Safe and comfortable positioning is a surgical necessity common to every case and every patient. With so many OR table accessories, positioners and padding products on the market today, selecting the right devices for your OR requires some consideration. Here's advice for choosing positioning equipment.

The importance of positioning
Patient positioning devices serve two purposes. They aid the surgical team in maintaining patients in the desired posture and they help reduce the pressure that the position and anesthesia produce on specific areas of the body.

They can also offer a staffing advantage in the OR by freeing up hands. Says Jason Krieser, director of marketing and new product development for Allen Medical Systems: "A lot of times, doctors and nurses are the positioning devices."

The key factors in choosing positioning devices are always patient safety and how they can make an operation more efficient in terms of saving time or staffing costs, says Ken Moore, president of Tenet Medical Engineering in Calgary, Canada.

In their book Positioning in Anesthesia and Surgery, John Martin, MD, and Mark Warner, MD, describe patient positioning as "a contest of varying degree between what the surgeon properly requires for access to the surgical site, and what the patient can tolerate."

The contest is a team effort between the surgeon, the anesthesiologist and the nursing staff, says Robert B. Dybec, RN, MS, CPSN, CNOR, the nurse manager for Winthrop-University Hospital in Mineola, N.Y. "Safe positioning will let the procedure be done without compromising the patient's airway and anesthesia process, or negatively affecting their bodily systems," says Mr. Dybec.

The primary risk associated with inadequate positioning is the development of pressure ulcers. Although all patients are at risk for pressure injuries, it has been reported that the two most important considerations are the patient's age - elderly patients tend to be more susceptible - and the length of time that the patient is on the OR table, since skin cells can begin to break down within two hours.

Obese and diabetic patients are also at high risk of pressure injuries, says Scott Sepinuck of Framingham, Mass.-based equipment manufacturer David Scott Co. "And once they happen, they're very expensive to treat and difficult to heal," he says.

"The use of adequate padding on the operating table will reduce significantly the risk of skin breakdown and pressure ulcer development," says Mr. Dybec. He cites an article in the May 2005 AORN Journal that found that viscoelastic polymer, or gel, overlays were most effective in the reduction of pressure ulcers.

"Gel acts like an extra layer of fatty tissue," says Mr. Sepinuck. "It potentially delays the onset of a pressure sore."

While the report found that alternating pressure mattresses are slightly effective, it noted that foam products - such as standard OR table mattresses - were relatively ineffective in reducing injury risks, and in one case study, foam actually resulted in more pressure ulcers.

"AORN recommends that padding and positioning devices used in the OR maintain a normal capillary interface pressure of 32mm Hg or less," says Mr. Dybec. "Pressure greater than this will cause capillaries in the skin to occlude, resulting in skin breakdown."

Foam products also raise economic questions, he notes. While they're easily accessible and extremely inexpensive per unit, you must keep the reusable-versus disposable debate in mind. You may be surprised that the difference in cost may be negligible when comparing the quantity of single-use products used, and the resulting waste disposal fees, to the overall expense of a similar reusable product, says Mr. Dybec.

Padding and placement
Chest rolls, head donuts and other padding products similarly need to relieve and reduce pressure to avoid intraoperative skin breakdown. The head, elbows, shoulders, heels and possibly even the hips are particularly critical areas, says Michael Holloway, the president of Medical Products Resource in Minneapolis, Minn. "Protective tissue is minimal over these bony prominences," he says.

In addition to the relatively simple concept of padding, positioning for surgical access is a growing trend. Specialized devices that attach to your OR table can hold a patient's arm, leg, head or body in place. These so-called patient positioning accessories, particularly useful in orthopedic cases, let surgeons easily manipulate patients' bodies during surgery to improve access to the surgical site.

"The disposable pads, rolls and donuts tend to be more generic for a multitude of procedures," says Mr. Krieser. "Many of the items that we sell are more procedure-specific."

With positioning devices, it's the ease of using them that's important, says Mr. Holloway. "The OR staff is overwhelmed with so many things. If something is too complicated, or they're not working with it on a daily basis, or they forget how to use it, that affects patient safety," he says.

The device may make holding a patient in place easier, but the patient's comfort must still be accounted for, even in the smallest details. Make sure that you don't have draping material creased against the skin, says Mr. Holloway.

Check with the manufacturer to see if positioning and padding devices provide recommended pressure relief and ask for research and documents that support the results clinically, suggests Mr. Dybec.

If you're planning to purchase a reusable product, keep infection control in mind. "Find out how you're going to clean it, if you have a lot of patients," adds Stephanie Checchi, associate product manager for AliMed. "It'll save time if it's easy to wipe clean, and doesn't trap any dirt."

Finally, listen to your surgeons and staff. "Nurses have a lot more influence over padding choices, while positioning device selection is pretty much driven by the surgeon," says Mr. Moore. "But any case that the surgeon's in on, he'll want to make sure that there aren't any pressure issues. He is ultimately responsible."