Safe Patient Handling and the Lift Team Concept

Dr. Seidl: Let me start by welcoming all of you and thanking you in advance for your time today. Bariatric Nursing and Surgical Patient Care has conducted a roundtable discussion focused on safe patient handling, but that discussion took place more than 4 years ago. The focus of that roundtable was to discuss best practices for moving bariatric patients in a way that minimized harm to both the caregiver and the patient. Therefore, what I would like to discuss today is the progress and evolution of best practices over the last several years, specifically in terms of the state of the science regarding occupational injury risk to healthcare providers, specifically those caring for bariatric patients, and to discuss the state of safe patient handling programs in healthcare institutions around the country.

To start, I would like to invite each member of our panel to introduce him or herself. Please state your title, affiliation, and anything else you would like the readership to know about you.

Ms. Laurie McGinley: I am the past president of NABN, and I am currently working as a Bariatric Nurse Manager and Coordinator at Western Bariatric Institute in Reno, Nevada.

Ms. Joann Bunke: I am the Clinical Director for Barrier Free Access, Inc., the Minnesota Distributor of Liko products. I have worked with multiple hospitals across the United States helping them plan, implement, and sustain safe patient handling programs in adult and pediatric acute care, as well as long-term care.

Ms. Marylou Muir: My profession is Occupational Health Nursing and my passion is in bariatric patient handling and care. I have had the opportunity to publish and consult on facility programs. I also serve as an independent bariatric patient handling nursing care consultant. I have a strong background in ergonomic programs, as well as research for injury prevention in healthcare workers internationally, specifically, Canada, the United States, and several European Countries.

Mr. Eric Race: I am the founder and CEO of Atlas Lift Tech, a San Francisco-based company that contracts safe patient handling services to the medical industry. I oversee general management and operations, and I also work one-on-one with facilities to improve their safe patient handling programs. My passion for Safe Patient Handling and Movement (SPHM) stems from working in various clinical settings, including extensive hands-on experience through previous work as a firefighter, a search and rescue instructor, a paramedic, and a hospital lift technician/coordinator.

Ms. Manon Short: I am a physical therapist (PT) and the injury prevention coordinator for Tampa General Hospital, a level 1 trauma center with 1,000 beds. I have been in this position for 11 years and have developed our safe patient handling program, which includes 26 lift team technicians and the purchase of more than $1 million of lifting equipment. Since inception in 2002, we have seen a 62% reduction of patient handling injuries and an 86% reduction in costs associated with patient handling injuries.

Mr. Shannon Gallagher: I am an independent consultant for safety, outcomes, and lift management. I bring a cross-industrial perspective to safe patient handling and movement, recognizing the barriers to the creation of a culture of safety, as well as indicators of success. Recently, I began working with Atlas Lift Tech.

Dr. Seidl: Thank you. To get us started, could a few of you set the stage by explaining the challenges that healthcare professionals today face in regard to patient mobility, safe patient handling, and risk of occupational injury?

Ms. Short: There are a lot of challenges. First, I think there has been a big change in the patient population. I have been in healthcare for more than 20 years, and I think it is not just the rise in obesity, but I think the patients are definitely sicker and they are left on life support a lot longer, so there is a change in patient acuity. Then, you look at our healthcare worker population; there is a nursing shortage, at least in Florida there is, and nurses are getting older. Then, speaking specifically about safe patient handling, I really do not think there are very good standards right now with consistent practice for safe patient handling. Every state has different rules and regulations. For those that have safe patient handling legislation, every hospital does it differently. It is not well embedded in the schools of nursing and therapy, so it makes it very hard to be consistent.

Mr. Gallagher: I could not agree more with Manon. Really, the work that is ahead of us at this point is getting safe patient handling in the hands of the end user. We have so many bright people coming up with different models that have been proven to work, and what we need is to fit these models to different facilities, matching the programs to their policies and procedures, and ultimately establishing the infrastructure to get these practices into the hands of the people who can use it every day.

Ms. Bunke: I would like to add that I think one of the biggest obstacles we have in healthcare is why patient safety is more important than staff safety or caregiver safety. I think we run up against that a lot; it is the Nightingale syndrome. We are used to giving up ourselves for our patients. Until we really realize that if we don't take care of our workers we cannot take care of the patients, not much is going to change. For some facilities, it is starting to improve, but I am still seeing this.

