Podcast: AliTalks with Mary Grace Hensell, RN, MSN, CNOR on Patient Positioning

September 13, 2019
Mary Grace


Daniel Litwin: Welcome to AliTalks, where we sit down with thought leaders to bring you medical product solutions that are leading industry trends, driving best practices, and delivering efficiencies for healthcare professionals everywhere. Hey everyone. Welcome to another episode of AliTalks with AliMed. I'm your host, Daniel Litwin, the voice of B2B. With today's episode, we're hoping to bring more awareness to a surprisingly underserved piece of gear in hospitals. And that is positioners.

Daniel Litwin: When patients are getting examined, treated, or going through surgery, you've got to twist and turn their bodies to get that perfect view or angle. And of course this means using positioners, often foam or beanbags, to support the patient. The issue though arises when hospitals use makeshift positioners. Not only do they not work that well, they can often further injure the patient. So here to break this down and provide some insight on the importance of proper positioners is Mary Grace Hensell, former director at Allegheny General hospital, an educator, and a medical legal consultant. As well as Steve Dunn, product manager for AliMed. Mary, Steve, welcome both of you to the podcast. How are you both doing?

Mary Grace Hensell: Great. Thank you.

Steve Dunn: Doing well today. Thank you.

Daniel Litwin: Yeah, it's a pleasure to have you both on. I'm excited to break this down. Mary, I want to start with you. I think it's important to give our audience some context on your background and when you personally saw how mismanaged positioners can cause some major problems in healthcare. So let's start with that. Breakdown a little bit of your history and how you came to understand that positioners need some reform.

Mary Grace Hensell: So I have been a nurse for 39 years. And actually been in the operating room for about 33 years. And during that course of time, I've been a circulator, a scrub, an educator, a charge nurse. I believe I've probably had every role in the operating room you could possibly imagine. But as I started into the operating room, we were taught a variety of different ways on how to position people. And we position people in positions that you probably would never do at home because we're doing surgeries. So we have the lithotomy, the lateral, the Trendelenburg, reverse Trendelenburg, supine position. And about 30 years ago it was acceptable, because we didn't have the knowledge base, on how to position patients. And we used pillows, foam, and nurses are very ingenious on a lot of different ways in how to get that position situated so we can do the surgery. But as it's moved forward, we found that we have to make our patients safe. And there's a lot more positioning agents out there that can do that instead of us trying to recreate the wheel and maybe not using the best methods while we're trying to manufacture it ourselves. So that's a little bit about myself and where I started and where we've really come from 30 years ago to now. That foams have gotten better, we have gel, and we really don't need to make our own devices as nurses anymore.

Daniel Litwin: Steve any commentary on that on any of her points?

Steve Dunn: I can attest, I have been in a number of cases myself. Things can change during the middle of a procedure. And I've seen nurses try to address that with whatever's nearby because time is of such essence. It's really an immediate need. And so what AliMed has been able to do over the years is we've developed relationships with OR nurses and been able to find out more problems. And actually engineer products that can take the place of pillows and towels, that can withstand and hold up to multiple hours. Because cases are getting longer, patients are getting larger. And the old standard just doesn't work as as well. It just, it won't last four to six hours. Great for an hour, hour and a half. But now with all the gels and lightweight gels that are out there, it can last that much longer. And so it's really where AliMed is moving forward.

Daniel Litwin: All right. So some questions now to both of you. And feel free to whoever wants to answer first can. But I think we see a lot of makeshift DIY positioners in the industry used daily. It hasn't really become a standard yet to reassess if these positioners are actually doing their jobs well. And what kind of product do we need to better serve our patients in this particular regard? Why do you both think these medical devices are not currently more professional or more standardized to the level that let's say AliMed is trying to craft?

