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Safe patient handling and mobility: The journey continues

Hazards associated with manual patient handling continue to compromise the health and safety of nurses. Among nurses who responded to the American Nurses Association’s (ANA’s) Health Risk Appraisal:

42% believe they are at risk at work from lifting or repositioning patients

13% have had a debilitating musculoskeletal injury

75% have access to safe patient handling and mobility (SPHM) technology, but only half use it consistently.

We must take a closer look at this problem and ask critical questions: Why do only half of the nurses who could use SPHM technology actually use it? Is the equipment relatively inaccessible? Is it heavy or difficult to use? Is enough SPHM technology available to meet patients’ needs? Have nursing staff received the education they need to use it properly? But even if every nurse had access to SPHM technology, equipment alone isn’t the answer. Comprehensive SPHM programs are necessary to eliminate manual patient handling. ANA’s Safe Patient Handling and Mobility: Interprofessional National Standards and the corresponding implementation guide provide a framework for developing effective and sustainable SPHM programs. Important program elements include:

maintaining a commitment to a culture of safety

choosing appropriate SPHM technology

ensuring SPHM technology is accessible

conducting ongoing training to maintain competency

conducting ongoing program evaluation and remediation.

This special report gives you the information you need to help you or your employer develop and implement an SPHM program or enhance an established one. The report details risk factors for patient handling injuries, describes a multifactorial approach to preventing these injuries, discusses the importance of a culture of safety and commitment to SPHM, and provides strategies that help prevent injuries. A graphic on the last page summarizes key points of the report. Additional information is available in the article “Five strategies to help prevent nurses’ patient-handling injuries.”

Debilitating musculoskeletal injuries have ended too many nurses’ careers. We can no longer allow the health and safety of the nursing workforce to be compromised. We’re all on this journey to a safer workplace together. We all need to do our part.

Ruth Francis is a senior policy advisor and Jaime M. Dawson is a program director in the Nursing Practice and Work Environment Department at ANA.

Selected References

Executive Summary: American Nurses Association Health Risk Appraisal (HRA). Preliminary Findings October 2013-October 2014. nursingworld.org/HRA-Executive-Summary.

American Nurses Association. Safe Patient Handling and Mobility: Interprofessional National Standards. Silver Spring, MD: American Nurses Association; 2013.

Patient handling injuries: Risk factors and risk-reduction strategies

For more than 40 years, nurses have had the highest jobrelated injury rates of all healthcare personnel. In a 2011 survey conducted by the American Nurses Association:

62% of nurses expressed concerns about experiencing a disabling musculoskeletal injury

56% reported musculoskeletal pain caused or exacerbated by their work

42% reported being injured at work at least once during a 12- month period

52% reported chronic back pain

38% said they’d had to take time off work due to occupation-related back pain

20% said they’d changed their unit, position, or employment setting due to lower back pain.

The costly and seemingly intractable problem of work-related injuries among nurses and other healthcare professionals prompted Sage Products to convene a June 2015 meeting with leading experts in safe patient handling and mobility (SPHM) to better define the problem, clarify risk factors, and identify risk-reduction strategies. Panel members reached a consensus that the term patient handling injury (PHI) is an accurate, well-recognized term for identifying nurses’ injuries stemming from direct patient care. This term promotes awareness and knowledge about specific causes of injuries, establishes a shared understanding of the problem’s magnitude, and helps identify solutions to enhance nurse and patient safety.

The overarching goal of SPHM programs is to support nurses’ efforts to provide the right care for the right patient at the right time. Nurses must be aware of PHI risk factors and participate fully in efforts to ensure their patients’ and their own safety through consistent use of SPHM practices. This article examines leading risk factors for PHIs and reviews strategies for designing and implementing effective SPHM programs at healthcare facilities.

Risk factors

The following factors contribute to PHIs in nurses:

prolonged work hours

longer shift duration

longer duration of exposure during a shift

more consecutive days worked

preexisting health conditions

excessive sleepiness

social and familial disruptions

psychological disorders

an older nurse workforce

greater use of complex technological innovations

increasing numbers of critically ill patients.

Certain organizational factors also contribute to high PHI rates—inadequate staff education in SPHM, failure to commit resources to technology to support safety, and limitations of systems that promote and reinforce SPHM.

