Back to basics: positioning the patient

Positioning the surgical patient - roles, responsibilities and challenges. A qualitative study

AIMS

The aim was to explore how representatives from the different professions in the surgical team experience roles, responsibilities and challenges in positioning the surgical patient.

BACKGROUND

Appropriate patient positioning on the operating table during surgery is vital for optimal anatomical exposure, access to essential equipment, patient comfort and to minimize the risk of injuries. Patient positioning has been described as a shared responsibility of the entire surgical team. The research on roles and responsibilities in patient positioning during surgery is sparse.

DESIGN

The study had a qualitative design, including 16 individual, semi-structured interviews, conducted in November and December 2023.

METHODS

Participants included surgeons (n = 4), anaesthetists (n = 4), operating room nurses (n = 4) and nurse anaesthetists (n = 4) in a hospital in Southeastern Norway. The data were analysed using Braun and Clarke's six-step Reflexive Thematic Analysis.

RESULTS

Three main themes with subthemes were identified, namely (1) A teamwork approach, with subthemes (a) facilitating surgery and (b) health professionals' roles and responsibilities. (2) A patient safety issue, with subthemes (a) risk patients and (b) procedural challenges. (3) Absence of a systematic approach, with subthemes (a) various approach to second time-out and (b) documentation and feedback issues.

CONCLUSION

Appropriate and safe positioning during surgery is a common responsibility of all members of the surgical team. Despite the common assumption that surgeons hold the primary responsibility, the operating room nurses seemed to hold the hands-on responsibility. Different health professionals emphasized different risk patients, risk procedures and perceived challenges. This suggests a connection between the specific focus of distinct professional domains, their tasks and expertise within the surgical context.

IMPACT

There is a lack of clear guidelines outlining roles and the distribution of responsibility in patient positioning, which may be a safety concern. A need for reviewing responsibilities and defining roles is identified. Systematic follow-up of documentation of post-operative observation and documentation of skin status and the "second time-out" procedure is crucial to establish measures rooted in guidelines supported by both professional and administrative management. This dual commitment may ensure a comprehensive strategy for systematic follow-up, fostering a culture of continuous improvement.

PATIENT CONTRIBUTION

Not applicable.

Impact of Surgical Table Orientation on Flow Disruptions and Movement Patterns during Pediatric Outpatient Surgeries

(1) Background: The surgical table within a typical ambulatory surgery operating room is frequently rotated and placed in different orientations to facilitate surgery or in response to surgeon preferences. However, different surgical table orientations can impact access to different work zones, areas and equipment in the OR, potentially impacting workflow of surgical team members and creating patient safety risks; (2) Methods: This quantitative observational study used a convenience sample of 38 video recordings of the intraoperative phase of pediatric outpatient surgeries to study the impacts of surgical table orientation on flow disruptions (FDs), number of contacts between team members and distance traveled; (3) Results: This study found that the orientation of the surgical table significantly influenced staff workflow and movement in the OR with an angled surgical table orientation being least disruptive to surgical work. The anesthesia provider, scrub nurse and circulating nurse experienced more FDs compared to the surgeon; (4) Conclusions: The orientation of the surgical table matters, and clinicians and architects must consider different design and operational strategies to support optimal table orientation in the OR.

A Change in Focus: Shifting From Treatment to Prevention of Perioperative Pressure Injuries

Hospital-acquired pressure injuries are a patient safety concern and can be costly for health care organizations. A multidisciplinary team of senior leaders, managers, nurses, and educators from departments that care for perioperative patients created an evidence-based perioperative pressure injury prevention bundle that includes skin and risk assessments, visual and electronic health record cues, prophylactic protection of at-risk skin, communication among providers and leaders regarding patient risk and injury throughout hospitalization, staff member education, compliance audits, root cause analyses, and wound care team follow-up. The prevention bundle resulted in a 50% reduction in perioperative pressure injuries the first calendar year after implementation and a zero-incidence rate for perioperative pressure injuries for at least a two-year period. This article discusses hospital-acquired pressure injuries related to the perioperative setting and outlines the full perioperative pressure injury prevention bundle.

Risk assessment for the development of perioperative lesions due to surgical positioning

OBJECTIVE

To evaluate the risk of developing perioperative lesions due to surgical positioning in patients submitted to elective surgeries.

METHODS

This is an analytical and longitudinal study carried out with 45 patients in a public hospital of medium and high complexity in the state of Piauí. The following data was used: perioperative evaluation instrument, Numerical Visual Scale, Braden Scale and the Risk Assessment Scale for the Development of Injuries from Surgical Positioning (ELPO).

