The best-laid patient positioning plans often go awry as soon as surgeons walk into the OR. "It's often done according to their preferences, which is a problem," says Lisa Bachetti, BSN, RN, CNOR, CNIV, staff nurse at Penn Medicine at University City Ambulatory Surgery Center in Philadelphia, Pa. "We have four surgeons who want patients positioning differently for shoulder arthroscopies. Three want patients in the lateral position, but each has slightly different variances on how they want it done. The other surgeon prefers to operate on patients in the beach chair."

The issue at Ms. Bachetti's facility was a lack of detailed positioning information for OR staff to reference. "A surgeon's preference card would note "?beach chair position,'" she explains. "But that's all it would say. As a nurse, I'd position patients how I'd want it done, but that wouldn't be how the surgeon liked it. There were so many small differences we had to manage."

Ms. Bachetti set out to develop surgeon- and procedure-specific educational tools that could be accessed easily in the OR. She gathered all the surgical nurses and asked them which types of cases had the most frequent positioning variations from surgeon to surgeon. Turns out, it was shoulder and knee procedures.

Ms. Bachetti then approached the facility's orthopedic surgeons to tell them about her project, and asked them about their specific positioning preferences, and their rationales for them. Once she collected that information, she created PowerPoint slides for each surgeon and the procedures they performed. But the idea wasn't to put them in a binder; she wanted the information easily accessible to the surgical staff.

She met with the hospital's IT department to develop a sharable file on a web-based collaborative platform. Now OR staff members can easily obtain positioning information through computers in the OR. "Staff access a list of our orthopedic surgeons," says Ms. Bachetti. "They click on a surgeon's name, and in his file are the procedures he frequently performs — ACL, rotator cuff, shoulder arthroscopy. Clicking on a procedure type displays the surgeon's digital preference card, which includes pictures of how they want patients positioned for the procedure."

Ms. Bachetti held in-services to educate the entire staff on the use of the web-based tool. Positioning ambiguities? Gone. In fact, the success of the program led orthopedic residents to create a website with video instructions for each surgeon's steps for prepping, draping and surgical approaches.

The digital positioning tool is especially helpful for visiting and rotating clinicians who might be unfamiliar with the facility's surgeons, according to Ms. Bachetti. By default, she is the point person for any modifications and additions that need to be made to the positioning information.

"I just update it as we go," she says. "Any facility can create PowerPoint slides of surgeons' positioning preferences, as long as they have one person designated to manage the project, and staff who constantly provide updated positioning information."

During the process, the positioning products the facility used were evaluated as well. "We always had gel devices, but it was the way in which we used them that made a difference," says Ms. Rusch. "For example, instead of using eggcrate foam on our padded arm boards, we considered using gel and taking the patient anatomy into consideration. We also wanted to use a gel-based axillary roll because the foam model we used compressed too much."

Importantly, Ms. Rusch implemented a surgical timeout called Pause for a Cause, a post-positioning verification process that takes place before skin prepping. "It's something our workgroup came up with to help the surgical team focus on proper patient positioning," she says.

The pause provides heightened awareness to everyone in the OR about checking and rechecking how patients are positioned. "Pause for a Cause is a team thing. It's not just nursing-driven," says Ms. Rusch.

"Anesthesia looks at the patient, and then everyone walks from head to toe to make sure the patient is centered appropriately, that they aren't at increased risk of suffering nerve or pressure injuries, and everything looks appropriate before prepping can begin."

The workgroup also introduced a requirement for the circulating nurse to assess the patient's positioning on an ongoing basis during cases, but that nurse doesn't work alone. Everyone in the OR is empowered and encouraged to voice concerns. "It's the communication in the room, and walking around making sure the patient's position hasn't changed, especially after the bed has moved," she says. "It's considered a total team effort to speak up if any part of the patient's body shifted — or if someone thinks it may have shifted."

Once adopted, the enhanced positioning program was a success. It reduced the facility's number of lateral positioning-related injuries to zero. Ms. Rusch and her team moved on to updating protocols for other positions — supine and prone are completed, with lithotomy currently in the pipeline.

"We've definitely taken the lessons learned from lateral positioning to what we're currently working on," she says. "It was a bit difficult to figure out how to make a standardized approach work. We decided to present the best evidence and best practices, and discuss tools we have available to make those methods work."

Members of the surgical team have the autonomy to position patients to the best of their abilities based on surgeon need, positioning aids and patient characteristics. For example, when placing patients in the lateral position, some staff members use a beanbag, which isn't suitable for use during certain procedures. Different surgical teams also use various techniques to place patients in the supine position. Plus, patients have individual positioning needs based on a variety of factors, including skin integrity and physical make-up.

"We wanted to empower staff to work with their team in the OR to make positioning happen with best practices always in mind," says Ms. Rusch.

Whenever a new position is rolled out, relevant information is posted on bulletin boards and shared at staff huddles. The info is also kept in resource binders in the ORs, as well as in a folder on the department's online server.