10 New Practices to Protect Patients from Positioning Injuries

Does your team discuss patient positioning during the preoperative briefing? If not, you need to start, according to Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, AORN director of Evidence-Based Perioperative Practice.

Spruce is lead author of the recently released updates to AORN’s Guideline for Patient Positioning and the new Guideline for Preventing Pressure Injury, which is now a separate guideline. Both updates will be released electronically May 9, 2022 on eGuidelines Plus.

She says, “communication and planning are two essential elements of a comprehensive positioning plan to prevent injuries to a patient’s skin, nerves and internal organs, which are still all too common across perioperative settings.”

Luckily, this new recommendation to discuss positioning during the briefing aligns with AORN’s Guideline for Team Communication, “so the tools and processes needed to implement standardized communication for positioning should be very familiar to perioperative teams,” Spruce suggests.

Clinical Practice Updates to Prevent Positioning Injuries

With your standardized briefing in place to communicate patient positioning, make sure to update your practices and get educated as a team on other new evidence-based practices added to the updates in the Positioning and Preventing Pressure Injury guidelines, including the following.

1. Plan Ahead to Prevent Falls

Identify and clearly communicate potential fall hazards associated with positioning activities such as when safety straps are removed or when moving the patient. Implement safe practices such as proactively determining which team members will be responsible for always observing the patient while on the OR bed. See Recommendation 3.2 in Positioning guideline.

2. Determine Individual Facility Practices to Safely Tuck Patient Arms

Arm positioning should be determined by the needs of the surgical team and the physical limitations of the patient, with the goal to place the patient’s arms in a neutral position with the palms facing the body and without hyperextension of the elbow. See Recommendation 3.18 in Positioning guideline.

3. Reduce Risks for Post-Operative Vision Loss

Recognize risks that put patients at increased chance of postoperative vision loss caused by intraoperative pressure, especially when patients are in the prone and Trendelenburg positions. Discuss as a team how quickly intraoperative pressure can lead to vision loss and review recent literature on these risks, including two systematic reviews cited in the updated Positioning guideline. See Recommendations 5.1 and 6.1 in Positioning guideline.

4. Don’t Use Shoulder Braces

Shoulder braces are no longer recommended to secure the patient because compression over the acromion by shoulder braces can injure the brachial plexus. Instead, use other methods to prevent the patient from sliding such as convoluted foam or viscoelastic gel overlays, vacuum-packed positioning devices, or other positioning devices designed for this purpose. See Recommendation 5.7 in Positioning guideline.

5. Bring Periop Representation to Your Facility’s Pressure Injury Prevention Program

Perioperative RNs should participate in the organization’s pressure injury prevention program to be looped into facility pressure injury prevalence data and to develop perioperative policies and procedures related to the prevention of perioperative pressure injury. See Recommendation 1.1 in Preventing Pressure Injury guideline.

6. Reevaluate Pressure Injury Risk Assessment

Use a structured risk assessment tool that has been validated or demonstrated reliable for use in perioperative patients, such as the Munro Pressure Injury Risk Assessment Scale for Perioperative Patients, the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning (ELPO), the perioperative risk assessment measure for skin (PRAMS), or the Scott Triggers tool. See Recommendation 2.2 in Preventing Pressure Injury guideline.

7. Update Support Surfaces Used for High-Risk Patients

Patients at high risk for pressure injury should be placed on high-specification reactive or alternating pressure support surfaces before and after surgery. See Recommendation 3.3 in Preventing Pressure Injury guideline.

8. Consider Patient Skin Tone to Identify Pressure Injury

Consider skin tone variances when assessing patients’ skin for signs of pressure injury after surgery. Patients with darkly pigmented skin should be assessed by checking the patient’s skin temperature, and the presence of edema, induration, and pain. See Recommendation 7.4.1 in Preventing Pressure Injury guideline.

9. Improve Skin Perfusion Assessment

Long-wave infrared thermography can be used to measure temperature differences in patient tissue to identify cold tissue that is not well perfused and at higher risk for pressure injury. See Recommendation 7.4.2 in Preventing Pressure Injury guideline.

Read a more in-depth summary of these guideline updates in the May issue of AORN Journal’s Guideline First Look articles for Positioning and for Preventing Pressure Injury.