Safe Patient Handling Programs: If Not Now, When?
September 1, 2023
In a time of lean hospital budgets and staff shortages, the cost-benefit equation tilts heavily in favor of implementing a safe patient handling and mobility (SPHM) program to prevent occupational injuries, retain staff, and improve patient outcomes, said Asha Roy, OTD, OTR/L, MBA, MAS PS HQ, CSPHP, CWcHP, CEAS II, senior director of workforce safety at Northwell Health in New York.
Roy spoke at a recent webinar presented by the Association of Occupational Health Professionals in Healthcare (AOHP).1 Roy presented unpublished data from a 528-bed Northwell hospital that implemented a comprehensive SPHM program that greatly reduced the number of injuries and introduced considerable cost savings. Considering multiyear averages for both pre- and post-intervention, patient handling injuries and related costs were $924,000 from 2011 to 2016.
“The [hospital] leaders invested in equipment, but also in a dedicated program,” Roy said. “Post-implementation, the average for three years was a 73% reduction.”
Average costs fell to $245,000 in the post-implementation period from 2017 to 2022. “We have to have a way of quantifying the program costs and benefits,” Roy said. “When you are trying the make the business case for safe patient handling, look at the reduced numbers of workers’ compensation [claims]. The pressure injury data might be in [the records] of the quality team.”
While costs can be cut and staff spared injury, there are ancillary benefits for healthcare workers. “Healthcare workers will experience all kinds of benefits,” Roy said. “Going home with less aches and pains because they are not using their body to mobilize patients. They are going to have longer careers because they are not going to be pulling their backs and their shoulders out and [filing for] workers’ comp injuries.”
The authors of a meta-analysis that included occupational injuries before and after implementation of such safe handling programs found a “56% decrease in injury risk overall following SPHM program implementation.”2
A study by the National Institute for Occupational Safety and Health (NIOSH) in nursing homes revealed SPHM programs reduced injury rates by 46% and workers’ compensation claims rates by 61%.3 “The initial investment of $158,556 for lifting equipment and worker training was recovered in less than three years on the basis of post-intervention savings of $55,000 annually in workers’ compensation costs,” NIOSH reported. “This is significant, given that cost is an often-cited barrier to purchasing lifting equipment.”4
The Pain
A major source of pain for healthcare workers is musculoskeletal injuries, often involving the back or shoulders. “These injuries are due in large part to overexertion related to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring and repositioning patients and working in extremely awkward postures,” OSHA reported. “In 2017, nursing assistants had the second-highest number of cases of musculoskeletal injuries. There were 18,090 days away from work, which equates to an incidence rate of 166.3 per 10,000 workers — more than five times the average for all industries.”5
Commonly cited patient benefits of SPHM programs include better quality of care, improved patient mobility, fewer patient falls and pressure ulcers, and higher patient satisfaction scores. Stage IV pressure ulcers in an immobilized hospital patient can be shockingly expensive, with one group of researchers reporting the average “treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during one admission.”6
Thus, an SPHM program can produce complementary benefits, with one hospital reporting a 39% decrease in employee injury rates and a 43% rate reduction in hospital-acquired pressure ulcers in patients.7
For all their benefits, there is no federal legislation requiring hospitals to implement SPHM programs.
“It’s not for the lack of trying, but it is probably not going to happen in my lifetime,” says Lynda Enos, RN, MS, COHN-S, CPE, an occupational health expert on safe patient lifting in Bend, OR. “There is a lack of knowledge by leaders in hospitals — [failing] to link [safe lifting] to patient safety, earlier mobility, and better outcomes.”
According to Roy, there are about a dozen states with laws requiring safe patient handling in hospitals: California, Hawaii, Illinois, Maryland, Minnesota, Missouri, New Jersey, New York, Ohio, Rhode Island, Texas, and Washington. Other states can call on OSHA to enforce these programs through its General Duty clause to protect workers.
“[That clause] basically states that employers shall [provide] places of employment which are free from recognized hazards that are causing or likely to cause death or serious physical harm to employees,” Roy explained. “If you are not in one of the 12 states listed, go back to the federal governance and use the OSHA guidelines as the basis of the program that you want to build.”
OSHA offers whistleblower protection against retaliation for employees who report hazardous working conditions.
Most Injuries Preventable
“Most of the injuries that take place in the patient handling world are preventable,” Roy said. “They are preventable if we first determine what task the healthcare worker was trying to perform, because that would allow us to understand what kind of engineering controls or work practice controls we need.”
Part of this understanding comes from conducting patient mobility assessments, “including upper mobility, upper extremity, lower extremity, the trunk, their ability to stand up and ambulate,” Roy noted. “All of this is what makes up an understanding of the patient’s functional status so we can look at the equipment options. Then, of course, complete the task in a safe manner by communicating not only with each other, but also with the patient and family member.”
There are various patient mobility tools, including an update of the popular “Bedside Mobility Assessment Tool 2.0,” which nurses can use to determine the patient’s mobility status and decide what safe patient handling equipment to use. “Standardizing nursing practice, processes, and procedures for safe patient handling and mobility equipment use promotes caregiver safety, reduces nursing care variability, results in better patient outcomes, and aligns with the American Nurses Association’s standards,” the authors noted.8
Of course, the national obesity epidemic translates to moving heavier patients, many of them with acute conditions. Some examples of patient handling tasks that may be identified as high-risk — requiring awkward posturing by workers — include transferring from toilet to chair, transferring from chair to bed, transferring from bathtub to chair, repositioning from side to side in bed, and lifting a patient in bed. “They are bending, twisting, reaching to be able to provide the care that they need at the moment,” Roy said. “Another risk is the repetitive movements that we have to engage in. You’re walking with someone to the bathroom, and they suddenly have their knees buckle, and they collapse. We can have patients of size who have a high acuity level who need to be moved from one place to the next. We have patients who we have to move from a lateral surface to another lateral surface. We can have patients who we have to turn for a multitude of reasons, and that can be high-risk activity.”
