safety solutions to create safer environments
DESCRIPTION
Guy Fragala Ph.D., PE, CSP, CSPHP Senior Advisor for Ergonomics, Patient Safety Center of Inquiry (P05, Friday, Lower NZI Room, 8.30-9.30)TRANSCRIPT
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