Upload
manissabella
View
5
Download
0
Embed Size (px)
Citation preview
FEATURED ARTICLE
Effect of a Safe Patient HandlingOutcomes
hD
bs
reduced workers compensation costs.17 However, the effects ofthese programs on patient recovery and rehabilitation are rela-tively unknown.
no. R03 HS020723-01).
No commercial party having a direct financial interest in the results of the research supporting
this article has or will confer a benefit on the authors or on any organization with which the authors
are associated.
0003-9993/13/$36 - see front matter 2013 by the American Congress of Rehabilitation Medicinehttp://dx.doi.org/10.1016/j.apmr.2012.08.213
Archives of Physical Medicine and Rehabilitationjournal homepage: www.archives-pmr.org
Archives of Physical Medicine aPsychology, Northeastern University, Boston, MA; cHebrew Rehabilitation Center, Boston, MA; and dDivision of Occupational Therapy, School ofHealth and Rehabilitation Sciences, The Ohio State University, Columbus, OH.
Abstract
Objective: To evaluate the effect of a safe patient handling (SPH) program on rehabilitation mobility outcomes.
Design: Retrospective cohort study.
Setting: A rehabilitation unit in a hospital system.
Participants: Consecutive patients (NZ1291) over a 1-year period without an SPH program in place (nZ507) and consecutive patients over a 1-year period with an SPH program in place (nZ784).Interventions: The SPH program consisted of administrative policies and patient handling technologies. The policies limited manual patient
handling. Equipment included ceiling- and floor-based dependent lifts, sit-to-stand assists, ambulation aides, friction-reducing devices, motorized
hospital beds and shower chairs, and multihandled gait belts.
Main Outcome Measures: The mobility subscale of the FIM.
Results: Patients rehabilitated in the group with SPH achieved similar outcomes to patients rehabilitated in the group without SPH. A significant
difference between groups was noted for patients with initial mobility FIM scores of 15.1 and higher after controlling for initial mobility FIM
score, age, length of stay, and diagnosis. Those patients performed better with SPH.
Conclusions: SPH programs do not appear to inhibit recovery. Fears among therapists that the use of equipment may lead to dependence may be
unfounded.
Archives of Physical Medicine and Rehabilitation 2013;94:17-22
2013 by the American Congress of Rehabilitation Medicine
In health care settings, manual patient handling tasks (such astransferring a patient) result in excessive physical loads that canlead to injury.1,2 Manual patient handling has been associated withinjuries to health care providers such as nurses, physical
therapists, and occupational therapists.3-5 In response to high ratesof injuries of health care providers and patient falls, hospitalsacross the United States have implemented safe patient handing(SPH) programs.6-8 These programs limit the manual handling ofpatients through a combination of policies and patient handlingtechnologies.6,9-11 The primary focus of most programs is onpolicies and equipment that are designed to reduce the physicalloads associated with common patient handling tasks such astransfers, repositioning, ambulation, and arresting falls.11-13
Settings for SPH programs include acute care, rehabilitation,and long-term care, where patient lifting is common. SPHprograms have reduced the incidence of provider injuries andpatient falls.6-8,14-16 They also have decreased lost work time and
Presented to the Safe Patient Handling and Movement Conference of the Veterans Admin-
istration Sunshine Health Network, March 18e22, 2012, Orlando, FL; presented as a poster to the
Combined Sections Meeting of the American Physical Therapy Association, February 8e11, 2012,
Chicago, IL.
