ENST06-0905: Positioning: Patient Safety Initiative
Author:
Terri Goodman, RN, PhD
1.2 contact hours
OBJECTIVES
1. Discuss the adverse outcomes of positioning
2. Identify risk factors that place patients in jeopardy of developing
tissue damage during positioning
3. Compare the three most common materials used in positioning devices
4. Identify the essential components of a patient safety initiative.
Since the
Institute of Medicine's 1999 publication, "To Err Is Human,"
focused the public's attention on medical errors, patient safety has
become a major focus in all healthcare environments. In surgery, positioning
is one of the major safety challenges. Every patient is positioned for
surgery, and each one is at risk for complications related to positioning.
Research in long-term care, critical care and rehab during the last
five to 10 years has identified a surgical experience as a common factor
among patients with pressure ulcers. For many reasons, surgical personnel
have been unaware of the number of adverse outcomes of positioning,
and that tissue damage related to surgical positioning is more prevalent
than previously realized. Tissue damage often goes unrecognized for
hours to days following the surgical procedure, and the connection to
positioning during surgery may not be explored or communicated. Lesions
discovered postoperatively are frequently unexplained as to cause. Usually,
a serious effort to find the cause does not begin until a suit is initiated
... and the real evidence and witnesses are no longer available. Until
recently, adverse outcomes of positioning have been documented much
more frequently in the legal literature than in medical journals.
1
With the awareness that positioning is a key safety issue comes the
need to identify a method to facilitate positive outcomes. Recent studies
of safety issues (e.g., medication errors) have underscored the need
to focus on processes, not individuals. With a process in place that
minimizes the opportunity for errors to be made, there is less chance
that individuals will err. Emphasis today is on the development of a
safety culture in which identification of safety needs leads to improvement
in practice, not punishment.
Adverse outcomes of positioning include nerve damage and trauma to skin
and underlying tissue. Nerves can be damaged through compression or
stretching. Nerve damage can be prevented with good anatomical alignment,
avoiding hyperextension of extremities, and by padding to avoid compression.
It is more difficult to protect patients from damage to skin and underlying
tissues caused by pressure and shear forces. Tissue damage most frequently
occurs over a bony prominence that is supporting the patient's weight.
Pressure on the tissues over the bony area compresses blood vessels,
diminishing the flow of oxygen and nutrients to the area, ultimately
resulting in cell death.
Normal capillary pressure is 32mmHG 2. In Landis' studies, capillaries
remained patent under pressures up to 32 mmHg; pressures greater than
32 mmHg collapsed the vessels. Although capillary pressure differs among
individuals, and among vessels in the same individual, our goal is to
maintain pressures less than 32 mmHg on tissue over bony prominences
during surgery.
In addition to pressure, shear forces cause significant tissue damage.
Shear occurs when tissue is pulled or pushed in two directions at once.
When the patient lies on the OR table, the bone pushes against the tissue
in one direction, and the patient's weight forces the tissue around
the bone in the other direction. (See Figure 1)
Figure
1. Tissue fibers are stretched, torn and compressed. Friction, the rubbing
of two surfaces against one another, also promotes tissue damage.
Pressure ulcers vary from superficial (or Stage I), a defined reddened
area of intact skin that does not blanch when pressure is applied, to
full-thickness skill loss with extensive underlying tissue necrosis
including muscle and bone (Stage IV or Deep Tissue Injury). The first
sign of increasing pressure is hyperemia, or redness and warmth of the
skin due to relaxing of arterioles or obstruction of the outflow of
blood (much like the reddened area you see when you uncross your legs).
When pressure is relieved quickly, the hyperemia resolves. It is not
unusual to see reddened areas on the patient's skin in areas of pressure.
However, redness that does not disappear in a few minutes may signify
that tissue has been severely damaged. Tissue damage that occurs during
surgical positioning frequently occurs in the deep tissues at the bone
interface and can remain undetected for hours to days following surgery.
Because of gravity, there is always some degree of pressure on our bodies.
Under normal circumstances, our bodies signal us when our tissues can
no longer safely sustain the pressure upon them. Pain and discomfort
cause us to shift our position, relieving the pressure, even during
sleep. During surgery, the body's normal defenses are inhibited by anesthesia.
