Safe Patient Handling: The Hazards of Immobility Nearly every health care organization has made some attempt to introduce safety measures in an effort to reduce musculoskeletal injuries related to handling and moving patients. What makes a multifaceted safe patient handling and movement implementation a challenge is the complexity involved in creating this safer work environment. A successful implementation of SPHM will consider the people, the technical solutions and critical elements of program management. In this session you will learn the lessons of why body mechanics training and other efforts fails. More importantly, you will hear what can be done to overcome the hazards of lifting. By knowing the pitfalls, you will be able to lead your team more effectively and avoid costly setbacks and injuries. Content includes: Pathophysiology and nature of work-related musculoskeletal disorders, physical demands of lifting tasks, ergonomic risk factors found in the patient care environment, fallacies of using proper body mechanics when manually lifting, transferring, moving and repositioning patient, examining workers’ compensation loss data, examining the consequences in direct and indirect cost of manual handling, trends in healthcare that are driving SPHM national regulation and legislation, obesity and workforce demographic trends, recognize essential elements to create sustainable and effective SPHM practices and, solutions and mechanical lifting devices. Prepared by :

Learning Objectives Discuss the opportunity for quality improvement using SPHM practices Discuss expected positive patient outcomes using SPHM practices Discuss the role of SPHM practices in patient care initiatives Discuss how a mobility assessment is able to meet individualized needs

Hospital Acquired Disability Hazards of immobility include: accelerated bone loss delirium malnutrition sensory deprivation isolation musculoskeletal weakness decreased cardiopulmonary function

Early Mobility Avoid the effects of immobility which include: functional decline increased morbidity increased mortality increased cost of care increased length of stay What is early mobility? Early mobility is the practice of introducing physical activity early into a patient’s hospitalization to combat the degenerative effects of prolonged hospitalization. This practice was developed originally to address functional decline, increased morbidity and mortality, increasing cost of care and improve length of overall hospital stay to mechanical ventilation in the intensive care setting. This has lead many hospitals to adopt an early mobility program for their Intensive Care Units. We have recently added such a program to Banner Baywood Medical Center as a result of research and progress in medicine.

Expected Practice Bed mobility Out of bed mobility Ambulation Toileting Boosting/repositioning/turning Transfers Others Since adopting a new system policy in May 2011, these safer procedures should be the expected practice for nearly every interface involving patient handling (i.e., in-bed mobility, limb holding, out-of-bed mobility, ambulation, toileting, boosting/repositioning, turning and transfers, etc.). What is lacking, is not only a general awareness of the problems but also a knowledgeable and skilled clinical specialist with time dedicated to focus on this project.

Benefits Comfort, safety and dignity for patient Accelerated patient mobility, independence and rehabilitation Fall prevention Improved skin integrity Positive patient outcomes Reduced hospital associated disability Safe patient handling and movement (SPHM) improves safety for patients, and leads to improved quality of patient care. Specific clinical benefits include: (1) increased patient comfort, satisfaction and dignity; (2) accelerated patient mobility, independence, and rehabilitation; (3) fall prevention; and (4) improved skin integrity. Additional positive patient outcomes are expected in efforts to reduce hospital associated disability.

Example: Clinical Application Certification in hip facture management High volume of hip fractures Orthopedic focus Target population Key metrics ED to OR < 24 hours < Hospital-acquired conditions < LOS < Readmissions Patient mobility focus PT starts POD 1 Screen mobility Efficient and safe Disease-specific certification in hip fracture management First for organization First for Arizona

Positive Patient Outcomes SPHM supports early patient mobility delirium prevention post-op knee initiatives small bowel initiatives HA pressure ulcer prevention HA pneumonia prevention

Positive Patient Outcomes (continued) SPHM benefits patient satisfaction increased movement and activity toileting and hygiene dignity and privacy improved response time

Revised NIOSH Lifting Equation

Summary of the Evidence Confirms risks associated with manual patient handling Shows tasks cannot be performed safely manually Demonstrates the result of cumulative trauma

2007 NIOSH Revision Maximum weight a caregiver should lift = 35 lbs (single leg of 200 lb patient) Lateral transfer guidelines: >157 lbs, use mechanical device or air-assisted device

Excessive Biomechanical Force 3400 N DCF Limit 1000 N SF Limit Type of patient transfer Disc compression forces (DCF): one person, two person; shear force (SF): one person, two person Marras et al., 1999

Evaluating Risk Factors Lifting heavy, awkward loads Supporting the patient’s body weight Working in small and/or tight spaces Maintaining awkward postures Reaching away from the body Pushing and pulling forces Force Repetition Awkward posture

Classifying Risk High risk activity High frequency task High probability for injury

Risk Assessment and Ergonomic Analysis How many patients are you caring for today? What physical tasks are the most frequent and difficult? How many people are typically needed to accomplish the following patient handling task?

Boosting with Draw Sheet Moving up in bed (Photo from Griffin AG, Potter PA: Clinical nursing skills & techniques, ed 17, St. Louis, Mo, 2010, Elsevier Mosby)

Stand and Pivot Transfer (Photo from Perry AG, Potter PA: Clinical nursing skills & techniques, ed 7, St. Louis, 2010, Mosby)

Slide Board Transfer (Photo from Perry AG, Potter PA: Clinical nursing skills & techniques, ed 7, St. Louis, 2010, Mosby)

Risk Assessment and Ergonomic Analysis (continued) How do you define the dependency level of your patients? How do you define the mobility level of your patients? How do you make decisions about how to do tasks and how many people are needed to perform them safely?