Mary Grace Hensell: I'm going to jump in right now. And what I'd like to just talk about is, traditionally, nurses have used pillows. And the AORN has a statement now that pillows, towels, things of that nature really are not acceptable because they bottom out. I noticed Steve was talking about it before, but when you're taking foam, or just an egg crate, or a [inaudible 00:05:31], there's all kinds of different types of foam. The due diligence hasn't happened in looking at do they bottom out? And quite frankly they do. And so there's a lot better foams out there. There's memory foams and things of that nature. So what I've seen nurses do is, 30 years ago, 20 years ago, we took a pillow and we put underneath your knees. At that point in time, feeling that we took your heels off the bottom of the bed and that we decrease that pressure on your heels. Thinking that you're not going to have redness, you're not going to have a pressure sore. But in all reality, what we have created, and there's literature out there to state this, that when you put a pillow under somebody's knees, there's two things that can possibly happen. One is you could actually cause pressure at the popliteal space. And that pressure could compress your popliteal artery, vein. And you could then potentially put them at risk for a DVT. The other piece is when you lift the heels up off of the bed. In reality, there's some studies out there from Korea and actually here in the United States, it's [Permanny] is, I believe the author of the one article. And what it states is when you lift it off, the heel, you're actually causing more pressure on the sacrum. So things that we did before, we thought, in a two hour period, and we didn't do as extensive surgery as we do nowadays. We're actually creating a different problem. So we could have pressure on the sacrum and you can end up with a bedsore where we ultimately wanted to decrease that pressure on the heel. So we've got to come up with the times of not using pillows, not using towels. Plus there's that shift, and when you have that shift with towels and with linen that you're pilling up pillows, what also occurs is that friction. And then you're creating bedsores as well. So we as nurses really need to get that knowledge out there.

Steve Dunn: And I just want to add that it's also a bit of, if it's not broke, don't fix it mentality. For years, taking foam or taking pillows, there hasn't been any direct issues that have seen. With the changes in reimbursement, once a patient is done in the OR, they move into observation, and that's when a lot of pressure injuries will start to be noticed. And then you start doing the backtracking. There was a discovery that it was happening in the OR. And so it's changing that mentality because they haven't seen it directly. And I can attest quite a few times that I've been called in to do in servicing on positioning. It's been because an incident has happened. In particular the Trendelenburg position. When a patient is tipped and their head is pointed towards the ground, it can be a very precarious position and you need to stabilize the patient, make sure they don't slide off the bed. With the increase of robotic procedures, there's been the tendency to shift slightly. And because of that, we developed a Trendelenburg positioner called the Secure Fit, and it secures the patient in that particular position so they don't slide. And a lot of the calls that I've gotten are we had patient shift and so we need to secure them. Do you have any options for us? If that's been the big mentality that we have to overcome. Trying to get to the awareness out before there's an incident or anything of that nature.

Daniel Litwin: What's interesting is that it's not like, these hospitals and nurses, they don't realize that there is potential injury that comes from twisting and turning the patients without proper positioning support. Though I'm not saying it's insidious that they're not upgrading their equipment. But it must be frustrating to see an issue and maybe to not have the resources or to not know where to start to get your patients what they need.

Mary Grace Hensell: So I think there's a couple of points that need to be made here. And I think Steve made some good points, as well as yourself. But nurses want to do a good job every day. And sometimes we haven't been taught that blankets and things of that nature aren't a best method. Are there financial constraints? Of course there are financial constraints. Being a director myself, you see that every day. But I think the key point that hasn't been out there is, previously, as Steve pointed out, we didn't realize that you had a positioning injury, particularly a pressure injury. And usually they do show up and there's a lot of literature out there. I've actually, at Hopkins, created a skin integrity team at one point in time and worked with our wound specialists. And what we're finding out is it's really about two to three days later. That you're in a position, whether it be in Trendelenburg or a lateral position. In three days, that pressure injury then becomes like a decubitus. It might've been a little abrasion or redness, but that pressure then surfaces and then you get a true decubitus injury at that point in time. Now here's the amazing part. The amazing part is that usually these patients are in an ICU on the floor, and guess what? The floor nurses and the ICU nurses think, well, it's attributed to them because they didn't turn the patient. But in all reality, the positioning injury, the pressure injury started in the operating room. And this is really just surfacing over the last five to 10 years that the injuries are occurring here. And so there's a lot more work to be done. Steve pointed out, too, in the Trendelenburg position with robotics, there are some key points there. When your head is down about two inches from the floor, and you're on a steep Trendelenburg position, how do you keep that patient on the bed? And that's really a challenge for OR nurses. And in the past, some thoughts have been, can we use a bean bag? And with the bean bag, bean bag's very hard that you place a patient on. Yes, it holds you in a position because it's hard and it folds up around you laterally along your body but also on your shoulders. So let's think about it. There's two ways to keep you on with your head about two inches from the floor. One is I can put shoulder rests on, which really puts the patient at risk. Or I could use a beanbag and curl it up, which is almost like a shoulder brace as well. And so when you think about that well, even if I pad it, am I still at risk? And yes you are. Because the brachial plexus comes down off of your neck and down into your arms. And so we're talking about pressure injuries, but there also are nerve injuries. There's stretch injuries. But in this, there might be pressure on your nerve. And with a brachial plexus injury, you may have some numbness maybe in your little pinkie or you might not be able to grip very well. And that might surface maybe an hour or two after you've woken up or maybe six hours later. So there's a lot of risk for positioning in the operating room. You can have stretch injuries, nerve injuries, pressure injuries. And we're challenged as nurses, and the company's are challenged, on how can we get devices out better?

