An earlier version of this article appeared online with an incorrect image and caption for Figure 1. The original image showed a picture of an Allen Advanced Table, but incorrectly labeled it as a Jackson Table. An accompanying legend also incorrectly identified Allen Medical Systems as the manufacturer of the Jackson Table. Both the image and caption have been corrected here.
Despite current advances in surgical technology, technique, and equipment, the act of positioning a patient prone for surgery has not fundamentally changed and still remains a largely uncodified and potentially injury-prone process. Numerous techniques have been documented for moving a patient prone before surgery.1,2 Although prone positioning may be necessary for a myriad of procedures, the most common indication is for posterior spine surgery. These processes can be a source of many potential injuries for patients and surgical staff. The most commonly reported methods are (1) manually turning the patient from supine on a patient cart to a prone position on a surgical table and (2) using a surgical table to surround, or “sandwich,” the patient.1,2 The Jackson Table (Fig. 1) method encompasses sliding the patient from a cart onto the table with appropriate padding placed while the patient is strapped securely on the table. The carbon fiber table frame is placed over the patient, and the patient-table construct is sandwiched together. The frame is locked in place, and a mechanical turn is performed by unlocking and rotating the unit 180 degrees so the patient is placed in the prone position.
Previous studies have reported on the benefits of using the Jackson Table in surgery1,3 and its safety for patients.3,4 Other case reports5 have documented hazards with the Jackson Table due to specific design features or staff unfamiliarity with the table specifics and specifications. To our knowledge, no study has reported on surgical staff perceptions toward using the Jackson Table for prone patient positioning. The purpose of this study was to explore patient and provider safety in moving patients from supine to prone using the Jackson Table. Understanding surgical team member views on the challenges related to the use of the Jackson Table and the ways to minimize them will assist in developing tools to improve safe patient handling and staff safety for spine surgery.
MATERIALS AND METHODS
This report is part of a larger project to evaluate equipment (including the operating room [OR] table) and develop protocols to safely position patients from supine to prone and back for surgery at Mayo Clinic, Rochester, MN. The larger, mixed-methods study used semistructured interviews and survey methodology. This article reports on the results pertaining to open-ended responses from the survey and semistructured interviews. Quantitative findings from survey data are reported elsewhere. The study procedures and the interview guide were approved by the institutional review board at Mayo Clinic, Rochester, MN.
Participants and Setting
Before data gathering, the research team conducted several presentations with providers performing spine surgery to introduce the study. During those sessions, the providers were given information about the study and how data were to be collected. Providers were eligible if they were on the surgical team, position patients prone for spine surgery, use the Jackson Table to position patients prone, and were willing to participate in the study.
After the study presentations, e-mails were sent to the surgical team members who met eligibility criteria, requesting their participation and consent. Links to a REDCap (research electronic data capture; http://project-redcap.org/) survey were supplied in the e-mails. The providers were additionally asked to contact the study team if they were interested in participating in an in-person interview. The research team followed up with the participants who called and expressed interest in an in-person interview. Semistructured, qualitative interviews and a REDCap survey (Vanderbilt University, Nashville, TN) were used to gather data on the participants' nature of work: role during patient flip, challenges with flipping patients, when they used the Jackson Table, and how often and whether the current process of patient positioning was considered safe for patients and staff. The participants were asked to provide an open-ended explanation as to why they think the current process of spinal positioning/repositioning was deemed safe or unsafe for the staff or patients. An interview guide and probes were used when needed to elicit further details of the challenges and incident of injury related to prone patient positioning, which was otherwise not achieved quantitatively by specific role on the team. Regarding the interviews, the participants were asked to share some of the difficulties and challenges associated with tasks during prone patient positioning and to express their perception of patient and staff safety during manual patient positioning versus use of the Jackson bed using the sandwich flip mechanism. All interviews were conducted by a research team member with expertise in qualitative research. Interviews were approximately 20 to 45 minutes in length and were audio recorded.
Interview audio files were transcribed verbatim by an institutional transcriptionist. Transcripts were then verified and proofed against the audio file and deidentified. Transcripts and data were collectively analyzed and interpreted by all research team members. An inductive analysis method was adapted in the early stages of the analysis from methods described by Patton.6 The process included detailed data analysis and identification of important patterns, themes, and categories. Open codes and themes were identified, analyzed, and compared. After inductively establishing themes and categories, final confirmatory analysis was deductively established by examining and eliminating deviant themes that did not align within defined categories. Similar themes were combined, and definitions for the categories were developed and refined. Representative participant quotations are included to inform the presentation of results. Data management and analysis were facilitated by Nvivo 10 (QSR International, Pty Ltd, Doncaster, Victoria, Australia).
