May 14, 2015

Fine-tuning the Munro Scale for pressure ulcers

By: OR Manager
Cassendra Munro, MSN, RN, CNOR

Cassendra Munro, MSN, RN, CNOR

Pressure ulcers affect up to 3 million adults in the US each year, according to the Agency for Healthcare Research and Quality. Surgical patients are at high risk to develop pressure ulcers because of immobility during long procedures and anesthesia that blocks sensitivity to pain and pressure.

Estimates of treatment costs range between $37,800 and $70,000 per ulcer, with total annual costs as high as $11 billion.

The Centers for Medicare & Medicaid Services now considers Stage III and IV pressure ulcers a healthcare-associated condition and will not pay more for the treatment of patients who acquire them in the hospital.

These are compelling reasons for perioperative nurses to be proactive in doing risk assessments and using preventive measures to protect their patients. No standard or tool for identifying surgical patients at risk for pressure ulcers is currently in use, but there is one on the horizon.

Cassendra Munro, MSN, RN, CNOR, perioperative educator at Providence St John’s Health Center, Santa Monica, California, created the Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients (Munro Scale) to identify adult general surgery patients at risk for pressure ulcer development. AORN has partnered with Munro to develop the scale.

An implementation study of the Munro Scale began this spring, Munro told OR Manager. Seven facilities are included in the study, funded by a Cardinal Health E3 Foundation Grant (Dublin, Ohio).


Munro Scale

The Munro Scale emphasizes assessment of patient risk; it is not a skin assessment. The patient’s risk level is scored for each phase of surgery (pre-, intra-, and postoperative), with a cumulative score that is communicated to the inpatient unit for continuation of care. Not only is it a standardized risk assessment, it is also a documentation and communication tool.

The preoperative score is based on factors such as comorbidities, nutritional status, body mass index, and mobility. The intraoperative score encompasses type of anesthesia, hypotension, blood loss, and length of procedure.

OR-specific risk factors include:

• use of positioning aids

• moisture on or under the patient

• friction and shear during transfers.

Patients continue to be at risk postoperatively. For example, a patient who was in the supine position for 10 hours during surgery should be turned from side to side if possible in the postanesthesia care unit to relieve the pressure.


Implementation study

Tools for facilities involved in the implementation study include:

• instructions for use, which are available in a printed document and presented via a webinar

• Munro Scale

• end-user feedback gathered electronically via a survey

• two case studies for practice

• references and a literature review

• two frameworks—Diffusion of Innovations Theory for the method of implementation and RE-AIM for evaluating the implementation.

Collaboration with the seven facilities is the key to this project, Munro says. “I could not have embarked on such a project without the collaboration of the facilitators at each site. Their feedback alone has been invaluable,” she says.

Munro believes feedback from the facilitators has greatly improved instructions for use, but she wants end-user feedback, too.

A validity and reliability study also is underway. The results from this study are needed before converting the Munro Scale to an electronic format and making it available for use, she says.


No changes foreseen

The types of changes that have been made to the Munro Scale so far have been made for ease of use and for clarification of instructions for use, Munro says. If any changes were made to the actual risk factors, they would have to be supported by evidence-based knowledge. Munro doesn’t foresee any changes unless the results from the validity and reliability study show more work is needed before the tool is put into clinical practice.

“We know that, like other tools, once you get them into clinical practice, you can gather more data and get more information, and others can begin their own studies,” Munro says. “That’s what I am looking forward to because I am in amazement of how much interest there is in the Munro Scale, and I welcome the collaboration of everyone helping to make it ready for clinical use.” ✥



Agency for Healthcare Research and Quality. Pressure ulcer treatment strategies: Comparative effectiveness. May 8, 2013.

Centers for Medicare & Medicaid Services. Hospital-acquired conditions.

Mathias J. Use of refined protocols reduces pressure ulcer rates. OR Manager. 2013;29(12):1, 6-8.

Mathias J. New pressure ulcer risk tool moves forward with implementation study. OR Manager. 2014:30(7):20-21.

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