It can be pressure against a nerve from an unpadded stirrup, an unintended slide that causes a burn or a sedentary patient's ulcer that develops into an infection. Whatever the reason, less-than-perfect patient positioning can cause post-op pain that's worse than a tender surgical site. Even though positioning techniques and products have evolved over the years, there's still slim data to support what we accept to be the best practices. Keeping in mind that proper patient positioning is both a science and an art, here's advice on formulating the best patient positioning practices for your facility.

Think about blood flow
A positioning device's most important feature is its ability to redistribute pressure and maintain proper body alignment. The standard OR pad - foam, usually one to two inches thick, and covered with black conductive laminated vinyl fabric - can raise the risk of pressure ulcers in surgical patients. Select products that maintain adequate capillary blood flow to tissues and nerves. Before you buy, look for clinical evidence that the product won't interfere with circulation as it provides stability. Also be sure it meets certain weight requirements in addition to being durable and cost effective.

Use devices that redistribute pressure
Look at the devices' ability to redistribute pressure and maintain proper body alignment without stretching the nerves. Avoid practices or devices that can cause injury, such as tight safety restraints, candy cane stirrups or shoulder braces. Avoid towel rolls, sheets, IV bags or sandbags because these devices aren't intended to redistribute pressure and may decrease circulation to the affected area.

Assess, assess and reassess
The best practices for patient assessment include a thorough pre-op interview to evaluate the patient's physical condition, skin integrity, the type and length of procedure, the position required, and any other limitations or concerns. Keeping the appropriate and properly functioning positioning devices on hand can prevent delays during the procedure. The perioperative staff should be versed in the potential problems associated with certain high-risk positions, such as lithotomy, prone and Trendelenburg, so they can spot and prevent them.

It's equally important for you to assess your environment and your unique patient demographic to determine your equipment needs. Every facility has its own concerns that will require individualized solutions. Facilities that perform neurosurgical, vascular or cardiac procedures should invest heavily in technology to promote patient safety.

Train your staff well
Investing in your perioperative staff's continuing education now can prevent a devastating nerve injury or pressure ulcer later. High-tech equipment is great, but your staff's knowledge of the effects of posture on each body system, primarily the respiratory, circulatory, musculoskeletal, integument and nervous systems, is essential for proper positioning.

The training should emphasize a thorough review of anatomy and physiology and the effects of each position. Some experts suggest that staff should practice difficult positioning scenarios on each other to simulate the patient experience. This gives you a chance to reinforce any procedural cautions and emphasize any possible contradictions to avoid positioning errors in the OR. Let end users have primary input into selection, trial and purchase of equipment including transfer devices.

Create a quality management program
At present there are no reliable published statistical data on the incidence of positioning complications, but litigation and personal accounts of injury seem to be rising. This puts the burden on you to find out how effective your methods are in preventing patient positioning problems. The best way to do this is to see if the devices and training are actually reducing injuries. Tracking and trending post-op complications can show you what the common problems are. From there, you can review the processes of care and conduct a root cause analysis to identify what, how and why something happened.

A comfortable future
No one will argue that properly positioning patients is vital, but identifying research-based best practices is a real issue. The techniques are constantly evolving as technology gives us new options. Whatever the future holds, keeping your staff educated and evaluating your own competencies will always be the best ways to minimize these post-operative problems.

Action Products
Patient Positioners
(800) 228-7763
www.actionproducts.com
Price: $54 for small, $64 for large, $76 for extra long
FYI: These three versatile positioners give you a more comfortable alternative to sandbags, says Action. They can be used for any procedure, especially for tracheotomy, thyroidectomy, tonsil and adenoid cases and cataract surgery.

AliMed, Inc.
Kirschenbaum Footrest
(800) 225-2610
www.alimed.com
Price: $300
FYI: The Kirschenbaum Footrest is designed to offer more stability than sandbags during knee surgery, says AliMed. The dome shape makes it easier to reach the foot and keep the limb stable. It can be used under the drape by attaching it to a standard side rail socket (sold separately) or sterilized and used over the drape.

Allen Medical Systems
Advanced Spinal Surgery Table
(800) 433-5774 or (978) 263-7727
www.allenmedical.com
Price: $35,000 for a complete system
FYI: The Allen Spinal System attaches to your existing operating table to give you more freedom when positioning patients for a discentomy, laminectomy or other back procedures. The carbon fiber frame provides unhindered C-arm access; the wing sets and C-Prone head positioner are designed to manage skin pressure and can be adjusted for a customized fit for each patient, says Allen. To move the patient in the right position, you can adjust the table so the patient is set in kyphosis or lordosis intraoperatively.

Contour Fabricators, Inc.
Deluxe Kit for Patient Positioning
(810) 750-5300
www.contourfab.com
Price: $146.79
FYI: The Deluxe Kit for Patient Positioning comes with all the odds and ends you might need for any given surgical procedure, says Contour. It includes three sizes of wedges, a circular disc, a cylinder, a decubitus block, a thin mattress and a table pad to accommodate smaller patient positioning situations.

