Creating & Maintaining a Culture of Safety: Safe Patient Handling in Acute Care

Jacki Chechile, PT, MSPT

Beth Christensen, PT, DPT

Meghan Church, PT, DPT

Danielle Nugent, PT, DPT

February 18, 2017

Objectives

• Comprehend quality improvement efforts for creating and maintaining culture change for safe patient handling and analyze applicability to your work environment

• Understand importance of infrastructure for safe patient handling programs to engage all stake holders in creating a safe working environment

• Identify ways to use safe patient handling equipment to achieve rehabilitation goals

Disclosure Statement

•Disclosure of Interest• No members of this presentation or the institutions we

work for have received remuneration or have a financial arrangement with any product discussed

•Written consent was obtained from all patients or their HCPs for video and photos

Overview

•Evidence Supporting Safe Patient Handling

•Safe Patient Handling at BIDMC

•Achieving Culture Change

•Safe Patient Handling for Rehabilitation

•Future goals

Evidence Supporting Safe Patient Handling

What is Safe Patient Handling (SPH)?

• “The use of assistive devices to ensure that patients can be mobilized safely and that care providers avoid performing high-risk manual patient handling tasks. Using the devices reduces a care provider’s risk of injury and improves the safety and quality of patient care” (VA, 2016)

•Body mechanics

•Thinking BEFORE doing (OSHA, 2016)

Why is SPH Important?

Cumulative Effects of Manual Patient Handling

•Research done by NIOSH revealed that healthcare providers develop microfractures to their vertebral endplates when lifting more than 35 lbs (Waters 2007)

CUMULATIVE

LIFTINGMICRO-

FRACTURES

NONUTRIENTS TO

DISCDISC ATROPHY

NERVE IMPINGEMENT

& INJURY

NIOSH Recommendations

•Recommend a 35lb maximum weight limit for handling patients when:• Patient follows commands

• Patient is not combative

• Amount of weight lifted can be estimated

• Lifting is smooth and slow

• Relatively constant position of caregiver’s body and hands in relation to the patient

•Recommended lifting limit should be LESS than 35lbs if these conditions are not met

Cumulative Effects of Manual Patient Handling

• “93% men, heavily tattooed, macho workforce, Harley-Davidson rider type guys. And they were prohibited from lifting over 35 pounds through the course of their work.”

(Zwerdling, 2015)

Injuries

0 100 200 300 400 500 600

Health care & social assistance

Manufacturing

Retail trade

Construction

Transportation and warehousing

Agriculture, forestry, fishing, & hunting

Mining,quarrying, & oil & gas extraction

Number of cases in thousands

America's Most Dangerous Jobs 2015(Distribution of Nonfatal Injuries by Industry)

(BLS 2014)

Injuries

•Most research on health care workers has focused on

nurses

• Nurses lift an average of 1.8 tons per 8 hour shift (Tuohy-

Main, 1997)

• 12-18% of nurses leave the profession due to chronic back

pain (Moses, 1992; Owen, 1989)

Injuries

0 50 100 150 200 250 300

Health care

Manufacturing

Construction

Agriculture, forestry, fishing, & hunting

Mining, quarrying, & oil & gas extraction

Utilities

Number of cases (in thousands)

Missed Days/Job Transfers by Industry 2015

CASES INVOLVING DAYS AWAYFROM WORK

CASES INVOLVING JOB TRANSFEROR RESTRICTION

‣ 47% of nurses

considered

leaving due to

required physical

demands (MADPH,

2014)

(BLS, 2016)

Injuries: PT specific

•Campo et al 2008• Incidence rate of work related musculoskeletal injuries in PTs• Specific risks

•Results• 1 year incidence rate = 20.7%• Specific risk factors

• Transfers

• Repositioning

• Bending/twisting postures

• Joint mobilizations

• Soft tissue work

• Job strain

High Risk Tasks: Rehab Specific

Manual Therapy27%

Transfer/Lift26%

Environment/Equipment11%

Multiple Activities6%

Patient Fall6%

Functional Activities4%

Patient Aggression or Restraint

3%

Floor Work3%

Therapeutic Exercise2%

Other12%

(Darragh, 2012)