Supported by the Agency for Healthcare Research and Quality (Small Research Award, grant
An audio podcast accompanies this article.Listen at www.archives-pmr.org.Marc Campo, PT, PhD,a Mariya P. Shiyko, PAmy R. Darragh, OTR/L, PhDd
From the aSchool of Health and Natural Sciences, Mercy College, DobProgram on Rehabilitation
,b Heather Margulis, PT, MS,c
Ferry, NY; bDepartment of Counseling and Applied Educational
nd Rehabilitation 2013;94:17-22
Rehabilitation services, in particular, are substantially impactedby SPH programs.18,19 In traditional rehabilitation settings, nurses,physical therapists, and occupational therapists provide assistancewith patient functional mobility (eg, ambulation and transfers),retraining patients to walk and transfer by lifting them and guardingthem manually. In rehabilitation settings with SPH programs, they
18 M. Campo et aluse advanced patient handling equipment to support or lift thepatient while they guide these activities, particularly when patientsare very heavy and/or dependent.19,20Although therapists are athigh risk for injuries and work-related pain,3,4 opinions on SPHprograms in rehabilitation are mixed. Among therapists, a beliefpersists that using patient handling equipment in rehabilitation mayimpede recovery.18 These devices were designed primarily forpassive patient movement and not rehabilitation,21 potentiallylimiting their usefulness as rehabilitative tools. A study of stand-assist devices, for example, found that equipment-assisted trans-fers were preferable to a poorly executed manual transfer butstill did not promote normal movement patterns. The samestudy also found that equipment may promote passive participationin the transfer.22
Arnold et al23 reported positive effects of SPH equipment onrehabilitation. They found that patients with stroke who underwentrehabilitation under an SPH program had greater improvements inmobility FIM scores than did patients with stroke who underwentrehabilitation without the program. The study, however, was basedon a small sample of patients (nZ94) with a single diagnosis.
In our own qualitative work examining the use of SPH equip-ment in rehabilitation, therapists in facilities with established SPHprograms described advantages to using the equipment duringpatient care.18,19 In addition to increased staff and patient safety,therapists reported that patients demonstrated increased participa-tion and activity, and therapists were able to mobilize bariatric andmedically complex patients earlier in the rehabilitation process.19
However, they also identified important limitations of the devices(eg, sling design and equipment maneuverability) as well aslimitations in device usage (depending on patient, environment, andactivity characteristics).
These initial studies provide some evidence for the usefulnessof SPH programs in rehabilitation, particularly for addressingfunctional mobility and for mobilizing patients who require themost assistance. However, given the design and sample sizelimitations of these studies, more formal evaluations, based onlarger and representative samples, are warranted.
The number and scope of SPH programs are increasing. TheVeterans Administration, for example, has recently implementeda large-scale initiative to implement SPH programs in all theVeterans Administration inpatient facilities.24 In addition, as of2012, 10 states had enacted some form of SPH legislation, withsome requiring full SPH programs in facilities.25 Other laws weredemonstration initiatives designed to promote SPH programs andincrease adoption. Considering the number and scope of SPHprograms, and the fact that they fundamentally alter patient care,there is an urgent need to examine the effect of SPH programs onpatient functional mobility in rehabilitation. The purpose of thisstudy was to determine the effect of an SPH program on patientfunctional mobility outcomes, as measured by the FIM.
List of abbreviations:
BMI body mass index
SPH safe patient handlingMethods
Study participants
This was a retrospective cohort study of patient rehabilitationoutcomes before and after the implementation of an SPH program.We obtained data from the electronic medical records of 1315patients admitted to the rehabilitation unit of a large hospital centerin Massachusetts. Any patients who died during rehabilitation orwho had a stay of 2 days or fewer on the rehabilitation unit wereexcluded from the study. The purpose of excluding patients withshort stays was to eliminate unstable patients who were likelytransferred out of the recuperative services unit shortly afteradmission. Based on this criterion, 23 patients were excluded (10 in1 group and 13 in the other group). An additional patient wasdropped from the analysis because of an unusually prolongedhospital stay (140 days, z scoreZ9.3). The final sample comprised1291 patients. The materials and methods of this project wereapproved by the institutional review boards of Hebrew Rehabilita-tion Center, Mercy College, and The Ohio State University.
Intervention
Intervention (SPH) and comparison groups (No-SPH) occurredhistorically within the same hospital at 2 different time periods. Thecomparison group was composed of 507 patients admitted torehabilitation between July 2005 and July 2006, prior to theimplementation of the SPH program. The intervention group wascomposed of 784 patients admitted to rehabilitation between April2008 and April 2009. We did not consider any patients admittedbetween August 2006 and March 2008 to allow the program to befully implemented. This provided therapists with time to becomecomfortable with the equipment and allowed them to fully transi-tion into the work environment with new practices and standards.
