monthly meetings, focusing on auditing case documentation and event reports.

Implications for Peri-operative Nursing: Collaborating as a multidisciplinary team with a shared goal has fostered an environment that encourages active communication among team members, leading to a decrease in hospital-acquired pressure injuries, improved patient safety, and progress toward our zero-harm target.