Cost of Injuries

•Difficult to fully understand costs associated with

injuries related to patient handling due to lack of data

reported

•Direct and indirect costs

• In Massachusetts

• Cost associated with hiring and training replacement staff (MADPH, 2014)

Average cost/injury $14,710

Median number lost work days/injury 13 days

Total lost work time 21,485 days

Obesity Epidemic• More than 1/3 U.S. adults are obese (CDC, 2016)

Medically Complex Patients

Aging Work Force

-6

-4

-2

0

2

4

6

8

Pe

rce

nta

ge C

han

ge

Year Labor Force Distribution Change

16-19

20-24

25-54

55+

1992-2002 2002-2012 2012-2022 (Projected)

Age

(BLS, 2016)

Legislation‣ Currently 11 states have enacted laws or

rules/regulations (ANA, 2016)

Effectively Reducing Injuries

•Strong evidence that interventions including body mechanics and transfer training classes have no impact on working practices or injury rates (Hignett 2003)

•Evidence that use of lifting devices minimizes risk • Require some patient repositioning • Place different forces on the caregiver

Effectively Reducing Injuries

LIFT

EQUIPMENT

BODY MECHANICS

FORETHOUGHT

(OSHA, 2016)

Safe Patient Handlingat

Beth Israel Deaconess Medical Center

Beth Israel Deaconess Medical Center

•Academic medical center in Boston, MA

• Level 1 Trauma Center

•672 licensed beds• 463 med/surg beds• 77 critical care beds• 60 OB/GYN beds

•12,000 employees• 8,400 employees with

patient contact

The Origin of SPH at BIDMC

• 2006: Rise in patient handling injuries led to formation of a group to look at:• SPH options

• Analyze data about employee injuries

• 2007: Vendor selected after intensive evaluation process

• 2008: Pilot program on one med/surg unit• 6 ceiling lifts installed over 8 inpatient beds

• 3 portable lifts available on the unit

Workers Compensation Claims Data

FY-05 FY-06 FY-07 *FY-08 *FY-09

Reported incidents

8 4 5 3 0

Days of work lost

8 2 7 0 0

Days of modified duty

0 27 5 0 0

Cost of claims $22,520 $11,260 $14,075 $178 $0

Pilot Program

* Pilot Program

Unit Renovation

•Different med/surg unit was renovated in July 2008

•Chief Nursing Officer championed SPH• All future renovations should include ceiling lifts

• Lifts installed over 100% of patient beds• 16 ceiling lifts over 24 patient beds

Improving Buy-In: Involving Front Line Staff•Organized and hosted an Employee Equipment Fair

• July 2009: trial in ICU to compare ceiling lifts to ErgoRN

• 100% of surveys indicated that ceiling lifts:

• Make it easier to mobilize patients

• Are easy to use

• Help to prevent staff injuries

• Require fewer staff to reposition patients

•Decision was made to install ceiling lifts over 100% of ICU

beds once funding available

ICU Installations

•Capital funding for safe patient handling approved every year since FY-10• Support from

• Chief Nursing Officer

• Associate Chief Nurse of Quality and Safety

• Installed ceiling lifts on one ICU at a time• Dec 2009 and April 2011

•9 ICUs, 77 critical care beds

Hospital Wide Installations

•June 2011: Installs began on med/surg units

•Units evaluated based on•Patient population•Number of employee injuries•Cost of employee injuries•Culture of the unit/likelihood of acceptance

Where the Program is Now: Ceiling Lifts

•615 inpatient beds / bays•99.3% of med/surg and ICU

beds•Partial coverage in:

• Radiology areas • Emergency Department • Bone Density • PACU• Autopsy

Where the Program is Now: Portable Lifts

•Golvo® lift (dependent mobile lift)• All inpatient units• Radiology • 1ambulatory clinic

Where the Program is Now: Portable Lifts•Sabina® lift (sit to

stand device)

• Available on 4 inpatient units

• Available in 3 ambulatory clinics

Where the Program is Now: Portable Lifts•Stedy® lift (manual standing aid)

• Available in the PACU

Where the Program is Now: Portable Lifts

• LiftMate™ (low high patient lift)• Available in 4 radiology areas

Where the Program is Now: Other Equipment

•HoverJack® (air-assisted lifting device)• 4 are available for patient falls

Where the Program is Now: Other Equipment

•HoverMatt® (air-assisted transfer device)• Reusable and disposable used in the OR• Reusable used on Bariatric Surgery unit and Labor &

