Safe Patient Handling and Mobility

Supplement to

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility

This supplement was funded by an unrestricted educational grant from Hill-Rom. Content of this supplement was developed independently of the sponsor and all articles have undergone peer review according to American Nurse Today standards.

Safe patient handling and mobility: A call to action Much more must be done to enhance safety for patients and caregivers.

By Melissa A. Fitzpatrick, MSN, RN, FAAN

confluence of demographic While the intentions of manual transportation orderlies, and others and economic trends is patient mobilization may be honor- in implementing the standards and A pushing us toward the per- able, the effects are far from opti- creating a culture of safety in their fect storm: mal for all involved. There’s no such organizations. However, only 11 • Today’s nursing workforce is thing as “safe lifting” when we use states have enacted SPHM laws aging. The average age of the our bodies as the lifting mechanism. and these laws vary significantly. American registered nurse is Old-school teachings about safe Much more work needs to be done 44.6. body mechanics have been proven to enhance safety for patients and • The patients we serve are heav- invalid, and many of us must un- caregivers. ier than ever. learn them. As nurses, we must This special report provides a • Experts predict increases in pa- change our mindset and get in the helpful resource to caregivers as tient acuity, age, and comor- habit of using safe patient handling they continue to practice SPHM—or bidity. and mobility (SPHM) technology to to embark on their SPHM journey if • Staffing issues continue to cause keep both our patients and our- they’re not already on it. National concern. Some experts project selves safe from harm. experts share their perspectives and the United States will be short How many times have you or a best practices to align people, about 250,000 nurses over the colleague suffered an injury to processes, and technology to set next 10 to 12 years. your back, shoulder, or both during the course for action. I’d like to • Economic imperatives requir e us manual patient handling? How thank all of the authors who’ve con- to move patients through the many colleagues have we lost to tributed to this special report for healthcare delivery system more our profession because of a career- sharing their expertise and strate- quickly to shorten stays and en- ending injury? How many millions gies, which we hope will be imple- hance financial reimbursement. of dollars are spent on workers’ mented where you work. Please compensation claims for employees take these best practices to heart Any one of these trends is who’ve had patient handling and and engage your colleagues to do cause for concern. All of them mobility injuries? Caregiver injuries the same. And please join all of us occurring at once is cause for adversely affect staff morale, at Hill-Rom on our mission to ensure alarm—and a call to action. staffing levels, and, ultimately, pa- SPHM. Much is at stake, and noth- Imagine older nurses lifting heav- tient safety. Such injuries have ing is more important than your ier, older, and sicker patients. Ob- made headlines in many communi- health and well-being—to enable viously, all parties are at greater ties and are top of mind for health- you to continue doing what only risk for injury. care leaders. Legislatures have tak- nurses can do. We’ve never need- In too many cases, nurses contin- en on the issue, and in 2013 the ed nurses more than we do now. ue to deliver care “the way we’ve American Nurses Association always done it.” For many, this (ANA) supported a federal bill to Selected references American Nurses Association. Safe Patient Han- means doing the heavy lifting need- eliminate manual patient handling, dling and Mobility: Interprofessional National ed to mobilize patients manually in including lifting, transferring, and Standards. Silver Spring, MD: Author; 2013. an attempt to avoid the many se- repositioning patients. That same Buerhaus PI, Auerbach DI, Staiger DO. The recent quelae of immobility—decreased year, ANA published national inter- surge in nurse employment: causes and implica- cardiovascular, pulmonary, integu- professional standards to guide tions. Health Aff (Millwood). 2009;28(4):w657-68. mentary, and psychological func- caregiving teams of nurses, physi- Melissa A. Fitzpatrick is vice-president and chief tioning, to name a few. cal therapists, nursing assistants, clinical officer at Hill-Rom.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 1 Current Topics in Safe Patient Handling and Mobility CONTENTS

Safe patient handling and mobility: A call to action 1 By Melissa A. Fitzpatrick “The way we’ve always done it” is no longer an acceptable rationale for manual patient handling and mobilization. We must change our mindset and embrace appropriate technology to keep ourselves and our patients safe from harm.

Elements of a successful safe 4 patient handling and mobility program By John Celona To build a successful program, identify your facility’s specific needs, design the program, obtain leaders’ and nurses’ commitment, and provide effective education and training.

Transforming the culture: 7 The key to hardwiring early mobility and safe patient handling By Kathleen M. Vollman and Rick Bassett Accomplishing early patient mobility and safe handling requires a culture change, deliberate focus, staff education, and full engagement.

Standards to protect 11 nurses from handling and mobility injuries By Amy Garcia Learn about ANA’s interprofessional national standards on safe patient handling and mobility, developed by a panel of interdisciplinary experts.

2 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Supplement to

www.AmericanNurseToday.com September 2014

Implementing a mobility assessment 13 tool for nurses By Teresa Boynton, Lesly Kelly, and Amber Perez The authors describe a nurse-driven tool you can use at the bedside to evaluate your patient’s mobility level and guide decisions about patient lifts, slings, and other technology.

The sliding patient: How to respond 17 to and prevent migration in bed By Neal Wiggermann Pulling patients up in bed carries a high risk of caregiver injury. Find out how to prevent patient migration and manage it safely when it occurs.

Prepare to care for patients of size 20 By Dee Kumpar Nearly a third of patient-handling injuries involve bariatric patients. Handling and mobilizing these patients safely requires skill and specialized technology.

Developing a sling management system 23 By Jan DuBose Disposable or launderable slings? In-house or outsourced laundering? These and other key decisions require input from all departments involved.

Making the business case for a safe patient 26 handling and mobility program By John Celona The author explains three approaches to justifying a safe patient handling and mobility program and presents a decision-analysis case study.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 3 Elements of a successful safe patient handling and mobility program Program success hinges on leaders’ and nurses’ commitment.

By John Celona, BS, JD

ince safe patient handling and mobility (SPHM) efforts Sbegan more than a decade ago, data show dramatic reductions in caregiver injuries after a safe patient handling and mobility (SPHM) program is implemented. So why doesn’t every healthcare facility have one? The first reason is cost. An SPHM program requires a sub- stantial outlay. Second, SPHM program results have been incon- sistent. Tales abound of equipment bought but not used because it’s too much trouble to fetch it from the closet, or because no one can locate the necessary sling. Finally, SPHM program value costs are clear but benefits are hard to quantify. This article addresses these issues by laying out the basic elements of a successful SPHM program. These elements can be divided into two broad categories—determining out what you need and making it happen. (See Simplifying the equation.)

Determining what you need Start by estimating how many patients on a given unit are totally

4 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Simplifying the equation This diagram shows in broad strokes how a healthcare organization can develop and imple- dependent on the nurse to lift or ment a safe patient handling and mobility program. mobilize them. Then estimate how many patients on the unit need Determining what you need partial assistance with mobility activities, such as toileting or moving from bed to chair. For each patient category, estimate the numbers and types of mobilization each will need over the course of an average stay. Types of mobilization include boosting, turning, moving from bed to chair, assisting with ambulation, and so on. For these categories and frequencies of mobilization tasks, figure out how much and what types of equipment are needed to eliminate variation in practice and standardize how to safely accomplish the task. In practice, most people develop rules of thumb or use intuition and experience rather than calcu- lating the four types of information described above. Also, vendors of handling and mobility equipment have experience in determining re- Compliance rate available, an organization can’t quired equipment. When designing and implement- standardize a new mobilization I’ve observed three different ap- ing an SPHM program, the compli- process, so the equipment gets proaches to supplying the equip- ance rate is the key variable an used for relatively few mobiliza- ment needed to mobilize patients: organization is driving. The com- tions. With higher investment lev- • installing overhead lifts—ceiling pliance rate is defined as the num- els, using the equipment becomes tracks to which lifting slings are ber of mobilizations for which part of caregivers’ routine, so the attached SPHM equipm ent is actually used, compliance rate goes up. • using portable lifts—floor- divided by the number of mobiliza- mounted structures for mobiliz- tions for which it should be used. Making it happen ing patients that can be moved The compliance rate is critical be- A successful SPHM program re- around as needed cause it drives program benefits. quires leadership commitment, • going the “equipment light” A rate of 0% means the equipment nursing commitment, and an edu- route—using a low-tech system is never used and isn’t producing cation and training plan. Leader- that combines slide sheets, limb benefits. A rate of 100% means ship commitment is needed to ap- lifters, and slide boards to mo- caregivers are using the equipment prove SPHM equipment purchase, bilize patients instead of using every time they should be, creat- design of training plans, and time ceiling-mounted or portable ing the maximum possible value away from duty for training. Such floor lifts. from the SPHM program. commitment is best obtained by Any of these approaches will A small level of investment in creating a business case to de- work to mobilize patients and SPHM equipment makes little dif- scribe the proposed SPHM pro- reduce caregiver injuries if the ference in the compliance rate or gram and quantify its total costs healthcare organization can get program results. Without the right and benefits, including return on staff to use them. amount or type of equipment investment (ROI). (See “Making

