An Evidence-Based Practice Handbook for the Reduction of Perioperative Pressure Injuries: An Implementation Guide

The Association of Perioperative Nurses (AORN) Prevention of Perioperative Pressure Injury Tool Kit is a comprehensive set of evidence-based practices that can reduce the development of pressure injuries (PI) (AORN, 2022). A bundled set of prevention strategies is positively associated with reducing the development of injury or ulceration and improved patient outcomes. To effectively implement this Prevention of Perioperative Pressure Injury Tool Kit, there are evidenced strategic practices to support change readiness, including engaging stakeholders around the reasons for the change, gaining leadership support, assembling an interprofessional implementation team, providing compelling information that highlights the need for the change, and identifying necessary resources. The implementation plan outlined in this guide systematically explains how organizations can prepare, implement, and evaluate the use of the AORN Prevention of Perioperative Pressure Injury Tool Kit and the key considerations that should be explored with implementing a practice. EVIDENCE-BASED PRACTICE HANDBOOK 4 An Evidence-Based Practice Handbook for the Reduction of Perioperative Pressure Injury: An Implementation Guide One of the biggest challenges in clinical practice and frequent complications of hospitalizations are pressure injuries (PI) (Blenman & Marks-Maran, 2017). A PI is described as localized damage to the skin or underlying soft tissue that usually occurs over a bony prominence (The Joint Commission, 2016). Pressure injuries can result from prolonged pressure with or without shearing and compression forces (The Joint Commission, 2016). Patients who acquire in-hospital PIs endure immense pain, complications, and suffering from the condition. Many adverse health outcomes are associated with PIs; these often result in extended hospital stays, decreased physical functioning, stress, future readmissions, multiple surgical interventions, and, at worst, death (Armstrong & Bortz, 2001; Goudas & Bruni, 2019). As many as 60,000 deaths occur annually from extensive harm and complications related to hospital-acquired pressure injuries (HAPI) (Padula & Delarmente, 2019). Unfortunately, the surgical environment exposes individuals to various factors that make them incredibly susceptible to developing a PI. Surgical positioning, the operating room table, devices, anesthesia-induced immobility, the length of surgery, and the inability to feel pain increase a surgical patient's chance of developing a PI (Goudas & Bruni, 2019). The Association of Perioperative Registered Nurses (AORN), Agency for Healthcare Research and Quality (AHRQ), Institute for Healthcare Improvement (IHI), and National Pressure Ulcer Advisory Panel (NPIAP) are just a few out of the many professional organizations and governmental agencies that profoundly agree on the necessity of a multi-component PI prevention initiative to protect patients, reduce harm and reduce healthcare costs (Association of Periperative Registered Nurses, 2021; Agency for Healthcare Research and Quality, 2021; European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2019; Institute for Healthcare Improvement, 2022). This evidence-based best practice handbook for reducing perioperative PIs has dual purposes. First, EVIDENCE-BASED PRACTICE HANDBOOK 5 it will review the evidence supporting the use of the AORN Prevention of Perioperative Pressure Injury Tool Kit. Secondarily, this paper will examine the strategies supporting change readiness and management. Significance of the Practice Problem Each year, an estimated 234 million surgical procedures are performed worldwide across the globe (Weiser et al., 2008). In 2014, the European Pressure Ulcer Advisory Panel (EPUAP), the Pan Pacific Pressure Injury Alliance (PPPIA), and the National Pressure Ulcer Advisory Panel (NPUAP) reported that 45 percent of hospital-acquired pressure ulcers were surgery-related (PPPIA, 2014). However, because PIs from the operating room can appear anywhere from 48 to 72 hours after surgery, the incidence of a PI following surgery is most often under-reported and frequently determined to be a missed event (Goudas & Bruni, 2019). Unfortunately, PIs continue to be a costly challenge for US patients and care organizations. Under the Hospital Value-Based Purchasing Program and the Centers for Medicare and Medicaid Services criteria for preventable conditions, PIs are not reimbursed; therefore, hospitals pay for the incidence of new PIs (Blenman & Marks-Maran, 2017). According to Spruce (2017), approximately 2.5 million patients develop HAPIs. Each injury led to non-reimbursed healthcare costs ranging from $500 to $70,000 (Blenman & Marks-Maran, 2017; Chen et al., 2012). Poor patient outcomes that result in high costs should be addressed by instituting evidence-based measures to prevent PIs. Care organizations with a surgical population must be diligent in executing exemplary prevention efforts to halt the complex problem of PIs. The National Pressure Injury Advisory Panel, the Agency for Healthcare Research and Quality (AHRQ), and the Association of Perioperative Registered Nurses (AORN) recommend a series of bundled interventions which includes an assessment of risk factors as a critical component of PI prevention (AHRQ, 2021; AORN, 2022; PPPIA, 2014). Further, they suggest each organization should implement an evidence-based prevention program specifically designed for patients entering the perioperative EVIDENCE-BASED PRACTICE HANDBOOK 6 environment, following guidelines and best practices that help enhance implementation and compliance with the perioperative care team (AHRQ, 2021; AORN, 2022; PPPIA, 2014). Healthcare organizations that do not meet this standard of care cause poor patient outcomes and compromise the quality of care for their surgical population. Despite overwhelming evidence, many healthcare organizations do not have a perioperative PI prevention program that includes tracking methods for perioperative PIs. Of concern are the current clinical practice gaps, which consists of an absence of a multi-pronged prevention approach such as a risk assessment, a hand-off communication, a patient repositioning plan, and most importantly, the use of an interprofessional team to evaluate practices, identify measures, and progress towards desired outcomes (AORN, 2022; AORN 2001). Failure to utilize a comprehensive prevention approach and monitor perioperative related PIs creates an obscure care environment in which performance is unknown to be improving, staying the same, or worsening. This contradicts the most fundamental principle of quality management, which is tracking and measuring performance (AHRQ, 2021). Aside from the essential quality and safety obligations, healthcare organizations hold an ethical and legal responsibility to evaluate the degree to which their health services increase or decrease the likelihood of desired health outcomes as outlined by the Triple Aim framework and provide the standard of care (IHI, 2019). Substandard care poses a significant legal risk for organizations, resulting in legal action if harm or injury to the patient occurs (Lockhart, 2002). When the standard of care is not met, everyone suffers a loss. Purpose of the Program This evidence-based practice handbook and implementation guide will outline a structured approach to implementing an evidence-based process to reduce perioperative PIs. Utilizing the AHRQ's framework for Improving Quality of Care as a framework, this project will feature how to create a culture of change, assess change readiness, incite change motivation, EVIDENCE-BASED PRACTICE HANDBOOK 7 enlist change support, and effectively manage change, all of which are critical prerequisites to implementing an evidence-based practice change (AHRQ, 2021). Setting and Population Facilities that would benefit from utilizing this handbook would be those that do not have a formal, comprehensive PI prevention program. These facilities would have an adult surgical population where care is delivered in a perioperative setting. The perioperative care setting would include a pre-operative unit, a surgical operating room, and a post-anesthesia recovery unit. Their perioperative environment would consist of pre-operative nurses, intraoperative nurses, post-anesthesia or recovery nurses, and patient care assistants. Key Solution Healthcare facilities for which this handbook and implementation guide are intended have no formal process, PI prevention program, or methods for monitoring PI performance. Therefore, their objective entails implementing the AORN (2022) Prevention of Perioperative Pressure Injury Tool Kit, utilizing a comprehensive PI prevention and management approach. Comprehensive PI programs such as the AORNs Prevention of Perioperative Pressure Injury Tool Kit use evidenced-based nursing interventions that are confirmed to decrease the development of PIs and organizational strategies that integrate these interventions into the daily routine care (Soban et al., 2017). In addition, the use of evidence-based best practices and guides for assessing organizational change readiness and the ability to manage change will help further support how healthcare facilities can meet the standard of care and improve patient

