Patient Safety. 20 The OR Connection

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The OR Connection

Patient Safety

Perioperative Positioning

Injuries on the Rise:

by Alecia Cooper, RN, BS, MBA, CNOR

Author’s note: In 2007, I wrote a “Back to Basics” article on the principles of proper positioning and prevention of posi-tioning injuries. I listed many types of injuries that can occur as a result of improper positioning before, during and after a surgical procedure. The content of that article still holds true, but when I went back to the topic recently in prepara-tion for a live presentaprepara-tion, I was alarmed to learn that these injuries were not on the decline, but rather on the rise. And that’s what prompted me to write this article as a refresher on positioning for perioperative professionals.

The importance of proper patient positioning must not be overlooked. More and more studies are attributing hospital-acquired pressure ulcers to lack of proper positioning in perioperative services. In fact,AORN’s2009 Perioperative Standards and Recommended Practicesstates that the incidence of pressure ulcers occurring as a result of surgery may be as high as 66 percent.1_{In addition, more and more}

lawsuits are being filed due to positioning injuries, not only because of avoidable pressure ulcers, but also physiologic compromises and nerve damage. The incidence of nerve injuries is unknown, however in the United States, nerve damage accounts for 15 percent of postoperative litigation claims.2

Positioning for a surgical procedure depends on the sur-geon’s preference, the anesthesia provider’s needs, the pro-cedure being performed and the need for exposure of the surgical site. Overall, positioning is recognized as a balance between the position a patient can physically assume and what can be physiologically tolerated, based on the patient’s age, height, weight and overall health. A patient’s body must be positioned adequately on an OR bed, and proper body alignment must be maintained to lessen the potential for injuries.3

Assessment

Proper patient positioning begins with an assessment before the patient ever arrives in the operating room. Elements to consider include the patient’s pre-existing conditions, the type and duration of the procedure and individual patient characteristics such as height, weight, age, skin condition, etc.1_{Regardless of these factors, however, all surgical}

pa-tients should be considered at risk for pressure ulcers be-cause of the uncontrollable length of surgery and the effects of anesthesia on the patient’s hemodynamic state, along with the use of vasoactive medications during surgery.3

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The OR Connection

Risk factors identified during the assessment can determine the degree of pressure the patient can tolerate. The following factors affect the ability of the skin and supporting struc-tures to respond to pressure:3

• Vasoactive medications and steroids • Comorbid diseases, such as cancer, cardiovascular and peripheral vascular deficiencies, diabetes and neurological or respiratory disease

• Extracorporeal circulation

• Impaired regulation in body temperature • Existing fractures

• Low hemoglobin and hematocrit levels • Nutritional deficiencies

• Obesity

• Low serum protein (i.e., prealbumin or total albumin plus globulin) • Smoking

• Low blood pressure

Maintaining optimal physiological conditions lessens the risk for complications both intraoperatively and postoperatively. When a patient has inadequate arterial blood flow, improper positioning can cause complications with blood pressure, decrease tissue perfusion and venous return and cause blood clots.

Pre-existing conditions are important to assess because certain patients are especially vulnerable to pressure ulcers and/or nerve damage.Patients with vascular disease may have existing tissue ischemia and often have additional risk factors such as age, nutritional deficits, obesity or diabetes.1 _{Interestingly, these are the} same patients who often undergo cardiovascular surgery, which already puts patients at higher risk for injury simply because the procedures typically last four hours or longer. In addition, patients who smoke often experience vaso-constriction, which contributes to pressure ulcer formation.1 Patients with respiratory, circulatory, neurologic or immune conditions are also more vulnerable to injury, as are those with physical limitations such as back problems and pros-theses or implants, such as an artificial hip or knee.

Special considerations for avoiding eye injuries

Patients are at increased risk of developing post-operative vision loss if they:

• Are undergoing procedures lasting 6.5 hours or more • Have substantial blood loss

• Are in a prone position

In general, direct pressure on the eye should be avoided to reduce the risk of central retinal artery occlusion and other ocular damage, including corneal abrasion. Assess eyes regularly, especially in long procedures and when the patient is in the prone position.

