The Keys to Pressure Injury Prevention

Making sure patients are positioned for surgery with safety in mind is a critical part of any procedure. Issues with positioning can make a straightforward surgery much more difficult to perform and could also cause pressure injuries, which negatively impact outcomes and might lead to hospitalizations for additional care. “The goal is always to protect the patient from harm,” says David Meyer, BSN, RN, CNOR, an OR staff nurse at Virtua Voorhees (N.J.) Hospital. “Proper positioning during surgery prevents skin breakdown on patients who are unable to protect themselves.”

Even if your facility currently has low rates of pressure injuries, there’s always room for improvement and several strategies can strengthen patient positioning practices.

First, it’s key to make sure your surgeons are placing patients in positions they’re familiar with for the procedures they perform. “Proper patient positioning should be dictated by surgeons based on what’s best for them to complete the operation safely,” says William Cirocco, MD, a surgeon at Banner MD Anderson Cancer Center in Phoenix.

Guided by their years of experience, surgeons might feel one position is best for specific procedures depending on the circumstances surrounding the surgery, including the location of the surgical site and the patient’s overall health. The surgeon’s own comfort level with certain positions also comes into play. The likelihood that errors occur or outcomes suffer increase when surgeons are forced to struggle through procedures during which the patient is in a suboptimal position. “In general, let surgeons guide how patients are positioned based on the techniques with which they have the most experience,” says Dr. Cirocco.

Teamwork among surgeons, anesthesia providers and the OR staff has a significant impact on safe patient positioning. At Virtua Voorhees, the entire surgical team collaborates to ensure best positioning practices are top of mind before and during procedures. “Surgeons, nurses, residents, anesthesia professionals — everyone comes together to prevent pressure injuries,” says Mr. Meyer. “Patients who undergo surgery in our hospital receive a high standard of care from the entire staff.”

As part of this approach, everyone on the patient care team follows the same safety standards for each surgical position. For example, whenever a patient is in the supine position, staff protect vulnerable areas by placing a pillow under the patient’s knees and use protectors to prevent the heels from contacting the table’s surface.

Virtua Voorhees’ team-based dynamic has increased buy-in for safe patient positioning protocols at all levels. “One thing our department is very good at is being transparent about our complication rates,” says Mr. Meyer. “At our monthly staff meetings, we discuss how many surgical site infections and pressure injuries have occurred. It reinforces that our outcomes are being monitored, and that complication rates aren’t just a number on a graph.”

Ultimately, what’s discussed at these meetings helps staff know that their actions impact patient safety, says Mr. Meyer. A key element that’s increased staff buy-in for maintaining safe patient positioning is that discussions about best practices are never punitive. Individual staff members aren’t blamed for pressure injuries that happen on their watch. Rather, the incidents are handled as learning opportunities that focus on what the team as a whole can do to improve. “Our interactions always focus on the collaborative effort,” says Mr. Meyer. “Teamwork is baked into the culture of the department. It’s not just about preventing one pressure injury and it’s not about one person’s actions. It’s about all of us maintaining the end goal of protecting patients from harm.”

Our interactions always focus on the collaborative effort. It’s not just about preventing one pressure injury and it’s not about one person’s actions.
— David Meyer, BSN, RN, CNOR

Teamwork is particularly important in preventing complications related to patient positioning that can arise during surgery. For example, a surgeon might have to pick a different position mid-procedure if the patient’s airway becomes compromised. In this situation, it’s important for the anesthesia provider, nurses and other staff to help determine which position is best, a process that often requires adjusting on the fly. Team members might have different opinions on what positioning tactics would work for the situation. Ultimately, says Dr. Cirocco, the surgeon should make the call on how to proceed, but having that conversation is an important part of the decision-making process. “Safe positioning isn’t always black and white,” he says. “We all have to work together to get through a procedure safely.”

Members of the surgical team should feel empowered to speak up before or during a procedure if they notice a positioning problem that could compromise the patient, such as inadequate padding or improper limb placement. “Facilities should establish a culture where issues can be voiced, including positioning concerns, before the team proceeds with surgery,” says Dr. Cirocco.

This empowerment can become even more crucial during procedures. “The surgeon, who is concentrating on the intricacies of the case, might not notice that the patient’s leg has become improperly positioned,” says Dr. Cirocco. “If the culture is such that all members of the surgical team feel like they can speak up and not fear some sort of retribution, the surgeon can be alerted to the issue, stop and change course to prevent patient harm.”

Surgical staff need opportunities to hone their positioning skills and practices in a no-risk environment. Mr. Meyer suggests scheduling in-services and training specifically focused on different techniques, especially if you’re considering investing in new positioning devices. 

Mr. Meyer suggests taking a “round-robin” approach to get the most out of patient positioning in-services. This involves having staff practice various positions on each other, including supine, prone and lithotomy. “Team members get a sense of how it feels to be placed in each one, determine how well positioning aids work and identify areas of the body that need to be protected,” says Mr. Meyer.

They can determine best practices for each position and offer suggestions to lower the risk of pressure injuries. “This helps them figure out what positioning protocols to implement,” says Mr. Meyer, who practices what he preaches. To make sure new positioning equipment is effective and comfortable, he often tries the devices out on himself before using them on patients.

Positioning in-services let staff discuss any discomfort they felt in certain positions or with positioning equipment, valuable feedback unconscious patients cannot share to inform the team. Through in-services, OR staff can also learn new techniques from each other. A nurse might be used to one positioning strategy, but could get insights about a more effective method from a colleague.

Above all, your facility’s philosophy on proper positioning should be guided by an unwavering focus on patient safety. The potential risks caused by issues with incorrect positioning far outweigh additional budget expenditures that ensure helpful equipment is always on hand or that staff are regularly trained on the latest techniques. “It would be irresponsible to perform a surgery and cause avoidable harm because you weren’t paying attention to padding vulnerable areas or proper positioning procedures,” says Dr. Cirocco. OSM