4 Ways to Improve Intra-op Patient Safety with Positioning Assessments

Research shows that intra-op repositioning can improve patient safety by catching inadvertent movement that goes unnoticed beneath the surgical drapes. For example, a patient’s limb might be at risk of slipping off the bed, or there could be a moment during surgery where a nurse can perform passive range of motion on a limb to prevent post-op stiffness.

However, many OR teams lack standardized processes for assessing patient position during surgery.

Without a plan in place, repositioning infrequently occurs, says perioperative nurse and researcher Sara Booth, RN, BSN, CNOR. Booth investigated intraoperative positioning practices in her own facility by auditing charts for cases lasting three hours or more, and discovered several telling trends:

• In 65% of cases, only one positioning assessment was conducted by the anesthesia care provider before "Incision/Start of Procedure."
• Only 4.11% of cases included nurse-led positioning assessments during surgery.
• Among 92 nurses involved in the audited cases, only 10 reported feeling comfortable or adequately trained in performing and documenting a positioning assessment during surgery.

Booth recognizes that there are significant barriers to making intra-op repositioning a standard practice. “It can be more complicated due to the surgeon working, the type of equipment being used on the patient, and having limited access to the patient under the drapes—but it’s possible.”

How to Implement Intra-op Positioning Assessments

To help her OR teams become more confident and consistent with intra-op positioning assessments, Booth combined her study findings with evidence-based practices in AORN’s Guideline for Positioning the Patient.

Here are 4 strategies she recommends any team can adopt:

1. Establish Repositioning Practices During Surgery

For procedures longer than three hours, positioning assessments should be completed every two hours and documented.

Tip: Booth helped create a tool within her facility’s intraoperative electronic medical record that alerts the circulating nurse when the next assessment is due. When that assessment is documented, the timer restarts, and the next prompt will appear in two hours.

2. Make Repositioning Documentation Easy

Have a designated place for surgical staff to document positioning assessments.

Tip: Booth’s organization has a "Positioning Assessment Flowsheet" to help nurses and anesthesia providers track who performed the last positioning assessment and when it was completed. When this project was rolled out, both specialties were educated on how to access the assessment flowsheet.

3. Note What Can’t be Assessed

There will be critical portions of a procedure where certain areas of the patient cannot be accessed. However, this does not eliminate the need for an assessment.

Tip: In Booth’s organization, OR staff can document areas as "unable to assess" when completing a full assessment. This ensures it’s clear what has been checked and what could not be evaluated.

4. Practice How to Fit Assessments In

Teams need to practice how intra-op positioning assessments can be integrated into the procedure. For example, nurses can practice making announcements and asking questions like this in the operating room suite:

• "It's been two hours since incision, I'm going to look under the drapes to assess the patient."
• "The surgical bed just changed orientation, is now a good time to check under the drapes to check safety strap placement?"

Tip: When the surgeon steps away to take a phone call or scrubs out for a break, these are opportunities for the circulating nurse to look under the drapes and assess the patient.

Check out this video Booth created to demonstrate a positioning assessment during surgery.