Patient Handling and Movement Assessments: a White Paper

The Facility Guidelines Institute, April 2010

Patient Handling and Movement Assessments: A White Paper

Prepared by the Martin H. Cohen, FAIA, FACHA, Chair Gaius G. Nelson, RA, Vice Chair 2010 Health Guidelines David A. Green Roger Leib, AIA, ACHA Revision Committee Mary W. Matz, MSPH, CPE Phillip A. Thomas, AIA Specialty Subcommittee et al.

on Patient Movement Carla M. Borden, editor This document is intended for free public download and sharing.

Martin H. Cohen, FAIA, FACHA Healthcare Architecture and Design for Aging Vice Chairman, 2010 Health Guidelines Revision Committee

David A. Green Center for Community Partnerships, University of Wisconsin Oshkosh

Gaius G. Nelson, RA Nelson-Tremain Partnership Architecture and Design for Aging

Roger Leib, AIA, ACHA Principal, Leib & Leib, Inc. Architecture & Product Design/Development

Mary W. Matz, MSPH, CPE Safety and Occupational Health Manager, Office of Public Health and Environmental Hazards Veterans Health Administration, Department of Veterans Affairs

Phillip A. Thomas, AIA Golden Ventures

Design by: GLM Design, Falls Church, VA.

Cover photograph: Deer River Health Care Center, Deer River, Minn. Courtesy of DSGW Architects, Duluth.

Readers should note that the material in this white paper is advisory and is not intended to be used as regulatory or accreditation requirements. CONTENTS

Preface ...... 4 Introduction ...... 6 AcknowledgmentsChapter 1: Rationale . . . .for . . . .Including ...... the . . . .PHAMA ...... in. . .the ...... 9 Illustration2010 Guidelines Credits for . .Design ...... and. . . . . Construction...... of. . . Health...... Care...... Facilities...... 15 11 Glossary ...... 12

Hazards of Manual Patient Handling ...... 18 Impact on Risk of Caregiver Injury Impact on Quality of Patient Care Current Patient Handling and Movement Equipment Categories ...... 22 Benefits of Patient Handling and Movement Technology ...... 23 Improving the Workplace and Reducing Risk of Injury Improving the Quality of Care Design Considerations and the Provision of Safe Patient Care Environments ...... 24 Flooring Materials and Finishes Space Constraints Storage Space Door Openings Hallway Widths Floor/Walkway Slopes and Thresholds ChapterElevator 2: Explanation Dimensions of PHAMA Components ...... 29 Headwalls/Service Utility Columns Weight Capacities of Toilets and Mounted Objects

Chapter 3, Part 1: Establishing the Business Case for a PHAMAPatient HandlingText in the and 2010 Movement Guidelines Program ...... 30 42 The Impact of Bariatric and Morbidly Obese Patient Care on Design ...... 39

Savings in Patient Health and Quality of Life ...... 42 Caregiver Savings ...... 43 Financing ...... 43 Grants and Similar Funding Sources Accrued Savings Based on Use of PHAM Equipment Out-of-Pocket Capital Investment Chapter 3, Part 2: Establishing the Business Case— Understanding and Increasing the Value of a PHAMP at Your Institution ...... 45

The Simple Answer and the Fly in the Ointment ...... 45 Decision Analysis Methodology ...... 46 The Decision Analysis Approach ...... 47 Decision Elements Framework for a Good Decision Understanding the Value ...... 49 Basis Development and Deterministic Structuring Probabilistic Analysis and Review ChapterInternal 4: FacilitatingRate of Return Acceptance of a PHAMP and PHAM Technology ...... 58 Increasing the Value ...... 55 A Compelling Case ...... 56

Getting Started ...... 60 Promote the Safe Patient Handling Concept to Leadership Identify a SPHM Facility Champion/Coordinator Institute a Facility SPHM Advisory Team Promote Critical Connections Implementing and Maintaining a PHAMP ...... 61 Develop Strategic Plans Select and Implement PHAMP Elements ChapterDevelop 5: A Standard Vision of Operating the Futur Procedurese of PHAMPs (SOPs) ...... 69 Facilitate Change and Program Acceptance Evaluate the PHAMP ...... 67

Perspectives for Achieving Optimal Patient Handling and Movement ...... 69 Patient-Centered Focus Caregiver Focus Systems Thinking Rethinking Basic Elements ChapterIdeas for 6:Improvement Patient Handling ...... and. . . . .Movement ...... Resour...... ces...... 7072 Short-Term Solutions Future Developments in Technology

General ...... 72 Design Guidance ...... 72 Clinical Guidance ...... 73 VA Toolkits/Resources ...... 74 Web Links ...... 74 Selected Journal Articles ...... 74 Appendices

Chapter 1

Appendix A: High-Risk Manual Patient Handling Tasks by Clinical Area ...... 77 ChapterAppendix 2 B: Legislative Report ...... 79 Appendix C: PHAM Equipment Categories ...... 85 Appendix D: Sling Selection Chart ...... 93

Appendix E: Patient Care Ergonomic Evaluation Process ...... 96 Appendix F: Patient Care Ergonomic Evaluation: Staff Interview Template ...... 98 Appendix G: Equipment Evaluation and Selection Process ...... 99 Appendix H: Clinical Unit/Area Characteristics and Ergonomic Issues Survey ...... 106 Appendix I: Ceiling Lift Coverage Recommendations by Clinical Unit/Area ...... 112 Appendix J: Floor-Based Lifts Coverage Determination ...... 115 Appendix K: Design/Layout Considerations for Ceiling/Overhead Lift Tracks ...... 118 Appendix L: Storage Requirements for PHAM Equipment ...... 124 ChapterAppendix 4 M: Infection Control Risk AssessmentÑ Matrix of Precautions for Construction and Renovation ...... 127 Appendix N: Bariatric Equipment Safety Checklist ...... 132

Appendix O: Making Critical In-House Connections for PHAMP Success ...... 133 Appendix P: PHAMP Element Descriptions ...... 136 Appendix Q: Safe Patient Handling and Movement Training Curricula Suggestions ...... 141 Appendix R: PHAMP Marketing Activities/Strategies Aimed at Staff ...... 143 ReadersAppendix should S: Safe note Patient that Handlingthe white Peerpaper Leader materials Unit are Activity advisory and and Program are not Status intended Log to . . be. . . .used . . . . .as . . .regu-145 latoryAppendix or accreditation T: Patient Care requirements. Equipment Use Survey ...... 147 PREFACE

he 2010 HGRC Specialty Subcommittee on with safe lifting technology, most legislative and Patient Movement began studying the issues regulatory efforts have focused exclusively on related to use of patient handling and movement workplace safety and the costs directly related to (PHAM) equipment in health care facilities in injured workersÑas well as indirect costs such as early 2007. In the course of sharing our research those for continually replacing and training and expertise with one another, we learned there skilled nurses and other health care workers. This is an abysmal lack of knowledge and information emphasis on workplace safety as the primary on this subject throughout the architecture and motivator has meant that, to date, programs design professions and only a slowly growing (whether proposed or implemented) have been recognition in regulatory agencies and in the almost universally identified as safe patient health care industry itselfÑa fact we are con- handling (SPH) programs. Consequently, both vinced must be addressed. current federal legislative proposals seek new During the time we worked on this document, occupational safety regulations, to be developed the health care industry, nursesÕ associations, and administered by the Occupational Safety and health care labor unions, federal and state regula- Health Administration (OSHA). tors, and many state legislatures have been I However, our reviews of the literature, discus- arguing for and against the capital costs associated sions, and debates have sensitized us to many with bills that would mandate minimal lift policies Iadditional advantages that PHAM equipment may and the use of assistive devices to prevent care- offer, including: giver injuries. To date, nine states have adopted I Better patient outcomes and improved quality safe patient handling legislation or resolutions, but of life for both patients and caregivers most of the proposed bills and enacted legislation Economic benefits from avoiding adverse have provided only unfunded mandates for poli- events related to manual patient handling cies, studies, and demonstration projects. Only The potential for hospitals and nursing homes Minnesota and Washington have actually to mobilize patients using assistive devices committed funds for grant or loan programs to immediately following a procedure or admis- assist with the acquisition of lift equipment. sion and diagnosis Concern about making capital expenditures in We have concluded that all of these benefits the face of shrinking Medicare and Medicaid reim- and possibilities deserve to receive more bursement rates has prompted many health care emphasisÑin addition to (rather than instead of) executives to hope that Congress will fund a workplace safety. legislative mandate. Representative John Conyers Accordingly, we have chosen the more generic of Michigan did introduce such federal legislation and descriptive label of Òpatient handling and in 2006 and again in 2007, but in both cases the movementÓ (PHAM) to identify this subject, with bills died in committees of the House of Represen- the goal of widening the discussion and high- tatives without being scheduled for a vote. lighting our recommendation that the health care Conyers recently reintroduced his bill in the industry must recognize, focus on, and develop current Congress and Senator Al Franken of the far greater potential we perceive for the Minnesota has introduced a companion bill in the equipment and technology employed in these Senate; grassroots lobbying efforts are under way. systems. Thus, instead of SPH, in the 2010 Guide- In reviewing this history, the specialty subcom- lines and in this white paper, we generally have mittee observed that to justify the expenditures employed terms that are variations on PHAM, required to develop studies and implement the such as PHAMA (patient handling and movement acquisition, installation, and training programs assessment) and PHAMP (patient handling and needed to equip and operate health care facilities movement program). PHAMA 5

After two and a half years of intense delibera- And when they do, we trust that both the 2010 tion and debate, we are convinced the PHAM Guidelines requirement to conduct a PHAMA for aspect of the health care industry is still in its every health care construction or renovation infancy. As legislatures and authorities having project and this white paper may serve as cata- jurisdiction broaden their horizons, look beyond lysts: both to encourage innovative health care the concept of safe lifting, and focus on all the projects based on further equipment research and issues involved in safe patient handling and move- development, and to guide project decision- ment in hospitals, ambulatory care, residential Martinmakers H. toward Cohen, FAIA,the realization FACHA of safe patient care facilities, and other venues, we hope they will Chairman,handling and 2010 movement HGRC Specialty throughout Subcommittee the nationÕs on begin to give more weight to the potential advan- Patienthealth care Movement facilities. tages and savings to be realized from the shorter Vice Chairman, 2010 Health Guidelines Revision lengths of stay, fewer readmissions, and reduc- Committee tions in caregiver injuries and adverse patient events anticipated from regularly using PHAM equipment. INTRODUCTION

ARTIN OHEN T M H. C , FAIA, FACHA Guidelines for Design and Construction of Health Care Facilities

he 2010 edition of the Facility Guidelines 2. To provide readers with information and Institute resources to help them prepare a PHAMA for (the 2010 Guidelines or a project. (See Chapter 2 and its many appen- FGI Guidelines) introduces a requirement for dices.) project applicants to conduct a patient handling What to consider and how to evaluate the and movement assessment (PHAMA) as part of needs of patient populations when preparing a the sequence of predesign functional and space PHAMA for a project are discussed as well as programming processes for new construction the components of a PHAMA. Although based and renovation projects. Further, the 2010 on the experience of the Department of Guidelines requires applicants to revise that Veterans Affairs (VA), which clearly has set the PHAMA as new information becomes available pace in implementing safe patient handling throughout project design, construction, and (SPH) programs in the United States to date, commissioning. the material presented here can be adapted to PHAMA findings, recommendations, and revi- the unique patient population, caregiving staff, sions are intended to inform development of the project conditions, and available resources of functional program for a project, then its space any health care facility. program, and ultimately its design, construc- 3. To help readers establish a business case for tion, and commissioning, by keeping the design implementation of a patient handling and and construction team advised about the patient movement program (PHAMP). (See the two handling and movement (PHAM) equipment parts of Chapter 3.) and associated accessories to be used and In analyzing costs and benefits, we believe accommodated in specified locations. Such the potential advantages and savings that assis- advice includes information about any spatial, tive devices and new technology may structural, utility, or design considerations offerÑincluding advantages to caregivers, related to the installation, storage, maneu- benefits for patients, and operational savings to vering, servicing, and use of such equipment and be realized by health care organizationsÑmust thus should be updated whenever changes be quantified and considered. This white paper occur in that information. offers, for the readerÕs consideration, a descrip- The Steering Committee of the 2010 Health tion of the potential savings and financing Guidelines Revision Committee (HGRC) commis- options, plus a decision analysis program that sioned its Specialty Subcommittee on Patient Stanford University Medical Center, in Palo Movement to develop this white paper with a Alto, Calif., successfully employed to convince number of goals in mind: its decision-makers to implement a PHAMP. 1. To provide users of the Guidelines with back- We think this methodology offers a prudent ground information on the new PHAMA risk analysis strategy that should encourage requirement and the rationale for including it project decision-makers, the agencies that in the 2010 edition. (See Chapter 1.) approve and finance their projects, and the The white paper aims to help readers appre- industries that compete for and service those ciate both the hazards of manual patient projects to engage in further product research, handling and the potential benefits of using design, and development and to invest in inno- PHAM equipment. To make the latter point, the vative project solutions based on that research. current state of the art in PHAM equipment is 4. To help health care facilities implement the described. recommendations for acquisition of PHAM PHAMA 7

equipment and implementation of technology While researchers all over the world programs defined in their PHAMAs for every continue to study whether there is a direct new construction and renovation project. (See causal link between patient outcomes and the Chapter 4 and its appendices.) use of mechanical assists, many medical and We discuss how to facilitate a patient industry experts have discerned that relation- handling and movement program (PHAMP) ship on an anecdotal basis, and the industry is and encourage technology acceptance. We responding. Physical therapists, occupational share how the VA has successfully addressed therapists, orthopedic and rehabilitation staff behavior change to improve the quality of nurses, and their professional associations are patient care. A PHAMA, with its focus on insti- all pushing for the use of lifts for movement tuting ergonomics in facility planning and (including self-ambulation and assisted and design, is only the beginning of a successful independent mobilization), not just lifting. PHAMP. Another critical part is implementa- Companies are promoting lifts to serve these tion of organizational PHAMPs that functions as well. Better slings are being devel- incorporate change management strategies to oped, and many stakeholders appreciate the help caregivers and patients adapt to the orga- relationship between mobilization and nizationÕs PHAM equipment. When new PHAM improved patient outcomes. technology is introduced, caregivers must Given the increasingly hazardous biome- essentially change the way they work, and chanical demands on caregivers today, it is patients must also become acquainted and clear the health care industry must rely on comfortable with new equipment and care technology to make patient handling and regimens. movement safe. To encourage these trends, 5. To challenge equipment designers, manufac- equipment and accessory designers and turers, facility planners, architects, and project manufacturers must make their systems executives with ÒVisions of the Future of affordable enough to be purchased and Patient Handling and Movement Programs installed, and user-friendly enough for care- (PHAMPs).Ó (See Chapter 5.) givers and patients to embrace their use. And, Recognizing that the most appropriate and working in concert with facility planners and effective equipment and accessories to meet designers, they must also make them attrac- every patientÕs physical and medical needs may tive enough to be selected for use in not yet be universally available, we advocate patient-centered, homelike environments, and going back to basics and responding to cher- locate them conveniently enough for timely ished beliefs and great expectations about use, throughout the spectrum of caregiving where this industry could and should be going. facilities. Recent articles in medical and nursing jour- 6. To provide resources for additional informa- nals have stressed that increased mobility and tion regarding patient handling and movement. mobilization are no longer simply options for (See Chapter 6 and endnotes throughout the patients and residentsÑthey are a medical white paper.) necessity. In the design of care environments as Endnotes (which appear at the end of Chap- diverse as critical care units in hospitals and ters 1Ð5 and some appendices) provide bathing spas in nursing homes, many experts sources of information on specific subjects believe that early mobilization and safe patient likely to become relevant during preparation of handling and movement must be considered as a PHAMA. A further list of resources is basic as provisions for infection prevention and provided in Chapter 6 to assist readers who power outages. Per those authorities, the old may want more information before making model of sedentary care is unsafe and a thing of decisions or reaching conclusions about the past; mobilizing patients must be accom- subjects addressed in their PHAMA. plished in a way that is safe for both caregivers To the best of our knowledge, no previous and the patients who depend on them. reference work has addressed the issues of design 8 PHAMA

and construction related to patient handling and As used in this white paper, the term Òmove- movement in health care facilities as we have mentÓ includesÑin addition to liftingÑboth done here. The authors of the FGI Guidelines (the assisted transfers (e.g., from bed to wheelchair, members of the HGRC) trust that this white paper stretcher, toilet, etc.) and transport to a destina- will begin to fill a critical gap in the education of tion (e.g., from patient room to diagnostic Guidelines users, by helping them better under- imaging, physical therapy, etc.) as well as mobi- stand the many complex issues related to patient lization (i.e., both assisted and independent handling and movement for the patients and care- exercise and/or ambulation using assistive givers involved. We also hope the white paper devices and/or mobility aids). Also note that, may prove helpful to the facility managers, admin- although people who enter hospitals and certain istrators, and regulators who oversee kinds of ambulatory care facilities for care are construction and renovation projects as well as usually referred to as ÒpatientsÓ or Òclients,Ó and the decision-making executives, trustees, and those who live in long-term care venues may corporate directors who fund them. The guidance traditionally be known as Òresidents,Ó the term offered and the resources identified are intended ÒpatientÓ is used throughout this document to to help each facility determine the needs of its represent all three types of users, in new and unique patient population and caregiving staff existing health care facilities. All PHAMA consider- and define the most appropriate strategy for ations apply equally to all recipients of care. meeting those needs in the context of its unique Readers should note that the white paper community, facility project requirements, and material is advisory and is not intended to serve available resources. as regulatory or accreditation requirements. ACKNOWLEDGMENTS

he consensus process through which the FGI We should note that while MaryÕs material is Guidelines are developed typically makes it the result of work supported with resources from almost impossible to identify an individual author the Veterans Health Administration and the use of as responsible for a specific section of the Guide- facilities at the James A. Haley VeteransÕ Hospital lines. While a proposal may be submitted by a in Tampa, the findings and conclusions relayed by member of the Health Guidelines Revision Com- Mary W. Matz in this document are those of Mary mittee (HGRC) or the general public, the review W. Matz and do not necessarily represent the process through which texts are crafted, chal- views of the Department of Veterans Affairs. lenged, debated, revised, and wordsmithed by We are particularly grateful to John Celona, BS, task groups, subcommittees, and/or the full HGRC JD, a Palo Alto, California-based management and typically makes each part of the consensus docu- economics consultant who, though neither an ment truly a group product. HGRC or specialty subcommittee member, volun- For this white paper, however, each chapter teered to write Chapter 3 about the Business Case was researched and drafted by a specific indi- when he met Mary and learned about this white vidual or group of individuals as principal paper. authors; often supplemented by sidebars or We also are indebted to David A. Green and sections prepared by contributing authors. Thus, Roger Leib, who co-authored Chapter 5, plus although every chapter was vigorously debated sidebars for other chapters; and to Gaius G. and revisions were suggested by members of the Nelson, RA, and Phillip A. Thomas, AIA, who 2010 HGRC Specialty Subcommittee on Patient authored parts of Chapters 2 and 3. Like Mary Movement as well as our editors, the final version Matz, all of these gentlemen also generously of each chapter is the responsibility of and has contributed insights drawn from their vast and been credited to the principal and contributing diverse experience as well as their energetic and authors identified in each chapter. entrepreneurial spirits and good humor, Outstanding among this group was Mary Willa devoting untold hours to researching, reviewing, Matz, MSPH, CPE, without whom, it may truly be critiquing, debating, and improving virtually said, this white paper probably would not exist. every part of this white paper. This certainly was a labor of love for Mary. Like all Other authors who contributed either parts of HGRC members, the specialty subcommittee chapters or sidebars that have enhanced the members were volunteers, working on the white scope and quality of this white paper include: paper on their own time during evenings, lunch Judene Bartley, MS, MPH, CIC hours, weekends, and vacations. But Mary gave up Martin H. Cohen, FAIA, FACHA many hours of personal time for nearly two years! James W. Harrell, FAIA, FACHA She originally was invited to participate as an Jane Rohde, AIA, FIIDA, ACHA, AAHID, LEED AP outside stakeholder because of the expertise she Wade Rudolph, CBET, CHFM has developed in her work in the VA National David M. Sine, MBE, CSP, ARM, CPHRM Patient Care Ergonomics Program. However, David Soens, PE, RA Mary became so involved in the work of the HGRC The Specialty Subcommittee on Patient and had so much to contribute, she was invited to Movement was a subcommittee of the 2010 join the HGRC and participated in all three of its HGRC. While HGRC focus groups are composed all-hands meetings. Not only did she author three exclusively of HGRC members, specialty of the white paper chapters, and contribute signif- subcommittees comprise both HGRC members icantly to two others, she also participated in and invited outside stakeholders. When formed almost every conference call and critiqued almost at the initial meeting of the 2010 HGRC in April every part of this document from cover to cover. 2007, the Patient Movement group had an initial 10 PHAMA

membership of 21 HGRC members and 11 outside Special recognition also is in order for the supe- stakeholders. Many of those original members sat rior work of two superb professionals, our editor in on work sessions at the second and third all- Carla M. Borden and our executive editor Pamela hands meetings of the HGRC in 2008 and 2009. James Blumgart. If this white paper seems intelli- However, as the work progressed through a gible and makes sense to you, it undoubtedly is grueling series of bi-weekly (and sometimes thanks to their tireless efforts. weekly) conference calls to review the contents of Finally, we should like to express our thanks to successive research efforts, outlines, and drafts the Steering Committee of the 2010 HGRC for over a period of 30 months, the following core their encouragement, support, and guidance group of committed individuals emerged as throughout the development of this paper. And to clearly deserving of recognition for their dedi- the FGI Board of Directors for their financial cated service and generous contributions in support of this white paper and offering to host it support of this white paper. Their varied back- on the FGI Web site: www.fgiguidelines.org. We grounds, vast experience, innovative thinking, are delighted that FGI will make it available free of cooperative spirit, and steady advice have truly charge to the public and invite the public to made this document what it is: comment and submit suggestions for its improve- Martin H. Cohen, FAIA, FACHA, Chair Martinment. We H. Cohen, hope FAIA,and trust FACHA this white paper will Gaius G. Nelson, RA, Vice Chair Chairman,help you realize 2010 HGRCsafe patient Specialty handling Subcommittee and move- on Carla M. Borden, Editor Patientment programs Movement in your facility projects. David A. Green Vice Chairman, 2010 Health Guidelines Revision Roger Leib, AIA, ACHA Committee Mary W. Matz, MSPH, CPE Phillip A. Thomas, AIA Other much appreciated contributors, who helped shape the final product either by participating in conference calls or by preparing drafts or reviewing drafts by others, included: Ramona Conner, RN, MSN, CNOR Thomas W. Jaeger, PE Lorraine G. Hiatt, PhD Thomas M. Jung, RA James W. Harrell, FAIA, FACHA Rita Rael Meek, RA Wade Rudolph, CBET, CHFM David Soens, PE, RA PHOTOGRAPHY CREDITS

Integrity Medical Products

The photographs included in this white paper Likoª , manufacturer of were provided courtesy of the organizations integrated patient lifting systems. ArjoHuntleighidentified here; theyInc. are reprinted with permis- www.integritymp.com sion and copyrighted to the manufacturers, all rights reserved. RoMedic, a Hill-Rom Inc. Services Inc. company, manufacturer of patient lifting systems. Dane Industries focuses on patient mobility www.hill-rom.com and wound management solutions. www.ArjoHuntleigh.com. , manufacturer of transfer, positioning,Stryker support,Medical and lifting products for safe DSGW Architects, manufacturer of medical patient handling. devices for safe patient handling. www.romedic.com www.danetechnologies.com TransMotion Medical, manufacturer Inc. of patient care Ergolet , a multi-office architecture firm and handling equipment. with expertise in health care planning and design. www.stryker.com/medical www.dsgw.com , manufacturer of Guldmann, manufacturer Inc. of overhead and portable Wrightmobile, motorizedProducts Inc.treatment and transport lifts for safe patient handling. stretcher-chairs for safe patient handling. www.ergolet.com www.transmotionmedical.com

HoverTech International, manufacturer of patient lifts for , manufacturer of the safe patient handling. Slipp¨ for safe patient handling. www.guldmann.net www.wrightproductsinc.com

, manufacturer of the Hovermatt and Hoverjack for safe patient handling. www.hovermatt.com GLOSSARY

Air-assisted lateral transfer device: Culture of safety:

A patient The collective belief of those transfer mattress that utilizes the force of air to withinCumulative a work trauma environment disorder: that safety is a shared decrease friction and ease movement of patients responsibility and is integral to staff and patient (inAmbulate: a supine position) from one surface to another. safety. Also decreases shear forces on the skin of patients during lateral transfers. (See Appendix C.) The outcome of Bariatric patients: repeated damage, or an accumulation of damage To walk or move about from place to over time, to a specific area of the musculoskeletal place with or without assistance. system. This damage includes micro-injuries such as micro-tears to the muscles and micro-fractures Persons overweight by more to the vertebral endplates of the spine. When Biomechanics:than 100 lbs. or with a body weight greater than uncontrolled,Ergonomics: such micro-injuries result in more 300 lbs., or (more commonly) with a body mass significant injuries, which often appear to be index (BMI) greater than 40. acute.

The study of the application of the The scientific study of the relation- lawsBody ofmass physics index and (BMI): engineering to define and ship between work being performed, the physical describe movement of the body and forces that act environment where the work is performed, and upon the musculoskeletal system. the tools used to help perform the work. The goal of ergonomics is to provide a workplace designed Caregiver: a patientÕs weight (in toErgonomic ensure that shower the biomechanical, chair: physiological, kilograms) divided by the square of a patientÕs and psychosocial limits of people are not height (in meters). exceeded.

Any person who provides direct A powered commode/ patient care, including moving and handling Floor-basedchair that is heightsling lift:and longitudinally adjustable patients. Caregivers are of varying clinical disci- to place a patient in a position for ease in personal plines and educational levels and may work in any care. (See Appendix C.) area where patient handling and movement Ceilingoccur, including or overhead long-term sling care; lift: acute care; home- Lifting equipment with a based care; dental or radiology/diagnostics wheeled base that rolls on the floor and can be practices; therapies; and the morgue. moved from room to room or area to area. Used for dependent patients and patients requiring Lifting equipment extensive assistance. The lift motor functions to used for dependent patients and patients Friction-reducingraise or lower the device:patient but caregivers must requiring extensive assistance. The motor that manually push the lift and patient to the desired lifts the patient is attached to a track or rail location. (See Appendix C.) suspended from the ceiling or attached to the wall. TheClient: motor functions to raise or lower the patient Devices made of slip- and sometimes to move the patient horizontally. pery materials that reduce friction during sliding (See Appendix C.) movements, making it easier to move a patient from one place to another or to reposition a A recipient of care; a consumer of care patient in a bed or chair. (See Appendix C.) services. PHAMA 13

Gantry lift: Manual patient handling:

Lifting equipment used for dependent Mechanical lateral transfer devices:Lifting, moving, patient and patients requiring extensive assis- sliding, transferring, or otherwise caring for a tance.HGRC: This type of lift is placed over the bed of a patient without mechanical assistance. patient and functions similarly to an overhead/ ceilingHigh-risk lift. (Seepatient Appendix handling C.) tasks: Powered by an electric motor or manual crank, these Health Guidelines Revision Committee. devicesMobilize: attach to a draw sheet or something similar and pull the patient from one surface to Patient care another. (See Appendix C.) activities that result in musculoskeletal injuries in caregivers.Infection control:Tasks are considered high risk based To move from place to place either with on their frequency and duration and the degree of assistanceMusculoskeletal or independently disorder to (MSD)/muscu-help a patient musculoskeletal stress imposed by the task. maintainloskeletal or injury increase (MSI): physical activity and movement, involving the entire body or just limb/s. Decreasing the risk of or preventing the invasion and multiplication of microorganismsICRA: in body tissues. Also, decreasing An injury to or disorder the risk of releasing microbiological materials into of the musculoskeletal system, including muscles, the environment. bones, joints, tendons, ligaments, nerves, carti- ICRMR: lage, and spine. Most work-related MSDs develop Infection control risk assessment. (See overNo-lift, time. zero-lift, MSDs ortypically minimal-lift affect policy:the back, neck, Appendix M.) shoulders, and upper limbs; less often they affect IP: the lower limbs. Infection control risk mitigation recommendations.Lateral transfer: (See Appendix M.) A policy Patient:that prohibits or minimizes manual lifting by insti- Infection preventionist. tuting a patient handling and movement program (PHAMP). Horizontal movement of a Liftingpatient inequipment a supine position (lifts): from one flat surface Patient careA recipient ergonomic of care; (PCE) also used evaluation: in this white to another (e.g., from a bed to a stretcher or paper to refer to clients and residents in residen- bathing trolley). tial care facilities.

Mechanical devices Use used to assist caregivers in performing patient of ergonomic principles to evaluate the ergonomic handling tasks, including lifting, transferring, hazards in a patient care environment in order to wound care, ambulation, and others. Lifts fall into generate recommendations for control measures, two categories: powered sit-to-stand lifts and full- including patient handling equipment and bodyLift team: sling lifts. The latter category is further programmatic recommendations such as institu- broken down into overhead/ceiling, gantry, and tionPatient of handlinga PHAMP and and movement standard assessment operating floor-based lifts. (See Appendix C.) procedures(PHAMA): for maintenance/repair and storage of patient handling equipment. (See Appendix E.) Caregivers organized into teams of two or more whose responsibility is to move and handle patients throughout the hospital. Team Structured guidance to direct and members receive specialized training in safe assist the design team in incorporating and lifting and moving techniques utilizing patient accommodating appropriate patient handling handling equipment. and movement equipment into the health care environment. 14 PHAMA

Patient handling and movement program Sit-to-stand lift: (PHAMP):

A lift that used to raise a patient A program for reducing ergonomic from a seated position and lower him or her to risk for caregivers and patients from patient another seated position. The patient must have handling activities. Includes support structures Sling:some upper body strength, cognitive ability, Patientand change handling management equipment: strategies to facilitate weight-bearing capability, and the ability to grasp use of patient handling equipment and foster a with at least one hand. (See Appendix C.) culture of safety in the patient care environment. A fabric device used with mechanical lifts to A variety of tools temporarily lift or suspend a patient or body part or devices used to assist caregivers in performing to perform a patient handling task or to reposi- patient handling tasks (e.g., transferring, ambu- tion/position a patient in bed or chair. Sling styles Patientlating, handlingrepositioning, tasks: lifting, toileting, includeSupine: seated, standing, ambulation, reposi- transporting, and many other tasks). (See tioning, limb support/strap, supine, toileting, Appendix C.) bathing, and others. (See Appendix D.) SPH: Tasks performed by Lying on the back or having the face caregivers when caring for patients, including SPHM:upward. bathing, transferring, wound care, repositioning, feeding,Peer leaders: and many more. Those considered high Transfer:Safe patient handling. risk result in injury when performed manually without assistive devices. Safe patient handling and movement.

Caregivers who represent their The movement of a patient from one clinical unit or area as safe patient handling and placeTransfer to anotherchairs: (e.g., from a wheelchair to a movementRepositioning/positioning: champions and experts. They are toiletÑvertical transferÑor from a bed to a informal leaders who have specialized training in stretcherÑlateral transfer). safe patient handling and movement. A device that converts from a Adjusting a chairTransport into a assistivestretcher anddevice: back. In the stretcher patientÕs position in bed or chair to prevent pres- position, the device facilitates lateral transfers. Resident:sure ulcers, promote comfort, accommodate (See Appendix C.) physiological functioning, or raise the patient to eye level to facilitate communication. Usually battery- powered devices that caregivers use to help move A recipient of care in a long-term/resi- patients from one location to another. These dential care facility. devices attach to handles of wheelchairs and to beds, and the caregiver simply guides the direction of the bed or wheelchair. (See Appendix C.)

CHAPTER 1 Rationale for Including the PHAMA in the 2010 Guidelines for Design and Construction of Health Care Facilities

Principal author:

Contributing author:

ARY ATZ M W. M , MSPH, CPE OGER EIB A R L , AIA, ACHA

significant impediment to providing safe manually lift or move a patient without mechan- and therapeutic environments of care is the prac- ical assistance. The increasing number of tice of manual patient handling. Manual patient morbidly obese, bariatric, and sicker (and thus handlingÑlifting, transferring, positioning, and more dependent) patients who must be moved sliding patients without assistive technologyÑ for various caregiving tasks adds to the amount of has been the norm in health care facilities for stress on caregiversÕ bodies. It requires little imag- decades. Nonetheless, it is an unsafe practice for ination to realize that caregiver injury has effects both caregivers and patients. on staffing, organizational costs associated with Manual patient handling puts caregivers at lost time and workersÕ compensation, andÑ 1 considerable risk for musculoskeletal injury: significantlyÑthe quality of patient care. Researchers have found that more than 80 Caregiver Tasks That Cause Concern AroundManual patient Safe Patienthandling alsoHandling increases the percent of nurses are injured at some point since, risk of injury, pain, and negative health outcomes in the most basic terms, there is no safe way to Every day, caregivers transfer, position, mobilize, toanother patients, flat surface in part and because (2) from of perch the toeffects perch such and support the ambulation of patients. Providing (from one seated position to another seated posi- this assistance manually, in the traditional manner, tion or to/from a seated position from/to a supine can involve excessive physical effort, which is position). further complicated when tubes and other devices tether a patient to fixed outlets and utilities. To be From one flat surface to another (lateral transfer). done safely, handling and moving adult patients of Although increasing numbers of procedures are any size must be performed with the aid of performed patient-side, dependent patients must special equipment designed for that purpose. still be transported throughout a care facility and Optimally, patients mobilize and ambulate often they must be moved from the surface on themselves or, for the sake of patient dignity, at which they are lying to another flat surface in least assist in the process. Therefore, the equip- order to be transported. Such “lateral” or “slide” ment and protocols caregivers use must remove transfers are also commonly performed when as much risk of physical injury from the physical moving dependent patients onto treatment, diag- environment and care process as possible. nostic, and procedure tables/surfaces. When The following descriptions of the types of performed manually in a location where no rails assistance caregivers typically provide are or armrests interfere, such lateral transfers intended to serve as a basis for understanding generally include these movements: The care- what constitutes patient handling and movement, giver brings the destination surface (bed, gurney, the associated need for assistive devices, and etc.) to the location of the transfer and aligns it how use of these devices affects the physical longitudinally alongside the originating surface. health care environment. When performed manually, in a conventional fashion, one, two, or more caregivers, standing Transferring on the open sides of both the origination and There are two general categories of transfers: destination surfaces, grab the drawsheet movement of a patient (1) from one flat surface to sidebar continues on next page 16 PHAMA: Rationale

tasks have on caregivers. Further, manual the financial to the health, and ultimately the patient handling, along with the often infrequent quality of life, of patients. use of assistive technology, may restrict oppor- The primary solution to the problems of tunities for patient movement, mobilization, and manual patient handling lies in assistive patient weight-bearing activities, which can compro- handling and movement (PHAM) technology. mise patientsÕ recuperation, rehabilitation, and Some countries have national policies that ban I overallsidebar health.continued Again, from previous the costs page of ignoring risks manualExamining lifting; a patient in the United States, federal legisla- I Performing a procedure, from minor surgery to causedand either by pullmanual or push patient it—and handling thus the patient—to go beyond tionre-bandaging, is pending, catheterizing,and several intubating,states have etc. adopted the destination surface. I Performing personal hygiene tasks I Grooming and feeding From perch to perch. “Perch” refers to a bed, I Providing emergency or “code”-response care. chair/sofa, toilet or toileting chair, dependency Not infrequently, due to extenuating circum- chair, or wheelchair—the key furnishings on which stances, these procedures are carried out with a patient comes to “perch” in the patient room. the patient on the floor. Given conventional furnishings, there is frequent need for movement between perches (from a sitting To prevent bedsores and other position-related position in one location to a sitting position in adverse outcomes. A patient’s position should be another location). In long-term care environments, changed at least every two hours, even at night, to care instructions and protocols typically demand prevent bedsores and/or minimize pooling of that residents spend as much of the day out of bed upper-respiratory fluids and to optimize infusion of as possible. In hospital settings, patients must often oxygen into the lungs. This activity involves rolling be “up in a chair” beginning as early and for as long patients from one side onto the other, and placing as possible. Respecting patient dignity also implies pillows or other supportive materials next to the minimal use of bedpans in favor of a toilet or patient to temporarily hold that position. It is one bedside commode. As well, patients are trans- of the most frequent manual moves performed by ported throughout a care facility for a variety of caregivers. diagnostic, treatment, and other procedures. For “manual” transfers from a flat or reclined To reposition patients for their comfort and position, the caregiver usually assists the patient to safety. Returning a patient who has slid down in a sitting position and rotates the patient’s body bed to the head of the bed is also a frequent while lifting or assisting movement of the patient’s manual move performed by caregivers. A patient legs over the side of the bed. From such a seated who slumps down in a chair, wheelchair, or position, the caregiver lifts the patient up from the dependency chair also needs to be pulled up. perch, pivots the patient a “quarter-turn,” and then Caregivers attending a conference in 2008 anec- lowers the patient onto the new perch. When trans- dotally reported as much as 50 percent of their ferring from a seated position onto a bed or other time with patients was spent repositioning them. flat surface, the caregiver may use a twisting These moves typically are among the highest-risk motion to lay the patient down. More independent tasks performed by caregivers. patients can use transfer aids/devices to move themselves to/from a bed and wheelchair when To address a clinical condition. arms or rails do not impede such a move. I Patients are positioned/repositioned in bed to ease breathing and/or reduce nausea. Positioning/Repositioning I The upper bodies of patients with compromised Patients are moved or repositioned for a number breathing function—commonly including of reasons: bariatric patients—must be raised, usually to a standard minimum angle. To accomplish patient care tasks. Patients may I Hypotensive patients are historically positioned be moved to facilitate performance of a clinical with the head lower than the body. procedure or patient care task, such as those I During feeding of debilitated patients, swal- listed below. In all these cases, the entire body, an lowing raises the risk of aspirating fluids or upper or lower portion of the body, the head, or a solids into the lungs and developing aspiration single limb may need to be moved or brought into pneumonia, so it is important to maintain a and maintained in a particular position. vertical upper body position. PHAMA: Rationale 17

such legislation. Government, professional, and (PHAMPs) as described in Chapter 4 of this docu- industry groups strongly support ergonomic ment promote the use of such technology and also interventions in the form of assistive technology facilitate organizational change by incorporating to keep caregivers and patients safe. However, to program elements that foster values essential to facilitate acceptance and use of such new tech- an effective culture of safety. nology by caregivers, programmatic and That PHAM technology is not more widely organizationalTo enhance communication.support structures Communicating must be put in employedto take a patient is partly from a one function area of of a thefacility constraints to of with patients at eye level supports patient dignity another (e.g., to radiology or a special treatment or place.and Patientenhances handling the quality and of movement communication. programs theprocedure built environment.area) include stretchers, Space must gurneys, be beds,adequate transport chairs, wheelchairs, and (less frequently) Mobilization and Ambulation portable bathing trolleys. When the human body is immobile, it deterio- The fact that patients may need to be trans- rates after a short period of time. Early and ferred onto these transport devices from less frequent mobilization of a patient or resident is mobile or less maneuverable perches (see thus critical to maintaining or regaining health. Transferring above) creates risk for both patients Many providers observe that the earlier a patient and caregivers in these situations. Additional is mobilized (particularly getting the patient up on challenges and risks arise from having to push, his or her feet and walking), the better the pull, shove, and maneuver the devices to reach a outcome. Conversely, many immobility-related destination, while at the same time overcoming adverse events, some with long-lasting conse- difficulties presented by soft floor coverings, quences, are linked to late or insufficient ramps, thresholds, inadequate clearances and mobilization. turning radii, and so on. As it relates to safe patient handling and Perhaps the greatest risks occur in emergency movement, mobilization includes the following: situations when there is no time to transfer a I Moving the limbs of dependent, non-weight- patient from a hospital bed onto a more special- bearing patients to preserve joint flexibility. ized transport device and caregivers undertake to This involves taking limbs through their full use the already-heavy beds as patient transport range of motion. vehicles. I Ambulating patients as early and as often as possible to maintain mobility and bone density. Wound Care Recent evidence suggests the need for early or In performing wound care, caregivers must lift immediate and frequent ambulation applies patients’ heavy limbs and hold them in place even to some of the highest acuity patients, throughout what can be lengthy procedures. such as ventilator-bound patients in the ICU, Additional difficulties result when a wound is located who in the past were left immobile. Patient on a part of the body that is difficult to access. ambulation involves a caregiver(s) supporting a patient on one or both sides, with the risk of Toileting suddenly having to prevent a fall. Assisting a patient in toileting is potentially one of the most difficult caregiver tasks. The difficulty of Lifting Off the Floor trying to suspend a patient over a toilet while Manually lifting patients who have fallen is another performing personal hygiene for them is rarely task that is high-risk for both caregivers and discussed. And patient falls, often serious, occur patients. A concern particular to this activity is most frequently between bed and toilet. ensuring that the patient is stable and has not Most institutions and caregivers subscribe to been injured; thus, examination and caregiving the value of maintaining patient dignity by helping must be provided in an awkward position from the patients as necessary to relieve themselves in/on floor. As well, lifting a patient who cannot help a built-in toilet within a private enclosure. from the floor is undoubtedly one of the most diffi- However, patient size, weight, dependency level, cult patient handling tasks caregivers perform. intubation, and hour of need often shortcut these aspirations with the following, less-desirable alter- Transportation natives: Transporting patients long distances and/or up and I Bedpans, a sometimes humiliating if necessary down inclines can be very difficult for caregivers default of choice and dangerous for patients. Transport devices used sidebar continues on next page 18 PHAMA: Rationale

Hazards of Manual Patient Handling

for equipment use and storage; weight capacities sufficient for mounted objects; and flooring surfaces, slopes, and clearances conducive to Always unsafe, manual patient handling has smooth movement of rolling equipment. For such become even more so today. As patient acuity accommodations to be provided as necessary, levels and weights have increased, so has recogni- architects and other designers must know the tion of the benefits of patient mobilization. With facts and possible solutions. The patient handling more demands for mobilization of increasingly and movement assessment (PHAMA) is intended dependent and larger patients come additional to facilitate the incorporation of assistive tech- risk of injury for both caregivers and patients. nology into the design of health care facilities to Today, higher patient acuity levels are ensure safety and positive health outcomes for commonlySurgery found in most clinical settings (e.g., patientssidebar as continued well as from safety previous and page positive work envi- patientsTransferring formerly patients consideredonto and off ofmedical/surgical a surgical ronments for their caregivers. patientstable presents are often all the found usual today difficulties in nursing inherent homes). in I In-cabinet toilets built into cabinetry and performing lateral transfers, along with others lacking a sense of privacy stemming from location in the surgical suite I Portable bedside commodes rather than the patient room. Enabling patients to safely reach the toilet is a major concern of caregivers. It is sufficiently diffi- Vehicle Extraction cult when patients signal their intentions, but even Patients arrive at health care facilities in varying more so when patients do not. Confusion, states of consciousness, physical and emotional compromised balance, poor lighting, unfamiliarity fragility, and pain; they are also of different sizes with environmental obstacles, and inadequate and weights. Some are able to leave their car door clearance for caregiver-assisted visits to the independently, but many cannot exit and lift toilet all exacerbate these concerns. themselves to a standing position. Assisting these patients from a vehicle, often from the back Showering/Bathing seat, frequently requires contortions on the part Safely getting a dependent patient into and out of of caregivers. The task is further complicated by a shower (or tub, where still used) represents the urgency of emergent situations. significant difficulties and dangers for caregivers and for patients. Bathing commonly takes place Patients Presenting Special Challenges in these venues: Care of obese/bariatric patients and combative I In bed patients takes patient handling and movement I In an in-room shower (within the patient bath- challenges to another level. Considering all the room), often on a wheeled shower chair patient handling activities noted above, risk of I In a shared bathing room with or without injury to both caregiver and patient is adequate clearances for maneuverability and compounded when obese/bariatric or combative necessary patient transfers patients are involved. Therefore, careful considera- I On a portable bathing trolley wheeled from the tion must be given to all details of the special patient room to the shower room challenges such patients present. Those suffering Showering/bathing a dependent patient pres- with dementia often become combative if they feel ents a unique set of difficulties: frightened or frustrated by something or someone. I The patient is in a highly vulnerable emotional This problem is not confined to special Alzheimer’s (and physical) state. care units, since many long-term nursing facility I All areas of the patient’s body must be reached, administrators report that up to 80 percent of their including the perineal area. To accomplish this, general patient populations may manifest at least patients and limbs must be lifted and turned, some degree of dementia. [For further information and, depending on the position of the patient, on one specific aspect of this problem, see A. L. caregivers must reach or stoop as necessary, Barrick et al, ed. Bathing Without a Battle: sometimes for extended periods. Personal Care of Individuals with Dementia (New I Working conditions can be wet and slippery, York: Springer Publishing Company, 2002).] and floors are sloped for drainage. I Patients are at greatly increased risk of falls. Roger Leib, AIA, ACHA PHAMA: Rationale 19

