Citations and References

Full List of Citations and References Throughout our Website

AORN Guidelines and Recommendations

• “The active warming device should be started as soon as possible when the patient arrives and prior to induction of anesthesia, Burlingame recommends. “The challenge is that many people may wait until everything is done to turn on and apply a warming device, which often requires catching up to maintain normothermia.”
  AORN Staff. “4 Updates for More Effective Hypothermia Prevention.” AORN, 22 Oct. 2019
• “The most common work-related musculoskeletal injuries among perioperative nurses are lower back problems related to patient handling tasks.”
  Periop Today: Ergonomic Hazards: How to Keep Periop RNs Safe | 9/2023
• “More than 60% of perioperative nurses experience lower back musculoskeletal injuries.”
  Periop Today: Ergonomic Hazards: How to Keep Periop RNs Safe | 9/2023
• “Moving patients can also contribute to injury. When moving patients, use assistive technologies to help prevent staff injuries and keep patients safe. These might include air-assisted transfer devices…”
  Periop Today: Ergonomic Hazards: How to Keep Periop RNs Safe | 9/2023
• “Prolonged standing during surgical procedures poses a high risk of causing musculoskeletal disorders, including back, leg, and foot pain, which can be chronic or acute in nature.”
  AORN Journal June, 2011

Environmental Cleaning

• “A standardized product selection process assists in the selection of functional and reliable products that are safe, cost-effective, and environmentally preferable and that promote quality care, as well as decreases duplication or rapid obsolescence.”
  Environmental Cleaning - Section 1.1

Positioning The Patient

• “Relieve, reduce, and redistribute contact pressure at bony prominences.”
  Positioning the Patient - Section 3.13
• “Do not use a horseshoe-shaped head positioner for patients in the prone, lateral, sitting, or semi-sitting positions.”
  Positioning the Patient - Section 3.25
• “Flex the patient’s knees approximately 5-10 degrees. Positioning the knees in a slight flexion prevents popliteal vein compression and reduces the patient’s risk for DVT.”
  Positioning the Patient - Section 4.2
• Demonstrating the use of the Pink Pad resulted in “significantly less [patient] movement at all anatomical landmarks.”
  Positioning the Patient - Section 5.6
• That establishes obesity as a “major predictor of movement” in Trendelenburg positions, where “researchers concluded that patients on the Pink Pad had significantly less displacement.”
  Positioning the Patient - Section 5.6
• “Use a padded footboard. Using a padded footboard helps prevent the patient from sliding downward on the OR bed and reduces the potential for injury to the peroneal and tibial nerves from foot and ankle flexion.”
  Positioning the Patient - Section 6.2
• “Assessing and monitoring the patient’s feet during the procedure confirms physiologic alignment and placement against the footboard, prevents rotation and increased pressure on the ankle, and may help to prevent circulatory or nerve damage.”
  Positioning the Patient - Section 6.2.1
• “Position the patient on two chest supports that extend from the clavicle to the iliac crest. Chest supports allow chest and abdominal expansion and decrease intra-abdominal pressure.”
  Positioning the Patient - Section 7.7
• “Providing additional pressure-redistributing padding at the patient’s knees helps prevent pressure injury.”
  Positioning the Patient - Section 7.10
• “Supporting the patient’s sacrum reduces the potential for injury.”
  Positioning the Patient - Section 8.5
• “A patient in the lateral position is at risk for injury from pressure on vulnerable points on the dependent side.”
  Positioning the Patient - Section 10.0
• “During prolonged surgery in the lateral position, the patient can experience local muscle compression with ischemia and subsequent reperfusion injury leading to compartment syndrome or rhabdomyolysis.”
  Positioning the Patient - Section 10.0
• “Place a pillow or head positioner under the patient’s head with the dependent ear assessed after positioning.”
  Positioning the Patient - Section 10.3
• “Place an axillary roll under the patient’s dependent thorax, distal to the axillary fold, at the level of the seventh to the ninth rib.”
  Positioning the Patient - Section 10.5
• “Maintain the patient’s physiologic spinal and neck alignment.”
  Positioning the Patient - Section 10.6
• “Place safety straps across the patient’s hips.”
  Positioning the Patient - Section 10.8
• “The lateral position increases the risk for injury to the common perineal nerve. Using padding helps to protect the perineal nerve on the dependent leg from being compressed between the fibula and the OR bed.”
  Positioning the Patient - Section 10.10
• “Direct pressure on the patient’s eyes may cause retinal artery occlusion. The eyes should be checked periodically throughout the surgery to make sure the head has not moved and there is no compression on the eyes.”
  Positioning the Patient - Section 11.21