The type of procedure dictates how the patient will be positioned on the operating table and the type of positioning equipment that will be required. The most common surgical positions are supine, prone, lateral and lithotomy. Each position carries its own risks and safety considerations, as shown inTable 1on page 29.

The length of the procedure is another consideration. Often, the longer a patient is on the operating table, the greater the risk for pressure ulcers. One study reported that intraoperative pressure ulcers increased when the proce-dure time extended beyond three hours. Cardiac, general, thoracic, orthopedic and vascular procedures were re-ported to be the most common types of procedures associated with pressure ulcer formation.1

Specific factors such as age, weight and skin condition, among others, are also important to assess prior to surgery.1_{Patients who are 65 years of} age or older experience the highest incidence of pressure ulcer development.3_{These patients also have less flexibility} and poorer peripheral circulation, making them more prone to skin- and nerve-related injury. The same holds true for obese patients.4 _{Of course, every individual is different,} and your assessment will reflect this. A fit, healthy 82-year-old may be less vulnerable than an overweight 35-year-82-year-old with diabetes. Very young pediatric patients are also at greater risk for surgical injuries, as are frail, malnourished individuals.

Continued on page 24 JBK_OR12.3.qxp:Layout 1 12/28/09 6:33 PM Page 22

NO PRESSURE,

JUST SUPPORT.

to form in as little as 20 minutes in the operating room.1

When every second counts, the surfaces used for positioning and transporting patients need to be chosen carefully.

Medline’s gel positioners are designed to help reduce pressure while providing exceptional support during surgical procedures. They’re latex- and silicone-free, antimicrobial, antibacterial and radiolucent. They’re also reusable and can easily be cleaned and disinfected with standard hospital disinfectants. Available in a wide variety of shapes and sizes.

Gel positioners are one of several products recommended as part of Medline's Pressure Ulcer Prevention Program. This proven, systematic approach combines education, best-in-class products and dedicated program management to reduce pressure ulcer incidence.

To sign up for a FREE webinar on perioperative pressure ulcer prevention, go to

www.medline.com/pupp-webinar.

References

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The OR Connection

Be sure to assess the patient’s skin before surgery, looking for dryness, skin tears and existing wounds, including pressure ulcers, and document your findings in the medical record.This information will be critical for comparing the condition of the patient’s skin after surgery to determine any damage that may have occurred in the oper-ating room. Many pressure ulcers that originate during sur-gery do not appear until one to four days after an operation, some are mislabeled as burns and some are unexplained because they appear and progress differently from the pressure ulcers seen in nonsurgical patients. OR-acquired pressure ulcers initially have a distinctive purple appearance.5

Shearing movement should be avoided when transferring patients onto the OR table, especially the elderly, whose frag-ile skin can tear more easily than the skin of younger patients. The overall goal of positioning elderly patients is to reduce stress and pressure on the spine and skin. The circulating nurse should be particularly vigilant about optimal body

align-ment and support of joints when an older adult patient is positioned after undergoing sedation. If not contraindicated, the circulating nurse should also place a pillow under the patient’s knees to avoid postoperative stiffness that may limit early mobility. Heels are an often overlooked but vulnerable area than can benefit from addi-tional padding as well.6

Planning

After assessment, the next step is planning. The nurse must anticipate the proper positioning equipment and supplies that will be needed based on the knowledge acquired during the assessment. The nurse should review the surgery schedule before the patient’s arrival – prefer-ably before the day of surgery – to identify potential conflicts in the availability of positioning equipment.1

The nurse should also confirm that the room is set up appropriately for the planned procedure before the patient arrives. In addition, positioning and transporting equipment should be periodically inspected and maintained. Properly functioning equipment contributes to patient safety and assists in providing adequate exposure of the surgical site.1

Even when you have a plan, observe the patient right before surgery to ensure that your positioning recommendations are still correct. Also double check that all necessary positioning devices and padding materials are in the operating room prior to transporting the patient.

