Positioning Patients for Surgical Success

Pressure injury prevention in an outpatient setting requires vigilance against complacency.

The risk of pressure injuries (PIs) may not be as obvious during outpatient surgeries, but they do exist. Outpatient facilities tend to deal with healthier patients and shorter surgeries, so while the risk of PIs is lower, it’s still very real. Before you position a patient for surgery, a lot of preventative work must be done to prevent PIs.

Risk factors

A patient’s basic risk factors for PIs apply regardless of inpatient or outpatient status: BMI, comorbidities, length of surgery, nutritional deficits and other factors, says Heather J. Carlisle, DNP, RN, CNOR, director of perioperative services at Baylor Scott & White Medical Center – Centennial in Frisco, Texas. She warns, however, that staff at outpatient facilities can develop a false sense of security due to their assumptions about reduced PI risks.

Deep PIs may not appear for as long as 14 days after surgery, so outpatient nurses may never be aware of PIs their patients developed. “The research shows that when nurses are more aware, they change their behavior even without being told to,” says Dr. Carlisle. “If they never hear about injuries that happened, they have no reason to question procedures that appear to be working.”

Prevention protocols

PI risk reduction begins well before patients enter the OR. Lisa A. Peterson, MSN, RN, CNOR, clinical nurse III at UC Davis Health in Sacramento, Calif., says it starts with a thorough and well-documented skin assessment in pre-op.

Documentation should be detailed, especially if a different nurse will handle the patient post-op. “You can palpate the skin, but if two nurses handle pre-op and post-op, they can’t easily compare if the skin is reacting differently,” says Ms. Peterson. Her facility’s protocols include asking patients for any skin conditions they have and using routine patient interactions during prep, such as untying their gowns for them, as opportunities to assess their skin.

Finding the right assessment protocol is crucial. The Scott Triggers Tool often fits nicely into the workflow of busy outpatient facilities. It’s a series of yes/no questions, with two or more “yes” answers indicating higher PI risk, says Dr. Carlisle. The Munro Scale is another option, but she warns that it’s a bit more complicated because it includes steps in the pre-, intra-, and post-op phases. Surgery center settings focus on quick turnovers, but proper pressure offloading requires some extra time.

Dr. Carlisle recommends leaning on technology and role-reversal exercises to drive home the fundamentals. Phone apps that walk them step by step through the pressure points where patients might need protection, for example, are especially helpful for newer nurses. Also, Dr. Carlisle recommends having nurses position each other as a training exercise, which allows them to experience first-hand what the pressure points feel like. “Ongoing education is key because anyone can get into a bad habit,” she says.

Positioning devices not created equal

Some positioning devices provide surgeons and anesthesiologists better access to the surgical site, while others increase patient comfort and safety, prevent potential nerve damage or keep airways and circulatory systems open throughout the procedure.

Some examples: Patients’ legs can be inserted into straps attached to a pole that keeps the thigh above the knee during knee surgery. Triangular, tubular and quarter-circle shaped positioners can be placed under the patient’s knee to improve surgeon access. Table attachments available include headrests, restraint straps, foot extensions, arm boards and arm supports.

Each surgical position has different critical pressure points that require different strategies to reduce peak pressures. Choosing the right positioning devices for your center isn’t always straightforward.

“Outpatient facilities can be limited by having low-tech prevention tools,” says Dr. Carlisle. “They’re less likely to have state-of-the-art mattresses that do pressure alternating and pressure mapping. It’s more likely to be a standard mattress and some pink foam or pads.”

Some of the newest, most effective — and more expensive — tools include pressure-altering mattresses with micro movement. “The movement is so smooth surgeons can’t detect it even when using microscopes during spinal surgeries,” says Dr. Carlisle. Another example is a pressure-mapping topper upon which patients are placed that provides real-time readings of pressure on various parts of the body.

Facilities that can’t access this pricier new equipment can still provide excellent patient experiences, however, using basic positioning equipment, says Ms. Peterson. “Utilize what your facility has while evaluating the new tech that is out there and what might work best for your facility and its specific needs,” she says, noting that vendors are constantly improving these products. “Keep up with them and evaluate which products are effective and realistic in terms of cost.”

In general, Ms. Peterson recommends static air cushions for distributing pressure and seat cushions to provide more support without risking the patient falling off the table. Dr. Carlisle recommends a five-layer silicone dressing with sticky backing that can be applied on pressure points preoperatively.

She advises teams to make sure the OR mattress is replaced every so often to ensure it reduces pressure at the rated level and that foam padding hasn’t bottomed out.

Ms. Peterson says simply making pressure offloading devices accessible to nurses is important. “You’d be surprised how often they get buried in storage or the facility culture isn’t prone to using them,” she says. “When that happens, they won’t be used.”

The importance of postoperative care

The PACU is where nurses should provide vital information to patients and their caregivers to monitor skin conditions at home during recovery.

“Look for reduced blanching, redness or swelling in the area, and skin breakthrough or bleeding,” says Dr. Carlisle. “Keep in mind, you won’t see that with deep tissue injuries.” If patients complain of any pain, even without signs of a wound, be wary of dismissing it, as it may be the first sign of a PI.

“This is where the pre-op notes and assessment are so important,” says Ms. Peterson. “With a good assessment, you know where to look for discoloration, or if an abnormality in skin tone was there before the procedure or not.”

Same-day surgery patients are often not seen again by providers for several days, and most patients and their caregivers likely aren’t thinking about PI risks. “You need to give them education that a PI can happen, what to look for, and if they are at higher risk, but you don’t want to alarm them or send them off Googling stuff,” says Dr. Carlisle.

When PIs do occur, surgeons must communicate it to the nursing staff. “Otherwise, unless you’re directly involved with a patient who had an incident, you may never hear about it,” says Ms. Peterson.

Dr. Carlisle says surgeons should inform nurses within two weeks of surgery when a patient develops a PI. “You can’t learn and improve if you don’t know there’s an issue,” she notes. OSM