Daniel Litwin: Right. Well, yeah, I guess because often the consequences of an improper positioner aren't seen immediately. It does have that kind of delayed reaction. So you often don't get that sort of immediate feedback on is what I'm doing hurting the patient?

Mary Grace Hensell: Right. The other thing I want to talk about is people creating their own devices. A DIY. Being a legal -

Daniel Litwin: Yeah. I'm actually glad you brought that up. I was going to ask not only how do these DIY positioners further affect care in healthcare, but also I'm sure that creating them takes time and ends up costing caregivers valuable care time because they're spending them trying to build some kind of positioner to help their patient.

Mary Grace Hensell: You're absolutely correct. I've seen that. Probably have been a part of it at some point in time. And here's the type of things that you may see. People think that they're actually saving money. And it becomes really, nurses can bring it to the attention of management, but management really needs to bring that forward. And having nurses cut up foam. I've even seen facilities where they've paid nurses time and a half or aide's time and a half to take an egg crate and cut it all up into foam pieces to do spot positioning. And let's just think about that. That egg crate may cost you very little. But your nurse may cost you $30 an hour or $27 an hour depending on where you are in the nation. And I'm saying a beginning nurse. Let's not even talk about it might be a very tenured nurse who's getting $45 an hour, let's pay her time and a half and let's do that for a couple of hours. So what may have seemed cost-effective at one point in time and you factor in all the labor, it no longer is cost-effective at all. You're actually paying more money when you could have bought a product that's a better product and not paid your labor to be making a device. And the next piece of that is when you make a device at a hospital, you actually become the manufacturer. And what does that mean? And so my legal hat is going to come on. And I'm going to tell you about that. When you become the manufacturer as the hospital, you became liable for positioning. It no longer becomes the person who makes the egg crate or if it's AliMed who's making a device. You have altered a device. So you become that manufacturer. And so you can be sued directly. As opposed to if the positioning device was at fault from the company, they would have equal liability. So anytime you alter a device as a hospital, you become the manufacturer.

Steve Dunn: So it's one of the big reasons that such stringent labeling regulations is specifically to add the protections. It's about the safety of the patient overall. And that's what the FDA is concerned about at the end of the day. And so in order to put those into place, they put in the regulations. And a medical company like AliMed makes a claim, they need to back back it up. But if you use a product off-label, as they say, then it removes the liability from AliMed, or any medical device company I should say.

Daniel Litwin: And have y'all seen that create some legal and financial headaches for care institutions?

Mary Grace Hensell: Sitting on and working with lawyers or attorneys, I would cite the hospital if they used a pillow. And again, that's an unintended device for positioning. Or a towel. Or let's be quite honest, I've seen somebody try to put somebody in a lateral position and put about five or six pillows on a mayo stand and wonder why that arm fell off and then there's a injury. So you're going to see issues and problems with that. By creating your own devices or being very ingenious, as what I talk about with nurses, and trying to put somebody in a device. It ultimately is going to cost the hospital anywhere, and what I've seen, is anywhere from about 50 to $100,000 in a possible injury suit, depending on how detrimental it is. If it's a permanent, obviously it could go higher, it could go into the millions. So really what you want your nurses, what I would like nurses to take away is, you don't want to accept that responsibility. You want to use devices that were made and intended for positioning and to do that particular job.