environment, following guidelines and best practices that help enhance implementation and compliance with the perioperative care team (AHRQ, 2021;AORN, 2022;PPPIA, 2014).
Healthcare organizations that do not meet this standard of care cause poor patient outcomes and compromise the quality of care for their surgical population.
Despite overwhelming evidence, many healthcare organizations do not have a perioperative PI prevention program that includes tracking methods for perioperative PIs. Of concern are the current clinical practice gaps, which consists of an absence of a multi-pronged prevention approach such as a risk assessment, a hand-off communication, a patient repositioning plan, and most importantly, the use of an interprofessional team to evaluate practices, identify measures, and progress towards desired outcomes (AORN, 2022;AORN 2001). Failure to utilize a comprehensive prevention approach and monitor perioperative related PIs creates an obscure care environment in which performance is unknown to be improving, staying the same, or worsening. This contradicts the most fundamental principle of quality management, which is tracking and measuring performance (AHRQ, 2021). Aside from the essential quality and safety obligations, healthcare organizations hold an ethical and legal responsibility to evaluate the degree to which their health services increase or decrease the likelihood of desired health outcomes as outlined by the Triple Aim framework and provide the standard of care (IHI, 2019). Substandard care poses a significant legal risk for organizations, resulting in legal action if harm or injury to the patient occurs (Lockhart, 2002). When the standard of care is not met, everyone suffers a loss.