Safe Patient Positioning

• “Use additional pressure-redistributing padding to support the patient and redistribute pressure from bony prominences and other pressure points.”
  Safe Patient Positioning - Section 3.14
• “After positioning or repositioning the patient, verify there are no areas where devices or equipment are resting against the patient.”
  Safe Patient Positioning - Section 3.15
• “Prevent the patient’s body from contacting metal portions of the OR bed and other hard surfaces (eg, the Mayo stand).”
  Safe Patient Positioning - Section 3.15
• “Hyperextension of the neck can stretch the brachial plexus, lead to cardiovascular complications associated with compression or mechanical manipulation of the carotid sinus, or injure the spinal cord.”
  Safe Patient Positioning - Section 3.8.1

Patient Temperature Management

• "Implement (active warming methods) to prevent and treat inadvertent perioperative hypothermia... for all patients during all phases of perioperative care (ie, preoperative prewarming, intraoperative, postoperative)"
  Patient Temperature Management - Section 3.2
• "Select and use active warming and passive insulation methods based on the patient's individual needs, with respect to identified risk, surgical procedure factors, and the anesthetic plan."
  Patient Temperature Management - Section 3.2
• "...Researchers concluded that active body surface warming was demonstrated to be effective in maintaining normothermia, decreasing the incidence of SSI, decreasing shivering, decreasing blood transfusions, and increasing patient satisfaction..."
  Patient Temperature Management - Section 3.2

Pressure Injury Prevention

• “Placing padding between the patient and hard surfaces and using additional padding on bony prominences and other pressure points increases patient comfort, helps redistribute pressure, and decreases the potential for nerve or PI.”
  Pressure Injury Prevention - Section 3.4
• “Do not use towels, sheets, and/or blankets as positioning devices. Using rolled or folded towels, sheets, or blankets as positioning devices increase pressure, contributes to friction injuries, and decreases the pressure redistributing properties of the support surface.”
  Pressure Injury Prevention - Section 5.5
• “Elevate the patient’s heels off of the underlying surface. Offloading the supine patient’s heels increases perfusion and helps prevent pressure injury.”
  Pressure Injury Prevention - Section 5.11

Safe Patient Handling and Mobility

• “Apply prophylactic materials (e.g., dressings, non-adherent devices designed to reduce PI risk) to bony prominences (e.g., heels, sacrum) or other areas subjected to pressure, friction, and sheer in patients identified as being at high risk for PI.”
  Safe Patient Handling and Mobility - Section 4.1
• “Select patient lift equipment that minimizes the physical forces required to move the patient.”
  Safe Patient Handling and Mobility - Section 4.3.1
• “Use assistive technology if any team member is required to lift more than 35 lb (16 kg) of the patient’s weight.”
  Safe Patient Handling and Mobility - Section 5.2.1
• “Use assistive technology specifically designed for the task to be performed (eg, lateral transfer) according to the manufacturer’s IFU.”
  Safe Patient Handling and Mobility - Section 5.2.2

Clinical References

Hospital-Acquired Pressure Injuries

1.1 Overlooked and Underestimated: Medical Adhesive-Related Skin Injuries:

• "Protects without the use of sticky adhesives, the removal of which may cause skin tears"

1.2 Preventing Pressure Ulcers in Hospitals. Agency for Healthcare Research and Quality:

• “US Government Data1 shows Hospital-Acquired Pressure Injuries (HAPIs):”
  • “Are the direct cause of death for roughly 60,000 patients each year”
  • “Add an estimated $43,180 in costs per hospital stay”
  • “Result in more than 17,000 medical lawsuits annually (the second most common claim after wrongful death)”
  • “Increase hospital stays by nine days on average”
• “HAPI occurrence affects 2.5 million patients per year, with an average cost exceeding $43,180 per case.”

1.3 Hospital-Acquired Infections. National Library of Medicine:

• “Single-use designs improve workflow and, most importantly, eliminate cross contamination and Hospital-Acquired Infection (HAI) risks. By removing the need for custom assembly, patient-safety best practices can be standardized. Avoiding the use of tape in patient positioning helps protect against equipment damage, and improves infection-control within the OR.”
• “Surgical site infections account for nearly 22% of the more than 700,000 HAIs that occur annually in the United States.”

1.4 Pressure Ulcers, Surgery’s Sore Subject: Outpatient Surgery Magazine

• “The risk of pressure injuries increases by 40% every 30 minutes of surgery”

1.5 Back to Basics: Positioning the Patient. AORN:

• “Localized areas of the patient are subjected to abnormal levels of stress during surgical procedures, potentially resulting in poor tissue perfusion with ischemia, tissue breakdown, and the development of pressure injuries.”

