What you do in the few minutes you have to position a patient for surgery can have long-lasting consequences. Candy cane leg holders that wrap around the head of the fibula can compress the leg's peroneal nerve. Excessively abducted hips increase strain on the obturator nerve and can cause pain and adductor muscle dysfunction. Hip flexion increases pressure on the femoral and lateral femoral cutaneous nerves and can cause painful paresthesias. Here are six positioning pointers to apply at your facility.
Did You Know?
One-fourth of post-op pressure ulcers are OR-induced, and nerve injuries are the most devastating complication from positioning. They result when a nerve is compressed or over-stretched, resulting in ischemia. Radial nerve injury, one of the most frequently reported injuries, results when the patient's upper arm is compressed against the OR table. This can happen even when you use padding.
1 Hold a refresher course
Retrain staff through hands-on techniques once a year. See for yourself how your staff uses gel pads, donuts and chest rolls. "Even if you've had Positioning 101 and you've been an OR nurse for 20 years, you should go through annual competency training for patient positioning," says Suzy Scott-Williams, MSN, RN, CWOCN, a surgical QI research nurse at the U.S. Department of Veterans Affairs Medical Center in Memphis, Tenn.
Training is especially helpful for surgical positions that are difficult or could put the patient at a high risk for injuries, says Geraldine Johnson, clinical director at the University of Tennessee Medical Center in Knoxville, Tenn. "You can never do too much to remind your staff of the cautions you need to take when positioning," she says.
Focus not just on how to position the patient, but on how staff can avoid injuring themselves, says Cynthia Edgelow, MSN, RN, CGRN, endoscopy nurse program director at the Mayo Clinic in Scottsdale, Ariz. Bring in an ergonomics specialist to talk to your staff, she says.
While sand dolls are often used for training purposes, let your staff also play the role of patient. "That can give them more empathy about positioning the patient," says Ms. Scott-Williams. "They realize that, if they don't pull my arm up this way or if they don't pull my legs up together, that hurts."
This technique is especially helpful for endoscopy positioning, says Ms. Edgelow. Many times staff push harder than they have to on a co-worker's abdomen to straighten the colon.
2 Make the most of pre-assessments
The best practices for a patient positioning pre-assessment, according to AORN standards, include a perioperative interview to assess the patient's physical condition, an evaluation of the patient's skin integrity, and an awareness of the type and length of the procedure and the positions it will require. When you have this information, Ms. Scott-Williams says you can have a briefing with your surgeons and staff at which the team will assemble, discuss the procedure and determine what they'll need to make it happen. "This is a good time for them to make sure you have all you need to make the case go smoothly," she says.
For example, says Ms. Edgelow, if a colonoscopy patient has had a knee replacement, she suggests putting a pillow between his knees to support the knee and ankle joints.
3 Staff need strong cores
Staff need to be sure their bodies are properly aligned with the OR table or bed. Their cores where the movement from their hips, torsos and shoulders is directed should be at the same level as the table so they can move freely without leaning or stretching.
During an endoscopy the height of the bed or table is usually set for the physician so he can perform the procedure as easily as possible. The rest of the staff should have stools handy if they're shorter than the physician or be ready to widen their stances if they're taller than the physician to maintain proper body alignment and proper core height.
How the patient is put on the bed or table can affect how much reaching your staff has to do, says Ms. Edgelow. At her facility, endoscopy patients are placed in the middle of the bed and positioned on their left sides so they'll be within easy reach for the nurses.
4 Store your devices and pads
To keep staff from having to search for missing positioning devices, store similar positioning devices together. For example, keep all of the stirrups and pads for OB/GYN cases in one cart, which you should place near the ORs used for those procedures, says Ms. Johnson.
Ms. Johnson also has her positioning devices checked on an annual basis to ensure they're serviceable. "If something is in a high-usage area, it will eventually become worn and won't hold," she says. "You risk having a piece falling off or the whole device coming off and a patient's limb falling."
As for the pads and foam, Ms. Johnson says she has her staff examine them frequently. "Sometimes pads get micro-holes in them and absorb solutions," she says. "If a pad is heavy or feels like it's soggy, throw it away and get a new pad."
5 Buy enough of the right stuff
It's not enough to have pressure-relieving pads in all of your ORs. "You need to have it, be sure it's in working order and know that you have enough devices to meet your caseloads," says Ms. Scott-Williams. "You have to calculate your cases. If you're doing 10 GYN cases a day and you only have three boot-fit stirrups, it's time to get more."
If you're planning to expand your case volume, Ms. Scott-Williams says, it's important to look at what you'll need for the next year, the next five years and the next 10 years. This means you'll have to buy more supplies but not necessarily all new devices. "Remember that some positioning equipment is designed to last for 10 years or more," she says.
6 Invest in prevention
As you know, surgery patients are at risk of developing bedsores because they lie for hours in the same position, putting unrelieved pressure on certain points of the body. Since Medicare will cease paying for avoidable injuries such as pressure ulcers on Oct. 1, Ms. Scott-Williams says, buying cheaper equipment won't save you any money in the long run. "When you price out the cost of these items over the cases you do and the length of time for procedures, compared to what it costs to treat an ulcer or have a patient stay longer in addition to what it will cost when you don't get reimbursed and the cost of litigation it's clear that the best way is to invest in prevention," she says.
Features you should look for in products include:
- How well they redistribute weight. The old two-inch thick foam pads are simply not adequate for longer cases, says Ms. Scott-Williams, especially now that new products such as dolphin pads (pressure-relieving pads that mimic the natural buoyancy of water) can effectively redistribute pressure to prevent injuries. "We need to upgrade the minimal standard of care to a higher level of weight redistribution," she says.
- Safety and access. Some of the newer devices can make this less of a trade-off. One example is the hybrid-boot candy cane stirrup, says Ms. Scott-Williams, because it gives access to the surgical site as candy cane stirrups do without the increased risk of nerve damage associated with those devices.
- How easy they are to clean. When shopping for footpads, look for ones with surfaces that can be easily wiped, says Ms. Edgelow.
Remember, it's a team effort
Your staff should be comfortable asking for help during a procedure, particularly if the patient is overweight. "They need to know that it's OK to say, ???Hey, I need help to position this patient because I can't do it myself,'" says Ms. Edgelow.