Prone positioning for surgery.
Abstract: The role of the registered perioperative practitioner (Operating Department Practitioner or Registered Nurse) includes the responsibility for safely positioning patients for surgery. The prone position is in common use for a variety of surgical procedures. The formal term for this surgical position is ventral decubitus (meaning laying face down).
Subject: Surgery (Practice)
Position (Surgery) (Practice)
Patients (Positioning)
Patients (Safety and security measures)
Patients (Laws, regulations and rules)
Patients (Practice)
Author: Bowers, Mark
Pub Date: 04/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: April, 2012 Source Volume: 22 Source Issue: 4
Topic: Event Code: 200 Management dynamics; 260 General services; 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation
Product: Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance
Accession Number: 293545458
Full Text: Manually handling unconscious patients and positioning them to facilitate surgical access brings with it the likelihood of inadvertent physical harm to the patient. Anaesthetised patients lack muscle tone, and iatrogenic injury in prone patients has been widely reported (Gill & Heavner 2006, Edgecombe et al 2008, Haushofer et al 2009, Hogan et al 2009). Theatre practitioners need to anticipate the risk of harm and introduce strategies to protect the health and safety of the surgical patient.

Theatre practitioners may also be at risk of sustaining physical injury as a result manoeuvring patients into this position, due to unstable posture or excessive and hazardous weight bearing. In the past twenty-five years evidence has emerged to inform safe practice in healthcare, in response to legislation and the financial compensation awarded for legal claims (Smith 2005). Mandatory training has now been established for all healthcare practitioners and back care advisers are employed in some clinical areas to provide advice and assist with problem solving for hazardous or controversial techniques (RCN 2003).

This article aims to address the key factors that inform safe proning of people undergoing surgery. The legislation is considered to provide context to common moving and handling techniques. Learning tasks are provided to enhance practitioner knowledge of personal accountability and indications for prone positioning, as well as enquiries made related to proning technique. Suggestions are made for techniques that are designed to reduce the incidence of patient injury. The focus of this specialist practice will encourage theatre practitioners to reflect on their knowledge and experience related to proning in theatre and how they may change their practice for the benefit of their patients (see Figure 1).

The role of the theatre practitioner when proning patients requires advanced knowledge of:

* clinical procedures

* anatomy and physiology

* safe use of medical devices

* risk factors associated with specific procedures

* how duty of care is interpreted in this context.

Figure 1 Key knowledge for proning surgical patients

The fundamental aims of proning for surgery

Patients are mainly placed in the prone position for surgical procedures on the spine, calf and ankle. Patient positioning is performed to optimise surgical access and the process of positioning requires planning to reduce risk of injury to the patient and to theatre staff. Theatre practitioners, surgeons and anaesthetists work collaboratively to position patients following this plan, considering support for a secure airway to maintain respiratory function and access to the patient for theatre practitioners working outside of the sterile field.

Adedeji et al (2010) described the prone position as being the patient laying face down upon an operating table; this position being achieved by moving the patient from a supine position. There are various ways of undertaking this manoeuvre, and the choice of technique will dictate the number of personnel that need to be involved (most frequently between three and six personnel). Methods include the traditional 'log roll' or 'flip and catch' method or a modified procedure employing purpose-made moving and handling devices. Edgecombe et al (2008) identified 17 different prone positions in their review paper.

Iatrogenic injury

There are significant risks involved with positioning people prone, particularly regarding the maintenance of cardiac and respiratory function (Edgecombe et al 2008, Hogan et al 2009). Injuries to nerves and the risk of pressure insults have also been identified (Winfree & Kline 2005). It is therefore preferable in some circumstances to operate with the patient on their side rather than face down. Surgical procedures involving the spine, short saphenous vein, Achilles tendon or calcaneus are likely to require the prone position for surgical access.

The standards set by the Health Professions Council and the Nursing & Midwifery Council require healthcare professionals to provide high quality patient care. Healthcare professionals are personally accountable for their acts and omissions and must be able to justify decisions made when caring for people undergoing surgery (Pirie 2011). Proficient skills, up to date knowledge and professional attitudes must be applied to clinical practice activities. In the context of prone positioning of patients the theatre practitioner must have knowledge of current evidence and apply safe handling of people and medical devices.