1.6 Incidence and Predicted Risk Factors of Pressure Ulcers in Surgical Patients: Experience at a Medical Center in Taipei, Taiwan. Biomed Res Int.

• “Prone positioning, in particular, is identified as a significant predictor of these occurrences.”

1.7 New Opportunities to Improve Pressure Ulcer Prevention and Treatment: Implications of the CMS Inpatient Hospital Care Present on Admission (POA) Indicators/Hospital-Acquired Conditions (HAC) Policy. A Consensus Paper from the International Expert Wound Care Advisory Panel.

• “Antiquated positioning systems, counter to their intended effect, may intensify risks of HAPI formation. For example, direct contact with non-breathable surfaces may increase the risk of skin maceration and tissue breakdown when moisture cannot dissipate at a natural rate. Additionally, abrasive surfaces may increase friction during and after positioning, increasing the risk of tissue damage and pressure injury. It is estimated that the cost incurred by hospitals per HAPI incident is $43,180.”

1.8 Contact Xodus Medical for Additional Information and Data

• “Significantly reduced peak pressure”
• “Increased immersion”
• “and envelopment”

1.9 Single Table Concomitant Post-Less Hip Arthroscopy Combined with Periacetabular Osteotomy for Hip Dysplasia. Arthrosc Tech.

• “With failures of periacetabular osteotomy linked to postoperative impingement and the high incidence of intra-articular pathology in the dysplastic hip, there has been a great interest in combining hip arthroscopy with the periacetabular osteotomy. Here, we describe a technique for a single table, single drape, postless combined hip arthroscopy and periacetabular osteotomy.”

Patient Temperature Management

2.1 Perioperative Temperature Management – National Quality Strategy Domain: Patient Safety:

• “IPH is a CMS measure for reimbursement and is associated with impaired surgical recovery and extended postanesthesia care unit (PACU) times.”

2.2 Prevention and management of perioperative hypothermia in adult elective surgical patients: A systematic review

• “Increased risk for admission to the ICU, and longer hospital stays.”

2.3 Preoperative Warming to Improve Patient Outcomes: Implementation of a Warming Protocol:

• “Reportedly, the most common surgical complication, IPH has an incidence rate greater than 40%.”

2.4 Incidence and Risk Factors for Postoperative Hypothermia After Orthopedic Surgery. J Am Acad Orthop Surg:

• “While incidence rates vary by surgical specialty, a recent study found that 72% of orthopedic surgery patients were hypothermic.”

2.5 Journal of Anesthesia and Surgery - Relative Clinical Heat Transfer Effectiveness: Forced-Air Warming Vs. Conductive Fabric Electric Warming, A Randomized Controlled Trial:

• “Improved core temperature control.”

2.6 Underbody blankets have a higher heating effect than overbody blankets in lithotomy position endoscopic surgery under general anesthesia: a randomized trial. Surg Endosc. 2022: Underbody Blankets Have a Higher Heating Effect Than Overbody Blankets in Lithotomy Position Endoscopic Surgery Under General Anesthesia

• “Easier to warm the body’s central region.”

2.7 Comparison of two different uses of underbody forced-air warming blankets for the prevention of hypothermia in patients undergoing arthroscopic shoulder surgery: a prospective randomized study. BMC Anesthesiol:

• “More effective in underbody warming applications relative to traditional, forced-air solutions”

2.8 Effect of forced-air warming by an underbody blanket on end-of-surgery hypothermia: a propensity score-matched analysis of 5063 patients. BMC Anesthesiol.

• “More effective in underbody warming applications relative to traditional, forced-air solutions.”

2.9 Unintended perioperative hypothermia. Ochsner J:

• “Core temperature can fall 0.5°-1.5° below normal within just 30 minutes of general anesthesia induction.”
• “Patients’ core temperatures decline most dramatically during the first hour of surgery.”
• “Implement (active warming methods)...for all patients during all phases of perioperative care (ie, preoperative prewarming, intraoperative, postoperative).”

2.10 Effects of perioperative hypothermia and warming in surgical practice. Int Wound J.:

• “HAPIs are the second most common hospital lawsuit claim after wrongful death, impacting 60,000 patients each year.”
• “CMS has estimated that a pressure injury adds more than $43,000 in costs to a single hospital stay.”