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 5 the business case for a safe pa- Why feedback is important ing more efficient lifting methods tient handling and mobility pro- Feedback is crucial for tracking and equipment might yield addi- gram” in this report.) and monitoring the SPHM program tional program benefits from time The entire nursing staff must be to determine how well it’s working. savings. Stanford University Med- committed, especially the chief Successful programs use two types ical Center compared the average nursing officer, who has to ap- of feedback. Compliance rate time for a chair-to-bed transfer prove the time required for staff monitoring gives some reassurance using ceiling lifts vs. portable training and education. Nursing that caregivers actually are using lifts. On average, a ceiling-lift commitment should be easy to get SPHM technology when they transfer was completed before the if the business case has identified should be. Such monitoring may portable-lift transfer even began. the program’s potential for reduc- be done indirectly by requiring an- These data were used to justify ing caregiver injuries, increasing nual staff certification to ensure ceiling lift installation in Stanford’s staff availability for duty due to in- they know how to use the equip- new hospital. jury reduction, and improving ment. Direct methods include ob- Monitoring SPHM program re- nursing retention and satisfaction. serving the unit to see if caregivers sults and comparing them against An education and training plan use appropriate SPHM methods. the potential results quantified in addresses which SPHM technolo- Some newer types of equipment the business case are crucial for gy is purchased, installed, and de- come with devices to measure how ensuring the program is working ployed and when and where it’s many times they’re used. as designed and the organization installed and deployed; who gets Program result monitoring, on is realizing the projected ROI. trained, at what level of training, the other hand, depends on SPHM When results vary from the ranges and when training takes place; program goals. These vary by identified in the business case, the and how program data will be facility but may include reduced cause must be identified and re- tracked and monitored to deter- caregiver injuries from patient medial action must be taken. mine if it’s achieving the intended handling, decreases in pressure Understanding and implement- results. In many cases, training ac- ulcers and patient falls, increased ing the essential elements of an counts for half or more of total patient and staff satisfaction, and SPHM program will help you en- SPHM program costs. improved staff retention. The busi- sure that your organization’s pro- ness case and ROI for the SPHM gram is successful and can truly Levels of expertise program should identify which achieve better outcomes for care- Three levels of expertise in using program results create the most givers and patients. 8 SPHM equipment and methods exist: value. Methods for monitoring • A facility champion can “train these results should be created if A valuable resource for establishing a safe patient handling and mobility pro- the trainers” and aid program they don’t already exist. gram is Implementation Guide to the Safe design and revision (adjusting Most SPHM programs monitor Patient Handling and Mobility Interprofes- the deployed equipment or workers’ compensation costs from sional National Standards, available at www.nursesbooks.org/SPHM-Package. training if needed). To be effec- caregiver injuries related to pa- tive, this person needs both ex- tient handling. Usually, this neces- Selected references tensive training and experience. sitates connecting incidence data Department of Veterans Affairs, Veterans Health • A super user (such as a unit on the types and causes of injuries Administration. VHA Directive 2010-032. Safe Patient Handling Program and Facility Design. peer leader at the Veterans (such as on the Occupational June 28, 2010. www.va.gov/vhapublications/ Health Administration) can train Safety and Health Administration’s ViewPublication.asp?pub_ID=2260. Accessed other caregivers in the unit and Form 300) with costs associated July 3, 2014. answer questions. Reaching this with those injuries (found in the Hodgson MJ, Matz MW, Nelson A. Patient handling in the Veterans Health Administration: fa- level of expertise requires in- workers’ compensation system). cilitating change in the health care industry. J depth training. Any equipment strategy (over- Occup Environ Med. 2013;55(10):1230-7. • A general caregiver knows head lifts, portable lifts, “equip- John Celona is a principal at Decision Analysis how to use SPHM technology ment light” or a combination) can Associates, LLC, in San Carlos, California. He is and methods but may not be drive a high compliance rate and the author of Decision Analysis for the Profes- qualified to train others. favorable program results. But us- sional, 4th ed.

6 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Transforming the culture: The key to hardwiring early mobility and safe patient handling Culture change requires deliberate focus, staff education, and full engagement.

By Kathleen M. Vollman, MSN, RN, CCNS, FCCM, FAAN, and Rick Bassett, MSN, RN, APRN, ACNS-BC, CCRN

arly mobility in the intensive care unit (ICU) is critical to a Epatient’s short- and long-term recovery. Studies show early mobility programs result in more ventilator-free days, fewer skin injuries, shorter ICU and hospital stays, reduced delirium duration, and improved physical functioning. But accomplishing early mobility requires significant coordina- tion, commitment, and physical effort by the multidisciplinary team. How do we balance the benefits of early mobilization against the potential risk of staff or patient injury during the mobilization activity? Part of the solution to ensuring safe mobilization of critically ill bility practices without a protocol, patients is to view mobilization and 52% hadn’t incorporated ear- along a continuum based on pa- ly mobility into routine care prac- tient readiness, progression based resources, patients’ physiologic in- tices. Barriers to implementation of on goals, strategies to prevent stability, lack of emphasis on the mobility initiatives included com- complications, and assessment of value and priority of mobilizing peting staffing priorities, insuffi- activity tolerance. This view keeps patients, and the ICU culture relat- cient physical therapy staff, and safety at the forefront. ed to mobility. A 2014 internation- concern about patient and care- Within the ICU, barriers to ear- al survey of early mobilization giver injury. The study found that a ly mobility may include clinicians’ practices in 833 ICUs found only standardized protocol may pro- knowledge deficits and fears, in- 27% had formal early mobility mote successful implementation of sufficient human and equipment protocols, 21% had adopted mo- an early mobility program.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 7 Learning progression for patient mobility This diagram shows the four stages of staff learning regarding early patient mobility and safe patient handling. Importance of a culture change Sustaining any clinical improve- Right type of support, right time ment initiative requires an organizational culture change. Baseline To progress to the next level: Educate regarding evidence and progressive mobility continuum, assessment of the current culture as use scenarios to build problem-solving skills well as early engagement of team around contingencies and high-risk patients. members is the starting point. In Leverage physical therapy in teaching nurses 2012, the authors led a VHA, Inc. specific skills. critical care improvement team col- laborative of 13 ICUs from eight Conscious STAGE 2: Conscious, STAGE 3: Conscious, organizations to implement safe unskilled skilled and effective early patient mobility “I care now, but I feel clueless.” “I know but need support and in the ICU. Efforts focused on extra time to execute.” • Staff are receptive to elements central to sustainable progressive mobility concepts. • Staff are ready to put progressive change. First, team members • Staff may be fearful of process mobility into daily practice. acquired key knowledge to under- and risks. • Staff are motivated by sense of stand why ICU mobility is impor- efficacy and success/failure tant. Next, strategies for organiza- experiences. 23 tional, leadership, and clinical staff engagement were discussed. To promote the transition in practice To progress to the next level: and the required culture change, Overcome staff's emotional and To progress to the next level: ICU clinicians needed guidance. intellectual barriers by using Coach and mentor staff during An organizational development storytelling and evidence, execution. Encourage through tool was designed to help teams engage in discussions and failure experiences (such as create an effective culture change. address positive/negative aspects patient not tolerating mobility), of immobility. Include sources and build sense of competence Although it was adapted specifical-

Consciousness (evidence and experience) by recognizing successes. ly to integrate with early patient outside the organization as well. mobility efforts in the ICU, this tool can be applied to other settings. (See Learning progression for pa- STAGE 1: Subconscious, STAGE 4: Subconscious, tient mobility.) unskilled skilled Three elements are crucial to “I don’t know why I should care “I am skilled and can help others.” successfully implementing and sus- about patient mobility.” • Staff skillfully put progressive taining an improvement initiative: • Staff are unclear on purpose mobility into daily practice. • Team members must understand behind progressive mobility. • Further staff learning is and be able articulate what’s • Old paradigms and enhanced by teaching and being proposed. To help them assumptions around immobility mentoring others. are present. understand, they must receive evidence-based literature and 1 To support4 process: educate staff regarding other relevant information. Subconscious how to effectively • Team members must grasp why mentor, coach. Unskilled Skilled the initiative is important to the Exapnd role: patient, themselves, and the or- storyteller, champion, ganization. Clinicians typically and mentor. respond favorably to change

8 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Decision tree for mobilizing hemodynamically unstable patients define the role of each team This diagram helps clinicians determine whether and when an intensive care unit patient is member and discipline. Under- ready to begin mobility activities. standing team roles creates a solid platform on which the culture change builds. Screen for mobility readiness within 8 hours of admission to the Key ICU and daily and initiate in-bed Four stages of learning HR: heart rate mobility strategies as soon as ICU: intensive care unit To learn a skill or concept, a per- possible. MAP: mean arterial pressure son progresses through four SBP: systolic blood pressure stages, according to a learning O2 sat: oxygen saturation model attributed to Abraham Is the patient hemodynamically Maslow. This model can be ap- unstable with manual turning? plied to clinicians learning about • O2 Sat ≤ 90% • New-onset cardiac arrhythmias safe patient handling and mobility No Begin in-bed mobility techniques or ischemia (SPHM). and progress to out-of-bed • HR < 60 or >120 mobility as the patient tolerates. • MAP < 55 or >140 Stage 1: Subconscious, • SBP < 90 or >180 unskilled • New or increasing vasopressor In this stage, team members are infusion unaware of how little they know and don’t realize a change is nec- Yes essary. Also, they may have fears Is the patient still and misconceptions about the hemodynamically unstable after No Begin in-bed mobility techniques change. For example, some criti- allowing a 5- to 10-minute and progress to out-of-bed cal care clinicians believe reposi- adaptation after position change mobility as the patient tolerates. tioning or mobilizing critically ill before determining tolerance? patients threatens the security of vital tubes and lines. But with the Yes proper knowledge, training, and No Allow the patient a minimum of 10 minutes of rest between resources, staff can mobilize and Have activities been spaced sufficiently to allow rest? activities and then try again to reposition ICU patients safely with- determine tolerance. out jeopardizing tubes and lines. Yes In one study, 1,449 activity events (such as sitting up in bed, sitting Has the manual position turn or No Try the position turn or head-of- in a chair, and ambulating) were head-of-bed elevation been bed maneuver slowly to allow performed with mechanically venti- performed slowly? adaptation of cardiovascular response to the inner-ear lated patients; fewer than 1% ex- postiion change. perienced adverse events. As part Yes of the culture change, misconceptions about SPHM need to be ad- Initiate continuous lateral rotation therapy via a protocol to dressed through education and train the patient to tolerate coaching. Once the purpose of turning. SPHM is defined clearly and mis- © 2012 Kathleen Vollman-Advancing Nursing LLC. conceptions have been addressed, team members are ready to move on to stage 2. team members understand why they may have fears about specif- Stage 2: Conscious, SPHM is important but don’t ic processes or actions involved unskilled know how to accomplish it. Al- in patient mobilization. For in- In the conscious, unskilled stage, though open to new learning, stance, they may fear certain