The longer a patient remains immobile, even healthy tissues become vulnerable
to pressure damage. Pressure studies generally agree that surgical procedures
lasting more than two to two-and-a-half hours put even the healthiest
of patients at risk.
Surgery encompasses the three prime contributors to tissue damage: pressure,
immobility and time. Any surgical experience subjects every patient
to all three of these factors. As the influence of each factor increases,
so does the likelihood of tissue damage.
Risk factors are those factors that increase or prolong pressure, increase
immobility, and reduce a patient's ability to maintain tissue health.
Risk factors can be extrinsic (inherent in the surgical environment)
or intrinsic (characteristics of the patients themselves). Extrinsic
factures include anesthesia, the type and length of the surgical procedure,
heat, moisture, and massage. Intrinsic factors include age, weight,
nutritional status, fluid volume and comorbid conditions.
Anesthesia and vasodilation reduce perfusion to bony prominences and
to elevated or dependent body parts. The normal vasomotor and muscular
mechanisms that maintain circulation and tissue perfusion are also inhibited.
The anesthetized patient cannot respond to the body's signals of increasing
pressure. Further, the affects of anesthesia can last for hours following
the surgical procedure. Heat raises the body's metabolic rate, increasing
the need for oxygen and cellular nutrients; cold cells produce less
energy. Both heat and cold interfere with cellular efficiency and predispose
them to damage. Even a one-degree Centigrade rise in temperature can
increase oxygen demand by 10 percent.3
Moisture macerates tissue and reduces its resilience to external forces.
Although further research is required, studies have suggested that extracorporeal
circulation may be a risk factor.4-5
Massaging reddened areas to increase circulation and prevent the development
of a pressure ulcer used to be common practice. Research 6-7
demonstrates that massage may be harmful. In one study, there was a
38 percent reduction in the incidence of pressure ulcers in non-massaged
vs. massaged skin.8
Studies have
identified age as an important predictive factor in pressure ulcer development
because of the vascular and neurological changes that occur with aging.
Thinning of the skin, loss of elasticity, reduced capillary perfusion
and decreased collagen regeneration all contribute to a diminished capacity
to withstand the effects of pressure and reduced healing potential. Neonatal
and low birth weight pediatric patients with immature skin, fragile immune
systems and poor nutrition are also at high risk. A patient's weight affects
both the amount of pressure placed on bony prominences and the amount
of subcutaneous tissue to cushion bony prominences.
Low albumin levels (>3.0 mg/dl) are an indicator of low levels of protein
in the blood and is considered a risk factor.4,9 Nutritional
deficiency has been identified more as a predictor of healing potential
than a risk factor for developing pressure ulcers. Malnourished patients
sustain more severe ulcers and have greater difficulty healing.10-11
Comorbid conditions that interfere with vascular perfusion and tissue
oxygenation or limit mobility and sensation are directly associated with
pressure ulcer development. 12,6
Assessing surgical patients to identify risk factors for pressure ulcer
development is essential to planning for adequate protection. Although
there is no assessment tool specifically designed for surgical patients,
scores on a Braden 13 or Norton Scale 14
used on the nursing unit would be helpful. Remember, too, that healthy
patients who have experienced a period of immobility due to illness or
accident are at higher than normal risk.
Each surgical position places the bony prominences bearing the bulk of
the patient's weight at highest risk. In the supine position (including
sitting and lithotomy), the areas of highest incidence of ulcer formation
are the occiput, the sacrum, and the heels. Alopecia (hair loss) over
the occiput is common during long procedures. 8
Although it usually resolved spontaneously, it can be permanent if tissue
damage is extensive. It is best to avoid using donut-shaped devices under
areas of high pressure; use a pillow or a positioner designed for that
body part. 15
In the prone position, the forehead or cheek bears the weight of the patient's
head. The female breasts and male genitalia must be protected. Other weight-bearing
bony prominences include the ischial tuberosities, knees, ankles and toes.
In the lateral position, the trochanter is susceptible to damage as is
the lateral knee and maleolus.
Nerves most often damaged during positioning are the brachial plexus due
to hyperextension of the arms; the ulnar, median and radial nerves due
to compression from inadequate padding; and the peroneal nerve when the
knees are not well-positioned and padded.
