Safety Solutions to Create Safer Environments

Presented by:Guy Fragala Ph.D., PE, CSP, CSPHP

Caregivers at Risk Helping Patients

Problem in Need of Solutions

• Caregiver Back Injuries

Musculoskeletal disorders among healthcare workers delivering direct care to patients continues to be a major problem requiring help and effective solutions

Occupations at Risk for Strains and Sprains

Number (in 1,000s) of work related musculoskeletal disorders involving time away from work by occupation. BLS

Total Musculoskeletal Disorders 592.5Nursing aids, orderlies and attendants 49.1

Truck drivers 43.9

Laborers, non-construction 36.6

Assemblers 19.7

Janitors and cleaners 14.0

Registered nurses 12.4

Stock handlers and baggers 11.3

Construction laborers 10.8

Reviewing Statistics• Incidence Rate for Overexertion Injuries is

Four Times Higher Than the National Average (Bureau of Labor Statistics 2000)

• Highest Rate of Musculoskeletal Disorders Among and More than Seven Times the National Average for All Occupations

(Bureau of Labor Statistics 2009)

For release 10:00 a.m. (EST) Wednesday, November 9, 2011

• The rate of nonfatal occupational injury and illness cases requiring days away from work to recuperate was 118 cases per 10,000 full-time workers in 2010, statistically unchanged from 2009,

• The MSD incidence rate for nursing aides, orderlies, and attendants increased 10 percent to an incidence rate of 249 cases. This occupation also had a 7 percent increase in the number of MSD cases.

(Bureau of Labor Statistics 2011)

REPOSITIONING IN BEDA problem in healthcare facilities that

very much needs solutions

How Bad is the Problem of Musculoskeletal Disorders Suffered by Healthcare Workers Resulting from Repositioning Patients in Bed?

Manual Techniques Taught

• Drag up bed - one nurse • Australian lift up bed

Traditional Manual Patient Repositioning Techniques

• Highest occupational risk task determined in biomechanics laboratory study

(Marras 1999)

• Even with draw sheets and sliding sheets peak low back compression exceeded NIOSH action level of 3400 newtons in 25% OF 418 trials

(Skotte &Fallentin 2008)

Is the Task Safe with Two Caregivers?

• This doesn’t work • Neither does this

Nursing Injury Studies

• Lifting Patient Up in Bed– 48% Injury Rate

(Harber 1985)

– 29% Injury Rate (Vasiliadou 1995)

Both number one on list in studies

Frequency Demands

• Forty Percent of Critical Care Unit Caregivers Performed Repositioning Tasks More Than Six Times Per Shift (Harber et al)

• Highest Frequency Physically Demanding Task Reported (Vasiliadou et al)

Other Studies• 50% of nurses required to do

repositioning suffered back pain (Smedley 1995)

• High Physical Demand Task– 31.3% up in bed or side to side– 37.7% transfers in bed

(Knibbe 1996)

Seven Hospital, Two-Year Study

• Number one injury causation activity: Repositioning Patients in bed (Fragala 2003)

Injuries to Hospital Workers

Activity Reported Injuries Percentage Rank

Repositioning Patient (Includes turning and lifting patient up in bed)

153 17.9 1

Object Lifting 109 12.7 2

Lifting Patient (not further specified) 102 11.9 3Transfer Bed/Chair 97 11.3 4

Transporting Patient (wheelchair/stretcher/bed)

94 11.0 5

Push/Pull Object 89 10.4 6

Aggressive Patient 70 8.2 7

Lateral Patient Transfer 49 5.7 8

Why Do Patients Need Repositioning?

• Medical Diagnosis• Physical Condition• Comfort• Benefits to Healing• Maintain Healthy Tissue

Studying the Problem Further

• Seeking to formulate effective solutions with input from caregivers.

• Ideas for the best solutions come from those who perform the task repeatedly each day.

REPOSITIONING PATIENTS IN BEDYour Input is Appreciated

1. What is your occupation?2. What type of unit do you work on?3. During a normal workday how many

patients, on average, are you responsible for providing care to?

4. During a normal workday how many of your patients, on average, require your assistance to be pulled up in bed?

REPOSITIONING PATIENTS IN BED (continued)

5. During a normal workday how many of your patients, on average, require your assistance to be turned in bed or be repositioned side to side in bed?

6. Are there any characteristics about a patient which make them more likely to need help repositioning?

7. Why do you reposition patients in bed?8. Is there a need for devices which will automatically

or mechanically reposition patients in bed?