Mr. Race: I have a strong background in both the clinical and the field setting. I was a firefighter in the seventh busiest engine company in the nation, so I had quite a bit of field experience. One thing that we were taught is that as a firefighter is you must put your safety first and your patient second. That is not to say that your patient is not as important as you, but if you become a patient, you are not good to your patient's care. That is one thing that we have to touch on when talking about safe patient handling.

Ms. Short: If I can add something to what you just said about healthcare worker safety. Not only does safe patient handling increase the safety of the healthcare workers, but we have seen increased safety for the patients. If an organization has a good safe patient handling program, there may also be improvements in patient safety, such as a decrease in patient falls, and patients who are able to get out of bed more frequently; patients may get turned more frequently, and there are less pressure sores if patients are turned more frequently. So there are a lot of benefits to patients.

Ms. McGinley: I think we need to appeal to the focus on patient safety and the do-not-cause-injury-to-your-patients aspect of it maybe even more so than the avoidance of staff injuries. Most nurses want to foster excellent care and protect their patients. As Ernestine Wiedenbach, one of my favorite nurse leaders stated, nursing is the art and science of caring. You certainly do not want to harm a patient. In addition, maybe more education about the patient safety risks that can result from improper lift technique and not using appropriate equipment would get more staff buy-in, and I think there should definitely be focus on safe patient handling during the hiring and orientation process for new staff, as well as annual training.

Ms. Short: I think it is important for hospitals and organizations to realize that this is not just about protecting healthcare workers, but it has a lot of patient safety benefits. This is not well documented in the literature, but even at Tampa General where we have had our program for 11 years, it is very hard to come up with hard data to show that we have had a reduction in falls and a reduction in pressure ulcers when we have such strong committees that encourage early reporting. Our facility has grown, so it is very hard to compare apples to apples when it comes to patient safety.

Dr. Seidl: That is an excellent point. Your program has been in place for 11 years, but it is still hard to show the impact of that program on patient outcomes. Do others agree?

Ms. Muir: Yes, absolutely it is difficult. One of the areas where I still find difficulty is the disconnect between the allied health professionals, such as physiotherapy, and nursing. The practices are not aligned because the goals are very different. An example of that is dressing, washing, bathing, and feeding. A lot of the work performed by allied health providers is tasks and goals that are intended to increase the patient's function, and there is frustration in getting us on the same page as our patient handling tasks move over to patient care. When we incorporate the tasks into the movement transfer assist from bed to chair, we do not have the same background, knowledge, skill, and goals. There seems to be that disconnect between the two professionals supporting each other in the way the task is going to be done.

Ms. Short: I really agree with Marylou. I am a PT and I have really seen a disconnect between our therapy staff and our nursing staff. I do have a PT background so at least I can speak their lingo, but it is very difficult to get the therapists onboard because they are so concerned about function. It literally has taken us 10 years to get our acute care therapists onboard and realize that there is a lot of room for using equipment to maximize function. I know the American Physical Therapy Association (APTA) is working closely with the American Nurses Association (ANA), but again, until it is embedded in the school curriculums, I think it is going to be difficult.

Dr. Seidl: I would like to ask a question based on what you just said. You said that now you are finally getting the PTs and the nurses working together. Can you describe any strategies you used to accomplish that?

Ms. Short: I should not say just nursing. It used to be nursing and therapy, but since we have a lift team, it is really the people that handle the transfers. It takes a lot of education, and it took a lot of persistence on my part because I tried to push forward a patient handling policy for years. The people that always rejected the policy were the therapists. They wanted exceptions put in the policy that it was okay for them to lift manually, and I think it just took a lot of persistence to educate them. We also started a unit-based, peer-leader program, and there are now three people in the therapy department that I work closely with in order to obtain support for using the equipment, but it took about a year for them to become comfortable and to really see the benefit.

I have to say, we have made progress; about 70% of our therapists are onboard. I think the therapists themselves are getting older, so perhaps they are becoming more open-minded about using equipment. I had to do a lot of education about this, but education works. Physical therapists are very research-driven now, especially now that they obtain doctoral degrees and become a Doctor of Physical Therapy (DPT). As a result, I think they are more inclined to look at the evidence base, and there is a lot of literature now compared to 10 years ago.

Mr. Race: I agree with that. Having been in a lot of facilities to evaluate their safe patient handling programs and ways to improve them, one of the keys to success is educating the end user about the versatility of today's equipment. They believe there are a lot of limitations to the equipment, but with simple education you can show them the capabilities of the new equipment. In the past, we had a lot of limitations with just the basic Hoyer lift. However, with all of the gap products that have filled the market today, we are able to incorporate many different mechanisms and machines that will not only assist the caregiver but will actually make the patient recovery cycle a lot quicker.