Huddle Up
The starting point for creating a SPHM program is forming a committee. Roy recommended the committee include roughly equal representation from management and frontline workers.
“This should not be a meeting of managers,” Roy said. “They can influence change by requesting for finances needed and resources needed, making sure effective policies and procedures develop to address some of these things. But if change needs to happen, the people who are going to be carrying out the change should be involved.”
The committee should include individuals with expertise or experience relevant to safe patient handling, including:
• occupational safety and health;
• risk management;
• human resources;
• quality and patient safety.
A good working definition of the scope of a SPHM program is one that includes engineering controls and lifting and transfer aids, Roy said.
The committee should perform a risk assessment, looking at where and how manual lifting is conducted, and identify potential hazards to worker and patient safety. These might be such issues as lateral transfer, fall prevention, and floor recovery of a supine or prone patient.
There are three basic types of safe lifting equipment, including the total assist lift, which can be either floor-based or on the ceiling. Then, there are sit-to-stand lifts, which can be powered or non-powered. The third primary lift device is for lateral assist, which include slide sheets and air-assisted equipment.
The cost of the lifting equipment should be included in making the business case, as well as any additional staff needed for training and other purposes. Roy estimated prices and ranges for safe patient handling equipment, including:
• Total assist lifts: $3,000-$7,000;
• Ceiling lifts: $8,000+;
• Sit-to-stand powered: $2,000+;
• Sit-to-stand non-powered: $1,000+;
• Air-assisted mattress: $70+;
• Slide sheets: Up to $60 per box;
• Air mattress for floor recovery: $5,000+.
In Harm’s Way
With so many variables in patient mobility and equipment selection, Roy stressed preparing for three tasks that will prevent most healthcare worker injuries. “Have interventions or tools and technology in place to address repositioning patients in bed, fall prevention and recovery, and lateral transfers,” Roy said. “Your program will benefit quite a lot. Those are the high-frequency tasks where we see [healthcare workers] get hurt quite a lot.”
For falls, first assess the patient’s level of cognition, pain, and any physical injuries. If the patient is alert and has no problem with those factors, they may be able to move to their hands and knees and stand with only light support. Some of this will depend on the patient mobility assessment. Otherwise, air lifts can raise the patient in a supine position up to stretcher height.
Most hospital beds include controls that can be used to change the height, allowing staff to adjust it below waist level. Some also use mattresses that are designed to assist with patient movement.
“The mattress can be inflated so that they’re not sinking into the mattress, making it easier for the healthcare worker to mobilize, move, or turn the patient,” Roy said. “These controls can be easy solutions rather than the uphill battle of [securing new funding], which could take time to get approved.”
The risk assessment should inform what patient safety equipment is needed, with workers trained initially (and at least annually) on how to use it. Training may come down to small but important details, like placing palms down for pushing a patient and palms up for pulling.
“It’s not just push-and-pull,” Roy noted. “The details, the ergonomics, and body mechanics associated with how we use the equipment is as equally important as the technical education that we have to do. If you don’t focus on the details, worker injuries may occur.”
For example, if a relatively new worker hurts his wrist using safe patient handling equipment, it is most likely user error. “You’ll continue to see incidents like that if the education piece doesn’t account for [the cause of injury],” Roy said.
Adverse incidents should be investigated and include a post-investigation review by the SPHM committee. In addition to the initial risk assessment, Roy recommended an annual performance evaluation of the program to determine its effectiveness.
“Understand that [SPHM] is not a wheel that hasn’t been invented before,” Roy noted. “Decades of research and best practice guidelines exist.”
REFERENCES
1. Association of Occupational Health Professionals in Healthcare. Promoting safety and well-being: Mastering safe patient handling and mobility in healthcare settings. July 19, 2023.
2. Teeple E, Collins JE, Shrestha S, et al. Outcomes of safe patient handling and mobilization programs: A meta-analysis. Work 2017;58:173-184.
3. Collins JW, Wolf L, Bell J, Evanoff B. An evaluation of a “best practices” musculoskeletal injury prevention program in nursing homes. Inj Prev 2004;10:206-211.
4. Bell J, Collins J, Galinsky TL, Waters TR. Preventing back injuries in health care settings. NIOSH Science Blog. Sept 22, 2008.
5. Occupational Safety and Health Administration. Safe patient handling. 2023.
6. Brem H, Maggi J, Nierman D, et al. High cost of stage IV pressure ulcers. Am J Surg 2010;200:473-477.
7. Walden CM, Bankard SB, Cayer B, et al. Mobilization of the obese patient and prevention of injury. Ann Surg 2013;258:646-650.
8. Boynton T, Kumpar D, VanGilder C. The Bedside Mobility Assessment Tool 2.0. American Nurse. July 2, 2020.
In a time of lean hospital budgets and staff shortages, the cost-benefit equation tilts heavily in favor of implementing a safe patient handling and mobility program to prevent occupational injuries, retain staff, and improve patient outcomes.
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