3, 4, 5, 6, 7, 8 Despite this fact, most health care facilities are not patients has been found to exceed caregiversÕ equipped to handle the growing population of biomechanical capabilities. It was recently morbidly obese and bariatric patients. Another determined that 35 lbs. is the maximum weight a especially significant factor in the quality of care caregiver should manually9 lift under the best of being provided is the global nursing shortage, circumstances (e.g., no tubes, contractures, which may be due in part to the overwhelming combative behavior, etc.). No amount of training use of manual patient handling and movement in proper body positioning or lifting will prevent techniques. The impact of manual patient injury when the load exceeds what the body can handling can be seen in injuries to the aging care- tolerate. We all may be aware of the potential for giverImpact workforce, on Risk of theCaregiver difficulty Injury facilities have transmission of infection and disease from recruiting and retaining qualified nurses, and the patients to caregivers, but many of us do not number of injured nurses of all ages. consider10 the ergonomic hazards caregivers face from manually lifting, moving, and handling patients. For more than 30 years, training in body A comparison with other general industry mechanics and ÒproperÓ lifting techniques was the occupations highlights the gravity of the situation. control measure of choice for decreasing injuries As can be seen in Figure 1-1, injury rates in the related to manual patient2 handling. Yet during this farming and construction industries have time,Biomechanics injuries from manualof Patient patient Handling handling Injuriesdecreased significantly over time, while those in continued to increase. The reason for this? Lifting the nursing and personal care industry have not. Carrying out an activity that exceeds a person’s contraction. Muscle fibers also can be damaged biomechanical capabilities causes damage to the from excessive loading or repetitive actions musculoskeletal system. Manually lifting patients without sufficient recovery periods.13 With who weigh more than 35 lbs. (even under optimal continued lifting and moving of excessive loads circumstances) is such an activity and, conse- (patients), micro-tears eventually progress to a quently, caregivers are injured.11 In acute injuries, major tear,14 and a person may be surprised when, damage occurs when one event results in an injury: in a simple motion of bending over to pick up a For instance, six caregivers attempt to manually pencil, his or her “back goes out.” move a 500-lb. patient, and the excessive load Excessive spinal loading is a consequence of results in a serious muscle tear to one or more lifting heavy loads and even light loads for a long caregivers. However, most patient handing injuries period of time. Such lifting results in compressive come from cumulative traumas. A cumulative forces on the spine. Twisting, reaching, bending, trauma injury results from the accumulation of pulling, and other similar motions produce shear micro-injuries over time and often manifests itself in forces on the spine that also add to spinal what would seem to be an acute injury. These loading.15 When a person’s spinal load capacity is cumulative traumas are not only the more common surpassed, vertebral endplate micro-fractures but the more insidious of musculoskeletal injuries. occur and scar tissue is formed. Normally, nutri- Such micro-injuries, in the form of micro-tears in ents easily diffuse through a healthy vertebral the muscles or micro-fractures on the end plates of endplate into the adjacent disc, but endplate spinal vertebrae, often progress silently over time, scar tissue impedes the flow of these vital nutri- until severe damage occurs.12 While the focus here ents. (Discs lack a blood supply and must gain is on damage to the muscles and spine, joints and their nutrients by means of diffusion through their bones can also be compromised. Most patient adjacent vertebral endplates.) Without adequate handling injuries are located in the lower back, but nutrient flow, a disc degenerates until nerve injuries also occur in the middle and upper back, impingement results in pain and decreased work shoulders, neck, arms, wrists, and even the hands capacity. The frightening aspect of this insidious and knees. injury cascade is that the discs have no nerve When muscle exertion occurs over an supply to warn of the degeneration, and so care- extended period of time or too often without givers are most likely unaware that such a adequate recovery, the muscle becomes fatigued cumulative trauma injury is progressing until and is no longer able to produce energy for damage has been done.16 20 PHAMA: Rationale

Figure 1-1: Comparison of Injury Rates in Construction, Nursing and Personal Care, and Farming 20 s r

e 15 k r o w e m i t - l l u

f 10 0 0 1 r e p s e i r 5 u j n I Construction Nursing & Personal Care Farmers

0 1983–87* 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 199 8 1999 2000

*Baseline figure Source: U.S. Department of Labor, Annual Survey of Occupational Injuries and Illnesses (2001)

Table 1-1: Nonfatal Injuries and Illnesses Table 1-2: Comparison of Work-Related Involving Musculoskeletal Disorders with Injuries and Illnesses in Three Health Days Away from Work Care Industries (2007)

Nurses’ aides/orderlies and attendants 29,980 Health Care Industry Number of Work-Related Registered nurses 8,810 Injuries and Illnesses Licensed practical and vocational nurses 3,400 Hospitals 264,300 Nursing TOTAL 42,190 Ambulatory health care services 127,500 Nursing care facilities 121,100 Laborers/freight-stock-materials movers 33,590 Total 512,900 Truck drivers (heavy/tractor-trailer) 17,770 Truck drivers (light-delivery services) 12,450 U.S. Department of Labor, Survey of Occupational Injuries and Illnesses (2007) Construction/laborers 9,190

Source: U.S. Department of Labor, Bureau of Labor Statistics, Lost- Work Time Injuries and Illnesses: Characteristics and resulting time Table 1-3: Reported/Accepted Non-Fatal away from work—2003 (April 10, 2004). MSDs* Requiring Days Away from Work with Ranking Between All Occupations

Number of MSDs Requiring Days Comparison Away from Work of Ranking Nursing aides, orderlies, and attendants 24,340 2nd highest Registered nurses 8,580 7th highest

*Musculoskeletal disorders U.S. Department of Labor, Survey of Occupational Injuries and Illnesses (2007) PHAMA: Rationale 21

High-Risk Tasks Included in VA Patient Care Ergonomic Guidelines Other comparison data from 2003 (see Table 1-1) I Transfer of patients to and from bed to chair, shows that nursesÕ aides/orderlies and attendants, chair to toilet, chair to chair, or car to chair registered nurses, and licensed practical and voca- I Lateral transfer of patients to and from bed to tional nurses have a much higher incidence of stretcher or trolley musculoskeletal injuries (and associated lost time I Transfer of patients to and from chair to from work) than laborers/freight-stock-materials stretcher, chair to chair, or chair to exam table I Repositioning of patients in bed, both side to movers, truck drivers, and construction/laborers. side and up in bed According to 2007 information, there were I Repositioning patients in wheelchair or 512,900 work-related injuries and illnesses (see dependency chair Table 1-2). The seriousness of this injury data is I Transfer of patients up from the floor substantiated by injury data broken down by I Tasks requiring sustained holding of limb(s) or access to body parts of bariatric patients occupation. In 2007 registered nurses suffered I Transporting bariatric patients (stretcher, wheel- 8,580 musculoskeletal disorders (MSDs) requiring chair, walker) days away from work, the seventh highest number I Bariatric toileting tasks of MSDs in the country, while nursing aides, order- Source: Patient Care Ergonomics Resource Guide: Safe Patient lies, and attendants suffered 24,340 MSDs, the Handling and Movement (Tampa: Veterans Administration Patient Safety Center of Inquiry, 2001); www.visn8.va.gov/ second highest number (Table 1-3). Astoundingly, PatientSafetyCenter/safePtHandling. the rate of injuries for nursing aides, orderlies, and attendants as a group (252 MSDs per 10,000 workers) was17 the highest rate of MSDs for any occupation, more than seven times the national 27 MSD average. 18 Researchers have found that 81 percent of ability of technology to reduce the risk. The nurses are affected by MSDs. As significant as the physical and medical conditions of the patient also existing injury data19 appears for patient caregivers, affect the risk of caregiver injury (e.g., in the many musculoskeletal20 patient handling injuries Impactbehavioral on healththe Quality setting, of constraintsPatient Car upone PHAM are not reported Ñaccording to some estimates, equipment are necessary to provide a safe envi- at least 50 percent. Because of this, we are not ronment for suicide-risk patients). aware of the true extent of caregiver injury or the consequences for patient care. That nurses often work when injured increases the risk of further The goal of a health care organization is to initiate injury to them and, in turn, the likelihood they will the healing process for patients and to provide a have to take leave or retire because21, 22, 23, 24, of 25 injuries. comfortable and pleasant environment of care. Research has been conducted in various Caregivers know that manual patient handling patient care environments to identify affects these goals, but only limited hospital33 data manual PHAM tasks that put caregivers at most is available that directly connects manual risk for injury, and findings confirm that these handling to adverse patient events. However, Óhigh-riskÓ patient handling tasks26 place excessive anecdotal stories tell of the dislodgement of inva- biomechanical and postural stress on the muscu- sive tubes and lines, dislocation34 of shoulders, loskeletal system of caregivers. Listed in the fracture of fragile bones, and patients dropped accompanying sidebar are some, but certainly not during manual patient handling. As well, skin all, PHAM tasks that are high risk when tears and abrasion are common when patients are performed manually. For a list of high-risk tasks pulled up and across beds, and manual patient by clinical area, see Appendix A. handling has been related to pain in critically ill The level of risk in already high-risk tasks can patients. Reports by critically ill patients 18 years be increased by their frequency and duration; the and older noted that pain experienced during patientÕs size, weight, level of cooperation, and turning/repositioning activities35 was greater than unpredictability; transfer distance; space during tracheal suctioning, tube advancement, constraints; awkward positions; and the avail- and wound dressing changes. 22 PHAMA: Rationale

Safe Patient Handling and Movement Guidelines, Legislation, and Regulations

Over the past decade, a variety of entities have instructed health care organizations to address turned their attention to the issue of safe patient ergonomic hazards related to patient handling by handling and movement. Professional health care utilizing patient lift equipment and lateral transfer groups, labor organizations, the health care industry, devices in compliance with its Environment of regulatory agencies, and the scientific community Care standard and by incorporating recognized have converged in attempts to arrive at effective best practices in their facilities.30, 31 solutions to protect direct patient caregivers from The United Kingdom, Australia, and Canada the ergonomic hazard of manual patient handling. instituted national “no lift” policies that banned the Regulating entities have taken stands against manual patient handling techniques many still manual lifting and promoted safe patient handling embrace in the United States, instead mandating techniques. Of all industries the U.S. Department the use of assistive devices to move and lift of Labor Occupational Safety and Health patients.32 As of this writing, nine U.S. states Administration (OSHA) targeted for development (Washington, Texas, Minnesota, Illinois, Rhode of an ergonomic guideline, the health care Island, Maryland, Ohio, New York, and New Jersey) industry was the first to receive one—“Guidelines have adopted legislation, and Hawaii passed a for Nursing Homes: Ergonomics for the preven- resolution. Legislation has been proposed at the tion of musculoskeletal disorders.”28 In addition, national level, and support is growing. OSHA identified “manual” patient handling as the For more information related to national poli- primary cause of musculoskeletal disorders cies and specifics of state legislation, see among patient caregivers. As a result, the OSHA Appendix B. For the current status of state and guidelines explicitly recommend the use of assis- federal legislation, link to the American Nurses tive technology and note that the guidelines can Association Web site at http://nursingworld.org/ be applied to other health care settings where MainMenuCategories/OccupationalandEnvironme patient care occurs.29 The Joint Commission ntal/occupationalhealth/handlewithcare.aspx.

Current Patient Handling and Movement Equipment Categories

Patient mobilization efforts are also affected negatively when manual means are the only or primary method for accomplishing this critical activity. The weight of evidence supports the posi- Fortunately, ergonomic interventions in the form tive effect of movement and mobilization on the of mechanical assistive technology are available to quality and speed of a patientÕs recovery and on decrease the risks of manual patient handling and the patientÕs ability to preserve current levels of movement for both patients and caregivers. The physical capability. Therefore, insufficient move- PHAM equipment categories listed in Table 1-4 are ment and mobilization puts patients at high risk36 of common as of this writing. Although not all of immobility-related adverse events (see the sidebar these have marked effects on design decisions, the for some complications of patient immobility). patient handling devices identified with an Patients may also be affected indirectly when asterisk (*) must be stored in accessible and staff members work in pain and discomfort appropriate locations, requiring thought to be and/or under medication due to injuries incurred given to storage space specifications. Furthermore, while manually handling patients. Unintentional during use, this equipment takes up additional errors may adversely affect patient care, and space in patient rooms and/or toilet rooms. To personnel shortages as a result of injuries cannot accommodate it, adequate space must be allowed help but affect the quality of care patients receive. for use by one or more caregivers (including a In addition, caring for patients with higher sufficient turning radius) in the bath, patient room, weights and acuity levels makes it even more diffi- and hallway. Importantly, use of larger, bariatric cult for overextended caregivers to find time to variations of patient handling equipment is essen- mobilize and transfer patientsÑactivities that, as tial for protecting caregivers and patients. mentioned above, are critical to the healing For detailed descriptions of PHAM equip- process and prevention of patient deterioration. ment, plus photographs, refer to Appendix C. PHAMA: Rationale 23

Some Complications 38 of Patient Immobility37

The sling selection chart in Appendix D can be A large number of complications are attribut- used to match patient handling tasks with able to insufficient movement during the recovery process. Examples are listed here: appropriate slings used with powered patient Respiratory: pneumonia lifting equipment. Cardiovascular: deep vein thrombosis (DVT), The key implementation strategy for reducing hypotension the risk of staff injury and improving the quality of Gastrointestinal: constipation patient care and mobilization is replacement of Genitourinary: urinary infection, incontinence manual patient handling with use of assistive Endocrine: hyperglycemia, insulin resistance PHAM equipment. Nonetheless, organizational Metabolic: altered pharmacokinetics (what the 39 body does to a drug) and programmatic support structures must be in Musculoskeletal: deconditioning, bone place to foster equipment use for this strategy to demineralization, osteoporosis be successful. Expecting caregivers to totally Skin: pressure ulcers (bedsores) change the way they perform their work without Psychosocial: depression, decreased func- such support structures often results in frustra- tional capacity, increased dependency tion and costly mistakes. Patient handling and Robert L. Kane et al. Essentials of Clinical Geriatrics, 5th ed. New York: McGraw-Hill (2004), 245–48; and Rosemary A. movement programs (PHAMPs) that include Timmerman, “A mobility protocol for critically ill adults,” knowledge transfer mechanisms and change Dimensions of Critical Care Nursing 26, no. 5 (Sept.-Oct. 2007): 175–79. strategies foster caregiver compliance with equipment use40 and ultimately improve the quality of patient care along with the workplace for caregivers.BenefitsChapter of Patient 4 in thisHandling document provides a Table 1-4. Common Patient Handling detailedand Movement discussion T ofechnology PHAMPs and implementa- and Movement Equipment, by tion strategies to reduce manual patient handling. Category Powered Patient Lifting Equipment or Hoists Full-body sling lifts Overhead lifts (ceiling-mounted, wall- mounted, or portable lifts) The quality of patient care, mobilization, reha- *Floor-based sling lifts *Gantry lifts bilitation, and quality of life and the risk to staff *Sit-to-stand (stand assist or standing) lifts and patients from moving and handling patients are positively influenced by the use of PHAM Lateral Transfer (Slide) Devices technology. For this reason, design solutions Air-assisted lateral transfer devices that include patient handling equipment and *Mechanical lateral transfer devices Friction-reducing devices (sliding boards, roller storage allotments for equipment will foster boards, slippery sheets, etc.) improvedImproving patientthe Workplace care and outcomes as well as saferand Reducing and more Risk professionally of Injury satisfying work Other Devices environments. *Transfer chairs Non-powered standing aids Transfer boards/devices Beds/mattresses *Stretchers/gurneys The development of PHAM equipment has *Transport assistive devices substantially reduced the act of strict manual patient handling as an essential function of patient care. To better understand how use of such equipment can reduce the risk of caregiver musculoskeletal injury, note that PHAM equipment operates as engineering controlsÑmethods41 of controlling exposure to hazards by modifying the source or reducing the amount of the hazard. 24 PHAMA: Rationale

49 Engineering controls are the best line of defense (APTA) supports the use of PHAM technology to for worker protection and can be effectively decrease risk for both staff and patients. applied to patient handling. In patient handling,42 Research on patient outcomes related to the the hazard is the force imposed on the muscu- use of safe patient handling techniques and loskeletal system of the patient care provider. technology is limited: A multitude of variables PHAM equipment functions to reduce the inju- within a health care environment (e.g., unique rious forces that result from performing a task, patient characteristics and medical conditions, thus lessening the hazard to a level within the patient care environment factors, and staffing capabilities and limitations of the human body. levels) make a direct causal relationship difficult Here the concept of ergonomics comes into to establish. However, several studies show play. Those tasks that exceed the biomechanical relationships between the use of certain types of capabilities of workers are ergonomic hazards, patient handling equipment and improvements and they result in musculoskeletal injuries (acute in patient outcomes. For instance, a hospital- and cumulative trauma). The goal of ergonomics based study comparing skin tears before and is to modify the work environment and/or after institution of procedures involving use of process to eliminate or decrease the impact on the ceiling lifts with repositioning50 sheets/slings musculoskeletal system. PHAM equipment takes found reduced tissue viability risk and reduced the ergonomic load off of caregivers, keeping the cross-infection risk. Another study found a work they do within their biomechanical limits. relationship between the use of PHAM equip- (See the sidebar on the biomechanics of patient ment and residentsÕ lower depression scores, handling injuries.) improved urinary continence, decreased likeli51- A number of researchers have conducted trials hood of falling, engagement in more activities, using safe patient handling programs that include and greater alertness during the day. PHAM equipment as the key risk reduction Researchers have observed a link between the element; their results have shown43, 44, 45,great 46 success in use of lifting52, 53 equipment and decreases in the reducing staff injuries and resultant lost work combative behavior of residents with time and modified duty days. Data on job dementia. In addition, much anecdotal infor- satisfaction showed increased feelings of profes- mation directly ties use of patient handling sional status and decreases in task requirements. equipment to increases in the quality of care SuchImpr ovingpositive the outcomes Quality47 of were Car ethought to improve and quality of life in residential settings. Many nursing retention and have a positive effect on stories relate positive outcomes such as nursing recruitment. decreasesDesign Considerations in54 pain, increases in thein dignity, Provision and improvementof Safe Patient in continence Care Environments when PHAM equipment is used. Assistive PHAM technology has raised the quality of nursing care provided when compared to care provided using manual lifting techniques. Mechanical lifting equipment and other assistive devices provide a more secure process for lifting, As we have seen, the use of PHAM technology can transferring, repositioning, and mobilization positively influence quality of patient care, degree tasks, particularly for geriatric populations. This of mobilization and rehabilitation, quality of life, may be why caregivers comment that use of and level of risk to staff and patients from moving PHAM technology lessens patient anxiety and and handling patients. Architecture and design enhances patient dignity and autonomy. In addi- that take into account patient handling equip- tion, the potential for patient injury (e.g.,48 skin ment, adequate space for safe patient handling, tears, joint dislocations, falls) as a consequence and storage allowances for equipment will foster of manual patient handling is reduced. In a improved patient care and outcomes as well as white paper on patient handling and patient safer and more professionally satisfying work care, the American Physical Therapy Association environments for staff. By extension, functional PHAMA: Rationale 25

spaces that do not take these factors into account legislative efforts, strides by government agencies make it much more difficult for health care organ- such as the Veterans Health Administration, and izations to implement safe patient handling support from the American Nurses Association, measures. American Physical Therapy Association, Associa- To date, design professionals have been at a tion of periOperative Registered Nurses, National disadvantage that this white paper aims to Association of Orthopaedic Nurses, and other clin- addressÑa lack of knowledge about PHAM tech- icalI organizations. nology. Patient handling equipment and its design I A number of design/architectural features parameters are new to many design professionals mustI be addressed in this context. They are in the United States; consequently, they have had discussedI in more detail in Chapter 2 and include: no consensus standards or master specifications I Flooring materials and finishes to follow and depended on the word55, 56, 57, and 58 expertise I Space constraints of manufacturers and the limited design recom- I Storage space mendations currently available. Those who I Door openings are familiar with safe patient handling may be Hallway widths reluctant to suggest inclusion of patient handling I Floor/walkway slopes and thresholds technology to their clients due to the associated Elevator dimensions costs. On the other hand, they may be hesitant not Headwalls and service utility to suggest it, given the increasing focus on the columns/systems provision of minimal manual lift patient care envi- Weight capacities of toilets and mounted Caregiver Stories from the Field ronments that is reflected in state and federal objects These stories were collected by Lisa Murphy, He said it helped him build strength in his arms RN, BA, BSN, who is nursing service collateral and legs and asked if he could help train other duty safety officer/SPH facility coordinator at staff in its use while he was there. Jesse Brown VA Medical Center in Chicago. Intensive care unit. A bariatric surgery patient Rehab medicine. The physical therapist utilized asked to use the sit-to-stand lift for ambulation an ambulation sling with ceiling lift for a patient as it gave him a greater sense of security when who was rehabilitating after a stroke. The sling he first got up after surgery. removed the fear factor for gait training, and the patient progressed much faster and, in fact, did Oncology unit. An air-assisted lateral transfer not want to stop his therapy. This patient, who mattress was used to take an older, frail, very tall was initially not walking, eventually went home patient for a CT scan. When the CT was done climbing stairs with a cane. and the patient returned to the unit, he asked if he could use the air mattress again. (Patients and Oncology unit. A patient came in so weak that a staff really like the air mattresses, which feel full-body sling lift was required to place him in a much better to patients than being pulled on chair. After a couple of days, he asked staff to something thin over bumps in procedural tables.) stand him up, so they utilized a sit-to-stand lift. After using it, the patient would not use the full- Nursing home. A nursing home resident had body sling lift and requested the sit-to-stand lift severe contractures, making it extremely difficult often because he liked being up out of the for staff to place him in a chair; consequently, wheelchair. He eventually went home with a this resident was rarely moved out of bed, wors- walker because he was able to gain strength ening not only his physical condition but also his using the sit-to-stand lift. quality of life. The situation improved after ceiling lifts were installed; almost every day thereafter, Surgery unit. During an equipment trial, a non- the resident was moved into a chair. powered sit-to-stand lift was used to assist a patient around his room and into a wheelchair. Lisa Murphy, RN, BA, BSN 26 PHAMA: Rationale

Flooring Materials and Finishes

and other objects found in a patient room. When Over the past several years, concern has been caregivers must continually move items to growing about work-related musculoskeletal provide proper patient handling, their risk of injuries associated with the movement of patients injury is compounded. As well, awkward postures and health care-related equipment on carpeted or resulting from lifting and moving patients in small padded tile surfaces. Such pushing and pulling spaces increase the risk of injury. Adequate space may result in excessive shear forces on59 the spine; Storagewill enhance Space the quality of nursing by facilitating70 these forces become particularly problematic mobilization of patients, reducing strain-related when performing turning maneuvers. Increases injuries to staff, and increasing staff productivity. in the shear forces to the spine are attributable60 to the difficulty in overcoming inertia when61, 62 initially pushing or pulling a 6wheeled3 object, surface Inadequate storage space is universally problem- resistance of the64 flooring material, wheel atic in health care facilities. The more patient design and condition, and the weight being rooms, the more revenue for the facility, and thus pushed/pulled. From a safe patient handling storage areas are often among the first spaces to perspective, rolling lifts over carpeting or wood be decreased or eliminated when design cost Spaceflooring Constraints compared65 with less resilient flooring constraints arise. In addition, the numbers and materials is a factor to consider when specifying types of equipment (including patient handling flooring materials. equipment) requiring storage space in clinical areas have increased. With OSHA and National Fire Protection Association (NFPA) regulations Understandably, health care organizations that prevent storage in hallways for life safety attempt to make the best use of available space, purposes, storage rooms are often filled to the andÑespecially in older health care facilities with brim. Limited and inaccessible storage space for multiple-bed wardsÑÒworkingÓ space is some- mobile patient71 handling equipment significantly times quite limited. However,66, 67moving rolling affects staff compliance with safe patient handling equipment in tight spaces compounds already techniques. If staff must take time to walk down difficult patient handling tasks. The effects of the hall, sometimes quite a distance, to a storage space constraints are readily observable when Doorroom Openingsfilled with other equipment and move that staff are seen performing patient care in awkward other equipment to access a lift, caregivers often positions, or when necessary patient handling opt instead to transfer patients manually. assistive devices cannot be used as a result of inadequate space in a patient room or toilet room. In certain room layouts, staff members need to Insufficient doorway dimensions can prevent use physically relocate beds and other patient furni- of mobile patient handling lifts and other rolling ture every time they transfer a patient into a equipment. Scraped knuckles and abrasions on wheelchair or onto a stretcher. Nurses sometimes the upper arms of staff can result from pushing describe their jobs as Òfurniture movers.Ó Some beds and equipment through doorways that are rooms are so small that patients must be moved in too narrow. Simple entry and exit, especially in their beds into the hallway or an adjacent room emergency situations involving bariatric beds, are for a safe lateral transfer onto a stretcher. problematic in many health care facilities. It is not Using floor-based patient handling equipment uncommon for morbidly obese and bariatric in small spaces such as a toilet room causes shear patients to receive treatments and procedures in forces on the spine that are significantly68, 69 greater their rooms rather than in a designated treatment than those caused by simply pushing portable or procedure area because their patient bed or equipment in adequate spaces. These findings equipment is too large to pass through the for portable lifting equipment may be extrapo- doorway. lated to pushing/pulling other types of equipment, such as beds, patient room furniture, PHAMA: Rationale 27

Hallway Widths Endnotes

1 P. French, L. F. W. Flora, L. S. Ping, L. K. Bo & W. H. Y. Rita, “The prevalence and cause of occupational back pain in Hong Kong registered nurses,” Journal of Advanced Nursing 26 (1997): 380–88. 2 U.S. Department of Labor, Bureau of Labor Statistics, Survey of occupational inquiries and illnesses, 2001 (Bureau of Labor Narrow hallways can add another level of diffi- Statistics: Washington, DC, December 19, 2002). 3 B. D. Owen, “Preventing injuries using an ergonomic approach,” culty to moving patients and equipment. An Association of periOperative Registered Nurses Journal 72, no. 6 inadequate turning radius in a hallway creates an (2000): 1031–36. 4 B. D. Owen & A. Garg, “Reducing back stress through an ergonomic unsafeFloor/Walkway situation Slopesin which and staff Thresholds must push a heavy approach: Weighing a patient,” International Journal of Nursing bed sideways in order to turn sharply around a Studies 31, no. 6 (1994): 511–19. 5 A. Garg & B. Owen., “Prevention of back injuries in healthcare corner or into a patient room. workers,” International Journal of Industrial Ergonomics 14 (1994): 315–31. 6 M. S. Rice, S. M. Woolley & T. R. Waters, “Comparison of required operating forces between floor-based and overhead-mounted Hospitals are filled with rolling equipment, yet patient lifting devices,” Ergonomics 52, no. 1 (2009): 112–20. 7 W. S. Marras, G. G. Knapik & S. Ferguson, “Lumbar spine forces high to medium thresholds abound, making it during manoeuvring of ceiling-based and floor-based patient difficult for staff to use rolling equipment and transfer devices,” Ergonomics 52, no. 3 (2009): 384–97. 8 A. L. Nelson, J. Lloyd, N. Menzel & C. Gross, “Preventing nursing unsafe for patients moving themselves or being back injuries: Redesigning patient handling tasks,” AAOHN Journal moved.Elevator Pushing Dimensions patients up and down inclines in 51, no. 3 (2003): 126–34. 9 T. R. Waters, “When is it safe to manually lift a patient?,” American beds or wheelchairs has the potential for causing Journal of Nursing 107, no. 6 (2007): 40–45. serious injury to both patient and caregiver. 10 M. Matz, “Understanding hazards and controls in health care,” in Working Safely in Health Care: A Practical Guide, ed. D. Fell-Carlson (New York: Delmar Thomson Learning Publishing Company, 2007). 11 Waters, “When is it safe to manually lift a patient?” 12 W. S. Marras, “Occupational low back disorder causation and TheHeadwalls/Service interior dimensions Utility of Columnselevators may prevent control,” Ergonomics 43, no. 7 (2000): 880–902. the use of certain types of high-tech and bariatric 13 T. Waters, “Science to support specific limits on lifting, pushing, and pulling and static postures” (Presentation at the 8th Annual Safe beds. Patient Handling Conference, Lake Buena Vista, Florida, March 2008). 14 Marras, “Occupational low back disorder causation.” 15 Ibid. Headwall and service utility column/system 16 Ibid. designs can promote or interfere with the installa- 17 U.S. Department of Labor, Bureau of Labor Statistics, Survey of occupational injuries and illnesses (Washington, DC: Bureau of tion and use of overhead liftsÑespecially traverse Labor Statistics, October 16, 2007). Retrieved from www.bls.gov. track systems. This is particularly problematic in 18 P. French et al., “The prevalence and cause of occupational back pain in Hong Kong registered nurses.” 72 very high-risk patient handling areas such as ICUs, 19 Occupational Health & Safety Agency for Healthcare (OHSAH) in where 100 percent ceiling lift installation is British Columbia, Ceiling lifts as an intervention to reduce the risk of patient handling injuries: A literature review (Vancouver, BC: OHSAH, recommended.Weight CapacitiesIf ofthey Toilets are not ergonomically 2006). Retrieved on 8/20/09 from http://control.ohsah.bc.ca/media/Ceiling_Lift_Review.pdf#search=% anddesigned, Mounted these Objects structures can also limit easy 22b%20owen%2C%20patient%20lifts%20ratio%22. access to patients and items required for care. 20 K. Siddharthan, M. Hodgson, D. Rosenberg, D. Haiduven & A. Nelson, “Under-reporting of work-related musculoskeletal disorders in the Veterans Administration,” International Journal of Health Care Quality Assurance Incorporating Leadership in Health Services 19, nos. 6–7 (2006): 463–76. 21 A. Nelson, unpublished research data from pilot study (Tampa: When care for morbidly obese and bariatric James A. Haley VA Medical Center, 1996). 22 A. L. Nelson & G. Fragala, “Equipment for safe patient handling and patients and visitors is provided or anticipated, movement,” in Back Injury among Healthcare Workers, eds. W. the weight capacities of toilets, chairs, handrails, Charney & A. Hudson (Washington, DC: Lewis Publishers, 2004), 121–35. sinks, grab bars, and other mounted objects in 23 B. Owen & A. Garg, “Assistive devices for use with patient handling tasks,” in Advances in Industrial Ergonomics and Safety, ed. B. Das patient rooms, toilet rooms, hallways, shower (Philadelphia, PA: Taylor & Frances, 1990). rooms, waiting rooms, and elsewhere must be 24 C. A. Sedlak, M. O. Doheny, A. Nelson & T. R. Waters, “Development of the National Association of Orthopaedic Nurses taken into consideration to avoid serious injuries. guidance statement on safe patient handling and movement in the orthopaedic setting,” Orthopaedic Nursing, Supplement to 28, no. 25 (2009): 2–8. 25 AORN Workplace Safety Taskforce, Safe Patient Handling and Movement in the Perioperative Setting (Denver, CO: Association of periOperative Registered Nurses [AORN], 2007). 26 Nelson et al., “Preventing nursing back injuries.” 28 PHAMA: Rationale

27 Ibid. 54 Nelson et al., “Development and Evaluation of a Multifaceted 28 U.S. Department of Labor, Occupational Safety & Health Ergonomics Program.” Administration (OSHA), Guidelines for Nursing Homes (Washington, 55 ARJO, Guidebook for Architects and Planners, 2nd ed. (ARJO DC: OSHA, 2002). Retrieved on 10/9/09 from Hospital Equipment AB, 2005). http://www.osha.gov/ergonomics/guidelines/nursinghome/final_nh_ 56 S. Hignett, “Determining the space needed to operate a mobile and guidelines.html. an overhead patient hoist,” Professional Nurse 20, no. 7 (2005): 29 U.S. Department of Labor, Guidelines for Nursing Homes. Retrieved 39–42. on 10/9/09 from http://www.osha.gov/ergonomics/guidelines/ 57 M. Muir & L. Haney, “Designing space for the bariatric resident,” nursinghome/final_nh_guidelines.html Nursing Homes/Long Term Care Management (November 2004): 30 Joint Commission on the Accreditation of Healthcare Organizations, 25–28. “Worker safety: Back injuries among health care workers in acute 58 J. Villeneuve, “Physical Environment for Provision of Nursing Care: care settings,” Environment of Care News 7, no. 6 (2004). Design for Safe Patient Handling” in A.L. Nelson, ed., Handle with 31 Joint Commission on the Accreditation of Healthcare Organizations, Care: Safe Patient Handling and Movement (New York: Springer “Worker safety: Reducing the rate of back injuries among health Publishing Company, 2006). care workers,” Environment of Care News 7, no. 7 (2004). 59 Marras et al., “Lumbar spine forces.” 32 J. Collins, “Safe lifting policies,” in Handle with Care: Safe Patient 60 AORN Workplace Safety Taskforce, Safe Patient Handling and Handling and Movement, ed. A. L. Nelson (New York: Springer Movement in the Perioperative Setting (Denver, CO: Association of Publishing Company, 2006). periOperative Registered Nurses [AORN], 2007). 33 A. Hudson, “Back Injury Prevention in Health Care,” in Handbook of 61 Marras et al., “Lumbar spine forces.” Modern Hospital Safety, 2nd ed., ed. W. Charney (New York: CRC Press, Taylor & Francis Group, 2010). 62 Rice et al., “Comparison of required operating forces.” 34 Hudson, “Back Injury Prevention.” 63 Ibid. 35 Ibid. 64 Ibid. 36 Robert L. Kane, Joseph G. Ouslander, Itamar B. Abrass, Essentials 65 Ibid. of Clinical Geriatrics, 5th ed. (New York: McGraw-Hill, 2004), 66 Marras et al., “Lumbar spine forces.” 245–48; Rosemary A. Timmerman, “A mobility protocol for critically 67 Rice et al., “Comparison of required operating forces.” ill adults,” Dimensions of Critical Care Nursing 26, no. 5 (Sept.-Oct. 2007): 175–79. 68 Marras et al., “Lumbar spine forces.” 37 Ibid. 69 Rice et al., “Comparison of required operating forces.” 38 A. Baptiste, M. McCleery, M. Matz & C. Evitt, “Evaluation of sling 70 Muir, “Designing space for the bariatric resident.” use for patient safety,” Rehabilitation Nursing (Jan.–Feb. 2008). 71 M. Matz, “Analysis of VA patient handling and movement injuries 39 A. L. Nelson, M. Matz, F. Chen, K. Siddharthan, J. Lloyd & G. and preventive programs” (Internal VHA report to Director, VHA, Fragala, “Development and evaluation of a multifaceted ergonomics Occupational Health Program, 2007). Retrieved on 10/9/09 from program to prevent injuries associated with patient handling tasks,” http://www.visn8.med.va.gov/PatientSafetyCenter/safePtHandling/ Journal of International Nursing Studies 43 (2006): 717–33. Analysis_VAPtHndlgInjuries.doc. 40 Nelson et al., “Development and Evaluation of a Multifaceted 72 M. Matz, “Patient handling (lifting) equipment coverage & space Ergonomics Program.” recommendations” (Internal VHA document presented to Director, VHA, Occupational Health Program, 2007). 41 B. Plog, J. Niland & P. Quinlan, eds., Fundamentals of industrial hygiene, 4th ed. (Itasca, IL: National Safety Council, 1996). 42 A. B. de Castro, “Handle with care: The American Nurses Association’s Campaign to address work-related musculoskeletal disorders,” Online Journal of Issues in Nursing, 9, no. 3 (2004): 3. 43 Nelson et al., “Development and Evaluation of a Multifaceted Ergonomics Program.” 44 J. W. Collins, L. Wolf, J. Bell & B. Evanoff, “An evaluation of a ‘best practices’ musculoskeletal injury prevention program in nursing homes,” Injury Prevention 10 (2004): 206–11. 45 B. Evanoff, L. Wolf, E. Aton, J. Canos & J. Collins, “Reduction in injury rates in nursing personnel through introduction of mechanical lifts in the workplace,” American Journal of Industrial Medicine 44 (2003): 451–57. 46 A. Nelson & A. Baptiste, “Evidence-based practices for safe patient handling and movement,” Nursing World / Online Journal of Issues in Nursing, 9, no. 3 (2004): 4. 47 Nelson et al., “Development and Evaluation of a Multifaceted Ergonomics Program.” 48 de Castro, “Handle with care.” 49 American Physical Therapy Association (APTA), “Strategies to improve patient and health care provider safety in patient handling and movement tasks: A collaborative effort of the American Physical Therapy Association, Association of Rehabilitation Nurses, and Veterans Health Administration,” PT Magazine (April 2005). Retrieved on 10/9/09 from http://www.apta.org/AM/Template.cfm?Section=Home&CONTENTID =18516&TEMPLATE=/CM/HTMLDisplay.cfm. 50 Heather Kirton, “Helping make 1:1 care mean 1:1 care!” (Poster presentation at the 8th Safe Patient Handling and Movement Conference, Lake Buena Vista, Florida, March 11–13, 2008). 51 A. L. Nelson, J. Collins, T. Waters, K. Siddharthan & M. Matz, “Link between safe patient handling and quality of care,” Rehabilitation Nursing 33, no. 1 (2008): 33–41. 52 Collins et al., “An evaluation of a ‘best practices’ musculoskeletal injury prevention program.” 53 B. Owen & A. Garg, “Reducing risk for back pain in nursing personnel,” AAOHN Journal 39, no. 1 (1991): 24–33.

CHAPTER 2 Explanation of PHAMA Components

Principal authors:

Contributing authors:

ARY ATZ AND AIUS ELSON M W. M , MSPH, CPE G G. N , RA AVID INE ANE OHDE D M. S , MBE, CSP,ARTIN ARM, CPHRM;OHEN J R , AIA,OGER FIIDA,EIB ACHA, AAHID,A VIDLEEDR EENAP; M H.UDENE C ,ARTLEYFAIA, FACHA; R L AMES, AIA, ACHA;ARRELL D G ; J B , MS, MPH, CIC; J W. H , AIA, ACHA A I I I I patient handling and movement assessment I Outpatient/primary care clinics (PHAMA) is conducted to direct and assist the I Nursing facilities/long term care units design team in incorporating appropriate patient I Spinal cord injury/TBI units handling and movement (PHAM) equipment into I Diagnostic areas the health care environment. Such equipment Treatment areas serves to increase or maintain patient mobility, Procedure areas independent functioning, and strength as well as Morgue to provide a safe environment of care for staff and Patient entrances, ambulance bays, reception patients during performance of high-risk PHAM I areas, and admitting units tasks. Both bariatric and non-bariatric patient I The PHAMA should be conducted by a multi- care are addressed in a PHAMA. disciplinaryI team that, at minimum, includes the The medical and physical characteristics of following:I patient populations vary from one patient or resi- Unit/area nurse manager/supervisor dent care area to another, as do the I Unit/area peer leaders environmental and space characteristics of the I Frontline staff different locations. For this reason, PHAM equip- I Risk management, safety, and/or ergonomics ment recommendations should be developed for I staff each distinct unit and clinical area undergoing I Facility design/construction staff new construction or renovation. This will ensure I Rehabilitative/therapy staff that the type, size, weight capacity, and quantity Infection control staff of equipment available in each location are Housekeeping staff optimal for that location and that sufficient Maintenance staff storage is allocated close to the point of use for Design team representative such equipment. Note that a PHAMA does not provide direction A PHAMA should be conducted for all areas for conducting a full patient care ergonomic (PCE) Iwhere patient handling and movement occurs evaluation, which is important to determine the Iand in any associated toileting, bathing, and show- PHAM technology needed to implement a true Iering areas. These areas include but are not Òminimal liftÓ policy and to identify other issues Ilimited to these: affecting equipment introduction and use. Note I Medical/surgical units also that the information given here focuses on I Rehabilitation units design and storage requirements for PHAM I Critical care units equipment currently in use that has significant I Dialysis units implications for building design and construction Pediatric units (e.g., ceiling lifts, floor-based lifts, beds, and Labor/delivery, antepartum, pospartum units gurneys). It is highly recommended that a thor- Emergency department/urgent care ough PCE evaluation be conducted to identify Perioperative areas other relevant PHAM technology and program- 30 PHAMA: Explanation of Components

PHAMAmatic issues Text related in the to patient 2010 Guidelineshandling and assis- Consideration of obese/bariatric patient weight tance. See Appendix E for steps in conducting a (2)and Types size is of also high-risk important patient to handlingensure appropriate and move- comprehensive PCE evaluation. mentequipment tasks toweight be performed capacities and and accommodated dimensions are provided.