The SPH program consisted of administrative policies, equip-ment, and a decision-making algorithm. Under this program,patients with a body mass index (BMI) >35 required a pread-mission consultation to select bariatric lift equipment. For allpatients admitted, regardless of BMI, all staff members exceptphysical and occupational therapists were required to use patienthandling equipment with 2 exceptions: patients could be manuallyhandled if they required only close supervision or contact guard orin the event of emergencies. For physical and occupational ther-apists, the requirement was to use equipment if a task required>15.9 kilograms (35 pounds) of effort or if a patient requiredanything more than minimal assistance. A level of 15.9 kilogramswas based on recommendations from the National Institute ofOccupational Safety and Health.26 The program was designed togive therapists more latitude when working on rehabilitationactivities while still reducing the risk from excessive loading.
Equipment included floor- and ceiling-based dependent patientlifts, sit-to-stand assists, motorized hospital beds, ambulationaides, multihandled gait belts, and powered shower chairs.Therapy staff members were trained in the use of equipment uponhiring and were required to pass competency evaluations. Therapyunits had peer leaders who were available for consultation.
Outcome measure
The outcome measure was the functional status of patients asdetermined by the mobility portion of the FIM. Admission FIMwww.archives-pmr.org
scores were determined by the lowest score observed by any inter-disciplinary member of the care team in the first 3 days followingadmission. Discharge FIM scores were determined by a similaralgorithm in the 3 days prior to discharge. The FIMmeasure consistsof 18 items, each rated on a 7-point scale by health care professionals(usually physical therapists, occupational therapists, and speechpathologists), where a score of 1 indicates total dependence anda score of 7 indicates complete independence.
The FIM categories and individual items are described infigure 1. In the current study, we defined the mobility FIM as thetotal of the 2 locomotion and the 3 transfer subscales. Thesesubscales were chosen because function in these activities was themost likely to be affected by the use of SPH devices in rehabili-tation. The FIM has demonstrated good reliability. In a meta-analysis including 11 studies, Ottenbacher et al27 found pooledmedian reliability coefficients of .95 for both interrater and test-retest statistics. In a systematic review, Glenny and Stolee28
found internal consistency values for the total FIM ranging from.88 to .97 and values for the motor domain of the FIM rangingfrom .86 to .98. The FIM has also demonstrated good construct29
and criterion validity.30,31 Therapy staff members were trained inFIM administration and were certified upon hiring. They wereretrained every 2 years thereafter.
Statistical analysis
Safe patient handling effects on rehabilitation 19Statistical analyses were conducted using SPSS Statistics v. 19a andIntercooled STATA v. 12.b We examined univariate statistics,distributional plots, and outliers for all variables. To establishbetween-group equivalence, we compared the intervention andcontrol groups on a number of demographic characteristics,including age, length of stay, and diagnosis. Group equivalence wasevaluated with independent sample t tests for continuous variablesand chi-square tests of association for categorical variables.
To evaluate the main research question of the effect of the SPHprogram on patient outcomes in rehabilitation, we used a linear
Fig 1 The FIM categories. The FIM includes 6 categories and 18
individual items, each rated from 1 to 7 by rehabilitation staff. The
mobility FIM is the sum of all the transfer and locomotion items.www.archives-pmr.orgResults
Demographic characteristics by group are described in table 1. Thegroups were comparable in their admission mobility FIM scores.The groups differed in terms of age (tZ2.67; PZ.01) and length ofstay (tZ2.11; PZ.03). The distribution of impairment codes wasdifferent between the groups (c2Z23.81; dfZ3; P
20 M. Campo et alDiscussion
The purpose of this study was to determine the effect of the SPHprogram on rehabilitation mobility outcomes in a large and diversesample of patients. Our main finding was that for the majority ofpatients, both patient handling practices yielded similar functionalmobility outcomes. Differences emerged for a subgroup of patientswith high mobility FIM scores at admission. Higher functioningpatients appeared to do better with SPH. The difference in discharge
Table 1 Demographic and baseline factors
Factor No-SPH SPH P
Number of subjects (n) 507 784
Number of excluded
subjects (n)
10 14
Age (y)
Mean SD 82.39.1 80.910.7
injuries in health care workers overall and in therapistsspecifically,3,4 these programs could potentially play a large
and
0
0
0.08
practices musculoskeletal injury prevention program in nursing
22 M. Campo et alhomes. Inj Prev 2004;10:206-11.
16. Charney W. The lift team method for reducing back injuries: a 10
hospital study. AAOHN J 1997;45:300-4.