Ms. Bunke: A couple of the hospitals I have worked with that have been most successful joining therapy and nursing is when they have actually had a nurse and a therapist co-chair the safe patient handling committee. That committee determines what will meet the goals of both disciplines and sets the standard for the rest of the hospital. This helps everyone understand where they can work together for the benefit of the patient. It has been very successful in several hospitals.

Dr. Seidl: Excellent point, JoAnn. In the last exchange, I heard the terms lift team, safe patient handling committee, equipment, equipment capabilities, and equipment limitations. What does the research point to as the most effective strategies for injury prevention in staff, whether that is nursing staff or allied health staff? Does the literature reflect your experience?

Mr. Race: I think that is like asking someone what is the best kind of car currently available. It is very subjective. Each hospital is a different breed. Manon Short works at a hospital that is a 1,000-bed hospital, where someone else might work at a 25-bed critical access hospital, and to each different facility there is a different model that works. There are definitely benefits to each type of program, but to identify and nail down the only type of program that works would be to pigeonhole ourselves into only one solution.

My belief is that it ultimately comes down to what is the best solution for a specific facility. We have to remember that this is a dynamic solution. The ultimate end goal is to increase patient safety and increase caregiver safety. So we have to look at what the adoption rate is, look at culture change, and look at what options a particular facility is open to. I am a strong believer in lift teams, but I recognize that not every facility fits the criteria for a lift team. I think Manon Short—and Manon, please forgive me for bringing this up while you are present—has done one of the best jobs of incorporating lift teams in conjunction with equipment. Tampa General Hospital is a success story that is beyond the rest when it comes to injury prevention.

Ms. Bunke: I think there is a lot of evidence now to support that when we are looking at strategies, we know that they have to be technology-based and have a minimal lift philosophy using the technology and equipment that is out there. We also have to address the space design in order to assure that it is suitable for providing safe patient care that is also safe for the caregiver.

In addition, an institutional policy needs to be in place to use the equipment. Then if you look at each one of those components, you can expand on it, saying, “Okay, so what needs to be in the space and what needs to be in the policy?” We need to talk about technology, and we also need to talk about the training aspects and the evaluation of the program. We know that strategically an organization should have a program they can evaluate, which is using technology and getting away from the old school of thought that relies on body mechanics training.

Ms. Short: When I review the literature, I see that some people think they are successful with just equipment, some with just education. I think that for hospitals, regardless of which strategy they use, there are certain components that are a must when it comes to being effective with safe patient handling, one being ensuring the purchase of adequate lifting equipment. But its more than equipment; you need to make sure that there is a good education program too.

I cannot tell you how many hospitals I speak to that purchase $2 million of equipment and the staff just do not use it. You really need to have a comprehensive program where you are looking at all the different pieces. I always think of safe patient handling as a puzzle, and you have to have all your components in place in order to succeed. You want to make sure you have education, buy-in, and support, not just at your senior management level, but from the frontline staff as well. People think we are successful because we have a lift team; but we do not just have a lift team, we have the other components in place as well. We have purchased equipment, we have facility champions, and we have a 3.5-hour education class for new employees. We also have unit-based peer-leader programs. In fact, we are constantly changing our program. We continue to purchase lifting equipment after even 11 years of having our program. I think facilities need to think of all these components. It is a comprehensive program that needs to involve everybody in the facility from the biomed staff to the frontline staff. It has to be a multifaceted program.

Ms. Bunke: When you think about strategies for injury prevention, I just want to mention the obvious one. Sometimes we do not look enough at engineering out the risk. Consider the study done by Bill Marras where he measured the push–pull forces of a mobile lift. That study demonstrates that overhead lifts are the way to go. I know that it is not possible for all facilities due to the initial costs, but it should definitely be the long-term goal. Another example is the use of gait belts and whether or not they provide a false sense of security. Minnesota OSHA just declared that gait belts are not designed for lifting patients and are not considered a “lifting device” by the National Institute for Occupational Safety and Health (NIOSH), or Minnesota OSHA. This has a lot of caregivers in Minnesota wondering what to do, as they were using gait belts. It has stirred a lot of discussion, which I think is good.