Guidelines for Design and Construction of TheHealth information Care Facilities below italicizedexplains the PHAMA requirements and information found in Section 1.2-5 and its related appendix in the 2010 edition Equipment decisions are also based on the Theof the PHAMA has two distinct yet interdependent types of high-risk PHAM assistance performed. phases. The first phase. includesAll a patienttext handlingis taken High-risk patient handling tasks demand verbatimneeds assessment from the to2010 identify Guidelines. appropriate patient moves, lifts, and other assistance that without handling and patient movement equipment for technology would place excessive biomechan- each service area in which patient handling and ical and postural stress on the musculoskeletal movement occurs. The second phase includes defi- systems of caregivers and pose risk of injury to 2, 3, 4 nition of space requirements and structural and patients. Researchers have identified many other design considerations to accommodate incor- such high-risk tasks in various patient care poration of such patient handling and movement environments (see Appendix A), but some equipment. high-risk tasks do not currently have technology Isolutions to make them less ergonomically 1.2-5.2.1 Phase 1: Patient Handling and stressful. High-risk PHAM tasks for which Movement Needs Assessment Iequipment is available to minimize risk include Evaluation of patient/resident handling and move- but are not limited to the following: ment needs shall include, but not be limited to, the I Vertical lifts/transfers (from/to bed/chair/ following considerations: commode/toilet/wheelchair/car) I Lateral transfers (from/to bed/stretcher/ 1.2-5.2.1.1 Patient handling and movement equip- gurney/trolley) ment recommendations, based on the following: I Positioning/repositioning in bed (side to side, I up to the head of the bed) (1) Characteristics of projected patient populations I Repositioning in chair/wheelchair/dependency I chair I Showering/bathing I Toileting I Dressing/undressing/changing diapers Wound care PHAM equipment recommendations are based on Lifting appendages the medical and physical characteristicsÑactual Transporting patients as well as potentialÑof the patient populations of Ambulating patients each clinical area or unit. Particularly critical to I The best source for identifying high-risk tasks determining the quantity and types of equipment performed on each unit is unit staff members who necessary for each location are the average perform these tasks on a regular basis. Therefore, dependency levels of the patient population. To the PHAMA process should include: simplify this determination, patients are grouped Interviews of frontline staff. Ask what tasks in categories based on their physical limitations staff members perceive as presenting a high rather than their clinical acuity. Categories1 include risk of injury for themselves and/or their total dependence, extensive assistance, limited patients, what they estimate to be the assistance, supervision, and independent. (Please percentage of patients at each dependency refer to Table H-1: Physical Dependency Levels of level, what PHAM strategies are in place, and Patient Population, in Appendix H, for definitions.) what present technology solutions are avail- PHAMA: Explanation of Components 31

I able and in use. (See Appendix F: Patient Care process. Those unit staff members who assist Ergonomic Evaluation Staff Interview patients in moving, transferring, and mobilization Template.) activities day in and day out are the best evalua- Surveys of frontline staff. This is another tool tors of different specific solutions and for collecting information on staff perceptions technologies. Not only do they know what equip- of high-risk tasks. (See Tool 1, Perception of ment will meet the needs of their patients, but, as High-Risk Task Survey, in Appendix H.) users of the equipment, they can best judge the Patient handling injury data for each clinical Òuser-friendlinessÓ of each variety of assistive unit/area are also a source of information for the technology. high-risk tasks in that location. Tool 2, Unit/Area Equipment trials and equipment fairs provide Incident/Injury Profile, in Appendix H offers a staffÑincluding maintenance and housekeeping template for collection and analysis of unit/area staffÑthe opportunity to judge equipment from patient handling injuries. However, this source their unique perspectives prior to purchase. (3)should Knowledge never be of used specific in isolationtechnology as appropriateinjuries are During such trials, it is recommended that staff tooften reduce not reported,risk for each which high-risk means task important infor- and others complete equipment evaluation mation may be missing from the data. surveys. These surveys should then be collated by clinical unit/area to ensure the appropriate equipment is selected for each unit/area. The survey information also should be used to determine specific manufacturers for inclusion in the bidding Many, many types of PHAM equipment are avail- process. For more information, see Appendix G: able to reduce risk from the variety of high-risk Equipment Evaluation and Selection Process, tasksI encountered in contemporary health care which covers equipment trials and fairs. environments. Presently, equipment that influ- When considering which manufacturers or ences design includes but is not limited to the vendors to use, keep in mind that if all ceiling lifts following:I in a facility come from a single manufacturer, staff I Lifting/transferring equipment members are more likely to become competent in I (portable/floor-based and fixed/ceiling or their use. In addition to being basic to safety, staff I wall-mounted) competency increases equipment use. In addition, I Bathing/shower chairs and tubs sourcing from different manufacturers may affect Beds/stretchers/trolleys/gurneys costs and ancillary equipment needs as most Wheelchairs, dependency chairs slings, hanger bars, and accessories are not inter- Transfer chairs changeable1.2-5.2.1.2 Typesfrom manufacturerof patient handling to manufacturer, and move- Mechanical lateral transfer devices althoughment equipment it is possible to beto stipulateutilized that(manual competi- or Since most of these devices are movable, plan- tivepower-assisted equipment fixedhave ceilingsome interfacing or wall-mounted protocols. lifts, ners must recognize the need for sufficient space manual or power-assisted portable/floor-mounted for proper storage, movement, and use of the lifts, electric height-adjustable beds, or a combina- equipment and accessories. New equipment tion thereof) designs should be evaluated for their impact on building design as they become available. A patient care ergonomic (PCE) evaluation process (Appendix E), mentioned above, will pullall together the preceding information and facilitate accurate PHAM equipment purchase decisions, Refer to Appendix C and Appendix D for a discus- which will affect design decisions. Remember that sion of the characteristics and merits of different it is important to conduct this evaluation in PHAM equipment solutions. areas where patient handling occurs. After recommendations for specific equipment Remember also that it is imperative to have types have been developed for a unit or area, the staff input in the PHAM technology selection unique features required for installing and/or 32 PHAMA: Explanation of Components

using the recommended equipment should be quantity of each type of PHAM equipment determined. These features are based on the needed for each area under consideration. results of the ergonomic and structural evalua- Methods for determining appropriate lift tions for the area (see Appendix E: Patient Care coverage for clinical units/areas are found in Ergonomic Evaluation Process, and Appendix H: Appendix I: Ceiling-Lift Coverage Recommen- Clinical Unit/Area Characteristics/Ergonomic dations by Clinical Unit/Clinical Area and Issues). Appendix J: Floor-Based Lifts Coverage Deter- Much research 5identifies, 6, 7, 8, 9, 10, 11, 12, ceiling 13 lifts as the mination. preferred, currently available solution for patient When calculating quantities for different types care environments, although existing of equipment needed in each unit/area, be sure to building configuration and structural issues may factor in any existing equipment already in use. An necessitate the use of floor-based lifts. In addition, equipment log, such as one found in Appendix H some clinical areas require special consideration (Tool 3), can keep track of existing equipment as regarding the type and style of equipment to be well as new equipment introduced into the introduced. For instance, the more homelike envi- unit/area. Since the log also captures the esti- ronments in long-term care settings encourage mated percentage of time each piece of equipment consideration of ceiling lifts and track systems is used, it will highlight the need for staff re- that blend in with the dcor of the room. In behav- training on equipment use and should help with ioral1.2-5.2.1.3 health settings,Quantity other of eachcritical type concerns of patient affect decisions about whether to acquire more equip- handlingequipment and selection movement and storage equipment options, needed as noted for ment of the same type. eachin the area accompanying under consideration sidebar. For units undergoing renovation or for new construction, consult with staff from existing units and/or staff who are aware of projected patient population characteristics. Staff members should be able to provide information on the quantity and types of existing equipment that will be trans- TheBehavioral patient care Healthergonomic Settings (PCE) evaluation ferred, if any, and/or assist in determining the process (Appendix E) helps determine the need for new equipment. Any equipment introduced into the environment urgent care, and some clinic settings where an of care of a behavioral health unit must be suit- observation bed may be needed; and therapy ably tamper-resistant and compatible with other areas where lifts might be used to move patients design choices intended to reduce/eliminate the onto or into an apparatus such as a tub. In such availability of points of attachment and thus the cases, behavioral patients must be kept under risk of suicide/self injury. constant observation. However, the great variation in behavioral Portable lifting equipment that is moved in and health patient populations means the risks from out of the room is an alternative to the ceiling lift; equipment (including non-platform beds) are however, the platform beds often found in such fewer for some patient populations than others. areas lie flat on the floor, eliminating the option of Thus, while a ceiling lift for an acute adult behav- using portable lifts with bases that normally fit ioral health patient population is unacceptable, under a bed. Other types of PHAM equipment, the risk may be sufficiently offset by the benefits such as inflatable devices that allow patients to to geri-psych patients and the staff that cares for be lifted from the floor and then transferred to an them. Similarly, the benefits of a standard mecha- appropriate location, have been quite useful in nized hospital bed on a medical psychiatric unit these areas. However, such equipment types may allow for the use of portable patient lift require sufficient space within the patient room, equipment on that unit. making room size an important consideration. Ceiling lifts may be present in outpatient settings—crisis intervention centers; emergency, David M. Sine, MBE, CSP, ARM, CPHRM PHAMA: Explanation of Components 33

1.2-5.2.1.4 Required weight-carrying capacities

closely with the lift manufacturer so the latter will be aware of building design factors that may affect Determine required weight-carrying capacities for installation and safe and easy use of equipment. each unit/area by reviewing facility and unit/area Considerations related to the selection and trends for obese and bariatric patients and by installationStorage requirements:of ceiling-lift tracks (e.g., coverage, interviewing unit/area staff. Lift weight capacities motorization, charging, design, and fastening) are range from around 350 lbs. to 1,000 lbs. or more discussed in Appendix K: Design/Layout Consid- for bariatric, expanded capacity lifts. Even though erations for Ceiling/Overhead Lift Tracks. bariatric floor-based lifts are available, carefully Unit staff will be best consider their use; pushing/pulling such equip- able to determine the most advantageous storage ment, added to considerable patient weight, exerts locations for portable lifts, other PHAM equip- a significant force on the caregiverÕs spine. Bari- ment, and slings associated with lifts. A method atric lifts also have a substantial footprint that for calculating storage space requirements for must be considered when planning space needs floor-based lifts is found in Appendix L: Storage for storage and use in patient rooms. Alternatives Requirements. These calculations do not include to bariatric floor-based lifts are ceiling lifts and aisle and access and other storage space needs. gantry lifts (see Appendix C for more information). In behavioral health settings, portable lifting For ceiling lifts, lifts with a 500Ð600 lb. weight and other equipment that is moved in and out of capacity will accommodate most patients. (Some 1.2-5.2.2the room Phase may 2:be Design used; Considerationsconsequently, storage obese patients can weigh 1,000 lbs. or more, Thelocations impact for of PHAMpatient devices handling should and movementbe easily however.) If bariatric admissions warrant, a needsaccessible on building as well asdesign lockable. shall be addressed in the 1.2-5.2.1.5minimum ofLocations/rooms/areas one expanded capacity/bariatric for use with PHAMA, including consideration of both bariatric installationceiling lift per requirements unit should (if be fixed) included, and/or in addition storage and non-bariatric patient needs. These design requirementsto the lower weight capacity lifts. considerations shall incorporate results from Phase 1 and shall include, but are not limited to, the Locations/rooms/areas for use: following:

1.2-5.2.2.1 Structural considerations to accommodate current and/or future use of patient handling Unit staff will and movement equipment be the best resource for determining which patient rooms require installation of ceiling lifts and use of other PHAM equipment. If 100 percent ceiling-lift coverage will not occur on a unit, caregivers should assist in identifying appropriate locations for installation of ceiling lifts and/or use Building plans should be reviewed by a structural of floor-based/portable lifts. Often ceiling-lift engineer to determine if the structural capacity of placement is based on the configuration of patient the areas where ceiling lifts will be mounted is rooms and the number of beds within them, in 1.2-5.2.2.2sufficient toElectrical support and them. mechanical Installation/attach- considerations order to cover the greatest number of patients forment current methods and/or for futureceiling-lift use and/or tracks installationare included of withInstallation the fewest ceilingrequirements lifts. Room for selection fixed liftfor patientin Appendix handling K. and movement equipment and systems:ceiling lifts also may be based on placement of the associated storage and charging areas sickest and most dependent patients, frequently near a nurse work station.

A manufacturerÕs recommendations and instructions are the best sources for installation requirements; however, facility staff and Building system design considerations for instal- others responsible for design/layout should work lation and use of PHAM equipment are of two 34 PHAMA: Explanation of Components

types: (1) electrical and ventilation needs for Where required, area(s) with adequate elec- storage and charging of PHAM equipment and (2) trical power must be provided to store and charge placement of building system components so they floor-based lifts and other PHAM equipment do not interfere with operation and use of PHAM powered by batteries. In addition to code- equipment. compliant battery charging systems, such storage Electrical requirements for use and storage of rooms may require air-conditioning and/or PHAM equipment depend on the equipment type exhaust systems, depending on the types of and manufacturer. An electrical connection at a batteries to be charged and whether noxious specific location is often all that is required, and fumes are produced during the charging cycle. usually a simple electrical supply is sufficient for Location of building system elements within charging ceiling-lift batteries. Some ceiling lift the occupied environment (e.g., light fixtures, fire tracks have an electronic charging system (ECS), suppression sprinkler heads, HVAC diffusers and which enables the lift motor to be charged from equipment, supports for cubicle curtain and IV contact with copper stripping present suspension tracks)Ñas well as structural throughout the length of the track; these systems supports, conduits, pipes, and ducts associated require planning during system design for the with these elementsÑmust be coordinated with location(s) and type(s) of electrical space needed to properly install and operate connection(s),Patient Movement which must Destinationbe identified in Points the PHAM equipment. Careful coordination of above- construction documents. ceiling building system components and Development of a comprehensive PHAM system ambulatory care, and long-term care settings. requires identification of the destination points to Starting points for acute care include the emer- which patients will be moved. These destination gency department and the patient room. The points are of two types: (1) those used by staff to primary starting point for long-term care settings provide patient care and (2) those chosen by is the patient/resident room. The starting point for patients to permit their involvement in activities ambulatory care is usually the patient examina- and relationships that are meaningful and impor- tion or intake room. tant to them. Determining the reasons for patient movement Emergency Department and the destinations to which patients are moved After admission to an emergency department, a in a particular health care environment is an patient is usually stabilized, placed on a wheeled essential step in the PHAMA process. The device, and transported to a destination for treat- resulting information is used to: ment. The device is typically a gurney or I Ascertain that appropriate PHAM technology is wheelchair. A patient may be taken to one of the in place in all areas needed on both ends of a following areas and may remain on the transport patient’s transport. device or be transferred to another transport I Develop a building design and select move- device at the destination. ment support technology that will encourage I Medical/surgical unit—transferred to hospital self-mobilization of the patient in order to bed or chair maintain and improve patient functioning. I Critical care units—transferred onto a hospital I Design a building layout that will increase staff bed efficiency by reducing turns and travel I Triage—remains on a gurney or in a wheelchair distances along routes to the most frequent I Examination areas, including: destinations. I Radiology, MRI, CT unit—transferred onto I Select floor coverings, locate handrails, and an integral treatment table or remains on a define rest areas that encourage patient self- radiolucent gurney mobilization by reducing fear of falling. I Lab for blood draw and fluid sampling— Patient movement involving destination points likely remains on a gurney or in a wheelchair includes both patient transport carried out by I Surgical suites or procedure areas—transferred staff members and patient mobilization without onto an operating table or special procedure staff assistance. It occurs within acute care, chair sidebar continues on next page PHAMA: Explanation of Components 35

structural elements required by lifting systems Throughout the facility, all open maneuvering 1.2-5.2.2.3can simplifyAdequate installation space and for future providing maintenance patient I areas should accommodate the expanded ofcare both. and for Adequate maneuvering clearance within and must around also areas be width of portable/floor-based lifts and other providedwhere staff for will operation use patient of the handling lifting equipment.or movement equipment such as standard and motorized equipment beds/gurneys/stretchers. Bariatric patient rooms and associated toilet I rooms should accommodate the expanded width of bariatric15 portable/floor-based lifts along with at least two to three staff members. When high-risk PHAM tasks are performed in AllNote: maneuvering space for lifting apparatus spaces that are too small, the risk of injury rises should be as recommended by the equipment substantially. For this and numerous other manufacturer or based on other special knowl- reasons, bed space requirements for health care edge of the user and designer. facilities have gradually increased over the years. Space provided adjacent to patient toilets Recently,14 five international publications recom- in compliance with ADA and ANSI A117.1 code mended a minimum bed space width of 3.6 requirements may be inadequate for safe patient meters. The following recommendations are movement and handling. For further information, intended to ensure the provision of adequate see Section 1.1-4.1 (Design Standards for the spacesidebar for continuedsafe patient from handlingprevious page in the patient room Disabled)I Bathing/showering—in in the 2010 Guidelines; an adjacent refer private especially to and elsewhere: 1.1-4.1.3room or (Special a shared Needs facility in Health Care Facilities). Acute Care Patient Room I Dining—in a shared dining area, three times a In short-stay care facilities such as acute care day hospitals and rehabilitation facilities, movement to I Special interest activities—craft rooms, the following destinations originates from the outdoors, kitchen, chapel, etc. patient room. Such transport may be by wheel- I Meetings with residents, family, friends, organi- chair, gurney, or lift technology. zations—various size rooms and spaces I Toilet I Exercise—outdoors, exercise equipment room, I Bathing/showering areas group exercise space, pool, etc. I Higher- or lower-acuity patient rooms or I Examination, treatment—special rooms and patient discharge due to a change in acuity spaces I Diagnostic and testing areas for examination I Socialization—café, lounge, outdoors, corri- I Procedural areas, suites, or labs (e.g., cath lab, dors (by walking or assisted movement) GI lab, dialysis area, etc.) I Therapy—physical, occupational, speech I Surgical suites therapy areas I Encounter room and therapy areas for group I Hair and nail care—barber and beauty shop support and therapy I Lobby, cafeteria, vending machines, or Outpatient Facilities outdoors for visiting, exercise, food, change of In ambulatory care settings, movement to some scenery of the destinations listed below originates in a I Morgue reception/waiting area, intake area, or examination/treatment room. Such transport may be by Long-Term Care Patient/Resident Room wheelchair, gurney, or lift technology. In long-stay patient facilities such as chronic I Toilet care hospitals and skilled nursing facilities, the I Diagnostic and testing areas following activities may require transport by I Procedural areas, suites, or labs (e.g., cath lab, wheelchair or lift technology to a particular GI lab, dialysis area, etc.) destination: I Surgical suites I Toileting—in a private or shared toilet adjacent to room Roger Leib, AIA, ACHA, and David Green 36 PHAMA: Explanation of Components

1.2-5.2.2.4 Destination points for patient transfers Note: and movement

1.2-5.2.2.6 PriorTypes ofto floordesign finishes, layout, surfaces, verify and portable/floor-basedtransitions needed to equipmentfacilitate safe dimensions and effective with theuse existingof patient or handling projected and lift movement manufacturer. equipment One of the most significant benefits of lifting equipment is its usefulness in transporting patients and residents from one location to another (i.e., from bed to toilet, bedside chair, or elsewhere). When determining the track system for ceiling lifts, it is important to know the location Thresholds should be flush with the adjacent of possible transfer points, and, when portable floor surface(s) to facilitate safe movement of lifts will be used, adequate space for their use rolling equipment. Transitions between different must be provided at destination points. adjacent floor surfaces should be designed to Ceiling lifts with tracks that provide full in- eliminate tripping, bumps, and strain on staff room coverage can support rehabilitation, pushing or guiding manual or powered equip- allowing patients to ambulate within their room ment. Care should be taken in choosing flooring using a ceiling lift and ambulation sling. Thus, materials for patient care settings where rolling before undertaking track design and layout, it is equipment is frequently used. From a safe important to consult with staff to determine desti- patient handling and movement perspective, the nation points for transfers as well as the potential increased difficulty of rolling wheeled equip- for rehabilitation use. See the sidebar on patient ment over carpeting compared to the effort 17 1.2-5.2.2.5movement destinationSizes and pointstypes forof backgrounddoor openings on required over less resilient flooring materials is patientthrough transport.which patient Further handling information and movement on track an important factor when specifying flooring designequipment and andlayout accompanying is located in staff Appendix must pass K. materials. To minimize the difficulty of handling rolled equipment when carpeting is chosen for acoustical or other reasons, careful consideration should be given to selection of the carpeting material as well as to construction and installation specifications for the carpeting and Typical patient room and associated toilet room its backing. In addition, the material, diameter, doors should accommodate the base widths of 1.2-5.2.2.7tread width,Coordination and suspension of patient and handling steering and portable/floor-based lifts (such as standard sit-to- systemsmovement for equipment the wheels installations of rolling with equipment building stand lift base widths and standard full body sling shouldmechanical, be carefully electrical, considered. and life safety systems lift base widths) along with accompanying staff members. Bariatric patient room and associated toilet room doors should accommodate the expanded width of bariatric portable/floor-based lifts, along with several staff members. The width of bariatric At least one facility elevator should be able to room doors should be sized16 to fit specific equip- accommodate attending staff and motorized ment used by the facility. Use of a double door patient beds 8 ft. in length and expanded capacity design is recommended. (bariatric) beds. Throughout the facility, all other doors through Bariatric patients are handled similarly to which patients pass should accommodate the 1.2-5.2.2.8normal weightStorage patients space in arequirements fire situation; and they loca- are expanded width of portable/floor-based lifts and tionsmoved available from oneor to fire/smokebe provided compartment to other equipment such as standard and motorized another on the same floor. beds/gurneys/stretchers. When a bariatric population will be served, doors of procedure rooms and other areas should accommodate the expanded width of bariatric beds/stretchers/etc. PHAMA: Explanation of Components 37

PHAMAs Affect the Environment of Care

Since programming, planning, and design are itera- Staff acceptance and consequent use of tive processes through which considerations such PHAM equipment will allow them to provide supe- as the care model, staffing, operations, equipment, rior care that increases patients’ comfort, dignity, space, architectural and interior design details, and sense of independence and control; fosters surfaces, and furnishings are assessed, correlated, faster and better rehabilitation regimens; and and resolved, a PHAMA can have a truly significant enables patient mobilization as soon as possible, impact on the environment of care. Specifically, at the same time protecting both the patient and PHAM needs must be assessed and assistive the caregiver from injury. Prior to the opening of a equipment requirements determined so this infor- facility, it is recommended that staff members who mation can inform the functional program, and helped prepare the PHAMA recommendations, ensure that all equipment selections, storage, circu- the functional program, and the design docu- lation, and staff access and maneuvering ments participate in developing training materials requirements are addressed during its creation. and sessions for the rest of the staff. In establishing the functional program, it is advis- Following is just a sampling of design features able to involve a multidisciplinary team so that to highlight how functional programming in patient and staff needs can be adequately antici- response to PHAMA recommendations may pated and addressed. As well, incorporation of benefit a completed project: specific equipment makes and models should be I Accessible storage areas that discourage considered at this early planning stage so that all “parking” of devices and equipment in corri- physical space requirements and details can be dors, where they impede circulation and create accommodated during the design phase. The goal is potential safety issues to maintain the intended care model and aesthetic I Recessed ceiling lift supports to minimize while incorporating the required PHAM equipment. exposed tracks in a “residentially” styled, long- Preparing mock-ups of patient/resident rooms, term care resident room bathrooms, other patient/resident areas, and patient I Casework that serves multiple functions (e.g., care support areas during the concept phase (or storage that accommodates both a lift and even earlier, during the programming and planning slings and linens), all as part of a decentralized phase)—and testing them with frontline staff using nursing station actual proposed equipment and accessories—can Many other aspects of patient care and be an excellent way to increase the designers’ building design may appropriately be improved understanding of the issues and to resolve all ramifi- when patient handling and movement issues are cations of a particular equipment response to identified in a PHAMA, addressed in the func- PHAMA recommendations. Further, caregivers who tional program, and resolved during the planning, have participated in preparing a PHAMA’s statement design, construction and commissioning of requirements and selecting a consensus process. response will experience a sense of ownership in the choice of equipment. Their familiarity with it will Jane Rohde, AIA, FIIDA, ACHA, AAHID, LEED also help them train and encourage peers and asso- AP; and Martin H. Cohen, FAIA, FACHA ciates to actually and properly use the equipment.

A method for calculating storage space require- PHAMA recommendations contribute to the ments for floor-based lifts is located in Appendix J. development of criteria for the functional These calculations do not include aisle, access, and program, which in turn informs development of other storage space needs. Information regarding the space program. Together, the functional and 1.2-5.2.2.9storage for Impactlift accessories of the installation (e.g., slings, and hanger use of space programs guide space planning and design, patientbars), other handling PHAM and equipment, movement and equipment infrequently on Guidelinesthen construction, for Design and and ultimately Construction the ofcommis Health- environmentalused equipment characteristics can be found in of Appendixthe environment L. Caresioning Facilities. of a project. For more information, see of care Chapter 1.2, Planning, Design, Construction, and Commissioning, in the 2010 edition of the FGI 38 PHAMA: Explanation of Components

1.2-5.2.2.10 Impact of the installation and use of patient handling and movement equipment on the aesthetics of the patient care space 1.2-5.2.2.11 Infection control risk mitigation requirementselements and the overall aesthetic context of the space in which they will be used.

Design professionals, who may be only just beginning to understand the workings of clinical settings, often focus primarily on aesthetics. It is in From the beginning of the planning process, part what designers are paid to doÑcertainly in organizations should include the infection long-term care facilities, where the aesthetics of preventionist (IP) in the equipment selection the environment have an outsize effect on process to ensure that chosen equipment designs marketability. On the other hand, most manufac- promote ease in cleaning and infection control. turers of PHAM equipment began by exclusively ManufacturersÕ instructions provide guidance on focusing on engineering and functionality, appropriate cleaning techniques, but the infection although many suppliersÕ products have evolved preventionist should develop infection control to an admirable level of design sophistication. procedures based on recognized government and Creating a successful health care environment health care organization standards. To ensure depends on consideration of both the visual that infection control is appropriate and sufficient impactAesthetic of the Conflictsindividual inPHAM the Designequipment of Healthto protect Care patients Environments and staff during the ceiling lift

Aesthetic conflicts affecting successful design in no surface detailing, and minimal textural differen- a health care environment stem from a variety of tiation along surfaces. The mechanical workings causes. The primary causes of this conflict are of building elements may be shown expressionis- discussed in this sidebar. tically, but more commonly they are hidden beneath shrouds or other smooth skins or cover- Mixing traditional and contemporary/modern ings. Products in this style are inherently easier to design elements. Basically, there are two clean (depending on the cleaners used and the aesthetic/design camps in health care: “tradi- nature of the surface material). tional” and “contemporary” or “modern.” There are no hard-and-fast rules as to what “Traditional” describes design modes and works and what does not in the aesthetics of appearance before the advent of modern design health care design. Chiefly, however, most in the early 20th century. More than just the conflict results from the contrast between the evocation of a particular historic design style highly differentiated surfaces of traditional design (e.g., French Provincial or Country), this approach elements (e.g., patterned wall coverings) and the is distinguished by the appearance of natural large, undifferentiated surfaces that characterize materials and greater or even overall surface contemporary/modern objects, including the new detailing, textural differentiation, and random- PHAM products currently in use and the mount- element or non-geometric patterning. It evolved ings that support them. in periods when much hand labor went into products, and more labor was available to meet Scale. While patients and patient furnishings are cleaning and maintenance requirements. Whether getting larger and PHAM considerations dictate true or not, many administrators and developers certain clearances, rooms do not always accom- believe that a traditional environment feels more modate these larger elements, either visually or “homey,” especially to an older audience. Thus, functionally. traditional design, for better or worse, remains the norm for most residentially focused health Overly clinical appearance. The lack of visual care environments. (and functional) integration among products from “Contemporary/modern” describes design a vast number of health care product manufac- modes and appearances that reflect machine turers means that clinical areas in particular manufacture and industrial fabrication techniques. become filled with large amounts of technological It is characterized by man-made materials, little to sidebar continues on next page PHAMA: Explanation of Components 39

I The Impact of Bariatric and Morbidly installationObese Patient process, Care refer on to informationDesign on infec- Doorways that permit entry and exit of tion control risk assessments in Appendix M. bariatric equipment (wheelchairs, lifts, etc.). Corridors wide enough to turn and manipulate bariatric beds As well, patient or resident rooms and associated toilet rooms suitable for safe bariatric patient The effects on design of caring for morbidly obese care should be provided. These should be large andI bariatric patients must not be overlooked. In enough to accommodate several pieces of large general, the following accommodations should be equipment (e.g., commode, wheelchair, floor- madeI when designing new facilities and reno- based lift) and six or more health care workers at vatingI existing facilities: the same time. In addition,18 extra-capacity Accommodations for special bariatric equip- (bariatric) ceiling lifts should be mounted in I ment with appropriate weight capacities bariatric patient rooms. Review of the bariatric Larger door openings safety checklist (Appendix N) may prompt addi- Handrails and grab bars with expanded weight tional thoughts regarding precautions for the care capacities of bariatric patients. Elevators able to hold larger bariatric beds sidebar continued from previous page secondary level of equipment and add textural differentiation to surfaces. In an attempt to fit their bits and pieces. When affordable, efforts are products into the aesthetic context of the space frequently made to hide some technology elements where they are used, some manufacturers have behind special enclosures—especially headwall begun to offer surface treatments that turn what utilities. But for more acute-level facilities, the might otherwise be incongruous architectural amount of equipment that accumulates in a patient elements into decorative accents. Such treat- environment is often beyond what can conveniently ments are particularly effective in surface- or and functionally be hidden or shrouded. wall-mounted or traverse-style ceiling tracks.

Visually incongruous elements: PHAM equip- Designers can: ment, particularly when it is ceiling-mounted, is 1. Stick to contemporary/modern idioms that often visually incongruous with its setting. One of more readily accept the aesthetics of most the most common examples of this issue is industrially produced equipment. traverse-style ceiling tracks. Although the upper 2. Recess ceiling-mounted elements where track may be recessed, the lower track is possible. suspended below it and tends to conflict with 3. Treat equipment as design elements rather anything else suspended from the ceiling, than as foreign invaders. including lighting fixtures and cubicle curtains— 4. Carefully consider storage and access. The elements that might otherwise soften the best designs can be destroyed by storage of institutional appearance of such planar ceilings. unintended elements in unintended places One manufacturer has recently introduced a because inadequate thought was given to headwall system that conceals a traverse track their volumetric and storage requirements and when it is not in use, but other examples of the ease with which they can be accessed or visual and functional incongruity (including brought into use. If storage areas are too far gantry-style lifts, wall-mounted lifts, and many from the point of use, equipment probably will portable hoists) await similar attention or superior not be used as intended. solutions from the industry. 5. Share ideas about improving the aesthetics of What can be done to resolve these aesthetic PHAM equipment with manufacturers. Often, and functional conflicts? the best ideas come “from the field.” And give your business to companies that are responsive. Manufacturers can add features to primary patient support furnishings to reduce the need for a Roger Leib, AIA, ACHA; and Gaius G. Nelson, AIA 40 PHAMA: Explanation of Components

The ICRA and the PHAMA

Infection control risk mitigation recommendations to the ceiling along with a portable negative air (ICRMRs) for renovation projects or new construc- machine, or NAM) when tiles are removed to tion in existing buildings come into play during assess the area above a ceiling for visible preparations for construction. These written plans dust/mold contamination. Such basic operations “describe specific methods by which transmission at least require relocation of the patient to of air- and waterborne biological contaminants will another room, given the movement of equipment be avoided during construction and commis- and risk of unexpected contamination. sioning.” For effective infection control risk Installation of patient handling equipment that mitigation, team members conducting the PHAMA requires alteration of the physical fabric of a should consult with an infection preventionist (IP) building will require more complicated infection about the facility’s general infection prevention prevention measures. For example, when ceiling and control guidelines. tracks are installed, the entire room will need to Installation of lift equipment requires input be sealed and maintained with airflow into the from—and regular interaction with—the facility’s room (i.e., negative with respect to the corridor). existing infection control risk assessment (ICRA) The intent of such measures is to ensure that team to address protection of patients and barriers isolate the room/area and prevent workers. Subjects for discussion should include contamination of adjacent occupied areas during at least the following: the installation/renovation. I Patient placement and relocation ICRMRs also require provisions for monitoring I Standards for barriers and other protective the infection control activities identified by the measures required to protect adjacent areas ICRA process, including written procedures for and susceptible patients from airborne emergency suspension of work and for protec- contaminants tive measures. These procedures also must I Temporary provisions or phasing for the indicate the responsibilities and limitations of process of constructing or modifying heating, each party (owner, designer) for making sure the ventilation, and air-conditioning; water supply; procedures are followed. or other mechanical and cabling systems There is no one best way to conduct an I Protection of adjacent occupied patient areas ICRA, comply with ICRMRs, or document the from demolition recommendations of the PHAMA panel. The I Measures for educating health care facility ICRA matrix located in Appendix M offers one staff, visitors, and construction personnel approach and includes a documentation form regarding maintenance of interim life safety (IC construction permit) to help determine the measures and ICRMRs level of precautions required for a particular Infection prevention measures are required project, based on the degree of anticipated even for projects that seem simple, such as using contamination. equipment generically called a “control cube” (a portable floor-to-ceiling enclosure sealed tightly Judene Bartley, MS, MPH, CIC

Endnotes

1 Ergonomics Technical Advisory Group, Patient Care Ergonomics 6 W. S. Marras, G. G. Knapik, and S. Ferguson, “Lumbar spine forces Resource Guide: Safe Patient Handling and Movement, A. Nelson, during manoeuvring of ceiling-based and floor-based patient ed. (Tampa: Veterans Administration Patient Safety Center of Inquiry, transfer devices,” Ergonomics 52, no. 3 (2009): 384–97. 2005). Available at: www.visn8.va.gov/PatientSafetyCenter/ 7 Occupational Health and Safety Agency for Healthcare (OHSAH) in safePtHandling. British Columbia, “Ceiling lifts as an intervention to reduce the risk 2 A. Nelson, unpublished research data from pilot study (James A. of patient handling injuries: A literature review” (Vancouver, BC: Haley VA Medical Center, Tampa, FL, 1996). OHSAH, 2006). 3 A. L. Nelson and G. Fragala, “Equipment for Safe Patient Handling 8 E. Carlson, B. Herman, and P. Brown, “Effectiveness of a Ceiling and Movement,” in Back Injury Among Healthcare Workers, eds. W. Mounted Patient Lift System,” AOHP Journal 25, no. 3 (2005): 24–26. Charney & A. Hudson (Washington, D.C.: Lewis Publishers, 2004), 9 P. L. Santaguida et al., “Comparison of cumulative low back loads 121–35. of caregivers when transferring patients using overhead and floor 4 B. Owen and A. Garg, “Assistive devices for use with patient mechanical lifting devices,” Clinical Biomechanics 20 (2005): handling tasks,” in Advances in Industrial Ergonomics and Safety, 906–16. ed. B. Das (Philadelphia, PA: Taylor & Francis, 1990). 10 A. L. Nelson et al., “Development and Evaluation of a Multifaceted 5 M. S. Rice, S. M. Woolley, and T. R. Waters, “Comparison of required Ergonomics Program To Prevent Injuries Associated with Patient operating forces between floor-based and overhead-mounted patient Handling Tasks,” Journal of International Nursing Studies 43 (2006): lifting devices,” Ergonomics 52, no. 1 (2009): 112–20. 717–33. PHAMA: Explanation of Components 41

11 C. Engst et al., “Effectiveness of overhead lifting devices in reducing the risk of injury to care staff in extended care facilities,” Ergonomics 48, no. 2 (2005): 187–99. 12 H. M. Tiesman et al., “Effectiveness of a ceiling-mounted patient lift system in reducing occupational injuries in long term care,” Journal of Healthcare Safety 1, no. 1 (2003): 34–40. 13 C. Engst, R. Chhokar, A. Miller, and A. Yassi, “Preventing back injuries to healthcare workers in British Columbia, Canada and the ceiling lift experience,” in Back Injury among Healthcare Workers: Causes, Solutions, and Impacts, eds. W. Charney & A. Hudson (Boca Raton, FL: Lewis Publishers, 2004), 253–63. 14 S. Hignett and J. Arch, “Ensuring bed space is right first time,” Health Estate Journal (Feb. 2008): 29–31. 15 “Special Handling and Movement Challenges Related to Bariatrics,” Chapter 12 in Ergonomics Technical Advisory Group, Patient Care Ergonomics Resource Guide. 16 M. Muir and S. Gerlach, “Reducing the risks in bariatric patient handling,” Canadian Nurse 99, no. 8 (2003): 29–33. 17 Rice et al., “Comparison of required operating forces between floor- based and overhead-mounted patient lifting devices.” 18 M. Muir and L. Haney, “Designing space for the bariatric resident,” Nursing Homes/Long Term Care Management (Nov. 2004):25–28.

CHAPTER 3 PART 1 Establishing the Business Case for a Patient Handling and Movement Program

Principal author:

Contributing authors:

HILLIP HOMAS P T , AIA OHN ELONA AND ARY ATZ P J C , BS, JD, M W. M , MSPH, CPE

revious chapters have discussed the risks bility-related and other adverse patient posed by manual patient handling (both to outcomes that result in costs for the organization. patients and to caregivers) and the elements of a Possible negative impacts of manual patient patient handling and movement assessment handling on patients are discussed in Chapter 1 (PHAMA). This chapter will discuss how to deter- and include falls, skin tears, joint dislocations, mine the financial resources needed to implement fractures, pain, and inadequate mobilization. a patient handling and movement program Although studies of patient outcome measures (PHAMP). A health care organization can use this are few, indications are that positive relation- information to build a business case for imple- ships exist between the institution of a PHAMP menting a PHAMP. and improvements in the overall quality of In an increasingly cost-constrained health care patient care as well as in specific outcome meas- environment, it is important to show that invest- ures such as skin tears, falls, and mobilization. ment in patient handling and movement (PHAM) For example, when mobilization is 1limited, equipment and training (whether in a new or prolonged bed stays may result in diminished existing facility) is cost-effective and a good use of health status and functioning of patients, leading scarce capital. to extended and/or repeated stays in health care In addition, the case must be made that, among facilitiesÑwith associated costs. the many competing priorities for funds to Among the complications known to arise from improve patient care, a PHAMP merits funding. immobility are pneumonia, deep vein thrombosis This chapter will present a methodology for (blood clots), insulin resistance, bed sores, and making an Òinvestment-gradeÓ evaluation of the increased dependency (see the sidebar ÒSome total costs and benefits of such a program. Complications of Patient ImmobilityÓ in Chapter The first part of the chapter discusses the 1 for a more complete list). ICU stays during various benefits of instituting a PHAMP along with which patients are not mobilized can have devas- financing mechanisms. The second part will cover tating long-term2 physical and emotional effects (1) how to quantify the total costs and benefits for that last beyond the illnesses that necessitated a particular facility and (2) the opportunity this hospitalization. Savingsanalysis createsin Patient to Healthformulate new patient The conditions described above may occur in andhandling Quality and ofmovement Life alternatives that can any direct patient care environment. The imple- increase the value of a PHAMP. mentation of a PHAMP, coupled with proper equipment and adequate training and support, will influence their occurrence, resulting in real cost savings to a health care organization.

The recommendations of a PHAMA can provide the foundation for new care plans that include patient handling equipment and minimize immo- PHAMA: Establishing the Business Case 43

Caregiver Savings

tion insurance and reductions in claims, claim payouts, and premiums for this insurance. Some Many researchers who have undertaken trials of specialized companies that sell PHAM equipment multifaceted safe patient handling programs with will ÒguaranteeÓ a specified cost savings based on PHAM equipment as the key risk reduction their analysis and formulas. element have achieved3 great success in The loss prevention option is the most practical decreasing both staff injuries and lost work and and most frequently employed solution based on modified duty days. When data on job satisfaction savings from implementing a PHAMP. Estimates were captured, results showed increases in feel- of potential savings form the basis for develop- ings of professional status and decreases in task ment of a PHAMP budget. Such a program to requirements, which resulted in improved job reduce the risk of injury to employees and satisfaction. Such positive outcomes4 were thought patients through training and use of appropriate to increase nursing retention and have a positive equipment should result in successful loss effect on nursing recruitment, thus affecting the containment. The savings should offset the cost of quality of patient care and an organizationÕs purchasing the equipment and implementing the bottom line. program. With this option, the equipment cost can Implementation of a PHAMP has also been be financed and repaid using savings realized shown to improve caregiver5 efficiency, substan- from insurance and incident reduction. This cost tially decrease6 workersÕ compensation costs, and payback will take place over a few years, but give a return on investment ranging from two to reductions in claims and settlement costs will four years. Reductions in indirect costs caused by constitute a perpetual savings to the organization. increased staff morale, decreased need for Research shows that reducing employee retraining and overtime pay, plus improvements in patient handling injuries produces a minimum of Financingthe quality of care and decreased associated costs7 30 percent8 and as much as 40 percent savings in have been estimated as high as five times the direct workersÕ compensation claims and associated costs, but more commonly are around two times. payments. These are considered direct costs. In addition, indirect costs will be reduced from two to as much as four times the cost savings from workersÕ compensation claim settlement CurrentGrants and basic Similar approaches Funding toSour financingces PHAM payments. Indirect costs include items such as systems are (1) grants, (2) loss prevention loans, employee replacement, incident investigation and (3) capital investments. time, supervisor time, staff training and staff morale, social cost of pain and suffering, possible resident injury, breakup of work teams, adminis- Private and government (local, state, and federal) trative time, and paid overtime. The combination grants, endowments, or private donations may be of decreases in direct and indirect costs will available to fund the purchase of PHAM equip- generate significant savings. ment, especially in localities that have adopted Direct financial outlays will include the cost of Òsafe liftingÓ legislation. This source of funds purchasing equipment necessary to reduce risk of would be the ideal solution for a health care injury. When construction activities are planned, organizationAccrued Savings with Based financial on challenges. Each the 2010 Guidelines require that each health care organizationUse of PHAM should Equipment research what might be avail- organization conduct a PHAMA to determine the able locally. need for and type of equipment that is best suited for the building structure and its patients. (See Chapter 2 and appendices for a discussion of how to make reliable equipment recommendations.) Hospitals and nursing facilities have ÒsoldÓ PHAM After suitable types of PHAM equipment have systems to fiscal decision-makers by outlining been determined, they can be priced by selected cost savings associated with workersÕ compensa- equipment companies. This will give the organiza- 44 PHAMA: Establishing the Business Case

tion actual cost estimates to run the projected savings scenarios for presentation to leadership. The cost scenarios and guarantees to the organization are typically provided by the equipment company or an independent consultant special- izing in conducting patient care ergonomic evaluationsOut-of-Pocket and Capital PHAMP Investment implementation. (See Part 2 of this chapter for a comprehensive method for determining organizational cost benefits.)

One final option is for the health care organization to pay for the equipment and training out of pocket, as part of doing business. The equipment may be financed through an internal appropria- tion, with an equipment loan, and/or as part of a major renovation or new construction loan package. The workersÕ compensation solution described above may serve as a secondary reason for choosing this approach because the cost can be justified and offset by the insurance claims savings.

Endnotes

1 Chris Allen, Paul Glasziou, and Chris Del Mar, “Bed rest: A potentially harmful treatment needing more careful evaluation,” The Lancet 354 (October 9, 1999): 1229–33. 2 Gina Kolata, “A Tactic to Cut I.C.U. Trauma: Get Patients Up,” New York Times, January 11, 2009. 3 A. L. Nelson, M. Matz, F. Chen, K. Siddharthan, J. Lloyd, and G. Fragala, “Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks,” Journal of International Nursing Studies 43 (2006): 717–33; J. W. Collins, L. Wolf, J. Bell & B. Evanoff, “An evaluation of a ‘best practices’ musculoskeletal injury prevention program in nursing homes,” Injury Prevention 10 (2004): 206–11; B. Evanoff, L. Wolf, E. Aton, J. Canos & J. Collins, “Reduction in injury rates in nursing personnel through introduction of mechanical lifts in the workplace,” American Journal of Industrial Medicine 44 (2003): 451–57; A. Nelson & A. Baptiste, “Evidence-based practices for safe patient handling and movement,” Nursing World / Online Journal of Issues in Nursing 9, no. 3 (2004): 4. 4 A. L. Nelson et al., “Development and evaluation of a multifaceted ergonomics program.” 5 K. Siddharthan, A. Nelson, H. Tiesman, and F. Chen, “Cost effectiveness of a multi-faceted program for safe patient handling,” Advances in Patient Safety 3 (2005): 347–58; A. B. de Castro, “Handle with care: The American Nurses Association’s campaign to address work-related musculoskeletal disorders,” Online Journal of Issues in Nursing 9, no. 3 (2004). 6 K. Siddharthan et al., “Cost effectiveness of a multi-faceted program for safe patient handling.” 7 Ibid. 8 Arjo USA, Injury Prevention Program Data.

