A Refresher Course in Patient Positioning

Keys to standardizing one of the most critical protocols in surgery.

It’s a common occurrence in facilities everywhere: A newer nurse or a traveler will come into an OR and notice some slight variations in how the perioperative team is positioning the patient for the case.

While some may argue that subtle differences are impossible to prevent in busy facilities with constant churn, the reality is even the most seemingly insignificant variations in your positioning processes can cause major safety issues for your patients. “It’s imperative that every member of your staff is doing everything the same, and that everything is standardized,” says Ashley Low, BSN, RN, CNOR, assistant nurse manager for Virtua Health Voorhees (N.J.). “You just need to make sure that everybody is on the same page, follows the same guidelines and has the same education.”

That sentiment is shared by Shannon Sims, BSN, RN, operating room charge nurse at Virtua Health Voorhees, who adds that there are serious risks to patients who are positioned incorrectly. “It could lead to nerve injuries, pressure ulcers, respiratory distress, hemodynamic instability, surgical complications and prolonged recovery times,” she says. “Proper positioning is critical to patient safety and positive outcomes. Everyone involved must be aware of what we’re doing and how we’re doing it.”

Vanquishing the variation

Indeed, everyone at Virtua Voorhees not only follows the same guidelines (AORN’s recommended positioning guidelines: osmag.net/position), but they also called together their OR Shared Governance Team to identify any positioning variations among its staff and created education based on the four primary positions used in its ORs:

• Supine: Patient lies on their back with head, neck and spine in a neutral position and arms either adducted alongside or abducted to less than 90 degrees.
• Prone: Patient lies on their front with head, neck and spine maintained in a neutral position.
• Lithotomy: Patient is placed supine with legs abducted 30 to 45 degrees from midline with knees flexed and legs supported with the foot of the bed lowered or removed.
• Steep Trendelenburg: Patient lies head down with their stirrup-supported legs reaching skyward at a 30- to 45-degree angle.

Using the updated guidelines, the team created a PowerPoint that was presented to all OR staff. Then it found a creative and hands-on way to make sure the protocols stuck: It hosted an in-service day where the Shared Governance Team divided the entire OR team into groups to demonstrate each of the four positions from different perspectives. “We’d have staff get on the bed and act as the patient and cover their eyes so they could feel what the patient felt,” says Ms. Low. “Then we’d have other staff position their colleague on the table.”

The Shared Governance Team would also intentionally position staff incorrectly, ask What is wrong with this position? and follow up with education when needed. “We’d say, ‘Show us how you’d position this person,’ and then we’d say, ‘Now here’s how you’re supposed to do it,’ and make the necessary corrections.”

If you’re looking for a way to streamline your own positioning protocols and eliminate potential variations, here are some universal best practices Ms. Low, Ms. Sims and the entire OR team at Virtua Voorhees employ:

• Start at the top. The guidelines you follow and the protocols you have in place must be ingrained in everyone’s collective consciousness — including your leaders. “It’s important for department leaders to know exactly what’s in the guidelines you follow,” says Ms. Low. “If you’re expecting staff to comply with strict, specific procedures, you need to know them yourself.” She adds that if staff — particularly newer staff — has a question or needs a little guidance, they should feel comfortable going directly to leaders and feeling confident those leaders will know what to do.

• Gather the team. A major part of preventing positioning injuries occurs long before the patient even enters the OR. “It’s really important to include everybody in a briefing before you even go to get the patient to make sure everyone is on the same page and has all the necessary equipment in the room,” says Ms. Sims, adding that “everybody” includes anesthesia, surgeons, nurses and techs. During these briefings, you want to pay attention to any cases that may require extra attention or resources. For instance, Ms. Low says a trend her facility has seen in the last few years is a steady, gradual increase in patients’ BMIs. “That’s something we keep an eye on because we need to make sure we have the proper equipment, supplies and staff available to ensure, first and foremost, that we don’t injure the patient but also that we don’t injure ourselves in the process as well,” she says.

• Interview with intent. You can learn a lot about potential positioning issues simply by asking patients directly or thoroughly reviewing their medical history. “When you’re interviewing the patient preoperatively, you want to ask if they’ve had any issues with their lower back, their hips or their knees,” says Ms. Sims, adding that you’re basically trying to uncover whether they have any underlying issues that would require modifications or extra padding.

“Our staff always looks over at a patient’s H&P before they come into the OR,” says Ms. Low. “That way, if someone had a previous spine surgery, we’re ready to put down extra gel pads on the bed.”

• Focus on the fundamentals. A major part of proper positioning involves pressure ulcer prevention, which often comes down to paying close attention to problem areas inherent in the various positions and getting foam or gel rollers underneath the patient’s legs, hips or any other vulnerable areas.

NEW RESOURCES

AORN Introduces Pocket Positioning Cards

CARD-CARRYING STAFF AORN recently introduced a new pocket-sized positioning resource that can serve as an invaluable tool for perioperative nurses.

Wouldn’t it be nice to arm your OR staff with a portable, easy-access tool to help them safely position patients for surgery? Now you can. AORN’s new Pocket Positioning Cards feature step-by-step instructions, tips and illustrations for each major surgical position: lateral, lithotomy, prone, reverse trendelenburg, trendelenburg, sitting/semi-sitting and supine as well as a card for general best practices in all positions.

For instance, the pocket positioning card for the supine position includes the following five steps:

1. Place the safety strap approximately two inches (5 cm) above the knees

2. Flex the patient’s knees approximately five to 10 degrees

3. Position the patient’s legs parallel with the ankles uncrossed

4. Do not hyperextend or hyperflex the feet, and

5. Elevate the patient’s heels off the underlying surface.

— Jared Bilski

“A lot of times, it comes down to adequately padding bony prominences,” says Ms. Sims. “We always try to keep a patient’s heels off the bed when they’re supine or their toes off the bed when they’re prone.” Getting foam or gel pads underneath the patient’s legs or hips as needed is a crucial way to prevent injuries, she adds.

Ms. Low echoes those sentiments on proper padding and offers a reminder on the importance of stability. “In a position like steep Trendelenburg, you need to make sure the patient doesn’t slide backward since they’ll have their feet elevated,” she says. “Here we rely on different gel pieces to keep them secure and prevent them from sliding.”

With these core principles at the forefront of your education and training, standardized positioning should become second nature to your staff.

That’s the way it should be because, as Ms. Low puts it, “proper positioning is really just about patient safety.” OSM