Purpose of the Program
This evidence-based practice handbook and implementation guide will outline a structured approach to implementing an evidence-based process to reduce perioperative PIs.
Utilizing the AHRQ's framework for Improving Quality of Care as a framework, this project will feature how to create a culture of change, assess change readiness, incite change motivation, enlist change support, and effectively manage change, all of which are critical prerequisites to implementing an evidence-based practice change (AHRQ, 2021).

Setting and Population
Facilities that would benefit from utilizing this handbook would be those that do not have a formal, comprehensive PI prevention program. These facilities would have an adult surgical population where care is delivered in a perioperative setting. The perioperative care setting would include a pre-operative unit, a surgical operating room, and a post-anesthesia recovery unit. Their perioperative environment would consist of pre-operative nurses, intraoperative nurses, post-anesthesia or recovery nurses, and patient care assistants.

Key Solution
Healthcare facilities for which this handbook and implementation guide are intended have no formal process, PI prevention program, or methods for monitoring PI performance.
Therefore, their objective entails implementing the AORN (2022) Prevention of Perioperative Pressure Injury Tool Kit, utilizing a comprehensive PI prevention and management approach.
Comprehensive PI programs such as the AORNs Prevention of Perioperative Pressure Injury Tool Kit use evidenced-based nursing interventions that are confirmed to decrease the development of PIs and organizational strategies that integrate these interventions into the daily routine care (Soban et al., 2017). In addition, the use of evidence-based best practices and guides for assessing organizational change readiness and the ability to manage change will help further support how healthcare facilities can meet the standard of care and improve patient outcomes.

Program Problem Statement
The PICO question that will guide this pressure injury reduction program is: in healthcare The outcomes organizations must measure should they implement this AORN Prevention of Perioperative Pressure Injury Tool Kit includes the incidence and prevalence of patients who have developed a PI during the perioperative period or within 72 hours of being in the perioperative care unit. The objectives of this evidence-based practice handbook and implementation guide for the reduction of perioperative PIs are outlined using the SMART format (specific, measurable, attainable, realistic, and timed) and are as follows: • Specific: Prepare the organization to implement the AORN Prevention of Perioperative Pressure Injury Tool Kit.
• Measurable: Identify and enlist 95% of critical stakeholders, forming an interprofessional team that is educated to the standards of care and the importance of why change is needed. Reduce the incidence and prevalence of developing a perioperative PI.
• Attainable: To successfully achieve this practice improvement, the Agency for Healthcare Research and Quality's Toolkit for Improving Quality of Care will help guide the assembly of the interprofessional implementation team, assess their readiness for change, and manage the change effectively (AHRQ, 2021).
• Relevant: This handbook supports improved patient outcomes by protecting patients from preventable harm and reducing the cost associated with HAPI (Sullivan & Schoelles, 2013).
• Timed: Change takes time, and it requires stakeholders to tactfully build and sustain momentum. Therefore, pre-implementation planning and initiating the change should move at a consistent pace for a suggested duration of 8 weeks; however, this can vary depending upon the organization.
The long-term objectives include: • Preventing the development of PIs in surgical patients (AORN, 2022).
• Adherence with the AORN Prevention of Perioperative Pressure Injury Tool Kit interventions.
• Sustainment of prevention practices into the daily care of surgical patients • Reduce the incidence and prevalence of PIs

Utility of Implementation Plan
Two vital prerequisites in implementing change are realizing the need for change and planning for change (Erwin, 2009). To successfully implement this practice change, the organization must prepare its employees in advance, equipping them with the primary purpose and objectives (Indriastuti & Fachrunnisa, 2021). Employees who are ready for change demonstrate high adaptability, positive attitudes, and a desire to be involved with implementation (Indriastuti & Fachrunnisa, 2021). Implementation will impact all perioperative services and rely heavily on interprofessional collaboration as a PI prevention program involves multiple workflows. Therefore, devoting time to assess change readiness will largely influence the overall success and uptake.
This implementation guide is helpful to organizations that wish to adopt the AORN Prevention of Perioperative Pressure Injury Tool Kit and assess their infrastructure's readiness and implementation ability. Objectively evaluating and monitoring the setting in which the change is set will help identify opportunities and barriers that may derail the implementation process. For example, hospital leadership's support, required training, and available resources must be evaluated and implemented to achieve a successful change. In addition, common barriers such as change fatigue must be addressed by providing a compelling case for why this change is necessary. Utilization of this implementation guide will help transform implementation plans into actionable tactics that move a change forward and closer toward the desired outcome.