A number of regulations have been published in the UK subsequent to the Health and Safety at Work Act 1974. One of these, The Provision of Work Equipment Regulations 1998 (PUWER, HSE 1998), seeks to regulate the availability and the use of equipment designed to reduce risk to people's health and safety. Notable among the principle aims is the requirement that equipment provided for use in the workplace is fit for purpose. An example of how these regulations can be applied relates to the inappropriate use of a bed sheet as a moving and handling transfer device, because it is not designed for use as a transfer device. If a patient or healthcare practitioner was harmed as a consequence of a bed sheet that tore whilst being used for a lateral transfer then PUWER may be invoked as part of a criminal prosecution. The professional judgment of registered practitioners could be challenged and the following questions would need to be answered: Is a bed sheet suitable for transferring patients from one surface to another? Is a bed sheet fit for this purpose?

The Management of Health and Safety at Work Regulations (MHSWR) 1999 requires employers to assess the risk of regularly performed manoeuvres and to provide employees with adequate health and safety training (HMSO 1999). These regulations also clarify the obligation of employees to take care of their personal health and safety, emphasising that they must comply with any policies and procedural guidance laid down by the employer. It is therefore possible that the employee who chooses to use a bed sheet as a transfer device, when existing policy or procedural guidance suggests that slide sheets (designed for that purpose) should be used, may be found liable for any harm caused by their actions. Both the MHSWR and the healthcare practitioner's own professional code of conduct could be invoked as part of a health and safety investigation.

Vicarious liability

In certain circumstances the employer may be considered liable for harm that occurs as a consequence of a moving and handling procedure. If an employee is fit to practise, and works appropriately according to a hospital policy or procedural guideline then the hospital may be considered liable for iatrogenic injury (RCN 2003, Pirie 2005, AfPP 2011). If the activity as described is flawed and causes injury, then the employer may be found to be vicariously liable. If the practitioner has worked outside of policy or guidance then they may be found personally negligent and vicarious liability does not apply. The Association for Perioperative Practice (AfPP) recommends that healthcare professionals should take steps to protect themselves from liability by having personal liability insurance (AfPP 2011).

Moving and handling principles

The Management of Health and Safety at Work Regulations require employers to assess all hazards and risks for employees and patients (HSE 2011). Assessments must be recorded and communicated to all practitioners that undertake hazardous activities (HMSO 1999). The perioperative practitioners who log roll and manoeuvre patients into prone positions may be adopting hazardous activities and applying controversial techniques by necessity (Figure 2). When fundamental biomechanical principles are not applied injury can occur to the participating practitioners (Pennington 2005).


Bariatric patients

Moving and handling bariatric patients is increasingly affecting the role of theatre practitioners who position patients for surgery (Al-Benna 2011). The Association of Anaesthetists of Great Britain & Ireland (AAGBI) provides guidance on perioperative management of morbidly obese patients. It refers explicitly to the importance of specialist manual handling devices, such as sliding sheets, and the requirement that healthcare practitioners should attend locally delivered moving and handling education sessions that include guidance on how to handle obese patients (AAGBI 2007). The AAGBI promotes the use of a central or departmental database of equipment for handling patients including manufacturer designated weight limits and stored location. Practitioners are required to check that devices are maintained and fit for purpose prior to use.

Devices for positioning and handling surgical patients

The Montreal mattress

The Montreal mattress is a shaped device designed to replace the central section of an operating table mattress. It was developed to facilitate prone positioning for spinal surgery. The design of this preformed cushion includes a shallow recess at one end to receive the chin with the aim of establishing anatomical alignment of the spine while allowing a neutral head position and mild flexion of the cervical spine. The most important design feature of the Montreal mattress is a large hollow in the centre to support normal physiological status of the thorax and abdomen. This space reduces the risk of abdominal compression in the prone patient allowing movement of the diaphragm, to maintain respiration when normal movement of the rib cage is constrained (Edgecombe et al 2008). The recess also alleviates pressure of the vena cava, which can increase surgical haemorrhage due to engorged collateral vessels such as the epidural venous plexus (Hogan et al 2009). This simple device is now used for other procedures performed on prone patients, such as percutaneous nephrolithotomy (Addla et al 2008). Alternative devices such as the Wilson frame and the Relson and Hall frame are reported in the overview of surgical patient positioning by Anderton et al (1988).

