When initially greeting a patient, the most important thing to do is to first wash your hands followed by a polite introduction.¹ Dress professionally and avoid wearing religious jewelry or political buttons that may interfere with a patient’s beliefs. The patient is often meeting an entire team in the hours before an operation. It is appropriate to greet the patient with your name, professional or student title, and role on his/her health care team.

After the formal meet and greet, the next step should be conducting a proper patient interview and obtaining a thorough medical history.² Important information to review includes: the patient’s past medical conditions, surgical history, and prior anesthesia complications if applicable. Verify blood type, current medications, and allergies.

After this review, assess the patient’s general state of health including mental capacity, emotional state, time of last meal, and last insulin
dose if diabetic. Perform a review of systems, including a thorough menstrual and obstetric history for female patients. Inquire about recent events that may have occurred in a hospital stay or at home.

In addition, identify risk factors for communicable diseases such as hepatitis and HIV.

During this interview, it is important to make the patient as comfortable as possible. This may be a difficult moment for the patient. In explaining your role on the team, you can let the patient know the plan for the rest of the operative day. Inform them of the plan of care such as anesthesia to be administered, the operative procedure, and estimated time of the procedure. At the end of the conversation, ask the patient if they have any further questions you or another member of the medical team may be able to answer. Make sure the patient has not eaten or had anything to drink for at least 8 hours prior to the procedure.

It may be important to fill in any gaps in the history and physical with a proper chart review including labs and imaging. Review past medical and/or surgical notes in order to see the full scope of the surgical patient. Pertinent labs and information include the following³: CBC, BMP, input/output, microbiology cultures, pathology reports, appropriate imaging, allergies, allied health updates (PT, OT), and medications.

While escorting the patient into the operating room, make the patient feel as comfortable as possible. As the patient enters the operating room, everyone should introduce himself or herself to the patient and then help team members properly position the patient.

Introduce yourself to the operating room staff and be sure to explain your role in the surgical team. The scrub tech and circulator will be arranging the equipment in the operating room in a sterile manner. Be aware of your surroundings and keep appropriate distance from
the sterile fields. Do not be timid in notifying the operating room staff if you suspect that the field or an instrument may have been contaminated. In addition, it is courteous to provide the scrub tech with your gown and sterile gloves.

For each procedure, it is important to review the patient’s imaging in the operating room. Therefore, it is imperative that films can be displayed on screens in the OR or that hard copy films are available for review. Preoperative planning for joint replacements may be accompanied by the use of a digital template. These templates
are designed for specific implants and are placed over the patient’s preoperative imaging, in order to plan for the size and type of surgical implant needed (Figure 8-2).

There are a variety of accessories that are used to prepare the OR table. Arm boards, lithotomy stirrups, lateral positioning bars, and posts attach to the table. Gel pads, positioners, pillows, bean bags, foam, and other padding devices are needed to prevent pressure ulcers (Figure 8-3). Pillows are also commonly used to prevent pressure ulcer formation (Figure 8-4). These devices keep a normal capillary interface with pressures at 32 mm Hg or less. Pay special attention to bony prominences as they are at greater risk for developing ulcers. As many as 25% of postoperative pressure ulcers may be induced from the OR.⁷

A time-out is a universal patient safety protocol performed by the surgical team to prevent errors in surgery.⁸ Before the patient is ready to undergo anesthesia, a time-out is run by a designated member of the surgical team (Figure 8-5). The purpose of the time-out is to

make sure the entire team is in agreement regarding the correct patient, side and location of surgery, all equipment is available, medications are given, and fire safety has been reviewed. A time-out involves immediate members of the surgical team such as the surgeons, physician assistants (PAs), nurse practitioners, anesthesia providers, circulating nurses, operating room technicians, students, and other members present in the operating room. The time-out should involve verification of the patient’s name and date of birth, procedure, and surgical site. Time-out needs to be performed for each individual procedure if the patient is undergoing more than one.

Before transferring the patient, make sure the stretcher is in a locked position.⁹,¹⁰ Anatomic alignment of the patient on the OR table should be maintained as closely as possible. This can be facilitated through placement of pillows between the legs if in a lateral position or posterior to the knees if supine.

It is of critical importance that all bony prominences be properly padded to prevent pressure ulcers. Keep anatomic alignment by assuring joints not be moved past normal range of motion. Lastly, secure the patient with straps or tape when on the OR table.

Patient positioning depends on the limb being operated on, the procedure being performed, and the approach that is taken (Figures 8-6, 8-7, 8-8, 8-9 and 8-10).⁹ Ask the attending beforehand how they would like the patient positioned. The following are four common positions used in orthopaedic surgery: