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Give Surgeons the Access They Need
Better exposure translates to faster and safer surgery.
Daniel Cook
Publish Date: December 20, 2013   |  Tags:   Patient Experience
patient positioning POSITION TO SUCCEED Spending a few extra minutes on positioning patients pays off in the end.

Proper patient positioning isn't just about preventing pressure injuries. "Patient safety is always the first priority, but you also have to realize that positioning needs to provide surgeons with optimal views of the surgical site," says Jay Bowers, BSN, RN, CNOR, TNCC, surgical services educator at West Virginia University Hospitals in Morgantown. "Focus on what will give the surgeon the optimal exposure they need to perform the procedure."

Easier, shorter, safer
Eric Crabtree, MD, says some surgical teams don't grasp the difference between good and limited surgical access. Dr. Crabtree, a staff anesthesiologist for Essentia Health and the Brainerd Lakes Surgery Center in Baxter, Minn., points out that proper patient positioning lets surgeons reach the operative area more effectively and with less strain, which helps speed cases along and, in turn, reduces complication risks associated with lengthier procedures.

Surgical teams sometimes settle for "good enough" when positioning patients. "If it's a straightforward case, that probably won't matter," says Dr. Crabtree. "But what if the procedure turns out to be a difficult one, as invariably happens?"

For example, consider what Dr. Crabtree sees as one of the biggest positioning challenges in the outpatient arena (followed, in his mind, by lithotomy for various GYN and urology procedures): the beach chair or lateral position for shoulder surgery.

Positioning patients for shoulder surgery is challenging because the surgeon operates in a tight space next to the patient's head and airway. "When you combine unnatural positions, limited surgical access space and concurrent comorbidities, risks don't become additive, they multiply," says Dr. Crabtree.

So what if the surgical team didn't focus on positing the patient properly? "Now the surgeon is dealing with a labral tear and has to get way down to the subcapsular zone," says Dr. Crabtree, "and would really appreciate having the patient turned a little more into the lateral position or slightly more upright in the beach."

heavier patients positioning CHALLENGING POPULATION Heavier patients present with unique positioning needs.

Prevent Pressure Injuries

When positioning patients for optimal surgical access, also take the time to ensure key pressure points are protected and padded. Here are positioning pointers for 4 commonly used positions from Jay Bowers, BSN, RN, CNOR, TNCC, surgical services educator at West Virginia University Hospitals in Morgantown.

  • Supine. This is the easiest position to place patients in, but don't ignore the importance of protecting pressure points. Place gel or foam pads under the ankles so the heels don't touch the bed and under the elbows to avoid skin breakdown.
  • Lateral. Pad under the down leg; place a support along the back from just under the arm to the top of the thigh to ensure the patient doesn't move mid-procedure; ensure the arm extended on the lateral armboard is padded correctly; place adequate padding between the legs; and ensure a safety strap secures the patient to the table.
  • Prone. Ensure female patients' breasts and male patients' testicles are not compromised. Pad underneath the knees and ensure the tops of the feet aren't touching the bed surface. Position the patient's head in a headrest that places no external pressure on the eyes or nose.
  • Lithotomy. Move the patient's legs up, out and into the stirrups slowly and simultaneously. Ensure the heels are adequately padded and the buttocks remain on the surgical surface.

When removing patients from stirrups, lift the legs simultaneously, bring them together, but lower them to the table one at a time so blood gradually drains from the legs instead of rushing back to the heart.

— Daniel Cook

But the patient's draped, and the surgical team groans at the hassle of adjusting the patient mid-procedure. "So they don't do anything," says Dr. Crabtree. "Now the surgery lasts an additional hour because the surgeon struggles to access the joint."

That's an important lesson: "Don't settle for inadequate positioning on the front end," says Dr. Crabtree. "It will probably work out, but it might not," he adds. "Commit to making positioning better, before every procedure."

Individual challenges
Everyone, including surgeons and anesthesia providers, must be actively involved in positioning patients — standing in the room while checking paperwork doesn't count. "Having more people involved increases the likelihood that the team won't settle, that someone will suggest the extra little movement or tweak that places the patient in perfect position," says Dr. Crabtree.

And constantly look for ways to improve your positioning practices, he suggests. "The way you've always done it isn't necessarily the best way, and it may not give you the best access," he says.

Assess patients' comorbidities, height and weight, and double-check that the required positioning equipment is available and operational so you don't end up canceling cases or pushing forward with suboptimal positioning.

Surgeons at WVUH note special positioning requests and positioning equipment needs on scheduling cards turned in to the surgical department 24 hours before cases. Surgeons, anesthesia providers and the nursing staff huddle each morning to review the surgical schedule and plan for special positioning equipment needs so staff isn't scrambling minutes before procedures are scheduled to start.

Even though surgeons prefer to use the same table frames or positioning aids for specific procedures, the days of operating on "typical" patients are over, says Mr. Bowers. "They aren't the same anymore," he explains. "Treat each patient as an individual with unique positioning needs."