CHAPTER 3 PART 2 Establishing the Business Case—Understanding and Increasing the Value of a PHAMP at Your Institution

Principal author:

OHN ELONA J N. C , BS, JD I

n this section, we present a method for creating valuation of incremental costs and benefits in an Òinvestment-gradeÓ business case for the value hand, it is possible to create any number of of a patient handling and movement program specific financial metrics to support an invest- (PHAMP) at your institution, including how this ment decision and business case. analysis can be used to create new options that The fly in the ointment is that the total future increase the value of a PHAMP. benefits of a PHAMP are uncertain, as are the In an ideal world, other programs competing totalNote future for costs. Smaller It can Institutionsbe difficult to make a for funding would be subject to similar analysis high-quality decision regarding whether to for an Òapples-to-applesÓ comparison, but one Smaller institutions may not have staff with the experience in financial and risk analysis and must begin somewhere. The methodology creating business cases that is needed to presented is certainly applicable to any invest- follow the methodology outlined here. Ideally, ment decision, although the particulars will differ. the analyst should have had coursework in The specifics presented here result from an evalu- decision analysis, which is part of the analytical ation of the PHAMP at the Stanford Hospital and methods core course at most business and engineering schools and some medical ClinicsThe Simple performed Answer jointly and by Strategic Decisions schools. Groupthe Fly and in theStanford Ointment Hospital and Clinics Risk If no staff members with the appropriate skill Consulting. set are available to calculate the actual costs and benefits for their facility, the results cited here can be used as a directionally correct indicator of the benefits to be expected from a PHAMP. However, divergences from Stanford’s results would be expected and should be kept EconomicsI would describe the value of a PHAMP in mind when using these results as an as withthe incremental value resulting from having a example. For instance, the benefits from reduced employee turnover will likely be greater programI in place compared to not having one. At at other facilities because the turnover at a grosswithout level, the calculation is simple: Stanford is exceptionally low. In addition, facili- I Calculate the total relevant economic value ties with significantly lower patient mobility a PHAMP.of scores than at Stanford have the potential for a Calculate the total relevant economic value much greater return from a PHAMP. a PHAMP. This analysis at Stanford took about five man-days of an experienced analyst’s time, Take the difference between the two. This is plus the time of Stanford personnel. As for the value the PHAMP. referring the task to a specialist for a consulta- As a shortcut, directly analyze the incremental tion, the value created is well worth the effort. value created by the PHAMP compared with not having a PHAMP and restrict analysis to differences in costs and benefits resulting from implementation of a PHAMP. This was done in the Stanford analysis. With a comprehensive 46 PHAMA: Establishing the Business Case

Figure 3.2-1: The Origins of Decision Analysis

Shareholder Value Movement Corporate Finance Rappaport Markowitz Siam & Stewart Sharpe Marakon Fama

System Engineering

Decision Theory LaPlace Bernoulli Bayes Von Neumann & Morgernstern Raiffa Behavioral Science Decision Analysis Howard

Organizational Behavior Simon March Janis Cognitive Psychology Edwards Kehnemen & Tversky Dynamics and Speed Quality Movement Real Options Deming Gaming Juran Feigenbaum TQM

institute a PHAMP program in the face of uncer- Strictly speaking, the probability 2of any single set tainty in both costs and benefits. However, the of projections about a PHAMP (or any other problem of making high-quality decisions amid program) coming to pass is zero. uncertainty comes up fairly often in life. Each Understanding the possible variations in bene- time we purchase (or choose not to purchase) fits and costs of establishing a PHAMP is critical to insurance and decide on the amount of the creating a robust and realistic business case. deductible or select between a fixed or variable- Could the costs be double? Or the benefits half? A rate mortgage, we are making a decision based variety of outcomes must be considered to create on uncertainty. a defensible, robust, investment-grade business When an organization considers whether and case and to present a picture thatÑwith the how much to invest in programs such as PHAMPs, uncertainty explicitly consideredÑis realistic. a decision must be made today in view of future The practice of decision analysis grew out of Decisionuncertain costsAnalysis and Methodologybenefits. Fortunately, the efforts to address the challenges of making high- discipline of decision analysis was developed to quality decisions amid uncertainty. It stemmed address exactly this problem. from the confluence of a number of disciplines, as illustrated in Figure 3.2-1, drawing lessons from each. Early work in Decision Theory contributed the You could ask: Why bother with the approach use of probability to describe uncertainty and described here? Why not just prepare a projection ways to structure decisions and uncertainties. The with a single set of numbers, as is commonly disciplines of System Engineering and Dynamics done? Why create extra work? and Speed supplied the means for modeling and The answer is that a single set of numbers analyzing complex decisions and uncertainties cannot reflect reality. Ignoring uncertainty can and changing dynamics. Cognitive Psychology only create a picture of what will not happen. tackled the problem of how to think correctly PHAMA: Establishing the Business Case 47

Figure 3.2-2: The Elements of a Decision

Alternatives

Information Logic Outcome ? & Beliefs Decision

Preferences

about uncertainty, while Organizational Behavior Decision analysis has become the standard covered decision-making in organizations. Corpo- Themethod Decision of making Analysis investment Approach and program deci- rate Finance and the Shareholder Value sions in a number of industries (including Movement contributed financial metrics and valu- pharmaceuticals). ation perspectives. The Quality Movement contributed notions for evaluating whether a decision is high quality. Seminal work in integrating all these threads was done by Howard Decision analysisElements applies a Òdivide and conquerÓ Raiffa at Harvard University and Ronald Howard approach to developing a robust understanding of at Stanford University. what the best course of action is and why. It is not within the scope of this chapter to provide complete instruction in the application of Alternatives decision analysis (indeed, decision analysisDecision is a A decision is broken down into its component four-yearAnalysis for PhD the programProfessional at Stanford). Rather, our elements, as illustrated in Figure 3.2-2. These purpose is to describe its application to creating elements are explained below: an investment-grade business3 case for a PHAMP. are what you could do. In this More on the theory can be found in context, they are having a patient handling and . movementInformation program and orbeliefs not having one as well as Decision analysis has been extensively the different levels of investment possible if a applied to medical decisions and in the public PHAMP is adopted (e.g., a minimal installation policy arena. Central to its approach are the versus a Ògold standardÓ one). steps of identifying, evaluating, and quantifying include all the infor- all the factors that bear on the costs and benefits mation available on a topic, such as studies on the of a particular decision. This understanding reduction in workersÕ compensation claims from leads to creation of new alternatives for implementing a PHAMP. This category also increasing the value to be gained from the deci- includes judgments (expressed with probabili- sion that is made. ties) for uncertainties, such as estimates of future Done well, decision analysis produces a reduction in workersÕ compensation costs at a robust, transparent, and defensible under- particularPreferences facility. These judgments on the range standing of total program value and a means of of uncertainty for future costs and benefits are identifying how to increase program value. This critical for building robustness and reality into the understanding of the ways in which programs business case. create value and the levers for increasing value include a time preference for can be communicated directly to decision- money (which determines the discount rate for makers without the details of analysis. calculating net present value of future cash 48 PHAMA: Establishing the Business Case

I flows) and a risk preference. Unless the invest- What is a number high enough that there is ment decision is so large that the ongoing only a 10 percent chance the actual outcome viability of the facility is at stake (possible will be higher? whenLogic deciding whether to acquire a hospital For what number is there a 50/50 chance that chain but not 4likely when deciding whether to the actual outcome will be higher or lower? implement a PHAMP), risk preference need not These questions are applied to every type of be quantified. cost and benefit, including training costs, replace- is captured in a simple spreadsheet ment and laundry costs for slings, reduction in model that shows the impact of making different workersÕ compensation claims, reduction in decisions (e.g., different levels of investment in a employee injuries, etc. (A more detailed list PHAMP) and different outcomes for the uncer- appears later in this chapter.) The rest of the tainties Decision(costs and benefits). This usually requires Frameworkspreadsheet foris justa Good simple Decision formulas so that, for simple formulas and range inputs for uncertain any setting of the inputs, you can calculate the costs and benefits so it can calculate a result for total costs and benefits. any specified scenario. The Outcome is what you decide to doÑfor example, a minimal patient handling and move- A framework based on the elements just ment program, an extensive program, or no described allows you to define a good decision for program at all. your facilityÑone that is logically consistent with The is what happens once the deci- the alternatives, information, and preferences you sion has been acted on. Suppose you implement a had at the time the decision was made. A good PHAMP. How will the costs and benefits actually outcome is what you hope will happen. turn out? Only one set of numbers will describe This framework also ensures that you have a what actually happens. If youÕve done a good job thorough and defensible understanding of the on the analysis, what happens will fall within the costs and benefits of the PHAMP proposed for range of possible outcomes you projected. A your facility, a business case that will stand up to comparison of the analysis and the outcome is scrutiny, and a solid roadmap for what to expect where the quality of the analysis is born out. with implementation. Using ranges instead of single numbers to Robustness is assured by using an iterative define uncertain costs and benefits is key to approach to building the business case. At each Ibuilding reality and robustness into an analysis step, look at what you have and the results thus and a distinguishing feature of decision analysis. far and ask these questions: Does it all make For every type of cost and benefit in a PHAMP, ask sense? Are there alternatives we are overlooking? three simple questions: Is there better information we could get on, for What is a number low enough that the chance example, the reduction in bedsores from imple- Figure 3.2-3: The Decision Analysis Cycle of the actual outcome being lower is only 10 menting a PHAMP? This iterative approach is percent? illustrated in Figure 3.2-3.

Initial Basis Deterministic Probabilistic Basis Action Knowledge Development Structuring Evaluation Appraisal

Iteration PHAMA: Establishing the Business Case 49

This iterative approach also provides a stop- approach is to consider how much equipment ping point. When the critical drivers (discussed sharing between adjacent spaces may be feasible. below) have been identified, estimates have been The purpose of studying multiple implementa- improved, and the recommendation still comes tion options is to identify the trade-offs between out the same, it is time to stop working the incremental costs and incremental benefits. numbers. The inherent uncertainty in the costs Suppose you do the Òbare bonesÓ implementation. and benefits is real, and you cannot make it go Does that cost half as much as the Òstate-of-the- away with more analysis. artÓ option, but provide only a quarter of the The objective is to achieve an understanding of benefits? Alternatively, use of extensive portable the uncertainty that is sufficiently accurate in lift equipment in an existing facility may achieve terms of the costs and benefits of each alternative all the benefits of overhead tracks at half the cost. to reveal both which is the best course of action The choice that makes most sense will depend on and why this is so. This qualitative understanding your facility, including other renovation work any is critical to the decision-makers. Your job is to get required changes to the physical environment Understandingto that qualitative theunderstanding Value with a reason- could be coordinated with. able balance between Òextinction by instinctÓ and The point is that you need to consider multiple Òparalysis by analysis.Ó alternatives to find these sorts of relationships and arrive at the most cost-effective (highest value) alternative. If you donÕt look for the trade- offs, you are unlikely to find themÑand thereÕs a The first step to understanding the total value of good chance these sorts of questions will be asked making a particular decision is to apply these at the investment committee level. structuring and analysis tools to the various I The next step is to calculate the costs and bene- PHAMPs you are considering, including no fits for each alternative. Making a list is a good programBasis Development at all. The andsecond step is to use the placeI to start. Here are the potential benefits we resultsDeterministic of this Structuringassessment to create new options identifiedI at Stanford: that increase the value of the best alternative. I Reduced patient falls and costs associated with I them I Reduced patient ulcers and treatment costs Increased patient satisfaction Start with your initial knowledge, and think about I Increased referrals from satisfied patients the options available to your facility for I Reduced staff injuries addressing patient handling and movement Reduced costs from workersÕ compensation issues. and lost or restricted work days The Òno PHAMPÓ choice should always be Improved worker satisfaction considered. This sets the baseline against which Improved worker retention and reduced comparisons can be made. If your facility is turnover costs already in operation, seek available data on Some of these categories (such as reduction in workersÕ compensation claims from patient5 lost or restricted work days) are ones your facility handling injuries, etc. For a new facility, averages is likely to have studied. Some (such as improved from studies by others provide a starting point. worker retention from a PHAMP) have not been. Identify different alternatives for imple- This disparity is not an issue with this method- menting a PHAMP at your facility. Other parts of ology. Just make the range wide enough to give this white paper provide guidance as to what may you a high degree of confidence that reality will be required, and equipment vendors are always fall within it. In the case of Stanford, we estimated happy to provide a quote. that, on the low side, a PHAMP would have no It is preferable to consider at least two levels of impact at all on turnoverÑbecause Stanford is a program implementation, perhaps a Òbare bonesÓ very desirable place to work and turnover is option and a Òstate-of-the-artÓ option. Another already so low. On the high side, we estimated that 50 PHAMA: Establishing the Business Case

among caregivers who handle patients

turnover they relate to one anotherÑinformation that can could drop by as much as 20 percent. be used to determine the value of the program. Such a calculation is straightforward: Project This diagram will also provide a map of what for perhaps five years the number of caregivers needs to go into the spreadsheet model. The who handle patients. If you have very low box(es) describe alternatives that should be eval- turnover, use the historical turnover rate. If you uated. Each oval is either a range assessment for have a high turnover rate, reduce that figure by 20 an uncertainty or a formula in the spreadsheet. percent. Multiply the number of nurses who For example, the financial benefit of reduction in ÒdidnÕt leaveÓ by the cost to train a new nurse (a turnover is a function of reduction in turnover, the well-studied number often put at $60,000). The cost to recruit and train new staff, and the mix of resulting figure is the value from reduced staff (RN vs. support) who handle patients, as turnover contributed by a PHAMP. discussed previously. The point is that, as you develop your list of This process of creating a valuation method is benefits (and then costs), you need to think about repeated for each part of the influence diagram. how to calculate the financial impact of each, The goal is to translate each oval into uncertainty including how they may affect one another. The range assessments or formulas. At the conclusion calculation method will consist of simple formulas of the process, simply add all the benefits and andI ranges for uncertain inputs, as illustrated subtract all the costs. with employee turnover. Typically, numbers are projected for however I For Stanford, we also developed a list of the many years make sense for the decisions being costs: evaluated. For the PHAMP at Stanford, five years Initial capital costs for equipment, including made sense because it was determined that was I labor for installation the period before the program would need a Ongoing costs for the equipment, including Òrefresh.Ó In contrast, when this methodology is batteries, sling replacement, laundry cost for applied to a longer-term facility decision (e.g., slings, etc. building a new mine), the life of the facility and the Costs for initial and ongoing training to numbers of years projected will be greater (25 to instruct staff in how to use the equipment 30 in the case of the mine). The purpose of the cost and benefits lists is to Each year after a program has been imple- make sure nothing has been forgotten. They are a mented, calculate its cash impact should be starting point for figuring out how all the costs evaluated. In the early years, the program will and benefits relate to one another to produce the have expenses for equipment installation and staff total value for the program. If youÕve already training. In later years, cash spent on these will be started thinking about the relationships between freed up relative to how much costs would have the benefits and costs (as we illustrated for been without the program. reduced employee turnover), you are part of the A risk-free discount rate is used to discount the way there. years of cash flow to a net present value. The To capture all the factors and their relation- discount rate should be the weighted average cost Iships in a compact and intuitive form, use an of capital for your organization (usually a Iinfluence diagram. Figure 3.2-4 shows the influ- weighted average cost of debt and equity capital, Ience diagram developed for the PHAMP at weighted according to the ratio of the two). Make IStanford. Interpreting it is straightforward: sure your discount rate and projections are both Decisions are indicated by boxes. given in the same termsÑeither real (inflation not The ultimate net value appears in a hexagon. included) or nominal (inflation included). Uncertainties appear in ovals. Whether real or nominal projections are used Arrows indicate the relationships between typically does not affect the conclusions, so we factors. usually make real projections. An influence diagram captures the decisions, By discounting the annual projections to a net costs, and benefits in one picture that shows how present value (NPV), you can represent any PHAMA: Establishing the Business Case 51

Figure 3.2-4: Influence Diagram for the PHAMP at Stanford

Ongoing Cost of Patient costs program mobility Initial costs Time Average cost replacement Mix of injured of replacement factor staff (RN vs. staff Required support) equipment Savings Reduction in on lost and employee restricted days injuries Savings on workers comp Direct Þnancial claims beneÞts Implementation Reduction in of a PHAMP patient falls Reduced claims from patient Mix of patient falls injuries (serious Average cost Value of of an injury Savings vs. minor) in ulcer the PHAMP treatments

Pressure ulcer BeneÞts from reduction rate Average cost employee of an ulcer satisfaction Reduction Mix of ulcer treatment stages acquired BeneÞts from in turnover patient satisfaction

Retention Mix of patient Average cost cost savings ProÞt from handling staff to recruit additional patient (RN vs. support) and train Equivalent HR referrals Change in budget savings employee satisfaction score (Gallup) Increases in patient referral Change in Equivalent patient satisfaction campaign score budget savings (Press Ganey)

scenario with a single numberÑthe NPV in that pressure ulcers; therefore, we have quantified scenarioÑwhich is helpful for comparing many those directly. scenarios. Each uncertainty range (three Other results of improved quality of life are numbers) leads to three scenarios. With eight captured in assessments of increased patient different ranges, you have 38 or 6,561 scenarios. satisfaction, which can produce a direct value The combination of all those scenarios (all the (from increased patient referrals) and an equiva- uncertainties) creates a picture of program lent value (e.g., how much would a public relations value you can have confidence in. campaign cost to produce an equivalent increase Before continuing, quality of life for patients in patient satisfaction?). perhaps bears special mention. In long-term care As with any value contribution we are inter- facilities especially, quality of life has become a ested in, the question of improved quality of life is focus at least as important as quality of care, if not how to model it to allow estimation of the value more so. created. For this analysis, we looked at specific meas- Developing the lists, influence diagram, and ures indicating improved quality of life for range assessments and building the spreadsheet patients and quantified how those measures complete the Basis Development and Determin- contribute to the overall value of a PHAMP. For istic Structuring stages of the decision analysis example, patients have better quality of life if cycle. there are reduced patient falls, injuries, and 52 PHAMA: Establishing the Business Case

Probabilistic Analysis and Review

causing the least, and plot the results on a graph. Before beginning an explanation of this next step, Because of the characteristic shape of this graph, it let us recap why it is critical to use ranges to is calledIdentification a Òtornado of chart.Ó factors The withbase casethe tornadobiggest define uncertain factors. In addition to the two chartvalue for driversthe PHAMP for theat Stanfordprogram. is shown in reasons previously discussed, we will add a third: Figure 3.2-5. 1. We can be highly confident that actual results Producing this chart has three purposes: will fall within the range assessed. 1. Identification of factors that are not key 2. Using ranges enables quantification of factors value drivers. These are that are difficult to quantify. prime candidates for developing better esti- 3. Ranges enable identification of which factors are mates and creating new alternatives. the most important drivers for program value. 2. Identifying the most important value drivers is Testing of yourIt analysis.is not worth spending more straightforward. When all the uncertain factors time or money trying to develop better esti- you assessed are set to the 50/50 (middle) value, mates for these factors (those small enough to we call the resulting program value the Òbase case fall below the top seven). value.Ó It is not what you expect to happen; rather, 3. The first key ques- it is the result when everything is set to the 50/50 tion for this chart is: Do you believe it? Does it value. It is only a starting point. all make sense to you, and can you explain how We then go through and, one at a time, set6 each the variation in value produced by the top uncertainty to its low value, record the NPV, set it drivers occurred? If not, there is some sort of to its high value, record the NPV, and so on. This error or miscalculation in your analysis, and it process is also known as Òdeterministic sensitivity should be corrected. analysis.Ó Before proceeding, you should be satisfied that FigureWe then 3.2-5: arrange Base the Case uncertain Value inputsTornado from Chartall the variation shown in the base case tornado those causing the most change in NPV to Nthoseet Present chartValue ( $makes'000) sense and reflects your best under- Base Value = $4,178

$2,000 $3,000 $4,000 $5,000 $6,000 $7,000 Base Value Reduction in turnover 0% 20% 2%

Increase in patient Press Ganey score (%/pt) 0% 3% 2%

Workers’ comp growth (baseline) -17% 19% 0%

Increase in staff Gallup Score (%/pt) 0% 2% 1%

Percentage of ulcers in Stage 1 or 2 80% 70% 75%

Reduction in workers’ comp 60% 82% 60%

Ulcer reduction rate 30% 40% 30% PHAMA: Establishing the Business Case 53

standing of the individual factors (uncertainty and the analysis than for showing to executives. This is calculation). because the cumulative probability distribution is The next step is to look at what the total uncer- often difficult for people to interpret at first and tainty is when all the uncertain inputs vary at the because the base case is just the number with all the same time (which is what will actually happen). uncertainties set to the middle, which is often Software can considerably simplify this process, different than the mean value. (In the Stanford but many consultants insist on writing their own example, the base case value was around $4 Excel macros. million, while the mean value is around $5 million.) Varying all 7 the factors at the same time What we really want to show is the important produces the probability distribution in overall messages of the tornado chart (the key value program value. Figure 3.2-6 shows the distribu- drivers and variability in value) based on the value tion for the value of the PHAMP at Stanford. considering all the uncertainty (the mean value) This chart is a cumulative probability8 distribu- rather than the base case value. tion as opposed to the more familiar bell curve Figure 3.2-7 shows the tornado chart based on (probability density function). We use this form the mean value (considering all the risks and because it makes it easier to see what is going on. uncertainties) rather than the base case value. For example, we can see that in a worst-case The calculation process for the mean value scenario (all costs at their highest and all benefits tornado chart is slightly different than for the base at their lowest), the PHAMP at Stanford will still case value tornado chart. Instead of setting all the add $2 million in value over a five-year period. In uncertainties to their 50/50 value (as for the base a best-case scenario, the value9 added could be as case chart), they are set to their mean value. The high as $10 or $12 million. And, given all the rest of the process is the same: Each uncertainty is uncertainty, the mean value is that the PHAMP at set to its low and then its high value, and the Stanford will add $5 million in value. resulting NPV is recorded and plotted from the The PHAMP at Stanford looks like a winner. biggest change in NPV to the smallest. However, these two charts (the base case For presentation purposes, the mean value tornado and the cumulative probability distribu- tornado chart is one of the two key charts we tion) usually belong in the appendices of your recommend showing. The second is the chart packageFigure rather 3.2-6: than Probability up front. DistributionThey are more for for the Valueshowing of the the breakdown PHAMP at between Stanford the investment your purposes in debugging and making sense of cost and all the various categories of benefits that 100% 90% 80% y

t 70% i l i b

a 60% b o r

p 50% e v i t 40% a l u

m 30% u C 20% 10% 0% $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000

Net present value ($ '000) (EV = $5,184) 54 PHAMA: Establishing the Business Case

Figure 3.2-7: Mean Value Tornado Chart Net Present Value ($ '000)

Mean value = $5,184

$3,500 $4,000 $4,500 $5,000 $5,500 $6,000 $6,500 $7,000 Mean Value

Reduction in turnover 0% 20% 6% Increase in patient Press Ganey score (%/pt) 0% 3% 2% Workers comp growth (baseline) -17% 19% 1% Increase in staff Gallup Score (%/pt) 0% 2% 1% Percentage of ulcers in Stage 1 or 2 80% 70% 74% Lost and restricted days growth (baseline) -17% 36% 5%

Reduction in workers’ comp 60% 82% 66%

Ulcer reduction rate 30% 33%

Percentage of patient referral 1% 20% 6%

Patient volume growth -1% 5% 1%

have been identified. This is usually displayed as a To accompany presentation of the mean value ÒwaterfallÓ chart in which the various pieces add up tornado and mean value waterfall charts to the to the overall mean value. The waterfall chart for investment decision-makers, other charts (e.g., the PHAMP at Stanford is shown in Figure 3.2-8. the cumulative probability distribution and the This chart illustrates in one picture how the Internalinfluence Rate diagram) of Return can be included in appendices mean initial investment cost of $1.5 million and to address questions regarding how the study was the mean values of all the elements of value minus conducted. the $144,00010 in ongoing costs add up to the overall mean value of $5 million contributed by the program. Before moving11 on to the topic of value creation, it In the case of Stanford (as for many facilities), will be helpful to review the internal rate of the PHAMP was initially justified based only on return (IRR) for the PHAMP at Stanford. workersÕ compensation savings and savings in Although investment committees often set a lost and restricted days because these were the Iminimum Òhurdle rateÓ for projects, we recom- only two categories for which historical studies mend looking at net present values for programs could be referenced. Also, equipment vendors rather than internal rates of return for the sometimes guarantee savings in one or both of following reasons: these areas. IRR identifies programs that have the highest The other areas of value are no less real; they rate of return rather than programs that create are just harder to quantify. Focusing only on I the greatest value. A very large project with a workersÕ compensation and lost and restricted lower rate of return can create more total days missed 80 percent of the total value we value than a small project with a high rate of expect the PHAMP to create at Stanford. return. The order of categories in the waterfall chart is If the cash flow does not change from negative arbitrary and can be changed to suit different in one year to positive the next year at least priorities for the decision-makers. once, the IRR cannot be calculated at all. PHAMA: Establishing the Business Case 55

Figure 3.2-8: Waterfall Chart for the PHAMP at Stanford

-$1,536 Initial Investment

Workers comp savings $1,789

Lost & restricted days savings $500

Patient falls savings $245

Ulcer treatment savings $1,761

Retention sosts savings $782

Gallup Score improvement $374

Press Ganey Score improvement $1,307

Patient referral $106

-$144 On-going costs

Mean NPV $5,184

-$3,000 -$2,000 -$1,000 $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 NPV ($ '000)

If the cash flow changes from negative to posi- analyzing the incremental value of implementing tive more than once (as when there is a the PHAMP over not having a program. For refer- I ÒrefreshÓ in patient handling and movement ence, this makes the value of no PHAMP equal to equipment), there will be multiple rates of zero. For all the charts, we could have included a returnÑall Òcorrect.Ó This situation defies zero value line to show the Òno programÓ value, interpretation. and you may elect to do so to ensure no misunder- IRR is not especially meaningful when projects standing. have a very high IRR. We did not analyze multiple PHAMP options Still, in case the question does arise, you might for Stanford because we conducted this study place the probability distribution on IRR in the after the decision to implement a program had appendices.12 Figure 3.2-9 shows the cumulative already been made and funded. Had we probability distribution on IRR for the PHAMP at commenced earlier, we would have considered Stanford. multiple options, as we recommend. We see that the mean value is an IRR of 111 This concludes our discussion of how the percent, which is not especially meaningful. methodology applies to understanding the total However, what may be of interest is that in the value of a program like a PHAMPÑincluding the worst-case scenario (all costs at their highest and uncertainty of costs and benefits. An equally all benefits at their lowest), the IRR is still around importantIncreasing topic the isValue how this analysis leads to 50 percent. In other words, there is virtual creating options to increase the value of a certainty that the IRR for the PHAMP at Stanford program. will exceed the organizationÕs IRR hurdle rate for investments. You may recall from earlier discussion that we recommend analyzing at least two alternatives for Stopping at understanding the uncertainty in implementing a PHAMP along with the Òno costs and benefits for a proposed program leaves programÓ option. For Stanford, we handled this by the job half done. One of the greatest strengths of 56 PHAMA: Establishing the Business Case

decision analysis is how it identifies the means for tional valueÑa 10-to-1 return on the $100,000 increasing a programÕs value. Two examples will cost. Stanford should consider funding an be given to illustrate how this analysis can be used employee communications program as part of its to increase the value of the PHAMP at Stanford. PHAMP. Refer back to our mean value tornado chart The second biggest swing factor in value is the (Figure 3.2-6). The uncertainty leading to the improvement in patient survey scores from a greatest change in the value of the PHAMP is the PHAMP. Anecdotal evidence cited elsewhere in reduction in employee turnover. Depending on this white paper suggests that improved patient how successful the PHAMP is at reducing satisfaction is indeed a possibility. The mean value turnover, the program value could swing from tornado chart13 suggests another million dollars in around $4 million to almost $7 million, nearly value could be created by supporting this double. The mean reduction in turnover is (.25 x outcome. Likewise, Stanford should consider 0%) + (.50 x 2%) + (.25 x 20%) = 6%. how to ensure that the patient benefits of a Suppose Stanford decided to invest $100,000 PHAMP are reflected in patient satisfaction scores. in an employee communications plan to make This may include, for example, feedback loops to sure caregivers use the PHAM equipment and ensureA Compelling that patients Case are able to request use of understand its benefits. How much this program PHAM equipment and that their improved satis- could help drive a larger reduction in turnover is faction is captured in survey scores. uncertain; however, for illustration purposes, say the communications program could double the turnover reduction from a mean value of 6 percent to one of 12 percentÑstill much less than Creating a compelling business case for imple- the maximum reduction of 20 percent. The graph menting a PHAMP is crucial to ensuring adoption shows that a 12 percent reduction would result in and to identifying the right level of implementa- a program value somewhere around $6 million tion (e.g., the ÒToyotaÓ plan or the ÒLexusÓ plan). (roughly halfway from the 6 percent mean value This chapter presented a methodology for to the 20 percent maximum value). quantifying the total costs and benefits for a In other words, if a communications program PHAMPÑincluding the uncertainty of those costs couldFigure double 3.2-9: the Cumulative turnover reduction Distribution from forthe the andPHAMP benefits. at StanfordCapturing that uncertainty is critical mean value, that would create $1 million in addi- to ensuring development of a business case that is 100% 90% 80% y

t 70% i l i b

a 60% b o r

p 50% e v i t 40% a l u

m 30% u C 20% 10% 0% $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000

Net present value ($ '000) (EV = $5,184) PHAMA: Establishing the Business Case 57

Endnotes

1 The author would like to thank Jeffrey Driver and Ed Hall of Stanford University Medical Center Risk Consulting and Stephen Leung and Pratik Dalal of Strategic Decisions Group, who helped in conducting the analysis reported here. robust and defensible and accurately portrays the 2 When we are dealing with continuous variables (such as the reduction in workers’ compensation claims from implementing a PHAMP), actual prospects for a program. there are an infinite number of possible values: 30% reduction, 40% To summarize, this methodology has two reduction, and all in infinite possible values in between. The probability of any single value occurring is 1/infinity = zero. The problem is phases: especially acute when dealing with many continuous variables, as in 1. Understanding the total value and uncertainty this case. 3 Peter McNamee and John Celona, Decision Analysis for the in costs and benefits for the options as formu- Professional, 4th ed. (Menlo Park, CA: SmartOrg, Inc., 2001–2007). Executive-level classes in Strategic Decisions and Risk lated Management (SDRM) are also offered by the Stanford University 2. Using the understanding of key value drivers to Center for Professional Development. (http://strategicdecisions. stanford.edu/) create new options for increasing the total 4 Not quantifying a risk preference means that the alternatives will be program value evaluated on a risk-neutral basis; that is, the value to the decision- makers is exactly what dollar value is. For bet-the-company decisions, risk aversion typically comes into play where potential losses are weighted greater than the dollar amount. See Decision Analysis for the Professional, Chapter 5, for a complete discussion of attitudes toward risk. 5 K. Siddharthan, A. Nelson, H. Tiesman & F. Chen, “Cost effectiveness of a multi-faceted program for safe patient handling,” Advances in Patient Safety 3 (2006): 347–58; M. O. Brophy, L. Achimore & J. Moore-Dawson, “Reducing incidence of low back injuries reduces cost,” American Industrial Hygiene Association Journal 62 (2001): 508–11. 6 Sensitivity analysis software considerably simplifies this process. A number of packages are available to automate the process, including Supertree, available from SmartOrg, Inc. 7 To assess ranges, we asked for a number for which there’s a 10% chance the actual will be lower, a number where there’s a 10% chance the actual will be higher, and a number where there’s a 50/50 chance the actual will be higher or lower. This allows us to guess at the rough shape of the distribution describing the uncertainty without having to establish a functional form (normal, lognormal, etc.) which we simply don’t have the data to do. It also breaks this unknown distribution into three convenient pieces. For the lower end of the distribution where there’s a 25% chance of being in that part of the distribution, the mean is the 10% low number. Likewise, for the upper part of the distribution (25% chance of being in that part), the upper 10% number is the mean. The 50/50 number is the mean of the middle part of the distribution (50% chance of being in that region). Accordingly, for varying all the uncertainties at the same time, we can say there’s a 25% chance of the low number, a 50% chance of the 50/50 number, and a 25% chance of the high number. This allows us to calculate probabilities for individual scenarios and to assemble an overall probability distribution. 8 The cumulative probability curve is obtained by integrating the probability density function (summing up the pieces as you go along). 9 The mean value is the same as the expected value, abbreviated as EV in the chart. 10 For the purposes of this presentation, we used a national average for the incidence rate of bedsores rather than the actual rate at Stanford. Because staff there have been diligently addressing this issue, the bedsore rate and the value created in this area at Stanford would be expected to be less. 11 Mathematically, the internal rate of return is the discount rate at which the net present value of a series of cash flows is zero. 12 This chart is created by the same process of running scenarios for all combinations of the uncertainties, but recording the IRR in each scenario rather than the NPV. 13 You may have noticed from the cumulative probability distribution shown in Figure 3.2-6 that the PHAMP at Stanford has a potential of creating value in the $10–12 million range. The question we are addressing is how to get there.

CHAPTER 4 Facilitating Acceptance of a PHAMP and PHAM Technology

Principal author:

ARY ATZ M W. M , MSPH, CPE A

t one time, many health care leaders thought Movement toward creation of an effective that simply introducing patient handling and culture of safety entails a fundamental change in movement (PHAM) equipment was sufficient to organizational thinking. To bring about such change the way caregivers perform their work, significant change requires an understanding of but over and over organizations have found this is all that goes into creating the best possible envi- not the case. Recognizable leadership support, ronment of care, including the physical setting program support structures, and the cooperation and patient handling technology. To be sustain- of a variety of hospital entities are required to able, the change must be built on person-centered change entrenched ways of performing tasks. values and on a vision of the patient, who, after his Consequently, as important as it is to conduct a or her encounter with the health care organiza- PHAMA and incorporate its recommendations tion, is as mobile as possible, functions at as high a into the design of a new building or renovation level as possible, and is as healthy as possible. The project, implementation of a patient handling and patient also should be maximally involved in the movement program (PHAMP)Ñalso known as a care process and as informed and prepared as safe patient handling and movement (SPHM) pro- possibleÑtogether with his or her personal gramÑis necessary to ensure that PHAM equip- supportersÑto continue into the next venue of ment is actually used and the organization sees a care. Means for achieving this vision include cost benefit. patient handling and movement assistive tech- The Department of Veterans Affairs (VA) has nology, staff members who are trained to been a leader in facilitating safe patient1, 2 properly use the technology, a complementary5 handling best practices, program acceptance, design for the physical setting, and a PHAMP with and implementation around the country. structures that support this vision. Elements of the OSHA guidelines were adopted As is apparent by now, use of PHAM equipment from the VA program. The American Nurses is the overarching program element in a PHAMP Association (ANA) used3 the basic concepts from and, because of this, much of the implementation the VA SPHM program to develop its Handle process revolves around the time when equip- with Care program. Other health care organiza- ment is introduced. But even though PHAM tions have taken the lessons of the VA and other equipment is essential, knowledge transfer PHAM programs and run with them, developing program support structures and change strate- their own programs to promote a safe environ- gies must be in place right from the beginning for ment of care. program success. After institution of the VA SPHM Not all health care organizations have opted to program, the clinical units involved were well on implement a PHAMP or to make use of PHAM their way to providing an effective culture of equipment to protect their staff and patients, safety. The elements of the successful SPHM however. The decision to implement a program program were comprehensive and included not depends on an organizationÕs basic organizational only PHAM equipment and an ergonomic process values and other factors that4 define its Òculture of to determine equipment 6needs but also appoint- safety.Ó (Factors that define a culture of safety are ment and training of facility SPHM summarized in Table 4-1. ) coordinators/champions, facility SPHM advisory PHAMA: Facilitating Acceptance 59

Table 4-1: Factors that Define a Culture of Safety and Ranges of Attainment

Aspects of a Culture of Safety Range of Attainment Negative Positive (Traits showing lack of an (Traits showing an effective effective culture of safety) culture of safety)

Values Focus is on productivity. Focus is on maintaining a safe patient care environment for staff and patients. Available The facility/organization has no or PHAM technology is state-of-the-art technology little patient handling and movement and found throughout the facility and/ (PHAM) equipment. or there is progress toward that goal. Procurement The purchasing department directs Frontline workers are actively of equipment selection and purchase of PHAM involved in selecting PHAM equipment/materials. equipment. Social interaction Management uses a top-down The workplace is one where approach. employees are empowered and co-workers are guided by a collective belief in the importance of safety, with the shared understanding that every member will uphold the group’s safety norms. Language The terms “injury” or “accident” The terms “minimizing risk” and (Terms/phrases are used. Staff members call out for “safety” are used. Staff members used as descriptors) “Big Boy” beds. take into consideration the feelings of obese patients and use “expanded capacity” or some other “sensitive” term. Knowledge transfer Staff members only follow Staff members are allowed to use (Sharing of knowledge procedures and policies. the knowledge they have gained and information learned from doing their work and their from doing a job and/ creativity to improve their workplace. or written information)

7 8, 9 teams, and unit/area SPHM peer leaders. Exten- This chapter provides guidance for (1) readers sive training on equipment10, and 11, 12 program elements who are learning about a PHAMP for the first time, was conducted, in addition to other avenues for (2) readers who already have an existing program transferring information. Written assess- in place and would benefit from a few program ments utilizing ergonomic algorithms and implementation or maintenance pointers, and (3) guidelines provided an efficient knowledge readers who would like to benchmark their transfer methodology plus the 13,desired 14, 15, 16, 17consis- program. tency in determining patient handling techniques Often, one or several persons who have been and patient equipment needs. Lifting educated about safe patient handling concepts or teams were not18 included in the VA program, but who have seen firsthand the impact of patient there is ample evidence to support their inclusion handling injuries are the initial drivers behind the in a PHAMP. (Please note that although the decision to implement a PHAMP in an organiza- program elements described here are listed tion. Sometimes these staff members become sequentially, they often overlap and may be facility coordinators/champions, but not always. enacted in a different sequence.) PHAMPS also may be instituted as a result of a 60 PHAMA: Facilitating Acceptance

PHAMP Benefits for Presentation to Leadership

Patient handling and movement programs have PHAMA process. In any case, at least one person been known to fail from lack of support from Gettingwill head Startedthe charge for the long term. The infor- organizational leadership and management. This mation presented in this chapter is aimed at those lack of support commonly results from insuffi- directing the PHAMP. cient understanding of patient care ergonomics, inattention to safe patient handling and movement issues, lack of incentives, outdated policies, space constraints, and cost concerns. Promote the Safe Patient Handling These roadblocks can be addressed by empha- AConceptnumber to of Leadershipsteps involved in getting a PHAMP off sizing the following benefits of instituting a the ground are outlined here. PHAMP: I Decreased costs related to patient handling injuries23, 24, 25, 26, 27 I Solidification of a designation as an “employer of choice”28, 29 Frequently, the first task of an individual working I Improved recruitment30, 31 to initiate a patient handling and movement I Increase in staff satisfaction, improved percep- program is to garner upper management/leader- tion of professional status and task requirements32, 33 ship support for the program. To do this, an I Improved staff retention34 organizationÕs bottom lineÑfinancial well- I Decreased injuries from patient handling beingÑmust be addressed. The good news is that tasks35, 36, 37, 38, 39 over the long term, financial benefits are seen I Enhanced regulatory compliance40 41 when an organization19, 20, 21, 22 implements a PHAMP, I Improved staff efficiency I Improved patient safety42, 43 including acquisition of the necessary PHAM I Facilitation of a culture of safety44 equipment. See Chapter 3 for strategies for developing a business case for instituting a PHAMP. In addition to the cost benefit of implementing a PHAMP, education on the rationale for the PHAMP, including the benefits for patients, staff, and the organization, should be communicated to The person selected as facility coordinator upper management. A quick overview of desired should have a clinical background, preferably in either nursing or therapy, and be accustomed to PHAMIdentify equipment a SPHM Facility is also helpful. This education handling, moving, and mobilizing patients. effortChampion/Coor should be ongoing,dinator with leadership continually updated on the status of the PHAMP. However, some facilities have appointed an individual from the safety staff with ergonomic knowledge. Most often, facility coordinators report to a nursing director. A resource guide for To maintain and even improve a PHAMP, a facility facility coordinators is available at needs a strong and proactive facility coordinator Iwww.visn8.va.gov/patientsafetycenter/safePtHa as well as a peer leader program. Facility coordi- ndling/default.asp.The facility coordinatorÕs role nators can creatively keep peer leaders involved, is to implement the PHAMP throughout the invested, and cohesive as a unit and are integral to facility and minimally includes the following: implementing and sustaining a successful PHAMP. I Conducting patient care ergonomic evaluations At least one full-time facility coordinator is I to develop recommendations for patient essential for program implementation success in handling technology based on the needs of large hospitals, nursing homes, and other facili- I each clinical unit/area ties. For health care organizations with many Facilitating PHAM equipment purchases facilities, it is helpful to have one person oversee Preparing for and coordinating equipment arrival, introduction, and installation all of the facility coordinators. Smaller institutions sidebar continued from previous page may be able to implement their program with a Leading and acting as the resource person for part-time staff member. the unit/area SPHM peer leaders PHAMA: Facilitating Acceptance 61

I Promote Critical Connections

I I Training/educating SPHM peer leaders, staff, I management, and administrators In health care organizations, a safe patient Leading the facility SPHM team handling and movement program is often thought I Acting as liaison between staff and manage- of as a ÒnursingÓ program, but staff quickly learn ment and administrators that a PHAMP affects a surprising number of I Acting as liaison between other organizational departments and people. If these ÒstakeholdersÓ I entities that affect the SPHM program are not included in program planning and imple- I Acting as the facility bariatric patient handling mentation from the beginning, they can present expert significant barriers to moving the program I Tracking PHAM equipment and slings forward.I Institution of a PHAMP requires good Tracking PHAM equipment use and maintenance working relationships with virtually all facility I Reviewing/identifying trends in patient entitiesI and services. Those with significant influ- handling injuries enceI include, at a minimum, those listed here: InstituteReviewing/ a Facility identifying SPHM trendsAdvisory in patient Team I Environment of care/facility safety outcomes related to patient handling activities I committee/accident review board Other duties related to the SPHM program I Safety/occupational health department I Middle management/frontline supervisors Frontline staff An interdisciplinary team should be appointed to I Education staff (nursing and facility) serve as advisers to the PHAMP. The team I Procurement/contracting staff members may include some or all of these: SPHM I Facility management/engineering/project peer leader representative; SPHM facility coordi- I management staff nator; nurse/facility educators; direct patient care I Housekeeping staff staff representatives (from nursing [LPN, CNA, Laundry service RN], therapy [OT, PT], radiology, and other patient Supply/processing/distribution staff care areas); staff from employee health, safety, Infection prevention staff union, and contracting/purchasing departments; Union risk manager; engineers/designers; nursing All of these entities can affect how easy it is to administrator; and patient/resident. The team implement a PHAMP in a facility, so the sooner may be an informal group or a more formal entity connections are made and the stronger the collab- chartered by the facility environment of care oration that results, the better. For some committee or facility management. individuals who are promoting a SPHM initiative, The purpose of the team is to provide support though, forging relationships outside their normal toI the facility coordinator by assisting in the work boundaries may be uncomfortable. Such followingI duties. (If the team is formed prior to individuals should partner with someone accus- selectionI of a facility coordinator, team members tomed to working across the facility or read a alsoI aid in the selection process.) book/attend a class on Òasking the right ques- Implement the PHAMP. tions,Ó Òcommunication in business settings,Ó or I Develop policy. something similar. See Appendix O: Making Crit- I Develop process. Implementingical Connections forand SPHM Maintaining Program Success,a PHAMP for I Facilitate program buy-in from other key elaboration on the importance of making critical players. associations with each entity listed above. I Ensure incidents/injuries are investigated. Review patient handling injuries/trends. I Facilitate equipment purchases (machines, accessories, slings). Once a facility leader and team are up and running Develop long-term and short-term strategic and working with various facility services and plans. entities, the real process of program implementa- Drive the program using goals and objectives. tion begins. It is indeed a process and takes the 62 PHAMA: Facilitating Acceptance

time and concerted efforts of many, not just those leaders from each unit/clinical area develop a on the SPHM team. Successful completion of the plan unique to their area. process, and especially this phase, requires the Strategic planning should be structured and support of organizational and middle manage- include short-term and long-term goals and objec- ment and the cooperation of many facility tives. Include time limits for various phases, but services, as previously noted. The larger and more be sure they are realistic; consult with others complex an organization, the more time and care whose responsibilities might affect a time frame. will be needed to successfully implement a Use marketing strategies to foster continued moti- PHAMP. There is no one single ÒrightÓ way to vation of peer leaders, staff, management, and implement a program; each one reflects the patients. Include strategies for continued training uniqueness of the organization. However, and succession planning for peer leaders. During following the guidelines below will help ensure this process, decide on what PHAMP elements to thatDevelop no major Strategic parts Plans of the program are missed in include in your program. Program element its planning and execution. Each organization options are described in the section below titled chooses what is right for it. ÒSelect and Implement PHAMP Elements.Ó The organizationÕs culture and the needs of the facility, along with current PHAMP status, will help deter- Developing a strategic plan for the facility as a mine which elements should be included in your whole will give direction to the PHAMP and facili- PHAM strategic plan. For additional information tateIdentifying its success. Developing Facility/Organizational a plan for facility peer Goalson patientand Objectives handling and movement strategic leaders as a group is also helpful, as is having peer plans, go to www.visn8.va.gov/patientsafety- Goals should be individualized to meet the acronym is helpful: Each indicator should be (1) mission of your organization or clinical area/unit as specific, (2) measurable, (3) action-oriented, (4) well as your PHAMP. Some suggested goals realistic, and (5) time-defined. Following are follow: possible indicators: I To reduce the incidence of musculoskeletal I Reduction in manual transfers by ___% within injuries ___ [chosen time frame (e.g., one year from I To reduce the severity of musculoskeletal program implementation)] injuries I Reduction in direct costs by ___% within ___ I To reduce costs from these injuries [chosen time frame] I To create a safer environment and improve the I Decrease in nursing turnover by __% within ___ quality of life for patients [chosen time frame] I To improve the quality of care for patients, I Decrease in musculoskeletal discomfort in decreasing patient adverse events related to nursing staff by ___% within ___ [chosen time manual patient handling frame] I To encourage reporting of incidents/injuries I Reduction in number of lost workdays due to I To create a culture of safety and empower resident handling tasks by ___% within ___ nurses to create safe working environments [chosen time frame] I To increase the frequency with which caregivers I Reduction in number of light duty days due to are able to move and mobilize patients resident handling tasks by ___% within ___ Key objectives should be individualized to meet [chosen time frame] organizational or clinical area/unit needs and to I Improvement in patient outcomes such as consider information/data that is available or can decreasing skin tears or falls by ___% [chosen be made available to measure outcomes such as time frame] effectiveness, acceptance, and support. Be sure I Decrease in patients’ average length of stay to establish credible baseline statistics for objec- (LOS) by ___% within ___ [chosen time frame] tives of interest prior to program implementation Source: A. L. Nelson, ed. Patient Care Ergonomics Resource Guide: and to measure the same events periodically Safe Patient Handling and Movement. Tampa: Veterans thereafter to gauge results. Use of the SMART Administration Patient Safety Center of Inquiry (2001). PHAMA: Facilitating Acceptance 63

Factors for Successful Program Implementation

According to a variety of sources, the following center/safePtHandling/default.asp. The following factors are important to success when imple- elements are often considered during strategic menting a patient handling and movement planning. program (PHAMP): 1. What goals related to safe patient handling do I Redesign of equipment and the work you want to achieve? (Individualize plans for environment I Education/training in the use of PHAM yourself, your co-workers, your patients, equipment and/or your unit/area.) I PHAMP peer leaders in each clinical unit/area 2. Identify target group(s) that will impact or be I Ergonomic evaluation/risk assessment of each impacted by a PHAMP. Whom do you want to clinical unit/area target and why? I Patient assessment for each clinical unit/area I Clearly communicated PHAM policy 3. Brainstorm to identify as many benefits of the I Change in work organization and practice PHAMP as possible. The VA conducted a research study that initi- 4. Identify which benefits will be most ated what became a highly successful SPHM convincing for each target group. program by introducing the program elements 5. Identify potential staff-, patient-, and organi- below: I Facility SPHM coordinator/champion zation-level ÒbarriersÓ to PHAMP I Facility SPHM team/committee implementation and maintenance and strate- I Unit SPHM peer leaders gies to overcome these. I Safety huddle/after action reviews 6. Identify staff-, patient-, and organization-level I Patient care ergonomic evaluations ÒfacilitatorsÓ for PHAMP implementation and I PHAM equipment I Staff training maintenance. I Patient assessment and algorithms for safe 7. Identify the first five tasks you will undertake. patient handling 8. What strategies will you use to evaluate the I Safe patient handling policy Selectsuccess and Implementof each task? PHAMP Elements 9. What strategies will you use to maintain the interventions over time?