RESULTS

Participants aged ≥ 46 years had a higher risk, and there were 33.4% of hypertensives among the 35.6% with comorbidities. The most prevalent position, with 64.5% was supine, with only 2.2% cases of pre-surgical injury. Regarding the risk for positional lesions, 68.9% presented low risk.

CONCLUSIONS

31.1% of the participants were at high risk for developing positional lesions, related to age and comorbidities.

Intraoperative peripheral nerve injury related to lithotomy positioning with steep Trendelenburg in patients undergoing robotic-assisted laparoscopic surgery - A systematic review

AIMS

To examine the incidence of intraoperative peripheral nerve injury, symptoms, risk factors, functions, and quality of life in patients undergoing robotic-assisted laparoscopic surgery to lithotomy positioning with steep Trendelenburg.

DESIGN

A systematic review.

DATA SOURCES

The Cochrane Library catalogue, PubMed, EMBASE, CINHAL and SveMed + databases were searched from January 2000 - February 2019.

REVIEW METHODS

Titles and abstracts were screened for inclusion. Full-text assessments of each paper were conducted by two reviewers. The quality of the included papers was assessed using the Mixed Methods Appraisal Tool. Descriptive statistics and thematic analysis were used to synthesize the data.

RESULTS

Eleven quantitative studies were included with three themes: (a) incidence of intraoperative peripheral nerve injury; (b) upper extremity intraoperative peripheral nerve injury related to steep Trendelenburg positioning; and (c) lower extremity intraoperative peripheral nerve injury related to lithotomy positioning. The overall incidence of intraoperative peripheral nerve injury in robotic-assisted laparoscopic urologic, gynaecologic and colorectal surgery was 0.16%-10.0% and the symptoms appeared immediately after surgical procedures. Risk factors for intraoperative peripheral injury were prolonged operative time, high American Society of Anesthesiologists scores, comorbidities and high body mass index.

CONCLUSION

Intraoperative peripheral nerve injuries are rare, but occasionally serious when related to lithotomy positioning with steep Trendelenburg. Operating room nurses have a responsibility both for positioning patients and for being familiar with the technological developments that will influence the preoperative handling of patients.

IMPACT

This systematic review emphasizes the need for operating room nurses together with surgical team to have knowledge about mechanisms for injury, positioning, anatomy/physiology, and evaluation of risk factors to ensure that patients are not exposed for intraoperative peripheral nerve injuries. Increased robotic-assisted laparoscopic surgery necessitates further research examining the incidence of intraoperative peripheral nerve injury related to positioning and how these affect patients' function and the quality of life.

Modelling an adult human head on a donut-shaped gel head support for pressure ulcer prevention

Patients who are stationary endure prolonged pressures and shear loads at contact areas between their body and the support surface, which over time may cause pressure ulcers (PUs). Donut-shaped gel head supports are commonly used to protect the occiput, which is among the most common anatomical sites for PUs; however, the biomechanical efficacy of these devices is unclear. To investigate their effects on scalp tissues, we have used our three-dimensional anatomically realistic finite element model of an adult head, to which we have added a donut-shaped gel head support. We then compared the occipital scalp tissue loads' occurrence while the donut-shaped gel head support is in use with those associated with a fluidised head positioner and a standard medical foam. The donut-shaped gel head support inflicted the greatest exposure to tissue mechanical stresses, particularly to the high (and therefore dangerous) stress domain, when compared to the other positioners. We concluded that while the donut-shaped gel head support is designed to avert tissue loads away from the occiput and disperse them to the surroundings, in practice, it fails to do so. In fact, the donut-shaped gel head support imposes the head-weight forces to transfer through a relatively narrow ring of scalp tissues, hence increasing the risk of developing occipital PUs. KEY MESSAGES: a donut-shaped gel head support is meant to reduce the occurrence of pressure ulcers in scalp tissues to investigate the effects of donut-shaped gel head support on scalp tissues, we have used our anatomically realistic computational model of an adult head the donut-shaped gel head support imposes the head-weight forces to transfer through a relatively narrow ring of scalp tissues the highly distorted and deformed tissues at that ring are at a high risk for injury.

Optimizing Patient Outcomes and Safety With Liposuction

Since its advent in the early 1980s, liposuction has made tremendous advancements, making it the most popular aesthetic surgery performed today. The goal of this Continuing Medical Education (CME) article is to provide a foundation of knowledge of the relevant anatomy, preoperative evaluation, intraoperative technique, and postoperative management for surgeons performing liposuction. Finally, the prevention and management of potential complications will be reviewed along with measures to optimize patient safety and outcomes.