Daniel Litwin: Right. So Steve, being a product manager for AliMed, you've spent a lot of time in the weeds. Not only making sure the product line reflects the needs of the industry, but the product line is also functional and accessible to these care institutions. What are some ways that you've seen AliMed, specifically, try to tackle this issue of inefficient positioners in a unique way?

Steve Dunn: So thankfully I've been able to get out and speak to OR nurses, attend to AORN, my myself. And just being able to listen to some of their problems, larger patients being a big positioning problem. We've been able to come back and work with our internal R&D team and develop product.
We've also worked with institutions and surgeons, bringing their positioning ideas to life. One in particular I mentioned earlier, it's for Trendelenburg positioning. We have our Secure Fit. And it was designed to allow safe positioning in Trendelenburg but still allow access to the chest and the arms, which are really areas that a lot of other positioners for Trendelenburg don't allow the access. A lot of straps go over the chest, which is used to stabilize the patient and keep them from sliding, but then it restricts access to the chest if they wanted to check breathing or the electrodes. And then of course just the lines that are going up the arm. We want to make sure that those are safe and they're not impacted. So as that's one of our biggest areas. But it's really about getting out in front and just letting nurses know that there's different styles of products. I mentioned earlier, lightweight gel. Gel itself can be very heavy. In fact, chest rolls, which are used in the prone position, are sometimes under the knees, can be upwards of 20 pounds. It can be very heavy to carry throughout the day. And so we developed a new style of gel positioner which actually has a foam core and gel on top. So it gives you the protection of gel, but it's about 50% of the weight. So it's only 10 pounds. Much easier to carry back and forth from the OR to wherever they're being stored. And those are the areas that AliMed really tries to it to listen and address and help out healthcare professionals every day.

Mary Grace Hensell: Steve, using some of these products that AliMed's used and other products as well. I did want to talk about that Trendelenburg position for the robot. In the beginning, the robot's been around for maybe 20 years, but when you're doing a robotic prostatectomy or a hysterectomy robotically, we briefly talked about that your head's about two inches off of the floor. You're in a Trendelenburg position. And really as a nurse there are several things that you are very concerned about. And one is the shift of the patient. So regardless of whether you're a three or 400 pound patient, or you're a 90 pound patient. Moving bed from a supine position to a Trendelenburg position, your key point is not to have that patient shift. Because there's going to be friction and with that friction could possibly be positioning injuries. The other piece is how do I get my patient to stay on the table when I'm in a Trendelenburg position that's very steep? I like to, unfortunately, I have some stories about when things go right and when things don't go so right. A not so good area to be in is one time we placed a patient, I'm not going to say at what hospital, placed a patient in a steep Trendelenburg position. And sure enough, the patient didn't stay stable to the bed. Which AliMed's positioner does a really nice job doing that. This patient shifted and so much so that their head came off of the head of the bed. And the anesthesia person was literally holding the patient's head so it didn't fall onto the floor. Now that requires, think about this for a moment. That requires the fact that now I have to take that patient out of the position again, basically start all over again. So if I was draped and starting to do surgery, we now have to pull out of it. That lengthens the procedure. It also causes a risk of losing somebody's airway and actually creating a neck injury. So unfortunately there's some things that I've seen that if you don't position that patient right and you don't create that stability, you could harm somebody very easily.

Daniel Litwin: So if these products are that essential for basically every day care in these healthcare institutions, what is education like around these products? And do physicians and nurses know that they don't have to be using DIY products? What have you seen? Why or why not? And how do you think education can change around getting these products in front of more people in the industry?