Analytical Framework
The AHRQ's framework for this implementation guide will help guide the assembly of the interprofessional implementation team, assess readiness and prepare for organizational change (AHRQ, 2021). In addition, it aims to support the efforts of healthcare organizations in need of implementing evidence-based PI prevention practices (AHRQ, 2021). At the heart of the AHRQ framework are six major questions for organizations to consider as they enlist members of the implementation team and strategize their efforts to put new prevention practices into motion (AHRQ, 2021): 1. Are we ready for a change?
2. How will change be managed?
3. What evidence-based best practices are we missing and need to use? 4. How will these best practices be implemented?
5. How will we measure or evaluate these practices?
6. How will we sustain these prevention practices?
Notably, the AHRQ framework encompasses all the essential preparatory and management components before and after the change is initiated (AHRQ, 2021).
Lastly, the Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals Model is integrated as it emphasizes the necessity of constructive and collaborative involvement in addressing health care challenges and meeting the complex needs of patients (Dang et al., 2022). In addition, with the interprofessional team being accountable for implementation, this model supports building consensus and guiding nursing knowledge and conformity (Dang et al., 2022).

Pressure Injury Prevention Programs
A two-part literature search strategy was conducted to identify peer-reviewed academic articles published in PubMed, CINAHL Complete, and OVID Emcare databases. The first literature search identified studies that evaluated the impact of bundled care interventions implemented to reduce to development of PIs. These studies were published between 2012 and 2022. Search terms used alone or combined with Boolean operators included prevention, control, perioperative, pressure ulcer, care bundle, and toolkit. PubMed and CINAHL Complete search results were filtered using the randomized control trial and systematic review selections.
In OVID Emcare, the "include related search terms" filter was used to broaden the search, and the "five stars" filter was selected to support relevancy. All studies were English and conducted on human subjects aged 18 years and older.
An independent screening of all abstracts was conducted that excluded non-original research non-research-based studies that were performed outside of an inpatient hospital setting. In addition, studies with no clear description of the multi-component interventions utilized were excluded, and studies that focused on a single prevention intervention instead of a multi-component prevention program. Studies with missing data, a mixed-methods design, or qualitative methods were also excluded.

Organizational Readiness
The second literature search was conducted through PubMed and CINAHL Complete and identified studies that evaluated organizational readiness for change and related psychosocial factors. These studies were published between 2012 and 2022 in the United States. Search terms used alone or in combination included organizational readiness for change, implementation, research, organizational change, psychosocial factors, and work environment. The following words were used with Boolean operators for CINAHL Complete and PubMed; (organizational readiness for change) (implementation research) (organizational change) (psychosocial factors) (work environment). The "apply equivalent subjects" function in CINAHL Complete was used to broaden the search. Search results were filtered using the "academic journal, English, and United States" functions. Under the subject major heading filter, "organizational change and change management" was selected. The "meta-analysis, systematic review, and randomized control trial" filters were chosen in the PubMed database.
The excluded studies were non-original and non-research-based studies conducted using other activities that did not address the PICO question.

Pressure Injury Prevention Programs
The final number of research articles evaluating the impact of a PI prevention program that evaluated a series of bundled interventions was five (figure 1). The five included studies focused on adult hospitalized patients and assessed the effectiveness of multi-component PI prevention programs on reducing the development, incidence, or prevalence of a HAPI. Using the Johns Hopkins Evidence Level and Quality Guide and the Strength of Recommendation Taxonomy or SORT tool, four Level I systematic reviews emerged and one Level I randomized control trial research study (Appendix A).

Organizational Readiness
The second literature search focused on assessing organizational readiness for change resulted in five primary research studies. These studies were appraised for their design and relevancy, in which three Level I systematic reviews and two Level II, B quality studies were selected ( Figure 2). Ten primary research studies were included (Appendix B, C).

Pressure Injury Prevention Programs
Five studies related to utilizing a multi-component prevention bundle were thoroughly reviewed, appraised, and synthesized to develop an overall understanding of the information related to the study question. The first literature search that focused on implementing multicomponent initiatives for PI prevention generated four Level I systematic reviews that received an A for quality and a Level I randomized control trial that demonstrated consistent generalized results (Dang & Dearholt, 2017). Unanimously, each study agreed PIs is a complex clinical challenge associated with substantial health and financial burdens to patients and care facilities (Chaboyer et al., 2016;Gaspar et al., 2019;Lin et al., 2020;Sullivan & Schoelles, 2013;Tayyib & Coyer, 2016). Each study also evaluated PI prevention strategies and program components to determine its effectiveness in decreasing PI occurrence (Chaboyer et al., 2016;Gaspar et al., 2019;Lin et al., 2020;Sullivan & Schoelles, 2013;Tayyib & Coyer, 2016). In addition, the Level I randomized control trial emphasized the importance of individualized prevention plans and found active patient participation as a reliable factor in reducing risks (Chaboyer et al., 2016).

