Ms. Goodwin is manager of clinical risk and patient safety at Cambridge Health Alliance, Cambridge, MA.
"A patient’s success on a claim of injury based on intraoperative positioning would likely be based on a negligence theory, or potentially a lack of informed consent theory," writes Brianne Goodwin, JD, RN.
Suppose you are a patient waking up from a robot-assisted laparoscopic prostatectomy (RALP). You were counseled ahead of time by your surgeon about what to expect regarding pain, recovery time, and urinary symptoms, among others. As the effects of anesthesia wear off, you note significant discomfort in your shoulders and arms. Ultimately, a diagnosis of compartment syndrome is made and you require an additional surgery to relieve this.
However, there is residual damage and you are left with a deficit in use of your left arm and hand. You might ask: How did this happen; the surgeon was nowhere near my arms and shoulders? How could prostate surgery leave me unable to use my left arm fully?
This is just one example of many past and pending malpractice actions across the country that center around the positioning of patients during surgery.
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In another case, a male patient had a RALP that took over 8 hours and he was in steep Trendelenburg the whole time. The patient developed compartment syndrome in the right arm and shoulder with residual deficits.
In a third case, a patient underwent a radical retropubic prostatectomy lasting just under 5 hours. The patient woke up with extreme back pain. Imaging and nerve studies confirmed damage to the back and pelvic areas. The patient was rendered disabled and unable to work.
In a fourth case, a female patient underwent nephrectomy in the lateral decubitus position and developed significant brachial plexus injury from improper placement of the chest pad.
Intraoperative positioning injuries can include nerve injuries, soft-tissue pressure injuries, compartment syndromes, and ocular deficits (bit.ly/patientpositioning). The incidence of these injuries as a whole is not well documented, as literature mostly focuses on case studies, retrospective reviews, or billing and claims data (bit.ly/patientpositioning). However, a recent paper found that robot-assisted surgeries had a 6.6% injury rate, suggesting that this type of surgery may incur further risk (bit.ly/patientpositionstudy).
Next: Good documentation, expert review needed for defenseGood documentation, expert review needed for defense
A patient’s success on a claim of injury based on intraoperative positioning would likely be based on a negligence theory, or potentially a lack of informed consent theory. For either of these claims, good clinical documentation and expert review will be needed for a solid defense. Assessing each patient’s risk of a positioning-related injury should ideally begin preoperatively when risks, benefits, and alternatives to surgery are being discussed.
Risk factors such as age, diabetes, hypertension, nutritional status, extremes in weight, and expected length of procedure would be known in advance and able to be discussed at a preoperative visit and documented in the record. In an older closed claims review, poor patient-physician communication was a factor in cases that resulted in an indemnity payment (BJU Int 2011; 108:477-8).
Intraoperative attentiveness to patient positioning is also important to preventing injuries. Use of the proper equipment and materials for preventing a patient from shifting on the table, routinized monitoring by nursing and anesthesia, and employment of second time-outs for cases expected to be lengthy are all ways the entire operative team can help ensure proper patient positioning during any surgical procedure (bit.ly/patientpositionstudy).
In the event that a case is elective and not time sensitive, a patient’s condition may be able to be optimized in the interim to avoid positional injuries even further. Efforts at improving nutritional status, increasing diabetes regimen compliance, and idealizing weight can be good preventive aids and motivational factors for patients in achieving the surgery they desire (bit.ly/patientpositionstudy).
One final case for thought: A patient is consented for a prostatectomy and told it would take approximately 2-3 hours to complete. The surgeon does not disclose that he will be doing the procedure robotically, and with a proctor present due to his level of inexperience. The surgery actually lasts close to 8 hours and afterwards the patient’s hands and arms are swollen and bruised, with numbness and tingling.
The patient sues the surgeon, the anesthesiologist, and the nursing staff in the OR for various failures in care and treatment. Ultimately, the plaintiff-patient failed to prove causation at trial, but the 6 years of legal proceedings, trial, and appeals undeniably take a toll on all involved.
Patient positioning in the operating room is everyone’s responsibility. The surgeon, anesthesiologist, and nurses all have a duty to contribute to establishing the optimal surgical exposure in a position that protects the patient’s airway, anatomic structures, and hemodynamic stability as much as possible. Documentation of risk factors in the record and mitigation of any in advance can help set expectations for the patient. Use of best practices and conscientious documentation are always desirable in crafting a meritorious defense should the case become a legal action.