The results are combined responses from the open-ended questionnaires and the qualitative interviews. For the open-ended questionnaires, the participants were asked to provide an explanation as to whether they think the current process of spinal surgery is safe for the patient and the staff.
Seventy-five surgical staff members completed the survey, and there were 43 responses provided to the open-ended questions on the survey. Eleven surgical team members participated in the face-to-face qualitative interviews. In all, there were 6 registered nurses, 4 certified surgical assistants (CSAs), and 1 certified surgical technologist. There were 9 individual interviews and 1 two-person interview. The participants had been in their current position for a mean (SD) of 15.3 (14.3) years.
Data analysis resulted in 6 main categories and their subthemes. These categories included general challenges with patient positioning, role-specific challenges, challenges with the Jackson Table and the sandwich mechanism, safety concerns for patients, safety concerns for staff, and recommendations for best practices. Description of the categories, their subthemes, and representative quotes are presented in Table 1.
General Challenges With Patient Positioning
This category describes 4 subthemes related to the major challenges surgical team members face when moving spine surgery patients from supine on the patient cart to prone upon the Jackson surgical table: limited staffing, patient weight, speed of the process, and the time and care involved in padding to prevent pressure ulcers.
The medical staff participants reported that they sometimes seek additional help outside the OR to assist in positioning or repositioning patients. This decision is influenced by health care worker staffing levels that vary with the time and day of the surgery. The anthropometry of the patient may be a source of anxiety and physical stress to the medical staff because of the greater work and difficulty in positioning very large patients. If providers rush the process of positioning patients, the result may be an imperfect initial prone position on the OR table with a resultant increase in rework for the team members requiring repositioning of the patient or injury to the patient. Generally, the participants reported that the attention and care required when fixing pads underneath the patient can be a daunting task.
In the current workplace culture, the optimal number of health care workers required to safely position an overly large or obese patient has not been defined. As a result, staff members will often have no choice but to move patients with the available number of staff present in the OR. The participants also recognize that, regardless of the number of staff present in the OR, there is no room for more than 3 people on each side of the bed.
There are specific challenges that are associated with the different roles that participants assume during patient positioning. The receiver role (which is defined as the person catching the patient during a flip from the supine position on the patient transport cart to the prone position on the OR table) was expressed as more challenging than the sender role (defined as the person flipping the patient away from himself/herself). In addition, CSAs were recognized as having a more demanding role than others during patient turning and positioning.
Challenges With the Jackson Table and the Sandwich Mechanism
Major difficulties associated with the Jackson Table and the sandwich flip were reported as setting the table up and using the sandwich mechanism. The participants reported that the Jackson Table is too cumbersome and setting it up is too difficult; there are too many steps, and there is the possibility of missing a step. Sometimes the team members had to get underneath the table to position and lock the patient's head in the positioning frame to the table frame. This can be difficult and complex. When equipment for the Jackson Table was not located in their OR, the staff members had to get other parts of the equipment from other ORs or storage.
Safety Concerns for Patients
The participants had mixed reactions to patient safety during patient positioning. Whereas some thought that the current process for spinal positioning was safe for the patients, others thought that it was not safe. Those who thought that the process was not safe for patients identified several issues such as skull lacerations, perceived near-miss events such as potential patient falls, and skin breakdown. Those who reported that the process was deemed safe also mentioned that they usually do not see the patients after the surgery so they may be unaware of what happens to the patient but are aware that there are sometimes pressure ulcers.
Safety Concerns for Staff
Similar to that of patients' safety, this category generated mixed perceptions on safety concerns for surgical team staff. Those who think that the process is not safe made references to how lifting and turning heavy patients put a strain on their backs. On the other hand, for those who think that the process is safe, using good body mechanics and waiting for additional staff are expressed as helpful. In addition, there is lack of knowledge of safety measures among some team members, which is concerning.
Recommendations for Best Practices
In this category, participants' responses yielded 6 major subthemes describing some suggestions and recommendations for best practices: changing padding, performing a thorough setup check, changing the Jackson Table or procuring another brand, using mechanical lifts, having more staff, and supporting staff through educational tools.