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 9 types of mobilization activities In bed and out-of-bed staff. During the transition from can cause hemodynamic instabili- activities stage 3 to stage 4, the skills and ty. Education and practical appli- Strategies to promote patient and knowledge required for the SPHM cation experiences can help them caregiver safety during mobiliza- initiative must become “hard- overcome this fear. Another way tion can be divided into two basic wired” or ingrained into care- educators can break through such categories—those used when the givers’ subconscious. This requires barriers is to use a decision tree patient is in bed and those used deliberate, focused energy on con- that incorporates the latest scien- when the patient is out of bed. In- tinued engagement. However, tific knowledge to help clinicians bed mobility encompasses reposi- staff energy, resource availability, minimize the hemodynamic im- tioning activities, lateral-rotation and competing priorities may pose pact or retrain patients to tolerate therapy, tilt-table exercises, and barriers to sustaining the change. movement. (See Decision tree for bed-chair sitting. Modern critical- Throughout stage 3, positive mobilizing hemodynamically un- care beds should be capable of ro- feedback, motivation, and sharing stable patients.) tating the patient continuously, cre- of successes and challenges are A critical resource used with ating a tilt table through the use of important for driving continual im- the VHA team was a nurse-driven, a reverse Trendelenburg position provement and culture change. evidence-based multidisciplinary and an adjustable footboard, pro- These goals can be accomplished progressive mobility continuum gressing the body through the in various ways. Here are some tool that addresses mobility phas- head elevation–foot down position examples: es and corresponding interven- to a chair, and ultimately assisting • Networking with other organi- tions. The team received education the patient with standing. These zations in various stages of the on the tool and how to apply it in features reduce the risk of patient practice change can be ex- and caregiver injury and make it tremely useful. It allows collabo- n-bed mobility encompasses easier to perform mobility actions. rative identification and sharing I For in-bed repositioning from of challenges, struggles, effec- repositioning side to side and moving up, using tive strategies, and success sto- a breathable glide sheet and spe- ries. This process creates syner- activities lateral-rotation cially designed foam wedges gistic energy among the team helps reduce shear and friction for members, helping to motivate therapy, tilt-table exercises, and the patient and help prevents in- them and accelerate the bed-chair sitting. juries to caregivers because they change. require a pulling rather than lifting • Within the VHA mobility collab- motion. In one study, implementa- orative network, teams shared practice. The tool provided a visu- tion of this turn-and-position system reward strategies. One team al foundation to guide safe mobili- reduced hospital-acquired pres- gave out M&Ms® when “caught ty practices, create consistency, sure ulcers by 28% and reduced in the act” of Moving and Mo- promote team communication, and staff injuries by 58%. Lifts can be bilizing patients. Such moments enhance processes. used for some in-bed mobility ac- present crucial coaching oppor- Numerous studies show that ed- tivities and are effective during tunities. For example, after a ucation, skill building, and proto- ambulation and the transition from mobility event, staff can huddle cols may not be enough to create in-bed to out-of-bed activities. briefly to discuss the event and sustainable change. Using strate- what, if any, improvements gies to evaluate available nursing Stage 3: Conscious, skilled could be made to make the resources and systems that can Stage 3 learning focuses on imple- process more effective. produce change makes it easier menting the change, with attention for clinicians to provide the right to fine-tuning the process. Coach- Stage 4: Subconscious, care for the right patient at the ing, mentoring, and maintaining skilled right time while balancing these engagement are critical. In previ- During this stage, the practice and needs against caregivers’ needs ous stages, much effort was ex- culture changes are well on their for safety. pended in educating and training (continued on page 25)

10 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Standards to protect nurses from handling and mobility injuries Learn about ANA standards that help safeguard both nurses and patients.

By Amy Garcia, MSN, RN, CAE

he intense focus on safe patient handling and mobility T(SPHM) in acute and long- term care has yielded a valuable benefit for nurses and other healthcare workers—a decrease in staff lifting injuries for the first time in 30 years. Nonetheless, nurses still suffer more musculoskeletal disorders than employees in the manu- facturing, construction, and ship- building industries. Many employers and nurses believe lifting injuries can be pre- vented by using proper body mechanics and that lifting equipment most patients’ weight. experts to develop standards. Par- is warranted only for obese A patchwork of regulations with- ticipants included representatives of adults. But the evidence contra- out teeth contributes to a hazardous patients; nursing; surgery; therapy; dicts this notion. The National In- environment for caregivers and biomedical engineering; risk man- stitute of Occupational Safety and patients. Congress passed the er- agement; architecture; law; acute, Health calculates maximum loads gonomic standard of the Occupa- long-term, home health, and hos- for manual lifting, pushing, tional Safety & Health Administra- pice care; the military; Department pulling, and carrying using a tion in 2000 but rescinded it in of Defense; certain government range of variables. Typically, a 2001 before the regulations could agencies; vendors; and profession- maximum load for a box with han- take effect. Only 10 states have al associations. dles is 51 lb (23 kg)—lower when laws requiring comprehensive In 2013, ANA published Safe the lifter has to reach, lift near the SPHM programs, typically targeting Patient Handling and Mobility: In- floor, or assume a twisted or awk- acute and long-term care settings. terprofessional National Standards ward position. Of course, patients Across the Care Continuum. Previ- don’t come in simple shapes or ANA standards ousdocum ents referred to safe pa- have handles. They may sit or lie The American Nurses Association tient handling and movement. The in awkward positions, move unex- (ANA) recognized the need for a workgroup changed the terminolo- pectedly, or have wounds or de- standard of care that applies to all gy from movement to mobility to vices that interfere with lifting. Al- healthcare disciplines and encom- distinguish patient-initiated mobility though proper body mechanics passes the entire continuum of care. from movement accomplished by and good lifting technique are im- In 2012, ANA convened an inter- others. Also, nurses use the word portant, they don’t compensate for professional group of subject matter mobility differently than physical or

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 11 occupational therapists. The termi- is an important step toward mini- sist on manual handling. It outlines nology change is designed to mizing risk to patients and nurses. the importance of using SPHM tech- align our practices with patients’ nology in a therapeutic manner, needs and highlight new research Standard 3: Incorporate er- with the goal of promoting inde- on the importance of early and gonomic design principles to pro- pendence. Nurses working in reha- progressive mobility in the inten- vide a safe care environment. bilitation or assisted-living settings sive care unit. The workgroup also This standard is based on the con- may believe using lifts or other tech- chose the term technology to de- cept of prevention through design, nology limits the patient’s independ- scribe all lifts, slings, slide sheets, which considers the physical lay- ence, but selecting SPHM techn- computer programs, and other out, work-process flow, and use of ology to be used in a progressive items used to promote patient mo- technology to reduce exposure to manner can provide support and a bility. It decided that the term injury or illness. Healthcare facili- sense of safety as the patient gains healthcare recipient is more inclu- ties should consider diverse per- or regains independent movement. sive than patient for general use. spectives, including those of nurs- For example, a patient may need es and therapists, when planning full-body lift technology immediately A closer look at the for construction or remodeling. after surgery, but then progress to a standards sit-to-stand lift for bedside toileting The eight ANA standards are Standard 4: Select, install, and and then to technology that sup- complemented by substandards, maintain SPHM technology. This ports ambulation. examples, resources, and metrics standard provides guidance in se- for evaluation. lecting, installing, and maintaining Standard 7: Include SPHM in SPHM technology. It emphasizes reasonable accommodation and Standard 1: Establish a culture the importance of investing in ap- post-injury return to work. This of safety. This standard calls for propriate amounts and types of standard promotes an employee’s the employer to establish a com- SPHM technology to meet the early return to work after an injury mitment to a culture of safety. This needs of patients in the organiza- and use of differently abled work- means prioritizing safety over tion’s specific environment. ers through a comprehensive competing goals in a blame-free SPHM program. environment where individuals can Standard 5: Establish a system report errors or incidents without for education, training, and main- Standard 8: Establish a compre- fear. The employer is compelled to taining competence. This stan- hensive evaluation system. The fi- evaluate systemic issues that con- dard outlines employee (and vol- nal standard calls for a compre- tribute to incidents or accidents. unteer) training and education hensive evaluation system for each The standard also calls for safe needed to participate in the SPHM SPHM program component, with staffing levels and improved com- program. Education should be remediation of deficiencies. munication and collaboration. multidisciplinary and include docu- The appendix of Safe Patient Every organization should have a mented demonstration of compe- Handling and Mobility provides procedure for nurses to report tency before the employee uses an extensive list of resources for safety concerns or refuse an as- SPHM technology. meeting each standard. To order signment due to concern about pa- the ANA book and the accompa- tients’ or their own safety. Standard 6: Integrate patient-cen- nying Implementation Guide to the tered SPHM assessment, plan of Safe Patient Handling and Mobili- Standard 2: Implement and sus- care, and use of SPHM technolo- ty Interprofessional National Stan- tain an SPHM program. This stan- gy. This standard focuses on the pa- dards, visit www.nursesbooks.org/ dard outlines SPHM program com- tient’s needs by establishing assess- SPHM-Package. 8

ponents, including an assessment, ment guidelines and developing an Visit www.AmericanNurseToday.com/ written program, funding, and individual plan of care. It also ad- Archives.aspx for a list of selected references. matching the program to the spe- dresses the need to establish an or- Amy Garcia is chief nursing officer for Cerner cific setting. Evaluating the physi- ganizational policy on the rights of Clairvia, specializing in workforce issues and was cal requirements of a task or role patients or family members who in- the technical writer for the SPHM standards.

12 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Implementing a mobility assessment tool for nurses A nurse-driven assessment tool reveals the patient’s mobility level and guides SPHM technology choices.

By Teresa Boynton, MS, OTR, CSPHP; Lesly Kelly, PhD, RN; and Amber Perez, LPN, BBA, CSPHP

patient’s mobility status affects treatment, handling A and transfer decisions, and potential outcomes (including falls). Hospital patients spend most of their time in bed—sometimes coping with inadvertent negative effects of immobility. Assessing a patient’s mobility status is crucial, especially for evaluating the risk of falling. Yet no valid, easy-to- administer bedside mobility assessment tool exists for nurses working in acute-care settings. Various safe patient handling and mobility (SPHM) technologies allow safe transfer and mobilization of patients while permitting maximum patient participation and weight-bearing (if indicated). A mobility assessment helps identify the SPHM technology needed to ensure safe activities while taking the guesswork and uncertainty out of deciding which SPHM technolo- need for SPHM technology. For and management have been un- gy is right for which patient. both patient and staff safety, a pa- der the purview of physical thera- Because mobility is so impor- tient’s mobility level must be linked pists (PTs) through consultations. tant during hospitalization, mem- with use of SPHM technology. But the entire healthcare team bers of a Banner Health multidisci- When used consistently, appropri- needs to address patient mobility. plinary SPHM team determined ate technology reduces the risk of Nurses conduct continual surveil- nurses should take a more active falls and other adverse patient out- lance of patients and their pro- role in assessing and managing comes associated with immobility. gress, but typically they haven’t patient mobility. We concluded it (See The link between patient im- performed consistent, validated was crucial to develop and vali- mobility and staff injuries.) mobility assessments. Instead, date a tool that nurses can use they’ve relied on therapy services easily at the bedside to assess a Communication barriers to determine the patient’s mobility patient’s mobility level and the Historically, mobility assessments level and management.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 13 The link between patient immobility and staff injuries Current mobility Patient immobility poses the risk of injury to healthcare workers. Nurse workloads continue to assessment options rise as patient acuity levels increase and hospital stays lengthen. This situation increases patients’ dependence on nurses for assistance with their mobility needs. Although tools to assess mobility What’s more, nursing staff frequently rely on the patient or a family member to report the and guide SPHM technology selec- patient’s ability to stand, transfer, and ambulate. But this information can be unreliable, espe- tion are used in hospitals, their val- cially if the patient has cognitive impairment related to the diagnosis or medications or if he or ue for the bedside nurse may be she has experienced unrecognized decreased mobility and deconditioning from the disease or injury that necessitated hospitalization. limited or inappropriate with many To decrease the risk of caregiver injury, nurses should assess patient mobility and use safe patients inacut e-care settings. patient handling and mobility (SPHM) technology. SPHM algorithms from the Depart- ment of Veterans Affairs have been valuable as training and decision- ed to perform SPHM. Especially if making tools in determining which Nurses aren’t trained in PTs aren’t available, nurses must SPHM technology to consider for rely on their own judgment to specific tasks. But these can be skilled therapy move and mobilize patients safely. hard to use at the bedside. Also, and may be ill But they may be uncertain as to they assume the patient’s mobility techniques which equipment to use for which status is known and don’t provide prepared to mobilize patients patients. While a total lift may be quick guidance in determining a used with many patients, such a patient’s overall mobility level. safely during routine daily lift doesn’t maximize the patient’s (See Limitations of common mobili- activities. mobility potential. ty assessment tools.)

