Evidence-Based Safe Patient Handling to Promote Safer Work Environments

1. Evidence-Based Safe Patient Handling to Promote Safer Work Environments Audrey Nelson, Ph.D., RN, FAAN audrey.nelson@.va.gov

2. 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.

3. 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.

4. The Ergonomic Challenge 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)

5. 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.

6. 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.

7. 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 Show me the Evidence!

8. Definition of Insanity “Doing the same thing over and over and expecting different results” Albert Einstein

9. 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.

10. Common Myths “Patient Handling Equipment is notaffordable”. The long term benefits of proper equipment FAR outweigh costs related to nursing work-related injuries.

11. 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.

12. 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.

13. 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.

14. Education & Training

15. Education and Training Use of peer safety leaders shows promise • Introduce new technology or practices • Conduct ongoing hazard evaluation of unit • Assure competency of staff • Sustain the program Back Injury Resource Nurses (BIRNs) Ergo Rangers Ergo Coaches

16. 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

17. Use of Technology

18. 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)

19. 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

20. 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

21. Expected Speed of Implementation 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.

22. Patient Handling Technology • Perceived by staff nurses as the #1 most effective solution for musculoskeletal discomfort.

23. Clinical Tools: Assessment & Decision Making

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

25. 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.

26. Algorithms AVAILABLE • SCI/Rehab • LTC/Nursing Home • Orthopedic • Perioperative • Bariatric IN DEVELOPMENT • Critical Care • Med/Surg • Home Care • Diagnostic/Radiology/Morgue • ER

27. Unit Risk (Hazard) Assessments

28. Patient Care Ergonomic Assessments of Units • This approach is used to assess hazards: • High Risk Tasks unique to each clinical area • Root cause analysis of patient handling injuries (staff and patients) • Equipment inventory • Walk through of physical environment • Make Recommendations

29. “No Lift” Policies

30. 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)

31. Summary “Reader’s Digest Version”

32. 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.

33. 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)

34. Emerging Evidence • unit-based peer leaders • clinical tools, such as algorithms and patient assessment protocols

35. 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

36. 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.

37. Summary Article Reference 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

38. Implementing and Sustaining Successful SPH Programs New Challenge

39. State & National Policies for Safe Patient Handling