In the initial questionnaire, approximately 60% of the respondents reported performing setup checks. In the qualitative follow-up interviews, the participants expressed that performing a thorough setup check can be daunting. It involves being attentive and going through all the necessary steps with caution: making sure all padding and straps are secure, wheels are locked, pins holding the bed together are fully in place, and the bed tilt mechanism is locked. The participants suggested that making a “pause” to get everyone's attention before flipping the patient can go a long way to prevent “near misses” (in which a patient would almost be dropped or slide through the rails when flipping). As part of the setup checks, 1 participant suggested that a team leader should conduct an audible and visual pause with all members of the surgical team before patient transfer. They also suggested having 1 person assigned to set up the Jackson Table and ensure that equipment is properly set up. A cue, namely “444” (which was created by 1 of the team members), ensures that the 4 top transfixion pins, the bottom 4 transfixion pins, and the 4 safety belts for the 180-degree mechanical (sandwich) flip are all secure before the flip.
Many other participants suggested that the Jackson Table should be changed and/or made larger to meet the needs of the different sexes and patient weights. However, the participants are aware that their suggestions may not be feasible in the short-term or for the surgeons because of increased reach to perform the spine surgery. Having correct equipment and more staff members to assist during patient turning and lifting can prevent skin breakdown for patients and staff back pain, respectively. Most of the team members reported that they could benefit from additional support through training.
DISCUSSION AND CONCLUSIONS
For this study, we reported the views of surgical team members regarding prone patient positioning using the Jackson Table: challenges encountered using the Jackson techniques, concerns for provider and patient safety, and ways of rectifying or minimizing those challenges and concerns. To our knowledge, this is the first study in the literature that has attempted to explore providers' views on the use of the Jackson Table in spine surgery.
There were mixed reactions to prone patient positioning using the Jackson Table. The providers raised several concerns that were general and specific to their roles in the OR. Positioning and repositioning the patient were reported as the most challenging in part because of patients' weight and limited staffing. In addition, the amount of time and care required during prone patient positioning can be heightened by the haste with which positioning is done by the surgical team. Difficulties related to individual provider role were expressed as demanding for those in the receiving roles and especially for the CSAs (who are most likely to lift the patient or receive the patient), and they may end up with back injuries and other work-related injuries. However, according to some providers, using good body mechanics when lifting or positioning patients makes their work less difficult.
Recommendations for best practices such as modifying the Jackson Table, using mechanical lifts, performing thorough setup checks, increasing the number of staff, and providing support through training were reported as ways to increase patient and staff safety. The cue “444,” created by one of the providers as a result of a near-miss event, has not been reported in the literature. Following suggestions from providers, best practices in the use of the Jackson Table were developed. These may include a standardized practice for transfer of patients, educational tools, and checklists for thorough equipment check (both manual and mechanical) during patient transfer and positioning. The suggestion to identify a team leader to conduct an audible and visual “pause” with all members of the team is significant. It has the potential to minimize injuries and increase provider and patient safety. The “pause,” as described by the participants and presented in this article, is comparable with performing “time out” (1 of the 3 principal components) of the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery approved by the Joint Commission (Oakbrook Terrace, IL).7 The standard requires all surgery staff members to take some time out before incision to communicate and agree on the correct patient identity, correct site, and procedure to be done. Adapting the “time out” can be beneficial for procedures that make use of the Jackson Table technique whether in manual or sandwich mode. The Jackson Table technique has been reported to be effective in surgical procedures3,4 and unsafe in other cases.5 Our findings suggest that the size, positioning aids, equipment, and the setup process for the Jackson Table can be cumbersome, overwhelming, and “a pain in the butt” for providers. These barriers could result in near misses as perceived by providers in this study and reported by other institutions.5
The use of the Jackson Table technique is a multistep process that must be performed accurately. The surgical staff is trained on the use and safety features of the Jackson Table when hired. However, because this technique is not used very often, it is very easy for individuals to forget even some of the important steps. In addition, the features of the table (including many of the safety features) are neither intuitive nor clearly labeled. Therefore, design features could be updated and educational reminders could be implemented to increase safety. It is imperative that surgical teams practice patient care techniques such as using the Jackson Table often to be proficient. Research supports the efficacy of appropriate training modules for OR staff when learning to perform complex tasks that necessitate coordinated effort among team members.8,9 Effective interventions can be built around educational tools and checklists for use during the transfer/positioning phase to increase staff satisfaction and comfort level in using spine table accessories/equipment.
An important generalization limitation to this study is the relatively small sample size of the providers who participated in the interviews. Despite the limitation, this study is an important step toward developing best practices as well as better equipment and protocol to reduce occupational injury of surgical staff and to ensure patient safety through minimizing near misses and reducing pressure ulcers, thus advancing future surgical team safety and future patient outcomes related to prone patient positioning. This research has identified several important practice opportunities for improving provider and patient safety in spine surgery and advances our understanding of how surgical team members qualitatively view the current process of spinal positioning.
The authors thank all volunteers and providers who participated in this study and the Center for Clinical and Translational Science for its support through the REDCap survey.