Patient care in the perioperative environment.

Patient care in the perioperative environment.

Abstract:	This article focuses on issues relating to patient positioning, by providing an overview of various patient positions, pressure area care and an awareness of some preventative measures to ensure safe patient care. KEYWORDS Patient positioning / Patient safety / Health and safety / Staff safety

Article Type:	Report
Subject:	Perioperative care (Management) Biosafety (Management) Operating rooms (Safety and security measures)
Author:	Pirie, Susan
Pub Date:	07/01/2010
Publication:	Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 Association for Perioperative Practice ISSN: 1750-4589
Issue:	Date: July, 2010 Source Volume: 20 Source Issue: 7
Topic:	Event Code: 200 Management dynamics; 260 General services Computer Subject: Company business management
Geographic:	Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number:	233826355
Full Text:	There is a wide range of issues to consider in relation to the provision of high quality safe patient care in the operating departments and it is not intended to cover all issues here. The aim is to focus on some of the main requirements to be fulfilled in order to promote an environment in which high standards of patient care and safety can be provided. In doing so, perioperative practitioners are fulfilling their accountability in relation to their employer, legal and professional requirements. All staff, irrespective of whether they are registered with a professional regulator such as the Health Professions Council (HPC) or the Nursing and Midwifery Council (NMC), have a legal duty of care to their patients and to their employer who has the right to expect them to fulfil their duties appropriately, in line with local and national guidance, policies and protocols. Patient positioning There is a lack of published research or guidelines relating to the actual positioning of patients (Beckwett 2010). Positioning patients intra-operatively is a necessity to enable full surgical access (Royal Marsden 2005). In undertaking patient positioning there are a number of related issues that need to be considered in order to ensure patient and staff safety. These include care of the airway, ensuring accurate monitoring equipment, maintaining and ensuring access to intravenous lines, as well as ensuring that the patient's circulation and peripheral nerves are not compromised during the positioning or duration of the intra-operative position (Royal Marsden 2005). Patient positioning carries a risk to staff as there is evidence that staff have been injured when positioning patients in healthcare. The issue was considered important enough to be the focus of a campaign by the Royal College of Nursing in 2004 (RCN 2004). Staff should only be undertaking patient positioning without equipment in exceptional or life threatening situations (Franklin-Barnes 2007). However, lifting equipment that removes physical participation from staff is not available in the perioperative environment, although aids such as pat slides and slide sheets are readily available. Using such aids will assist in reducing the risk of injury to staff, and all staff should receive mandatory training as required by the Manual Handling Operations Regulations (HMSO 1992/2002). It is often the case that a patient will require to be moved or positioned during their time in the perioperative environment. Even procedures undertaken in the supine position may require the transfer of the patient from a bed or trolley to the operating table prior to a procedure and back at the end of the procedure (AfPP 2009).The procedure to be undertaken will determine the position that will be required and the more commonly defined positions are as follows: Lateral The patient will be turned onto their side and care must be taken to ensure that the spine is in alignment at all times. Suitable restraints are required to ensure that the patient is secured in the correct position for the duration of the procedure. Extra care should be taken to maintain normothermia as heat loss is an acknowledged risk for patients in this position. Surgical procedures which may require the lateral position are hip surgery, neurosurgery, renal surgery and thoracic surgery (NATN 1999, AfPP 2007, Collis Pellatt 2007). Lithotomy Patients in this position will be supine but will have their legs raised and supported in lithotomy poles. The lower end of the operating table will be removed in order to gain surgical access. It is important that the patient's anterior superior iliac spine is positioned at the break of the table and that care is taken to ensure that the buttocks are fully supported and not overhanging the table. The patient's legs should be raised simultaneously with care taken to ensure that