Tools for Proper Positioning

The goal is to use equipment that is designed to redistribute pressure and decrease the risk for positioning injuries. An

Continued on page 26

References

1_{Braden Scale for Predicting Pressure Sore Risk. Available at:}

www.bradenscale.com/braden.PDF. Accessed November 6, 2008.

2_{Recommended practices for positioning the patient in the perioperative practice setting. In:}

KEEP YOUR SURGICAL

PATIENTS DESERT DRY.

Medline’s Sahara®_{Super Absorbent OR table sheets}

are designed with your patients’ skin integrity in mind.

QuickSuite® OR Clean Up Kit

The Braden Scale tells us that moisture is one of the major risk factors for developing a pressure ulcer.1_{We also}

know that as many as 66 percent of all hospital-acquired pressure ulcers come out of the operating room.2

That’s why we developed the Sahara Super Absorbent OR table sheet. The Sahara’s super-absorbent polymer technology rapidly wicks moisture from the skin and locks it away to help keep your patients dry.

Sahara OR table sheets are available on their own or as a component in our QuickSuite®_{OR Clean Up Kits,}

which were designed to help you dramatically improve your OR turnover time and help reduce cross contamina-tion risk through a combinacontamina-tion of disposable products.

To sign up for a FREE webinar on perioperative pressure ulcer prevention, go to

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The OR Connection

Special considerations for avoiding

nerve injuries

Surgery-related nerve injuries most often are attributed to careless positioning. The most common injury is to the ulnar nerve, followed by the brachial plexus. To minimize the risk of nerve injury, safety measures should include:

• Padded arm boards attached at less than a 90-degree angle for the supine position • Placing the patient’s hands palms up with

fingers extended

• Keeping shoulder abduction and lateral rotation of the patient to a minimum

• Preventing the patient’s extremities from dropping below the level of the procedure bed.

• Placing the patient’s head in a neutral position, if not contraindicated by the surgical procedure or the patient’s physical limitations

• Adequate padding for the saphenous, sciatic and peroneal nerves, especially for patients in the lithotomy or lateral position

• Placing a well-padded perineal post against the perineum between the genitalia and the uninjured leg when a patient is positioned on a fracture table inverse relationship may exist between the duration and

intensity of pressure. Low-intensity pressure over a long period can initiate tissue breakdown, as can high-intensity pressure for a short period of time.3

During the positioning procedure, it is the nurse’s respon-sibility to:1

• Restrict access to the operating room • Close all doors

• Limit traffic within the operating room • Minimize exposure

• Provide auditory privacy • Prohibit prejudicial behavior

Positioning devices.Safety is the primary concern when determining the adequate number of personnel and type of devices to safely transfer and position the patient. Trans-ferring is accomplished with a lateral transfer device (e.g., slide boards, air-assisted transfer devices) that reduces friction and shear.3

One study involving the review of 16 perioperative incident reports showed that in 63 percent of the cases, patients were above the weight limit for the equipment. To avoid this situation in your practice, ensure in advance that you will be using a bed that is sufficiently sized for the patient, obtain pressure redistribution table pads and be sure that arm-boards are available.1

Use specific positioners for head and neck surgeries, extremities procedures and procedures performed on the torso.