PHAMPs that are multi-faceted have been found Phasing in the VA program elements in the order to be the most effective. Although inclusion of shown in the sidebar ensured that structures PHAM equipment is key to a successful PHAMP, were in place to support knowledge transfer and programs composed of only the equipment staff members were familiar with change strate- component have been largely unsuccessful. Other gies. Appointing and training SPHM leaders and program elements with the most evidence instituting safety huddles established a structure demonstrating their value include patient care for participation in the patient care ergonomic ergonomic assessments, safe patient handling and evaluation process, which drove the recommen- movement policies, and patient lift teams. The use dations and introduction of PHAM equipment. of SPHM peer leaders and clinical tools such as Since the use of the safe patient handling algo- 45, 46 algorithms for safe patient handling are more rithms and adherence to a policy required the recent and less studied interventions that show newly introduced PHAM equipment to be opera- 47, 48, 49 great promise. See the sidebar for factors tional and staff training50 completed, these program shown to be important in successful program elements were introduced last, after the equip- implementation. ment was in place. PHAMP elements must function to transfer Safe Patient Handling and Movement: A GuideDetailed for Nurses descriptions and Other Healthof the Care VA Providers program knowledge and facilitate change with the goal of elements discussed here (as well as lift teams, encouraging acceptance ofÑand thus compliance which the VA study did not include) are found in51 withÑnew patient handling technology that the book reduces ergonomic risk and provides a safer envi- . ronment of care for both patients and staff. For more information related to the VA program 64 PHAMA: Facilitating Acceptance

elements listed in the sidebar, refer to Appendix P: Other strategies that foster change and knowl- Safe Patient Handling and Movement Program edge transfer in a systematic way include those (SPHM) Element Descriptions. Further informa- listedI below. Brief explanations of a few of these tionDevelop can Standardalso be found Operating on the Procedures VA Web (SOPs)site at followI the list. If you have further interest, many www.visn8.va.gov/patientsafetycenter/safePtHa articlesI and books expand on these topics. ndling/default.asp. I Change strategies include: I Knowledge transfer mechanisms I Education and training in SPHM It is important to develop procedures specific to I Social marketing the types of PHAM equipment to be adopted prior CoachingKnowledge strategies transfer and techniquesmechanisms to its introduction. In addition to following manu- Periodic review of PHAMP elements and status facturersÕI instructions and recommendations, Development of strategic plans and action plans each facility must develop its own guidelines and Leadership from unit/area peer leaders standardI operating procedures (SOPs) for at least . In this52 theI following: context, the knowledge to be transferred is I Sling laundering, tracking, storage, distribu- common information learned from doing work. I tion, and infection control The information may be written in policies or Equipment cleaning and infection control procedures, but most important is what is found FacilitateEquipment Change maintenance and Program and repair Acceptance in peopleÕs headsÑwhat they have learned from Equipment storage doing the work they do. Safety huddles, peer Others as needed leaders, and lift teams act as powerful agents for knowledge transfer. They empower staff members by tapping into the knowledge they Woodrow Wilson once said, ÒIf you want to make possess and facilitating exchanges of information. enemies, try to change something.Ó This is the The ultimate purpose is to foster frontline staff challenge often faced when introducing equip- acceptance of the PHAMP, and involving staff in ment that changes the way caregivers do their program development and implementation work. However, sometimes knowledge of SPH nearly ensures this. Leaders who recognize that concepts and the rationale for change can trans- everyEducation person theyand leadtraining has valuablein SPHM information late into power to advance rather than a to share, and who listen to and act on that infor- roadblock to change. mation, will effect change more easily and on a Already discussed are program elements that broader scale. facilitate change. For instance, peer leaders and . Education lift teams act as change agents by promoting safe and training are forms of knowledge transfer and lifting practices and serving as resources for their are critical for any organizational transformation. co-workers. As SPHM change agents, peer leaders Staff, peer leaders, management, and leadership and facility champions assist in implementation of must be educated in the risks surrounding manual aI program that promotes significant ÒthoughtÓ patient handling as well as in the technology to and ÒbehaviorÓ changes. control those risks. In addition, peer leaders and I To be an effective change agent, a person needs staff must be trained on equipment use and SPHM knowledge of program elements. Peer leaders will also need to I Why the program is being implemented learn techniques for facilitating staff behavior (rationale/background) changes and adoption of the new program. I What the program includes (program Appendix Q: Safe Patient Handling and Movement elements) Training Curricula Suggestions provides ideas for What will be used to implement the program SPHM curricula for staff, peer leaders, and facility (program materials/tools) coordinators. How the program will be implemented For continuity, plans must be made for ongoing (action plan) SPHM orientation and training for new employees PHAMA: Facilitating Acceptance 65

The Social Marketing Process

1. Define your goal(s). I What is/are your goal/s? and new peer leaders. In addition, to facilitate I What do you want to change? smooth transitions between outgoing and I Why? incoming peer leaders and to avoid a break in 2. Identify target groups. leadership, a strategy should be established for I Whom do you want to target? (Staff, patients, nurse educators, facilities facility peer leader succession. This should management, others) include a plan for timely orientation and training 3. Brainstorm to identify benefits of goal(s). of new peer leaders. 4. Match target groups with benefits. Education about SPHM concepts is also very important for patients and their families. The best place to start is when a patient is first admitted. Include a brochure in your organizationÕs admissions packet that summarizes your program, its rationale, and the PHAM equipment in your facility. Another effective way of increasing (American Nurses Association), and NIOSH patient and family awareness of SPH concepts is (National Institute for Occupational Safety and to include a segment on the subject for the contin- Health). These groups worked together to uous loop video played on patient room develop SPHM curricula for schools of nursing, televisions. A VA video includes clips of patients which are available online at www.cdc.gov/ Òflying, gliding, and slidingÓ easily from one place niosh/review/public/safe-patient/introduction. to another, making for a light-hearted and effec- html. Others, such as the American Physical tive demonstration of the use of PHAM Therapy Association (APTA), are also working to equipment. developPHAMP curricula. marketing. The APTA SPHM white paper SPHM curricula have been developed for can be found at www.apta.org/AM/Template. schools of nursing; however, U.S. schools still cfm?Section=Archives3&TEMPLATE=/CM/HTML teach outdated and risky manual techniques that Display.cfm&CONTENTID=18516. have been banned in other countries (e.g., the Discussed here are two United Kingdom, Canada, Australia, and the approaches to marketing a PHAMP at your facility. Netherlands). Progress is being made, though , One provides suggestions for determining Table 4-2: Sample Social Marketing Grid: Matching Benefits to Target Groups and much of it is due to the efforts of the VA, ANA marketing messages through the use of social Target Benefits Groups Cost Decrease Decrease Decrease Increase Employer Others saving injuries injury nursing patient of choice severity turnover safety

Caregivers Nurse educators Nurse managers Nurse educators Facilities management Others 66 PHAMA: Facilitating Acceptance

“Feed the Plants…Not the Weeds”

According to safe patient handling program implementation experts Hanneke Knibbe, Nico Knibbe, and Annemarie Klaassen of the chanical capabilities) than to promote personal Netherlands, a great coaching tip is to “feed the behavioral changes and changes in the behaviors plants, not the weeds.” They say you can spend of others. Thus, training and practice on coaching 80 percent of your time trying to change techniques will help the SPHM change agents be behavior in the 20 percent of people who are successful. resistant, or you can spend 20 percent of your time fostering good behavior in the 80 percent Numerous books have been written on this who support your efforts. Which makes the best subject, and many techniques are available. Table use of your time? 4-3 summarizes the marked differences between the way the ÒworstÓ boss/supervisor and a ÒperfectÓ coach might behave. ÒNegativeÓ boss behaviors do not engender staff input or program acceptance and should be avoided. To understand the importance of coaching, you must understand the process by which coaching marketing techniques, while the other focuses on effects change. Change occurs on three sequential a variety of strategies for marketing the program levels: (1) The intellect takes in information/ to staff. knowledge and learns about the subject and the Social marketing offers a structured way to rationale for the change; (2) there is an emotional ÒsellÓ your idea or program. Engaging in the steps reaction, which combines with the information of the social marketing process (see sidebar) will learned; and (3) change occurs. The second level allow you to strategically direct the focus of can be experienced in a variety of ways. For marketing efforts. For instance, although leader- instance, a person who has been injured during ship would be very interested in the cost savings patient care or whose co-worker has had a debili- of implementing a PHAMP, nurse educators tating injury may easily bind emotionally to the would likely be more interested in other benefits. concept of safe patient handling and movement. Taking time to define your goals, identify groups Another person may internalize the information important to the success of the PHAMP, and deter- regarding the inherent risk in manual patient mine the benefits most relevant to each group will handling and the potential for serious injury. help you develop targeted Òtalking pointsÓ to Still others may53 emotionally connect by way of Table 4-3: “Worst” Boss vs. “Best” increase the effectiveness of the marketing effort. negativeCoach organizational Behaviors consequences for non- Which benefit(s) will motivate each group? Using compliance. What rewards or punishes one a grid to match benefits with target groups can be BOSS COACH helpful, as shown in Table 4-2. Talks a lot Listens a lot More general marketing techniques are also Tells Asks useful. You can never go wrong feeding caregivers Fixes Prevents to get their attention, and use of the traditional Presumes Explores pens, mugs, T-shirts, and buttons is always good. Seeks control Seeks commitment Any type of program with recognition awards and Orders Challenges rewardsÑsuch as a trip to a SPHM conferenceÑ Works on Works with Puts product first Puts process first certainly helps, but there are other creative ways Using coaching strategies to support Wants reasons Seeks results PHAMPto market implementation. your PHAMP. Refer to Appendix R: Assigns blame Takes responsibility SPHM Program Marketing Activities/Strategies Keeps distant Makes contact Aimed at Staff for some ideas. Source: M. Cook, Effective Coaching (New York: McGraw-Hill, 1999). Coaching strategies are extremely important; it is actually much easier to learn the technical information related to a PHAMP (i.e., how to use a piece of equipment or how the body is affected by exceeding its biome- PHAMA: Facilitating Acceptance 67

Using Staff and Patient Injury Outcome Measures to Evaluate Program Effectiveness

Injury indicators of the effectiveness of a PHAMP factors can make the data less helpful. First, must be used carefully. Many variables related to a under-reporting of patient handling injuries is patient’s clinical and physical status may influence surprisingly common, but, when staff are educated the effect of SPHM techniques and equipment. on safe patient handling risks and understand that For instance, reductions in skin tears have been their minor aches and pains may lead to more used as reliable indicators of the usefulness of significant health problems, injury “reporting” may ceiling lifts with repositioning slings or air-assisted increase even when the actual incidence of injuries lateral transfer devices. However, when using skin decreases. Second, patient handling injuries are integrity as an indicator of improved quality of usually the result of cumulative traumas and—as care, it is important to recognize that medical the name implies—are the result of the accumula- conditions and environmental and other factors tion of “micro” injuries over time. An injury may can contribute to skin breakdown and consequen- have been initiated prior to the introduction of tial skin tears. PHAM equipment but not reported at that point. If Staff injury data is always tracked as an indi- reporting occurs after PHAMP implementation, cator of effectiveness for PHAM equipment and injury data will not show a true picture of program program interventions. The severity of patient effectiveness. This cumulative characteristic of handling injuries should be captured as well. patient handling injuries also affects reports of lost Severity indicators are total number of lost time time and modified duty days.55 Finally, there is no days for all injuries, number of lost time injuries, universally accepted denominator for staff injuries, total number of modified duty days for all injuries, so it is difficult to calculate rates that allow for and number of modified duty injuries. These benchmarking and making comparisons between statistics also must be used with care as a few organizations.

person does not necessarily reward or punish measures is critical. Staff job satisfaction, patient another, though. Feeling good about the work satisfaction, peer leader activity (Appendix S: Safe they are doing is reward enough for some. The Patient Handling Peer Leader Unit Activity and attitude of a supervisor54 toward an individual may Program Status Log), staff musculoskeletal be a reward or punishment, as might the attitude discomfort, use of PHAM equipment (Appendix T: of a co-worker. However it is attained, the Patient Care Equipment Use Survey), perception combination of emotional attachment and knowl- of the risk of patient handling tasks (Appendix H, edge fosters a change in behavior, the ultimate Perception of High-Risk Task Survey Tool), cost goal. It is the job of the coach to provide the comparisons, and other outcome measures also Evaluateknowledge the and, PHAMP when needed, to foster the relay informationPatient Care about Ergonomics program effectiveness.Resource Guide emotional change in order to promote the Information about designing a PHAMP evalua- behavior change. tion and sample SPHM data collection tools for many outcome measures are found in the VA/DoD , Chapter 11, at www1.va.gov/visn8/patientSafe- Program evaluation methods are a cornerstone of tyCenter/resguide. management oversight, and, for programs the magnitude of a PHAMP, evaluation tools should minimally relay the effectiveness, acceptance, and cost benefit of the instituted program. Often, patient clinical outcomes/adverse events and staff injuries are the first PHAMP outcome measures that come to mind for demonstrating program effectiveness. However, a good understanding of the variables affecting these 68 PHAMA: Facilitating Acceptance

Endnotes 27 de Castro, A.B. 2004. Handle with Care: The American Nurses Association’s campaign to address work-related musculoskeletal disorders. Online Journal of Issues in Nursing 9(3). 1 A. L. Nelson et al., “Development and evaluation of a multifaceted 28 Nelson et al., “Development and Evaluation of a Multifaceted ergonomics program to prevent injuries associated with patient Ergonomics Program.” handling tasks,” Journal of International Nursing Studies 43: 717–33 (2006). 29 M. Matz, “Analysis of VA patient handling and movement injuries and preventive programs” (internal VHA report to Director, VHA, 2 U.S. Veterans Health Administration, Patient care ergonomics Occupational Health Program, 2007). Retrieved on 7/30/09 from resource guide: Safe patient handling and movement (Parts 1 and 2) www.visn8.med.va.gov/PatientSafetyCenter/safePtHandling. (Tampa: Patient Safety Center of Inquiry, 2003). Accessed on 7/31/09 from www.visn8.med.va.gov/patientsafetycenter/ 30 Nelson et al., “Development and Evaluation of a Multifaceted safePtHandling/default.asp. Ergonomics Program.”. 3 A. B. de Castro, “Handle with care: The American Nurses 31 Matz, “Analysis of VA Patient Handling and Movement Injuries and Association’s campaign to address work-related musculoskeletal Preventive Programs.” disorders,” Online Journal of Issues in Nursing 9, no. 3 (2004). 32 Nelson et al., “Development and Evaluation of a Multifaceted 4 M. Matz, “Safe patient handling & movement/back injury resource Ergonomics Program.”. nurse training program” (HealthCare Ergonomics Conference, 33 Matz, “Analysis of VA Patient Handling and Movement Injuries and Portland, Oregon, June 26, 2006). Preventive Programs.” 5 Personal communication, David Green and Roger Leib, AIA, ACHA. 34 Nelson et al., “Development and Evaluation of a Multifaceted 6 J. J. Knibbe, N. Knibbe, and A. M. Klaassen, “Safe patient handling Ergonomics Program.” program in critical care using peer leaders: lessons learned in the 35 Ibid. Netherlands,” Critical Care Nursing Clinics of North America 19, no. 36 Matz, “Analysis of VA Patient Handling and Movement Injuries and 2 (2007): 205–11. Preventive Programs.” 7 U.S. Veterans Health Administration., Patient care ergonomics 37 Evanoff, B., Wolf, L., Aton, E., Canos, J., & Collins, J. (2003). resource guide. Reduction in injury rates in nursing personnel through introduction 8 Nelson et al., “Development and evaluation of a multifaceted of mechanical lifts in the workplace. American Journal of Industrial ergonomics program.” Medicine, 44, 451-457. 9 A. L. Nelson, ed., Safe Patient Handling and Movement: A Guide for 38 Collins, J. W., Wolf, L., Bell, J, & Evanoff, B. (2004). An evaluation of Nurses and Other Health Care Providers (New York: Springer a “best practices” musculoskeletal injury prevention program in Publishing Company, 2006). nursing homes. Injury Prevention, 10, 206-211. 10 S. Hignet et al., “Evidence-based patient handling: systematic 39 U.S. Department of Labor, Occupational Safety and Health review,” Nursing Standard 17, no. 33 (2003): 33–36. Administration. 2003. Ergonomics Guidelines for Nursing Homes. 11 A. L. Nelson et al., “Development and Evaluation of a Multifaceted Retrieved on 9/30/09from http://www.osha.gov/ergonomics/guide- Ergonomics Program to Prevent Injuries Associated with Patient lines/nursinghome/final_nh_guidelines.html. Handling Tasks,” Journal of International Nursing Studies, 43:717-33 40 Nelson et al., “Development and Evaluation of a Multifaceted (2006). Ergonomics Program.” 12 Nelson, Safe Patient Handling and Movement. 41 Matz, “Analysis of VA Patient Handling and Movement Injuries and 13 A. Nelson et al., “Algorithms for safe patient handling and move- Preventive Programs.” ment,” American Journal of Nursing 103, no 3:32–34 (2003). 42 Ibid. 14 Hignett et al., “Evidence-based patient handling.” 43 de Castro, A.B. 2004. Handle with Care: The American Nurses 15 de Castro, “Handle with care.” Association’s campaign to address work-related musculoskeletal disorders. Online Journal of Issues in Nursing 9(3). 16 Nelson et al., “Development and Evaluation of a Multifaceted Ergonomics Program.” 44 Nelson et al., “Development and Evaluation of a Multifaceted Ergonomics Program.” 17 U.S. Department of Labor, Occupational Safety and Health Administration. 2003. Ergonomics Guidelines for Nursing Homes. 45 A. Nelson & A. Baptiste, “Evidence-based practices for safe patient Retrieved on 9/30/09from http://www.osha.gov/ergonomics/guide- handling and movement,” Nursing World / Online Journal of Issues lines/nursinghome/final_nh_guidelines.html. in Nursing 9, no. 3 (2004): 4. 18 A. Hudson, “Back injury prevention in health care,” in Handbook of 46 A. L. Nelson, A.S., Baptiste, M. Matz & G. Fragala, “Evidence-based Modern Hospital Safety, 2nd ed., ed. W. Charney, (New York: CRC interventions for patient care ergonomics,” in Handbook of human Press, Taylor & Francis Group, 2010). factors and ergonomics in health care and patient safety, ed. P. Carayon (Mahwah, New Jersey: Lawrence Erlbaum Associates, 19 B. Evanoff, L. Wolf, E. Aton, J. Canos & J. Collins, “Reduction in Publishers, 2007), 323–45. injury rates in nursing personnel through introduction of mechanical lifts in the workplace,” American Journal of Industrial Medicine 44 47 Hignett, S., Crumpton, E., Ruszala, S., Alexander, P., Fray, M., & (2003): 451–57. Fletcher, B. (2003). Evidence-based patient handling: systematic review. Nursing Standard, 17(33), 33-36. 20 J. W. Collins, L. Wolf, J. Bell & B. Evanoff, “An evaluation of a ‘best practices’ musculoskeletal injury prevention program in nursing 48 U.S. Department of Labor, Occupational Safety and Health homes,” Injury Prevention 10 (2004): 206–11. Administration. 2003. Ergonomics Guidelines for Nursing Homes. Retrieved on 9/30/09from http://www.osha.gov/ergonomics/guide- 21 A. L. Nelson et al., “Development and Evaluation of a Multifaceted lines/nursinghome/final_nh_guidelines.html. Ergonomics Program.” 49 Nelson et al., “Development and Evaluation of a Multifaceted 22 U.S. Department of Labor, Occupational Safety and Health Ergonomics Program.” Administration. 2003. Ergonomics Guidelines for Nursing Homes. Retrieved on 9/30/09from http://www.osha.gov/ergonomics/guide- 50 Ibid. lines/nursinghome/final_nh_guidelines.html. 51 Nelson, A.L. (Ed) (2006). Safe Patient Handling and Movement: A 23 K. Siddharthan, A. Nelson, H. Tiesman & F. Chen, “Cost effective- Guide for Nurses and Other Health Care Providers. New York: ness of a multi-faceted program for safe patient handling,” Springer Publishing Company. Advances in Patient Safety 3 (2005): 347–58. 52 N. M. Dixon, How Companies Thrive By Sharing What They Know 24 Evanoff et al., “Reduction in injury rates in nursing personnel.” (Cambridge: Harvard Business School Press, 2000). 25 Collins et al., “An evaluation of a ‘best practices’ musculoskeletal 53 Matz, M. and Haney, L. Unit-based Peer Leader Training Program. injury prevention program in nursing homes.” 8th Annual Safe Patient Handling and Movement Conference. Lake Buena Vista, Florida, April 1, 2009. 26 Nelson, AL, Matz, M, Chen, F., Siddharthan, K., Lloyd, J., Fragala, G. (2006). Development and Evaluation of a Multifaceted 54 F. Fournies, Coaching for Improved Work Performance (New York, Ergonomics Program To Prevent Injuries Associated with Patient NY: McGraw-Hill, 2000). Handling Tasks. Journal of International Nursing Studies, 43, 717- 55 Nelson et al., “Development and Evaluation of a Multifaceted 733. Ergonomics Program.”

CHAPTER 5 A Vision of the Future of PHAMPs

Principal authors:

OGER EIB AVID REEN AND AIUS ELSON R L , AIA, ACHA; D G ; G G. N , RA T

I he technology currently applied to patient han- Patient needs include not only their physical dling and movement in various settings is, in some requirements but also their emotional, intellec- respects, in its infancy. Initially, patient handling tual, and social needs. and movement (PHAM) equipment was devel- Physical needs include the use of all possible oped to assist caregivers with routine acts of daily I muscles and weight-bearing activities to main- care that require lifting and transporting patients. tain health and functioning and preclude the A rather large array of equipment has been pro- onset of immobility-related adverse events duced for this purpose, particularly in the last I (see Table 5-1). decade. More recently, health care providers and Emotional needs include preservation of researchers have recognized the importance of dignity during mechanically assisted move- mobilizing patients as a means of maintaining or I ment. improving their health and optimizing short- and Intellectual needs include the ability to make long-term outcomes by keeping them physically as many decisions as possible related to active as early and as often as possible. assisted movement. Unfortunately, equipment that addresses the Social needs include maintaining sitting and need for mobility is not widely available or afford- standing positions normally associated with able. In addition, the equipment that is available to social and clinical interactions. support mobility is often not designed appropri- CaregiverAll of Focusthese needs are most effectively ately. In this chapter, we offer our vision for addressed through active engagement of the equipment based on two broad values: well-being of patient in control of the PHAM equipment. the patient as a whole person and staff safety and health. Two essential components of patient well- being are provision of the maximum opportunity for Facilitating the ability of direct caregivers to self-determination and maintenance of the patientÕs respond to all of a patientÕs range of needs is Perspectivespersonal dignity. Forfor staffAchieving to live out Optimal these values on essential for the well-being of patients and the Patienta daily basis Handling in all patient/staff and Movement interactions requires safety and health of the staff. Equipment should be staff training as well as proper technology. designed to enable all tasks that involve musculoskeletal stress, and the proper equipment should be located so it is convenient to use. Care- giversSystems also Thinking need to be encouraged to problem-solve so they can respond to PHAM To make progress toward realizing our vision, issues they have not previously encountered. healthPatient-Center care organizationsed Focus must keep the following concerns in mind when making decisions related to patient handling, movement, and mobility. Many shortcomings in available PHAM solutions arise from failure to consider the health care delivery system as a whole and the interrela- Understanding the patient perspective must be tionship of all its elements. PHAM issues must the starting point for designing PHAM equipment. be addressed contextually rather than as 70 PHAMA: A Vision of the Future

Table 5-1: Potential Effects on Patient from Loss of Mobility*

Physiological Bedsores Blood clots (deep-vein thromboses) Compromised breathing Compromised peristalsis, gas build-up, and constipation De-conditioning of gross muscles De-conditioning of cardiovascular system and reduced cardiac output Decreased bone density Insulin resistance Orthostatic hypotension and increased falls

Behavioral Decreased field of vision Depression and anxiety “I’m sick” syndrome Increased dependency

Institutional Increased burdens on staff Increased cost of care

*Includes loss of ability to use all possible muscles and engage in weight-bearing activities.

Ideas for Improvement

I I isolatedI problems. The best solutions will consider these factors: I Ease and efficiency of use of PHAM equipment Ideas for improving PHAM equipment are many. I Convenience of equipment storage locations TheShort-Term suggestions Solutions outlined here are divided into I Convenience of equipment charging/ potential short-term improvements and those I recharging that will take more time to achieve. I Location of equipment relative to point of use I Patient dignity I I Patient and staff safety These are suggestions for improvement of Staffing levels existing equipment and near-term development I Staff training Iof new equipment: I Aesthetics Beds that reduce or eliminate the need for Compatibility with other patient care equip- the caregiver to lean over the patient (Òcanti- ment and functions I levered careÓ) RethinkingEffect on buildingBasic Elements structure Beds and chairs that provide the opportunity Impact on building systems (e.g., mechanical for staff and visitors to sit in a normal conver- systems) I sational relationship with patients in bed Beds that provide arm support for caregivers during long-term care procedures such as PHAM equipment supplements basic care I spoon-feeding a patient elements such as beds, chairs, and toilets. The Devices for gripping a patientÕs body that are design of these basic elements also must be dignified and safe for both the caregiver and rethought to determine what can be done to mini- the patient mize the need for additional PHAM equipment Universal sling and lift pieces that reduce the and to facilitate interaction of these elements with challenges of storing and finding the correct equipment required for the patient activities of item and using it with a patient sleeping, sitting, toileting, and moving about. PHAMA: A Vision of the Future 71

I Beds that accommodate sequential compres- sion devices (SCDs) and bring them into I position with limited caregiver effort Overhead lifts that are compatible with ceiling- I mounted equipment and have a residential appearance Overhead lift vests that permit use of normal I clothing during toileting A variety of motorized floor-based lift or I stand-and-move devices that make use on carpeting easier for caregivers Floor-based lifts with narrow support platforms I that can be used in narrow doorways and spaces Beds, chairs, and toilets that incorporate PHAM capability to reduce dependence on I specialized equipment Patient support platforms that provide rocking I and continuous motion to maintain normal body functions Patient support surfaces that perform omni- directional horizontal translation I Overhead track systems throughout a care environment that continuously support a patient in a standing position and bear all or part of a patientÕs weight FutureSterile Developments quick-disconnect/reconnect in Technology IV tubing, I catheters, etc., that allow a patient to ambulate untethered from lines restraining movement I

Floor surfaces that reduce or absorb sufficient I impact to prevent fractures as a result of falls Intuitive controls that give the patient a greater role in directing the use of handling, I movement, and mobilization technology Exoskeletal devices that multiply the physical strength of caregivers as they perform manual lifting and carrying functions I Exoskeletal devices that supplement and enhance a patientÕs physical capabilities for movement and mobility. Programmable devices would be the next level. Robotic caregivers

Ultimately, our vision is care facilities in which patients maintain or increase their physical functioning and weight-bearing capacity during their stay and caregivers remain free of work-related injury throughout their career.

CHAPTER 6 Patient Handling and Movement Resources

T Safe Patient Handling and Movement: A Practical Guide for Health Care Professionals.

he material in this chapter is presented as Nelson, Audrey, PhD, RN, FAAN, ed. Generalsources for further information. Many of these ref- erences are also cited throughout this white paper New York: Springer as sources for the information provided herein. I Publishing Company (2006). Working Safely in Health Care, A Practical ÒThis book presents best practices in safe patient Guide, handling and movement. Caregiver safety Iapproaches include: Baptiste, A. ÒSafe Client Movement and HandlingÓ Evidence-based standards for safe patient in I movement and prevention of musculoskeletal edited by D. Fell-Carlson. New York: injuries DelmarHandbook Learning, of Modern Thomson Hospital Safety,Corporation I An overview of available equipment and (2008). technology DesignArchitectural Guidance designs for ergonomically safe Matz, M., ÒBack Injury Prevention in Health CareÓ patient care space in 2nd ed., InstitutionalGuidebook policies, for Architects such as anduse ofPlanners, lift teamsÓ edited by W. Charney. New York:Handbook CRC Press, of TaylorHuman & Factors Francis and Group Ergonomics (2010). in Health Care and Patient Safety, Nelson, A. L. et al. ÒEvidence-based Interventions ARJO. 2nd for Patient Care ErgonomicsÓ in ed. ARJO Hospital Equipment AB (2005). For a copy of this book, contact ARJOHuntleigh edited by P. Carayon. at [email protected]. Mahwah, NJ: LawrenceThe Illustrated Erlbaum Guide Associates, to Safe PublishersPatient Handling (2007), andpp. 323Ð45.Movement. Bottomley, Gryan, and Associates. ÒThe Victoria Hospital Industrial Association (VHIA) Design Nelson, Audrey; Kathleen Motacki; and Nancy Advisory Service: Final Report and Evaluation.Ó Nivison Menzel. Melbourne, Vic. (Australia): WorkSafe Victoria New York: (September 2005). Springer Publishing Company (2009). This report demonstrates that the design of work- ÒThe authors present the Evidence-Based Safe places in the health care industry is critical to Patient Handling Program, a practical system of achieving sustained improvements in occupa- guidelines to help reduce caregiver and patient tional health and safety. Introduction of better injuries during patient handling. Each chapter designs can reduce risks to health and safety by explains how to apply the program to specific clin- identifying and addressing issues at the earliest ical settings, such as medical and surgical, critical point. Retrieved from www.worksafe.vic.gov.au/ care, pediatrics, labor and delivery, rehabilitation wps/wcm/connect/wsinternet/WorkSafe/Home settings, the perioperative suite, and nursing /Forms+and+Publications/Educational+ homes.Ó Material/VHIA+Design+Advisory+Service+Report. PHAMA: Resources 73

Safe Patient Safe Patient Handling and Handling and Movement in the Perioperative Movement: A Practical Guide for Health Care Setting. Villeneuve,Professionals, J. ÒPhysical Environment for Provision Association of periOperative Registered Nurses of Nursing Care: Design for Safe Patient Workplace Safety Taskforce. HandlingÓ in Designing Workplaces for Safer Denver: AORN (2007). The AORN Handling of People:edited byFor A. Health,Nelson. AgedNew York:Care, Guidelines can be purchased from www.aorn SpringerRehabilitation Publishing and Disability Company, Facilities Inc. (2006). bookstore.org/product/product.asp?sku=MA N167&mscssid=KA8KPFTXNHFW8HXVNCDF Worksafe Victoria. NM3XJP0W4HXF.

, 3rd ed. National Association of Orthopaedic Nurses. ÒSafe Melbourne, Vic. (Australia): Victorian Patient Handling and Movement in the WorkCover Authority (September 2007). Orthopaedic Setting.Ó www.orthonurse.org/ Formerly titled ÒDesigning workplaces for safer ResearchandPractice/SafePatientHandling/ta handling of patients and residents,Ó this publication bid/403/Default.aspx. is written for planners, facility managers, and direct care staff. It is intended for those who have design Occupational Safety and Health Administration. and layout of a current workplace contributing to ÒGuidelines for Nursing Homes: Ergonomics for injuries, organizations designing new facilities or the PreventionPatient of MusculoskeletalHandling in Small Disorders.Ó Facilities: planning renovations, and for workers involved in Awww.osha.gov/ergonomics/guidelines/nursingCompanion Guide to Handle with Care. the planning process for a workplace. Retrieved home/final_nh_guidelines.html. Clinicalfrom Guidancewww.worksafe.vic.gov.au/wps/wcm/ connect/d39b9b004071f551a67efee1fb554c40/V WorkSafe BC. GeneralWA531.pdf?MOD=AJPERES. WorkersÕ Compensation Board of British PatientColumbia Care Ergonomic(2006). www.worksafebc.com/Evaluation Process publications/health_and_safety/by_topic/asseErgonomics: How to Contain On-the-Job ts/pdf/patient_handling_small_facilities.pdf.Injuries in Health Care. American Nurses Association. ÒSafe Patient Handling and MovementÓ presentation for nursing students. www.cdc.gov/niosh/ review/ Fragala, G. Patient public/safe-patient/patienthandling2.html. Care Ergonomics ResourceChicago: Guide: Joint Safe Commis- Patient This is a segment of the ANA ÒHandle with CareÓ Handlingsion (1996). and Movement Campaign. Ergonomics Technical Advisory Group. American Physical Therapy Association. ÒStrate- gies to Improve Patient and Health Care , edited by A. Nelson. Provider Safety in Patient Handling and Move- Tampa: Veterans Administration Patient Safety ment Tasks: A CollaborativePT Magazine Effort of the Center of Inquiry (2001). Available at American Physical Therapy Association, Asso- www.visn8.va.gov/PatientSafetyCenter/safePt ciation of Rehabilitation Nurses, and Veterans Handling. Health Administration.Ó Originally published in (April 2005), Matz, M. ÒPatient handling (lifting) equipment this piece is now posted at www.apta.org/AM/ coverage & spaceSafe recommendations.Ó Patient Handling Internal and Template.cfm?Section=Home&CONTENTID= Movement:VHA document A Practical presented Guide to forDirector, Health VHA,Care 18516&TEMPLATE=/CM/HTMLDisplay.cfm. ProfessionalsOccupational Health Program (2007).

Nelson, A., ed.

New York: Springer Publishing Company, Inc. (2006). 74 PHAMA: Resources

Human Factors for Informatics Usability.

Shackel, Brian, and Simon J. Richardson, eds. Safe Patient Handling in Washington State: www.washingtonsafepatienthandling.org/ Cambridge: Cambridge University Press (1991). resources.html Retrieved 10/11/09 from http://books. google.com/books?id=KSHrPgLlMJIC&pg=PA3 VA Patient Safety Center, Safe Patient Handling &lpg=PA3&dq=shackel++ergonomics+defined Web page: www.visn8.va.gov/PatientSafety &source=bl&ots=ITSrLRXYy8&sig=GQ0ybVDG Center/safePtHandling. ZiDac-KNFLXTEOZVepU&hl=en&ei= VAYZnSSqLaL4Kntgej0KTwAw&sa=X&oi=book_ Toolkits/Resources ForSelected more links, Journal enter Articles Òsafe patient handlingÓ or result&ct=result&resnum=1&ved=0CAwQ6AE Òpatient care ergonomicsÓ into an Internet search wAA#v=onepage&q=&f=false. engine.Bariatric Design

Nursing Homes/Long Term I Care Management TheI VHA documents listed below can be found at www.visn8.va.gov/PatientSafetyCenter/safeI Muir, M., and L. Haney. ÒDesigning space for the PtHandling.I bariatric resident.ÓThe Director Technology Resource Guide , November 2004:25Ð28. I Sling Toolkit Bariatric Toolkit Biomechanics/ErgonomicsMuir, M., and L. Haney. ÒErgonomics and the I Safe Patient Handling Guidebook for Facility Bariatric Patient.Ó 12(3):143Ð46 Champions/Coordinators (2004). I Safe Patient Handling Unit Binder for Peer Journal of Advanced Nursing I Leaders and Staff Algorithms for Safe Patient Handling and Hignett, S. ÒSystematic review of patient handling I Movement activities startingEvidence-Based in lying, sitting, Patient and Handling: standing I No Lift Policy Draft Tasks.positions.Ó Equipment and Interventions. Comprehensive Safe Patient Handling 41(6):545Ð52 (2003). Bibliography WebSafety Links Huddle Hignett, S., et al. Patient Handling Equipment: Making Recom- American Journal of NursingNew York: mendations and Product Selections Routledge (2003).

DesignWaters, T. R. ÒWhen is it safe to manually lift a patient?Ó American Nurses Association, Handle with Care 107(6):40Ð45 (2007).Health Estate Journal, Program: http://nursingworld.org/MainMenu Categories/OccupationalandEnvironmental/ occupationalhealth/handlewithcare.aspx. Hignett, S., and J. Arch. ÒEnsuring bed space is right first time.Ó LIKO Safe Lifting Portal: www.liko.com/web/ February 2008:Professional 29Ð31. Nurse frameset.asp?qadwords=&toggle=&topnumbe r=2&market=&marketid=135&pageid=4626& Hignett, S., and E. Keen. ÒDetermining the space menuid=1694 needed to operate a mobile and an overhead patient hoist.Ó 20(7):40-2 Occupational Health and Safety Agency for (2005). Health Care in British Columbia (includes safe sidebar continued from previous page patient handling chapters): www.hsaa.ca/ occupational_health_and_safety/OHS_BC_ ceiling_lift.pdf PHAMA: Resources 75

Equipment/Slings

Journal of Nursing Administration Rehabilitation Nursing Trinkoff, A. M.; B. Brady; and K. Nielsen. ÒWork- Baptiste,Patient Assessment A.; M. McCleery, for SelectingM. Matz; and C. Evitt. place prevention and musculoskeletal injuries AppropriateÒEvaluation Equipment of Sling Use for Patient Safety.Ó in nurses.Ó , Jan.-Feb. 2008. 33(3):153Ð58 (2003).Spine American Journal of Nursing Yassi, A., et al. ÒA randomized controlled trial to Resident/Patientprevent patient Safety lift and transfer injuries of Nelson,Peer Leaders A. et al. ÒAlgorithms for Safe Patient health care workers.Ó 26(16):1739Ð46 Handling and Movement.Ó (2001). Rehabilitation 103(3):32Ð34 (2003). Nursing

Critical Care Nursing Clinics of North Nelson, A.L., et al. ÒLink Between Safe Patient Knibbe,America J.; N. Knibbe, and A. M. Klaassen. ÒSafe Handling and Quality of Care.Ó patient handling program in critical care using 33(1):33Ð41 (2008). Programpeer leaders: Implementation lessons learned in the Nether- lands.Ó 19(2):205Ð11 (2007). Injury Prevention

Collins J., et al. ÒAn evaluation of a Ôbest practicesÕ musculoskeletal injury prevention program in nursing homes.Ó 10:206Ð11 (2004). American Journal of Industrial Medicine Evanoff, B.; et al. ÒReduction in injury rates in nursing personnel through introduction of mechanical lifts in the workplace.Ó 44:451Ð57Nursing Standard(2003).

Hignett, S., et al. ÒEvidence-based patient handling: systematic review.Ó 17(33), 33Ð36 (2003). Journal of International Nelson,Nursing A. L. Studies et al. ÒDevelopment and Evaluation of a Multifaceted Ergonomics Program to Prevent Injuries Associated with Patient Handling Tasks.Ó 43:717Ð33 (2006).