ConMed Patient Care
AirSoft Positioning Devices
(800) 448-6506
www.conmed.com
Price: Not disclosed
FYI: The AirSoft Positioning Devices meet AORN recommended practices for positioners as well as all federal guidelines and fire codes, says ConMed. They're also resistant to stains, urine, Betadine and blood, and come with a 12-month warranty. The full line is designed to fit into a wheeled storage cart (sold separately) for easy organization.

Cygnus Medical
Universal Pads
(800) 990-7489, ex. 110
www.cygnusmedical.com
Price: Not disclosed
FYI: The new AirFlow Positioning Aids use contoured channels to create greater airflow and patient comfort. These provide an effective and economical solution for safe patient alignment and support during surgery, because the unique product prevents pressure sores and nerve and ligament damage while the patient is under anesthesia, says Cygnus Medical. The Cygnus positioning products are non-latex, non-toxic and fire retardant.

David Scott Company
Static-Free Patient Transfer Boards
800-804-0333
www.bdgel.com
Price: Not disclosed
FYI: The new static-free Patient Transfer Boards from David Scott Company are lightweight and radiolucent. They're constructed with a protective coating to prevent patients from sticking to the mover during transfers from one bed to the next, says the company. These boards are only available in white and in two sizes: 33in. by 22in. and 72in. by 22in.

HoverTech International
Heat-Sealed HoverMatt
(800) 471-2776
www.hovermatt.com
Price: Not disclosed
FYI: The inflatable HoverMatt, heat-sealed to prevent infections, is designed to cradle patients for comfort. Repositioning the patient is as simple as inflating or deflating the device until they are at the right level, says HoverTech, and it comes with straps to help secure the limbs and head into place.

Innomed, Inc.
Assistant Free Robb Leg Positioner
(860) 793-0391
or (800) 467-4944
www.innovativemedical.com
Price: Not disclosed
FYI: The Robb Leg Positioner's slotted base lets you easily flex or extend the leg and rotate the foot during knee surgery, says Innomed. It comes with a sterilizable table clamp that fits over the drape to the OR table's side bar for a secure mounting.

Mercury Medical
Troop Elevation Pillow Addition
(800) 237-6418
www.mercurymed.com
Price: $148.10 per box of two disposable additions; $262 for the reusable vinyl covered addition
FYI: This wedge-shaped positioner is designed to be put on top of the Troop Elevation Pillow and then have a head cradle or standard intubating pillow placed on top of the flat/plateau part of it, says Mercury. This combination positions the morbidly obese patient (those weighing 450 to 500 pounds with a BMI greater than 50) in the head-elevated laryngoscopy position.

OR Comfort, LLC
Shoulder-Float
(973) 239-1950
www.orcomfort.com
Price: $128 for a box of five and $256 for a box of 10
FYI: The Shoulder-Float is designed to position patients for lateral decubitus surgeries such as shoulder arthroscopy and epidural anesthesiology, says OR Comfort. This device lets nurses raise or lower patients without lifting or moving them by inflating the pillow with a squeeze bulb and altering the pressure as necessary with a three-way adjustable stopcock.

Steris Corporation
Cmax Shoulder Chair
(440) 354-2600
www.steris.com
Price: $8,865 for the full package; $7,400 for the chair alone
FYI: The Cmax Shoulder Chair puts the patient in the perfect position for open or arthroscopic procedures, says Steris. It features a multi-axis head positioning capability including roll, pitch and yaw axes that make intubation and posturing easy. The powered back section inclines back 90 degrees and the removable shoulder panels give excellent access to each shoulder, says the company.

Tenet Medical Engineering
T-MAX
(403) 571-0750
www.tenetmedical.com
Price: Not disclosed
FYI: The Tenet Maximum Exposure Shoulder Position-er, or T-MAX, gives excellent adjustability and stability for beach chair shoulder procedures, says Tenet. Its fully adjustable head positioning system provides neutral head and neck positioning while side lateral supports hold the patient snugly in place.

Valley Technology, Inc.
Cloud 9 Medical Gel Products
(888) 246-1606
www.valleytechnology.com
Price: $29 to $268
FYI: Cloud 9 Medical Gel Products are made from viscoelastic polymer gel and are very elastic so they always return to their original shape after heavy pressure or impact, says Valley Technology. They don't absorb fluids or odor, don't conduct heat or electricity and are easy to clean, adds the company.

Xodus Medical
Gel Positioning Products
(800) 963-8776
www.xodusmedical.com
Price: $47.06 to $469.01
FYI: Xodus Medical offers a line of gel positioning products for all areas, ranging from prone head rests to heel protectors and including pads for every part of the OR table. These pads are soft, durable and comfortable, and are bar-coded to make inventory management easier, says the company.