Mary Grace Hensell: Well, that's a pretty complicated question. The education piece. I think it's really getting out there, having people ... We need to move forward with skin integrity teams in hospitals and understanding that what we do in the operating room really reflects on the postoperative care. And I think that education needs to start in the operating room but also needs to go out to the floors. If you remember correctly, I said the floors actually think that they've created the problem when in all reality it's started. So I think there's education that we as a professional group from AORN and through hospitals throughout the United States need to really talk this up. Positioning is not a small deal. It's big. We need to change how we educate. We need to take accountability for it. We also as administrators have a duty to listen to our nurses and see what's out there on the market. And not just say, "Well we've always done it this way." Nurses and administrators, we need to get with the times and to understand that we no longer can create our own positioning devices. One is it's not really cost-effective. Paying nurses is not cost-effective to create them. It also puts us at risk for liability. So I think we need to start with education. I think that partnering with our manufacturers is really important. Because we can tell them the problems that we have and they can create these devices. They've done a great job listening to us, but we need to continue to do that.

Mary Grace Hensell: I also think that they need to understand, somebody like myself, I've been in three different arenas. So what is that cost in injury? So you can take that to administrators that this may cost you something. And then ultimately you can also take that back to the nurses because as much as they are cost-conscious, they also, it's really about patient care. And we don't want to cause injuries. So I think frontline nurses, administrators need to partner with your manufacturers so we can get that education out. And I think it's going to take some time and we need to do the podcasts, webinars, and we need to do our due diligence and research.

Steve Dunn: Yeah. And thankfully the movement is moving forward. AORN over the past number of years has a very high focus on patient positioning and the problems that can arise from it. And I've noticed in a lot of facilities when management starts taking that education piece on themselves and ensuring that it's disseminated throughout the entire facility, that is when a lot more of the traction really starts taking over. And it's not just positioning in general, it's education overall. It becomes more of the forefront. And protecting staff and protecting the patients while they're there.

Mary Grace Hensell: I just wanted to bring one more thing to the forefront. I've been in the adult world for most of my career. And just recently I've been asked, when I gave a lecture at the expo in Nashville, and from some different nurses, as to we've put a big focus on the adult world. But the question came back is what are you doing with the pediatric world? And I have to be quite honest with you, I think that's a groundbreaking area that we probably haven't touched very well. But I think overall there's a lot of work to be done in both worlds, pediatric and in adult to get our positioning devices where they should be.

Steve Dunn: And thankfully that is an area that AliMed addressed. We can continue to address it, but we do have some neonatal positioners in gel and pediatric positioners. It's not just positioning a smaller adult. There is a much larger deal, especially when we're talking about neonatal, because their bones are not fully developed. They're actually more sensitive to the pressures and pressure injuries in general. So there's more of an awareness and we are trying to make larger strides in order to position pediatric and neonatal patients.

Mary Grace Hensell: About 2.5 million patients are affected by acute care pressure injuries every year. And we have nerve injuries. But I still believe that there's a lot of work to be done in pressure injuries and there's a lot of tools out there with devices. But I think we're just entering the of awareness and starting down the path of how can we fix this by assessing our patients. And we have to look at nutrition, we have to look at, I know Munro and Scott Triggers have an assessment tool out there. And I think, again, there's a lot of work to be done in this area. And to create that awareness so we can decrease injuries. But I just wanted to put out there's quite a few patients out there that indeed have injuries. And so this is an important subject.

Daniel Litwin: Yeah. And like we've said, it is something where the caregivers don't get that immediate feedback that oh, we might be doing something wrong here. Though like you said, when you're dealing with over 2 million patients that deal with injuries sustained because of poor positioning, it's not something to ignore. It's definitely something that needs to be at the forefront of conversation in these care institutions. And I think it's up to people like you, Mary, and to companies like AliMed to continue to educate and continue to try to get quality products in the hands of qualified care givers. So thank you both so much for joining us on the podcast. It was a pleasure getting to break this down and get your insights on it. Steve Dunn, Mary Grace Hensell. Thank you both again for joining us. It was a pleasure.

Mary Grace Hensell: Thank you.

Steve Dunn: Thank you.

Daniel Litwin: And thank you everyone for listening to today's episode of AliTalks. And if you like what you heard and want to listen to previous episodes, you can head to There, you'll be able to find all of our recent podcasts as well as written content and video content on a variety of different subjects. You can also find our podcast on Apple Podcasts and Spotify. And make sure you leave a rating and a comment wherever you listen to your podcast content. I'm your host, Daniel Litwin, the voice of B2B. Till next time.


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