Based on a literature review and professional experience, Sage’s expert panel identified four major risk factors linked specifically to patient handling that increase nurses’ PHI risk. (See Risk factors for patient handling injuries.)

Multifaceted approach to injury prevention

Multifaceted SPHM programs are more effective than any single intervention in reducing or preventing PHIs; research shows such programs reduce PHI risk. A comprehensive effort to achieve sustained PHI reductions and improve patient safety hinges on multimodal strategies that take into account available human and equipment resources, as well as how these resources interact with work systems in diverse healthcare settings (such as perioperative, long-term care, and critical care and other acute-care environments). Successful SPHM programs must encompass appropriate technology along with worker education, a culture of safety, commitment from the top down, and routine periodic program evaluation.

Technology

Technological advances and assistive devices aid the critically important work of promoting patient movement and mobility while reducing or eliminating PHI risk factors. Proper use of assistive devices to lift, move, reposition, and transport patients is the foundation of a successful SPHM program. Assistive devices include mobile mechanical patient lifts, ceiling-mounted lifts, friction-reducing devices, lateral transfer aids, in-bed turning and repositioning devices, and height-adjustable electric beds. Ideally, this equipment should be located at or near the bedside of all patients.

All staff involved in patient handling activities must embrace and endorse integration of tools and technology into the care delivery process. Where nurses have easy access to appropriate equipment, evidence-based SPHM programs are crucial— but these alone are insufficient to guarantee program success (for instance, some nurses may choose not to use SPHM equipment). What’s more, SPHM programs may reduce injuries initially, but if nurses eventually revert to old, familiar patient-handling behaviors, injury reductions may not be sustained.

Also, assistive devices must match patients’ physical, cognitive, and clinical needs; nursing tasks to be performed; workplace design; and nurse characteristics. Furthermore, nurses must work within the structure of their organization to be effective agents of change for SPHM. An organizational investment in SPHM equipment and integration of this equipment into daily patient care is vital to a successful program.

Education

Competency-based employee education on use of SPHM devices and associated work practices is crucial. Both new hires and permanent staff involved in patient handling should receive education on an ongoing basis to promote, sustain, and increase their proficiency.

Culture

Successful design and implementation of SPHM programs requires meaningful, sustained changes in the workplace culture. Establishing a culture of safety at the individual, group, and organizational levels rests on understanding the complexity of healthcare delivery systems with tightly interwoven and constantly changing work processes. The organization’s current culture and SPHM program design must be evaluated from a systems perspective to ensure that the program has a sustained favorable impact on PHI rates.

In an organizational culture of safety:

nurses feel a sense of responsibility and are willing to report adverse events, injuries, and near misses

administrators respond to these reports consistently and effectively

everyone involved is treated fairly, with the cause of the event viewed  from a systems perspective rather than assigning blame to individuals. (See Activities that promote a culture of safety.)

Commitment

To build and sustain a successful SPHM program, leaders, managers, and clinical staff must demonstrate a consistent commitment and nurse and patient safety must be integrated into clinical and business goals. Frontline nursing staff must be actively engaged and participate in planning, implementing, and evaluating the program. Visible active support of all program elements by senior leaders, mid – level managers, and engineering and construction staff can overcome barriers and promote changes in ways that frontline staff may be unable to achieve. Also, a well-designed and supported SPHM mentoring or coaching program at the unit or department level continuously reinforces SPHM principles and use of appropriate equipment, which are crucial to maintaining cultural changes.

Evaluation

SPHM program outcomes and processes must be evaluated objectively on a routine basis. Relevant outcome measures include decreased PHI rates, improved patient safety, reduced direct costs (including medical costs for injury treatment and rehabilitation, as well as compensation to injured workers), fewer days of lost work, increased employee satisfaction, and ongoing identification of opportunities for refining SPHM processes and policies. Outcome metrics at the system and unit levels can be disseminated through the facility’s intranet or “dashboards” that display safety data in real time. Employees should be encouraged to share stories of safety events with full transparency.

Thoughts, words, and actions

An industry-wide effort to prevent PHIs through SPHM programs requires partnerships and coalitions, staff education, increased access to and use of assistive devices, and ongoing education—all supported by federal and state SPHM initiatives in development. Numerous resources are available to assist organizations on their journey to SPHM.