Delivery unit• Additionalrentals available

Where the Program is Now: Other Equipment

•Rollboard• Available in the OR and in Radiology

Where the Program is Now: Other Equipment

•Stretcher chairs• Available in all ICUs, ortho/trauma unit and for rental

Training

•Training occurred after every installation of ceiling lifts or any time portable equipment was purchased

• Initial training done by vendor or SPH team

•Employees signed off on skill sheets

SPH Program Infrastructure

•SPH Policies

•SPH Steering Committee

•SPH Team

•Champions and Lead Champions

SPH Policies

• Ceiling Lift and Golvo Lift Policies• “Safe patient handling equipment and/or other patient

handling aids will be used, where available, to limit the manual lifting and handling of patients to less than or equal to thirty-five pounds of force, in accordance with NIOSH guidelines for health care workers, except in the case of a medical emergency or other life threatening situation.”

• Patient Rights Policy• “Be considerate and respectful of other patients and medical

center personnel. Your rights may be restricted if you are not respecting others' rights or putting at risk the health and/or safety of other patients and medical center personnel.”

SPH Steering Committee• Established 2009

• Purpose• Oversight of the SPH program

• Provide updates on SPH program and installations

• Problem-solve issues

• Meets quarterly

• Comprised of

o SPH Clinical Coordinatoro Inpatient Rehab Managero Associate Chief of Nurseso Director of Employee

Occupational Health Serviceso Clinical Engineering

o Facilitieso Radiologyo Contracting o Linen Serviceso Infection Controlo Wound Care

SPH Team

• Established March 2015

• Purpose• Separate SPH from PT

• Gain insight into front-line

issues

• Create hospital-wide culture

change

• Meets quarterly

• Comprised of • SPH Clinical Coordinator

• Two inpatient physical therapists

• Two nurses / unit-based educators

• Responds to email inquiries and issues regularly

Annual Goals

•As the program has grown, there was a need to focus attention of the SPH team

• Identified set written goals

•Assess these goals at quarterly SPH team meetings

•Example of goals• Root cause employee injuries• Create a better infrastructure for SPH• Install SPH equipment throughout Radiology and PACU• Create unique bi annual refreshers

Champions and Lead Champions

•Unit-based employees who attend a 4 hour off-site training offered by the vendor

•Chosen by unit managers who are given selection criteria• Engaged with SPH• Outgoing• Resourceful• Proactive• Seen as leaders

Other Components of SPH Program

•Maintaining Equipment

•Sling Management

• Laundering Slings

•Monitoring Employee Injuries

Maintaining Equipment• Initially all preventative maintenance and lift servicing was

contracted out

• March 2012: Clinical Engineering department took over servicing lift equipment• Takes service calls 7 days/week

• April 2013: Clinical Engineering took over all preventative maintenance (PM)• Monthly schedule of lifts that require PM

• Challenging to complete PM in a timely manner given high census

Sling Management

• Initially used disposable slings

• July 2010: Switched to reusable slings• Staff resistance due to the size of the RepoSheet®• Significant loss of slings after switching to reusable

• Slings being thrown out

•Budget for 10-20% replacement annually

Laundering Slings

• Slings are stocked on each unit daily

• Par levels have been established for each type of sling on each unit

• Difficulty with sling laundering• All slings look similar

• Low frequency items

• Bariatric slings

• Walking slings

• Shortages

Monitoring Employee Injuries

• Receive monthly report of patient handling injuries from Employee Occupational Health Services (EOHS)• Minimal information available

• EOHS system limits report to 85 characters

• Try to determine if injury could have been prevented• Follow up with managers for additional information

• Partnering with EOHS to root-cause injuries in the ED

Hospital-Wide Patient Handling Injuries Over Time

0

20

40

60

80

100

FY-11 FY-12 FY-13 FY-14 FY-15 FY-16

Achieving Culture Change

Creating Culture Change

•Changing culture for SPH takes time and continuous attention for sustainability (Stevens, 2013)

•Solutions for controlling risk need to

incorporate•Engineering•Administrative•Behavioral controls

SPH Champion Program

• Unit-based peer leaders are a major component of sustainability (Stevens, 2013)