Prevention of Pressure Injuries in the Operating Room: A Quality Improvement Project

Prevention of hospital-acquired pressure injuries (HAPIs) remains a crucial clinical challenge especially for those patients undergoing surgery. The purpose of this project was to examine whether a 5-layer silicone foam dressing applied to the sacrum of patients undergoing vascular surgery decreased the occurrence of sacral pressure injuries and to explore participant characteristics associated with the development of operating room (OR)-related pressure injuries. A pre-/postintervention design, quality improvement project in a convenience sample of 81 patients undergoing vascular surgery, in a 700-bed level I trauma acute care setting, in the Northeastern United States. Eighty-one patients undergoing vascular surgery participated in this project. Thirty-seven were in the preintervention group who were identified from the housewide pressure injury prevalence data from May and December 2010 and received standard pressure injury prevention while hospitalized. Forty-four patients in the intervention group were identified from a hospital-based outpatient vascular surgery office and preoperatively received the 5-layer silicone foam dressing in addition to standard care. Data were collected on the third and seventh postoperative days via the electronic medical record and paper medical records. Collected data included age, gender, comorbidities (diabetes, hypertension, peripheral vascular disease and, smoking status), presence of a 5-layer silicone sacral foam dressing, and pressure injury occurrence. Analysis included descriptive statistics, Fisher exact test to compare groups, and logistic regression to identify associated risk factors. More than 50% (n = 19) in the preintervention group developed a hospital-acquired pressure injury while only 1 subject (n = 2%) in the intervention group developed a hospital-acquired pressure injury (P = .000). Findings indicate that, after controlling for age, gender, and other comorbidities, application of a 5-layer silicone sacral foam dressing significantly reduced the likelihood of development of a new pressure injury (OR= 0.04, 95% confidence interval, 0.00-40; P = .006). This pre-/postquality improvement project, using a 5-layer silicone sacral foam dressing in addition to standard operating room pressure injury preventive interventions, for elective vascular surgical cases, resulted in a significant decrease in sacral operating room-related pressure injuries. These findings suggest the effectiveness of a 5-layer silicone foam dressing when added to standard preventive interventions. The findings warrant further investigation of additional preventative interventions in the OR specific to high-risk populations.

What makes a good head positioner for preventing occipital pressure ulcers

Patients who are stationary endure prolonged soft tissue distortions and deformations at contact areas between their body and the support surface, which may lead to the onset of pressure ulcers (PUs) over time. A novel technology for patient positioning employs innovation in materials science, specifically viscoelastic materials with shape memory properties that compose the Z-Flo™ head positioner (Mölnlycke Health Care, Gothenburg, Sweden). Head positioners are generally known to reduce the occurrence of PUs in scalp tissues and the ears, but quantitative assessments of their biomechanical efficacy are missing in the literature. To determine potential differences in mechanical loads formed in the soft tissues of the back of the head while in contact with 2 head positioner types, Z-Flo vs flat medical foam, we developed 2 comparable finite element model configurations, both including the same 3-dimensional adult head. For both model variants, stresses in skin and fat peaked at the occiput. The skin at the back of the resting head is subjected to greater stress values with respect to fat; however, the Z-Flo positioner reduced the exposure of both skin and fat tissues to elevated stresses considerably (by a factor of 3) compared to the medical foam support. We found the Z-Flo device effective in reducing tissue loads at the surface of the head as well as internally in scalp tissues, with a particular strength in reducing internal tissue shear. The Z-Flo device achieves this protective quality through highly effective immersion and envelopment of the back of the head, generated in the process of manual moulding of the device in preparation for use. Additional protection is achieved through the viscoelastic response of the filling material of this positioner, which relaxes promptly and considerably under the weight of the head (by more than 2-fold within approximately 1 s) as opposed to the elastic recoil of the foam that pushes back on scalp tissues.

Assessment scale of risk for surgical positioning injuries

OBJECTIVE

to build and validate a scale to assess the risk of surgical positioning injuries in adult patients.

METHOD

methodological research, conducted in two phases: construction and face and content validation of the scale and field research, involving 115 patients.

RESULTS

the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning contains seven items, each of which presents five subitems. The scale score ranges between seven and 35 points in which, the higher the score, the higher the patient's risk. The Content Validity Index of the scale corresponded to 0.88. The application of Student's t-test for equality of means revealed the concurrent criterion validity between the scores on the Braden scale and the constructed scale. To assess the predictive criterion validity, the association was tested between the presence of pain deriving from surgical positioning and the development of pressure ulcer, using the score on the Risk Assessment Scale for the Development of Injuries due to Surgical Positioning (p<0.001). The interrater reliability was verified using the intraclass correlation coefficient, equal to 0.99 (p<0.001).

CONCLUSION

the scale is a valid and reliable tool, but further research is needed to assess its use in clinical practice.