Organizational change to support and promote SPHM occurs only when all organization members focus on three key questions: What are we are doing? Why are we doing it? What’s my role? Full engagement and cultural transformation can occur only when everyone responds effectively to these questions in thoughts, words, and actions.

Guy Fragala is a senior advisor for ergonomics at the Patient Safety Center of Inquiry in Tampa, Florida. Teresa Boynton, an occupational therapist, previously served as an ergonomics and injury prevention specialist and workers’ compensation consultant at Banner Health, Western Region, in Greeley, Colorado. Marlyn T. Conti is a patient safety initiatives manager at Intermountain Healthcare in Salt Lake City, Utah. Lee Cyr is director of insurance services with Synernet, Inc. in Portland, Maine. Lynda Enos is a certified professional ergonomist and ergonomics/human factors consultant with HumanFit, LLC, in Portland, Oregon. Devon Kelly is an injury prevention project manager in the safety department at OSF Saint Francis Medical Center in Peoria, Illinois. Nancy Mc- Gann is system manager of ergonomics and safe patient handling for SCL Health in Colorado, Kansas, and Montana. Kathleen Mullen is the safe patient handling coordinator for CoxHealth in Springfield, Missouri. Susan Salsbury is system lead for safe patient handling and mobility at OhioHealth and Associate Health and Wellness in Columbus, Ohio. Kathleen Vollman is a clinical nurse specialist/consultant for Advancing Nursing, LLC, in Northville, Michigan.

References

American Nurses Association. 2011 ANA Health & Safety Survey: Hazards of the RN Work Environment. 2011. goo.gl/b5sBd5

American Nurses Association. Handle with Care Fact Sheet. goo.gl/6gh30b

American Nurses Association. Safe Patient Handling and Mobility: Interprofessional National Standards. Silver Spring, MD. American Nurses Association; 2013.

Bassett RD, Vollman KM, Brandwene L, Murray T. Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative. Intensive Crit Care Nurs. 2012;28(2):88-97.

Gallagher S. Implementation Guide to the Safe Patient Handling and Mobility Interprofessional National Standards. American Nurses Association. Silver Spring, MD; 2013.

Joint Commission, The. Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation. November 2012. goo.gl/ZnzqTd

Mayeda-Letourneau J. Safe patient handling and movement: a literature review. Rehabil Nurs. 2014;39(3):123-9.

Mohammed S, Singh D, Johnson GT, et al. Evaluation of occupational risk factors for healthcare workers through analysis of the Florida Workers’ Compensation Claims Database. Occup Dis Environ Med. 2014;2(4):77-85.

Nelson AL, Motacki K, Menzel N. The Illustrated Guide to Safe Patient Handling and Movement. New York, NY: Springer Publishing Company, LLC; 2009.

Occupational Safety & Health Administration. Worker Safety in Hospitals. Caring for our Caregivers. osha.gov/dsg/hospitals/program_development.html

Powell-Cope G, Toyinbo P, Patel N, et al. Effects of a national safe patient handling program on nursing injury incidence rates. J Nurs Adm. 2014;44(10):525-34.

Schoenfisch AL, Lipscomb HJ, Pompeii LA, et al. Musculoskeletal injuries among hospital patient care staff before and after implementation of patient lift and transfer equipment. Scand J Work Environ Health. 2013;39(1):27-36.

Trinkoff AM, Geiger-Brown JM, Caruso CC, et al. Personal safety for nurses. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008; 2-473-2-508.

CLABSI

Three practice bundles to reduce CLABSIs

Healthcare-acquired infections (HAIs) remain a significant problem for most hospitals, despite a decade of focused improvement efforts using evidence-based guidelines. One type of HAI, central-line associated bloodstream infection (CLABSI), carries a mortality of 12% to 25%. CLABSIs also can be costly for hospitals, extending patient stays. The Centers for Medicare & Medicaid Services no longer reimburses hospitals for the cost of treating these infections.

Fortunately, we’ve made progress against CLABSIs. The Centers for Disease Control and Prevention (CDC) reports a 58% reduction in CLABSIs from 2001 to 2009. That’s an impressive decrease—but we still have room to improve. In 2009, about 18,000 intensive care unit patients were diagnosed with CLABSIs; an additional 23,000 cases occurred in acute-care unit patients and 37,000 in outpatient hemodialysis patients.