Answering Questions

• Demands on caregivers to reposition

patients• Patient characteristics related to

repositioning• Why caregivers reposition patients• Solutions caregivers want

Respondents

* Other Units include telemetry, orthopedics, imcu, nursing home, float, oncology, ER, radiology, neurology, pacu, long term care, endoscopy, sds, ambulatory, ed, rehab tcu

Occupation n

Registered Nurses 313 RN Critical Care Unit 61 RN Intensive Care Unit 77 RN General Medical 112 Other Units* 63 Licenses Practical Nurses 30 Nursing Aids 87 Other Occupation 27 (Missing) 2Healthcare workers 459

Number of Patients Requiring Pulling up in Bed

RN

RN ICU

RN CCU

RN GMSLPN

Nursing Aid

pulling up

care0

2

4

6

8

10

12

Nu

mb

er

of

Pa

tie

nts

/da

y

Number of Patients Requiring Pulling up in Bed

    Patients Pull Up

  n Mean SD Min Max Mean SD Min Max

All Respondents 459 7.74 6.26 0 41 6.04 5.42 0 40

Registered Nurses 313 5.87 5.19 0 41 4.81 3.81 0 22

RN Critical Care Unit 61 3.05 1.85 1 10 3.49 2.75 0.5 16

RN Intensive Care Unit 77 2.51 2.53 0 22 4.44 4.79 1.5 22

RN General Medical 112 7.48 4.94 0 41 4.67 2.53 0 16

Licenses Practical Nurses 30 10.02 8.56 3 40 7.83 6.70 3 38

Nursing Aids 87 11.83 4.96 4 35 8.11 5.75 0 35

Number of Patients Requiring Repositioning

RN

RN ICU

RN CCU

RN GMSLPN

Nursing Aid

reposition

care0

2

4

6

8

10

12

Nu

mb

er

of

Pa

tie

nts

/da

y

Number of Patients Requiring Repositioning

  Patients Reposition

  n Mean SD Min Max Mean SD Min Max

All Respondents 459 7.74 6.26 0 41 5.09 4.88 0 40

Registered Nurses 313 5.87 5.19 0 41 4.40 3.78 0 22

RN Critical Care Unit 61 3.05 1.85 1 10 2.93 2.65 0 16

RN Intensive Care Unit 77 2.51 2.53 0 22 4.27 4.69 1 22

RN General Medical 112 7.48 4.94 0 41 4.09 2.53 1 16

Licenses Practical Nurses 30 10.02 8.56 3 40 6.60 5.57 2.5 30

Nursing Aids 87 11.83 4.96 4 35 5.81 5.16 0 35

Solution Strategies• Eliminate the need to perform the high risk

activity.• Redesign the task to eliminate components of

the high risk task.• Minimize the frequency of the high risk task.• Make Optimum Use of Equipment Features to

Facilitate• Reduce risk through application of an aiding

device.

Studying the Problem Further

• Seeking solutions

• Input from caregivers

• Involving the Patient

What is the Central and Most Important Furnishing in the Care Environment?

• The Bed• Why?• Can we address many of our patient handling

challenges with proper bed selection for our Patients and Residents?

Finding Solutions

• What are the safe patient handling challenges we can address with proper bed system selection?

• How do Healthcare Facilities currently make decisions about bed selection and who is involved?

• How should Healthcare Facilities make decisions about bed selection and who should be involved?

Develop a Process for Bed Selection

• Who should be involved in the process?• Understand your patient and resident

population.• What are the required features for all your

beds?• What options and modifications will you

require to address the needs of individual patients and residents?

Patient Handling Challenges

• Bed egress unassisted• Bed egress with assistance• Bed egress total lift and transfer• Repositioning in bed• Delivering care in bed

Bed Systems

• Not just a bed but a Bed System

• Two Major components

• The Bed Frame

• The Bed Surface

Solving Problems With Bed Systems

• What can be accomplished with bed frames • What can be accomplished with bed surfaces• How do frames and surfaces work together to

enhance quality of care

Frame Design

• Facilitate bed egress• Reduce migration in bed • Provide position changes of patient• Facilitate repositioning when required• Facilitate access for care delivery• Provide comfort• Provide safety

36

Reducing the Frequency

• Can we improve how we keep the patient properly positioned in bed

• Can we change postures without repositioning• Can we consider less frequent repositioning• Can we better involve the patient in the

repositioning activity• Proper Bed System selection

37

Bed Frames

Reducing the Need to Reposition

• Head of Bed Articulation Pushes Patient Down in Bed

• Patient Requires Pulling Back to Head of Bed• Movement Over Bed Surface Creates Shear• Pulling Patient Up in Bed Difficult and

Demanding• How Does the Head of the Bed Articulate?• Can Articulation Mechanism be Redesigned?