JAMA, October 26,2011 Vol. 306, No. 16; 1782-1793

Clinical Application Define the root cause of exposure Develop common language—consistency Standardize decision making Customize solutions for routine procedures Select appropriate equipment

Banner Mobility Assessment Tool

Clinical Application Risk assessment tool for nurses Solutions for “Good, Better, Best, and Avoid” Linkage with clinical outcomes Developed and mentored champions Integration with shared-leadership councils

Modified Independence Mobility is Linked with Solutions Total lift, rollboards, air-assistive device, slide-sheets or slide-tubes Mobility Level 1: Mobility Level 2: Total lift or powered sit-to-stand lift Non-powered stand aid, gait belt, cane, crutches, walker or ambulation equipment Mobility Level 3: Modified Independence No equipment required however, supervision is needed to promote safety What equipment do I need? Once you know your patient’s assessment level you should be able to decide what assisted devices, if any, should be used to ensure safety and promote early mobility. All patient transfers to another departments for exams, procedures, and treatments… The mobility level will be assessed and communicated to you through a variety of mediums sharing the patients abilities and limitations. This information and process will increase the safety and efficiency of our areas as we no longer need to guess our patients ability. This information will be clearly identified and communicated to you. For example: Assessment Level 1: This patient is the highest of acuity; the patient requires the most assistance and may require the use of such safety equipment as: Total lift, roller boards, air-assistive device, slider-Sheets or slide-tubes. Assessment Level 2: This patient is able to sit yet is not able to bear weight. The total lift or powered sit-to-stand lifts should be used. Assessment Level 3: This patient is able bear some weight with assistance or assistive devices. The non-powered stand aid can be used; gait belt, cane, crutches, walker or ambulation equipment should be used. Assessment Level “Modified Independence” This patient is able to walk without assistance yet each patient should be supervised to promote and ensure safety. This patient is the most independent. Always default to the safest lifting method (total lift) if there is any doubt in the patient’s ability to perform the task. Always default to the safest method (total lift) if there is any doubt in the patient’s ability to perform the task.

SPHM Equipment

Equipment Solutions Slider Sheets Roller Board Ambulation Pants Sit-to-Stand Ambulation Vest How do we practice Early Mobility? Early Mobility can be from range of motion exercises to supervised ambulation with the expectation of increased activity correlating with increased capabilities. Exercises are identified and specific goals and tools are used to promote growth specific to meet the patient’s needs and ability change while maintaining a safe environment by utilizing Safe Patient Movement and Handling Tools and equipment. Safe Patient Handling Equipment and Movement (SPHM): is available to aid in early mobility by maintaining a safe environment for the patient to maximize work while preventing injury as well as protecting staff injury in the process. Sitting Upright Transfer Device Convertible Chair Range of Motion

Why Safe Patient Handling? Essential skill set for patient outcomes Rethink how we provide care Innovative practices Technology and equipment Clinical tools, protocols and procedures Work design changes Results—better, safer and more reliable Patient handling and movement activities are essential job functions in healthcare, but what makes for the safe handling and movement of our patients. In plain words, safe patient handling means rethinking how we provide care to patients in ways that are innovative, linking best practices in clinical care with clinical practices. This program rests on scientific evidence implementing: (1) technology and equipment; (2) clinical tools, protocols and procedures; and (3) work design change to provide better, safer and more reliable care to patients.

Bariatric Considerations Provide rooms with overhead/ceiling-mounted lifts Evaluate weight capacity of lift system Propose minimum room dimensions Measure bathroom door width Measure shower stall width Evaluate shower bench weight capacity

Bariatric Considerations (continued) Evaluate toilet weight capacity floor mounted toilet wall mounted toilet toilet jack installation Consider proximity to nurses’ station

Create a Bariatric Suite Bariatric bed with pressure reducing mattress Extended capacity patient lift(s) Extended capacity wheelchair Extended capacity and extra wide walker Extended capacity shower chair or shower stretcher Extended capacity standing aids

Create a Bariatric Suite (continued) Extended capacity floor-based toilet Extended capacity bedside commode Bariatric patient recliner Bariatric size friction reducing devices (air-assisted and/or slide sheets or tube sheets) Bariatric rollboard Optimal space in room and bathroom Doors that are wide enough for egress

Results of a Pilot Program Program milestone metrics Workers’ compensation data frequency severity task specificity

Frequency of Injury

Pilot Project Light Duty Days (2010–2012)

Pilot Project Lost Duty Days (2010–2012) Prepared by :

Pilot Project (2007–2009 vs. 2010–2012) 54% Decrease 65% Decrease

Implementation Success Dedicate an SPHM coordinator Encourage interdisciplinary involvement Partner with facility leadership Integrate with system initiatives and projects Create opportunities to share the need and shape vision

Safe Patient Handling and Movement Safe for staff and patients: process driven (continuous improvement) evidence-based behavior based: assessment and critical thinking competent selection of proper equipment proficient execution of task tool for achieving objectives

If you have questions or would like a copy of this presentation, please contact: Merl Miller, MS, ATC, CIE Ashton Tiffany, LLC (602) 751-3769 merl.miller@ashtontiffany.com