2.11 Contact Xodus Medical for Additional Information and Data

• “19% better heat retention vs. traditional positioning foam”

Surgical Site Infections/Infection Control

3.1 The Leap Frog Group:

• “Each year in the US, more than 14,000 patients suffer from blood clots or internal bleeding caused by blood vessels injured during surgery.”

3.2 CDC.gov | National Healthcare Safety Network: Surgical Site Infection Event (SSI)

• “SSI is the most costly Hospital Acquired Infection (HAI) type, where total incremental Length of Stay (LOS) increases by 9.7 days.”
• “The added cost of hospitalization can exceed $20,000 per admission.”

3.3 Bacterial Contamination of Surgical Instruments Used at the Surgery Department of a Major Teaching Hospital in a Resource-Limited Country: An Observational Study.

• “Streamline cleaning exchanges by eliminating the need to pass instruments to and from the surgical site. Reduce the risk of surgical site infections, enhance procedural efficiency, and enable your team to stay focused on what matters most—patient safety.”

3.4 Risk Factors Associated with Surgical Site Infections: A Retrospective Report from a Developing Country. National Library of Medicine:

• “Studies show a 34%+ increased likelihood of SSIs for every 60 minutes of surgery time”
• “For each hour of the duration of surgery, the risk of SSI increased by 34%”

3.5 Contact Xodus Medical for Additional Information and Data

• “Improved moisture control”/li>

3.6 Overlooked and Underestimated: Medical Adhesive-Related Skin Injuries. Journal of Wound Care.

• “Protects without the use of sticky adhesives; the removal of which may cause skin tears”

3.7 Looking for Holes in Sterile Wrapping: How Accurate Are We? Clinical Orthopedics and Related Research

• “Imperfections in sterile wrapping provide opportunities for contamination, thereby increasing the risk of SSI.”

3.8 Implant Contamination as a Cause of Surgical Site Infections in Spinal Surgery: Are Single-Use Implants a Reasonable Solution? – A Systematic Review. BMC Musculoskelet Disord

• “Because sterile wrap perforations are often overlooked in the Operating Room, prevention of tears or perforations is critical”

3.9 The Clinical and Economic Case for Sterile, Disposable Instruments and Implants

• “Minimum re-sterilization "wait cost" for the OR [is] (per incident)... Instrument availability and reliability are essential to a well-run, cost-effective OR environment.”

Cost Efficiency

4.1 The Leap Frog Group:

• “Each year in the US, more than 14,000 patients suffer from blood clots or internal bleeding caused by blood vessels injured during surgery.”

4.2 Health and economic outcomes associated with uncontrolled surgical bleeding: a retrospective analysis of the Premier Perspectives Database. Clinicoecon Outcomes Res.

• “Uncontrolled intraoperative bleeding can cost hospitals up to $61,000 per patient.”

4.3 What is a Minute Worth in the OR? OR Management News.

• “Saves your hospital up to $1,900 per procedure*”
  • “*Based on OR costs of $100/minute, and 20-minute average setup times for competitive systems”

4.4 Estimating the Costs of Operating Room Time for Critical Care Patients. Critical Care Medicine.

• “Saves your hospital up to $1,900 per procedure*”
  • “*Based on OR costs of $100/minute, and 20-minute average setup times for competitive systems”

Perioperative Risk Factors

5.1 Anesthesia Duration as an Independent Risk Factor for Early Postoperative Complications in Adults Undergoing Elective ACDF. Global Spine. National Library of Medicine:

• “Prolonged anesthesia duration is associated with increased odds of complication, venous thromboembolism, increased length of stay, and return to operating room”

Healthcare Worker Safety

6.1 CDC. About Safe Patient Handling and Mobility. Healthcare Workers:

• “Patient handling, including manual lifting and repositioning, is the single greatest risk factor for musculoskeletal injuries in healthcare workers.”

6.2 Prevalence of Work-Related Musculoskeletal Disorders Among Nurses: A Meta-Analysis. Iran J Public Health:

• “The annual prevalence of Work-related Musculoskeletal Disorders (WMSDs) among nurses was found to be 77.2%.”

6.3 Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health:

• “The incidence rate of lost-workday injuries from slips, trips, and falls in hospitals was 90% greater than the average rate for all other private industries, combined.”
• “Contaminants on the floor, such as water, grease, and body fluids, are the leading cause of slip, trip, and fall incidents in healthcare facilities. Camel Mats from Xodus Medical help address these common safety concerns.”

6.4 American Nurse. Slips, Trips, and Falls of Healthcare Workers:

• “Data show that hospitals have a 67% higher rate of STF incidence than all other employers in the U.S. private industry. The average cost to an employer when a worker experiences a fall is $12,470. Therefore, employers who implement a prevention program can experience substantial savings.”