SPH Champion Program

•As a SPH Champion, you should• Be proficient in the use of SPH equipment and techniques• Act as unit expert and resource on patient care

ergonomics, equipment use, and SPH techniques• Know where SPH equipment is located on your unit• Problem solve patient handling issues• Motivate/coach peers • Participate in bi-annual SPH refreshers• Know how to contact the SPH Team if you need help

answering a question

SPH Champion Program

•As a SPH Lead Champion, you should• Perform all listed duties of SPH Champions• Attend bi-monthly Lead Champion meeting • Notify SPH Clinical Coordinator when patient handling

problems/incidents arise.• Identify competency needs and provide refresher training

for unit staff on use of equipment

SPH Champion Program

• Lead Champion Meeting• Held bi-monthly for 45 minutes

• Led by two members of the SPH Team

• Goals

• Discuss ideas

• Disseminate

new information

• Problem

solve issues

• Develop

programming

• Part of facility intranet

• SPH has access to edit at any time

• Post recent news and pictures

• Practical information

SPH Portal

SPH Portal

• How to contact SPH team

• Equipment information

• Lists of champions

• Laundry information

• Monthly tips

• Patient education

• Policies and algorithms

Biannual Refreshers

•Staff require training every six months due to a drop off in usage of SPH equipment and techniques (Nelson, 2006)

•Goal to engage staff to think about SPH

Biannual Refreshers

•Active• Practicing skills• Sample weight• Jeopardy• Fastest lift time

•Passive• SPH story• Survey• Peer observation and

reward

Monthly Tips

• Includes• Injury Report• Quote• Monthly Topic

•Topics• Troubleshooting• Proper use• Reminders• Recent issues

•Ask for ideas at lead champion meetings

Sample Monthly Tip

Sample Monthly Tip

myPATH

•Goal to reach all patient care staff with access to SPH equipment

•Objectives•Demonstrate benefits of SPH• Introduce equipment available• Educate on when to use equipment

•Content was developed to both introduce and annually review the SPH program

myPATH

•myPATH is a hospital wide online Performance and Training Hub

•Approval • Learning Council

•Programming• Senior Learning

Specialist• Software

•Upload to server and users

myPATH

• myPATH content includes

• Importance of SPH• Best practice with equipment• Equipment available in the hospital• Weight limits for lifts and slings

• Methods to obtain regular and bariatric RepoSheets® and slings

• Purpose of each sling• Methods to lift a patient from the floor• Provide patient privacy while using the lifts• Multiple choice quiz at end of session

myPATH

•Other utilization of myPATH•Observation Checklists• Instructor Led Training

Culture Change

•PTs perception of SPH equipment

• Injuries can be prevented with correct lifting

techniques

•Quality of physical therapy is diminished

•Reduced active patient participation

•Reduced ability of therapist to provide training

•Reduced intervention time

•Negative patient perceptions

Safe Patient Handling for Rehabilitation

SPH Equipment in Rehabilitation

•SPH supported by APTA, Veteran’s Health Administration and Rehabilitation Nursing Association (Waters, 2010)

• Improved outcomes with SPH• Arnold, 2011• Nelson, 2008

•No difference between outcomes• Campo, 2013• Darragh, 2013• Darragh, 2014

RepoSheet®

•Explanation• Lift sheet• Bed sheet placed

under patient• Straps attach to

sling bar of an overhead lift

Indications & Considerations

• Indications• Any patient who is not

independent with bed mobility• Roll• Boost• Transfer

• Hygiene• Patients of size• Reduces shear forces• Falls to floor• Placing a patient prone

• Considerations• Patient weight <1,100 lbs

Examination & Treatment

• Examination• Integumentary examination

• Auscultation of breath sounds

• Treatment• Assisted rolling

• Positioning in bed

• Transfer to stretcher/shuttle chair

• CPT

• Progression of treatment• Decreased angle of assistance

• Progress to independent rolling

MultiStraps™

•Explanation• Lift aide•Assisting with ROM

and therex•Strap attached to sling

bar of an overhead or portable lift

Indications & Considerations

•Indications• Strength <3/5

• Stretching

• Therex

• Other uses• Performing ADLs

• Wound care

• Placing a patient on a bedpan

• Rolling

•Considerations• Skin breakdown

• ROM restrictions

Lifting and Holding Limits for Limbs

Patient Weight (lbs)