the hips and knees are not flexed more than 90 degrees, and that the legs are positioned on the outside of the lithotomy poles in order to prevent nerve damage. The patient's arms should either be placed on suitable angled arm boards or folded across the abdomen and secured. If the latter is used, care must be taken to ensure that respiration is not compromised by the position of the patient's arms. Surgical procedures which will require the use of the lithotomy position include obstetrics and gynaecology, urology and rectal surgery (NATN 1999, AfPP 2007, AORN 2008). Lloyd Davies This is a similar position to lithotomy and therefore the same care is required in relation to positioning the anterior superior iliac spine and the buttocks. Care must be taken to fully support the patient's calves in the Lloyd Davies supports, ensuring that thromboprophylactic devices can operate effectively and that all possible measures to prevent compartment syndrome are undertaken (Wilde 2004). As with the lithotomy position, care must be taken when positioning the patient's arms, irrespective of whether they are secured to the side of the patient or placed on arm boards to ensure venous access. The Lloyd Davies position will be used in some genitourinary procedures as well as procedures where access is required to both the abdominal and perineal areas in procedures such as an anterior resection (AfPP 2007). Jack-knife/ Knee chest position This is similar to the prone position and will require additional positioning aids. Care must be taken to ensure that minimal pressure is exerted on the abdomen, neck, pelvis or spine with the careful use of pillows. The arms should be placed on suitable angled arm boards and the head should be fully supported whilst turned to one side, but ensuring suitable airway access for the anaesthetist. The patient should be maintained in the agreed position with the use of suitable operating table restraints and accessories. It is imperative that there is a sufficient number of suitable trained staff to manoeuvre the patient into this position. This position may be utilised for some adrenal, rectal or spinal surgery procedures (AfPP 2007). Prone As with the Jack knife position, there should be sufficient staff to facilitate the rolling of the patient onto their abdomen. Care must be taken to ensure that cervical alignment is maintained at all times, and that the chin, eyes and forehead are all adequately protected. It is important that a reinforced tracheal tube is used or alternatively, if a laryngeal mask airway is used, that the anaesthetist is competent and experienced to manage the airway in this position. A padded horseshoe should be used to support the head and to prevent the neck being hyper-extended. Care should be taken to ensure that there is no torsion to the breasts or male genitalia when patients are in the prone position, and that the patient's legs are padded from the knee to the feet by a pillow. The patient's arms will need to be brought forward simultaneously and placed on arm supports with no more than 90 degree flexion. The prone position will be used for patients who are undergoing surgery to the buttocks or heels, for varicose vein surgery involving the short saphenous vein, and spinal surgery (NATN 1999, AfPP 2007). Supine Most patients will remain in the supine position for their perioperative procedure. Care must be taken to ensure that the spine maintains alignment and that legs and ankles are parallel. The head should be maintained in a neutral position and the arms may be placed on suitable angled arm boards, or alternatively secured at the side of the patient's body. Pregnant patients will often require a 20 degree tilt to the left in order to prevent pressure on the inferior vena cava and associated hypotension. Care should be taken to ensure that all pressure areas are adequately protected (NATN 1999, AfPP 2007, Collis Pellatt 2007). Trendelburg This involves the patient being in a head down position on the operating table and this should be no greater than 20 degrees of tilt. The impact of gravity in this position will allow the abdominal contents to move towards the diaphragm and will also minimise blood loss at the operative site due to the elevation of the legs. It is important that the operating table has a non slip mattress and that restraints are used appropriately. This position is often utilised for the insertion of a central line or for lower abdominal or gynaecological procedures as well as some lower limb vascular procedures. This position should be avoided if at all possible for morbidly obese patients as there is an increased risk of respiratory and circulatory compromise (NATN 1999, AfPP 2007, AORN 2008). Reverse Trendleburg As the name suggests, this position involves the patient's head being