OwenInternational B. D.; K. Keene; Journal and of S.Nursing Olson. StudiesÒAn ergonomic approach to reducing back/shoulder stress in hospital nursing personnel: A five-year follow up.Ó

39:295Ð302 (2002). APPENDICES APPENDIX A High-Risk Manual Patient Handling Tasks by Clinical Area

Nursing Home or Other Long-Term Care Facility I I I I

I I I I Making an occupied bed I Transferring a patient between toilet and chair I Bathing a confused or totally dependent I Transferring a patient between chair and bed I patient I Transferring a patient from bathtub to chair I Lifting a patient up from the floor I Transferring a patient from chair lift to chair Weighing a patient I Weighing a patient OperatingApplying Room anti-embolism stockings I Lifting a patient up in bed I Repositioning a patient in bed I Repositioning a patient in bed from side to side I Making extensive dressing changes I Repositioning a patient in a chair I Changing an absorbent pad I Making an occupied bed I Standing for long periods of time Undressing a patient I Adopting unnatural positions in order to work CriticalTying Carsupportse Units effectively or leaning over a patient for I Feeding a bedridden patient I protracted periods Making an unoccupied bed I Lifting and holding a patientÕs extremities I Holding retractors for extended periods of I time Transporting a patient in a bed or stretcher, HomeTransferring Care a patient on and off OR beds I frequently with heavy monitors and multiple I Reaching, lifting, and moving equipment I lines Repositioning a patient in an OR bed Laterally transferring a patient from bed to I I stretcher I Lifting a patient to the head of a bed I Providing patient care in a bed that is not I Transferring a patient on and off a cardiac height-adjustable chair I Providing care in a crowded area, forcing I Repositioning a patient in bed from side to side awkward positions Making an occupied bed PsychiatryToileting and transfer tasks without proper Moving heavy equipment and accessing elec- I lifting aids trical outlets I Having no assistance for tasks I Providing patient handling tasks in a crowded area, where multiple lines and monitoring I equipment force caregivers into awkward I Restraining a patient positions I Escorting/toileting/dressing a confused or I Performing cardiopulmonary resuscitation or I combative patient other procedures when many team members Toileting a confused or combative patient Medical/Surgicalare present and Unitsit is impossible to have the I Dressing a confused or combative patient I bed at the right height for every staff member Picking a patient up from the floor Applying anti-embolism stockings Bathing/showering a confused or combative I patient Performing bed-related care Transferring a patient from bed to chair or stretcher Moving an occupied bed or stretcher 78 PHAMA: Appendix A

Rehabilitation/Spinal Cord Injury Units I I I

I Transferring a patient from toilet to chair I Transferring a patient from wheelchair to bed I Repositioning a patient to the head of a bed, I or side to side I Repositioning a patient in a wheelchair I Making an occupied bed I Dressing/undressing a patient Feeding a bedridden patient Trauma/EmergencyAmbulating a patient (limited at high research risk for regarding falls high-riskShowering tasks) a patient or providing a bed bath I Applying anti-embolism stockings

Orthopedic Units I Transferring patients into and out of personal vehicles I

I Turning an orthopedic patient in bed (side to side) I Vertically transferring a postoperative total I hip replacement patient Vertically transferring a patient with an extremity cast/splint Note:Ambulating a patient Lifting or holding a limb with or without a cast or splint Handle with Care: SafeExcept Patient for the Handling section andon orthopedic Movement units, the information for this appendix is adapted from A. Nelson, ÒVariations in high-risk patient handling tasks by practice setting,Ó in , A. L. Nelson, ed.Orthopaedic (New York: Nursing, Springer Publishing Company, 2006). The information for orthopedic units is from National Association of Orthopaedic Nurses, ÒSafe patient handling in orthopaedic nursing,Ó Supplement to 28, no. 2 (2009). The latter is available at www.orthopaedicnursing.com. APPENDIX B Legislative Report

S1788: Nurse and Health Care Worker Protection Act of 2009

The information in this appendix is current as of FederalJanuary 2010; Legislation to learn the current status of bills in Congress, paste the bill number and title into an S1788 was introduced in the U.S. Senate by Al InternetHR 2381: search Nurse engine. and Patient Safety and Franken (D-MN) on October 15, 2009. This bill Protection Act of 2009 requires the Secretary of Labor to Òpropose a standard on safe patient handling and injury preventionÓ to Òprevent musculoskeletal disorders for direct-care registered nurses and all other health care workers handling patients in HR 2381 remains in committee. This bill for safe health care facilities.Ó patient handling was originally introduced on The standard would require the use of engi- September 26, 2006, as HR 6182: Nurse and neering controls to lift patients and the elimination Patient Safety and Protection Act of 2006 by U.S. of manual lifting of patients with the use of Representative John Conyers Jr. (D-MI). It called mechanical devices, except where patient care for an amendment of the Occupational Safety and may be compromised. In summary, it would also Health Act of 1970 to reduce injuries to patients, require health care employers to (1) develop and nurses, and other health care providers with a implement a safe patient handling and injury safe patient handling standard. prevention plan, (2) provide workers with training Representative Conyers reintroduced the bill on safe patient handling and injury prevention, as HR 2381: Nurse and Patient Safety and Protec- and (3) post a uniform notice that explains the tion Act of 2009 on May 13, 2009. HR 2381 would standard and procedures for reporting patient Òdirect the Secretary of Labor to issue an occupa- handling-related injuries. It would require the tional safety and health standard to reduce Secretary to conduct unscheduled inspections to injuries to patients, direct-care registered nurses, ensure compliance with safety standards. and other health care providers by establishing a The bill allows health care workers to (1) safe patient handling standard.Ó refuse to accept an assignment in a health care If HR 2381 is successful, a federal safe patient facility that violates safety standards or for which handling standard, calling for Òall health care facil- such worker has not received required training itiesÓ to comply, will be enacted Òto prevent and (2) file complaints against employers who musculoskeletal disorders for direct-care regis- violate this act. It prohibits employers from taking tered nurses and other health care providers adverse actions against any health care worker working in health care facilities. This standard who in good faith reports a violation, participates shall require the elimination of manual lifting of in an investigation or proceeding, or discusses patients by direct-care registered nurses and violations. It authorizes health care workers who other health care providers, through the use of have been discharged, discriminated against, or mechanical devices, except during a declared state retaliated against in violation of this act to bring of emergency.Ó legal action for reinstatement, reimbursement of HR 2381 was referred on May 13, 2009, to the lost compensation, attorneysÕ fees, court costs, Committee on Education and Labor, the and other damages. The Secretary of Health and Committee on Energy and Commerce, and the Human Services (HHS) is required to establish a Ways and Means Committee. On June 11, 2009, it grant program for purchasing safe patient was referred to the Subcommittee on Workforce handling and injury prevention equipment for Protections. health care facilities. 80 PHAMA: Appendix B

StateS1788 Laws was assigned to the Senate Health, that musculoskeletal disorders are the leading Education, Labor, and Pensions committee on occupational health problem plaguingNote: nurses, October 15, 2009. HCR 16 says, ÒBe it resolved . . . that the Legislature of the State of Hawaii supports the policies contained in the American Nurses AssociationÕs ÔHandle with CareÕ campaign.Ó Does not Nine states have passed legislation pertaining to require a safe patient handling policy or program safe patient and/or resident handling. Seven of orIllinois use of patient lift equipment. the nine directly require development of safe See www.capitol.hawaii.gov/session2006/ patient handling policies and/or implementation Bills/HCR16_.pdf. of safe patient handling programs and/or use of mechanical patientHawaii lifting equipment, with variations in the scope Texas,of the requirements.Washington, The Rhode two HB 2285 (August 13, 2009). Public Act 96-0389 remainingIsland, Maryland, states lend Minnesota, support toIllinois efforts for Newsafe requires that state mental health centers, state patientJersey and/or resident handling. developmental centers, and the University of Illi- One stateÑ Ñhas adopted a resolution. nois Hospital comply with these provisions, Seven statesÑ effective January 1, 2010. The law requires a , and policy that will identify, assess, and develop Ñhave passedOhio legislationNew requiring York safe strategies to control the risk of injury to patient and/or resident handling policies and/or patients/residents, nurses, and other health care programs and/or lifting equipment, with much workers associated with lifting, transferring, variation in scope among the different state laws. repositioning, or movement of a patient/resident. Two statesÑ and Ñhave Restriction of lifting must be achieved to the passed legislation that does not directly require, extent feasible with existing equipment and aids; but is supportive of, safe patient and/or resident manual handling or movement of all or most of handling. Ohio will provide interest-free loans to the patientÕs body weight is to be done only during nursing homes wishing to implement lift equip- emergency, life-threatening, or otherwise excep- ment, and New York requires a demonstration tional circumstances. Some other provisions project on safe patient handling. include staff education, staff training, and a proce- Of particular interest is the difference among dure for a nurse to refuse to perform or be states in addressing the safe handling of hospital involved in handling or movement that the nurse patients and/or nursing home residents. Ideally, believes in good faith will expose the patient/resi- legislation should cover the safe handling of dent,Maryland nurse, or other health care worker to an dependent persons across all health care settings. unacceptable risk of injury. HawaiiA short comparison of the states, in alphabet- See www.ilga.gov/legislation/publicacts. ical order, is provided. For additional detail, refer to the supporting links. HB 1137 and SB 879 (April 10, 2007) define Òsafe patient liftingÓ as the Òuse of mechanical lifting HCR 16 (April 24, 2006) calls for safeguards in devices by hospital employees, instead of manual health care facilities to minimize musculoskeletal lifting, to lift, transfer, and reposition patients.Ó injuries to nurses and for the State Legislature to Hospitals are required to develop a safe patient support policies in the American Nurses Associa- lifting committee with an equal number of tionÕs ÒHandle with CareÓ campaign. HCR 16 states managers and employees by December 1, 2007, that in 2005, the Council of State GovernmentsÕ and a safe patient lifting policy to reduce Health Capacity Task Force adopted and employee injuries from patient lifting by July 1, supported the policies contained in the ANA 2008. Consideration is to be given to patient ÒHandle with CareÓ campaign and asked member handling hazard assessment; enhanced use of states to also support the campaign. Recognizing mechanical lifting devices; development of PHAMA: Appendix B 81

specialized lift teams; training programsNote: for safe Newcompliance York in premiums and for ongoing funding patient lifting; incorporatingnot space and construc- Art 2, Sec 36, and work groups on safe patient tion design for mechanical lifting devices in handling and equipment Sec 37, pp. 58Ð59. architectural plans; and evaluating the effectiveness of the safe lifting policy. Covers hospitals only, nursing homes. Covers A7641 and S4929 (October 18, 2005). Created a Òhospital employeesÓ and thus not limited to two-year ÒSafe Patient Handling Demonstration nurses. ProgramÓ to establish safe patient handling For the text of HB 1137, see http://mlis.state. programs and collect dataNote: on nursing staff and md.us/2007RS/chapters_noln/Ch_57_hb1137T.Minnesota patient injury with patient handling, manual pdf. For the text of SB 879, see http://mlis.state. versus lift equipment, in order to describe best md.us/2007RS/chapters_noln/Ch_56_sb0879T.pdf. practices for health and safety of health care workers and patients. Does not require health care facilities to implement safe patient HF 712 and SF 828 passed within HF 122 (May 25, handling policies and programs. 2007). Every licensed health care facility See http://assembly.state.ny.us and (including hospitals, outpatient surgical centers, www.senate.state.ny.us. and nursing homes) is required to have a safe A7836 (July 3, 2007) extends the demonstra- patient handling program, with a safe patient tion program for two years to research the effect handling committee and a policy to minimize of safe patient handling programs and to build manual lifting of patients by nurses and other Note:upon existing evidence-based data, with the goal direct patient care workers by utilizing safe of designing best practices for safe patient patient handling equipment, rather than people, handling in health care facilities. It also establishes to transfer, move, and reposition patients and specifications for safe patient handling programs. residents in all health care facilities. The program Does not require implementation of safe will address acquiring adequate, appropriate, safe patientNew Jersey handling policies and programs. patient handling equipment; training; remodeling For summary text, see http://assembly. and construction consistent with program goals; state.ny.us/leg/?bn=A07836. and evaluations of the program. Financial assistance will include matching grants and development of ongoing funding sources to SB 1758 and AB 3028 (January 3, 2008) cover acquire and provide training on safe patient general and special hospitals, nursing homes, handling equipment, including low-interest loans, state developmental centers, and state and county interest-free loans, and federal, state, or county psychiatric hospitals. Each facility establishes a grants, plus a special workersÕ compensation fund safe patient handling committee, with at least 50 of $500,000 for safe patient handling grants. The percent of the membersÕ health care workers MinnesotaNote: State Council on Disability shall representing disciplines employed by the facility. convene a work group to study the use of safe A safe patient handling program and policy on all patient handling equipment in unlicensed outpa- units and all shifts is required as well as a plan for tient clinics, physician offices, and dental settings. prompt access to patient handling equipment; Covers hospitals, surgical centers, and posting the policy in a location easily visible to nursing homes. Covers nurses and Òother direct staff, patients, and visitors (to minimize unas- patient care workers.Ó sisted patient handling); and includes a statement See HF 122 at www.leg.state.mn.us/ on the right of a patient to refuse assisted patient leg/legis.asp. Language in three areas: (1) grant handling. ÒAssisted patient handlingÓ means the funding Art 1, Sec 6, Sub 3, pp. 25Ð26; (2) main use of mechanical patient handling equipment, body of wording Art 2, Sec 23. 182.6551 to Sec 25. including, but not limited to, electric beds, 182.6553, pp. 48Ð51; and (3) study ways for portable base and ceiling track-mounted full body workersÕ compensation insurers to recognize sling lifts, stand assist lifts, and mechanized lateral 82 PHAMA: Appendix B

transfer aids; and patient handling aids, including, of injury. These reportable incidents shall be but not limited to, gait belts with handles, sliding included in the facilityÕs annual performance eval- boards, and surface friction-reducing devices. uation. Availability and use of safe patient There shall be no retaliatory action against any handling equipmentNote: in new space or renovation is health care worker who refuses a patient handling to be considered, with input from the community task due to reasonable concern about worker or to be served. Legislative findings include that safe patient safety or the lack of appropriate and avail- patient handling can reduce patient skin tears able patient handlingNote: equipment. Bills include threefold. Covers both hospitals and recommendations for a capital plan to purchase nursing facilities. Covers Òemployees,Ó so not equipment necessary to carry out the policy, limited to nurses. which takes into account the financial constraints For text of H7386, see www.rilin. of the facility. Covers hospitals, nursing state.ri.us/Billtext/BillText06/HouseText06/H73Texas homes, developmental centers, and psychiatric 86Aaa.pdf. For S2760, see www.rilin.state.ri.us/ hospitals. Covers Òhealth care workers,Ó so not Billtext/BillText06/SenateText06/S2760A.pdf. limited to nurses. OhioFor the text of the New Jersey Safe Patient Handling Act, see www.njleg.state.nj.us/ SB 1525 (June 17, 2005). Texas was the first state 2006/Bills/PL07/225_.PDF. to require both hospitals and nursing homes to establish a policy for safe patient handling and movement. The goal is to control the risk of injury Ohio passed HB Note:67 (March 21, 2005) to create a to patients and nurses; evaluate alternative workersÕ compensation fund for interest-free methods to manual lifting, including equipment loans to nursing homes for lift equipment and for and patient care environment; restrict, to the implementation of ÒNo Manual Lifting of Resi- extent feasible with existing equipment, manual dentsÓ policies. Does not require nursing handling of all or most of a patientÕs weight to homes to purchase and implement lift equipment emergency, life-threatening,Note: or exceptional or to develop safe resident handling policies and circumstances; and allow nurses to refuse to programs. Offers interest-free loans for lift equip- perform patient handling tasks believed in good mentRhode to Island nursing homes but not to hospitals. faith to involve unacceptable risks of injury to a For text, scroll to Sec. 4121.48 at www.legislature. patient or nurse. notCovers both hospitals and state.oh.us/bills.cfm?ID=126_HB_67_EN. nursing homes. Requires safe patient handling policy only. Does not require safe patient handling program or provision and use of lift equipment. H7386 and S2760 (July 7, 2006) require hospitals SpecifiesWashington nurses. Does cover nurse assistants. and nursing facilities to achieve maximum reason- Enrolled text: www.capitol.state.tx.us/ able reduction of manual lifting, transferring, and tlodocs/79R/billtext/html/SB01525F.htm. repositioning of patients and residents except in emergency, life-threatening, or exceptional circumstances. As a condition of licensure, health HB 1672 (March 22, 2006). Washington was the care facilities shall establish a safe patient first state to mandate provision of lift equipment handling committee chaired by a professional by hospitals and to offer financial assistance with nurse with at least half the membersÕ non-mana- implementation by tax credits and reduced gerial employees providing direct patient care workersÕ compensation premiums. Hospitals and a safe patient handling program and policy for must establish a safe patient handling committee all shifts and units. An employee may report, with at least half the membersÕ frontline non- without fear of discipline or adverse conse- managerial employees providing direct patient quences, being required to perform patient care, a safe patient handling program, and policy handling believed in good faith to expose the for all shifts and units. Hospitals may choose patient and/or employee to an unacceptable risk either one readily available lift per acute care unit PHAMA: Appendix B 83

on the same floor, one lift for every ten acute care March and April 2007. On September 28, 2008, for inpatient beds, or lift equipment for use by the fifth time in as many years, the governor specially trained lift teams. Employees may refuse vetoed legislation for safe handling of health care without fear of reprisal patient handling activities patients in California. believed in good faith to impose an unacceptable For the amended text of SB 171, see risk of injury to an employeeNote: or patient. www.leginfo.ca.gov/pub/07-08/bill/ With hospitalnot construction or remodeling, the sen/sb_0151-0200/sb_171_bill_20070423_ feasibility of incorporating patient handling amended_sen_v98.pdf. For the amended text of equipment is to be considered, or of designing to ConnecticutAB 371, see http://info.sen.ca.gov/pub/07-08/ incorporate at a later date. Covers hospitals bill/asm/ab_0351-0400/ab_371_bill only. Does cover nursing homes. Provides _20070423_amended_asm_v97.pdf. financial assistance to implement lift equipment and programs. Covers Òemployees,Ó which would include nurse assistants and other health care SB470 (2008) attempts to address a number of workers, not limited to nurses only. different nurse retention issues, including a provi- OtherEnrolled State text: Legislative www.leg.wa.gov/pub/billinfo/ Efforts sionFlorida for purchasing lift equipment. There has been 2005-06/Pdf/Bills/House%20Passed%20 no action on the bill since February 26, 2008. Legislature/1672-S.PL.pdf. See www.cga.ct.gov.

California, Connecticut, Florida, Kansas, Massachusetts, Michigan, Missouri Florida reintroduced companion bills for safe NevadaEight additional states have introduced legislation patient handling in February 2007; these would with varied results at the date of this report have created a new Florida statute for safe patient ( handling and movement practices, but both bills , and died in committee on May 4, 2007. S2208 would California). A short description of the efforts in each have required hospitals to adopt a policy for safe state is provided. For details, refer to the links movement of patients and would have prohibited provided. hospitals from retaliating or discriminating against employees who, in good faith, reported violations of the act. H1193 would have required California introduced safe patient handling legis- hospitals and nursing homes to incorporate lation every year after Governor Arnold patient handling equipment into the construction Schwarzenegger vetoed the original legislation in or remodeling of hospitals or nursing homes and 2004. SB 171, reintroduced in February 2007, was provided credit for equipment purchase. amended in April of that year and passed as the KansasFor S2208 links to history and text, see Hospital Patient and Health Care Worker Injury www.flsenate.gov. For H1193, see www. Protection Act. It requires general acute care myfloridahouse.gov. hospitals to establish a patient protection and health care worker back injury prevention plan; conduct needs assessments to identify patients HB 2846 (2008) would have required a safe needing lift teams and lift, repositioning, or patient handling policy and program to apply to transfer devices; use lift teams and lift, reposi- allMassachusetts ÒmedicalÓ facilities. It is no longer active. tioning, and transfer devices; and train health care See www.kslegislature.org/legsrv-legisportal/ workers on the appropriate use of lift, reposi- index.do. tioning, and transfer devices. The bill was passed without funding and referred to the appropriations committee. A companion bill, AB 371, was Massachusetts has pursued legislation for safe introduced in the Assembly and referred to the patient handling since December 2004. The bill Appropriations Committee. It was amended in was reintroduced in January 2007 as S1294 and 84 PHAMA: Appendix B

Missouri

referred to the committee on Public Health. If passed, it would require every licensed health HB 1940 (2008) introduced legislation requiring care facility to implement an evidence-based hospitals to establish safe patient handling and policy for safe handling and movement of patients movement policy and programs. It was consoli- and to provide training on use of patient handling dated into HB 1933, but no further action was equipment and devices, patient care ergonomic taken. assessment protocols, no-lift policies, and patient NevadaSee www.house.mo.gov/billtracking/bills081/ lift teams. H2052, a companion House bill, was bills/HB1940.htm and www.house.mo.gov/bill also introduced in January 2007 and referred to tracking/bills081/bills/HB1933.htm. the Public Health committee. On October 24, 2007, both bills were discussed during a public hearing. On February 28, 2008, the AB577, introduced on March 26, 2007, required House reported favorably and referred the bill to hospitals and skilled nursing facilities to establish the Health Care Financing committee. On January a program and policy for safe handling of patients, 6, 2009, the Senate Ways and Means committee including a committee on safe patient handling, took no action. annual training for employees on safe handling of For history on S1294, see www.mass.gov/ patients, annual evaluation of the policy, consider- legis/185history/s01294.htm; for H2052, see ation of incorporation of lifting equipment during www.mass.gov/legis/185history/h02052.htm. construction or remodeling, and annual reports to ForMichigan S1294 text, see www.mass.gov/legis/bills/ the Nevada Legislature concerning safe patient senate/185/st01/st01294.htm; for H2052, see handling. After consideration by the Committee www.mass.gov/legis/hbillsrch.htm. on Health and Human Services, on April 23, 2007, AB577 passed the Assembly as amended. After it was moved to the Senate, the bill was referred to Introduced in March 2007, Senate Bill 377 would the Committee on Human Resources and Educa- have required hospitals to establish a safe patient tion. On May 26, 2007, it was determined no handling committee by January 1, 2008, and a safe further action was allowed. patient handling program by September 1, 2008. For AB577 history, see https://www.leg.state. Hospitals could choose one of three options for nv.us/74th/Reports/history.cfm?Document acquisition of lift equipment by December 31, PrincipalType=1&BillNo=577. author: For text with amendments 2011. The bill was referred to the Committee on Contributingadopted April author: 23, 2007, see https://www.leg.state Health Policy on March 27, 2007; it died in .nv.us/74th/Bills/AB/AB577_R1.pdf. committee. Sources: SB 377 included provision for employees David Soens, PE, AIA refusing, without reprisal, to perform patient Wade Rudolph, CBET, CHFM handling they believe in good faith to be unsafe and specifies that Òsafe patient handlingÓ means the use of engineering controls, lifting and American Nurses Association (ANA): transfer aids, or assistive devices, by lift teams or www.nursingworld.org. other staff, instead of manual lifting for lifting, United American Nurses (UAN): transferring, and repositioning health care www.uannurse.org. patients and residents. Work Injured Nurses Group (WING USA): For SB 377 history, see www.legislature. www.wingusa.org. mi.gov/(S(aei3m12r0ei40i3bjivvhe55))/mileg.as px?page=getobject&objectname=2007-SB- 0377&query=on. For text, see www.legislature .mi.gov/documents/2007-2008/billintroduced/ Senate/htm/2007-SIB-0377.htm. APPENDIX C PHAM Equipment Categories

Notes

1. A variety of terms are used to identify much of The patient handling and movement (PHAM) the equipment listed in this appendix. The terms used here are those commonly used in equipment categories discussed here are those the United States. most commonly used at present; however, not all 2. The definitions in this appendix may refer to categories will have a marked effect on design dependency levels based on physical limita- decisions. tions of patients. (See Table H-1: Physical To encourage use, the patient handling devices Dependency Levels of Patient Populations in Appendix H for definitions.) identified with an asterisk (*) must be stored in accessible and appropriate locations; to accomplish this, consideration must be given to storage space specifications during planning for new construction and renovation projects. Further- more, space must be provided in patient rooms Full-Body Sling Lifts and/or patient toilet/bath rooms for use of this permanently affixed to the structural component equipment by one or more caregivers. This space of a ceiling or wall. must accommodate a sufficient turning radius in the toilet room, bathroom, patient room, and hallway. Use of bariatric (and therefore larger) Full-body sling lifts utilize a variety of sling styles to variations of these equipment types is essential provide total support and assistance for dependent Powerfor protectinged Patient caregivers Lifting and bariatric patients, so and extensive-assistance patients as well as partial Equipmentthe larger areas or required Hoists for this equipment must support for patients with some weight-bearing also be considered during planning. ability. Weight capacities range from around 350 lbs. to 1,200 lbs. for bariatric patients. Of the three types of full-body sling lifts, ceiling lifts and floor-based lifts are by far the most commonly used. However, research points1, 2, 3, 4, 5 to Powered patient lifting equipment or hoists come significant biomechanical advantages to using in both overhead and floor-based designs. Care- ceiling lifts rather than floor-based lifts. In givers use this equipment to help them lift and addition,6, 7, 8 clinical staff generally prefer ceiling lifts transfer patients, mobilize and ambulate patients, because of their greater convenience 9,and 10, 11, accessi 12 - reposition patients side to side and up in bed, and bility, which leads to increased staff acceptance lift patient limbs as well as other patient handling and thus greater use of ceiling lifts. Most tasks. Some lifts can also be used to extract clinical areas alsouniversal benefit orfrom seated the sling variety of patients/residents from vehicles. usable sling applications available for ceiling lifts. Lifts controlled with a handheld device are The real value of lifts to a health care facility is powered with a rechargeable battery pack. determined by sling usage Repositioningand availability. slings A Presently, the two major categories of powered common sling, the (Figure lifting equipment are full-body sling lifts and sit- C-1), is used to transferStrap patients slings from seated posi- to-stand (stand assist) lifts. Full-body sling lifts are limbtions supportto seated slings positions (e.g., bed to wheelchair, further categorized as floor-based lifts, gantry chair, toilet, or commode). lifts, or overhead lifts (including ceiling-mounted, (Figure C-2) assist in repositioning patients side wall-mounted, and portable lifts). The term to side and up in bed. , also known as Òceiling liftÓ is generally used in place of Òoverhead (Figure C-3), have a variety of liftÓ to identify lifts with track systems that are helpful functions including limb support and 86 PHAMA: Appendix C

Figure C-1: Seated Slings ©RoMedic ©Guldmann golet ©Er ©Guldmann Figure C-2: Repositioning Slings ©Liko ©Liko Figure C-3: Strap or Limb Support Sling ©Guldmann

Figure C-4:

Ambulation Slings ©ArjoHuntleigh PHAMA: Appendix C 87

Figure C-5: Supine Sling ©Liko™ ©Ergolet golet ©Er

In toilet room (©Ergolet) ©Liko

a d

b ©RoMedic c

Figure C-6: Full-Body Sling Lifts Overhead/Ceiling Lifts © Integrity Medical Products

©Liko f e

ambulation slings

lateral rotation. When attachedSupine to slings an overhead lift, case, if possible and appropriate, wall-mounted (Figure C-4) serve to provide bracing systems can be used to support the track. support for those who are in the process of reha- Ceiling motor/lifts are normally permanently bilitating and who have a goal of increasing attached to the fixed track system; however, some mobilization capabilities. (Figure C- organizations opt to use portable motor/lift 5) Overheadkeep patients lifts in a flat position and are used to systems that can be moved from room to room lift patients from the floor/ground, off of the bed when needed and attached to existing track in the in order to make the bed, and for lateral transfers room. Challenges similar to those encountered and other tasks. with floor-based lifts arise when using this type of (Figure C-6 aÐf). Ceiling- portable system, and even though it may seem to mounted lifts are attached to fixed track systems. be an economical solution, it often is not because The motor/lift traverses a track that is attached to staff compliance in using it is often low. Floor the building infrastructure, usually the I-beam or space requirements are not an issue with over- concrete floor above. Although this type of instal- head/ceiling lifts, and they are the lift of choice, lation is preferred, structural deficiencies in especially in new construction and in existing existing buildings may prevent it. When that is the buildings with small rooms. 88 PHAMA: Appendix C ©RoMedic

golet i ©Er g ©RoMedic h

Figure C-6: Full-Body Sling Lifts Floor-Based Sling Lifts ©Liko j

*Floor-based sling lifts

16, 17 (Figure C-6 gÐi). locate and transport the lift to the patient18, room,19 These portable/mobile lifts move along the floor and*Gantry adequate lifts storage requirements. Flooring surface on wheels attached to an expandable characteristics such20 as flooring materials and base for spreading around chairs/wheelchairs. thresholds impact the ease of use of this type of Weight capacities range from around 350 lbs. to rolling equipment. 1,000 lbs. for bariatric patients. Accordingly, (Figure C-6 j). This type of mobile space requirements vary with weight13, 14,capacities 15 lift has two vertical side supports and a support Bed/Mattress Patient andHandling the size of Featurthe equipment.es Obstacles to use of bar that extends horizontally between the two floor-based lifts include accessibility, time to side supports. The lift motor traverses across the I Electric/powered movement horizontal bar. The gantry lift is placed over the I Retractable footboard bed of a patient and functions similarly to a ceiling I Percussion/vibration lift. Usually these lifts are mobile, so they can be I Raised knee platform moved from room to room when necessary; I Capillary perfusion enhancement I Built-in scale however, they are not used to transport a patient I Adjustable height from a patient room to another room or location. I CPR function They are often leased but sometimes purchased I Bariatric accommodation when storage is adequate. When leased, they are I Motorized capability most often used for very obese and bariatric I Lateral rotation therapy I Others patients when there is no ceiling lift available to move and lift these patients. The gantry lift is not recommended as a substitute for fixed ceiling lifts, but it has advantages over the use of floor-based full-body sling lifts for morbidly obese and bariatric patients. PHAMA: Appendix C 89 ©Liko Hovermatt® (©HoverTech) Figure C-7: Powered Sit-to- Stand Lifts Figure C-8:

©ArjoHuntleigh Air-Assisted Lateral Transfer Devices Hovermatt® (©HoverTech)

Powered Sit–to-Stand (Stand Assist Lateral Transfer Devices or Standing) Lifts

These powered lifts (Figure C-7) are mobile and Lateral transfer devices provide assistance for move along the floor surface on wheels attached moving patients horizontally from one flat surface to an expandable base that can spread around to another (e.g., transfers to/from bed to stretcher chairs/wheelchairs. The lifts are used for patients to exam or treatment table). These devices mini- who can provide some assistance in transferring mize frictional resistance and thus decrease the and ambulating (i.e., those with partial weight- pulling force required to move patients. Some of bearing capability). These patients must also have these devices may also be used for repositioning upper body strength, the ability to grasp with at patients in bed, both up in the bed and laterally least one hand, and the ability to follow simple sideAir-Assisted to side. CurrentlyLateral Transfer available Devices devices fall into instructions. The lifts are used for transfers from one of three categoriesÑair-assisted, mechanical, seated position to seated position (e.g., bed to or friction-reducing lateral transfer devices. wheelchair or commode) and for assistance in dressing, pericare, toileting, and other activities. Sit-to-stand lifts with ambulation capability can Air-assisted lateral transfer devices (Figure C-8) also be used for assistance in patient mobilization float patients on a layer of air from one surface to and ambulation therapy. another and are used not only for lateral transfers Weight capacities range from around 350 lbs. but also for repositioning patients up and from to 1,000 lbs. for bariatric patients, and thus space side to side in bed. The devices consist of a motor- requirements vary with weight capacities and21, 22,the 23 ized blower, hose, and mattress with pin holes on size of the equipment. Obstacles to use of floor- the bottom. The blower forces air into the based lifts include accessibility of the 24,lift, 25 mattress and the air escapes through the holes, time needed to locate and transport the lift to the26, 27 providing a layer of air for ease in sliding patients patient room, and storage requirements. Archi- as well as decreasing shear forces on the patientÕs tectural details such as the28 flooring materials skin. There is some evidence that the decreased and type of threshold impact the ease of use of this shear force on the skin diminishes the occurrence type of rolling equipment. of skin tears associated with manual patient 90 PHAMA: Appendix C

Figure C-9: Mechanical Lateral Transfer Device ©ArjoHuntleigh ©ArjoHuntleigh Figure C-10: Friction- Reducing Devices (FRDs) Slipp® ©Wright Products Inc.

Figure C-11: ransmotion Medical

©T Transfer Chairs

handling. Air-assisted devices also provide excel- down in the bed and/or in a chair/wheelchair. lent reduction in force on the spine of a caregiver. *TFRDsransfer are especially Chairs helpful when inserting and Research*Mechanical in a Lateralmedical29, 30 Transferintensive Devices care setting found removing patient lift slings underneath large this style of lateral transfer device was preferred patients. over other designs.

Mechanical devices (Figure C-9) are powered by Transfer chairs (Figure C-11) are used to elimi- an electric motor or manual crank. They attach to nate the need to perform vertical (seated to a draw sheet or something similar and, when seated) transfers. They convert from a chair posi- energized, pull the patient from one surface to *Non-Poweredtion to a flat (supine) Standing position inAids which the patient another.Friction-Reducing Another variation Devices operates (FRDs) by extending can be laterally transferred to a bed, exam table, a rigid surface under the patient, which is then stretcher, or other table. used to move the patient from place to place.

FRDs (Figure C-10) are very low-friction sheets or Non-powered standing aids are useful for patients membranes that readily slide across other mate-31, 32 who are able to help themselves rise from a sitting rials or each other to decrease frictional to a standing position. The equipment furnishes a resistance when manually sliding a patient. secure, steady handle or something similar for Depending on the type of material, some are used patients to grab onto while pulling themselves up. for lateral transfers and for repositioning patients Some aids may be used without the assistance of a up and side to side in bed. Some are designed with caregiver and therefore facilitate independence one low-friction side and one high-friction side, for the patient. Many styles exist; some are free- which reduces the tendency for patients to slide standing, and some attach to beds. PHAMA: Appendix C 91 ©Stryker Figure C-12: Stretcher ©Dane Industries

Figure C-13: Transport ©ArjoHuntleigh Assistive Device Figure C-14: Ergonomic Shower Chair

Sliding Boards/Devices

this becomes a problem when elevators and door- *Stretchers/Gurneysways are not large enough. (For example, bariatric Sliding boards/devices function to bridge the bed widths can exceed 48Ó and therefore cannot fit space between, for example, a bed and wheelchair through the typical 48Ó-wide hospital door.) or bedside commode. They are used by more independently functioning patients and afford patients a degree of autonomy, since patients can often perform transfers on their own with these Stretchers and gurneys (Figure C-12) with special devices. However, some patients still require care- features can facilitate transporting patients, later- Bedsgiver assistance. The devices are made of a rigid ally transferring patients, lifting patients from the material with a smooth surface for greater ease in floor, and so on. Motorized stretchers or gurneys moving from one place to another. are especially helpful in facilities with walkways of various levels that require caregivers to push up an incline and limit acceleration when pushing down the incline. Special features important to Beds are also considered patient handling tech- reducing risk from patient handling include either nology. They raise and lower patients to motorization or a wheel system that helps move advantageous work heights and can be made co- and maneuver a non-motorized stretcher. A planar with other surfaces onto which a patient is hydraulic lift or some other powered raising and to be laterally transferred. In emergencies, when *Transportlowering mechanism Assistive canDevices also decrease the time is of the essence, they are used for patient ergonomic risk involved in lifting a patient from a transport. low position. Some beds and mattresses have features that provide assistance with patient handling tasks (see sidebar) such as lateral rotation therapy, percussion, and bringing patients to a sitting position. In Transport assistive devices (Figure C-13)33 assist addition, motorized patient beds have become caregivers in pushing heavy rolling objects such as more common. However, the dimensions of many beds, wheelchairs, and heavy equipment. These of these motorized beds and bariatric beds are devices are usually battery-powered and attach to greater than those of standard patient beds, and the equipment, the head of a bed, or the back of a 92 PHAMA: Appendix C

14 Nelson et al. “Development and evaluation of a multifaceted ergonomics program.” 15 Daynard et al., “Biomechanical analysis of peak and cumulative spinal loads during patient handling activities.” 16 M. Matz, “Analysis of VA patient handling and movement injuries and preventive programs” (Internal VHA report to Director, VHA, Occupational Health Program, 2007). Retrieved on 8/30/09 from: wheelchair. To operate them, a caregiver simply http://www1.va.gov/VISN8/PatientSafetyCenter/safePtHandling/Anal steers the device in the right direction. However, ysis_VAPtHndlgInjuries.doc. 17 A. Nelson, G. Fragala & N. Menzel, “Myths and facts about back when the devices are used with a patient bed, they injuries in nursing,” American Journal of Nursing 103, no. 2 (2003): extend the length of the bed, making them of 32–41. 18 Rice et al., “Comparison of required operating forces between floor- limited use when beds must be moved between based and overhead-mounted patient lifting devices.” floors unless a device can be located on each floor 19 Marras et al., “Lumbar spine forces.” where one is likely to be needed. Transport assis- 20 Matz, “Analysis of VA Patient Handling and Movement Injuries and Preventive Programs.” tive devices are especially helpful in facilities with 21 OHSAH, “Ceiling lifts as an intervention to reduce the risk of patient *Ergonomicwalkways of various Shower levels Chairs or whenever care- handling injuries.” 22 Nelson et al. “Development and evaluation of a multifaceted givers must push patients up an incline or limit ergonomics program.” acceleration when pushing down an incline. 23 Daynard et al., “Biomechanical analysis of peak and cumulative spinal loads during patient handling activities.” 24 Nelson et al., “Myths and facts about back injuries in nursing.” 25 Matz, “Analysis of VA Patient Handling and Movement Injuries and Preventive Programs.” 26 Rice et al., “Comparison of required operating forces between floor- These chairs (Figure C-14) position patients so based and overhead-mounted patient lifting devices.” that staff can easily access a patientÕs body areas 27 Marras, “Lumbar spine forces during manoeuvring of ceiling-based and floor-based patient transfer devices.” without squatting or excessive bending. Most 28 Matz, “Analysis of VA Patient Handling and Movement Injuries and ergonomic shower chairs are height adjustable Preventive Programs.” 29 J. Lloyd & A. Baptiste, “Friction-reducing devices for lateral patient andEndnotes can tilt the patient into a reclining position. transfers: A biomechanical evaluation,” American Association of Occupational Health Nurses 54, no. 3 (March 2006):113–19. 1 W. S. Marras, G. G. Knapik & S. Ferguson, “Lumbar spine forces 30 A. Baptiste et al. “Friction-reducing devices for lateral patient trans- during manoeuvring of ceiling-based and floor-based patient fers: A clinical evaluation.” American Association of Occupational transfer devices,” Ergonomics 52, no. 3 (2009): 384–97. Health Nurses 54, no. 4 (April 2006):173-80. 2 M. S. Rice, S. M. Woolley & T. R. Waters, “Comparison of required 31 J. Lloyd & A. Baptiste, “Friction-reducing devices for lateral patient operating forces between floor-based and overhead-mounted transfers: A biomechanical evaluation.” patient lifting devices,” Ergonomics 52, no. 1 (2009): 112–20. 32 Baptiste et al., “Friction-reducing devices for lateral patient trans- 3 P. L. Santaguida, M. Pierrynowski, C. Goldsmith & G. Fernie, fers: a clinical evaluation.” “Comparison of cumulative low back loads of caregivers when 33 AORN, Safe Patient Handling and Movement in the Perioperative transferring patients using overhead and floor mechanical lifting Setting, Associaion of periOperative Nurses. devices,” Clinical Biomechanics 20 (2005): 906–16. 4 A. Nelson, J. Lloyd, C. Gross & N. Menzel, “Preventing nursing back injuries,” AAOHN Journal 51, no. 3 (2003): 126–34. 5 Santaguida et al., “Comparison of cumulative low back loads of caregivers.” 6 Occupational Health & Safety Agency for Healthcare (OHSAH) in British Columbia, “Ceiling lifts as an intervention to reduce the risk of patient handling injuries: A literature review” (Vancouver, BC, 2006). Retrieved on 7/30/09 from http://control.ohsah.bc.ca/media/ Ceiling_Lift_Review.pdf#search=%22b%20owen%2C%20patient% 20lifts%20ratio%22. 7 A. L. Nelson, M. Matz, F. Chen, K. Siddharthan, J. Lloyd & G. Fragala, “Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks,” Journal of International Nursing Studies 43 (2006): 717–33. 8 D. Daynard, A. Yassi, J. E. Cooper, R. Tate, R. Norman & R. Wells, “Biomechanical analysis of peak and cumulative spinal loads during patient handling activities: A sub-study of a randomized controlled trial to prevent lift and transfer injury health care workers,” Applied Ergonomics 32 (2001): 199–214. 9 Nelson et al. “Development and evaluation of a multifaceted ergonomics program.” 10 OHSAH, “Ceiling lifts as an intervention to reduce the risk of patient handling injuries.” 11 Santaguida et al., “Comparison of cumulative low back loads of caregivers. 12 Daynard et al., “Biomechanical analysis of peak and cumulative spinal loads during patient handling activities.” 13 OHSAH, “Ceiling lifts as an intervention to reduce the risk of patient handling injuries.” APPENDIX D Sling Selection Chart

Activity Sling Criteria Special Considerations Choices

Vertical transfers SEATED Patient can tolerate sitting I Consider presence of wounds for (To/from bed/ position and has adequate hip sling application and patient wheelchair/ and knee flexion. positioning. commode/ I Consider precautions of total hip dependency replacement patients. chair/etc.) STANDING Patient can grasp and hold I Consider presence of wounds for handle with at least one hand, sling application and patient has at least partial weight- positioning. bearing capability, has upper body strength, and is cooperative and can follow simple commands.

Lateral transfers SUPINE Patient cannot tolerate sitting I Do NOT use if patient has (To/from bed/ position and has restricted hip respiratory compromise or if stretcher/shower and/or knee flexion. Patient can wounds present may affect trolley/gurney) tolerate supine position. transfers/positioning.

Bathing SUPINE Patient cannot tolerate sitting I Do NOT use if patient has position and has restricted hip respiratory compromise or if and/or knee flexion. Patient can wounds present may affect tolerate supine position. transfers/positioning. SEATED Patient can tolerate sitting I Consider presence of wounds for position and has adequate hip sling application and patient and knee flexion. positioning. I Consider precautions of total hip replacement patients. LIMB Sustained holding of any I Consider wounds, comfort, SUPPORT extremity while bathing in bed. circulation, neurovascular and joint conditions, if task is of long duration.

Toileting SEATED Patient can tolerate sitting I Consider presence of wounds for position and has adequate hip and sling application and patient knee flexion. positioning. I Consider precautions of total hip replacement patients. STANDING Patient can grasp and hold handle I Consider presence of wounds for with at least one hand, has at least sling application and patient partial weight-bearing capability, positioning. has upper body strength, and is cooperative and can follow simple commands.

Repositioning SEATED Patient can tolerate sitting position I Consider presence of wounds in chair and has adequate hip and knee for sling application and patient flexion positioning. I Consider precautions of total hip replacement patients. 94 PHAMA: Appendix D

Activity Sling Criteria Special Considerations Choices

Repositioning SUPINE Patient cannot tolerate sitting I Do NOT use if patient has up in bed position and has restricted hip respiratory compromise or if and/or knee flexion. Patient can wounds present may affect tolerate supine position. transfers/positioning. SEATED Patient can tolerate sitting position I Consider presence of wounds and has adequate hip and knee for sling application and patient flexion. positioning. I Consider precautions of total hip replacement patients. REPOSITIONING Patient can tolerate supine position. I Do NOT use if patient has respiratory compromise or if wounds present may affect transfers/positioning.

Turning a SUPINE Patient cannot tolerate sitting I Do NOT use if patient has patient in bed position and has restricted hip respiratory compromise or if and knee flexion. Patient can wounds present may affect tolerate supine position. transfers/positioning. REPOSITIONING Patient can tolerate supine position. I Do NOT use if patient has respiratory compromise or if wounds present may affect transfers/positioning.

Making an SUPINE Patient cannot tolerate sitting I Do NOT use if patient has occupied bed position and has restricted hip respiratory compromise or if and/or knee flexion. Patient can wounds present may affect tolerate supine position. transfers/positioning. SEATED Patient can tolerate sitting position I Consider presence of wounds and has adequate hip and knee for sling application and patient flexion. positioning. I Consider precautions of total hip replacement patients.

Functional STANDING Patient can grasp and hold handle I Consider presence of wounds sit-stand with at least one hand, has at for sling application and patient training/support least partial weight-bearing positioning. capability, has upper body strength, and is cooperative and can follow simple commands.

Dressing STANDING Patient can grasp and hold handle I Consider presence of wounds with at least one hand, has at least for sling application and patient partial weight-bearing capability, positioning. has upper body strength, and is cooperative and can follow simple commands. LIMB Sustained holding of any extremity I Consider wounds, comfort, SUPPORT while dressing in bed. circulation, neurovascular and joint conditions, if task is of long duration.

Pericare STANDING Patient can grasp and hold handle I Consider presence of wounds with at least one hand, has at least for sling application and patient partial weight-bearing capability, positioning. has upper body strength, and is cooperative and can follow simple commands. PHAMA: Appendix D 95

Activity Sling Criteria Special Considerations Choices

Ambulation WALKING Partial weight-bearing, level of I Do NOT use if wounds present training cooperation, consult doctor that affect transfers and and support and/or therapist for readiness. positioning. STANDING Patient can grasp and hold handle I Consider presence of wounds for with at least one hand, has at least sling application and patient partial weight-bearing capability, positioning. has upper body strength, and is cooperative and can follow simple commands.

Wound LIMB Sustained holding of any extremity I Consider wounds, comfort, care/dressing SUPPORT while dressing/caring for wounds circulation, neurovascular and while patient in bed. joint conditions, if task is of long duration.

Surgical LIMB Sustained holding of any extremity I Consider wounds, comfort, procedures SUPPORT while performing surgical circulation, neurovascular and procedure in bed. joint conditions, if task is of long duration.

Fall rescue SUPINE Patient cannot tolerate sitting I Do NOT use if patient has position and has restricted hip respiratory compromise or if and/or knee flexion. Need for wounds present may affect patient to remain flat. Patient can transfers/positioning. tolerate supine position. SEATED Patient can tolerate sitting position I Consider presence of wounds for and has adequate hip and knee sling application and patient flexion. positioning. I Consider precautions of total hip replacement patients.