Turning or sliding sheets

These devices are manufactured with low friction surfaces to facilitate the ergonomic movement of loads (ArjoHuntleigh, no date). They can be used in pairs, singly, or in conjunction with a bridging device such as a Patslide. Modifications to the width of the sheet or the addition of long strap handles can reduce the risk of staff injury by enhancing the biomechanical positioning of staff performing moving and handling procedures (HSE 2011).

Sliding board

A solid plastic board with a low friction surface to facilitate the transfer of loads. It is used as a bridge between two surfaces for lying to lying transfer. Grips on the underside are included to maintain a static position when loads are moved across it. The brand name PatslideTM (Briggate Medical Company) is often used generically.

The ProTurn[TM] is a combination of manual handling devices for the purpose of proning patients. A turning sheet with long straps, that includes a sleeve for a positioning bolster, is used to roll the patient from supine to prone using three personnel (Figure 3). A pair of sliding sheets is employed to allow repositioning on the Montreal mattress (or alternative spinal frame). The manufacturers claim that this system reduces risk of injury to theatre practitioners when compared to alternative methods in current use (Hospital Direct, no date).


Moving a patient from supine to the prone position for surgery

The technique for moving surgical patients from a supine position on a hospital bed or trolley to a prone position on an operating table has been described in the literature. However, the consideration given to the moving and handling issues involved with this is insufficient. Theatre practitioners who perform patient positioning rely on local policies or procedures for guidance and the evidence suggests that this may be based on individual opinion.

Hovord (no date) recommends that each arm is moved unilaterally as this offers a greater range of movement. It is implied that the alternative method of simultaneous movement (as in the butterfly swimming stroke) increases the risk of shoulder injury. This is in opposition to the benchmark promoted by AfPP (2011), although the standard is not supported with an evidence base. Craig (2003) describes the movement of the arms when adopting the final position but it is unclear whether or not they are moved unilaterally or in a synchronized manner.

Examples of 'proning' techniques

The 'flip and catch' method - see Anderton, Keane and Neave (1988)

This technique requires a team of five people to move and position the patient (Figure 2). The authors advocate a manoeuvre from supine in a bed or trolley to operating table. Then, with one practitioner at the head end (usually an anaesthetist) and three people on one side of the trolley the patient is manually turned into a lateral position. This is achieved by two of the practitioners sliding their arms between the patient and operating table surface, one supports the pelvis the other supports the thorax. The third practitioner supports the legs. On completion of the turn the two practitioners supporting the pelvis and thorax remain in position with their arms between the patient and the table surface.

The patient is then lifted up and off the table surface and a practitioner on the opposite side of the table slides a spinal frame into position under the patient. The patient is then rolled into prone on the receiving surface (Montreal mattress or alternative).

'Four stage proning manoeuvre' - see Craig (2003)

In 2003 Kay Craig, a registered theatre nurse, described a technique of proning patients with the aim of promoting a safe manoeuvre. This article was written at a time when a standard technique which ensured that theatre practitioners conformed to biomechanical principles, had not been established. Craig's system aims to address the issue of staff harm. It requires a total of four trained personnel and a collection of materials and devices to facilitate movement to reduce the risk of neuromuscular injury.

The four stages begin with the alignment of the patient alongside the operating table with the patient positioning support in place. A hard sliding board is required, together with three sliding sheets and two bed sheets. The arrangement of the bed sheets is key, as the overlap is employed during the manoeuvre to slide the patient to the edge of the operating table (stage two). In stage three the patient is rolled into a prone position. The two receiving personnel are described as grasping the bed sheet with one hand (to control the roll), while the other hand is used to resist the momentum of the patient by opposing the shoulder and the thigh. The final stage offers the opportunity to move the patient up or down the table using a bed sheet between the patient and a sliding sheet.

