Sustainable Patient Handling Programs
Why is manual patient handling unsafe? The cumulative weight a nurse or nursing assistant may have to lift during patient lifts or transfers within an eight-hour shift can be as much as 1.8 tons.
Nurses, nursing assistants, orderlies, therapists, and other care staff are regularly required to perform high-risk manual transfers of patients in hospitals and residents in long term care facilities. High-risk patient handling tasks, such as transferring a patient/resident from a bed to a chair, repositioning the person in bed or lifting him from the floor, require lifting excessive loads using sustained and extreme bending, reaching, and twisting postures. In addition, patients/residents can move unexpectedly, increasing the stress on the worker's body. These tasks place workers at high risk for sprains, strains, and other work-related musculoskeletal injuries (MSDs). Such injuries can cause life-altering, career-ending, disabling, and chronic conditions in these workers and in home health aides and emergency medical service workers.
The leading cause of these injuries is repeated manual lifting, transferring, and repositioning of patients and residents. To put this into perspective, in 2007, direct-care registered nurses ranked seventh among all occupations for the number of cases of MSDs resulting in days away from work in the United States -- 8,580 total cases. Nursing aides, orderlies, and attendants had an MSD rate of 252 cases per 10,000 workers, a rate more than seven times the national MSD average for all occupations. Back injuries due to manual patient handling remain the leading injury reported in health care. Additionally, it is estimated that as much as 50 percent of work-related MSDs are not reported by health care workers.
MSDs are costly. Back injuries among health care workers, excluding other MSDs, are estimated to cost $20 billion annually in direct and indirect costs. Another consequence of manually handling patients is nurses leaving the profession due to pain and injury. One study indicated 12 percent of nurses who "leave for good" cite back pain as the main contributory factor. Moreover, when staffing is insufficient, health care workers are less likely to seek assistance, which further increases injury risk.
If the staffing levels are not safe for the caregivers, they will not be safe for the patients/residents. Further, manually handling patients can result in injury to the patient/resident, who may be fall or be dropped during a manual transfer. Patients also may experience skin abrasions or tears from the friction associated with pushing and pulling them from a bed to a chair or when repositioning them in bed. A patient's dignity and privacy can be compromised during difficult manual patient-handling situations.
Health care workers have been taught that "proper body mechanics" will prevent patient-handling injuries. However, 35 years of research provides no evidence that body mechanics alone will prevent MSDs when manually lifting patients and residents. In fact, the safe lift limit for manual handling of patients is only 35pounds.
Elements of Safe Patient Handling Programs
The good news is that these patient handling injuries are preventable. Safe Patient Handling (SPH) programs that are multifaceted and participatory have been shown to be effective in reducing the risk of MSDs in health care environments. The key elements of effective, sustainable SPH programs are:
1) Define the problem:
- Form a multidisciplinary SPH team with active involvement by management, nurses, CNAs, therapists and other direct care staff, as well as representatives from safety and ergonomics, infection control, purchasing, maintenance, environmental services, and the organization's worker's compensation insurance carrier.
- Gain visible support from the administration. This may require education for management about the need for the SPH program by "making the business case" to demonstrate cost savings.
- Collect baseline injury data, such as injury incidence, severity, time loss, and cost data that are used to monitor program outcomes.
- Develop a written program plan that is part of an ongoing process. Spreadsheets are helpful for tracking details. Include strategic and tactical aspects. Include the program mission, specific measurable goals, and methods of communicating program information and getting staff engaged in the program from the start.
- Conduct baseline needs and risk assessments. Use standardized tools to collect information about current risk factors that occur in units or work areas with reported injuries related to manual patient/resident lifting. Evaluate equipment, storage, and maintenance procedures related to SPH issues. Evaluate effectiveness of existing SPH policies.
