A Quality Improvement Initiative
Keywords: Corneal abrasion, ocular injury in anesthesia, surgical eye protection
Background
Corneal abrasion (CA) is a painful condition that occurs as the result of injury to the top layer of the eye surface. The cornea contains one of the richest nerve tissues in the body and when it is disrupted by injury, the nerves are exposed causing severe pain, tearing, sensitivity to light and decreased vision (Malafa, Coleman, Bowman, & Rohrich, 2016). Surgery is a risk factor for CA because the autonomic nerve responses that keep the eyes closed during sleep are inhibited by the effects of anesthesia. Hence, the eyelids remain partially opened (lagophthalmos), allowing the surface of the eye to become dry, making the cornea more vulnerable to abrasion (Malafa, et al. 2016). The abrasion and symptoms most often resolve within 1 to 2 days, after treatment, but can lead to complications of infection and vision loss (Carniciu et al., 2017). Tragically, it is the most common eye injury that occurs to anesthetized patients during surgery (Nuzzi & Tridico, 2016). Occurrence is reportedly low, ranging from 0.01% to 0.11% but consequences of a single occurrence can be devastating (Malafa, et al. 2016). Corneal abrasion occurrence as a post-surgical outcome not only causes patient harm and discomfort, but also negatively impacts patient satisfaction and trust in the institution and can increase healthcare costs during immediate and follow-up care (Weed & Syed, 2012).
There are recommended guidelines provided by the Association of Operating Room Nurses (AORN, 2019) to protect patient eyes from opening during anesthesia, yet there is no gold standard method to achieve this goal. Patient risk factors for predisposing them for CA during surgery are increased age, history of dry eye, prominent or bulging eyes, pre-op anemia and intraoperative hypotension (Morris, Bonanno, & Bennett, 2018). Environmental risks for CA during surgery are mechanical injury from stethoscopes, name badges, instrumentation, surgical drapes, gauze sponges, oxygen saturation probes, eye pads, prep solutions and removal of eye tapes (Malafa, et al. 2016). Additional CA risks include length of procedure > 60- 90 minutes, surgeries where the head is exposed and surgeries where taping of the eyes is not possible (Malafa, et al. 2016). The literature finds that a knowledgeable surgical team, initiating proper eye protection for the patient during surgery, can prevent corneal abrasion (Martin et al., 2009).
Local Problem
Since 2018, an urban surgical center in the Northeast region of the United States, experienced an increase incidence of ophthalmology consultations to assess complaints of severe eye pain from patients in the post anesthesia care unit (PACU) following non-ocular surgery. The findings of these consults often resulted in a CA diagnosis, requiring treatment to manage pain and prevent infection. An internal institutional audit of eye closure methods revealed multiple methods utilized by perioperative staff to try and achieve proper eye closure. Similarly, informal focus groups of operating room nurses at two allied urban hospitals identified the lack of standard procedure, inconsistent application of eye protection and a belief that eye protection was the responsibility of the anesthesia provider.
Purpose
The aims of this project were to identify best practices for prevention of CA, increase perioperative staff awareness about this preventable surgical risk and to provide education on clinical interventions to mitigate it.
Methodology
A quality improvement audit tool was developed and used to determine methods of eye protection utilized by clinicians for anesthetized patients. Audits of eye protection practices used during surgical procedures showed variations based on anesthesia provider preference, type of surgery, product available for protection, types of positioning and difficulty of intubation. Eye taping methods were also found to inconsistently applied across the setting. Water based lubricant was used when visualization of the eyes was needed by the surgeon during the procedure, thereby disallowing taping. To identify any patterns or trends, a review of n= 134 safety reports submitted between the years of 2014 -2018, cases numbering 134, concerning corneal abrasion, was completed to collect data regarding method of eye protection used, surgical procedure, patient positioning and any presence of post-op delirium.
This information was incorporated into an instructor lead, PowerPoint based, educational program provided to perioperative staff. Learning objectives were developed and program content which included an overview of evidence- based AORN guidelines recommended to prevent eye injury during anesthesia was given to 23 staff members. A pre-test was distributed to each attendee to provide a knowledge baseline regarding corneal abrasion during non-ocular surgery. A post program evaluation was done to identify if participants had an increase in awareness of the problem and to elicit the likelihood that the clinician intended to adopt the evidence-based guidelines presented.
Results
Participants pre-test assessments showed various knowledge levels regarding corneal abrasion and the type of surgical position, eye protection methods, patient risk factors and clinician responsibility. Post evaluations of the program revealed attendee’s consensus with gaining awareness of corneal abrasion and 100% reported willingness to incorporate gained knowledge into practice. This educational program given to perioperative staff was successful as the first step in an ongoing quality improvement initiative to increase perioperative staff awareness of CA risk, inform on best practices for eye protection during anesthesia and to guide future institution policy to standardize eye protection protocols and eliminate CA complications during non-ocular surgery.
Discussion
Injury during surgery such as CA, harms the patient, and decreases patient satisfaction and trust in the institution. Increased cost of treatment and follow up care are an additional burden. A knowledgeable, collaborative surgical team that provide evidence-based eye protection to anesthetized patients will help prevent corneal abrasion and its sequelae.
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