elevated and body lowered, thus providing maximum venous drainage from the operative site. Again, the operating table must have a non slip mattress and the patient will need to be secure. This position may be utilised in head and neck surgery, upper GI tract procedures including gall bladder procedures and for some shoulder surgery (NATN 1999, AfPP 2007,). Pressure area care The condition of the patient's skin should be noted prior to and following the procedure and should be fully documented. It is known that procedures which last for two to three hours significantly increase the risk of pressure damage (AfPP 2007, AORN 2008, AfPP 2009). The prevention of pressure damage is a key element of perioperative practice, and mistakes are costly for the NHS (Radford et al 2004). Some of the predisposing factors for the formation of pressure ulcers or sores are identified as follows: * Pressure * Shear * Friction Standard operating table mattresses may contribute to the degree of pressure that the patient's skin is subjected to, and some warming devices can also increase pressure. Pressure relieving mattresses are known to address some of these issues. Pressure is the most likely cause of pressure damage as it leads to compression of the vascular system, thereby decreasing the nutrition and oxygen levels as well as allowing a build up of waste products within the tissues. The force applied to a patient when their skin remains in contact with a mattress, yet their internal tissues and skeletal systems actually move, is described as a shearing force or shear. The consequences of shear are a disruption of the microcirculation within the tissues and the potential for these tissues to be torn. If excessive force is used during the transfer of patients, particularly when anesthetised, then the skin itself will move against the surface, thereby increasing the level of tissue damage the patient will suffer. There are a range of other factors that may predispose patients to sustain pressure damage when in the operating theatre and these are as follows: * Advanced age, which may result in poor skin integrity. * Poor nutritional status, which may increase the pressure caused by bony prominences if thin or emaciated. * Patients who are obese may experience greater shearing and friction on transfer movements and may also have poor tissue perfusion. * Long periods of immobility, including the immobility of a long perioperative procedure. * Dehydration will also affect the skin integrity and therefore the potential for pressure damage. * Excessive moisture can affect the integrity of the skin, particularly if pooled on the drapes. * Difficulty in maintaining normothermia, particularly inadvertent hypothermia, may result in poor skin integrity. Some of the measures which may minimise these factors are as follows: * Efficient pre-assessment that identifies at risk patients, using tools such as the waterlow scale and ensuring efficient communication to enable high quality care to be provided. * Staff who are competent at manual handling and patient transfer and ensure the safe handling and positioning of patients at all times. * Ensuring that adequate pressure relieving aids are used during the perioperative period * All instruments should be returned to the trolley and care should be taken to ensure that the surgical team do not lean on the patient. * Ensuring that all pre and post operative skin assessments are fully documented (AfPP 2007, Hind & Wicker 2000). Prevention of errors in perioperative procedures The list below of the potential errors that may occur in the perioperative environment is not comprehensive, but addresses some of the issues around patient identification, the procedure list and the count. * All patients should have an identity band applied on admission and the identity band should comply with current guidance (NPSA 2007). * Patients should be sent for in line with local policies and protocols and the agreement of the anaesthetist and operating surgeon (AfPP 2007). * All patient details, including the operative procedure should be checked prior to leaving the ward, on arrival in theatre, transfer to the anaesthetic room, transfer into theatre, transfer from theatre to recovery and again on discharge from recovery to the ward area. * The operating list should be compiled by the operating surgeon and delivered to the perioperative department at least 16-24 hours in advance of the start of the operating session (AfPP 2009). * Changes to the operating lists should be avoided wherever possible, but if required should be undertaken in line with local policy and communicated to all concerned (AfPP 2007). * All swabs needles and instruments should be counted by two practitioners, one of whom should be registered, prior to the start of the procedure, at the