The manoeuvre is described as requiring four personnel (two either side of the patient) however analysis of the published description reveals that the anaesthetist is not included in this figure. The minimum number of personnel for this manoeuvre should therefore be considered to be five. Figure 4 in Craig's article provides the evidence that five personnel are present. Craig claims benefits for the patient and personnel including a reduced incidence of shoulder and back pain, although no evidence is provided to support this statement. The use of bed sheets as moving and turning devices could be challenged.


The ProTurn[TM] system - see Hospital Direct, no date

The ProTurn[TM] system describes a manoeuvre that requires a minimum of three personnel, including a practitioner (presumably an anaesthetist) at the head end. The manoeuvre utilises a set of equipment comprising of a pair of slide sheets, a base mat and patient-rolling device, which incorporates a bolster and straps (Figure 3). Four stages are described which relate in practice to those described by Craig (2003) although the ProTurn[TM] system benefits from devices that are designed for the purpose of moving and handling. The manufacturers of this system claim that less staff are needed, that hazardous procedures and staff injuries are reduced and that post-operative manoeuvres are enhanced (Figure 4).

Summary of the clinical implications of the three techniques described

The three methods of proning patients appraised here suggest that some techniques offer better protection for patients and healthcare practitioners.

Certainly the intention of Craig (2003) to reduce the risk of neuromuscular injury is commendable and in my own practice experience this source represented significant progress in the safe moving and handling of prone surgical patients. The ProTurn[TM] system takes this concept a stage further with fewer personnel and the application of devices that are fit for purpose. The proning of surgical patients now appears to be safer than before, but there is a lack of evidence to support this. This topic will be the focus of further research employing the use of high fidelity simulation. A comparative analysis using a validated tool for measuring the ergonomics of proning will be conducted employing the Rapid Entire Body Assessment tool (Hignett & McAtamney 2000).


Historically some proning procedures that are hazardous for perioperative practitioners have been tolerated in the workplace. This may be due to an absence of benchmarks illustrating safe principles of moving and handling (Craig 2003, Beckett 2010). Craig developed a manoeuvre that introduced elements of safe biomechanical principles not observed in the techniques described in Anderton et al (1988). In the intervening years knowledge of manual handling principles has improved, and an emerging evidence base now directs the behaviours of healthcare practitioners. Craig's work was commendable in many respects but this article also promotes the use of bed sheets as a turning device, a method that can now be challenged. Perhaps the ProTurn[TM] system brings the process of proning up to date. The next step for theatre practitioners is to establish evidence that can inform the safe prone positioning for surgical patients.

Task 1

List four surgical procedures that are likely to be performed with the patient in a prone position. Identify five potential injuries that can occur due to poor positioning for each surgical procedure.

What is done in your practice to reduce the risk of these injuries occurring?

Notional Learning Hours

1 hour

Knowledge and Skills Dimension

Core 3: Health, safety and security

Core 4: Service improvement

Core 5: Quality

Task 2

Review your duty of care, responsibility and accountability within your professional standards of proficiency or code of conduct. How can you link these sources of evidence to the activity of positioning patients for surgery?

Health Professions Council 2008 Standards of proficiency for ODPs

Health Professions Council 2008 Standards of conduct, performance and ethics

Nursing and Midwifery Council 2008 Standards of conduct performance and ethics for nurses and midwives

Notional Learning Hours

1 hour

Knowledge and Skills Dimension

Core 3: Health, safety and security

Core 4: Service improvement

Core 5: Quality



What are the potential injuries to theatre practitioners who move patients into the prone position? Make a list of possible injuries and identify devices used in your practice that can reduce the risk.

Notional Learning Hours

1 hour

Knowledge and Skills Dimension

Core 3: Health, safety and security

Core 4: Service improvement

Core 5: Quality


Make a list of new knowledge acquired from this Open Learning Zone resource. Briefly explain how the activities you perform in your workplace might be informed by this information.

Notional Learning Hours

1 hour

Knowledge and Skills Dimension

Core 3: Health, safety and security

Core 4: Service improvement

Core 5: Quality


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About the author

Mark Bowers RODP, BA (Hons), MSc

Senior Lecturer in Perioperative Care, Oxford Brookes University

No competing interests declared

by Mark Bowers Correspondence address: Mark Bowers, School of Health and Social Care, Oxford Brookes University, Headington Campus, Gipsy Lane, Oxford OX3 0BP. Email:
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