Knowing what nerves need protecting and how to protect them, and what
bony prominences to pad adequately, are essential components of a positioning
safety initiative. However, the quality of positioning devices is also
a factor in protecting the patient. Not all of the devices we use achieve
the outcomes we expect.
Positioners are most frequently composed of one of three materials: linen,
foam or gel. Linen is the least patient-friendly of these materials. Rolls
and bolsters fashioned from towels, sheets or blankets keep the patient
stable during the procedure, but produce high and inconsistent pressures.
Linen promotes friction injuries and is not fluid-proof. Fashioning positioning
devices from linen is time-consuming and expensive. Also, linens used
to cover positioning devices (e.g., pillowcases, towels and sheets) reduce
the effectiveness of the positioner.
Gel products are viscous polymers that exhibit qualities of both liquids
and solids. They provide a degree of buoyancy depending upon the chemical
makeup of the gel, but are proportionally quite heavy. In surgery, gel
is more appropriate for small positioning devices. There has been little
testing of the effectiveness of gel positioning devices in the surgical
setting, but in long-term care and rehab, gel support materials have not
proven to provide controlled relief for immobile patients.
Foam is lightweight, fashions easily into a variety of shapes and contours,
and the density can be adjusted to produce different levels of support.
Although foam is the most versatile material, effective foam positioners
must achieve a balance between softness to relieve pressure and density
to prevent bottoming out. Cover materials can alter the pressure-reducing
properties of foam.
The material covering a positioning device affects its pressure-reducing
capability. Stitching versus heat-sealing affects the ability to prevent
the transfer of fluid and microorganisms. AORN -- in Recommend Practices
for Positioning the Patient in the Perioperative Practice Setting16 --
lists 11 criteria for an ideal positioning device.
The AORN Criteria for Positioning Devices (from Recommended Practices
for Positioning the Patient in the Perioperative Practice Setting) are
as follows:
- Availability in a variety of appropriate sizes and shapes
- Durable material and design
- Ability to maintain normal capillary interface pressure
- Resistance to moisture and microorganisms
- Radiolucency
- Fire resistance
- Nonallergenic to the patient
- Ease of use
- Easily cleaned/disinfected if not disposable
- Easily stored, handled and retrieved
- Cost effectiveness
The key to evaluating the effectiveness of positioning products is to
study product testing. A positioning device should demonstrate its ability
to achieve peak pressures (pressures under the bony prominences) of well
below 32mg Hg. Select positioning devices that demonstrate adequate pressure
reduction and meet all of the AORN criteria.
The Patient Safety Initiative
Effective safety programs are systems designed to reduce the potential
for human error. A positioning safety initiative includes best practices,
education and best products. Best practice includes policies that identify
the requirements for each surgical position -- identifying the anatomy
at highest risk for damage, identifying patient risk factors that predispose
them to adverse outcomes, and providing clear instructions for protecting
the patient adequately. Education insures that all practitioners have
the knowledge and skill to apply the policies effectively. Best products
insure that the items we use to protect our patients, in fact, provide
the protection we expect.
Practitioners
in a safety culture assume the responsibility for insuring that the
outcomes of their practice achieve their expectations. They are sensitive
to information that suggests the need for improvement. They strive for
excellence, responding to opportunities to improve positively and productively,
not punitively.
Note: The research for this article was funded with an educational
grant from ConMed, Inc.
For 15 years, Terri Goodman, RN, PhD has practiced in the operating
room and as an educator in acute-care facilities in several states.
She left the acute-care environment to become director of education
for Johnson & Johnson Medical, where she developed and implemented
professional education programs in the United States, Asia Pacific and
Latin America. Now, as a consultant, she continues to develop continuing
education programs, publish, and speak at professional seminars and
conferences. Goodman is active in several nursing organizations, serving
on the board, on committees, and as webmaster.
Figure 1. Tissue at the bone/tissue interface sustains downward pressure
from the bone and upward pressure from the surface, resulting in both
pressure and shear injury. Copyright (c) 2002 Nucleus Communication,
Inc. All rights reserved. www.nucleusinc.com
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