In many cases, though, a PT’s Limitations of common mobility assessment doesn’t translate to assessment tools meaningful actionable items for Several of the mobility assessment tools discussed below already are in use, but nurses. What’s more, PTs don’t al- each has certain drawbacks. ways adequately communicate a The Timed Get Up and Go Test starts by having patient’s SPHM needs to other the patient stand up from an armchair, walk 3 healthcare team members. For ex- meters, turn, walk back to the chair, and sit down. ample, confusion surrounds termi- But it gives no guidance on what to do if the patient can’t maintain seated balance, bear weight, nology typically used by PTs, such or stand and walk. as numeric mobility levels (1+, 2+, The Quick 5 Bedside Guide tool, developed by indicating a one-person or two- a registered nurse and physical therapist (PT), person assist, respectively) as well was the basis for a research project on what be- as ranges (minimum, moderate, or came known as the Quick 3. This tool takes the patient through three functional tasks but doesn’t maximum assist by one or more fully address patient limitations. Nor does it rec- healthcare workers). Also, PTs are ognize weight-bearing limitations or address the consulted only for a limited num- issues or abilities of an ambulatory patient. Also, ber of patients and at different it provides only limited recommendations for points during the hospital stay. SPHM technology. Nurses, for their part, aren’t The Egress test, also developed by a PT, is used in hospital settings. It starts with the patient per- trained in skilled therapy tech- forming three repetitions of sit-to-stand, at the niques and may be ill prepared to bedside, marching in place, and advance step and mobilize patients safely during return with each foot. But it’s tailored to PTs and routine daily activities. doesn’t address how the patient performs bed mobility or comes to a standing po- In addition to communicating sition. Also, it gives only limited guidance for nurses on use of SPHM technology and isn’t appropriate for certain patients (such as those unable to weight bear on potential risk to other healthcare one or both legs). team members, mobility assessment can identify technology need-

14 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Banner Mobility Assessment Tool for nurses Nurses have found that the Banner Mobility Assessment Tool (BMAT) is an effective resource for performing a bedside assessment of patient mobility.

Fail = Choose most appropriate Test Task Response equipment/device(s) Pass

Assessment Sit and shake: From a semi-reclined Sit: Patient is able to follow MOBILITY LEVEL 1 Passed Assessment Level 1 position, ask patient to sit upright and commands, has some trunk strength; • Use total lift with sling and/or Level 1 = Proceed Assessment of: rotate* to a seated position at side caregivers may be able to try weight- repositioning sheet and/or straps. with Assessment •Trunk strength of bed; may use bedrail. bearing if patient is able to maintain • Use lateral transfer devices, such Level 2. • Seated balance Note patient’s ability to maintain seated balance longer than 2 minutes as roll board, friction-reducing bedside position. (without caregiver assistance). device (slide sheets/tube), or Ask patient to reach out and grab your Shake: Patient has significant upper air-assisted device. hand and shake, making sure patient body strength, awareness of body in Note: If patient has strict bed rest reaches across his/her midline. space, and grasp strength. or bilateral non-weight-bearing restrictions, do not proceed with the assessment; patient is MOBILITY LEVEL 1.

Assessment Stretch and point: With patient in Patient exhibits lower extremity MOBILITY LEVEL 2 Passed Assessment Level 2 seated position at side of bed, have stability, strength and control. •Use total lift for patient unable to Level 2 = Proceed Assessment of: patient place both feet on floor (or stool) May test only one leg and weight- bear on at least one leg. with Assessment • Lower extremity with knees no higher than hips. proceed accordingly (e.g., • Use sit-to-stand lift for patient who Level 3. strength Ask patient to stretch one leg and stroke patient, patient with can weight-bear on at least one leg. •Stability straighten knee, then bend ankle/flex ankle in cast). and point toes. If appropriate, repeat with other leg.

Assessment Stand: Ask patient to elevate off bed or Patient exhibits upper and lower MOBILITY LEVEL 3 Passed Assessment Level 3 chair (seated to standing) using assistive extremity stability and strength. • Use non-powered raising/stand aid; Level 3 AND no Assessment of: device (cane, bedrail). May test with weight-bearing default to powered sit-to-stand lift assistive device • Lower extremity Patient should be able to raise buttocks on only one leg and proceed if no stand aid is available. needed = Proceed strength for off bed and hold for a count of five. May accordingly (e.g., stroke patient, •Use total lift with ambulation with Assessment standing repeat once. patient with ankle in cast). accessories. Level 4. Note: Consider your patient’s cognitive If any assistive device (cane, • Use assistive device (cane, walker, Consult with ability, including orientation and CAM walker, crutches) is needed, crutches). physical therapist assessment if applicable. patient is Mobility Level 3. Note: Patient passes Assessment Level when needed 3 but requires assistive device to and appropriate. ambulate or cognitive assessment indicates poor safety awareness; patient is MOBILITY LEVEL 3.

Assessment Walk: Ask patient to march in place at Patient exhibits steady gait and good MOBILITY LEVEL 3 MOBILITY LEVEL 4 Level 3 bedside. Then ask patient to advance balance while marching and when If patient shows signs of unsteady gait MODIFIED Assessment of: step and return each foot. stepping forward and backward. or fails Assessment Level 4, refer INDEPENDENCE • Standing balance Patient should display stability while Patient can maneuver necessary turns back to MOBILITY LEVEL 3; Passed = No • Gait performing tasks. for in-room mobility. patient is MOBILITY LEVEL 3. assistance needed Assess for stability and safety awareness. Patient exhibits safety awareness. to ambulate; use your best clinical judgment to determine need for supervision during ambulation.

Always default to the safest lifting/transfer method (e.g., total lift) if there is any doubt about the patient’s ability to perform the task.

Banner Mobility nurse-driven bedside assessment achieve (such as mobility level Assessment Tool of patient mobility. It walks the 1). Then it guides the nurse to the At Banner Health, we developed patient through a four-step func- recommended SPHM technology the Banner Mobility Assessment tional task list and identifies the needed to safely lift, transfer, Tool (BMAT) to be used as a mobility level the patient can and mobilize the patient. (See

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 15 Banner Mobility Assessment Tool appropriate interventions are im- or require greater focus. Although for nurses.) plemented and the outcomes eval- we know nurses should be more in- uated. Nurses need to be empow- volved in assessing mobility than Implementing BMAT ered and able to recognize the they have been historically, we rec- The BMAT was created in our hos- connection between these assess- ognize the value of involving and pital’s electronic medical record ments and choice of interventions, communicating effectively with all (EMR) in a way that guides the including SPHM technology. members of a good interdiscipli- nurse through the assessment Here’s an example of BMAT in nary team to help reduce patient steps. Patients are determined to action at Banner: A 35-year-old falls and staff injuries caused by have a mobility level of 1, 2, 3, male was admitted to a surgical patient handling. 8 or 4 based on whether they pass floor late in the evening. He was Selected references or fail each assessment level. Edu- 6'2" tall and weighed 350 lb Dionne M. Practice Management: Stand and de- cational tools and tip sheets are (158 kg). He didn’t want to use a liver. Physical Therapy Products. March 2005. used to train nurses and support bedpan, but his nurse wasn’t com- www.ptproductsonline.com/2005/03/stand- staff on what technology to consid- fortable getting him up to use the and-deliver/. Accessed June 30, 2014. er for patients at each level. bathroom because he hadn’t been Hook ML, Devine EC, Lang NM. Using a com- puterized fall risk assessment process to tailor evaluated by physical therapy, interventions in acute care. In: Henriksen K, Bat- and a PT wasn’t available in the tles JB, Keyes MA, Grady ML, eds. Advances in o stay current on the patient’s evening. A nurse passing by Patient Safety: New Directions and Alternative T Approaches; vol 1. Assessment. AHRQ Publica- who’d used the BMAT (which had- tion No. 08-0034. Rockville, MD: Agency mobility status nurses are n’t been formally rolled out Ban- for Healthcare Research and Quality; 2008. ner-wide at that time) came in and www.ncbi.nlm.nih.gov/books/NBK43610. Ac- expected to complete the BMAT on assessed the patient; the assess- cessed July 10, 2014. ment found him at mobility level 3. Mathias S, Nayak US, Isaacs B. Balance in eld- admission, once per shift, and with erly patients: the “get-up and go” test. Arch He was transferred to the toilet us- Phys Med Rehabil. 1986;67(6):387-9. the patient status changes. ing a nonpowered stand aid. Both Oliver D, Healey F. Falls risk prediction tools for patient and nurse were relieved hospital inpatients: do they work? Nurs Times. and happy. 2009;105(7):18-21. Communication tools also are Oliver D, Healey F, Haines TP. Preventing falls used. For instance, a sign outside A step in the right and fall-related injuries in hospitals. Clin Geriatr Med. 2010;26(4):645-92. the patient’s room indicates his or direction Nelson AL. Safe patient handling and move- her mobility level, instantly telling As a quick bedside assessment ment: A guide for nurses and other health care anyone passing by or entering if tool, the BMAT is a step in the right providers. New York, NY: Springer Publishing the patient can ambulate inde- direction. It’s part of a broad pro- Company, Inc.; 2006. www.springerpub.com/ samples/9780826163639_chapter.pdf. Ac- pendently or if SPHM technology gram of increased staff awareness, cessed June 30, 2014. must be used. To stay current on education, and training around pa- Nelson A, Harwood KJ, Tracey CA, Dunn KL. the patient’s mobility status (for in- tient assessments, preventing staff Myths and facts about safe patient handling in stance, at handoffs, after proce- injuries and patient falls, and rehabilitation. Rehabil Nurs. 2008;33(1):10-7. dures, with medication changes, achieving better patient outcomes. Wright B, Murphy J. “Quick-5 Bedside” Guide. or after a potentially tiring therapy Initial evidence from a validation Franklin, MA: Liko, Inc.; 2005. session), nurses are expected to study completed at one Banner hos- Teresa Boynton is an injury prevention and complete the BMAT on admission, pital supports the BMAT as a valid workers’ compensation consultant, ergonomics once per shift, and with the pa- instrument for assessing a patient’s specialist, and certified safe patient handling tient status changes. The BMAT mobility status at the bedside. professional for Risk Management at Banner also is linked to Banner’s fall as- As we work toward customizing Health, Western Region, based in Greeley, Col- sessment risk in the EMR. actions and interventions to meet orado. Lesly Kelly is the RN clinical research program director for Banner Good Samaritan Throughout BMAT implementa- individual patient needs, we contin- Medical Center in Phoenix, Arizona. Amber tion, we recognized that identify- ue to evaluate which additional as- Perez is a safe patient handling clinical con- ing a patient’s mobility level and sessment components or fall inter- sultant for Handicare North America based in fall risk score are pointless unless ventions or precautions are needed Phoenix, Arizona.