Adapted from A. Baptiste, M. McCleery, M. Matz & C. Evitt, “Evaluation of sling use for patient safety,” Rehabilitation Nursing (Jan.–Feb. 2008). APPENDIX E Patient Care Ergonomic Evaluation Process

Please note:

1. It is important to conduct a PCE evaluation for all areas in which patient handling occurs: The patient care ergonomic (PCE) evaluation critical care units, medical/surgical units, radi- process is used to pull together information that ology/MRI/CT/nuclear medicine suites, can facilitate accurate purchase decisions for therapy areas, labor/delivery suites, outpatient patient handling equipment as well as generate clinics, treatment areas, procedure areas, dial- recommendations for changes in policies and ysis, the morgue, pediatric locations, nursing homes, etc. procedures to improve the safety of the patient 2. PCE data collected from each area/unit must care work environment. The following process is be analyzed separately so that specific Introductionadapted from one to developedErgonomics by Guy Fragala, PhD, recommendations for each may be generated. CSP. Other variations are available (see resources listed at the end of this appendix). I

To understand why an ergonomicHuman evaluation Factors for is 2. Evaluate the workplace environment: Informaticsnecessary, a Usability brief introduction to ergonomics may Review the design of the physical work be helpful. Simply put, ergonomics is the study of I environment and identify ways to reduce work. More completely defined by Brian Shackel risk, remove barriers, minimize travel, etc. and Simon Richardson in 3. Evaluate other factors that may influence , it is the scientific study of the ergonomic risk: relationship between people and the work they Consider other factors that affect work do (occupation/job), the tools (equipment) they performance, such as lighting, noise, equip- use in their jobs, and the characteristics of the ment storage, and maintenance issues, and environment in which they work (workplace). The determinePatient Car howe toErgonomics address their ergonomic When any of these aspects of a personÕs job/tasks Evaluationrisks. Process affects his or her musculoskeletal system, an 4. Implement changes in the workplace. ergonomic hazard is present. Ergonomic hazards are those stressors, forces, and loads that impact the musculoskeletal system. When the forces exceed the bodyÕs biomechanical or physiological limits, injury occurs. TheBefore PCE the evaluation Ergonomic has Site three Visit phases: (1) before, Ergonomics provides a step-by-step approach (2) during, and (3) after the unit ergonomic site for ensuring that appropriate technology is in visit. place to reduce musculoskeletal stress and strain and thus to reduce the risk of injury. The following outline,I based on one developed by Guy Fragala, Collect data that will be used to give a snapshot of PhD, CSP, briefly lays out an ergonomic approach the ergonomic issues of each unit/area, confirm to decreasingI the risk of injury. information gathered during the site visit, and 1. Evaluate jobs and tasks performed: make recommendations to decrease ergonomic Identify jobs and job tasks that stress body risk. Begin gathering this information at least one parts beyond limits. month prior to the site visit and submit informa- Develop solutions to change the demands of tion at least one week before the site these tasks. visit/walk-through takes place. PHAMA: Appendix E 97

DevelopI lists of the following information DocumentI the results of interviews and obser- before the site visit: vations. (See Appendix F: Patient Care High-risk tasks performed on the unit. High- ErgonomicI Evaluation, Staff Interview riskI tasks can be determined by Template.)I Surveying staff for their perceptions of the Existing/ordered patient handling unitÕs high-risk tasks (See Tool 1: Perception I equipment I of High- Risk Task Survey in Appendix H.) I Occurrence of high-risk tasks Analyzing unit injury data (See Tool 2: I % total dependent and extensive assistance Unit/Area Incident/Injury Profile in patients, % partial assistance patients Appendix H.) I Occurrence of bariatric/obese patients Unit/areaI characteristics/issues relevant to I Room configurations ergonomicI risk and actions to reduce it (See I Number of beds on the unit and average AppendixI H: Clinical Unit/Area Characteristics daily census andI Ergonomic Issues Survey.) After Storagethe Ergonomic issues Site Visit I Space Other pertinent information I Storage Equipment/sling recommendations Equipment maintenance/repair DuringPatient the Ergonomic population Sitecharacteristics Visit Staffing characteristics Analyze information collected during the previous I Equipment inventory two phases, and use the results to generate equip- mentI recommendations. For a comprehensive PCE evaluation, prepare a report that covers the The following activities take place: followingI categories, if appropriate for the Interview staff to confirm data collected prior unit/area:I I to the site visit and discover staff attitudes, Patient handling equipment and sling concerns, ideas, information. (See Appendix F: recommendationsI PatientI Care Ergonomic Evaluation, Staff Inter- I Storage recommendations view Template.)I Recommendations to alter design features ObserveI the physical characteristics of the that impact patient handling and movement unit/area.I I Repair/maintenance process recommendations EquipmentI Recommendations for facilitating injury I Availability reporting and the capture and analysis of I Accessibility I injury data I Use Suggestions for improving the facility I Storage location(s) and capacity patient handling and movement program I Condition (PHAMP) I Structural issues that affect use Methods for improving the facility bariatric I Patient room and toilet room program I Sizes/configurations Ceiling characteristics I Location of AC vents/TVs/sprinklers I Showering/bathing facilities I Safety design issues (e.g., thresholds, doorways) Note the way tasks are performed. Showering/bathing process Toileting process APPENDIX F Patient Care Ergonomic Evaluation Staff Interview Template Date: Facility: F .Appendix (dependent/extensive- (partial-assistancepatients) up to head of bed W. Matzrev. 12/09 Unit/Description: Verticaltransfers/lifts Verticaltransfers/lifts Ambulationtraining Transportation Lateraltransfers to side side Repositioning Pulling Repositioningin chair Wound care Tedhose application Toileting Showering/bathing #beds: ____ Averagecensus:_____ bariatric:_____ % Room ______Storage: ______configurations: total % dependent/extensive assistance:_____ Notes: %total partial assistance:______M. assistancepatients) APPENDIX G Equipment Evaluation and Selection Process

Note: Much of the information contained in this appendix either reflects lessons learned from VHA experience in conducting equipment evaluations or is taken from Ergonomics Technical The first stage in the evaluation and selection Advisory Group, Patient Care Ergonomics process for patient handling and movement Resource Guide: Safe Patient Handling and (PHAM) equipment is to review and screen poten- Movement, A. Nelson, ed. (Tampa: Veterans Administration Patient Safety Center of Inquiry, tial products for the desired purpose. Review 2001), available at www.visn8.va.gov/ product information from the manufacturer for PatientSafetyCenter/safePtHandling. each product under consideration, and then contact those manufacturers of interest to ask whether they have or know of information on prior or current clinical or lab evaluations. If the product manufacturer performed the evaluation, look at the findings carefully, as they may be biased. A literature search may unearth more specific patient populations, ease of maintenance information related to each product and company and repair, and the cost-benefit of purchasing of interest. Limiting the number of competitive such equipment. products to three to five will make it easier to do a Clinical trials test equipment in a clinical unit or thorough search. area. The product is installed or loaned to the Bring purchasing in early in the process to area/unit for a period of time. During this time, assist in the above tasks as well as with perform- staff members are trained on the equipment, then anceI or cost of operation measures related to the use it with patients/residents. After a period of equipment or the vendor. use, staff and patients or residents offer their I Performance measures considered by thoughts on the equipment verbally or through purchasingI staff include the following: specially designed product-rating surveys. Special features of the product not offered by (Sample surveys can be found on pages 6Ð7 of this I comparable products appendix.) I Trade-in considerations An equipment fair may be an all-day event held I Probable life of the product compared to on site in a large hall/auditorium so that many I similar products vendors may display their products, or it may be a Warranty considerations smaller event focusing on one category of patient Maintenance requirements and availability handling equipment. For each event, as many Past performance nursing staff as possible should come to try out Environmental and energy-efficiency the equipment under scrutiny. Housekeeping, considerations maintenance, and other staff whose work may be After representative equipment and vendors impacted by the equipment should also be invited have been selected, it is important to give front- to evaluate it. As with the clinical trials, staff line staff an opportunity to try out the equipment. should be asked to offer their thoughts after using Therefore, the second stage of the equipment the equipment, usually on product rating surveys evaluation and selection process is to give front- developed or modified to suit a particular facilityÕs line staff an opportunity to actually use and needs. If purchase is for long-term care facilities, evaluate the equipment. Equipment clinical trials physically and cognitively alert residents may also and equipment fairs can provide information to be asked to rate equipment and complete a help compare the safety and usability of products survey. (See examples on pages 94Ð95.) and determine equipment appropriateness for 100 PHAMA: Appendix G

Criteria for Selection of Lifting and Transferring Devices

Equipment chosen should have the following Vendors selected were required to bring characteristics: only the requested product(s). I It is appropriate for the task to be b. Approximately 15 pieces of equipment were accomplished. I It is safe for both the patient and the care- selected for the equipment fair. Vendors giver. The device must be stable and strong were contacted individually, told what items enough to secure and hold the patient. Use to present, and given a point of contact for of the device should not subject caregivers 2. Coordinateeach facility. site logistics.No participation fees were to excessively awkward postures or high solicited from the vendors, but travel costs exertion of forces when gripping or operating equipment. were borne by the vendor. I Use of the equipment is comfortable for the patient. It should not produce or intensify pain, contribute to bruising of the skin, or a. The event was held at seven sites within a tear the skin. two-week period. Dates were chosen to I The equipment can be managed with relative ease. In addition, instructions for its use accommodate individual facility needs and should be relatively easy to understand. given to the vendors. All vendors chose to I Its use is efficient time-wise. participate. I The equipment requires minimal b. One individual in each facility was selected to maintenance. coordinate the logistics for the fair at that I It has reasonable storage requirements. I It can be maneuvered in a confined work- location, including communication with space. 3. Promotevendors the about event. their setup needs, arrange- I It is versatile. ments for space, safety issues, and promotion I It is easy to clean and comply with infection of the event. control requirements. I It is purchased in adequate numbers so that accessibility is not an issue. I It is affordable. a. Various modes of communication were employed to promote the event, including Adapted from A. Nelson, ed., Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement, Chapter 12 (Tampa: e-mail, promotional posters, discussion at nurse Veterans Administration Patient Safety Center of Inquiry, 2001). staff meetings, and education of key personnel. b. Key personnel contacted included nurse Equipment Fair Lessons Learned managers, safety personnel, occupational health staff, nurse educators, union representatives, back injury resource nurses, engineering staff, and administrators. c. The event was promoted to all staff and emphasized in high-risk patient care units. To ensure an equipment fair conducted as part of (A high-risk unit is defined as an inpatient its effort was successful, the VHA Safe Patient hospital unit with a high proportion of Handling and Movement Research Project engaged dependent patients with frequent moves in many individuals in a collective effort. Preplanning and out of bed. It includes long-term nursing and coordination of multiple facilities, vendors, and and spinal cord care units.) staff1. Select members equipment were requiredand participating to orchestrate vendors. the d. In an effort to entice participation, compensa- event. Following is an outline of the steps the VHA tion time was offered to high-risk nursing staff took to prepare for and conduct the fair: who did not work during event hours. Nurse managers were encouraged to offer nursing staff time away from the unit to participate. a. A panel of experts in the field of safe patient e. In most facilities, one hour of patient safety handling and movement selected equipment training was awarded to participants. for inclusion based on a literature review Education sign-in sheets were made avail- and their familiarity with the product. able at the site. PHAMA: Appendix G 101

4. Conduct the event on the designated day.

Site Coordinator Instructions making sure the surveys are distributed, filled a. Most of the sites held the event between the out, and collected follow. hours of 7 a.m. and 4 p.m. This afforded all three nursing shifts the opportunity to participate. A simple questionnaire has been prepared to b. VHA police were notified of the activity in assist in decision-making with respect to safe advance. Vendor setup time was patient handling technologies for our facility. prearranged with the site coordinator and Please express to nurse managers/supervisors averaged 1.5 hours. Five of the facilities held and staff how important their cooperation is in the event in a large auditorium; the other completing these questionnaires. Purchasing two used vacant patient rooms. decisions for our facility will be greatly influenced c. The facility site coordinator or a designee by staff preferences. Therefore, the more staff was responsible for coordinating events members who participate in the equipment fair throughout the day. and complete these questionnaires, the more reli- d. A member of the research projectÕs core able the decisions will be. team was present to facilitate the evaluation Please ensure there aresite enough coordinator copies of theor 5. Conductprocess the and equipment to ensure survey the vendors during thedid fair.not designeeevaluation before form so that all staff can evaluate each distract VHA staff members from completing piece of equipment, probably [insert your the evaluation process. number] products in all. Completed formsclinical should unit/areabe handed back to the staff members leave the equip- a. Participants were asked to fill out an equipment demonstration hall. ment rating survey for each piece of Evaluation forms must be collated by equipment. The survey sought to identify the . equipment preferences and needs of the You will probably be asked about the outcome specific facility through a rating system ofClinical the survey. Unit/Area Inform Nurse staff how the survey will be based on five questions related to patient analyzedManager/Supervisor and that cost Instructions factors will also help deter- care. (See forms on pages 92Ð95.) mine equipment selection. b. All facility staff members were allowed to complete the survey. 6. Collatec. High-risk and analyzeunit nursing the survey staff members results. were directed to complete a color-coded survey The Safe Patient Handling Equipment Day will be packet and to place it in a designated area. here soon. In preparation for this, we have developed a simple questionnaire to assist in decision-making with respect to safe patient a. Equipment rating surveys were forwarded handling technologies for our facility. (Please to staff for analysis. review, discuss with staff, and post so they will be b. Equipment purchasing decisions were to be aware of what they will be asked to comment on.) Equipmentbased on Rating the survey Surveys data, specific facility Please express to your staff how important needs identified through on-site ergonomic their cooperation is in completing these question- analysis, and cost considerations. naires. Purchasing decisions for our facility will be greatly influenced by staff preferences. Therefore, the more staff members who participate in the equipment day and completebefore these question- At the end of this appendix are two sample naires, the more reliable the decisions will be. equipment evaluation questionnairesÑone for Completed forms should be handed back to the staff members and one for patients or residents Safe Patient Handling and Movement Project site of the facility. Instructions for staff members coordinator or designee staff members who have been assigned the responsibility for leave the equipment hall. 102 PHAMA: Appendix G

Product Feature Rating Survey (Caregiver)—Individual Product Form

Caregiver #: ______Product #: ______Date: ______

Please examine the product very carefully and answer the following questions as they relate to this product ONLY. Answer each question using a scale from 0 to 10 by circling the number that matches your impression, where 0 indicates a very poor design and 10 indicates a very well-designed feature.

WeHow encourage would you you rate to yourexpress OVERALL any ideas COMFORT you may havewhile for using improving this product? the product design. Please make your comments alongside the appropriate feature rating.

Very0 1 2 3 4 Average 5 6 7 8 9 Very 10 Poor Good What is your impression of this product’s OVERALL EASE OF USE?

Very0 1 2 3 4 Average 5 6 7 8 9 Very 10 Poor Good How EFFECTIVE do you think this product will be in reducing INJURIES?

Very0 1 2 3 4 Average 5 6 7 8 9 Very 10 Poor Good How EFFICIENT do you feel this product will be in use of your TIME?

Very0 1 2 3 4 Average 5 6 7 8 9 Very 10 Poor Good How SAFE do you feel this product would be for the PATIENT?

Very0 1 2 3 4 Average 5 6 7 8 9 Very 10 Poor Good PHAMA: Appendix G 103

Product Feature Rating Survey (Caregiver)—Comparison Form

Caregiver #: ______Date: ______

Please look at each of the products you have just used. Rank each of these products in order of preference. Place the letter assigned to each product (AÐE) alongside the rank order you feel is most appropriate,Overall comfort: where 11: is ______your most 2: preferred ______design 3: ______and 5 is your4: ______least preferred 5: ______design. Note any comments you may have in the space provided. [Note: This form can be revised if more or fewer than five products are being evaluated.]

Comments:Ease of use: ______1: ______2: ______3: ______4: ______5: ______

Comments:Stability: ______1: ______2: ______3: ______4: ______5: ______

Comments:Durability: ______1: ______2: ______3: ______4: ______5: ______

Comments:Versatility: ______1: ______2: ______3: ______4: ______5: ______

Comments: ______104 PHAMA: Appendix G

Product Feature Rating Survey (Patient)—Individual Product Form

Patient #: ______Product #: ______Date: ______

This questionnaire examines ONLY the product you have just used. Please rate each of the following design features on a scale from 0 to 10 by placing a mark along the line, where 0 indicates a very poor design and 10 indicates a very well-designed feature. Overall comfort We would appreciate hearing any ideas you may have for improving the product design. Please make your comments beside the appropriate feature rating or on the overleaf if you need more space.

Very0 1 2 3 4 Average 5 6 7 8 9 Very 10 Poor Good Security

Very0 1 2 3 4 Average 5 6 7 8 9 Very 10 Poor Good Safety

Very0 1 2 3 4 Average 5 6 7 8 9 Very 10 Poor Good Other relevant feature

Very0 1 2 3 4 Average 5 6 7 8 9 Very 10 Poor Good PHAMA: Appendix G 105

Product Ranking Survey (Patient)—Product Comparison Form

Patient #: ______Date: ______

Please look at each of the products you have just used. Rank each of these products in order of preference.Overall Place comfort: the letter 1: assigned______to 2:each ______product 3: (AÐE) ______alongside 4: ______the rank 5:order ______you feel is most appropriate, where 1 is your most preferred design and 5 is your least preferred design. Note any comments you may have in the space provided.

Comments:Security: ______1: ______2: ______3: ______4: ______5: ______

Comments:Safety: 1: ______2: ______3: ______4: ______5: ______

Comments:Other relevant ______feature: 1: ______2: ______3: ______4: ______5: ______

Comments: ______APPENDIX H Clinical Unit/Area Characteristics and Ergonomic Issues Survey

Type of Unit/Area: ______Facility: ______

PART 1—SPACE/MAINTENANCE/STORAGE

a. Describe unit, including number of beds, room configurations (private, semi-private, 4-bed, etc.), and toilet rooms:

# rooms w/ 2 beds: ______w/ 3 beds: ______w/ 4 beds: ______private: ______

Toilet rooms: In room?____ Community? ____ Use tub? ____ Bathing chair? ____ Other? ____ b. Describe current storage conditions and problems you have with storage. If new equipment were purchased, where would it be stored?

c. Identify anticipated changes in the physical layout of your unit, such as planned unit renovations in next two years. Are typical room doorways narrow or wide? Is the threshold uneven? d. Describe space constraints for patient care tasks and use of portable equipment; focus on patient rooms, toilet rooms, shower/bathing areas.

Is equipment on a PM schedule? e. Describe any routine equipment maintenance program or process for fixing broken equipment. What is the reporting mechanism/procedure for identifying, marking, and getting broken equipment to shop for repair?

f. If the potential for installation of overhead lifting equipment exists, describe any structural factors that may influence this installation, such as structural load limits, lighting fixtures, AC vents, the presence of asbestos, etc. PHAMA: Appendix H 107

PART 2—STAFFING

a. Peak lift load times (Think about the time of day thatÕs the busiest. What is the number of staff that would be lifting at same time?):

b. Discuss projected plans or upcoming changes in staffing, patient population, or bed closures in the PARTnext 3—PATIENTS/RESIDENTStwo years.

a. Describe the average patients/residents on your unit (hospice, Alzheimer, TBI, etc.) and variability in this.

b. Discuss proposed changes in the average daily census over the next two years. (Base on physical limitations, not on clinical acuity.)

Table H-1: Physical Dependency Levels of Patient Population* c. IdentifyTotal typical dependence: distribution (%) of patients by physical dependency level according to the definitions below. Extensive assistance:

______Cannot help at all with transfers, full staff assistance for activity during entire seven-day period. Requires total transfer at all times. ______Limited assistance: Can perform part of activity, usually can follow simple directions, may require tactile cueing, can bear some weight, sit up with assistance, has some upper body strength, or may be able to pivot transfer. Over the last seven-day period, help provided three or more times for weight-bearing transfers or may have required a total transfer. ______Supervision: Highly involved in activity, able to pivot transfer, and has considerable upper body strength and bears some weight on legs. Can sit up well, but may need some assis- Independent:tance. Guided maneuvering of limbs or other non-weight-bearing assistance three or more times, or help provided one or two times during the last seven days. ______Oversight, encouragement, or cueing provided three or more times during the last

*This table isseven excerpted days from or Patient physical Care Ergonomics assistance Resource provided Guide: Safe only Patient one Handling or two and timesMovement during the last seven days. ______(www.visn8.va.gov/PatientSafetyCenter/safePtHandling).Can ambulate normally without assistance, but in unusual situations may need some limited assistance. Help or oversight may have been provided only one or two times in the lastall seven days.

d. Have staff complete (collated by unit and shift) Tool 1: Perception of High-Risk Task Survey. 108 PHAMA: Appendix H

PART 4—PATIENT HANDLING INJURIES

PART 5—EQUIPMENT Have each unit complete Tool 2: Unit/Area Incident/Injury Profile.

a. Use Tool 3: Unit Patient Handling Equipment Inventory to provide an inventory of all patient care equipment. This should include a description of the working condition of each piece of equipment and how frequently it is used.

b. What percentage of high-risk tasks is completed using proper equipment? Why?

c. Identify your problem areas.

d. What equipment do you think you need?

Person completing report:

______Name Date Patient Care Ergonomics______Resource Guide: Safe Patient Handling and Movement Title Phone #

(This survey form is a revision of Figure 3-3: Pre-Site Visit Unit Profile in A. Nelson, ed., Chapter 4, p. 24 (Tampa: Veterans Administration Patient Safety Center of Inquiry, 2001). Available at www.visn8.va.gov/PatientSafety Center/safePtHandling.) PHAMA: Appendix H 109

Tool 1: Perception of High-Risk Tasks Survey

Directions: Assign a rank (from 1 to 10) to the tasks you consider to be the highest risk tasks contributing to musculoskeletal injuries for persons providing direct patient care. (A 10 should represent the highest risk and a 1 the lowest.) Consider the frequency of the task (high, moderate, low) and Patientthe musculoskeletal Handling Tasks stress (high, moderate, low)Task when Frequency assigning a Stressrank. ofDelete Task tasks Rank not typically performed on your unit. You can have each nursingH staff = high member completeH = high the form and summarize10 = highest risk the M = moderate M = moderate 1 = lowest risk data, or you can have staff work together by shift toL = develop low the rank Lby = lowconsensus.

Transferring patient from bathtub to chair Transferring patient from wheelchair or shower/commode chair to bed Transferring patient from wheelchair to toilet Transferring patient from bed to stretcher Lifting patient up from the floor Weighing patient Bathing patient in bed Bathing patient in a shower chair Bathing patient on a shower trolley or stretcher Undressing/dressing patient Applying anti-embolism stockings Lifting patient to the head of the bed Repositioning patient in bed from side to side Repositioning patient in geriatric chair or wheelchair Making occupied bed Feeding bedridden patient

AdaptedChanging from B.absorbent D. Owen & A. pad Garg, AAOHN Journal 39, no. 1 (1991). Transporting patient off unit Other task: 110 PHAMA: Appendix H

Tool 2: Unit/Area Incident/Injury Profile days 4 days ______No ______Patientroom d: ______te le p m o c ! te nit: ______U _ Da Shoulder ______S/S " ______

pulling hurts hurts ______Reaching, night— all residents shoulder d: ______lude s inc lity: ______e i t c a a (side Repositioning to side) F D ______#1 Cause: #1 Activity: ______Modified duty trend? ______#2 Cause: #2 Activity ______Lost time trend? PHAMA: Appendix H 111

Tool 3: Unit Patient Care Equipment Inventory

Patient Care Manufacturer/ Inventory # in % Being # Equipment Style/Name Working Used NowRequested Order Unit:______Facility:______Date completed:______FULL-BODY SLING LIFTS (Total # in (e.g., Arjo Maxi Move) unit now) (Comment) powered non-poweredFloor-based, lifts (e.g., Arjo Maxi Move) Ceiling-mounted Floor-based, lifts Bathing(e.g., Hoyer) lifts (e.g.,LATERAL BHM Voyager) TRANSFER AIDS lifts Mechanical

Friction-reducinglateral transfer aids (e.g., Mobilizer, TotaLift II, On-3) Air-assisted lateral sliding aids (e.g., Sliding/Surf Boards, RTA, Phili slide) OTHER EQUIPMENTlateral transfer aids (e.g., AirPal, Hovermat)

Transfer chairs (e.g., Transitchair) Dependency chairs (e.g., Broad, Geri-Chair) Powered standing assist and repositioning lifts (e.g., Translift, Raisa Lift) Standing assist and repositioning aids (non-powered) (e.g., Super/Pivot Pole, Bed-Bar) Gait belts (with handles) Other APPENDIX I Ceiling Lift Coverage Recommendations by Clinical Unit/Area

Step 2:

Determining ceiling Ceiling lift Lift coverage for clinical Determine the number and configuration units/areasCoverage canUsing be accomplished the Table by using Table I- of rooms requiring ceiling lift systems per unit. 1 and/or by calculation (see second head below). ForUse unitsthe w/average only private percentage patient rooms: of patients requiring ceiling lift coverage to calculate the number of rooms needing ceiling lifts:

Table I-1 can be used to make ceiling lift coverage recommendations that stipulate the percentage of ForNumber units with of patients only semi-private rooms: Calculatingpatients who should Ceiling be covered Lift Coverage on a particular unit x Average % patients requiring ceiling lifts or area. Remember, insufficient coverage will result Number of private patient rooms with ceiling lifts in increases in the risk of staff and patient injury.

Number of patients divided by 2 (Use only for units/areas assigned ranges of Forx Average units with % patients a mix of requiringroom configurations: ceiling lifts coverage in Table I-1.) Number of semi-private patient rooms with ceiling lifts Because the patient characteristics of clinical units/areas vary widely, it is critical to base ceiling lift purchase decisions on these characteristics. Unit For cost-effectiveness in existing construction, ceiling lift coverage is based on the type of unit/area; and if appropriate for the unit, begin calcula- Note:the dependency levels of the patient/resident popu- tions with ceiling lifts placed in most or all lation; and the number of private, semi-private, Examplargerle: wards (three- and four-bed wards), then three-bed, or four-bed rooms on the unit. as appropriate in smaller rooms (private and semi-private). Step 1:Patient dependency level is based on physical limitations and dependency. It is not the same This sample calculation is for a as clinical acuity or patient acuity. medical/surgical unit that accommodates 30 patients and has four private rooms, 10 semi- Determine the average percentage of private rooms, and two three-bed rooms. patients requiring ceiling lift system coverage. Approximately 70 percent of the patients on the unit will require the use of ceiling lifts. There- Add the average percentage of totally fore, the unit should have coverage for 21 dependent patients on the unit to the average patients (70 percent x 30 patients). For cost- percentage of patients needing extensive assis- effectiveness, and if appropriate for unit needs, tance. (Use Table H-1: Physical Dependency ceiling lift coverage may be as follows: ceiling Levels of Patient Population in Appendix H to lifts in two three-bed rooms (covering 6 determine the numbers of patients at each patients), seven semi-private rooms (covering dependency level on the unit; the total for the 14 patients), and one private room (covering one five categories should equal 100 percent.) patient) in order to have ceiling lift coverage for 21, or 70 percent, of the patients. Average % totally dependent patients on unit + Average % extensive assistance patients on unit Average % patients requiring ceiling lift coverage PHAMA: Appendix I 113

Table I-1: Ceiling Lift Coverage Recommendations by Clinical Unit/Area

CLINICAL UNIT/AREA CEILING LIFT PATIENT/BED PREFERRED TRACK COVERAGE CONFIGURATION

(BasedMedical/surgical on Veterans unit Health Administration50–100%* patient populations) Traverse Post-surgical unit 50–100%* Traverse Provide one supine sling and hanger bar system for unit. Rehab unit 50–100%* Traverse Consider installing straight (If unit is primarily neuro rehab, track down hallway for provide a minimum of 70% coverage.) ambulating patients. Provide one supine sling and (For new construction or rooms large hanger bar system for unit. enough for ambulation within rooms, provide 100% coverage to assist in gait training, etc.) MICU 100% Traverse SICU 100% Traverse CCU 50% Traverse or straight ICU (Combined 100% Traverse MICU/SICU/CCU) Nursing home/long-term care 70–100%* Traverse (Less coverage may be provided (Into bathroom) for primarily dementia units.) Hemodialysis 50–100%* Straight or traverse (Ceiling lift coverage is needed (One straight track over several over areas where lateral transfers bays in a row would be from stretchers or inpatient beds appropriate.) to dialysis beds occur.) Radiology (X-ray, CT, etc.) 50% Traverse or straight (Overhead/ceiling lift system must be compatible with ceiling- mounted radiological equipment. Careful coordination is required to avoid conflicts between ceiling lift tracks and gantries in radiology rooms with traverse ceiling- mounted equipment.) MRI 100% Straight (Located in adjacent MRI patient transfer area) Nuclear medicine 50% Procedure areas 100% 100% (GI, cystoscopy, etc.) (Positioned as needed) Cath lab 100% Traverse or straight PACU 100% Straight (If possible, extended over all beds in a row using one lift system per row) 114 PHAMA: Appendix I

CLINICAL UNIT/AREA CEILING LIFT PATIENT/BED PREFERRED TRACK COVERAGE CONFIGURATION

Operating room 100% Traverse (Ceiling- or wall-mounted equipment in ORs requires careful coordination between lift tracks, traversing lift motors, and other equipment suspended from or mounted on ceilings and walls.) Physical therapy clinics 100% Preferred design: Traverse system covering the entire area possibly using two or more motors simultaneously (on the parallel bars and at any treatment tables) Alternate design: Straight track installed over parallel bars, traverse track system covering treatment tables and activity areas Spinal cord injury 100% Traverse into bathroom Outpatient SCI clinic 100% Traverse exam/treatment rooms Outpatient/primary care clinics Depending on patient population, Traverse one or more regular and/or one expanded capacity/bariatric lift Emergency department 50–100%* Preferred design: Traverse over Urgent care exam rooms multiple bays in a row or in Provide one supine sling and private rooms hanger bar system for unit. Alternate design: Straight track over several bays in a row or in private rooms Ambulance bay Depending on patient population, Traverse one regular or one expanded (Ensure proper coordination of capacity/bariatric lift under canopy ceiling lift track with entrance doorways.) in ambulance bay Dental Depending on patient population, Straight or traverse one regular and/or one expanded capacity/bariatric lift Pediatrics 20% Traverse Morgue 100% Traverse or straight (Expanded capacity lift with minimum (Lift system should be able to assist in weight capacity of 600 lbs. or greater inserting and extracting trays into depending on patient population cooler as well as lifting and moving characteristics. Include supine lift bodies into and within autopsy suite.) frame in purchase.) Nurse training area One Straight

*For those clinical units/areas with a range for required lifts (e.g., 30–100 percent), determine coverage using patient characteristics as instructed in the directions above the table. APPENDIX J Floor-Based Lifts Coverage Determination

I Sit-to-stand lift recommendations I

To determine the number of floor-based lifts required for a unit or facility, the general rule of The recommendations shown in Table J-1 thumb is one portable lift per 8Ð10 patients. For apply when there is no other means of risk example, the number of sit-to-stand lifts needed I control for the patient characteristics and for a unit with 30 patients, 30 percent of whom activities being addressed (toileting, are categorized as requiring partial assistance, dressing, peri-care, vertical transfers, etc., of (n=9) is one lift. The number of floor-based, full- partially dependent patients). body sling lifts required in a unit with no ceiling Now that ambulation slings with ceiling lifts lifts in place and 30 patients, 60 percent of whom are used more often to assist in ambulating are considered fully dependent or require exten- and vertical transfers, the quantity of sit-to- sive assistance (n=18), is two lifts. stand lifts needed (and associated space requirements) will decrease when other When deciding how much portable equipment to ceiling lift adaptations or technology are purchase, consider peak patient handling and used and/or available. movement times/loads during each shift. Note that the number of portable, floor-based lifts will be reduced with the introduction of fixed lift systems, such as ceiling-mounted systems.

TableI Floor-based J-1 can be sling used liftto determine recommendations the number of floor-based liftsÑboth full-body sling lifts and sit- to-stand liftsÑneeded for each clinical area/unit.

I . These are based on ceiling lift coverage as specified and calculated using Table I-1 in Appendix I. If ceiling lift coverage is less than that in Table I-1, the need for floor-based sling lifts will increase, requiring more storage space. I Use the rule of thumb of one per 8Ð10 dependent patients not covered by ceiling lifts (from the NIOSH article referenced in Table I-1). With full ceiling lift coverage as in Table I-1, floor-based sling lifts may be shared by units on one or more floors, decreasing the number required. 116 PHAMA: Appendix J

Table J-1: Portable/Floor-Based Lift Minimal Coverage by Clinical Area/Unit

CLINICAL UNIT/AREA RECOMMENDED COVERAGE Sit-to-Stand Lifts Floor-Based Sling Lifts2

General medical unit One per 8–10 partially One per floor or unit weight-bearing patients1 Medical/surgical unit One per 8–10 partially One per floor or unit weight-bearing patients1 Post-surgical unit One per 8–10 partially One per floor or unit weight-bearing patients1 Rehab unit One per 8–10 partially One per floor or unit weight-bearing patients1 MICU One per 8–10 partially One per floor or unit weight-bearing patients1 SICU One per 8–10 partially One per floor or unit weight-bearing patients1 CCU One per 8–10 partially One per floor or unit weight-bearing patients1 ICU (Combined MICU/SICU/CCU) One per 8–10 partially One per floor or unit weight-bearing patients1 Nursing home/long term care One per 8–10 partially One per floor or unit weight-bearing patients1 Geri-psych One per 8–10 partially One per floor or unit weight-bearing patients1 Psychiatry One per 8–10 partially One per floor or unit weight-bearing patients1 Emergency dept./urgent care One One Radiology/diagnostics (X-ray, CT, One per entire radiology/diagnostic area One per entire radiology/ nuclear medicine, MRI) Note: Tables must accommodate lift bases. diagnostic area (If possible, specify diagnostic tables Note: Tables must without pedestals or with pedestal design accommodate lift bases. that accommodates placement of portable/ floor-based lifts under table and around pedestal.) Physical therapy clinics One per clinic One per clinic OR None None PACU None None Procedure areas (GI, cystoscopy, One per floor/unit One per floor or unit cath lab, etc.) Spinal cord injury unit None or one One per floor or unit (Depending on patient population) Outpatient SCI clinic None or one None exam/treatment rooms (Depending on patient population) Outpatient/primary care clinics One One Exam tables must accommodate lift base. (May need additional lifts if clinics are not (May need additional lifts if in close proximity to one another) clinics are not in close proximity to one another) PHAMA: Appendix J 117

CLINICAL UNIT/AREA RECOMMENDED COVERAGE Sit-to-Stand Lifts Floor-Based Sling Lifts2

Hemodialysis One None Chair design must accommodate lift base. (Depending on typical patient population and whether using chairs and/or beds) Dental One None Dental chairs must accommodate lift base. Pediatrics One One Nurse training area One One Morgue None If no ceiling lift, provide “morgue lift.”

1 J. Collins et al., Safe Lifting and Movement of Nursing Home Residents (DHHS [NIOSH] Publication Number 2006-117, 2006). 2 These recommendations are based on ceiling lift coverage as shown in Table I-1 in Appendix I. APPENDIX K Design/Layout Considerations for Ceiling/Overhead Lift Tracks

At present, not all clinical units or areas require charging options, options for the physical move- 100 percent ceiling lift coverage (Table I-1), but ment of ceiling lifts, track design options, track with expansion in ceiling lift and sling technology, Ceilingdesign suggestions Lift Motor for Charging various clinical Options areas, track this is expected to change. In the near future, full support and fastening options, and other track coverage may be warranted for most patient Stationarydesign/layout charging options system. for consideration. rooms. Therefore, some patient handling experts recommend installing tracks in every room during new construction or renovation to accommodate future installation of a ceiling lift system. A charging/docking Installing the track during construction (new or station is attached to the track, and for charging to renovation) may decrease the ultimate cost for Electronictake place, the (continuous) lift must be brought charging to and system docked installation of a ceiling lift system. (ECS).at the charging station. Usually, the charging The information in this appendix is intended to station is located away from traffic areas. assist in selection of the best ceiling lift track design and installation options, and to ensure consideration is made for other decisionsFigur ethat K-1: TraverseThe track contains copper strippingc. that Into toilet impact ceiling lift design. These includeTrack ceiling Design lift enables charging of the lift motor throughout theroom

d. In room with other ceiling- mounted equipment PHAMA: Appendix K 119

Ceilinglength of Lift the Movement track at all times. Continuous and is motorized, a Òreturn-to-chargeÕ function charging occurs along the entire length of the moves the lift to the charging/docking station track not just in one specific location. afterTrack a patientDesign has Options been moved or lifted. With an ECS, the lift can be charged at any location along the track.

All ceiling lifts enable a patient to be lifted up and Traverse (room covering) track. I lowered vertically. However, some lifts offer options for side to side, horizontal movement. A Three track design options are commonly used. ceiling lift can be moved horizontally by the care- Non-motorizedgiver either manually track. using a non-motorized track n most rooms, or with a hand-held (remote) device using a a traverse track (Figure K-1) gives staff more motorized track. options for transfers and performance of patient handling activities. This design also offers the Most caregivers prefer to patient more opportunity for rehabilitation and pull the lift horizontally by hand rather than press more timely patient handling assistance. a button and wait for the lift to move to the However, traverse track designs may affect the desired location. Movement is quite smooth and use of privacy curtains. When including a traverse easy with this design. However, caregivers must track, room design specifications must incorpo- pull the lift manually, although easily, to the Straightrate solutions track. that ensure patient privacy. (See Motorizedrecharging areatrack. if there is a charging/docking below for more information on privacy station. With an ECS, the lift can be charged at any curtains/screens.) location along the track. A straight track configuration A motorization component (Figure K-2) is only recommended when a room is enables the caregiver to use a hand-held (remote) small and the straight track can reach all areas device to move the lift horizontallyFigur alonge K-2:the track Straightwhere patient handling and placement will occur as well as to move the patient upTrack and down Design (verti- (when the sink is in line with the bed, the chairs cally). If the lift has a charging/docking station have easy access to the bed, etc.). ©RoMedic

©RoMedic ®

h. Over parallel bars in PT clinic

i. In dialysis clinic

120 PHAMA: Appendix K

Figure K-3: Curved Track Design

b. In patient room/toilet room

c. In patient room

Figure K-4: Integrated Track Design

d. In intensive

Curved track. Spinal cord injury (SCI) patient room I

Curved tracks (Figure K-3) are CCU/ICU patient room used for turns/transitions from one room into I Traverse track covering patient room another; when ceiling obstructions such as lights, extending into toilet room (Figure K-5) Integratedsprinklers, ortrack. other objects hang too low to I accommodate a straight track; and to enhance the I appearance of the lift system. Preferred layout: Traverse track covering patientI room (Figure K-1) Track Designs for ClinicalA fourth Ar easoption is a track Alternate layouts: system integrated into a headwall or utility NursingStraight home rail/track care unit over (NHCU) patient patient bed room column (Figure K-4). I (Figure K-2) Integrated track system (Figure K-4)

Following are track design recommendations for I specific clinical areas. (Please note that track Preferred layout: Traverse track covering extension into the toilet room is highly recom- patient room extending into toilet room Standardmended for patient all patient room rooms. However, it is not Bariatric(Figure patientK-5) room universallyI included below as it is not always I Alternate layout: Traverse track covering feasible.) patient room (Figure K-1) I

I Preferred layout: Traverse track covering Preferred layout: Traverse track covering patient/resident room (Figure K-1) patient room extending into toilet room Alternate layout: Straight rail/track over (Figure K-5) patient bed (limits room coverage) (Figure K-2) Alternate layout: Traverse track covering patient room extending into toilet/shower PHAMA: Appendix K 121

©Liko® (3)

a–c. Traverse design into toilet room

K-5: Ceiling-Lift Tracks Extending from Patient Room into Toilet Room ®

©Liko

d–e. Straight track chitects design with curve Figure K-7:

into toilet room DSGW Ar Suspended Track

Figure K-6: Toilet Room

Incorporated (2) into Bariatric ®

Other Track Design Options

Alternate designs for clinical areas. area with open room/toilet room design (Figure K-6) Tracks may be suspended (Figure K-7) or recessed (Figure K-8). The recessed option is I A few alter- preferred, as this style diminishes the aesthetic native track design options are suitable for SCI, impact in patient rooms; however, suspended bariatric,I nursing home, and other patient rooms tracks allow clearance for sprinkler heads, lights, that require or allow coverage into toilet rooms. curtainTrack Support/Fastening tracks, and other Options obstacles. When Ceiling lift tracks into toilet room through installing recessed tracks, ensure that the doorway (Figure K-4) dropped ceiling grid is butted up against the track. Bariatric room design that incorporates the toilet/shower area into the bariatric patient room, using screens/privacy curtains rather The structural capacity of the building element to than doors, making it easier to run track and which the lift is anchored must be capable of transport bariatric patients from one area to supporting the combined weight capacity of the the next (Figure K-6) lift, weight of the lifting equipment, and all other 122 PHAMA: Appendix K

b. Upright ®

support ©Liko

Figure K-10: Pendant ® (2) ® Attachment

superimposed loads. Both static and dynamic Othersystem Ceiling attached and Wall-Mountedto spanning beams Track or loads must be considered. This capacity should be Designtrusses. and Tracks Layout can Considerations be fully or partially evaluated by a structural engineer. recessed into the ceiling (Figure K-11). Three types of attachment options are described here; others may be available. Consult I Items in ceiling: with ceiling lift manufacturers for options specific for their tracks. Be aware that the interstitial The following should be considered in deter- spaceI Wall dictates mount: the amount of lateral bracing miningI Items track above layout: ceiling: required. In addition, the type of attachment Light fixtures, AC diffusers, method (rod or pendant) needed to achieve a fire sprinkler heads, televisions, X-ray equip- stable system varies. I Wall-mountedment, OR lights, barriers:and other fixtures. Attached to wall with a wall Other ceiling-mounted I bracketPendant: and/or uses an upright support. For a I Structuralequipment (e.g.,materials radiology in building equipment), frame: HVAC traverse track, suspended in a wall channel ducts, electrical conduits, plumbing, etc. track. Economical, appropriate for renovations I Building system elements:TVs, light fixtures, (Figures K-9). cabinets, and door swing radius. Steel plate bolted to an engineered metal framing system and anchored to the I UniqueBuilding architecture: elements such as joists, beams, etc. supporting structure. Lateral support is Mechanical and I Threadednormally used rod: when interstitial space is greater electrical system features such as air ducts and than 19.5 in. See manufacturerÕs specification electrical conduits. and instructions. Tracks can be fully or partially Multi-level ceiling recessed into the ceiling (Figure K-10). heights, vaulted ceilings, soffits, non-structural Threaded rods can be or radius walls. mounted using an engineered metal framing PHAMA: Appendix K 123 (2) ® ©Liko

Figure K-12: Privacy Curtains

Privacy curtains for semi-private rooms. d. Separate tracks over each bed e. Wall-mounted curtains

I Doors and door walls (structural and non- I Location/design of privacy curtains: structural walls):

I Fire/life safety code requirements The I Ceiling height: The use of tracking through use of privacy curtains is affected by the instal- structural walls creates more challenges in lation of traverse track designs. Use of privacy room-to-room tracking. screens, curtains attached to booms, and other I Motor maintenance: unique designs may be a suitable alternative to Ceiling height must allow the curtains hung from the ceiling. In some situa- minimum lifting range required for use of tions, privacy curtains can be split and then I liftingMotor equipment. charging: fastened together with Velcro or buttons. (See Allow enough space Figure K-12.) I betweenStorage space:the track-end and wall for removal of the motor. Provide a code-compliant recharging location for the lift motor. Provide storage space that I Headwallallows immediate design: accessibility for the motor and hanger bar when they are not in use but keeps the lift system away from areas of foot travel. Some designs prevent installation of tracks and thus use of ceiling lifts, especially in ICU areas. APPENDIX L Storage Requirements for PHAM Equipment

Calculating Storage Space Requirements for Floor-Based Lifts

This appendix provides information to help determine how much storage space is needed for several types of patient handling and movement (PHAM)Lift Storage equipment. Space Requirements The recommendations given here are based on a I Use average (non-expanded base) dimensions unitI or facilityÕs ceiling lift coverage, as mentioned (given below or from the lift manufacturer) to elsewhereI in this white paper. determine the minimum space necessary for I the required number of both types of lifts. Space requirements are based on the following: I Space requirements will vary with lift weight The type of clinical unit capacities. The footprint of bariatric floor- based lifts will be greater than that of the The number of patients on the unit non-bariatric lifts given below. Footprint/dimensions of floor-based lifts I Space requirements will depend on the storage arrangement (side by side, end to end, To determine minimum space requirements for or a combination). storing portable/floor-based lifts on each unit: Lift Footprint/Dimensions Consult with staff and/or the lift manufacturer for 1. Multiply the number of sit-to-stand (STS) lifts true dimensions. required for the unit/area (as derived from I Average sit-to-stand lift = Table J-2) by the space requirements for the 27 in. wide x 43 in. long (~8 sf) (Expanded base width = ~ 50 in.) lift(s) in use or to be purchased (for informa- I Average floor-based sling lift = tion about determining the lift footprint, see 27 in. wide x 54 in. long (~10 sf) the sidebar). (Expanded base width = ~ 60 in.) # STS lifts/unit x lift footprint dimensions = Example (NHCU) One sit-to-stand (STS) lift is recommended for sit-to-stand lift space requirement (sf) every 8–10 partially weight-bearing patients/residents, and one floor-based sling lift (FBSL) is 2. Multiply the number of floor-based sling lifts recommended for each unit or floor. On an (FBSL) required for the unit/area (as derived NHCU with 60 beds and an average of 25 resi- from Table J-2) by the space requirements for dents who are partially weight-bearing, storage accommodations for 3 STS lifts and one FBSL the lift/s in use or to be purchased (see will be needed. Using the above average non- sidebar). expanded base dimensions to determine space necessary for these 4 lifts, 34 sf should be # FBSL/unit x lift footprint dimensions = allotted for these 4 lifts. FBSL Space requirement (sf) STS space requirements: 27 in. x 43 in. = 8 sf x 3 STS = 24 sf 3. Add the space requirements for the sit-to-stand FBSL space requirements: and floor-based sling lifts to obtain the 27 in. x 54 in. = 10 sf x 1 FBSL = 10 sf minimum storage space requirements for the Total space requirements: 34 sf portable/floor-based lifts.

FBSL + STS lift space requirements = TOTAL storage space requirements for portable lifts PHAMA: Appendix L 125

Storage for Lift Accessories and Other Equipment

In patient rooms, provide hooks for storing patient-specific slings. Slings assigned to a specific Sling and Hanger Bar Storage Battery-Chargingpatient should be Equipmentstored in the patient room to Storage space must also be provided for lift acces- provide instant accessibility and ensure use sories and other related equipment. compliance.

Surplus slings should be stored in the same loca- Storage spaces for patient handling and move- tion as floor-based lifts. Provide hooks for hanging ment equipment often include locations for slings and/or shelving for storage of folded slings. charging batteries. For more information, refer to Standard shelving is acceptable for storing an the requirements for battery charging in Guide- assortment of slings (see Figure L-1) and extra lift lines text 1.2-5.2.2.2, quoted in Chapter 2 of this hanger bars (see Figure L-2). white paper.

Other Equipment

Standard shelving is used to store other patient handling and movement equipment, such as fric- Storagetion-reducing for Infrequentlydevices (Figure L-3) and air-assistedUsed Equipment lateral transfer aids with a motor (Figure L-4).