Head of Bed Articulation

Can Migration be Minimized

Investigate Articulation Action

42

NEW BED FRAME FEATURES

• Full and reverse Trendelenburg positioning provides versatile, clinical abilities

• Comfort chair recliner-type functionality• Four-section sleep surface for an array of

therapeutic positions• Extraordinary travel range – from 7" low

height (Model 790 & 795 low height is 9") for resident safety to 30" high height for caregiver convenience.

• Sleep surfaces are 35" wide and either 76" or 80" long

• Six-function pendant makes adjustments easy for both resident and caregiver

• 500 lbs maximum weight capacity

790 Bed

770 Bed

795 Bed

43

Task Redesign Solution Gravity Assist Repositioning

• Integrated into the existing central room furnishing, the bed

• Easy to achieve with one touch of the bed control

• Quantifiable reduction of force and effort required from the caregiver

• Reduced risk of injury to the patient

44

Head Down Gravity Assist

45

Gravity Assist Improvement• Measured force to reposition 200 lb

mannequin 12 inches by varying head down angle

• Area under force vs. distance chart is total work

Repositioning without Slide Sheet

0

20

40

60

80

100

120

0 2 4 6 8 10 12 14

Distance (inches)

Fo

rce

(lb

s) 0 Degrees w/o SS

4 Degrees w/o SS

6 Degrees w/o SS

8 Degrees w/o SS

12 Degrees w/o SS

Bett

er

Blue is total work at 0 ْ head down

Yellow is total work at 6 ْ head down

46

Impressive Results Applying Gravity Assist

• By increasing the angle to 6 ْfrom 4 ْ results in 3 X work reduction– 49% for 6 ْ– 16% for 4 ْ

Work to Reposition

(in*lb)% Reduction

in Work1507 0%1265 16%

769 49%499 67%12 degrees

Angle0 degrees4 degrees6 degrees

Work to Reposition 200 lb Resident 12 inches

0

200

400

600

800

1000

1200

1400

1600

0 degrees 4 degrees 6 degrees 12 degrees

Head Down Angle

Wo

rk (

in*l

b)

20%

30%

40%

50%

60%

70%

80%

90%

100%

Work (Actual)

% Work vs. 0 Degrees

47

Bed Positioning Aid

48

Solutions With Surface Design

• Redistributes Pressure• Reduces Moisture• Can Facilitate Turning• Influences Repositioning Frequency• Wound Prevention and Treatment• Provides Comfort

How Often Should a Patient be Turned

• Every four hours?• Every two hours?• More frequently?• New research supports possible less frequent

repositioning when applying appropriate pressure redistribution surface.

(reference American Journal of Nursing 2009)

Non-Powered Surfaces

• Foam Type and Density• Foam Surface Cut and

Layout• Foam and Air Cells

Combined

Good Foam Surface• Single-ply, therapeutic high-

density foam mattress, which encourages envelopment and redistributes pressure. Combines quality, comfort and value.

• Incorporates sloped heel section to redistribute pressure in delicate heel and lower leg areas

• Available in flat construction style or with raised sidewalls

Better Foam Surface• Soothing, Visco memory foam in heel

slope for delicate heel section. Optional TEMPUR material for heel section.

• Firm perimeter and Tru-fit sizing help meet FDA/HBSW guidelines

• Strategically located mattress base cuts promote easier flexing during bed frame articulation - reduces wear and tear to help extend mattress life

• Optional raised sidewall available • Soft, yet highly resilient foam gently

cradles head and torso sleeping section

Best Foam Surface• Dynamic non-powered pressure

relieving mattress replacement. • Firm perimeter provides added

stability during resident care/ transfer and help support resident safety

• Incorporates sloped heel section to redistribute pressure in delicate heel and lower leg areas

• Tubular foam cylinders provide comfort and pressure redistribution

Foam and Air Cell Surface• The P.R.O. Matt Plus is a non-

powered convertible alternating pressure mattress replacement system featuring our P.R.O. (Pressure Relief Optimization) technology. This mattress replacement system allows healthcare providers to provide optimal interface pressures through controlled air cell inflation for at-risk residents and treatment for Stage I and II pressure ulcers. The P.R.O. Matt Plus may also be indicated for additional therapeutic intervention based on resident’s specific assessment.