16 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com The sliding patient: How to respond to and prevent migration in bed Migration can cause negative patient outcomes and caregiver injuries resulting from repositioning.

By Neal Wiggermann, PhD

n hospital settings, where the A 1995 study at one hospital carries an extremely high risk of head of the bed (HOB) com- found nurses pulled patients up in caregiver injury. Less research Imonly is elevated, gravity caus- bed an average of 9.9 times per has been done on the effects of es patients to slide, or migrate, shift. More recent evidence sug- migration on patients. This article toward the foot of the bed. Nurs- gests this activity may be even describes how migration can af- es are well aware of this, as more common in some hospitals fect patient outcomes, outlines rel- they’re regularly required to pull and units. evant scientific evidence, and dis- patients back toward the HOB if Studies show that pulling pa- cusses strategies for managing they can’t reposition themselves. tients who’ve migrated in bed patient migration.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 17 Considerations when purchasing hospital beds n't been studied for hospital beds, Before purchasing hospital beds, clinicians and hospital purchasing staff should evaluate relevant manufacturer claims and test data to determine how well the product performs to reduce it’s reasonable to expect migration patient migration. Keep the following points in mind. would result in discomfort, espe- • Migration test results may vary based on methodology, so be suspicious of marketing cially in patients with low back materials that don’t describe test methods. pain or disc herniation. • Consider the relevance of test conditions to their clinical application. Responding to patient • Be aware that a proper experimental design can improve test result accuracy. For example, a laboratory motion-capture system produces less error than a tape measure, and a migration large subject sample (10 or more) with subjects of varied heights and weights is more ac- To help prevent negative outcomes curate than a small or homogenous sample. associated with patient migration, • Make sure migration is reported with respect to the bed surface. Because the top sections be diligent in repositioning pa- of some hospital bed frames can move back relative to the floor, measuring migration tients who’ve migrated downward. relative to the floor rather than the bed surface can lead to the mistaken conclusion that But be aware that repositioning is a patient has migrated several inches less than he or she actually has. most likely to affect outcomes related to torso angle (such as VAP, reduced lung capacity, and discom- Negative effects of tion decreases. A pilot investiga- fort)—not friction and shear linked migration tion of 10 healthy subjects lying to pressure-ulcer development. A 2013 study found that patients with the HOB at 30 degrees Among patients unable to boost or in traditional hospital-bed designs showed their torso angle was reposition themselves in bed, migrated about 13 cm (5") when about 30 degrees when properly those on mechanical ventilators the HOB was raised to 45 de- aligned with the hip indicator, and those with back pain may be grees. Both bed movement and compared to about 12 degrees most in need of repositioning by gravity cause patients to slide when they migrated 23 cm (9") the nurse. down in bed over time if the HOB past the hip indicator. Repositioning patients manual- is kept elevated. Such migration Positioning the HOB at or ly is associated with a high risk presumably causes friction and above 30 degrees is intended of musculoskeletal injury, so al- to reduce the risk of ventilator- ways use repositioning aids for associated pneumonia (VAP) be- patients unable to reposition cause torso elevation decreases themselves. Using lift equipment, Once patients have migrated the risk of aspirating gastric con- such as a ceiling-mounted or mo- tents into the lungs. Once patients bile lift, is the best way to reduce farther down the mattress, have migrated farther down the healthcare worker strain, accord- the HOB may no mattress, elevating the HOB may ing to the American Nurses Asso- elevating no longer reduce aspiration risk ciation’s Safe Patient Handling longer reduce aspiration risk. because their torsos are flatter. At and Mobility: Interprofessional that point, if they’re not reposi- National Standards, which calls tioned, they may be at increased for eliminating manual lifting in risk for VAP. all healthcare settings. shear forces between the mattress When patients migrate down in If lift equipment isn’t available, and skin as the patient slides bed with the HOB up, they slide use a friction-reducing sheet and against the bed surface. Although out away from the pivot of the place the bed in the Trendelenburg friction and shear have been HOB section and the lumbar spine position (if the patient can tolerate linked to pressure-ulcer format ion, goes unsupported, causing kypho- it). If the patient is on an air sur- no research has evaluated whether sis. Kyphosis reduces lung capaci- face, use the “max inflate” func- friction and shear caused by mi- ty, so respiratory function may tion. Patients who can provide par- gration directly contribute to pres- diminish in patients who’ve migrat- tial assistance should participate in sure-ulcer risk. ed. Although the relationship be- mobilization by placing their feet As patients migrate toward the tween kyphotic postures caused flat on the mattress and “bridging” foot of the bed, the torso eleva- by migration and discomfort has- when being repositioned. The pa-

18 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com tient also may pull on traction factors as predictors of intense or disabling low equipment, a trapeze bar, or the Be aware that any method back pain; a prospective study of nurses’ aides. Occup Environ Med. 2004;61(5):398-404. bed side rails, if available. that involves manual Kotowski SE, Davis KG, Wiggermann N, However, be aware that any Williamson R. Quantification of patient migra- method that involves manual lifting lifting can cause injury tion in bed: catalyst to improve hospital bed de- can cause injury to the nurse. One sign to reduce shear and friction forces and nurs- researcher found that based on to the nurse. es’ injuries. Hum Factors. 2013;55(1):36-47. the postures adopted when han- Lin F, Parthasarathy S, Taylor SJ, et al. Effect of different sitting postures on lung capacity, expi- dling patients, caregivers who lift ratory flow, and lumbar lordosis. Arch Phys with forces above 16 kg (35 lb) Med Rehabil. 2006;87(4):504-9. are at increased risk of injury. The cm (5" to 11"). Most likely, migra- Marras WS, Davis KG, Kirking BC, Bertsche PK. most effective way to prevent self- tion caused by bed movement will A comprehensive analysis of low-back disorder risk and spinal loading during the transferring injury when repositioning patients continue to decrease as manufac- and repositioning of patients using different is to use a ceiling-mounted or mo- turers develop beds more compati- techniques. Ergonomics. 1999;42(7):904-26. bile lift. An air-assisted lateral ble with the changing geometry of Mehta RK, Horton LM, Agnew MJ, Nussbaum transfer device also can be used the patient as the HOB rises. (See MA. Ergonomic evaluation of hospital bed de- to reposition the patient up in bed. Considerations when purchasing sign features during patient handling tasks. Int J Ind Ergon. 2011;41(6):647-52. hospital beds.) Preventing migration Metheny NA, Davis-Jackson J, Stewart BJ. Effec- More research is needed to tiveness of an aspiration risk-reduction protocol. Despite the impact of migration on confirm indications that patient Nurs Res. 2010;59(1):18-25. patients and caregivers, little re- migration toward the foot of the Michel DP, Helander MG. Effects of two types of search exists on how to prevent it. bed increases pressure-ulcer and chairs on stature change and comfort for indi- The bed’s contribution to migration VAP risk, causes patient discom- viduals with healthy and herniated discs. Er- gonomics. 1994;37(7):1231-44. has been investigated in laborato- fort, and reduces lung capacity. Poole-Wilson T, Davis K, Daraiseh N, Kotowski ry studies, but patient movement Many tools are available to help S. Documenting the amount of manual handling has yet to be studied. nurses safely reposition patients performed by nurses in a hospital setting. Pro- To limit migration when articu- who’ve migrated. Using auto- ceedings of 2014 Symposium on Human Fac- tors and Ergonomics in Health Care: Leading lating the bed, use auto-contour (a contour when raising the HOB or the Way. Chicago, IL: The Human Factors and knee gatch that rises automatically the knee gatch may help prevent Ergonomics Society; 2014. and simultaneously as the HOB migration or slow its rate. Design Skotte J, Fallentin N. Low back injury risk during rises) to reduce migration by up to of the bed’s articulation also af- repositioning of patients in bed: the influence of 2.5 cm (1"). If the bed doesn’t fects the distance that a patient handling technique, patient weight and disabili- ty. Ergonomics. 2008;51(7):1042-52. have auto-contour, raise the knee migrates. 8 Vasiliadou A, Karvountzis GG, Soumilas A, gatch before raising the HOB. Be- Roumeliotis D, Theodosopoulou E. Occupational sides limiting migration from bed Selected references low back pain in nursing staff in a Greek hospi- articulation, keeping the patient’s American Nurses Association. Safe Patient Han- tal. -J Adv Nurs. 1995;21(1):125-30. dling and Mobility: Interprofessional National knees raised also may help limit Waters TR. When is it safe to manually lift a pa- Standards. Silver Spring, MD: Author; 2013. tient? Am J Nurs. 2007;107(8):53-9. migration over time. Of course, Bakker EW, Verhagen AP, van Trijffel E, Lucas these strategies can be used only Wiggermann NE, Vangilder C, Davis K. Patient C, Koes BW. Spinal mechanical load as a risk migration toward the foot of the bed affects tor- if the patient can tolerate knee factor for low back pain: a systematic review of so angle. 2014 National Teaching Institute Re- bending. prospective cohort studies. Spine (Phila PA search Abstracts. http://ajcc.aacnjournals.org/ 1976). 2009;34(8): E281-93. Design of the bed-frame articu- content/23/3/e19.full?sid=039ddc07-4db1- Bartnik LM, Rice MS. Comparison of caregiver 4bc4-aaca-5855cc684831#sec-175. Accessed lation seems to have an even big- forces required for sliding a patient up in bed July 15, 2014. ger effect than auto-contour on the using an array of slide sheets. Workplace Williams MM, Hawley JA, McKenzie RA, van amount of patient migration. For Health Saf. 2013;61(9):393-400. Wijmen PM. A comparison of the effects of two example, across three different Drakulovic MB, Torres A, Bauer TT, et al. sitting postures on back and referred pain. Supine body position as a risk factor for noso- Spine (Phila Pa 1976). 1991;16(10):1185-91. bed-frame designs, mean cumula- comial pneumonia in mechanically ventilated tive movement (total amount of patients: a randomised trial. Lancet.1999;354 Neal Wiggermann is a senior biomedical engi- sliding when raising and lowering (9193):1851-8. neer and ergonomics specialist for Hill-Rom in the HOB) ranged from 13 to 28 Eriksen W, Bruusgaard D, Knardahl S. Work Batesville, Indiana.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 19 Prepare to care for patients of size How to make mobilization and lifting safer for bariatric patients and staff