Support surfaces.Proper padding around the patient’s body helps prevent skin breakdown, especially on high-risk areas where soft tissue is compressed between a bony prominence and a hard surface, such as the OR table. Use of too many pads or blankets, however, can cause the capillary pressure to rise over 32 mmHg, which increases the risk for poor tissue perfusion, causing the patient to be at risk for developing pressure ulcers.3

Pressure redistribution devices should be used to promote reduction of interface tissue pressure for patients at high risk of developing pressure ulcers or nerve injuries. Several

types of pressure redistribution support surfaces are avail-able. One type is an overlay, which is placed directly on the mattress or bed frame as a replacement for the standard foam OR mattress.3

Foam, static-air and gel are common types of overlays. Static-air overlays allow air to exchange through multiple chambers when a patient lies on the overlay. This type of overlay must be reinflated periodically. Gel overlays prevent shearing, support weight and prevent bottoming out. One study found that gel overlays helped prevent skin changes and pressure ulcers in older adults, including those with chronic health comorbidities or vascular disease and those experiencing extended surgical duration.3

Mackey reviewed three OR trials that indicated that the use of air and gel pressure overlays might be beneficial in reducing the incidence of pressure ulcers for high-risk surgical patients.3

tion, moistening the skin and repositioning.3

Note: Rolled sheets and towels should not be used beneath the procedure bed mattress or overlay because they may negate the pressure-reducing effect of the mattress or overlay.1

Position to protect and support

• Pad bony prominences

• Protect arms from nerve damage • Confirm finger locations

• Carefully apply safety restraints to avoid nerve damage

• Ensure no body parts touch metal equipment • Elevate heels whenever possible

• Align head and upper body with the hips • Keep legs parallel (do not cross ankles) • Position head in neutral position on a headrest • A pillow may be placed under the back of the

patient’s knees to relieve pressure on the lower back • If pregnant, insert a wedge under the right side • Do not tuck arms at patient’s sides unless

absolutely necessary

who does what when positioning a patient for a surgical procedure? According to legal experts, the nurse should document exactly who did what to make it easier to deter-mine liability in case of a lawsuit. Remember that everyone in the OR is responsible for their own actions.7_{If the} anes-thesia provider tucks the patient’s arm to the side, give that person the credit on the operative record. If the surgeon positions the patient’s legs in stirrups, document that fact. Of course the nurse must always check to make sure all pressure points are padded or that pedal pulses are intact after the legs are positioned.

It may be time-consuming and cumbersome to chart all of the specifics of positioning; however, it is advisable for the nurse’s protection. To simplify the task, a checklist could be developed, and the nurse could simply write the initials of the responsible party next to each task performed.7 Documentation should include the following:1

• A written preoperative assessment, including a skin assessment on arrival and discharge • The type and location of positioning equipment • Names and titles of persons participating

in positioning

• Position patient is placed in and new position if repositioning occurs

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The OR Connection

If it’s not recorded, it didn’t happen5

A 60-year-old patient with multiple medical problems underwent 12-hour vascular reconstruction of the right leg. Sacral pressure ulcers were noted soon after, and despite treatment, severe necrosis developed. The patient’s leg was amputated below the knee and the sacral ulcer required surgical debridement with grafting. The patient alleged negligence in positioning during surgery, which resulted in severe sacral pressure ulcers that required pro-longed hospitalization and additional surgery. A review of the medical record revealed a lack of documentation by the surgeon, anesthesiologist and the OR nursing staff regard-ing the patient’s increased risk for skin breakdown. Although serious skin breakdown may not have been pre-ventable, documentation of heightened awareness by staff, as well as preventive measures, and a description of the patient’s skin after surgery, may have made it easier for the hospital to defend the case. The OR nursing documenta-tion lacked informadocumenta-tion on the condidocumenta-tion of the patient’s skin, and the padding used to position the patient on the OR table. The patient received a $100,000 indemnity pay-ment and later sought additional compensation.