Organizational Readiness
The second literature search related to organizational readiness for change generated three Level I, Quality A and B, systematic reviews, and two Level II, B Quality research studies.
The evidence generated supported various elements of driving organizational change, assessing organizational readiness using instruments, and the critical factors that affect change adoption (Gagnon et al., 2014;Kho et al., 2020;Miake-Lye et al., 2021;Mohamed-Hussein & Abou-Hashish, 2016;Mrayyan, 2020). Readiness for change is how employees accept and integrate a planned change into their standard routine (Mrayyan, 2020). The organization's readiness of its employees directly reflects employees' commitment to change and the efficacy of carrying it out (Mrayyan, 2020). Three Level I systematic reviews critically analyzed how organizations can assess and operationalize readiness by utilizing readiness instruments that focus on contextual factors and characteristics specific to the organization (Gagnon et al., 2014;Kho et al., 2020;Miake-Lye et al., 2021). Evaluating organizational readiness through a formal assessment should examine the domains such as implementation climate, structural characteristics, networks and communication, culture, institutional resources, and motivation (Gagnon et al., 2014;Kho et al., 2020;Miake-Lye et al., 2021). Although one systematic review specifically addressed change readiness regarding telemedicine services, it thoughtfully demonstrates the same strategic practices for preparing for change (Gagnon et al., 2014).
Collectively, this body of evidence agreed on the necessity of utilizing an assessment to address the organization's characteristics, needs, and expectations of stakeholders and the overall objectives of the change (Gagnon et al., 2014;Kho et al., 2020;Miake-Lye et al., 2021).
The remaining two Level II, B quality research studies further supported the importance of assessing organizational readiness for change with an additional focus towards the overall work environment and its correlation to preparedness. These studies outlined the strategic practices and ideal work environments that support change readiness and concluded how a positive work environment is associated with hospitals' readiness for change (Mohamed- Hussein & Abou-Hashish, 2016;Mrayyan, 2020). Throughout this body of evidence, a highlighted theme was the properties associated with successfully implementing change, including leadership support, an interprofessional team approach, a clear understanding of the objective, and mutually agreed-upon methods (Mohamed- Hussein & Abou-Hashish, 2016;Mrayyan, 2020). To support organizational change, all healthcare organizations should focus on teamwork, encourage nurse participation on all organizational committees, and support nurses' involvement in decision-making (Gagnon et al., 2014;Kho et al., 2020;Miake-Lye et al., 2021;Mohamed-Hussein & Abou-Hashish, 2016;Mrayyan, 2020). Factors that can negatively impact include competing demands and increased workload imposed on frontline staff

Recommendation Statement
Based on a rigorous review of the evidence, it is recommended healthcare facilities utilize a structured approach towards implementing the AORN Prevention of Perioperative Pressure Injury Tool Kit that first starts with using readiness instruments that focus on contextual factors and characteristics specific to the organization (Gagnon et al., 2014;Kho et al., 2020;Miake-Lye et al., 2021). Bundled interventions are the most effective best practices for PI prevention (Chaboyer et al., 2016;Gaspar et al., 2019;Lin et al., 2020;Sullivan & Schoelles, 2013;Tayyib & Coyer, 2016). In addition, implementing a multi-component prevention program is evidenced to reduce the occurrence of PIs and improve patient outcomes (Chaboyer et al., 2016;Gaspar et al., 2019;Lin et al., 2020;Sullivan & Schoelles, 2013;Tayyib & Coyer, 2016). The adoption success of evidence-based clinical practices will require the use of a formal assessment instrument that helps define an organization's readiness for change.
These assessment tools help prepare stakeholders to implement and sustain PI prevention tactics that meet the standard of care (Gagnon et al., 2014;Kho et al., 2020;Miake-Lye et al., 2021;Mohamed-Hussein & Abou-Hashish, 2016;Mrayyan, 2020). This approach aligns with the AHRQ's framework for Improving Quality of Care framework, highlighting the importance of exploring readiness to help identify action steps that improve organizational readiness and increase implementation success (Berlowitz et al., 2014).

Implementation Plan
The implementation plan outlined in this guide is supported and driven by the evidence and will systematically explain how organizations can prepare and implement the AORN Prevention of Perioperative Pressure Injury Tool Kit and the key considerations that should be explored with change readiness. Each section will explore six key subject areas that should be explored when implementing the AORN Prevention of Perioperative Pressure Injury Tool Kit based on the AHRQs framework.