By Dee Kumpar, MBA, BSN, RN, CSPHP

thrombosis, muscle wasting, and pneumonia. Increased patient size is a significant barrier to early mobility, as are lack of proper equipment to lift and move the patient. Yet providing early mobilization for dependent patients is challenging, and when they’re large, it may seem overwhelming. The bariatric patient may be at even greater risk for immobility and deconditioning during hospitalization because nurses may fear they’ll in- jure themselves while providing patient care. Manual patient mobilization increases the risk of muscu- roviding care for bariatric available to help nurses and other loskeletal injury to caregivers. One patients is a concern for healthcare professionals care for study found that although bariatric Phealthcare facilities and staff and support best practices for patients accounted for less than everywhere. Delayed patient mo- bariatric patients. (See Bariatrics 10% of the patient census inacut e- bilization due to fear of injury and by the numbers.) care facilities, patient-handling in- lack of proper policy, knowledge, juries involving them accounted for or equipment for handling these Mobility matters 29.8% of staff-reported injuries. patients can lead to poor out- When patients can’t mobilize inde- Safe patient handling and lifting comes—and may pose legal and pendently, they rely on nursing and requires skill and specialized prod- ethical concerns. Specialized physical therapy staff to prevent im- ucts that support early mobility, lift- equipment, beds, patient lifts, and mobility complications—pressure ing, and ambulation. surgical instruments must be made ulcers, contractures, deep vein Bariatric patients may fear falling and may be embarrassed that it takes four or five people to lift, move, or support them during Bariatrics by the numbers toileting or out-of-bed activities. In 2011, the Centers for Disease Control and Prevention reported that 69% of adults were over- They may have moderate to se- weight, including 35% who were obese. Among adolescents ages 12 to 19, 18.4% were obese; vere mobility limitations due to among children ages 6 to 11, 18% were obese; and among children ages 2 to 5, about 12% body type, decreased range of were obese. Obesity is defined as a body mass index (BMI) of 30 to 39; morbid obesity, a BMI of 40 or higher. Overweight is defined as a BMI between 25 and 29.9. motion at the hip and knee, gener- Overweight and obese persons are at increased risk for many diseases and disorders, includ- alized adiposity, and location and ing type 2 diabetes, hypertension, hyperlipidemia, coronary heart disease, gallbladder disease, size of the pannus (a dense layer cancer, osteoarthritis, sleep apnea, and depression. of fatty tissue over the lower ab- dominal area).

20 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Promoting a culture of Other assessment considera- Facility Guidelines Institute, titled safety tions include: Patient handling and mobility as- As a nurse, you can lead the way • weight-bearing capability (full, sessment (FGI-PHAMA), provides to creating and maintaining a cul- partial, or none) recommendations for the right ture of safety by supporting and • whether the patient has bilater- amount of equipment in the right modeling safe patient-handling al upper-extremity strength location based on the specific practices on your unit. A focused • patient’s level of cooperation needs of patients on each type of approach to managing bariatric and comprehension unit. (The ANA publication men- patients’ mobility needs requires • medications, such as vasopres- tioned above cites this document thoughtful planning and knowl- sors and paralytics as supporting evidence on select- edge of the technology designed • conditions that may affect to support care for these patients choice of transfer technique, Barriers to moving independently— throughout their entire stay. Lifting such as stomas, fractures, severe and mobility practices can be edema, or joint replacements. not the patient’s weight—should standardized successfully if nurses be the main criteria for determining have a voice in developing a safe For more information on assess- patient-handling and mobility ment, read “Implementing a mobil- the need for lift equipment. (SPHM) program and in selecting ity assessment tool for nurses” in SPHM technology. this supplement. ing and using lift equipment.) For example, we know many patients Assessing the level of Patient-handling in intensive care units (ICUs) are assistance needed algorithms dependent and must rely on nurses Changing practice begins with In 2003, the Veterans Administra- to boost, turn, and reposition them evaluating the types of lifting and tion created algorithms to provide frequently throughout the day. FGI- moving tasks required. Bariatric pa- guidance on how to safely per- PHAMA recommends 100% ceil- tients may need assistance with form high-risk activities related to ing lift coverage in ICUs to ensure common activities, such as toileting, patient handling and movement. patient mobilization activities can bathing, skin care, eating, sitting Each algorithm specifies the sug- be done without delay or injury to upright, and ambulating. To elimi- gested number of caregivers as nurses. For medical-surgical units, nate variations in care practices, well as selection and use of ap- FGI-PHAMA recommends 50% caregivers should be clear on how propriate lift equipment. To down- ceiling lift coverage, because gen- to assess a patient’s mobility status. load these algorithms, visit erally half the patients on these Barriers to moving independently— www.tampavaref.org/safe-patient- units depend on the nurse to lift, not the patient’s weight—should be handling.htm. manage, move, and support their the main criteria for determining the ambulation activities throughout need for lift equipment. Organizational guidelines some portion of their stay. Standard categories of depend- Manual lifting of any patient isn’t ency levels include: safe. The National Institute of Oc- Challenging environments • dependent—the patient relies cupational Safety and Health (part Advances currently are under way on the nurse or caregiver for all of the Occupational Safety and to promote safe patient handling lifting and moving activities Health Administration), recom- in other challenging hospital ar- • minimally to moderately de- mends 35 lb (15 kg) as the safe eas, such as the operating room pendent—the patient relies on patient-lifting limit for healthcare (OR), emergency department, out- the nurse or caregiver for more workers. The American Nurses As- patient areas, and ancillary units. than 50% of lifting and moving sociation (ANA) supports a policy Preplanning for patient flow and activities of no manual lifting, as discussed transfer activity to and from these • independent—the patient can in its 2013 book, Safe Patient units is essential. The care team perform lifting and moving ac- Handling and Mobility: Interpro- must communicate, coordinate, tivities without assistance from fessional National Standards. and cooperate during patient the nurse or other caregiver. A 2010 white paper from The transport, lateral transfers, and

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 21 Case study: Bariatric surgery using the proper SPHM technology ple concerns for healthcare work- By Ronda Fritz, RN, BSN, MA ers. We encourage all nurses to An estimated 179,000 bariatric surgeries were performed in the United States in 2013. De- speak up about safety and to mand for such surgery continues to rise. However, using safe patient handling and mobility support a SPHM workplace en - (SPHM) technology in the operating room (OR) can be challenging because of the sterile 8 environment and potential lack of knowledge about safe equipment use—especially for vironment. such tasks as lifting the pannus and limbs. This case study shows how one nurse was able to promote a culture of safety in the OR and how the surgeon recognized the benefits to both Selected references American Nurses Association. Safe Patient Han- the surgical team and patient. As described below, a team of experts in the hospital deter- dling and Mobility: Interprofessional National mined how to incorporate the patient lift system to support the pannus during surgery to Standards. Silver Spring, MD: Author; 2013. protect staff from injury and enhance the surgeon’s visualization and safety. A morbidly obese patient weighing 488 lb (221 kg) with a BMI of 70 was scheduled for a American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers. panniculectomy (pannus removal) and hernia repair. The surgeon requested use of a pa- 2014. http://asmbs.org/2014/03/estimate- tient lift during the procedure to lift and hold the pannus. As the patient was being prepped of-bariatric-surgery-numbers. Accessed June 24, for surgery, the surgeon learned that the requested Böhler Steinmann pin holders, which 2014. would attach to the lift to support the pannus, weren’t available. He cancelled the surgery American Society of Bariatric Surgeons. Med- and rescheduled it for a later date. He said he wouldn’t perform the surgery without the pa- ical options for treating obesity fact sheet. Up- tient lift because he didn’t want staff to hold the pannus, which weighed more than 100 lb dated May 2014. www.asbp.org/images/ (45 kg), for the 3 to 5 hours the surgery would take. PDFs/Resources/Obesity-Algorithm_FactSheet The panniculectomy was rescheduled. Before the operation, the nurse worked with SPHM .pdf. Accessed June 24, 2014. experts to assess how to best handle the patient and developed a plan to incorporate the The Facility Guidelines Institute. 2010 Health patient lift system to support the pannus during surgery, thus protecting staff from injury Guidelines Revision Committee Specialty Sub- and enhancing the surgeon’s visualization and safety. committee on Patient Movement. Patient han- The surgery was performed with use of a portable patient lift. The patient was positioned dling and movement assessments: A white pa- on an OR table appropriate for his size and weight and prepped in sterile fashion. The pan- per. April 2010. https://www.dli.mn.gov/wsc/ nus was suspended with two Steinmann pins attached to two Böhler Steinmann pin holders PDF/FGI_PHAMAwhitepaper_042710.pdf. Ac- and a Golvo® 7007 lift. The patient was draped and prepped in standard sterile fashion. An cessed June 24, 2014. SPHM expert positioned and operated the lift during the procedure. The panniculectomy re- Gallagher S. Implementation Guide to the Safe moved 40 lb (18 kg) of adipose tissue. When the surgery was completed, the patient was Patient Handling and Mobility Interprofessional transferred off the OR table with an air-assisted lateral transfer device. National Standards. Silver Spring, MD: Ameri- can Nurses Association; 2013. Benefits of using the proper equipment Gallagher S. The Challenges of Caring for the Using the proper patient-handling equipment during the panneculectomy yielded the fol- Obese Patient. Edgemont, PA: Matrix Medical lowing benefits: Communications; 2005. • No unpredictable movement of the pannus occurred while it was attached to the lift. It Ogden CL, Carroll MD, Kit BK, Flegal KM. was moved only when the surgeon moved the tissue or directed the SPHM expert to Prevalence of childhood and adult obesity in the reposition or lift it. United States, 2011-2012. JAMA. 2014; • Use of the lift during the surgery enhanced patient safety. 311(8):806-14. • The patient’s adipose tissue was hiding many blood vessels. Having the pannus stabilized Randall SB, Pories WJ, Pearson A, Drake DJ. by the lift helped avoid unintentional vessel dissections. Estimated blood loss was 300 mL. Expanded Occupational Safety and Health Ad- • Use of OR staff was improved. Although six additional staff members were assigned to ministration 300 log as metric for bariatric pa- assist with holding the pannus and transferring the patient off the OR table, they weren’t tient-handling staff injuries. Surg Obes Relat Dis. needed and were released to other duties. 2009;5(4);463-8. • No staff members were injured during the procedure. Because the air-assisted lateral Schallom L, Metheny NA, Stewart J, et al. Effect transfer device was used, no patient or staff injuries occurred during transfer from the OR of frequency of manual turning on pneumonia. table to the bed. Am J Crit Care. 2005;14(6):476-8. • No patient injuries occurred. U.S. Department of Veterans Affairs. Safe patient handling and movement. Reviewed/Updat- Ronda Fritz is a safe patient-handling facility champion at VA Nebraska-Western Iowa Health Care System in ed April 30, 2014. www.visn8.va.gov/visn8/ Omaha, Nebrask a. She is on the board of directors of the Association of Safe Patient Handling Professionals. patientsafetycenter/safePtHandling/default.asp. Accessed June 24, 2014.

