DUAL GOALS Good patient positioning maintains the patient's safety while allowing access to the surgical site.

Try this sometime: Lie down on an OR bed and you'll get a sense of how a patient feels in different positions. If it hurts to hyperextend your arms more than 90 degrees, imagine the jolt to an anesthetized patient who can't speak up. The prolonged pressure and shear force of improper positioning can seriously hurt your patients, even in short procedures. Here are 7 tips to avoid loss of circulation and such deep tissue injuries as pressure ulcers and nerve compression that can result from poor positioning.

1. Let staff feel what patients feel
Simulating patients' experiences often serves as a powerful teacher. That's why Jay Bowers, BSN, RN, TNCC, clinical coordinator at West Virginia University Hospitals in Morgantown, W.Va., launched a one-day class for new hires more than a decade ago — after observing the consequences of incorrect positioning. "If we train our employees what the patients are feeling in these positions, that's a great start in preventing positioning injuries," says Mr. Bowers.

Maintaining a patient's body alignment and routinely modifying the positioning are central elements in safe OR practice. Think of it as striking a balance between providing optimal access to the surgical site and controlling airway management and ventilation while limiting unnecessary exposure.

2. Perform a careful pre-op assessment
A thorough pre-operative assessment should precede any positioning maneuvers. In examining a patient's skin for signs of frailty, it's also prudent to inquire about limitations in mobility. "I can't emphasize enough to my nurses how important it is to not cut corners on positioning," says Brent Klev, MBA, BSN, RN, nursing manager at the University of Utah Health Care's South Jordan Health Center in South Jordan, Utah.

Sometimes positioning concerns force you to consider an alternative surgical approach. Hyperextending the arms upright for 2 or 3 hours poses a risk of injury to the brachial plexus — the nerve network that controls movement of the shoulder, arm and hand, says Marichi Capino, MD, MSN, RN, quality and safety manager for the John Hopkins Home Care Group and Pediatrics at Home Support. Because an injury can occur with either overextension or compression of these nerves, surgical protocols have evolved accordingly. Take thyroid surgery, for example. In transaxillary robotic thyroidectomies, there've been reports of neuropraxias when the patient straightens and extends the arm that's on the same side as the target thyroid lobe above his head. To avoid such injuries, some surgeons have revisited the more conventional incision through the neck, wherein the patient lies supine with both arms at his sides, says Dr. Capino. Others have modified the positioning for the robotic procedure so that the patient flexes his extended arm about 90 ? at the elbow with the forearm resting over the forehead. Still other facilities no longer perform the procedure.

HYPEREXTENSION Take care to place limbs in a natural, relaxed position and to provide adequate padding and fixation.

3. Transfer with care
It pays to be extra careful when you transfer or position a patient. Pulling a patient across a stationary surface can cause shearing or friction. "Anytime you move somebody, always do it with the natural range of motion of the patient," says Mr. Klev, "so you're not overextending an arm or leg that doesn't rotate that way naturally."

Collaboration among surgeons, nurses and anesthesiologists is vital in preventing patient transfer mishaps. When it comes to lifting patients, be sure to enlist the help of an adequate number of personnel. Teamwork helps prevent injuries among staff, and it reduces the risk of accidentally dropping a patient.

Some frown upon moving patients the traditional heave-ho way altogether. "We shouldn't be manually lifting patients anymore because of back injuries to the employee," says Mr. Bowers. "We should be using devices that help move the patients more safely and accurately." If a patient's weight exceeds 200 pounds, Mr. Bowers recommends an air-powered mover to assist in transitioning from a stretcher to an OR bed and then back to the stretcher after surgery.

4. Secure patients to the table
Leg and waist straps also help avert positioning mishaps. The patient's weight and position on the OR table should guide you in deciding the type and number of belts to secure the patient to the table, but constant oversight is still necessary, says Dr. Capino. A patient in Trendelenburg can roll off the table during prepping, she cautions. Designate an employee to monitor who removes and replaces the straps, especially during repositioning.

5. Use pads wisely
Proper padding is essential, too, says Dr. Capino. For example, in cervical surgeries (both supine and prone), place pads between the elbow pit and wrist, making sure not to compress them or hyperextend them during positioning, she says. An obese patient placed in a prone position requires more padding on his belly, chest and knees (which must be slightly flexed). In long surgeries requiring the lumbar position, a pressure ulcer may develop if you neglect to pad a woman's breasts or a man's pelvis.

Nurse managers may differ in their preferences for memory foam or gel foam content in mattresses on OR tables. Whichever product you choose, it's important to follow the manufacturer's recommendations. For surgeries lasting more than 3 hours, Mr. Bowers's staff uses memory foam mattresses. He's working toward outfitting all the OR beds with these costly mattresses. "It's what should be done for all patients," he says, "so we're trying to get there."

No matter which OR bed is in use, preventive dressings on pressure points provide some cushioning. "You want to make sure you're protecting those areas," says Mr. Bowers. For a patient in the supine position, the dressings should be placed on the buttocks, heels, elbows, and the back of the head.

Gel cushioning has advantages over foam, says Mary Grace Hensell, RN, BSN, MSN, CNOR, director of surgical services at Allegheny General Hospital in Pittsburgh, Pa. She has found that gel offers higher density than foam for better patient positioning and skin protection in most cases.

Ms. Hensell also has seen personnel roll up a blanket or a sheet as a means of hyperextending a patient's leg or neck, allowing optimal visualization of the surgical site. She cautions against using any product for a purpose other than the manufacturer's design. Neither a blanket nor a sheet offers pressure reduction. Using either one "sets nurses up for failure in protection and may impose a liability."

6. Form a skin integrity team
The best defense against inappropriate use? As surgeries become more complex, Ms. Hensell recommends convening a committee to continuously evaluate products intended to help prevent injuries.

Forming a skin integrity team is another approach to foster safe patient positioning. Ideally, the team would consist of nurses in various roles — from wound care to front-line staff, as well as floor nurses who collect data post-operatively, says Ms. Hensell, who is in the process of assembling such a team.

Because pressure ulcers tend to appear 1 to 5 days after surgery, too often they're attributed to the floor nursing staff, whereas the more likely culprit is deep pressure applied in the operating room, she says. A dressing can be left in for as long as 5 days after the procedure and is very helpful in preventing ulcers on the heels or buttocks.

7. Protect elderly patients
Despite your diligence, acuities and comorbidities tend to escalate along the age spectrum. Be on the lookout for fragile skin, which is more common in the elderly. If it's thin or you notice bandages or skin tears, those are red flags for potential injuries, says Mr. Klev. It's also better to err on the side of asking too many questions rather than not asking enough questions. Before any procedure, he suggests inquiring: Have you had any joint or back surgeries? Do you feel any pain in those areas? And do you currently have open sores? With safe practices, elderly patients tolerate positioning in the OR well. Earlier this year, Mr. Klev recalls, a 95-year-old female patient successfully underwent a Mohs repair for skin cancer without incurring any injuries or pressure sores.

If it isn't written
And don't forget to document anything and everything. The medical record should include the patient's positioning, the names and roles of personnel in the OR, the specific positioning aids that were used, and where they were placed. With so much multitasking underway, says Dr. Capino, never underestimate the importance of detailed documentation.

Documentation of safe positioning helps ensure optimal standards for a patient, Ms. Hensell says, adding that it's "critical in determining if products work and if the injury occurred in the OR." OSM