Perfecting the Prone Position

We place many of our neuro patients in the prone position. Until recently, we were also re-positioning them in the prone position. Quite a bit. Not good. The more you move patients in prone, the more likely they'll suffer the adverse effects of poor positioning — post-op pain, brachial-plexus injuries to the shoulders, arms and hands, and, of course, skin breakdown and pressure ulcers.

In an effort to prevent this needless suffering, we took a step back and asked ourselves, "What are we doing wrong and how can we fix it?" What we came up with was a methodical, team-based system for preventing prone positioning injuries that you can apply to all types of surgical positioning. Here's a detailed breakdown of our approach.

Our positioning process starts long before we flip our patients over from the stretcher onto the OSI table with a Jackson frame we use for procedures that require prone positioning. Prior to surgery, our nursing staff meets with all patients in a staging area — one of the 22 holding rooms located adjacent to our 24 ORs — to find out any limitations or restrictions that may affect the patient's positioning. Individuals with high BMI are at a greater risk for injuries, especially pressure ulcers, because they put more weight and pressure on their pressure points during surgery. In general, the heavier the patient, the greater the pressure. And the greater the pressure, the shorter the time period the patient can endure the procedure. That's why it's so critical to get the positioning right from the start.

When patients enter the staging area pre-surgery, we're looking for any type of apparent skin tears or redness that we need to make our entire OR team aware of before surgery. Again, we're extra careful with those high BMI patients, where we double-check for tiny tears underneath areas like the panniculus or under the breasts.

While we obviously know about patients' past shoulder or neck surgeries, we get into the specifics about their range of motion during this consult. We use this pre-op patient meeting to find out things that wouldn't necessarily show up in their EMR by asking questions like Do you have any — even very minimal — shoulder or neck pain?

The info we get via observation and consultation helps, but demonstration is paramount to our positioning success. Before every procedure in which patients will be in the prone position, we ask them to demonstrate how they'll hold their arms during surgery. Patients must be comfortable extending both of their arms into right angles. If there's any pain or discomfort that could potentially lead to problems during the surgery, we learn about it during this demonstration phase and note it for our team.

Before we changed things up, our positioning method was like an orchestra where each musical section played a different song. The anesthesia team would be adjusting the patient's head while the nursing team fiddled with the hip pads and the doctor worried about something else entirely. Yes, everybody was doing their part, but they weren't doing it together. Result: A whole lot of unnecessary readjustments and, in too many cases, skin tears.

Then we changed our process so everyone is on the same page at the same time, and now our team is as in synch as the London Symphony Orchestra. The new approach starts at the patient's head and moves down step by step to the feet to ensure everything is anatomically correct. Anesthesia goes first to make sure everything is in position (Is the vent good? Are the eyes good?) because you can't proceed to the next step if the airway isn't secured. Once anesthesia does its thing, our RN and RNA will check the head to ensure that it's properly positioned and safe for the patient to remain in for up to several hours. We follow the same anesthesia-nursing 1-2 check for each of the patient's remaining pressure points — the neck, shoulders, arms, chest, hips and knees and, finally, the feet. Once we get through the initial check and make any glaring adjustments (left arm noticeably different than the right, for example), we start our final checklist. Again, we do this from the same spot in the very same way with each patient.

From the foot of the bed, everybody (nurses, doctors, anesthesia, techs) will do one last check — this time from feet to head — to make sure the patient is properly positioned. As we move up, our team will look to answer questions like Are the hips level or is one slightly tilted? Is the spine perfectly straight? Is one shoulder higher than the other? Are the elbows at the same level? Not every variation is the result of poor positioning. Sometimes patients have certain anatomical abnormalities that make it appear as if they're misaligned. But this final checklist ensures no mistakes are made on our end. When we're satisfied everything is where it should be, the surgeon gives the final approval on the positioning.

An extra layer

Sometimes even the most methodical manual positioning isn't enough. That's why we'll often add intraoperative neuromonitoring — a way to monitor the case via the spinal cord using EEG needle electrodes to stimulate the various pressure points throughout the body, and uncover and correct any positioning errors in real time — to the process.

Around 50% of our spinal procedures involve neuromonitoring, and it's used during posterior procedures such as a spinal fusions or tumor removals. Before patients are even transferred from stretcher to table, tiny EEG needles are inserted into strategic areas — feet, calves, thighs, abdomen, anal sphincter, and in the arms (location varies by patient) — and a certified neuromonitoring technician will monitor the electrode signals for the duration of the case from a laptop right in the OR. These techs are looking to make sure the signal goes all the way through the connected areas. If there's an impingement or excess pressure on one of the EEG-connected locations, the signal won't pass all the way through the body. In these situations, the tech will call it out to our physicians, and we'll make adjustments before there's any damage done.

Hold your course

Getting everyone onboard with our new positioning protocol was no small task. With any major change to your processes, there's going to be that faction of people saying, "Wait a minute here, we've been doing it for years this way. Why do we have to stop now?" It's up to surgical facility leaders to take charge and say, "Well, this is how we're doing it now." Trust me, it's worth the initial growing pains. Before we changed course, we were constantly repositioning patients in the prone position and causing too many unnecessary skin tears in the process. Now, it's not uncommon for us to go through an entire procedure without repositioning a patient — and our injuries have decreased as a result. OSM