Thorough nursing documentation wins the case8

A patient sued her surgeon and the hospital over persist-ent numbness in her right hand, which she first noticed after a total right hip replacement. Her lawsuit alleged the numbness was an ulnar nerve injury from improper posi-tioning or the surgeon pressing against her arm or hand during surgery. All defendants were exonerated from blame due to the effort made by the circulating nurse to docu-ment in precise detail how the patient had been positioned, stabilized and padded before surgery. Of special note was the nurse’s documentation of the steps taken to extend the patient’s arms out of harm’s way and to pad her arms and hands to avoid injury due to positioning or pressure. The court record reiterated the circulating nurse’s docu-mentation word-for-word: “6 table with safety strap in place 2 in. above knees – supine with bean bag underneath pa-tient post induction & catheter insertion into the left side, with right side up, per __MD & __MD, - auxiliary roll in place (1000 cc bag IV fluid wrapped in muslin cover) – held in place per surgeons until bean bag deflated with suction – pillow placed under right leg with left leg bent slightly – U drape in place per surgeons pre-prep – left arm extended on padded arm board - right arm placed on mayo tray that is padded”

References

1. Recommended practices for positioning the patient in the perioperative practice setting. In:Perioperative Standards and Recommended Practices.

Denver, Colo.:AORN, Inc. 2009.

2. Prevention of injuries in the anaesthetised patient. Available at: http://www.surgical-tutor.org.uk/core/preop1/perioperative_injuries.htm. Accessed October 23, 2009. 3. Walton-Geer PS. Prevention of pressure ulcers in the surgical patient.AORN Journal.

2009;89(3):538-548.

4. Meltzer B. A guide to patient positioning. Outpatient Surgery. 2001;2(4). Available at: http://www.outpatientsurgery.net/issues/2001/04/a=guide-to-patient-positioning. Accessed December 3, 2009.

5. ECRI Institute website. Executive summary. Pressure ulcers. HRC.2006;3(4). Available at: http://www.ecri.org/documents/patient_safety_center/pressureulcers.pdf. Accessed December 3, 2009.

6. Doerflinger DMC. Older adult surgical patients: presentation and challenges.AORN Journal.2009;90(2):223-240.

7. For the nurse’s protection, it is advisable to document all specifics of positioning a patient for surgery.AORN Journal.1993;58(1):116.

8. Ulnar nerve injury alleged from surgery: hospital not liable – circulating nurse’s documentation of patient’s positioning carries the day.Legal Eagle Eye Newsletter for the Nursing Profession. 1997;5(1):3. Available at: http://www.nursinglaw.com/ ulnar.pdf. Accessed December 4, 2009.

Documentation Makes or Breaks the Case at Trial

Position

Risk

Safety Consideration

Supine

Prone

Lateral

Lithotomy

Pressure points, including occiput, scapulae, thoracic vertebrae, olecranon process, sacrum/coccyx, calcaneae, and knees.

Neural injuries of extremities, including brachial plexus and ulna, and pudendal nerves.

Head Eyes Nose

Chest compression, iliac crests Breasts, male genitalia

Knees Feet

Bony prominence and pressure points on dependent side

Spinal alignment Hip and knee joint injury Lumbar and sacral pressure Vascular congestion

Neuropathy of obturator nerves, saphenous nerves, femoral nerves, common peroneal nerves, and ulnar nerves.

Restricted diaphragmatic movement Pulmonary region

• Padding to heels, elbows, knees, spinal column, and occiput alignment with hips, legs parallel and uncrossed ankles. • Arm boards at less than 90-degree angle

and level with floor. • Head in neutral position.

• Arm board pads level with table pads. • Maintain cervical neck alignment. • Protection for forehead, eyes, and chin. • Padded headrest to provide airway access. • Chest rolls (ie, clavicle to iliac crest) to

allow chest movement and decrease abdominal pressure.

• Breasts and male genitalia free from torsion. • Knees padded with pillow to feet.

• Padded footboard.

• Axillary role for dependent axilla. • Lower leg flexed at hip.

• Upper leg straight with pillow between legs. • Maintain spinal alignment during turning. • Padded support to prevent lateral neck

flexion.

• Place stirrups at even height. • Elevate and lower legs slowly and

simultaneously from stirrups.

• Maintain minimal external rotation of hips. • Pad lateral or posterior knees and ankles to

prevent pressure and contact with metal surface.

• Keep arms away from chest to facilitate respiration. • Arms on arm boards at less than 90-degree