17. Siddharthan K, Nelson A, Tiesman H, FangFei C. Cost effectiveness
of a multifaceted program for safe patient handling. In: Henriksen K,
Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety:Corresponding author
Marc Campo, PT, PhD, School of Health and Natural Sciences,Mercy College, 555 Broadway, Dobbs Ferry, NY 10522. E-mailaddress: [email protected].
Acknowledgments
We thank Karen Drake, PT, GCS (Hebrew Rehabilitation Center),for her assistance with data acquisition; Lena L. Deter, RN, MPH,CSPHP, Clinical Program Specialist (Hebrew Senior Life), forproviding information about the safe patient handing program; andSusan E. White, PhD, CHDA (The Ohio State University), forstatistical consultation.
References
1. Marras WS, Davis KG, Kirking BC, Bertsche PK. A comprehensive
analysis of low-back disorder risk and spinal loading during the
transferring and repositioning of patients using different techniques.
Ergonomics 1999;42:904-26.
2. Garg A, Owen BD, Carlson B. An ergonomic evaluation of nursing
assistants job in a nursing home. Ergonomics 1992;35:979-95.
3. Campo M, Weiser S, Koenig KL, Nordin M. Work-related musculo-
skeletal disorders in physical therapists: a prospective cohort study
with 1-year follow-up. Phys Ther 2008;88:608-19.
4. Darragh AR, Huddleston W, King P. Work-related musculoskeletal
injuries and disorders among occupational and physical therapists. Am
J Occup Ther 2009;63:351-62.
5. Smedley J, Egger P, Cooper C, Coggon D. Prospective cohort study of
predictors of incident low back pain in nurses. BMJ 1997;314:1225-8.
6. Nelson A, Matz MW, Chen F, Siddharthan K, Lloyd JD, Fragala G.
Development and evaluation of a multifaceted ergonomics program to
prevent injuries associated with patient handling tasks. Int J Nurs Stud
2006;43:717-33.
7. Li J, Wolf L, Evanoff B. Use of mechanical patient lifts decreased
musculoskeletal symptoms and injuries among health care workers.
Inj Prev 2004;10:212-6.
8. Evanoff B, Wolf L, Aton E, Canos J, Collins J. Reduction in injury
rates in nursing personnel through introduction of mechanical lifts in
the workplace. Am J Ind Med 2003;44:451-7.
9. de Castro AB. Handle with Care: the American Nurses Associations
campaign to address work-related musculoskeletal disorders. Orthop
Nurs 2006;25:356-65.
10. Waters T, Collins J, Galinsky T, Caruso C. NIOSH research efforts to
prevent musculoskeletal disorders in the healthcare industry. Orthop
Nurs 2006;25:380-9.
11. Nelson A, Motacki K, Menzel NN. The illustrated guide to safe patient
handling and movement. New York: Springer; 2009.
12. Nelson A, Baptiste A. Update on evidence-based practices for safe
patient handling and movement. Orthop Nurs 2006;25:367-8.
13. Nelson A, Baptiste AS. Evidence-based practices for safe patient
handling and movement. Online J Issues Nurs 2004;9:4.
14. Stenger K, Montgomery LA, Briesemeister E. Creating a culture of
change through implementation of a safe patient handling program.
Crit Care Nurs Clin North Am 2007;19:213-22.
15. Collins JW, Wolf L, Bell J, Evanoff B. An evaluation of a bestfrom research to implementation, Vol 3. Rockville: Agency for
Healthcare Research and Quality; 2005.
18. Darragh AR, Campo M, Olson D. Therapy practice within a minimal
lift environment: perceptions of therapy staff. Work 2009;33:241-53.
19. Darragh AR, Campo M, Frost L, Abernathy M, Petntico M, Margulis
H. Safe patient handling equipment in therapy practice: implications
for rehabilitation. Am J Occup Ther. In press.
20. Sedlak CA, Doheny MO, Nelson A, Waters TR. Development of the
National Association of Orthopaedic Nurses guidance statement on
safe patient handling and movement in the orthopaedic setting. Orthop
Nurs 2009;28:S2-8.
