Evidence-Based Safe Patient Handling to Promote Safer Work Environments

Audrey Nelson, Ph.D., RN, FAANaudrey.nelson@.va.gov

Problem Statement Musculoskeletal injuries associated with patient care have

been a problem for decades.

Efforts to reduce patient handling injuries are often based on tradition and personal experience rather than scientific evidence.

Despite strong evidence, published internationally over three decades, most clinical settings have used significant resources to implement strategies that are not evidence-based.

There is a growing body of evidence to support interventions that are effective or show promise in reducing musculoskeletal pain and injuries in care providers.

Purpose Provide a brief overview of the research

related to nursing and musculoskeletal injuries-- pointing out what we know and

common myths associated with risks.

The adult human form is an awkward burden to lift or carry. Weighing 200 pounds or more, it has no handles, it is not rigid, and it is susceptible to severe damage if mishandled or dropped. (circa 1950)

The Ergonomic ChallengeThe Ergonomic Challenge

No wonder nurses are injured! In an eight hour shift, the cumulative

weight that nurses lift equal to an average of 1.8 tons per day.

Common Myths

“Classes in body mechanics and lifting techniques are

effective in reducing injuries”.

30+ years of experience shows us training alone is

not effective.

Show me the Evidence! Brown, 1972 Dehlin, et al, 1976 Anderson, 1980 Daws, 1981 Buckle, 1981 Stubbs, et al, 1983 St. Vincent &

Teller, 1989

Owen & Garg, 1991 Harber, et al, 1994 Larese & Fiorito,

1994 Lagerstrom &

Hagberg, 1997 Daltroy, et al, 1997

Definition of Insanity

“Doing the same thing over and over and expecting different results”

Albert Einstein

Common Myths“Back belts are effective in

reducing risks to caregivers”.

There is no evidence back belts are effective. It appears

in some cases they predispose nurse to higher level of risk.

Common Myths“Patient Handling Equipment is not

affordable”.

The long term benefits of proper equipment FAR outweigh costs related to nursing work-related injuries.

Common Myths“If you buy it, staff will

use it”

Reasons staff do not use equipment: time, availability, time, difficult to use, space constraints, and patient preferences.

Common Myths“If you institute a No-Lift Policy

nurses will stop lifting”.

Before Zero Lift Policies are implemented, infrastructure needs to be in place-- technology and culture.

Common Myths“Various lifting devices are

equally effective”.

Some lifting devices are as stressful as manual lifting. Equipment needs to be evaluated for ergonomics as well as user acceptance.

Education & Training

Education and Training

Use of peer safety leaders shows promise Introduce new technology or practicesConduct ongoing hazard evaluation of unitAssure competency of staff Sustain the program

Back Injury Resource Nurses (BIRNs)Ergo RangersErgo Coaches

Back Injury Resource Nurses (BIRNs)

• New Education Model: Credible Peer Leader• Selected for each high risk unit • Provide ongoing hazard identification• Assure competency in use of equipment • Implement algorithms

Ergo Guide Book Free!http://www.patientsafetycenter.com

Use of Technology

Manual Lifting Techniques

Manual lifting techniques increase risk for injury. Many have been banned because they also pose risk and discomfort for patient: Hook and Toss (aka Drag Lift)Arm and leg lift (two person lift with caregiver

arms under patient axilla and thigh)Shoulder lift (aka Australian Lift)

NIOSH Weight Limits for Safe Lifting

Manual Materials Handling

Maximum = 51 lbs.

Patient/Resident Handling Lifting Maximum = 35 lbs.

Tom Waters 2007 American Journal of Nursing

New Curriculum Needed

Working with ANA and NIOSH to develop this curriculum

27 schools of nursing participating USA is behind other countries in this area

It takes an average of 17 years for new knowledge generated by RCT to be incorporated into practice, and even then, the application is highly uneven.

Balas, EA and Boren, SA. (2000). Managing clinical knowledge for healthcare improvement. Yearbook of medical informatics. Bethesda, MD: National Library of Medicine, pp. 65-70.

Expected Speed of Implementation

Patient Handling Technology

Perceived by staff nurses as the #1 most effective solution for musculoskeletal discomfort.

Clinical Tools: Assessment & Decision Making

Practice Tools

Algorithms show promise in standardizing decisions related to type of equipment and number of people needed to perform a task safely.

High Risk Tasks Vary by Setting

Nelson, AL, Menzel, N, and Motacki, K. (In development). Safe Patient Handling: An Illustrated Guide. New York, NY: Springer Publishing.

Algorithms

AVAILABLE SCI/Rehab LTC/Nursing Home Orthopedic Perioperative Bariatric

IN DEVELOPMENT Critical Care Med/Surg Home Care Diagnostic/

Radiology/Morgue ER

Unit Risk (Hazard) Assessments

Patient Care Ergonomic Assessments of Units This approach is used to assess hazards:

High Risk Tasks unique to each clinical areaRoot cause analysis of patient handling

injuries (staff and patients)Equipment inventory Walk through of physical environment

Make Recommendations

“No Lift” Policies

Safe Patient Handling (No Lift) Policy Several multi-site studies that addressed no lift

policies, demonstrating they are effective. (Note: Multifaceted, with no-lift one aspect)

Need to integrate lessons learned from UK, Australia, and much of Europe into practices in USA.

Myths Associated with “No Lift” Lessons Learned from UK (New)

Summary “Reader’s Digest Version”

Unfortunate Disconnect between Practice and Research The most common patient handling approaches

in the United States over the past decade include manual patient lifting classes in body mechanics training in safe lifting techniques back belts

There is strong evidence that each of these commonly used approaches is NOT effective in reducing caregiver injuries.

Evidenced-Based Practices

patient handling equipment/devices patient care ergonomic assessment protocols no manual lifting policies training on proper use of patient handling

equipment/devices patient lift teams (where equipment is used)

Emerging Evidence

unit-based peer leaders clinical tools, such as algorithms and

patient assessment protocols

Multifaceted Programs

Multifaceted programs are more likely to be effective than any single intervention.

Why? Complexity of this high-risk, high volume,

high-cost problem

Research/Practice Disconnect

It takes an average of 17 years for new knowledge generated by RCT to be incorporated into practice, and even then, the application is highly uneven.

Balas, EA and Boren, SA. (2000). Managing clinical knowledge for healthcare improvement. Yearbook of medical informatics. Bethesda, MD: National Library of Medicine, pp. 65-70.

Summary Article Reference

Nelson, AL Nelson, AL and Baptiste, A. (2004). Evidence-Based Practices for Safe Patient Handling and Movement. Online Journal of Issues in Nursing, 19 (3) Manuscript 3. Available: www.nursingworld.org/ojin/topic25/tpc25_3.htm

Implementing and Sustaining Successful SPH Programs

New Challenge

State & National Policies for Safe Patient Handling