Under Pressure

Patient Positioning Injuries 

As I sit in my office I hear multiple conversations echoing down the hallway.  Yet, one conversation has caught my attention. A new perioperative nurse is complaining about how long it has taken to position a surgical patient.  The response from her preceptor is that positioning is like construction you have to build a good foundation.  Positioning matters, and it should take time because the last thing you want to happen is your patient to have a pressure injury or nerve damage. At my hospital, pressure injuries have been a major topic of concern across multiple care settings, and we have organized a multidisciplinary team to address the issue.

There are many risks to surgery. However, most patients and family members are worried about post-operative pain, surgical site infections and anesthesia complications. Patient positioning is a risk that most do not consider, however, immediate post-operative complication can occur as well as more long term complications like disability and pain.  Some positioning complications are as follows:

• Soft tissue injuries can occur due to friction and pressure that can lead to ischemia
• Nerve, joint and muscle injuries can occur due to stretching, pressure and compression
• Circulatory system can be compromised from positioning due to diminished blood flow to limbs and or diminished venous return 
• Respiratory system can be impacted due to diminished air flow and restriction of the diaphragm or rib cage. This typically occurs in more obese surgical patients (AORN, 2018).

 Perioperative nurses play a vital role in prevention of positioning injuries.  The patient is positioned to allow for optimal surgical access and for the safest and most efficacious placement to prevent injury. There are a variety of surgical positions utilized in surgery, yet, the main ones are supine, lithotomy, lateral, Trendelenburg, reverse Trendelenburg and prone. The following video (Incision, 2021) reviews how to properly position surgical patient for surgery in the different position mentioned above. 

Hospital acquired pressure injuries are typically preventable. These injuries occur due to extrinsic pressure being applied to a bony structure.  These injuries have cost healthcare institutions in the United States alone over 26 billion dollars a year on average (Aderden et al., 2021).  How often do these injuries take place? On average, they occur between 5-10% in critical care settings, however, the most prevalent threat is to surgical patients (Aderden et al., 2021).  The prevalence of pressure injuries increases with the length of surgery. 

Patients who acquire a pressure injury have a greater risk for the following:

• Sepsis
• Pneumonia
• Adverse events
• Higher mortality rate (Joseph et al., 2019) 

The National Patient Injury Advisory Panel (2021) has created a synopsis of data with regard to pressure injuries in the United States, see link and data below. 

https://cdn.ymaws.com/npiap.com/resource/resmgr/public_policy_files/npiap_word_fact_sheet_08mar2.pdf

How Do We Prevent The Risk of Pressure Injuries

The prevention of pressure injuries is multifaceted and involves multiple care teams. The potential for injury to occur takes place in the operating room, however, the possibility of the pressure injury increases during the patient’s hospital stay (Eberhardt et al.,2020).  Pressure injury prevention necessitates improvement across various disciplines and care teams.  Prevention mandates a change in the healthcare culture and practice where teamwork and effective communication are leading the way. Recent studies reveal that prevention of pressure injuries occur due to knowledge deficit, organizational culture issues and staffs refusal to change (Teo et al., 2018).  I am sure everyone has dealt with “this is how we always do it, why should we change” mentality. 

The transfer of care is an optimal time to provide patient specific data from one provider to another to ensure safe, efficacious continuity of care. A structured electronic medical record handoff will provide staff with essential information at their fingertips and would optimize patient outcomes and communication.  Studies have shown that electronic handoff communication have been shown to reduce medical errors and ameliorate patient care (Tisdale et al., 2019). Currently, our transfer of care relies on a verbal dialogue where information is omitted or miscommunication occurs. During the post-operative transfer of care the surgical team provides a verbal report to the PACU staff or the intensive care unit. This process is rushed and typically hectic due to the receiving teams focus on the incoming patient and ensuring placement of monitors. 

An improved handoff tool would ameliorate post-operative transfer of care by increasing efficiency, reliability and standardization. At my institution, post-operative transfer of care is problematic for the following reasons:

• Incomplete information
• Inaccurate information
• Time constraint
• Un-standardized tools for hand off
• Interruptions
• Verbal format

Furthermore, many members of the interdisciplinary team have various levels of knowledge and training.  At my hospital, we discovered that many nurses were not aware of the various surgical positions.  In addition, they were not aware of the pressure points associated with these specific surgical positions.  Education can ameliorate and familiarize staff with patient positioning during surgery and pressure points to focus on during their skin assessments.

                                                                          (Gefen et al., 2020)

How Can IT Help Solve the Problem

A handoff process that is standardized will improve patient outcomes. Evidence based practice reveals that standardization of transfer of care with checklists improve communication and patient outcomes (Hong Mershon et al., 2021). Incorporating an electronic health record checklist that also has cognitive aids will assist with communication.  For instance, incorporating a picture into the electronic health record of how the patient was positioned during surgery will assist the care teams with care and skin assessments. It will be a shared drive with electronic images of surgical patient positions and arrows that will highlight the pressure point areas. The operating room nurse will select an image from an image library that will denote the actual position the patient was placed during surgery.  This will allow the operating room team to communicate through an electronic image the surgical position and the potential pressure injury areas that may be of concern. The image selected will be placed in the electronic health record and will be utilized as a guide across the continuum of care to prevent pressure injuries.

In addition, electronic learning to assist care teams understand and familiarize themselves with surgical positioning techniques and the pressure points associated with those positions. These educational opportunities are available for the operating room but would be beneficial for multiple care teams that support and care for the surgical patient. These educational videos would assist in alerting the care team of what pressure point to be concerned with during their skin assessment and to protect these pressure points from future harm. 

Going forward, all nurses have the opportunity to prevent pressure injuries.  The possibility of the injury may begin in the surgical suite, however, multiple care settings can assist and do their part. Incorporating the evidence based protocols for doing complete skin assessments and documenting findings so this data can be used to track and determine the prevalence of pressure injuries. In addition, nutrition, skin care, mobilization, turning the patient to prevent pressure injuries and education will assist in improving patient outcomes by reducing pressure injuries.  The adoption of the tools presented will assist the care teams with communication and will assist with the care of the patient especially skin assessments.