LimbLimb

Weight (lbs)

Lift Hold (2 Hands)

1 Hand 2 Hands <1 min <2 min <3 min

< 40

Leg < 6.3

Arm < 2

40-90

Leg < 14.1

Arm < 4.6

90-140

Leg < 22

Arm < 7.1

190-240

Leg < 29.8

Arm < 9.7

Waters, 2009

Examination & Treatment

ROM

•Hip abduction

•Hip flexion

•Knee flexion

•Knee extension

•Elbow extension

•Shoulder abduction

Strength

•Gravity eliminated• Hip abduction/adduction

• Elbow flexion/extension

• Shoulder abduction/adduction

• Shoulder horizontal abduction/adduction (sitting)

•Against gravity• Short arc quads

• Hip flexion (modified heel slide)

High Back Sling

•Explanation• Whole body sling• Sling places

patient in seated position

• Attached to sling bar of an overhead or portable lift

Indications & Considerations

• Indications• Bed mobility requiring significant manual assistance• Decreased postural control• Inability to stand step transfer

•Considerations• Hemodynamic stability• Respiratory status• Patient weight <1100lbs• Skin breakdown• Sling discomfort

Examination & Treatment

•Examination• Postural control• Dix Hallpike test

•Treatment• Postural control• Epley maneuver

•Progression of treatment• Decreased assistance with edge of bed balance from lift• Supported reaching activities• Supported therex• Supported performance of ADLs

Sabina®

•Explanation• Sit-to-stand device• Supported weight-bearing through the lower extremities

• Indications• Significant assistance required for sit to stand transfers• Significant assistance required for static or dynamic

standing balance

Considerations

• Patient weight < 440 lbs

• Lower extremity injury

• Level of seated postural control

• Level of arousal/participation

• Hemodynamic stability

• Skin Integrity

• Bracing

Examination & Treatment

•Examination• Standing tolerance

• Orthostatic vital signs

• LE strength

•Treatment• Pre-gait activities

• Standing tolerance

• ADLs

• Sit to stand transfer

• Therex• Mini-squats

Evidence

•Effects of sit-to-stand devices•Atypical movement patterns (Burnfield, 2013; Ruszala, 2005)

• Lower overall muscle activation (Burnfield, 2013; Ruszala, 2005)

•Preferable to incorrectly performed manual transfers (Ruszala, 2005)

•Potential for increasing muscle strength and improving joint flexibility (Boyne, 2011; Burnfield, 2012)

Walking Slings

LiftPants™ MasterVest™

Walking Slings

•Explanation• Slings that allow for increased patient support in standing• Can allow for body weight support (BWS) training

• Indications• LE weakness• Impaired gait mechanics• Balance impairments• WB restrictions• Patients of size

Walking Slings

•Considerations• Skin integrity• Hemodynamic stability• Level of arousal/participation• Anatomy• Pregnancy

•Examination• Static and dynamic standing balance• Gait

Treatment

•Standing tolerance

•Endurance training

•Static/dynamic standing balance

•Gait training• Body weight support (BWS)• WB status• With or without an AD

•ADL training

Evidence

•BWS has shown positive effect in patient populations:•Stroke•Spinal cord injury•Parkinson’s disease•Cerebral palsy

•Over ground vs treadmill training for BWS

Challenges

•Met with unexpected resistance

•Changing rehab culture

•A few recent injuries

•Many new graduates•Taught in school to perform maxA transfers•Not introduced during clinical experience

Future Goalsat BIDMC

Future Goals at BIDMC

•Expand SPH program to all hospital areas• Emergency Department• Procedural areas• Ambulatory Care• Off-sites

• Improve accessibility of slings

• Improve diversity of equipment

•Strengthen SPH policy

•Mandatory retraining

•And ultimately…

Achieve Culture Change!

•It takes a long time to achieve culture change

•Advocate for yourselves and for your patients

•Be persistent

Questions

Contact Information

Jacki Chechile

jchechil@bidmc.harvard.edu

Beth Christensen

eachrist@bidmc.harvard.edu

Meghan Church

mchurch@bidmc.harvard.edu

Danielle Nugent

dnugent@bidmc.harvard.edu

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