21. Waters TR, Rockefeller K. Safe patient handling for rehabilitation
professionals. Rehabil Nurs 2010;35:216-22.
22. Ruszala S, Musa I. An evaluation of equipment to assist patient sit-to-
stand activities in physiotherapy. Physiotherapy 2005;91:35-41.
23. Arnold M, Radawiec S, Campo M, Wright LR. Changes in Functional
Independence Measure ratings associated with a safe patient handling
and movement program. Rehabil Nurs 2011;36:138-44.
24. Petzel R. VHA Directive 2010-032: safe patient handling program and
facility design.Washington (DC): Department of VeteransAffairs; 2010.
25. Enacted Safe Patient Handling (SPH) Legislation. 2012. Available at:
http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/
State/Legislative-Agenda-Reports/State-SafePatientHandling/Enacted-
Legistation. Accessed July 1, 2012.
26. Waters TR. When is it safe to manually lift a patient? Am J Nurs 2007;
107:53-8; quiz 59.
27. Ottenbacher KJ, Hsu Y, Granger CV, Fiedler RC. The reliability of the
Functional Independence Measure: a quantitative review. Arch Phys
Med Rehabil 1996;77:1226-32.
28. Glenny C, Stolee P. Comparing the Functional Independence Measure
and the inter-RAI/MDS for use in the functional assessment of older
adults: a review of the literature. BMC Geriatr 2009;9:52.
29. Stineman MG, Ross RN, Fiedler R, Granger CV, Maislin G. Func-
tional independence staging: conceptual foundation, face validity, and
empirical derivation. Arch Phys Med Rehabil 2003;84:29-37.
30. Corrigan JD, Smith-Knapp K, Granger CV. Validity of the Functional
Independence Measure for persons with traumatic brain injury. Arch
Phys Med Rehabil 1997;78:828-34.
31. Gosman-Hedstrom G, Svensson E. Parallel reliability of the Func-
tional Independence Measure and the Barthel ADL index. Disabil
Rehabil 2000;22:702-15.
32. Long JS, Ervin LH. Using heteroscedasticity consistent standard errors
in the linear regression model. Am Stat 2000;54:217-24.
33. Hayes AF, Matthes J. Computational procedures for probing interac-
tions in OLS and logistic regression: SPSS and SAS implementations.
Behav Res Meth 2009;41:924-36.
34. Wallace D, Duncan PW, Lai SM. Comparison of the responsiveness of
the Barthel Index and the motor component of the Functional Inde-
pendence Measure in stroke: the impact of using different methods for
measuring responsiveness. J Clin Epidemiol 2002;55:922-8.
35. Beninato M, Gill-Body KM, Salles S, Stark PC, Black-Schaffer RM,
Stein J. Determination of the minimal clinically important difference
in the FIM instrument in patients with stroke. Arch Phys Med Rehabil
2006;87:32-9.
36. Vincent HK, Vincent KR. Obesity and inpatient rehabilitation outcomes
following knee arthroplasty: a multicenter study. Obesity 2008;16:130-6.
37. Stenson KW, Deutsch A, Heinemann AW, Chen D. Obesity and
inpatient rehabilitation outcomes for patients with a traumatic spinal
cord injury. Arch Phys Med Rehabil 2011;92:384-90.
38. Jain NB, Al-Adawi S, Dorvlo AS, Burke DT. Association between
body mass index and Functional Independence Measure in patients
with deconditioning. Am J Phys Med Rehabil 2008;87:21-5.
39. Stineman MG, Shea JA, Jette A, et al. The Functional Independence
Measure: tests of scaling assumptions, structure, and reliability across 20
diverse impairment categories. Arch Phys Med Rehabil 1996;77:1101-8.
40. Cournan M. Use of the Functional Independence Measure for
outcomes measurement in acute inpatient rehabilitation. Rehabil Nurs
2011;36:111-7.www.archives-pmr.org
Effect of a Safe Patient Handling Program on Rehabilitation OutcomesMethodsStudy participantsInterventionOutcome measureStatistical analysis
ResultsDiscussionStudy limitationsClinical implications
ConclusionsSuppliersKeywordsCorresponding authorAcknowledgmentsReferences