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.
Supine Positioning Kit
Price: less than $500
FYI: Action's four-product Supine Positioning Kit offers critical point coverage where patients need it most: the head, elbows and heels, the company says. Effective, reusable and easy to maintain, Action says the polymer donut head pad, ulnar protectors, heel protectors and multi-use dome positioner help prevent pressure and shear.
Phat Pad Head Donut
Price: $80 for adult, $65 for pediatric
FYI: Made from soft, non-sticky, self-contained gel, the Phat Pad Donut demonstrates superior pressure relief, even if struck by a scalpel, run over by a cart or washed in the laundry, the company says. Its bright color prevents loss or accidental disposal and its durability is backed up by a lifetime warranty.
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."
Allen Medical Systems
Siegel Mast Intraoperative Leg Positioner
FYI: The Siegel Mast Intraoperative Leg Positioner, an addition to Allen's family of knee, shoulder, wrist and elbow positioning devices, lets surgeons place a patient's leg in extension, flexion, hyperflexion, valgus and figure-four positions for knee surgery while freeing the OR staff from having to hold the leg manually, the company says. An ergonomic unlocking lever allows easy repositioning and automatic locking in place.
CFI Medical Solutions
Carbon Fiber Armboard, Mounting and Pad System
Price: $800 to $1,200 for complete system
FYI: CFI's Carbon Fiber Armboard can be customized to fit any surgical table design, the company says. Carbon fiber offers radiolucency, structural strength and minimal weight, and armboard pads are available in Ultrafoam for firm support or memory foam for patient comfort.
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.
David Scott Co.
Blue Diamond Bean Bag Positioners
Price: $165 to $365 each
FYI: Available in various sizes, Blue Diamond Bean Bag positioners are made of durable, pliable, stain-resistant black urethane, and can be obtained with gel overlays, the company says. The valve system is replaceable if compromised; replacement costs only $25 and the repaired product is shipped back the same day.
PurGel Head Donut
FYI: Gaymar's line of PurGel products assist in proper positioning and stabilization of patients in the OR, as well as minimizing the effects of pressure during surgery by redistributing the tissue load over bony prominences, the company says. The head donut (pictured) cradles the head in all positions and can be used in most procedures.
FYI: The Nicholson Headrest provides patient support and positioning for arthroscopic and open shoulder surgery in the beach chair position, the company says. It can be used with standard OR tables without modifications and is quickly placed and adjusted. An optional gel pad forehead strap is included.
Innovative Medical Products
Turnstile Casting Stand
Price: $685 for folding, $590 for non-folding
FYI: The Turnstile Casting Stand maintains appropriate foot and ankle positioning while applying short leg casts. The company says its efficient design can actually increase productivity by providing for better patient compliance. Available in both a folding and non-folding model for quick setup and storage.
Medical Products Resource
Standard Profile Leg Holder
FYI: Combining a stainless steel frame with a foam insert, the Leg Holder eliminates leg rotation by providing quadrilateral support to any size thigh during open or arthroscopic surgery, the company says. Leg manipulation is made easier, which enhances joint visualization and improves instrument access to the knee.
Troop Elevation Pillow
FYI: The Troop Elevation Pillow is a better approach to airway management for morbidly obese and large-framed patients, the company says. The solid foam, single-use pillow raises the patient's head and upper airway above their chest and abdomen to improve ease of breathing, replacing an unstable stack of blankets.
"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."
Olympic Medical Corporation
Price: $192.50 to $559.50, depending on size
FYI: Vac-Pac Positioners mold to a patient's shape, holding them securely in place during surgery, the company says. Each positioner is filled with thousands of tiny plastic beads and becomes firm when suction is applied. The size 38 Vac-Pac (pictured) positions the patient's shoulder for arthroscopic or open surgery.
Z-Flo Fluidized Positioners
Price: rents from $5 per day
FYI: Z-Flo Fluidized Positioners blend support and contouring to achieve the best possible therapeutic result, the company says. Z-Flo lets you customize positioning treatment, and helps positioning needs without the friction or shear associated with foam and gel devices.
Tenet Medical Engineering
Spider Limb Positioner
Price: $9,000 to $10,000
FYI: The Spider Limb Positioner, distributed globally by Smith and Nephew Endoscopy, combines strength and flexibility to provide optimal intraoperative positioning for upper-extremity procedures, the company says, making it the ultimate solution for limb positioning.
Epidural Positioning Device
FYI: The Epidural Positioning Device lets you position patients safely and comfortably for placement of epidural catheters, the company says. Its innovative design ensures that even sedated patients will remain secure and stable during a procedure, freeing nurses to perform other duties.
Xodus Gel Pads
Price: $40 to $400
FYI: Xodus Gel Pads' wide variety of shapes and sizes effectively meet any OR positioning or padding challenge, the company says. Fluid- and odor-resistant, the pads can be washed with standard detergents and disinfectants. The pads are radiolucent to allow use during patient imaging and are bar-coded to assist in inventory management.