- Formulate solutions. These will include use of equipment (such as mobile mechanical patient lifts, ceiling-mounted lifts, friction-reducing devices/lateral transfer aids, bed repositioning devices, and height-adjustable beds) and work practice changes needed to safely lift, move, reposition, and transport patients/residents, to reduce or eliminate the injury risk. Equipment choices should "fit" the physical and clinical needs of the patient/resident, the task to be performed, the caregiver, and the design of the facility.
3) Implement solutions:
- Develop an implementation plan that includes specific steps, responsibilities, and timelines. Make use of published clinical tools that include algorithms and patient/resident assessment protocols for SPH programs, such as the Veterans Administration's (www.visn8.va.gov/patientsafetycenter/safePtHandling/default.asp). Include SPH procedures that guide processes for safe lifting and movement of patients/residents and address a variety of clinical needs, including consideration for patients of size.
- Involve staff in meetings, equipment fairs, and realistic equipment trials. Use of SPH champions, peer leaders, and mentors at the unit or department level is essential to the success of the program. These individuals should be direct care staff who are involved in all aspects of the SPH program.
- Plan and provide support for culture change among all management and staff, including direct care staff, such as nurses, aides, and therapists, and other staff from support departments involved in the SPH program, such as maintenance and environmental services.
- Provide customized education that includes "hands on" competency-based training involving use of SPH equipment in realistic patient/resident care scenarios when implementing the program and at regular intervals. Conduct SPH training for new, temporary, and float pool staff.
- Develop explicit "No Lift" policies that are made available to all management and staff, as well as patients/residents and their families.
4) Evaluate the program:
- Develop a plan to evaluate the SPH program that includes outcome measures, timelines, and responsibilities.
- Monitor results. Compare injury data at least annually and evaluate whether equipment is being used and used correctly. Identify non-compliance with SPH policies and address barriers to equipment use. Evaluate staff and patient/resident satisfaction with the program. Measure other benefits of the program to patients and residents as feasible.
- Plan for program sustainability. Have a plan to keep the program fresh, to monitor for compliance, and for periodic retraining and competency.
SPH Program Benefits
Evidence is mounting that SPH programs are successful in decreasing:
- Patient-handling worker's compensation injury rates by 30-95 percent
- Lost workday injury rates by 66-100 percent
- Restricted workdays up to 38 percent
- Worker's compensation costs by 30-75 percent
- Insurance premiums by as much as 50 percent
- The number of workers suffering from repeat injuries
Research also has shown increases in caregiver job satisfaction, decreases in "unsafe" patient-handling practices performed, and reports of significant reductions in staff turnover. Further, SPH programs and equipment have been shown to be cost effective. The initial investment for the purchase of equipment and training costs can be recovered in about two to three years.
Early evidence indicates that these programs also benefit patients and residents by:
- Decreasing combativeness with the use of lift equipment
- Causing patients/residents to report feeling more comfortable and secure
- Reducing skin damage and pressure ulcers
- Reducing falls
- Increasing physical function and activity levels
- Supporting early and positive rehabilitation outcomes in acute care
- Protecting patient dignity
Indeed, the Oregon "Facility of Choice" program, a pilot program funded by Oregon OSHA to create model SPH facilities in acute care and long term care, is demonstrating reduced MSD injury incidence, severity, and cost; reduced worker turnover; and improved patient, resident, and family satisfaction. Moreover, such multifaceted SPH programs are proving to be more effective than any single intervention, indicating the need to develop an organizational culture that integrates staff and patient/resident safety and engages and values staff involvement.
In Oregon, the Coalition for Healthcare Ergonomics (OCHE), a partnership between business and labor groups whose mission is to improve health care employee and consumer safety by promoting ergonomics best practices, has developed a website (http://www.hcergo.org/) that provides multiple resources for developing SPH programs.
In conclusion, evidence shows that repeated manual lifting and moving of patients and residents cannot be performed safely by any health care worker regardless of age, gender, or level of fitness. SPH must be incorporated into the organizational culture and care environment. Sustainable, multifaceted, participatory programs are cost effective, reduce injury risk, and result in healthier workers and patients.
This article originally appeared in the November 2010 issue of Occupational Health & Safety.