Dee Kumpar is the director for Safe Patient Handling Programs at Hill-Rom in Batesville, repositioning. With technology (For a case study on bariatric Indiana and a member of the workgroup for available to prevent injury to both equipment use in the OR, see ANA’s Safe Patient Handling and Mobility: In- caregivers and patients, no de- Case study: Bariatric surgery us- terprofessional National Standards. She is on partment should put staff at risk ing the proper SPHM technology.) the board of directors of the Association of Safe for injury during transfer activities. Bariatric patients present multi- Patient Handling Professionals.

22 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Developing a sling management system Learn about key decisions for this segment of an SPHM program.

By Jan DuBose, RN, CSPHP

patient mobility assessment determines your new patient A needs a dependent sling. But when you finish your admission intake and reach the sling inventory storage site, you find no slings are available. Or perhaps you see a sling hanging on a hook and wonder if it’s clean or dirty. If you’ve had an experience like this, you’re probably eager for your workplace to adopt a safe patient handling and mobility (SPHM) program that addresses slings, among other things. But before adopting such a program, a healthcare facility must perform a unit assessment to evaluate: • medical conditions and mobility needs of its patient population the laundry department is criti- source laundering to a laundry • maximum number of bariatric cal. Each type of sling has bene- company. patients on the unit at a given fits and drawbacks. (See Com- time, and how often the unit paring launderable and dis- In-house laundering reaches this number posable slings.) If the committee Advantages of in-house launder- • tasks performed on the unit chooses launderable slings, ing include: • unit staffing the next decision is whether to • negligible number of missing • storage constraints. launder them in-house or out- or lost slings because all slings Other parts of an SPHM program related to sling use include infection control and selection of Comparing launderable and disposable slings the sling fabric. Despite their laundering costs, launderable slings are more cost-effective than disposable slings because they’re reusable. Also, more launderable sling types are available, giving Launderable vs. healthcare facilities more solutions for patient transfer and lifting needs. However, these disposable slings raise concerns about infection control and sling sharing. The SPHM committee, which Disposable slings, on the other hand, are easier to store. With no laundering process, the oversees all aspects of the SPHM safe patient handling and mobility (SPHM) program is simpler, no slings are lost to laundering, and infection control is easier. On the flip side, the ever-increasing cost of replacing program, must decide if the facil- slings can be a financial drain even on a successful, sustainable SPHM program. Also, dispos- ity should use launderable and able sling styles are limited, which can reduce the potential success of the program by failing reusable slings, disposable to address all the manual tasks required. slings, or both types. Input from

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 23 Case study: On-site laundry with centralized distribution If the facility has chosen to out- By Deanna Watkins, MSN, RN, CSPHP source its sling laundering, it One hospital chose to build an 800-square-foot on-site laundry facility to reduce overall must establish a good working product processing costs, reduce the required product inventory, and decrease the risk of relationship with the laundry product loss. The laundry facility also represented an investment in the hospital's infra- structure. Achieving return on investment was estimated to take less than 18 months. company, with clear and regular The hospital purchased four times the estimated inventory of slings and accessories, communication. compared to six times the inventory that offsite laundering would require. Keeping products on-site keeps losses low and allows barcoding of all items for product management Inventory purchase and and tracking. Also, the on-site facility custom-launders linens with the potential for future stocking of supplies savings. The hospital has a centralized process managed by the linen service of the environ- A sling management process in- mental services department. This allows better inventory tracking and accountability. Each cludes estimating the number and unit and department has an established inventory or periodic automatic replenishment sizes of slings a unit uses, pur- (PAR) level of lift products. PAR levels were determined by reviewing patient demograph- chasing inventory, and stocking ics for each unit; the most difficult tasks reported by the staff; admission, discharge, and supplies in an organized, effec- transfer data; average patient weight; and location from where most patients are admit- tive way. Several factors can af- ted (such as direct admit vs. postoperative). All products are barcoded and labeled with organization identification, not unit or de- fect inventory. For instance, as the partment identification. That way, slings can be transferred with the patient as he or she SPHM program grows, the facility flows throughout the care continuum. This is accomplished by the linen service using a will need more slings and acces- laundry cart exchange process. Carts are exchanged daily depending on product use. Spe- sories, and purchasing may be cialty slings and accessories (such as amputee slings) also can be acquired through the slow to catch up. The laundry centralized system by calling the main phone number for linen distribution. service, whether in-house or out- Deanna Watkins is a nursing administrative specialist at Mayo Clinic Hospital in Phoenix, Arizona. sourced, also may be unable to keep up with demand. And despite seemingly reasonable initial stay in the facility dering include a reduced impact expectations, turnaround time • shorter turnaround time due to on laundry staff and transfer of re- might become impractical as the better control of the process sponsibility for a smooth, success- SPHM program evolves. Also, the • reduced sling purchase cost ful process off-campus. Disadvan- number or sizes of slings a unit due to reduced inventory tages are possible loss of slings, uses may have been estimated im- • better oversight for maintaining sling damage from industrial laun- properly initially. sling standards. dering methods, long turnaround Healthcare facilities have two time, and costs (determined by options for establishing and keep- Disadvantages include: the pound or item). ing a satisfactory sling inventory— • the need for a dedicated staff periodic automatic replenishment member to oversee and man- Fabric maintenance (PAR) or centralized distribution. age the process Whichever laundering process is • the need for space to house a chosen, fabric maintenance PAR system washer, dryer, drying cabinet, guidelines must be followed. To maintain a PAR level, the folding surface, and storage Meeting infection-prevention stan- facility must keep enough slings carts dards is paramount. For exam- on hand so it doesn’t run out • a properly vented environment ple, a protocol for disposing of while waiting for resupply. Space to avoid dampness and mold or treating soiled or infected constraints may limit the PAR • possible injuries to laundry slings must be established, along level. PAR requires not just a staff due to the added work- with protocols for single patient storage area but also a load. (See Case study: On-site use of slings. Fabric integrity dedicated staff member, along laundry with centralized distri- must be maintained to extend with unit staff, transport staff, and bution.) sling life; preserving sling quality laundry staff for backup. What’s for prolonged fabric reliability more, if specialized slings are Outsourced laundering and sling longevity promotes pa- stored on specific units, they’re Advantages of outsourced laun- tient safety and cost-effectiveness. not easily available on other units. On the other hand, using a Sling tracking and put in place procedures for PAR system means slings will be Sling tracking promotes return of sling purchase, inventory mainte- readily available on all shifts, slings to the proper unit. Tracking nance, care, laundering, track- which leads to better compliance can be handled in several ways: ing, and replacement. Once these with the SPHM program. • Slings can be labeled with an issues have been addressed, the indelible marker, barcoded, or facility is ready to embark on an Centralized distribution embroidered. A simple mark- SPHM program that can improve With this system, access to slings ing system can yield valuable patient care and help prevent may not be available when need- benefits. staff injuries. 8 ed, especially on evenings, • Vendors may have sling track- nights, weekends, and holidays. ing systems your facility can Selected references A staff member must be put in use. The Facility Guidelines Institute. 2010 Health charge of maintaining central stor- Guidelines Revision Committee Specialty Sub- Support for the SPHM committee on Patient Movement. Patient han- age for efficient distribution, and dling and movement assessments: A white pa- a process for obtaining slings program per. April 2010. https://www.dli.mn.gov/wsc/ must be established. For instance, A well-developed sling manage- PDF/FGI_PHAMAwhitepaper_042710.pdf. Ac- is a runner needed? If so, who ment system supports a facility’s cessed June 24, 2014. supplies the runner? SPHM program. The SPHM must Occupational Safety and Health Administration. Lift program policy and guide: Introduction Nonetheless, a well-organized elicit input from units that will use to the lift program. https://www.osha.gov/ centralized distribution process the system and from the laundry CWSA-attachment/beverlyliftprogramguide.pdf. can be highly effective if commu- department or outsourced laun- Accessed July 3, 2014. nication is clear and consistent. dry company to ensure all par- Also, lack of unit storage for ties’ needs are met. It must Jan DuBose is director of Safe Patient Handling slings isn’t a concern. choose sling styles and fabric Programs and Services at Hill-Rom.