Powered Surfaces

• Number of Cells and Zones• Alternating Pressure• Low Air Loss• Customization of Surface

SURFACE OPTIONS ADDING POWER

• Non-powered convertible alternating pressure mattress replacement system featuring P.R.O. (Pressure Relief Optimization) technology

• Four zones (head, shoulder, torso and foot) • High resiliency foam topper provides

maximum pressure relief• Treatment for Stage I and II pressure ulcers• Dimensions: 80"L x 36"W x 7"H• Meets flammability standards including

Federal 16 CFR 1633, Cal 117 and Boston IX-II

• 500 lbs. maximum weight capacity

CairTurn RTLateral Rotation Therapy

Benefits

• Highly specialized quilted therapy pad reduces friction and shear force while providing moisture relief without drying out patients skin

• “Autofirm” mode provides maximum air inflation designed to assist both patient and caregiver during patient transfer and treatment

• Advanced design turning therapy cells provide optimal turning therapy

• Six turn cycle times and eight therapy settings maximize patient compliance, healing and lateral rotation options

• Preset optimal turn of 30° offers safe, comfortable rotation for both organ drainage and pressure relief

• Quiet, comfortable, easy to set up and use and incorporates both rotation and floatation therapy

Benefits

• Specially designed quilted therapy pad reduces friction and shear force while providing moisture relief without drying out patient’s skin

• Up to two hundred liters of airflow wicks away moisture to help prevent skin maceration

• “Autofirm” mode provides maximum air inflation designed to assist both patient and caregiver during patient transfer and treatment

• True 40º turn (80º arc) provides maximum benefit for wound healing and reduction of fluid in lungs

• Inflatable side air bolsters provide additional patient safety• Turning done by inflation provides for a more significant turn

while maintaining pressure relief• Fowler boost inflates sacral section to provide adequate

pressure relief when head of bed is elevated at 25º or greater

TurnCair™ PlusLateral Rotation and Low Air Loss

FlapCair™ Cellular Low Air Loss Support

Benefits

Sixty individual therapy cells help to evenly distribute patient’s weight and maximize pressure relief

Highly specialized quilted cover reduces friction and shear force while providing moisture relief without drying out patient’s skin

Up to two hundred liters of airflow wicks away moisture to help prevent skin maceration

Designed for healing flaps and graft sites as well as pressure ulcers

Low air loss mattress replacement provides ten inches of therapeutic support

“Pulsate” mode to enhance wound healing and patient comfort

Lower safety mattress prevents bottoming out by remaining inflated up to 24 hours in the event of a power failure

In a recent independent study, the FlapCair pressure mapped and

performed comparable to the Clinitron.

Turn1000™ Bariatric Lateral Rotation and Low Air Loss

Improving patient outcomes and increasing patient and caregiver safety.

Benefits

• Specially designed quilted therapy pad reduces friction and shear force while providing moisture relief without drying out patient’s skin

• Up to 200 liters of airflow wicks away moisture to help prevent skin maceration

• “Autofirm” mode provides maximum air inflation designed to assist both patient and caregiver during patient transfer and treatment

• Turn angle set options of ¼, ½, ¾ and “full” provides maximum benefit for wound healing and reduction of fluid in lungs

• Turn set times of 10, 20, 30 and 60 minutes provide individualized patient therapy settings

• Lower safety mattress provides pressure reduction by remaining inflated up to 24 hours in the event of a power failure

CairRails™ Risk Management Air Bolsters

Protect your facility from liability…And provide your patient with a safe, secure healing

environment.

Benefits

A bilateral side bolster solution which can enhance your facilities entrapment/risk management program

Transfer friendly-deflate for ease of assisted transfer or when bolsters are not required

Unique contoured design allows ease of ingress/egress, while providing additional protection, comfort and supports patient compliance

Promotes maximum independence by allowing caregiver to decide when added protection is required

Other Patient Handling Challenges

• Bed egress unassisted• Bed egress with assistance• Bed egress total lift and transfer• Delivering care in bed• Patients at Risk for Falls

Bed Egress

• What can be done to facilitate bed egress

• Assisted Bed Egress• Independent Bed

Egress

Bed System Solutions

• Deluxe Assist Handles mounted on bed frame sides provide a secure hand hold to assist residents to safely stand and egress the bed

• Auto Transfer Height as part of the AdvanceCare positioning package easily sets the bed frame at the optimum bed egress height for most of the population

Foot of Bed Egress

Height Adjustment Egress Assist

Increase Bed Surface Width

• UltraWide adds nearly 20% width to the bed surface providing more space for the resident similar to conventional residential bed surface area encouraging a comfortable night’s sleep and reducing the exposure of rolling out of bed.

Body Center of Gravity on Bed Surface

Risk for Falling Out of Bed

Figure 2: Average Risk for All Target Populations

51%

44%

33%

0%

10%

20%

30%

40%

50%

60%

35 inch 39 inch 42 inch

Per

cen

t R

isk

of

Fal

lin

g d

ue

to H

ip W

idth

Co

ntr

ibu

tio

n

Average Risk for All Populations

14% Improvement

36% Improvement

Benchmark

Under Bed Lighting

• The Under bed night light provides soft lighting to the bed egress floor area adding safety for residents to exit the bed during evening hours

Low Beds Reduce Injury severity

• Ability to be placed in a very low surface position to reduce risk of injury severity related to rolling out of bed

Gait Training Application