This article discusses basic practice bundles that have helped us achieve our current success and highlights several interventions beyond the bundles, which may further decrease CLABSIs.
In 2005, the Institute for Healthcare Improvement (IHI) launched the 100,000 Lives Campaign, which sought to reduce HAI morbidity and mortality through the use of bundled interventions. In particular, IHI promoted a central-line insertion bundle to reduce CLABSIs. Healthcare organizations that implemented the IHI bundle reduced CLABSIs significantly, as shown by the CDC’s national estimates. The concept and content of bundles now goes beyond those initially recommended by IHI. CLABSI bundles can be divided into three categories—insertion, maintenance, and patency.

Central-line insertion bundle

IHI’s insertion-bundle recommendations include proper hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis, optimal catheter site selection, and daily assessment for removal of unnecessary lines. The following practices related to central-line insertion go beyond the basic bundle and are supported by evidence:

  • ultrasound-guided peripheral I.V. placement by registered nurses to reduce the need for central line access
  • antimicrobial- or antiseptic-coated catheter use if the central line will stay in place beyond 6 days
  • midline catheter as an alternative to a central line if therapy is likely to exceed 6 days
  • ultrasound guidance for central-line placement to avoid multiple placement attempts
  • dedicated advanced practice nurse teams for central-line insertion.

Central-line maintenance bundle

Most healthcare facilities use a maintenance bundle for ongoing care of patients with central lines. Typically, the bundle includes many of the recommendations in the CDC’s Guidelines for the Prevention of Intravascular Catheter-Related Infections or other professional society guidelines.

Basic maintenance bundle elements focus on proper hand hygiene, catheter disinfection before central-line access, and aseptic technique for site care, tubing, and dressing changes. Evidence-based interventions related to central-line maintenance that go beyond the basic bundle include:

  • disinfectant caps that cover needleless connectors and injectable ports on tubing
  • chlorhexidine-impregnated transparent dressings or sponges
  • sutureless securement devices to stabilize catheters
  • daily bathing with chlorhexidine alone or combined with mupirocin ointment to the nares.

Central-line patency bundle

Studies link catheter thrombosis with development of bloodstream infections. Healthcare facilities typically have policies and procedures addressing catheter patency but may not consider these part of a bundle.

Components of a patency bundle include such items as catheter-flushing technique, optimal flush solutions, anti-reflux devices, and interventions for managing catheter occlusions. Here are some evidence-based practices related to central-line patency:

  • needleless connectors with neutral/zero fluid displacement during access and de-access
  • prophylactic antimicrobial lock solutions instead of heparin or saline solution
  • standing orders for managing catheter occlusions.

Beyond bundles

Nurses are uniquely positioned to influence CLABSI reduction. As keen observers during catheter insertion, we should feel empowered to stop the procedure if we see practice lapses. Also, we are primarily responsible for care and maintenance of all central lines, and are the main advocates for removal when these lines are no longer necessary. In addition, we teach patients and families how to care for their lines when they need them at home. For these reasons, the American Nurses Association and National Quality Forum deemed CLABSI one of many nurse-sensitive indicators, meaning patient outcomes (such as CLABSI rates) improve with more nurses or a higher quality of nursing care.

Implementing research-based practice bundles has helped us make great strides. We must continue to partner with other clinicians, infection control practitioners, hospital administrators, and patients to develop and refine additional prevention strategies—and, eventually, to make the goal of zero HAIs a reality.

Cass Piper Sandoval is a clinical nurse specialist in adult critical care at the University of California San Francisco Medical Center.

Selected references

Centers for Disease Control and Prevention. Vital signs: central line-associated blood stream infections – United States, 2001, 2008, 2009. MMWR Morb Mortal Wkly Rep. 2011;60(8):243-8.

How-to Guide: Prevent Central Line-Associated Bloodstream Infections. Cambridge, MA: Institute for Healthcare Improvement; 2012. ihi.org/resources/pages/tools/howtoguidepreventcentrallineassociated
bloodstreaminfection.aspx

O’Grady NP, Alexander M, Burns LA, et al.; Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections, 2011. Clin Infect Dis. 2011;52(9): e162-e193. cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf

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