An equipment bank located in the basement or other out-of-the-way area of the health care facility is helpful for storing large, infrequently used equipment such as bariatric beds, portable bariatric (gantry) lifts, floor-based full body sling lifts with an eight-point hanger bar for a supine sling, and extra lifts. Such an area would need an electric supply for charging batteries. Hovermatt (©HoverTech) Figure L-4: Air-Assisted Lateral Transfer Device with Motor (Air mattress folds into smaller size) © ArjoHuntleigh

Figure L-3: Friction- Reducing Devices Products Inc.) right Products (©W ® Slipp APPENDIX M Infection Control Risk Assessment Matrix of Precautions for Construction and Renovation

Step One:

identify Type of Construction Project Activity (Type A-D).

TYPE A Inspection and non-invasive activities Includes, but is not limited to: I Removal of ceiling tiles for visual inspection only (e.g., limited to 1 tile per 50 square feet) Using the following table, the I Painting (but not sanding) I Wall-covering, electrical trim work, minor plumbing, and activities that do not generate dust or require cutting of walls or access to ceilings other than for visual inspection

TYPE B Small-scale, short duration activities that create minimal dust Includes, but is not limited to: I Installation of telephone and computer cabling I Access to chase spaces I Cutting of walls or ceiling where dust migration can be controlled

TYPE C Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies Includes, but is not limited to: I Sanding of walls for painting or wall-covering I Removal of floor coverings, ceiling tiles, and casework I New wall construction I Minor ductwork or electrical work above ceilings I Major cabling activities I Any activity that cannot be completed within a single work shift

TYPE D Major demolition and construction projects Includes, but is not limited to: I Activities that require consecutive work shifts I Projects that require heavy demolition or removal of a complete cabling system I New construction

Step 1: ______

Steps 1-3 and construction permit: Adapted with permission from V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14: Adapted with permission from Fairview University Medical Center, Minneapolis, MN. Forms modified/updated and provided courtesy of Judene Bartley, ECSI Inc., Beverly Hills MI 2002. Updated 2009. 128 PHAMA: Appendix M

Step Two:

identify Patient Risk Groups

Low Risk Medium Risk High Risk Highest Risk Using the following table, the that will be affected. If more than one risk Office areas Cardiology CCU Any area for care of group will be affected, select the higher riskEmergency group: room immunocompromised patients Echocardiography Labor and delivery Burn unit Endoscopy Laboratories (specimen) Cardiac cath lab Nuclear medicine Medical units Central sterile supply Physical therapy Newborn nursery Intensive care units Radiology/MRI Outpatient surgery Negative pressure Respiratory therapy Pediatrics isolation rooms Pharmacy Oncology Post-anesthesia care unit Operating rooms, including Surgical units C-section rooms

Step 2: ______

Step Three:

Patient Risk Group Low, Medium, High, Highest Construction Project Type A, B, C, D Class of Precautions I, II, III or IV

Match the ( ) with the planned ( ) on the following matrix, to find the IC Matrix - Class of( Precautions:) or Constructionlevel of infection Pr controloject byactivities Patient required. Risk (Class IÐIV and Color-Coded Precautions are delineated on the following page.) Construction Project Type Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW I II II III/IV MEDIUM I II III IV HIGH I II III/IV IV HIGHEST II III/IV III/IV IV

Note:

Step 3:Infection ______Control approval will be required when the construction activity and risk level indicate that Class III or Class IV control procedures are necessary. PHAMA: Appendix M 129

D escription of Requir ed Infection Control Precautions by Class During Construction Project Upon Completion of Project

1. Use methods to execute work that minimize dust raised 1. Clean work area upon completion of task. I

S from construction operations. 2. Immediately replace any ceiling tiles displaced for visual

CLAS inspection.

1. Provide active means to prevent airborne dust from 1. Wipe work surfaces with cleaner/disinfectant. dispersing into atmosphere. 2. Contain construction waste before transport in 2. Water-mist work surfaces to control dust while cutting. tightly covered containers. II S 3. Seal unused doors with duct tape. 3. Wet mop and/or vacuum with HEPA-filtered 4. Block off and seal air vents. vacuum before leaving work area.

CLAS 5. Place dust mat at entrance and exit of work area. 4. Upon completion, restore HVAC system 6. Remove or isolate HVAC system in areas where work is where work was performed. being performed.

1. Remove or isolate HVAC system in area where work is 1. Do not remove barriers from work area until being done to prevent contamination of duct system. completed project has been inspected by the 2. Before construction begins, complete all critical barriers owner’s Safety and Infection Prevention & (i.e., sheetrock, plywood, plastic) to seal work area from Control departments and thoroughly cleaned non-work area or implement control cube method (cart with by the owner’s Environmental Services plastic covering and sealed connection to work site with department. III

S HEPA vacuum for vacuuming prior to exit). 2. Remove barrier materials carefully to 3. Maintain negative air pressure within work site utilizing minimize spreading of dirt and debris associated with construction. CLAS HEPA-equipped air filtration units. 4. Contain construction waste before transport in tightly 3. Vacuum work area with HEPA-filtered covered containers. vacuums. 5. Cover transport receptacles or carts. Tape covering unless 4. Wet mop area with cleaner/disinfectant. solid lid. 5. Upon completion, restore HVAC system where work was performed.

1. Isolate HVAC system in area where work is being done to 1. Do not remove barriers from work area until prevent contamination of duct system. completed project has been inspected by the 2. Before construction begins, complete all critical barriers owner’s Safety and Infection Prevention & (i.e. sheetrock, plywood, plastic) to seal area from non-work Control departments and thoroughly cleaned area or implement control cube method (cart with plastic by the owner’s Environmental Services covering and sealed connection to work site with HEPA department. vacuum for vacuuming prior to exit). 2. Remove barrier material carefully to minimize 3. Maintain negative air pressure within work site utilizing spreading of dirt and debris associated with IV

S HEPA-equipped air filtration units. construction. 4. Seal holes, pipes, conduits, and punctures. 3. Contain construction waste before transport in tightly covered containers. CLAS 5. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA 4. Cover transport receptacles or carts. Tape vacuum cleaner before leaving work site or they can wear covering unless solid lid. cloth or paper coveralls that are removed each time they 5. Vacuum work area with HEPA-filtered leave work site. vacuums. 6. All personnel entering work site are required to wear shoe 6. Wet mop area with cleaner/disinfectant. covers. Shoe covers must be changed each time the worker 7. Upon completion, restore HVAC system exits the work area. where work was performed. 130 PHAMA: Appendix M

Step 4:

Identify the areas surrounding the project area, assessing potential impact.

StepUnit Below 5: Unit Above Lateral Lateral Behind Front Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group

Step 6: Identify specific site of activity (e.g., patient rooms, medication room, etc.). ______

Identify issues related to ventilation, plumbing, electrical systems in terms Step 7: of the occurrence of probable outages. ______

Identify containment measures, using prior assessment. What types of barriers (e.g., solid wall barriers)? Will HEPA filtration be required? Step 8: (Note:______Renovation/construction area shall be isolated from occupied areas during construction and shall be negative with respect to surrounding areas.) Step 9: Consider potential risk of water damage. Is there a risk due to Stepcompromising 10: structural integrity (e.g., wall, ceiling, roof)?

Step 11:Work hours: Can or will the work be done during non-patient care hours?

Step 12: Do plans allow for an adequate number of isolation/negative airflow rooms?

Do the plans allow for the required number and type of hand-washing sinks? Step 13: Does the infection prevention and control staff agree with the minimum number of sinks for this project? (Verify against FGI Design and Construction Guidelines for types and area.) Step 14: Does the infection prevention and control staff agree with the plans relative to clean and soiled utility rooms?

Plan to discuss the following containment issues (e.g., traffic flow, environmental servicesÑhousekeeping, debris removalÑhow and when) with the project team. ______Appendix: ______

Identify and communicate the responsibility for project monitoring that includes infection prevention and control concerns and risks. The ICRA may be modified throughout the project, but revisions must be communicated to the project manager. PHAMA: Appendix M 131

Permit No.: Location of construction: Project start date: Project coordinator: Estimated duration: Contractor performing work: Permit expiration date: Supervisor: Telephone: TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk TYPE B: Small scale, short duration, moderate to high levels GROUP 2: Medium Risk TYPE C: Activity generates moderate to high levels of dust, GROUP 3: Medium/High Risk requires more than one work shift for completion TYPE D: Major duration and construction activities GROUP 4: Highest Risk Requiring consecutive work shifts 1. Execute work using methods that minimize dust raised by inspection. CLASS I construction operations. 3. Minor demolition for remodeling 2. Immediately replace any ceiling tiles displaced for visual 1. Provide active means to prevent airborne dust from covered containers. dispersing into atmosphere. 7. Wet mop and/or vacuum with HEPA-filtered vacuum 2. Water-mist work surfaces to control dust while cutting. before leaving work area. CLASS II 3. Seal unused doors with duct tape. 8. Place dust mat at entrance and exit of work area. 4. Block off and seal air vents. 9. Isolate HVAC system in areas where work is being 5. Wipe surfaces with cleaner/disinfectant. performed; restore when work completed. 6. Contain construction waste before transport in tightly 1. Obtain infection control permit before construction begins. 6. Vacuum work with HEPA-filtered vacuums. 2. Isolate HVAC system in area where work is being done to 7. Wet mop with cleaner/disinfectant prevent contamination of the duct system. 8. Remove barrier materials carefully to minimize CLASS III 3. Complete all critical barriers or implement control cube spreading of dirt and debris associated with method before construction begins. construction. 4. Maintain negative air pressure within work site utilizing 9. Contain construction waste before transport in tightly HEPA equipped air filtration units. covered containers. Date 5. Do not remove barriers from work area until complete 10. Cover transport receptacles or carts. Tape covering. project is checked by Infection Prevention & Control and 11. Upon completion, restore HVAC system where work Initial thoroughly cleaned by Environmental Services. was performed. 1. Obtain infection control permit before construction begins. 8. Do not remove barriers from work area until the 2. Isolate HVAC system in area where work is being done to completed project is checked by Infection Prevention prevent contamination of duct system. & Control and thoroughly cleaned by Environmental. CLASS IV 3. Complete all critical barriers or implement control cube Services. method before construction begins. 9. Vacuum work area with HEPA-filtered vacuums. 4. Maintain negative air pressure within work site utilizing 10. Wet mop with disinfectant. HEPA-equipped air filtration units. 11. Remove barrier materials carefully to minimize Date 5. Seal holes, pipes, conduits, and punctures appropriately. spreading of dirt and debris associated with 6. Construct anteroom and require all personnel to pass construction. Initial through it so they can be vacuumed using a HEPA 12. Contain construction waste before transport in tightly vacuum cleaner before leaving work site, or they can wear covered containers. cloth or paper coveralls that are removed each time they 13. Cover transport receptacles or carts. Tape covering. leave the work site. 14. Upon completion, restore HVAC system where work 7. All personnel entering work site are required to wear shoe was performed. covers. Additional requirements:

______Exceptions/additions to this permit Date Initials Date Initials are noted by attached memoranda. Permit request by: Permit authorized by: Date: Date: APPENDIX N Bariatric Equipment Safety Checklist

HOSPITAL BED PATIENT CARE ENVIRONMENT

I I

Weight limit: ______lbs. Patient chair Side rail support: ______lbs.I I Weight limit: ______lbs. Bed scale? Yes No Width: ______in. If yes,I weight limit: ______lbs. Seat height: ______in. WidthI of bed: ______in. Geri/cardiac chair AdjustableI for width? Yes No TRANSFERWeight limit: DEVICES ______lbs. MattressI type Width: ______in. Pressure relief Seat height: ______in. WHEELCHAIRPressure reduction o Alternating I I Rotational Other ______Lateral transfer devices Weight limit: ______lbs. Width: ______I I in. Weight limit:I ______I lbs. Powered? YesI NoI Width: ______in. Full-body sling SeatSTRETCHER height: ______in. Weight limit: ______lbs. Handle width: ______in. Powered? Yes No Powered? Yes No Goes to floor?I YesI No Sit-to-stand devices ANCILLARYWeight limit: DEPARTMENTS ______lbs. I I Weight limit: ______lbs. Width: ______in. Width: ______in. Powered? Yes No SeatBEDSIDE height: COMMODE/SHOWER ______CHAIR in. Handle width: ______in. Powered? Yes No Door widths: ______in. I I X-ray table SCALES Weight limit: ______lbs. Weight limit: ______lbs. Width: ______in. Seat width: ______in. CT scan equipment Adjustable height? Yes No Weight limit: ______lbs. WALKER Width: ______in. Weight limit: ______lbs. OR table Width: ______in. Weight limit: ______lbs. Width: ______in. BATHROOM Emergency room equipment Weight limit: ______lbs. Weight limit: ______lbs. Width: ______in. Width: ______in. Waiting room furniture Weight limit: ______lbs. Doorframe width: ______in. Width: ______in. Shower door width: ______in. ExamNOTE: Allroom patient table care devices and supplies should be carefully Weight limits evaluatedWeight for limit: bariatric ______capacity. lbs. Toilet: ______lbs. Width: ______in. Wall-mounted grab bars: ______lbs. Wall-mounted skin: ______lbs. APPENDIX O Making Critical In-House Connections for PHAMP Success

A win-win situation occurs when the facility safe in pulling cost data for use in cost-benefit patient handling and movement (SPHM) leader is analyses. included in the facility environment of care or That patient handling and movement (PHAM) safety committee, or accident review board. technology improves the quality of care for Simple presentation of status reports to these patients is even more reason for safety and occu- bodies, even when given by the SPHM leader as a pational staff interest and involvement in such guest, fosters program success by educating those programs. These staff members can provide who would not normally be aware of the patient important information and data showing the handling and movement program (PHAMP). benefits of using PHAM equipment for patient Such face-to-face meetings have many benefits, outcomes, such as reductions in the incidence of including keeping the committee or board falls, skin tears, and other adverse events. They apprised of PHAMP progress. Even more impor- Middlemay be ableManagement to help make the case for PHAMP tantly, the facility departments that usually belong implementation and the introduction of patient to bodies concerned with safety issues are those handling technology. departments particularly important to the success of a safety program. Thus, these meetings provide Safetya valuable and opportunity Occupational to facilitate Staff working associations between entities that can influence Support or lack of support from frontline supervi- implementation of a PHAMP. sors and other middle managers can make or break a PHAMP. Forging alliances and fostering good communication with these groups through one-on-one meetings, supervisor meetings, and Safety and occupational health staff are charged other means are essential. Always meet face-to- with providing safe environments for staff and face and one-on-one with each of these key patients, and the close relationship between staff players to educate them and enlist their support. safety and patient safety often means patient For successful program implementation, these safety staff and risk managers are naturally inter- managers must help the facility PHAMP coordi- ested in PHAMPs. During development and nator select unit/area peer leaders, allow implementation of a PHAMP, their input can be employees to spend time performing as peer valuable and should be pursued. leaders, allow time for staff training on new equip- One of the most important contributions safety mentFrontline and StaffPHAMP program elements, and and occupational staff members can make to the promote the ideals behind safe patient handling PHAMP is provision of information on staff and movement. patient handling injuries in the facility. They will most likely be the source of accident reports for review, and they may assist in tracking injuries and developing reports for leadership. In addition, The time to introduce the safe patient handling some safety staff members have formal education and movement (SPHM) concept to frontline staff in ergonomics and may help facility coordinators is early on, not after PHAM equipment has been understand that science and even conduct introduced on the unit/area. A variety of tech- ergonomic evaluations. Staff members who follow niques can be used to increase their awareness workersÕ compensation claims will also be helpful and interest: 134 PHAMA: Appendix O

I I

Provide an overview or awareness training for Appendix G for information on holding equip- frontline staff. ment fairs and conducting equipment trials.) I Have each unit/area complete Tool 1: Percep- Purchasing or contracting staff are responsible tion of High-Risk Tasks Survey (in Appendix for making the actual purchase of the equipment, H) by shift. Collate the results by shift and post but they may require the facility coordinator to them in each unit/area. I develop a statement of work (SOW) or purchase Ensure that staff members are involved in order. Since facility coordinators often come from evaluating potential PHAM equipment during clinical backgrounds, a good working relationship I equipment trials and/or equipment fairs. Make with contracting staff can be very helpful. sure they know their voices are being heard by The job of purchasing or contracting staff is to having them complete equipment rating work with vendors. They know how to make survey forms (Appendix G). the best deals with vendors and how to follow Involve as many staff members as possible in Facilityappropriate Management organizational Staff policies and proce- the patient care ergonomic evaluation process dures, most of which are unfamiliar to facility Facility(Appendix Educators E). Those who show keen interest champions with clinical backgrounds. may be appropriate as PHAMP unit/area peer leaders.

Facility management/engineering/project management staff members can be allies in implementation Because comprehensive training is critical for ofI a PHAMP in several ways, and it is important to peer leaders and staff when a new PHAMP is have their involvement from the very beginning. introduced, inclusion of facility educators in Due to their expertise, they must be included in the training development is important. Who actually following activities: conducts and coordinates the training varies from Ergonomic site visit walk-through: It is impor- facility to facility. Remember to include educators tant for facility management staff to accompany from both nursing and facility staffs, as training is the site visit team as they walk through the Facilityrequired Procurementfor all who move Staff and handle patientsÑ facility and make recommendations for PHAM physical therapists, radiology technicians, and equipment. The facility staff will know the others, as well as nurses. structural and environmental issues (asbestos, lead) that will affect certain types of lift track installation, and this information will ensure I the structural integrity of the building is main- Communication with staff members responsible tained if fixed lifts are installed. Be sure to have for procurement and contracting must be started facility staff look at patient and toilet room early in the PHAMP for a number of reasons: space constraints and conflicts posed by Close association with purchasing staff is existing ceiling-hung equipment. While they are important so they will understand why PHAM with you, have them help find hidden storage equipment must be selected with staff input I areas. Often, it may be feasible to create addi- rather than on a cost-only basis. (It is integral tional storage for PHAM equipment and to the philosophy of a PHAMP that staff who accessories by freeing up space that contains will use PHAM equipment have input into sinks or hoppers that are no longer in use. equipment purchase decisions as well as the I Equipment evaluations: Be sure to include program development process overall.) facility management staff in PHAM equipment Include purchasing staff in preparations for evaluations and ask them to consider ease of equipment trials on the unit or during equip- maintenance and repair. ment fairs. Usually contracting staff make Lift installations: Facility management staff initial contact with the vendors who will be members oversee the installation of fixed-lift asked to exhibit or test their equipment. (See systems. PHAMA: Appendix O 135

Environmental Services Staff Unions

Housekeeping staff will most likely be responsible Union representatives, by definition, support staff for cleaning PHAM equipment within the room, rights and safety, and so generally unions are very especially ceiling lifts. In their eyes, installation of supportive of SPHM initiatives; they can be signif- a lift system gives them Òone more thingÓ to keep icant partners in promoting your cause with clean. Recognizing that reservations regarding a leadership and others. As is their job, they will be Supply/Processing/Distributionpotential increase in workload are normal, (SPD) Staffwork very protective of their workers and may want to with these staff members to make the additional review the method for selecting peer leaders to work as easy as possible. ensure that all who wish to become a peer leader are given an equal opportunity. Understandably, I unions may resist collateral duty positions for peer leaders, not wanting to add responsibility DependingI on the facility, supply/processing/ without compensation or to overwork an distributionI staff may be responsible for: employee. Keep union representatives apprised of I Storing equipment and accompanying mate- PHAMP activities from the beginning, and include rials (e.g., slings, air mattresses) their representation in your facility SPHM team. Laundering slings Cleaning PHAM equipment Distributing equipment to units/areas as needed Working with these staff members to develop well-thought-outInfection Preventionists procedures for these activities will improve the lives of all involved and facilitate use of PHAM equipment.

Infection control professionals will ensure that PHAM equipment is suitable for its proposed use from an infection control standpoint and that disinfection/sterilization will be achievable. Bringing these staff members into your planning process early on will benefit both the PHAMP and the infection prevention effort. APPENDIX P PHAMP Element Descriptions

PeerThis appendixLeaders provides descriptions of the movement occurs, including radiology, therapy, program elements that make up a patient and nursing units and other procedure and treat- handling and movement program (PHAMP). ment areas. One peer leader per shift per unit is recommended to ensure availability around the clock. Because peer leaders may leave their unit, 1, 2 position, or organization, early thought must be Peer leaders have been identified as key to the given to succession planning to facilitate a smooth success of a PHAMP. These individuals obtain transition between peer leaders. their expertise through extra training and work in The VHA implemented a peer leader program as the field. As staff resource persons and equipment the first element in its PHAMP as a way to facilitate Òsuper users,Ó they are available to answer their co- staff buy-in and assistance in program roll-out on workersÕ questions about use of patient handling the units. An SPHM unit binder with information to and movement (PHAM) equipment and PHAMP support peer leaders in program implementation, elements. As well, their presence is crucial for staff equipment tracking, and other unit SPHM issues; a compliance with use of PHAM equipment and tools. weekly process log for capturing peer leader Another vital role of peer leaders is transfer of activity; and other resources developed by the VHA knowledge. In a new model for the education of areSafety available Huddles at www.visn8.va.gov/patientsafety4, 5 - caregivers, PHAMP peer leaders, rather than center/safePtHandling/default.asp. Further education staff, train co-workers. They serve as information is referenced in the footnotes. unit/area safe patient handling and movement (SPHM) champions, andÑeven more impor- tantÑas SPHM change agents in their areas, where they are responsible for facilitating signifi- At the VHA, after the SPHM peer leaders were6 in cant change in the way their co-workers perform place on their unit, their first function was to train their jobs. The peer leadersÕ value in this regard co-workers in the use of safety huddles. Safety cannot be overstated. Finally, peer leaders can huddles offer a venue for unit staff to share ideas help assess how implementation of a PHAMP is on patient and staff safety issues, best practices, progressing, and their feedback is critical to and solutions for problematic unit concerns. They program success. Appendix S offers a log for provide a forum for reviewing near-miss and capturing the unit activity and program status of injury incidents with the goal of preventing their SPHM peer leaders. recurrence. Most important, they provide an Although each peer leader is a ÒleaderÓ in his or opportunity for staff to discuss problems and her own right, peer leaders3 as a group require a come up with solutions. group leader, and the facility SPHM coordinator Brainstorming in a safety huddle is guided should assume this role. Without someone in this using the five questions below: position, peer leader programs tend to fade away, 1. What happened? even if one or two facility peer leaders take on a 2. What was supposed to happen? broader leadership role. The support of a dedi- 3. What accounts for the difference? cated program leader can expand the activity of 4. How could the same outcome be avoided in peer leaders on facility units and prevent existing the future? PHAMP elements from losing their impact. 5. What is the follow-up plan? Peer leaders are frontline staff who work in Safety huddles do not gather information that clinical units or areas where patient handling and will serve as evidence for punishment; only PHAMA: Appendix P 137

solutions and recommendations are recorded. of injury for caregivers, improving the quality of This approach facilitates candor and openness care for patients, and increasing mobilization of among the staff. patients. However, if the equipment chosen is not Knowledge transfer mechanisms like the safety appropriate for a facilityÕs patient population or is huddle have been used in some organizations not easy to use, its purchase may turn out to be a very successfully, especially in the military. ÒAfter- costly mistake. For this reason, once appropriate action reviews,Ó as they are called in the military, PHAM equipment types have been identified are ingrained in the culture; consequently, few through the PCE process, staff should test the activities take place without such an opportunity equipment to determine what brand is best for to debrief those who were involved in the action their patient population and most user-friendly and to review the incident with those who were for them. not involved. The goal is to take information from Holding PHAM equipment fairs and trials can one person or group and share it with others so ensure staff participation in the equipment selec- that negative outcomes can be prevented and tion process, which will promote staff acceptance positive ones repeated. of the equipment and the PHAMP. Refer to The VHA has found that safety huddles help Appendix C: Patient Handling and Movement facilitate staff buy-in and contribute to successful Equipment Categories for descriptions of different PHAMP roll-out on the units. Safety huddle types of PHAM equipment and to Appendix G: resources, such as a brochure and templates for EquipmentProcurement. Evaluation and Selection Process for collectingSafe information,Patient Handling are and Movement:found atA information on making good equipment purchase Practicalwww.visn8.va.gov/patientsafetycenter/safePtHa Guide for Health Care Professionals. decisions. Chapter 2 covers important design ndling/default.asp. A comprehensive discussion considerations for specifying equipment. ofPatient safety huddlesCare Ergonomic and Òafter-action Evaluations reviewsÓ is7 also Due to the great variation in found in procurementInstallation. criteria and activities among organizations, it is best to connect with your purchasing departmentI before contacting vendors, to ensure thatI organizational policies are followed. During this phase, the following After the VHA peer leaders were in place, activitiesI will take place: ergonomic evaluations were conducted, and Coordination with facility management staff PHAM equipment recommendations were gener- I Coordination with supervisors/staff in the ated based on information gathered from unit areas where installation will occur staff and the characteristics of the patient popula- I Check that the correct equipment has been tion of the unit/area under consideration. These received recommendations were general, such as acquiring Check that the correct equipment has been ceiling lifts, sit-to-stand lifts, or air-assisted lateral installed in the correct room or area transfer devices, and usually did not specify a Check for satisfactory completion of installations particular manufacturer unless a one-of-a-kind Each facility and organization will have its own Patientpiece of Handlingequipment Equipmentwas suggested. For more methods for facilitating these activities. It is crit- information, see Appendix E: Patient Care Assessments,ical for facility SPHM Algorithms, coordinators and to be familiar Ergonomic Evaluation Process. Guidelineswith them and for to Safe develop Patient working Handling relationships with facility management staff and other entities.

Selection. Once a health care facility has decided to utilize PHAM equipment, the next step is to choose, acquire, and install the equipment. Research has been conducted to identify the It is generally accepted that PHAM patient handling tasks that put caregivers at equipment and aides are key to reducing the risk greatest risk for injury (Appendix A), and many of 138 PHAMA: Appendix P

Table P-1: Algorithms for Safe Patient Handling* Algorithm Task

1 Transfer from bed to chair, chair to toilet, chair to chair, or car to chair and vice versa 2 Lateral transfer from bed to stretcher/trolley and vice versa 3 Transfer from chair to stretcher or chair to exam table and vice versa 4 Reposition in bed (side-to-side, up in bed) 5 Reposition in wheelchair and dependency chair 6 Transfer a patient up from the floor Bariatric 1 Bariatric transfer from bed to chair, chair to toilet, or chair to chair or vice versa Bariatric 2 Bariatric lateral transfer from bed to stretcher or trolley and vice versa Bariatric 3 Bariatric reposition in bed (side-to-side, up in bed) Bariatric 4 Bariatric reposition in wheelchair, chair, or dependency chair Bariatric 5 Patient handling tasks requiring sustained holding of a limb/access Bariatric 6 Bariatric transporting (stretcher, wheelchair, walker) Bariatric 7 Toileting tasks for the bariatric patient Bariatric 8 Transfer a bariatric patient up from the floor

*Adapted from “Algorithms for Safe Patient Handling and Movement,” posted at www.visn8.va.gov/patientsafetycenter/safePtHandling/default.asp.

these Òhigh-riskÓ tasks have ergonomic control Patient HandlingÓ (ÒalgorithmsÓ) into practice to measures (PHAM equipment) that decrease their help staff select the most appropriate14 equipment risk. Consequently, these tasks have been the for each high-risk task based on specific patient focus for development of ergonomic clinical algo- characteristics and requirements. (See Table P-1 rithms and guidelines that incorporate equipment for a list of algorithms developed by the VHA and interventions to decrease injuries and the risk of Figure P-1 for a sample algorithm.) Later, staff with injury. Before these algorithms and guidelines can expertise in specific clinical areas found they be utilized for 8,a 9,patient, 10 however, an assessment needed ergonomic guidelines specific to their clin- of the patientÕs moving and handling needs must ical areas and patient15 characteristics. As a result, be completed. Use of such an assessment, the Association of periOperative16 Registered along with algorithms specific to each type of Nurses (AORN) and the National Association of high-risk task, helps staff select appropriate Orthopedic Nurses (NAON) developed patient handling technology for each patientÕs ergonomic guidelines and algorithms. The NAON needs. In patient care areas where the clinical guidelines are found at www.orthonurse.org/ status of patients is relatively constant, written ResearchandPractice/SafePatientHandling/tabid/ recommendations are 11,generated 12, 13 to facilitate 403/Default.aspx, and the AORN guidelines can be consistency in transfer of information from staff purchased from www.aornbookstore.org/ to staff and shift to shift. In clinical areas with product/product.asp?sku=MAN167&mscssid=KA patients whose clinical status changes rapidly, the 8KPFTXNHFW8HXVNCDFNM3XJP0W4HXF. The algorithms and/or guidelines should be readily AmericanSafe Patient Physical Handling Therapy Association (APTA) has available on site and staff trained in how to use alsoand recognizedMovement the Policy importance of focused guide- them. Suggestions for promoting them include lines and is in the process of developing them. posting the guidelines/algorithms in patient rooms or break rooms or hanging laminated copies on equipment. After PHAM equipment had been introduced and staff trained, the VHA program put the ÒPatient A SPHM policy ties all of the PHAMP elements Assessment, Care Planning and Algorithms for Safe together and gives strength to the program. Such PHAMA: Appendix P 139

Figure P-1: Algorithm 5—Reposition in Wheelchair and Dependency Chair

Start Here Caregiver assistance not needed; stand by for Fully able safety as needed. Can the patient assist? I If patient has upper extremity strength in both Partially able arms, have patient lift up while caregiver pushes knees to reposition. No I If patient lacks sensation, cues may be needed to remind patient to reposition.

Can the patient Yes Recline chair and use a seated repositioning bear weight? device and 2 caregivers.

No Use floor-based lift or stand-assist aid and Yes 1 to 2 caregivers. Is the patient cooperative? No Use floor-based lift and 1 to 2 or more caregivers.

Notes 1. Make sure the chair wheels are locked. 2. Take full advantage of chair functions (e.g., move a chair that reclines or use the armrest of a chair to facilitate repositioning). 3. During any patient transfer task, if any caregiver is required to lift more than 35 lbs. of the patient’s weight, the patient should be considered to be fully dependent and assistive devices should be used. [T. Waters “When is it safe to manually lift a patient?” in American Journal of Nursing, 107, no. 8 (2007), 53–59.]

a policy is developed prior to PHAM equipment nology. They are mandated to move patients only introduction, but cannot be put into practice and with proper patient handling assistive enforced until the equipment is in place and staff devices?never manually. When properly imple- members have received training on its use and on mented, lift team programs can be quite Liftthe programTeams elements. A policy template can be successful and allow busy nursing staff to found at www.visn8.va.gov/patientsafetycenter/ complete nursing tasks other than moving and safePtHandling/default.asp. lifting patients. However, lift teams must be adequately staffed so their help and expertise is available when needed on all shifts and in all locations of a hospital. Otherwise, if nursing staff A lift team has been defined as Òtwo physically fit must expedite a patient transfer without the lift people, competent in lifting techniques,17 working team (either before the team arrives or because together, using mechanicalincorrect equipment to accom- the team is busy elsewhere), the result may be plish high-risk patient transfers.Ó However, lift detrimental to the patient and/or the staff teams were often understood to be a team of men member. The staff member may not have experi- (usually) whose job is to manually lift and move ence in using PHAM equipment on a day-to-day patients. When such an interpretation basis and thus may use it without full competency of a lift team is the standard procedure in a or choose to perform the patient handling activity facility, the staff members involved are placed at manually. As noted, with sufficient staffing and great ergonomic risk. True lift teams are those use of appropriate equipment, lift teams provide with special education in patient handling and busy staff with much needed assistance. movement and the use of patient handling tech- 140 PHAMA: Appendix P

Endnotes

1 M. Matz, “Unit-based peer safety leaders to promote safe patient handling,” in Safe Patient Handling and Movement: A Practical Guide for Health Care Providers, edited by A. L. Nelson (New York: Springer Publishing Company, 2005). 2 H. Knibbe, “Ergonomic approach in the Netherlands: Experience,” presentation at the 5th Annual Safe Patient Handling and Movement Conference, St. Pete Beach, FL (2005). 3 M. Matz, “Patient handling (lifting) equipment coverage & space recommendations” (Internal VHA document presented to Director, VHA, Occupational Health Program, 2007). 4 Matz, ”Unit-based peer safety leaders to promote safe patient handling.” 5 M. Matz et al., “Back injury prevention in health care,” in Handbook of Modern Hospital Safety, 2nd ed., W. Charney, ed. (New York: CRC Press, Taylor & Francis Group, 2010). 6 M. Matz, “After-action reviews,” in Safe Patient Handling and Movement: A Practical Guide for Health Care Providers, A. L. Nelson, ed. (New York: Springer Publishing Company, 2005). 7 Matz, “Unit-based peer safety leaders to promote safe patient handling.” 8 S. Hignett et al., “Evidence-based patient handling: systematic review,” Nursing Standard 17, no. 33 (2003): 33–36. 9 A. L. Nelson, ed., Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement (Tampa: Veterans Administration Patient Safety Center of Inquiry, 2001). 10 A. Nelson et al., “Algorithms for safe patient handling and movement,” American Journal of Nursing 103, no. 3 (2003): 32–34. 11 A. L. Nelson, ed., Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement. 12 A. Nelson et al., “Algorithms for safe patient handling and movement,” .American Journal of Nursing, 103, no. 3 (2003), 32-4. 13 Nelson, “Algorithms for safe patient handling and movement.” 14 Nelson, Patient Care Ergonomics Resource Guide. 15 AORN Workplace Safety Taskforce, Safe Patient Handling and Movement in the Perioperative Setting (Denver, CO: Association of periOperative Registered Nurses [AORN], 2007). 16 C. A. Sedlak, M. O. Doheny, A. Nelson & T. R. Waters, “Development of the National Association of Orthopaedic Nurses guidance statement on safe patient handling and movement in the orthopaedic setting,” Orthopaedic Nursing, Supplement to 28, no. 25 (2009): 2–8. Retrieved 10//1/09 from www.orthonurse.org/ResearchandPractice/SafePatientHandling/tabi d/403/Default.aspx. 17 J. Meittunen, K. Matzke, H. McCormack & S. C. Sobczak, “The effect of focusing ergonomic risk factors on a patient transfer team to reduce incidents among nurses associated with patient care. Journal of Healthcare Safety, Compliance and Infection Control 2, no. 7 (1999): 306–12. APPENDIX Q Safe Patient Handling and Movement Training Curricula Suggestions

SPHM Peer Leaders

StaffThis appendix provides suggestions for SPHM curricula for staff, peer leaders, and facility coordinators. Special training that is more in-depth than staff training should be offered to peer leaders. This should provide scientific evidence for instituting SPHM programs, introduce SPHM program All staff members who move and handle patients elements that are part of the facility program, should participate in SPHM staff awareness andÑto ensure successÑmake peer leaders training. This training should include basic infor- aware of tools and resources that will facilitate mation about the rationale for using patient acceptance of the program and promote safe handling and movement equipment, SPHM patient handling and movement. As in the staff program elements specific to the facilityÕs training, various types of patient handling equip- program, and tools and resources for facilitating ment (e.g., lifts/slings, lateral transfer devices, safe patient handling and movement, such as algo- repositioning aids, and more) should be shown rithms used to determine the number of staff and discussed, and sling selection and use and members and type of equipment needed for safe bariatric patient care should be covered. If time movement of individual patients. Various types of and equipment is available, demonstrate a few patient handling equipment, including lifts/slings, key pieces of equipment. lateral transfer devices, repositioning aids, and In addition to the SPHM information provided, more, should be shown and discussed. Training Peerpeer leaderleader training SPHM programstraining objectives:should address should also include information on sling selection these subjects: adult education, change manage- and use and bariatric patient care. ment strategies, and coaching techniques. If there is time and equipment is available, I demonstrate a few key pieces of equipment, On knowing that further training will be provided for completionI of this training program, participants proficiency. Facility coordinators, peer leaders, or willI be able to: education staff will be responsible for conducting Relay the rationale for implementing a safe competency training and skills check-offs for staff I patient handling and movement program. Staffmembers. SPHM For awareness a sample template training for objectives: tracking staff Relay the elements of the facilityÕs SPHM program. skills and competencies, go to www.visn8.va.gov/ I Identify ergonomic and other hazards in health patientsafetycenter/safePtHandling/default.asp. care environments. I I Explain the relationship between ergonomics On and risk from patient handling activities. completion of this training program, participants Understand and facilitate the support Iwill be able to: I processes needed for an effective program. Explain why patient handling and movement Select and safely use the appropriate piece of equipment must be used instead of manual I equipment and slings for patients with a I techniques. variety of medical and physical conditions. I Select the appropriate piece of equipment and I Institute strategies for safe and sensitive slings for patients with a variety of medical bariatric patient care. and physical conditions. Utilize change strategies to facilitate co-worker Relay the elements of the facility SPHM program. adoption of safe patient handling behaviors. Provide safe and sensitive bariatric patient care. Effectively coach and train co-workers. 142 PHAMA: Appendix Q

Working Safely in Health Care: A Practical Guide.

Peer leaders will become the patient handling Fell-Carlson, D., ed. equipment Òsuper usersÓ on their units or in their Handbook of ModernNew York:Hospital Delmar Safety, Thomson clinical areas. To attain this designation, peer Learning Publishing Company, 2007. leaders need extra training on the use of equipment. The best resources for this training are the Hudson, A. ÒBack injury prevention in health careÓ equipment manufacturers, but such involvement in afe Patient Handling2nd anded., is not always possible. Facility champions or unit editedMovement: by W. A GuideCharney. for Nurses New York:and Other CRC HealthPress, peer leaders with advanced expertise may need to TaylorCare Providers. & Francis Group, 2010. take on the training role. Another important consideration is the need Nelson, A. L., ed. S for equipment users to understand the impor- he tance of thinking through the best and most Illustrated GuideNew to SafeYork: Patient Springer Handling Publishing and sensitive approaches when using the equipment Movement.Company, 2006. with patients. Facility coordinators or education staff will be Nelson, A. L., K. Motacki, & N. Menzel, eds. T responsible for conducting competency training and afe Patient skills check-offs for peer leaders. For a sample Handling GuidebookNew York: for SpringerFacility Champions/Publishing SPHMtemplate Facilityto track peer Coordinators leader skills and competencies, Coordinators.Company, 2009. go to www.visn8.va.gov/patientsafetycenter/ safePtHandling/default.asp. U.S. Department of Veterans Affairs. S

www.visn8.med.va.gov/Patient SafetyCenter/safePtHandling. Facility SPHM coordinators must be able to relay information required to train staff and peer leaders, and thus must have a higher level of knowledge than either. Such information can be obtained from this white paper and from journal articles, books, Web sites, and conferences. See Chapter 6 for lists of SPHM resources, including these: APPENDIX R PHAMP Marketing Activities/Strategies Aimed at Staff

I I

I The importance of marketing in support of a Other facility/unit information patient handling and movement program I Results of unit staff completing the Perception (PHAMP) or safe patient handling and move- I of High-Risk Task Survey Tool (Appendix H) ment (SPHM) program is discussed in Chapter 4: I Algorithms for determining the need for PHAM Facilitating a Patient Handling and Movement equipment PeerProgram leader and unit Technology walk-through Acceptance. This I Photos of peer leaders appendixI suggests marketing activities suitable I Research data forI such an effort. I Photo of nurse executive/administrator/staff I in a ceiling lift I SPHM articles Activities:I I Quality data related to SPHM Walk through units. Information on conferences/meetings related I Ask staff questions on equipment use and to SPHM usability. FacilitySafety newsletter/e-mails huddle recommendations I Ask staff if they have any questions about Best practices from peer leader conference I equipment or related issues. calls I Give awards for answering questions I correctly, etc. I After the walk-through, discuss the findings. Publish or send out articles on a regular basis that Coordination of activities: promoteScreensaver peer with leaders, SPHM the or SPHM peer leaderprogram, logo posi- I Determine activities to include. tive results from engaging in safe patient handling I Determine date/time/length of activity. NurseÕsand movement, Week etc. Ask supervisors to permit peer leaders to I participate. Advise unit supervisors of date and time. I Write down questions for peer leaders to ask Letter/e-mail to employees I staff. launchingShowcase peerprogram leaders as part of plans for this Order T-shirts or pins for peer leaders to week. Vendorwear. equipment fairs Open house after installation Order awards. Skills/equipmentOther fair

Bulletin boards Competitive games IHave the facility director be the first person lifted Iin a demonstration. I I Post information such as the following on bulletin I Have peer leaders lead their unit/area team boards throughout hospital; note peer leader Competition between units involvement. Game show, relay race, Safe Patient Handling Facility/unit patient handling injury data/goal Jeopardy, etc. to reduce number of injuries Have peer leaders and staff write questions 144 PHAMA: Appendix R

SPHM Walk

Brochures/fliers/posters that promote peer leader Web site(Organize training hospital-wide ÒwalkÓ forI SPHM.)

I I Include rationale for safe patient handling and Develop/producethe peer leader program. facility peer leader video I Include content outline, etc. Note that CEUs are offered. I

PromotionalLight-hearted/fun items video Ð show use of algo- I rithms and equipment (right way/wrong way) I Medical media I

Create SPHM program logo/title. I Create peer leader logo/title. Labels: ÒI got caught lifting safely,Ó ÒLifting I patients safely keeps staff healthy,Ó ÒNo LiftingÓ I sign on pin or sticker, etc. Pens, pins, mugs, T-shirts, caps, buttons, Newbanners, employee etc. orientation I Awards Other I

I Include peer leaders in the development of SPHM information. Include information on the peer leader SPHMprogram. poster to promote whole program Have peer leaders conduct the SPHM training piece of new employee orientation. APPENDIX S SAFE PATIENT HANDLING PEER LEADER Unit Activity and Program Status Log

Type of unit: ______Peer leader: ______

Dates included in this report: Sunday ______through Saturday ______

Part 1: Being a peer leader for your clinical unit

Indicate the number of times during the past weekÉ NUMBER

one-to-one a. One of your co-workers asked for your advice about patient handling and movement. group b. You met in person with a nurse about patient handling tasks. lifting c. You met in person with staff in a setting about patient handling tasks. other d. You demonstrated the use of patient equipment (portable or ceiling-mounted sling lifts, stand assist lifts, etc.). e. You demonstrated the use of patient handling or movement equipment (lateral transfer aids, stand-assist aids, transfer/ Partdependency 2: Other chairs, activities transfer/gait related belts, to being etc.). a peer leader f. You were asked to deal with a problem in the operation of a lifting device. Indicate the number of times during the past weekÉ NUMBER

a. You demonstrated the use of the algorithms for safe patient handling and movement or one of your co-workers asked for your advice about their use. b. You were asked to evaluate a potential ergonomic/safety hazard on your unit. c. You performed an ergonomic hazard evaluation on your unit. d. You led an AAR. e. You participated in an AAR led by another. f. You attended activities related to being a peer leader other than those above (meetings w/nurse manager, other peer leaders, site coordinator, or training, etc.). g. You completed paperwork related to being a peer leader. h. You asked your nurse manager for support/info/help related to being a peer leader. 146 PHAMA: Appendix S

Part 3: Support and interest

During the past weekÉ YES NO

a. My nurse manager was enthusiastic about the Back Injury Prevention Program and supported my efforts. b. Nursing co-workers were enthusiastic about the Back Injury PartPrevention 4: Program Program effectiveness and supported my efforts. c. Patients, residents and/or families were enthusiastic about the Howchanges effective taking do placeyou think or supported these have what been they in knew preventing of my/our musculoskeletal efforts. incidents and injuries?

NOT AT ALL SOMEWHAT NO EFFECT SOMEWHAT EXTREMELY UNSURE EFFECTIVE INEFFECTIVE EFFECTIVE EFFECTIVE I I I I I I I I I I I I

Unit peer leader I I I I I I After action reviews I I I I I I Use of lifting equipment I I I I I I Ergonomic hazard analyses

Safe patient I I I I I I handling and movement policy

Algorithms for safe patient handling and movement APPENDIX T Patient Care Equipment Use Survey IIIII

How many times in a typical day would you say you use the following patient care aids?

1. Powered full-body sling lifts (ceiling-mounted) I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A

2. Powered full-body sling lifts (portable base) I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A

3. Mechanical lateral transfer aids I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A

4. Friction reducing lateral aids I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A

5. Air-assisted lateral aids I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A

6. Transfer chairs I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A

7. Dependency/geri-chairs I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A

8. Powered standing assist and repositioning lifts I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A

9. Standing assist and repositioning aids I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A

10. Gait belts I 0–None I 1 I 2 I 3–4 I 5–6 I 7–8 I 9–10 I Greater than 10 I N/A