Any surgical operation comes with many risks, but the most overlooked are those complications that arise from improper positioning of the patient. From pressure sores due to poor mattress support through to nerve damage as a result of use of the wrong type of stirrup, such injuries must be prevented. Patient positioning and pressure management expert Dan Allen tells Nic Paton about the consequences and treatment of these issues
It’s a largely unsung part of the operating theatre environment, but the complications that can result from getting patient positioning wrong can be significant, severe and costly for the hospital and, more importantly, for the patient.
As Dan Allen, inventor of the Allen stirrup and founding partner of MEDICUS Surgical and the Nursing CE Portal, points out, improper patient positioning can cause long-term post-procedure injury and pain.
"I’ve recently been involved in a court case as an expert witness for a nurse who underwent a hysterectomy," Allen recalls. "A candy cane stirrup was employed instead of an Allen stirrup – even though the patient, a nurse who had seen the candy cane stirrup’s adverse effects many times over the years, had asked for it not to be used – and, three years on, she is still unable to walk unaided.
"People outside the industry know that patient positioning is an issue, but they do not fully realise the challenges faced around continuity of protection requirements."
Keeping pace with technology
With surgical and device technology now advancing at a rapid pace, especially in the field of robotics, the need for patient positioning awareness and best practice is greater than ever. Changes and advances in technology can often have knock-on – and sometimes unforeseen – consequences for patient positioning, and so effective management must involve constant review and education, as well as investment in new devices.
"Many patient positioning injuries do not start in the operating theatre," says Allen. "Particularly with issues such as pressure sores, problems can start the moment the patient takes the analgesia – before they even enter the theatre.
"The anaesthesiologist’s top priority is to ensure that the patient does not feel pain during the procedure, which is as it should be; however, positioning needs to be a key part of this circle of safety and continuity of protection," he stresses.
While it is vitally important, Allen acknowledges that patient positioning is something of a "moving target", particularly as technology continues to evolve and improve.
"Three decades ago, an operating table only tilted 20° and had a 300lb weight limit; today, it’s 45° and 1,000lb," Allen says. "But that, in turn, creates new issues around gravity, patient weight and pressure."
So, in the face of such technological advances, what problems need to be addressed?
"There needs to be a greater focus on secondary accessory lines," Allen declares. "You can spend $2 million on a new robotic device, but if the patient comes out with pressure sores, the hospital is going to be liable for the full extent of the therapy and treatment required to get that patient back on their feet.
"Although the technology we now have in the operating theatre benefits us all, it must be matched by complementary patient positioning procedures and devices," he adds.
The challenges of robotic surgery
Robotic-assisted laparoscopic surgery is at the cutting-edge of surgical innovation, but the use of such techniques comes with its own set of patient positioning challenges, Allen argues.
"If you are doing a laparoscopic procedure and the patient slides 2-3in, it won’t be a huge problem because the surgeon can adjust," he explains. "During a robotic procedure, however, the patient could be in real trouble."
If the patient slides just half an inch during robotic surgery, the robotic arms, instruments and trocars will maintain their fixed location as programmed. Such injuries can result in severe and prolonged post-operative pain, bruising or even necrosis.
Allen claims that there is a "substantial void" between real-time positioning requirements, existing patient positioning standards and guidelines, and the availability of next-generation, robot-compatible accessories.
Current positioning principles and guidelines generally apply to traditional laparoscopy, but robotic surgery entails new positioning requirements. This can mean that some of the traditional restraint devices become inappropriate, particularly when a patient is in the Trendelenburg position (which allows a surgeon access to the pelvis and is especially useful during lithotomies or to remove bladder stones).
Shoulder braces, tape and foam, and traditional anatomical concavities, for example, may not be complementary with traditional Trendelenburg positioning when robotic devices are in use. Devices with restraint straps and traditional skin friction or skin shear techniques may also become problematic.
Contemporary toboggan devices, while effective in cradling the arms for minimally invasive surgical procedures, may also be impractical for use during robotic surgery because they often clash with the robot arms or interfere with the assistant, Allen points out.
When it comes to solutions, he argues that, contrary to Association of peri-Operative Registered Nurses (AORN) guidelines, tucking arms has become standard when performing robotic procedures. There are also now many arm restraint devices available that are designed specifically for robotic surgery and which meet or exceed AORN guidelines (see ‘Doing the robot – the right way’, right).
The costs of poor positioning
The financial cost of failing in this area can also be significant. Allen estimates that between 13% and 40% of surgical patients are injured as a result of poor positioning. Pressure sores alone cost the US healthcare system $1 billion a year, he adds.
"In my opinion, all positioning injuries are preventable and unnecessary, " declares Allen. "Nowadays, there is no excuse for poor patient positioning as the technology exists for zero operating-theatre-acquired injuries.
"Hospitals, however, have to be prepared to spend the money, and put in the time and education to protect patients, otherwise they will end up paying in the long term through litigation. Prevention is clearly more preferable – and cheaper – than litigation."
He explains that there is too frequently a trade-off with financial constraints. Medical practitioners need a greater awareness and understanding of the ramifications of poor patient positioning, as well as the fact that new techniques and technologies exist to combat it. Even when it is high on the agenda, he asserts, budgetary issues too often get in the way.
"Hospitals are less willing nowadays to pay extra for innovation; they do not want to spend any more money than they need to, so it takes people with a passion for these issues to keep pushing these important messages," Allen says.
"Often, they may commit money to these issues, but have to wait for the new budget. Then, when that new budget is released, a new surgical device or ultrasound machine comes along that creates conflicting spending pressures. This means that getting, say, a new stirrup gets overlooked."
Patient positioning-related injuries or complications can, however, also result in patients spending longer periods recuperating in hospital, which in turns incurs higher costs of care. For instance, the treatment of a pressure sore, according to Allen, can take up to a month.
Using as an example his own Allen stirrup – a boot stirrup that was created primarily for lithotomies – he points out that, prior to its development, about 3% of lithotomy patients were coming out of surgery injured, with some even ending up losing a leg because the stirrup had cut off the blood flow to their entire lower leg.
"This shows that patient positioning can be very much an issue of life or death if it is not managed properly," he says. "The biggest issue is that you cannot just hold an arm or leg in place without risking cutting off the blood supply to the nerve, which could potentially lead to patient neuropathy.
"The accessories you have to prevent positioning injuries are vital – especially if you are operating on a patient who is morbidly obese," he continues. "Similarly, if the patient is elderly or has arthritis, patient positioning must be considered very closely. A surgeon even leaning on a patient can create a problem – for example, moving an arm from 45-90° can stretch a patient’s nerve and cause neuropathy or sciatica – and leave them in excruciating pain post-operation."
How can healthcare professionals ensure safe positioning at every step of in-theatre procedures? Allen acknowledges that this involves juggling many different issues.
"You must keep feeling for a pulse at the far end of an extremity," Allen asserts. "You need to check the patient’s breathing, blood flow, range of motion, skin and nerves, while also keeping in mind vascular considerations.
"Skin shear, for example, can be a potential problem, and nerve injuries are clearly a big issue. If a patient is sitting down, there will be fewer nerve issues but more skin issues; yet if they are in a prone position, how are they going to breathe? Sometimes, it can be something as small as a wrinkle in a support or mattress that creates a pressure sore. There must be ongoing awareness and diligence."