(continued from page 10) patient to the chair using the hos- Deliberate focus, full way to becoming firmly rooted pital’s mobility protocol. In many engagement and incorporated into caregivers’ ICUs, such a patient would be Incorporating new evidence into daily practice. Although the prac- bedbound. But at St. Luke’s, early daily practice isn’t enough to sus- tice change is becoming the new mobility is now routine practice tain a culture change to empha- norm, coaching and mentoring even for these patients. Conversa- size early mobility and SPHM. are needed to help maintain motion about mobility occurs in daily Such a change comes only with a mentum. Stories learned along the rounds and often is a major focus deliberate focus on three key ques- journey should be used to inspire of daily patient goals. tions: What are we are doing? both novice and expert clinicians. In fact, staff members are likely Why are we doing it? What’s my Objective evaluation of the im- to comment that they no longer ask role? Full engagement and cultural provement process should contin- the question “Can we mobilize this transformation can occur only ue, focusing on outcome measures patient?” Instead, they ask, “Is when all team members can re- and identifying improvement op- there a reason why we can’t mobi- spond to these questions with full portunities to promote refinement. lize the patient?” Key lessons understanding. 8 Team members are now doing learned to promote and maintain Visit www.AmericanNurseToday.com/Archives/ things they never thought were this cultural transformation include aspx for a multidisciplinary progressive mobility possible—and previously believed the importance of testing new prac- continuum tool and a list of selected references. to be unsafe. Recently, I learned of tices on a small scale, getting regu- Kathleen M. Vollman is a clinical nurse specialist, a ventilator patient at St. Luke’s lar feedback of performance and educator, and consultant with Advancing Nurs- Medical Center, Boise/Meridian outcome data, providing sufficient ing, LLC in Northville, Michigan. Rick Bassett is a (Idaho) who was receiving contin- education, and increasing care- cardiovascular clinical nurse specialist in adult uous renal replacement therapy givers’ will to mobilize patients by critical care at St. Luke’s Medical Center, (CRRT). Staff safely mobilized the seeing the work in action. Boise/Meridian, Idaho.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 25 Making the business case for a safe patient handling and mobility program Learn about three approaches to preparing an investment justification.

By John Celona, BS, JD

he value of a safe patient ers alternative program designs handling and mobility and includes projections for the re- T(SPHM) program is clear, but sults if the proposed program isn’t the benefits may be difficult for implemented (such as increased some nurse leaders to quantify. workers’ compensation costs and STRATEGY 2: Some investment justifications are increased pressure ulcers). Net Complete a simple template available from vendors of SPHM benefits commonly are measured The next most accurate way to equipment, but even when well by subtracting costs with the pro- prepare an investment justification done, they don’t give a complete gram in place from costs without is to fill out a simple template. picture of potential benefits—and the program in place. Most likely, your employer’s fi- inevitably are discounted because Although preparing such pro- nance department or capital com- vendors are in the business of sell- jections is feasible for those with a mittee has a standard template for ing equipment. This article de- master’s degree in business admin- proposed expenditures. Most or- scribes how to make an independ- istration or a similar education, ganizations require a cost-benefit ent, unbiased business case for an many SPHM program champions projection for 5 years into the fu- SPHM program and presents a have clinical backgrounds. Here ture. The cost part is fairly easy, case study of a decision analysis are some possible strategies they and most people are familiar with process used at Stanford Universi- can use, starting with the easiest preparing budgets for what they ty Medical Center. but least facility-specific. propose to spend. Be sure to include estimates for equipment pur- Elements of a good STRATEGY 1: Refer to a chases and training time. business case published study As for benefits, the most com- A business case should: The easiest but least facility-spe- monly cited ones for an SPHM • describe the proposed pro- cific and least accurate way to program are reductions in work- gram, such as required equip- prepare an investment justifica- ers’ compensation costs and in ment and training tion is to refer to published stud- lost or restricted staff days due to • quantify program costs and ies. For example, the risk-man- patient handling and mobility in- benefits agement study I undertook for juries. Unless your facility already • show the program’s net benefit Stanford, published in the April has identified these costs, you’ll (benefits minus costs), express- 2011 issue of Journal of Health- need to crossmatch data from the ed eit her as a net present value care Risk Management, shows Occupational Safety and Health or return on investment (ROI). what a facility with all the ele- Administration Form 300 (listing ments of a successful SPHM pro- causes of injuries and whether A good business case consid- gram can achieve. they led to lost or restricted duty

26 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Influence diagram An influence diagram is a simple, graphic way of showing all items of interest and demonstrating what’s related to what. Uncertainties are shown in ovals, decisions in boxes, and the final value as a hexagon; arrows show relationships among items. This influence diagram shows all safe patient handling and mobility (SPHM) costs and benefits of interest to leaders at Stanford University Medical Center when consider- ing whether to invest in an SPHM program.

days) against cost data in the STRATEGY 3: Prepare a • identifies how to get more val- workers’ compensation system. decision analysis ue out of the SPHM program Typically, organizations esti- Preparing a decision analysis is • specifies which result measures mate they’ll save 60% to 80% of more difficult than referring to a should be tracked to validate workers’ compensation costs relat- published study or using a tem- that the program is working as ed to patient mobilization if they plate. But it’s facility-specific and it should be, and pinpoints have an SPHM program, and will thus provides the most complete what the values for those meas- save zero to 50% of the cost of and accurate picture. Of course, it ures should be. replacement staff to fill in for out- must be done by someone skilled of-work or restricted-duty staff (de- in decision analysis. But for large Generally, a decision analysis pending on the facility’s replace- investments, the cost of the analy- costs much less than 1% of the ment staff policy). Subtracting sis is well worth it, because it: program cost. What’s more, it pro- each year’s costs from the benefits • delivers a highly accurate duces recommendations for in- yields the annual net benefit. If quantification of costs and ben- creasing program value, which your facility’s template hasn’t built efits, including uncertainties dwarf the cost of the analysis. in these costs, someone from the • shows worst- and best-case sce- I worked with Stanford on a de- finance department can help con- narios for costs and benefits cision analysis for its SPHM pro- vert the year-by-year figures to a and describes exactly how gram because it became apparent net present value or ROI. these might occur that the simple-template approach

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 27 Tornado chart: Key value drivers In this so-called tornado chart, the key value drivers for Stanford’s safe patient handling and mobility (SPHM) program appear at the top. Uncertainties farther down the chart (the complete chart had 40 uncertainties) don’t merit much time or attention. For example, whether 35% or 50% of restricted staff time was replaced with other staff time didn’t significantly affect total program value. In reality, of course, all uncertainties are varying at the same time, rather than one at a time as shown in this chart.

Reduction on turnover Percentage point increases in Press Ganey score Workers’ compensation cost (baseline) growth rate Percentage of relevant staff with improved Gallup score Percentage of ulcers in stage 1 or 2 Final workers’ compensation reduction rate Final ulcer reduction rate Lost and restricted days (baseline) growth rate Percentage of referral from improved patient satisfaction Equipment costs (based on patient mobility) Patient volume growth rate Average cost to treat stage 3, 4, or unstageable growth rate Training costs (HR wages) Patient falls Nurse retention Ongoing costs Pressure ulcers Staff satisfaction Patient referrals Initial investment Replacement staff Net present value Final replacement costs reduction rate Patient satisfaction Workers’ compensation Time replacement factor

initially used there missed most of train a nurse ($60K to $80K, duced workers’ compensation the value and wouldn’t justify a based on a literature search) costs and lost and restricted days program in the new hospital under • estimate of how much the alone. construction. SPHM program would reduce The next step was to set each staff turnover. uncertainty (such as a change in Case study: Standford the nurse turnover rate) to the low decision analysis We did similar work for each value in the range, record the total At Stanford, we began by draw- type of cost and benefit. Unlike us- program value, set the uncertainty ing an influence diagram to show ing a simple template or referring to the high value in the range, all SPHM costs and benefits of in- to a published study, the decision- and record the total program val- terest to leaders. (See Influence di- analysis approach enabled us to ue. The difference between the agram.) For each cost or benefit, use a range of numbers to repre- two program values was plotted more detailed work explored ex- sentuncert ainty regarding how on a bar chart. When the bars actly how to quantify the results. significant the future impact might were sorted from highest to lowest For example, to estimate the bene- be. For turnover reduction, we impact on program value, the fits of reduced staff turnover, we used a range of 0% to 20%. characteristic tornado shape result- needed to know: These data were then pro- ed. (See Tornado chart: Key value • number of nurses mobilizing grammed into a Microsoft Excel drivers.) patients who would be affected spreadsheet. One immediate result Stanford leaders were surprised by the SPHM program was that the total value of an to learn that reduced staff turnover • average annual staff turnover SPHM program (including hard-to- had the greatest potential for get- rate quantify benefits) would amount to ting more value out of the SPHM • average cost to recruit and more than twice the value of re- program, possibly increasing total

28 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com Components of total SPHM program value This “waterfall” chart shows that the largest components of value for Stanford’s safe patient handling and mobility (SPHM) program are decreases in workers’ compensation costs and in pressure ulcers and increased patient satisfaction. Nurse retention is a small component of total program value in the base case scenario shown here (with only a 2% reduction in turnover), although it has the largest potential for increasing program value if turnover reduction could be pushed up to 20%. Net present value ($ millions)

Patient falls Nurse retention Ongoing costs Pressure ulcers Staff satisfaction Patient referrals Initial investment Replacement staff Patient satisfaction Net present value Workers’ compensation

program value from about $4 mil- nents of cost and value. This pro- ers’ com pensation claims were on lion to $6.5 million. As a result, duces a so-called waterfall chart. track (within the 60% to 80% Stanford decided to inform the (See Components of total SPHM range forecast), but baseline work- nursing staff that it was going to program value.) ers’ compensation costs were put in place the SPHM tools need- growing faster than the maximum ed to keep them healthy and able Outcome of the decision 19% annual increase forecast. A to work. Stanford also surveyed analysis closer look revealed that a return- staff satisfaction improvements re- Stanford’s decision analysis to-work program had been discon- sulting from the SPHM program. produced: tinued, sending costs skyrocketing. Combinations of all the variables • a high degree of confidence Stanford quickly reinstated that produce thousands of scenarios, that the actual value of the program. 8 best shown in a probability distri- SPHM program and uncertainty Selected references bution. The probability distribution in that value had been quanti- Celona J, Driver J, Hall E. Value-driven ERM: for Stanford showed that the mean fied accurately Making ERM an engine for simultaneous value program value was more than dou- • a deeper understanding of how creation and value protection. J Healthc Risk ble the estimate from the template the program would add value Manag. 2011;30(4):15-33. approach. It also showed that in a and which benefits were most Celona JN, McNamee PC. Decision Analysis for the Professional. 4th ed., rev. Menlo Park, CA: worst-case scenario, the program important SmartOrg, Inc., 2001-2007. would still pay for itself. • insight into how to get more val- The Facility Guidelines Institute. 2010 Guide- An easy way to show the com- ue from the program lines for Design and Construction of Healthcare ponents of program value is to • identification of which value mea- Facilities. Dallas, TX: Author; 2010 take the overall program value sures would need to be tracked John Celona is a principal at Decision Analysis from the base case (all uncertain- to validate program results. Associates, LLC, in San Carlos, California. He is ties set to their middle value) and the author of Decision Analysis for the Profes- break these down into compo- At Stanford, reductions in work- sional, 4th ed.

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