Are We Ready for Change?
The efforts to reduce the development of PIs can span across multiple levels, disciplines, and workflows (Berlowitz et al., 2014). Given the overall complexity of implementing a change that affects various stakeholders, the evidence suggests assessing readiness by first Providing key or baseline PI statistics on the global, national, local, and organizational level will help stakeholders recognize the value and relevancy of the change (Berlowitz et al., 2014;Kho et al., 2020).
Gaining leadership and management support is the most critical component of developing consensus and assessing for change readiness (Kho et al., 2020). Determining their interests and how their engagement will be sustained will impact the overall success of the change (Kho et al., 2020). A questionnaire survey is recommended to assess stakeholder attitudes, motivation, and interests in the change (Berlowitz et al., 2014). This will help inform how much effort must be exhausted in achieving buy-in (Berlowitz et al., 2014). The Clinical Staff Attitudes Toward Pressure Ulcer Prevention Survey (Appendix C) is a validated instrument that provides a quantitative measurement of health professionals' attitudes toward a change (Moore, 2004). To help determine the level of leadership support, The Leadership Support Assessment (Appendix D) developed by Boston University can examine areas where support is needed and inform leadership on the necessity of the change (Berlowitz et al., 2014). The use of readiness surveys such as these serves as the initial step towards assessing for change readiness helping stakeholders understand why change is needed and the rationale for a PI prevention program (Berlowitz et al., 2014;Gagnon et al., 2014;Kho et al., 2020;Miake-Lye et al., 2021;Mohamed-Hussein & Abou-Hashish, 2016;Mrayyan, 2020).

Is the Need for Change Compelling?
Providing baseline PI statistics and making a case of why PI prevention is essential, the case must also be compelling in a way that moves behavior from complacency to action (Berlowitz et al., 2014). Establishing urgency is a vital component of the change management process because it creates the picture behind the need for change. Identifying and collaborating with stakeholders who have responsibility or oversight on PIs, such as wound care nurses, can help develop the case for why PI prevention is necessary. A stakeholder analysis tool (Appendix E) will help define the different stakeholder groups and discover what elements they care about most (Berlowitz et al., 2014). Ultimately this supports the development of a plan to communicate the reasons for the change while also appealing to the interests of stakeholders, all of which help reduce any potential risks that could negatively impact implementation (Gagnon et al., 2014;Kho et al., 2020;Miake-Lye et al., 2021;Mohamed-Hussein & Abou-Hashish, 2016;Mrayyan, 2020).

Senior Leadership Support
When it comes to change readiness and implementation success, the support and buyin of top management are key (Mrayyan, 2020). Buy-in from senior leadership will help strengthen the urgency and efforts behind the change and PI prevention (Berlowitz et al., 2014).
A leadership support assessment should be conducted to identify potential opportunities or risks with leadership and evaluate their response and support of the change (Berlowitz et al., 2014).
They play a crucial role in managing organizational change through timing, training, and resources (Berlowitz et al., 2014). Their involvement ultimately influences employees' attitudes towards organizational change and how well the changes are integrated (Mrayyan, 2020).
Once leadership buy-in has been obtained, meetings with leadership and clinical staff should take place to address concerns and gain acceptance (Kho et al., 2016;Mrayyan, 2020).

How Will This Change Be Managed?
Essential in any project that requires a redesign of practice is identifying solid advocates from various disciplines who can influence change, encourage collaboration, and align the improvement initiative to existing goals (Berlowitz et al., 2014;IHI, 2019;AORN, 2022). After assessing and establishing the readiness for change, the organization must consider assembling an interprofessional team to help manage the change (Berlowitz et al., 2014). In their systematic review, Kho et al. (2020) recognized the amount of work required to undertake change and the importance of guiding a change coalition through partnerships. Implementation teams with a strong network of communications and access to any needed resources are evidenced to be a significant contributor to successful implementation (Berlowitz et al., 2014;Gagnon et al., 2014;Kho et al., 2020;Mohamed-Hussein & Abou-Hashish, 2016;Mrayyan, 2020;Sullivan & Schoelles, 2013). Pressure injury prevention champions and advocates should be identified using instruments such as The Interprofessional Professionalism Assessment Instrument (IPA) (Frost et al., 2018). Tool such as the IPA can be used to assess team member collaboration and communication skills by evaluating individual team member's behavior and professionalism (Frost et al., 2018). Tools that help evaluate processes that promote effective teaming and team building skills such as actively listening, being honest, demonstrating respect and compassion, and being open and flexible are crucial to guiding the improvement efforts (Harris et al., 2018). Team members could include wound care nurses, physicians, operating room nurses, anesthesiologists, clinical managers, skin committee members, perianesthesia nurses, and health care personnel who play an active role in prevention through direct patient care and are responsible for adhering to the bundle interventions.
Once the implementation team has been assembled, the scope of their work should be clearly defined along with the roles and responsibilities of each member (Berlowitz et al., 2014).
Roles and responsibilities should then be communicated to senior leaders along with the preferred feedback exchange mechanism that supports frequent communication (Berlowitz et al., 2014;Sullivan & Schoelles, 2013). Senior leadership should ensure the team has the resources and tools necessary to successfully implement the practice change (Berlowitz et al., 2014). The implementation team should devote much time to the specific practice change and any redesign of everyday work (Berlowitz et al., 2014). The implementation team should also establish a routine meeting structure that provides them with the necessary time to plan and develop implementation methods and a timeline of tasks that need to be completed (Berlowitz et al., 2014).

