We have all done it. We have started an IV, or given a dose of medication, or performed a procedure, and then ‑- because we didn’t have a table close by — we put an IV catheter cap, or a syringe, or some other piece of “debris” on the patient’s bed, intending to remove it once finished. Not all of those caps got picked up again.

We are all extremely compulsive about removing anything sharp from the bed, as we should be. We are sometimes not so compulsive when it comes to loose discarded odds and ends that come with our needles and catheters. I cannot tell you the number of small pieces of plastic that I’ve found hiding under the sheets of patient beds over the years. And these loose bits and pieces will eventually end up underneath your patient if not removed because the mattress sags and gravity directs objects to the lowest point in the bed.

The picture above shows some representative pieces of plastic that I have found trying to sneak under patients over the years. Imagine laying on one of these for several hours. Any patient might suffer a pressure injury.

Who Is At High Risk of Pressure Injury?

• inability to move without great difficulty
• having prolonged surgery (prolonged being a relative term)
• inability to change position without assistance/inability to control body movement
• equipment/objects/hard surface pressing or rubbing on skin
• significant anemia (hemoglobin < 9 g/dL)
• persistent temperature > 37.5C for more than 12 hours
• poor peripheral perfusion (cold extremities/capillary refill > 2 seconds/cool mottled skin)
• inadequate nutrition
• low serum albumin level (<3.5 g/dL)
• incontinence (if inappropriate for age) because moisture make since friable and prone to infection

To summarize, those at particular risk are sicker patients with or without fragile skin, little subcutaneous fat, compromised nutrition, and impaired blood flow.

In addition, small children present another high risk group simply because of the relative size of their little fingers, blood vessels and nerves compared to the size of even small objects. Among neonates and children, more than 50% of pressure ulcers are related to equipment and devices (2). Picture a needle cap lying in the ulnar groove of a baby. Makes you cringe doesn’t it?

Once under a patient, even moving the patient to another bed does not guarantee the object will not stick to the patient’s now indented skin and be carried over.

This is just a simple reminder to avoid laying anything in a patient’s bed that doesn’t belong there. Put it on the floor, hand it to a colleague, consider putting a clean piece of (unsharp) plastic like a cap in your pocket – never put needles in your pocket. But if you absolutely must lay something on the bed, place it on a cloth or wrapper to contain it and keep it visible. Never cover it up. If you cover it: out of sight out of mind- it is more likely to be left behind. And just like counting instruments in the OR, look for everything that you know you put down to make sure it’s accounted for. Move the patient if you have to.

Your Monitors And The Patient Position Can Also Cause Pressure Injury

And while you are looking for anything you or your team might have left on the bed or the OR table itself, check for BP cuff tubing, IV tubing, pulse oximeter cables. Any of those things can also lie in the ulnar groove or be trapped between the patient and a hard surface and cause a nerve or pressure injury in the high risk patient.

I tell me students to imagine themselves lying in that position for several hours. If you do this, you will easily be able to predict what is going to be uncomfortable, or what might hurt you, and by extension, your patient. It’s another tool we have in our arsenal to protect our patients.

Detail matters. Even the smallest of things can hurt your patient.

May the Force Be With you

Christine E Whitten MD

References

1. Baharestani MM and Catherine R. Ratliff CR. ADV SKIN WOUND CARE 2007;20:208- 220
2. Willock J, Harris C, Harrison J, Poole C. Identifying the characteristics of children with pressure ulcers. Nurs Times 2005;101(11):40-3.