6.5 American Nurse. Practical Strategies to Prevent Surgical Sharps Injuries.

• “Reduces Risk of Sharps Injuries by 59%.”

Sustainability

7.1 Greening the OR | Practice Greenhealth:

• “…one of the greatest challenges for greening the operating room can be convincing the surgical teams, who rely on empirical data and consistencies in structure and process, to consider changes in their respective practices.”

7.2 Sustainable Healthcare Resource Center | TJC:

• “Cost savings may be realized by utilizing energy-efficient technologies, implementing waste management strategies, and taking advantage of the climate provisions in recently enacted federal law…”

7.3 Initiatives Aim to Make the Operating Room Sustainable. Stanford Medicine Magazine:

• “Operating rooms are hubs of hospital activity: They earn up to 60% of a hospital’s revenue; account for 40% to 60% of its supply budget; produce more than 30% of its total waste and two-thirds of its regulated medical waste… All this activity creates opportunities for green initiatives.”

Published Research

P.1 Under Pressure: A Quality Improvement Initiative to Reduce Rhabdomyolysis and Hospital-Acquired Pressure Injuries Following Retroperitoneal Surgery. Urology Practice. American Urological Association.

• “After the implementation of The Pink Pad, our whole cohort saw a significant decrease in surgery-related HAPIs and elevated postoperative CKs with no incidence of clinical rhabdomyolysis.”
• “The (Pink Lat Pack) was significantly associated with reduced rates of postoperative elevated CK, rhabdomyolysis, and HAPIs caused by lateral decubitus positioning..”
• “We find that use of (The Pink Lat Pack) in our complex lateral decubitus-positioned retroperitoneal surgery population was associated with a significant reduction in pressure-related postoperative complications.”

P.2 A Prospective Randomized Trial of Antislip Surfaces During Minimally Invasive Gynecologic Surgery. Journal of Gynecologic Surgery:

• “Patients on the Pink Pad had significantly less displacement with Trendelenburg and faster positioning compared to the other surfaces.”
• “The Pink Pad is made specifically for direct skin contact with materials that are immersive, enveloping, soft, breathable, and moisture-wicking. Its design maintains skin protection while supporting patient safety.”
• “Independent studies show it effectively reduces erythema compared to other positioning systems.”
• “The Pink Pad is clinically proven to reduce post-operative pain in surgical patients.”
• “There was significantly less pain in the Pink Pad group versus the gel-pad group.”
• “Patients on the Pink Pad had significantly less displacement with Trendelenburg and faster positioning compared to the other surfaces.”
• “The Pink Pad was associated with less postoperative pain than the gel pad and less postoperative erythema than the beanbag.”
• “Postoperative erythema was significantly less common on the Pink Pad…”

P.3 Journal of Minimally Invasive Gynecology 27:

• “…There was significantly less pain in the Pink Pad group… [it] presents a novel opportunity to limit the narcotic requirement after minimally invasive gynecologic surgery.”
• “Uterine manipulation was easier on the Pink Pad…”

P.4 Postless Hip Arthroscopy: A Safer Alternative for Treatment of Femoracetabular Impingement Syndrome. Video Journal of Sports Medicine.

• “When discussing this technique with patients, it is important to highlight that it diminishes the possibility of iatrogenic pressure injury to the pudendal nerve and skin of the perineum. … Postless technique prevents any compression and pressure to these regions”

P.5 Nailing Femoral Shaft Fracture with Postless Distraction Technique: A New Technique Enabled by Shape-Conforming Pad. J Orthop Traumatol.

• “In the control group, 15 patients reported pudendal nerve neurapraxia with an average duration of 10 days... Two patients (4% of the males) in the control group reported erectile dysfunction for 4 months. None reported pudendal complications in the postless group.”

P.6 The Pink Pad: A Method of Post-Free Distraction During Hip Arthroscopy. Arthroscopy Techniques,

• “This post-free distraction technique for hip arthroscopy is a simple, cost-friendly alternative to conventional methods that eliminates the possibility of iatrogenic groin and perineal injuries caused by distraction through a post.”
• “[The Pink Hip Kit] can be used with a standard hip arthroscopy table, is easy to learn, allows for adequate distraction, and allows for greater access to the femoral neck during osteochondroplasty...”

P.7 Postless Hip Distraction System Contributes to Less Pain, Fewer Complications

• “Transitioning away from using the typical setup for hip arthroscopy, all Duke hip specialists have adopted as best practice an innovative postless distraction system, which has been shown to cause fewer potential postoperative complications.”