closure of each cavity or cavity within a cavity and at skin closure (AfPP 2009). n Operating surgeons must allow time for these counts to be undertaken, and must verbally acknowledge the outcome of the count to the scrub practitioner (AfPP 2007). * In the event of a wrong count, a thorough search must be undertaken and the surgeon informed. If the item cannot be found, then a plain x-ray with a portable machine from x-ray must be undertaken (MHRA 2005). The aim of this article has been to raise awareness of some of the issues pertaining to patient safety in the perioperative environment. There is a number of patient safety and legal issues to be considered in relation to patient care in this environment and these have been highlighted in the text. It has been acknowledged that there is a dearth of literature pertaining to patient positioning in this environment and it is anticipated that this article may provide a useful reference to the issues that have been highlighted. Task 1 [ILLUSTRATION OMITTED] Read Read the following article: JPP2010 20 (1) 26-29 Are we doing enough to prevent patient injury caused by positioning for surgery? Notional Learning Hours 15 mins Knowledge and Skills Dimension Core 3: Health, Safety and security Core 4: Service Improvement Core 5: Quality Task 2 [ILLUSTRATION OMITTED] Reflect 1. Identify the general and specific pressure relieving devices in your department 2. Ensure that you are familiar with their usage by reading the literature provided by the manufacturer and any local policies that may be available 3. Reflect on whether the current practices with these devices reflect the manufacturer's guidance and local policies Notional Learning Hours 1 hour Knowledge and Skills Dimension Core 1: Communication Core 3: Health, Safety and security Core 4: Service Improvement Core 5: Quality Task 3 [ILLUSTRATION OMITTED] Reflect 1. Reflect on a patient safety incident or a near miss such as a wrong count, poor surgical site marking , incorrect consent etc that you have been involved in or has occurred in your department 2. What measures have been put in place, if any, to prevent this or a similar incident occurring again Notional Learning Hours 1 hour / 30 mins / 2 hours Knowledge and Skills Dimension Core 1: Communication Core 3: Health, Safety and security Core 4: Service Improvement Core 5: Quality Reflective model You will find several reflective module templates for you to utilise when utilising reflective practice for your CPD under the career development tab on the AfPP web site. Provenance and Peer review: Commissioned by Head of Publishing/Editorial; Peer reviewed; Accepted for publication March 2010. References American periOperative Room Nurses Association 2008 Perioperative Standards and Recommended Practices Denver, AORN Association for Perioperative Practice 2009 Safeguards for Invasive Procedures: managing the risk Harrogate, AfPP Association for Perioperative Practice 2007 Standards and Recommendations for Safe Perioperative practice Harrogate, AfPP Beckwett AE 2010 Are we doing enough to prevent patient injury caused by positioning for surgery Journal of Perioperative Practice 20 (1) 26-29 Collis Pellatt G 2007 Clinical skills: bed making and patient positioning British Journal of Nursing 16 (5) 302-305 Franklin-Barnes A 2007 Erasing the word 'lift' from nurses' vocabulary when handling patients British Journal of Nursing 16 (18) 1144-1147 Hind M, Wicker P 2000 Principles of Perioperative Practice Edinburgh, Churchill Livingstone Her Majesty's Stationery Office 1992 Manual Handling Operations Regulations (MHO) 1992 as amended in 2002 Norwich, The Stationery Office Medicines and Healthcare Products Regulatory Agency 2005 One liners Issue 35 Available from: www.mhra.gov.uk/Publications/Safetyguidance/OneLi ners/CON1004209 [Accessed April 2010] National Association for Theatre Nurses 1999 Back to Basics Harrogate, NATN National Patient Safety Agency 2009 WHO Surgical Safety Checklist London, NPSA National Patient Safety Agency 2007 Standardising Wristbands Improves Patient Safety London, NPSA Radford M, County B, Oakley M 2004 Advancing Perioperative Practice Cheltenham, Nelson Thornes Royal College of Nursing 2004 Safer Patient Handling London, RCN The Royal Marsden NHS Foundation Trust 2005 The Royal Marsden Hospital Manual of Clinical Nursing Procedures 6th edition Oxford, Blackwell Publishing Wilde S 2004 Compartment syndrome British Journal of Perioperative Nursing 14 (12) 546-550 Susan Pirie RGN MA Health Care Ethics & Law Practice Educator Theatres, Surrey and Sussex Healthcare NHS Trust, Redhill No competing interests declared Correspondence address: c/o AfPP, Daisy Ayris House, 6 Grove Park Court, Harrogate, HG1 4DP. Email: spirie2000@yahoo.co.uk
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