Failed airways, OR fires and malignant hyperthermia episodes rarely happen, and yet I'd bet everyone in your facility knows how to respond to them at a moment's notice. So why doesn't the handling of patients, which happens countless times a day, get the same kind of attention? Let's look at ways to make 3 high-risk maneuvers safer.

1. Lifting and transferring
Unless you're operating on the stretcher that has rolled the patient into the OR, as some ophthalmic surgery centers do with convertible stretcher-chair tables, you'll need to transfer the patient to the surgical table. While a transfer presents some potential risks to the patient, who may be unable to assist or cooperate in the process, the staff carrying out the task must also guard themselves against injury.

• Know the risks. Friction is the primary danger to patients during transfer. Pulling or dragging a patient across bed sheets or other surfaces instead of lifting them or using a friction-reducing device can break the skin, leaving it vulnerable to infection. Make sure that the stretcher is braked and immobile, and that it is exactly level with the surgical table before making a slow, smooth move, supporting all body parts and maintaining proper alignment throughout.
• Use proper mechanics. As with any on-the-job lifting, exercise extreme caution while carrying out a transfer. Lower back and other muscular or neurospinal injuries are painful and potentially debilitating. They also do damage to your facility's efficiency, as productivity levels go down when medical absences leave you short-staffed. Instruct your staff on the importance of applying proper body mechanics at all times, whether they're lifting patients or equipment from the bottom shelf in the storage room. Bend down with your knees and lift with your legs, keeping your back straight. Move as close as you can to the patient or the object you're lifting to alleviate tension and strain on your back. Even when you're idle, such as standing to the side during a long case, occasionally shift your weight and change position.
• Ask for assistance. The importance of asking for help in lifting and transfers cannot be overstated. A lack of available staff to assist a nurse or tech in these tasks is a sign that the safety of your employees and patients is at risk. Ideally, you'll have adequate personnel to distribute strength around the patient, to support the head, the sides and arms, and the feet, during a lateral slide on or off a stretcher.
• Depend on devices. Many manufacturers offer lift- and transfer-assist devices in a range of costs and of varying complexity. Equipping your facility with these devices is an investment in your staff's safety, as long as your staffers let the equipment do the heavy lifting for them. Make sure the devices are used, and used properly, according to the manufacturers' directions. And, while speed and efficiency are goals of surgery, don't leave the transfer-assist device behind. I've seen it happen: A large patient is transferred to a stretcher with a board. Later, recovering from anesthesia in PACU, he asks for pain medication, complaining of back pain. The cause of the pain? A rigid board at his lower back, where the OR team left it.

2. Positioning
Patient positioning is critical for surgery, both in allowing the surgical team access to the patient and in preventing delayed injuries while the patient lies immobile on the OR table. A lot of factors go into determining how a patient will be positioned, including the surgical site; the necessary airway, IV and monitoring access; and the patient's physical limitations.

• Pad pressure points. Once positioned, the patient must be protected at the places that will support him during the course of the procedure, through padding beneath the back of the head, elbows, knees, heels and other pressure points. The weight of a patient's body, pressing it against an inadequately padded OR table, can restrict blood flow and subsequently oxygen delivery to the tissue at the body's pressure points, resulting in ischemia and pressure ulcers. Prolonged pressure on a patient's peripheral nerves can result in temporary or permanent damage to sensory or motor functions. Unattended areas of tension (such as beneath the knees when a patient is in supine position) can create muscle strain.

To prevent these injuries, use pillows or positioners to pad and support bony prominences and other sensitive areas. Overpadding is never a bad thing. It might not be any more helpful, but it won't do any harm. Stretchers and OR tables with the flexibility to adjust into a range of different positions and which accommodate attachments such as arm boards and headpieces are often able to support patients with less of a need for stacks of positioning devices. (Tables and stretchers with adjustable height are also ergonomically kind to surgeons and staff of different sizes.)

• Stay off drapes. During many orthopedic procedures, a patient's arm, leg or joint must be manipulated to test its range of motion and to compare the results of surgery to the intended goals. Most of the surgical team members, however, can't see the patient's body beneath the drape. So the responsibility falls to the circulator to check under the drapes and ensure that proper positioning is maintained following the intraoperative manipulations — to make sure the patients' arms are in place on the arm boards, for example — and to the anesthesia provider to ensure that the airway has not been disrupted. Intraoperative changes of position present a risk of shear forces, which can injure tissue when the skeletal structure moves but the skin doesn't.

Surgical drapes conceal what's on the table, which sometimes leads to a blurring of the line between the patient and the workspace that you're gathered around. Admit it: You've seen electrical cords, retractors, power tools and other instruments placed on top of a draped patient. You or your surgeons may even have leaned, rested, propped or wedged your bodies against the patient for stability and balance during surgery (without even realizing it). Over time, this, too, can cause pressure injuries.

3. Moving to PACU
Once surgery has been completed and it's time to take patients to the PACU, there are usually a few more details to handle carefully. While lifting and transferring patients from the OR table to the stretcher, and while positioning the patient for recovery, make sure you're supporting not just the patient's arms, legs and trunk, but also the IV line, Foley catheter, fixation device, splint or tension sutures now connected to the patient, so they remain in place. The anesthesia provider should maintain the airway and monitor vital signs during transfer and transport. Notify the PACU staff expecting the arrival in advance of any special handling considerations.

One for all
Flawed patient handling during the perioperative process can complicate patients' recoveries by creating skin and musculoskeletal injuries. It can also injure staff members who assist in the lifting and positioning of the patients. Individually and as a team, you must all be masters of your patients' — and your own — safety by integrating safe handling practices into your daily routines.