What Practices Are We Missing and Need to Use?
Next, the implementation team should focus on understanding the current state of practice and what processes need to be changed, modified, reintroduced, or initiated in The implementation team will address gaps between evidence and clinical practice, working to support using the AORN Prevention of periOperative Pressure Injury Tool Kit in its completeness. The following will review each of these bundle practices that make up a Perioperative Pressure Injury Prevention Program.

Pre-operative Skin and Risk Assessment
Identifying at-risk patients is the first best practice in PI prevention as it informs care management decisions and is necessary to cascading the appropriate measures to prevent PIs

Intra-operative Skin Assessment and Interventions
The primary purpose of the intra-operative skin assessment is to perform another visual inspection of the patient's skin while positioning the patient on the operating room table (AORN, 2022). Surgical positioning, the operating room table, devices, anesthesia-induced immobility, the length of surgery, and the inability to feel pain increase a surgical patient's chance of developing a PI (Goudas & Bruni, 2019). Performing an intra-operative "skin scan" helps reduce the risk of PI development (AORN, 2001). It also informs the interventions that should be used to minimize injury (AORN, 2001). The intra-operative prevention interventions include the selection of appropriate surfaces that support pressure redistribution, such as the Pink Pad, a shape-conforming foam that reduces friction (Greenberg, 2013). Intra-operative interventions should also include using safe patient handling devices to move the patient to and from the operating table (AORN, 2022). Clinical support surfaces such as gel pad overlays should be readily available and utilized to help distribute pressure evenly and decrease the potential for injury (AORN, 2001). Its use helps protect vulnerable bony prominences that bear weight or pressure, such as the hips, buttocks, heels, and elbows (AORN, 2022). After the procedure is completed, an intraoperative "skin scan" or assessment should be conducted to determine if any new alterations in skin integrity occurred and documented (AORN, 2001).

Hand-off Communication
The

Post-operative Skin Assessment
Lastly, the recovery nurse's post-operative full skin inspection following surgery is vital to continuing preventative PI interventions, especially among patients identified pre-operatively as at-risk for PI development (Webster et al., 2015). In their study sample, Martinez et al. (2019) found that the participants classified as being high risk increased exponentially from their admission to 48 hours post-operatively after conducting the post-operative skin assessment. Improvements to reducing the development of perioperative PIs require real-time interventions and evaluation of patient-specific processes that determine if a new injury has developed and the efficacy of the preventative measures itself (Martinez et al., 2019). A nursing intervention adherence checklist (Appendix G) can be designed to help support and measure adherence to these components.

How Will We Implement?
The implementation team can create a checklist of identified resources needed to launch the practices or survey the stakeholder groups for any needs (Berlowitz et al., 2014). A resource needs assessment (Appendix H) can help determine what is required to accomplish the task or implement the change. Most commonly, the primary resource required is staff education and training. Providing training and education is central to successful adoption and will depend on the components of the AORN Prevention of Perioperative Pressure Injury Tool Kit that will be implemented (Kho et al., 2020). For example, if the pre-operative risk assessment tool is a critical aspect missing from the current care standards of the organization, education and training should focus on the importance of an early evaluation.

Education
Education on the complications associated with PIs and the importance of reducing harm through early detection should be reviewed. Staff should be trained on conducting a complete skin and risk assessment following the AORN's guidelines which highlight areas most susceptible to PIs and educated on how their efforts contribute to reducing incidence and prevalence. Educational content should also incorporate materials found within the AORN Staff education must consist of assessing and documenting tissue damage caused by pressure and/or shearing forces, which is the first step in calculating incidence and prevalence (Berlowitz et al., 2014). In addition, a skin assessment on every patient must take place (Berlowitz et al., 2014).

How Will We Measure These Practices?
It is important to measure and track PI performance, indicating whether the organization's prevention efforts enhance or diminish care. Reflecting on the timeline and goals, a pre-implementation and post-implementation evaluation should occur, examining outcomes specific to PIs. In addition, pre-implementation baseline data on the incidence and prevalence of perioperative PIs should be obtained, reviewed, and disseminated to stakeholders to understand the effects of their efforts. First, establish a baseline of the organization's performance and current PI rates. The organization can then research national PI benchmarks starting with the U.S. Centers for Medicare & Medicaid and the National Database of Nursing Quality Indicators™ Centers, which provide hospital-acquired pressure ulcer data. Once gathered, this information will allow for an initial comparison and determination of the organization's current performance.
After data and national benchmarks have been collected, the organization will implement the AORN Prevention of Perioperative Pressure Injury Toolkit to put the new practices into operation. Key indicators to measure are PI incidence and prevalence. Pressure injury incidence measures the number or percentage of patients who have developed a new injury in the perioperative setting (Berlowitz et al., 2014). Pressure injury prevalence examines the number of PIs at a given period and takes the number of patients with a PI divided by the total number of patients (Berlowitz et al., 2014). The incidence and prevalence data should be monitored and calculated monthly (Berlowitz et al., 2014). A quantitative data analysis of the rates should include the percentage of patients who developed a PI compared to national benchmark data and previous baseline data (Berlowitz et al., 2014). and incidence rates and test whether incidence rates during the pre-intervention period differed from the post-intervention period.
An analysis of the evaluation table (Appendix K) can be used and shared with staff to communicate helpful information on the impact of the AORN Prevention of Perioperative Pressure Injury Tool Kit and how the results compare to benchmark or baseline data. A balanced scorecard performance management tool can also be developed to track implementation adherence and monitor progress (Berlowitz et al., 2014). This tool can also report data, sharing it with key stakeholders such as senior leadership and project participants.
Quality tools such as Pareto charts and control charts can be used to analyze data related to the frequency of PIs and also display the data showing how performance has changed over time (ASQ, n.d.). Organizations should prioritize incorporating these performance management tools and information as an essential sustainability practice.

How Do We Sustain These Practices?
The organization should devote much attention and energy to the sustainment of change. Conducting a quarterly review of incidence and prevalence rates, incorporating competency education annually and consistent updates to staff are a few sustainability practices (Sullivan & Schoelles, 2013). In addition, the use of skin committees can help establish and support accountabilities for sustaining prevention efforts on an ongoing basis (Berlowitz et al., 2014). Also critical to sustainability is recognizing and reinforcing desired results (Berlowitz et al., 2014). Celebrating and rewarding small successes is another change management practice to keep staff motivated and engaged with sustaining the practice change (Berlowitz et al., 2014).

Dissemination Plan for the Organization
It is critical to utilize an education outreach approach with frontline nurses and clinicians, increasing information sharing and spreading the intervention and project results. Plans for dissemination and translating the results of the AORN Prevention of Perioperative Pressure Injury Tool Kit should be presented and shared with all the stakeholders. Individuals responsible for implementation should receive regular weekly updates on the data collected and performance feedback. Once the data is captured and measured, and any patterns, trends, or defects have been identified, that information should be shared amongst committee or quality improvement teams, wound care nurses, perioperative staff, and leadership. A presentation of the results and the program's overall impact should be formally shared with all stakeholders, which is essential to influencing nursing practice and the uptake and sustainment of change.

Implementation Timeline
Given the sequence of events discussed, the implementation plan will need to be customized or tailored to meet and address the organization's unique circumstances. The proposed implementation timeline (Appendix I) considers the pre-implementation planning phase, assembly of an interprofessional team, the training and education of staff, and implementation of the change itself. To tactfully build and sustain momentum for change, the underlying objective and vision must be communicated and broadly understood. Below is the chronological order of events that include the defined goals the organization should meet before moving to the next phase.
1. Why this change is needed -To prevent apathy or resistance, identify and communicate specific reasons for the change.
2. Stakeholders understand why the change is necessary -The goal is to assimilate value and understanding by providing a compelling case for why this change is needed.
3. Is there a sense of urgency -Assess attitudes and current motivation to gauge how much effort needs to be placed on achieving buy-in. The goal is to develop a plan to communicate the reasons for the change while appealing to stakeholders' interests and reducing potential adverse risks.

4.
Is there senior leadership support -Identify any potential opportunities or risks with leadership and evaluate their response and support of the change. Because leaders play a crucial role in supporting the change initiative, their buy-in must be obtained.

Who will own implementation efforts -Assign roles and assemble an
implementation team to take ownership of the subsequent planning steps.

Dissemination Plan for this Implementation Guide
The dissemantion of this evidence-based practice handbook will be conducted at a care organization located in the midwestern United States on an organizational and system level.

Plans for dissimenation also include the Minnesota Hospital Association's Pressure Injury
Committee. This implementation guide will be archived at the University of Saint Augustine for Health Sciences Library Scholarship and Open Access Repository (SOAR) as a student capstone.

Conclusion
With over 200 million surgeries performed worldwide, the perioperative setting is a unique environment that places individuals at an increased risk due to various extrinsic factors.
This evidence-based best practice toolkit for reducing perioperative pressure injuries reviews the evidence supporting using the multi-pronged AORN Prevention of Perioperative Pressure Injury Tool Kit. In addition, this paper examined how organizations can successfully execute the