Mr. Gallagher: I want to get back to the question of which types of programs opinions and research support. Really, just as every safe patient handling task begins with an assessment of the individual patient, every program should begin with a thorough assessment of a facility. When you are looking at facility-wide programs, they really succeed in facilities that have a lot of interdisciplinary buy-in; facilities that have reputations for implementing progressive programs and instill that progressive identity in their workers as part of their team. We see that first model with Stanford and their success, but in certain instances lift teams excel because they have highly trained individuals who are committed to performing safe patient handling tasks “by the book” as their job description. That is not to say that one is universally better than the other, but when we take the time to assess the influential factors, one is generally better than the other in each situation.

Ms. Muir: We have to remember that the lift teams and the patient transfers are just one part of an ergonomic program. When you are at the bedside and you are doing awkward postures, for example, for all the high-risk tasks that have been identified that also cause difficulty for injuries for staff, they include applying embolism stockings. They include making an occupied bed. They include bathing the patient, and dressing and undressing the patient. Certainly, your programs need to go beyond; what we call patient handling really needs to be expanded to ergonomics for patient care activities.

Mr. Gallagher: I would like to clarify that last point I brought up. Following assessment in any program, lift team, or facility-wide minimal lift, equipment is essential and it is essential that it be respected like any other tool upon which we depend to do our jobs. This is why it is so important to make sure that equipment is well maintained, that it is going to be well maintained in 5 years, that it is going to be conveniently stored, and that parts and accessories are available.

Dr. Seidl: So, does this really go back to the structures that a facility would have in place to maintain a program? When Manon mentioned the biomedical engineering department in the facility, was she referring to an assessment of all the resources an institution has to implement programs safely over time?

Mr. Gallagher: Yes, especially because often we do not see the desired results in the first year or even the second year. Facilities that are implementing safe patient handling programs correctly do see their injury rates and their lost work day rates start to settle at a lower level around the third or fourth year.

Ms. Short: I think that people also need to realize that moving patients is really a skill. I think Bill Charney really points that out in his book. It becomes a skill, and having people that do it every single day has a lot of benefits, not just for the healthcare workers but for the patients. We are still dealing with the whole culture change and trying to change the way people do things; we are creatures of habit.

Nurses just have so many different areas of expertise; we cannot expect them all to be experts in everything that they do. Having experts with the ability to mobilize and move patients safely is also a time saver. It might take a nurse 15 minutes to figure out how to use a floor lift, even though she has undergone annual competency training and received the education. Nurses just have so many things that require competency, whereas a lift team can get a patient in and out of bed in less than 5 minutes using a ceiling lift or a floor lift because they are so competent in using the equipment.

Ms. Muir: When it is a bariatric client, it is even more difficult to learn the skill and to problem solve because very often the equipment lift slings, for example, are difficult to fit, and the equipment interface between different devices such as a floor lift and power chair is a little bit more complicated and may cause problems during the transfers. One of the issues that we have had with a bariatric clients, for example, is that if a unit does not care for enough of these patients to become really proficient, then staff need to relearn the skill every time. As you have seen with a lift team, if you have somebody who is performing the task regularly, then they are able to maintain the knowledge and continue to problem solve adequately.

Ms. Short: I completely agree with that. We have a bariatric surgery unit, but there are bariatric patients located throughout the hospital. If it is a cardiac patient, the patient is in the cardiac unit. If it is an orthopedic patient, the patient is on the orthopedic unit. So bariatric patients are really scattered around the hospital, and the lift team is really the only team that consistently follows that bariatric patient throughout the length of stay. They are involved from getting the patient out of the ambulance onto a hover-mat in the ER. They follow the patient to the trauma ICU and then to the step-down unit and med/surg unit, and then ultimately to rehab. The members of the lift team are really the ones who do the plan of care for patient mobility. Every bariatric patient is really different, and what works for one patient may not work for another. They become very good at problem solving difficult cases.

Ms. Muir: I think that is such a good point. I used the term bariatric, but I think that we could expand that to any unique individual that is not a typical type of patient for a unit, and the challenging handling tasks that we might encounter. For example, it could be somebody who has an odd body shape or has amputations, or has a very rare kind of illness and presentation. I can certainly see where the lift teams would be an excellent strategy for consistency.

Mr. Race: One reoccurring program type that I am hearing, and I agree with completely, is the lift team model. Just to add on to that a little bit, I would like to clarify one of the misconceptions: that lift teams work without SPHM lift equipment. We must get away from the belief that lift teams are two big, strong football players that come in and do brute-force lifting. Lift team members are quite the opposite; they are actually the lift experts of a facility. They become a valuable resource and are commonly referred to as the safe patient handling experts.

We need to recognize that a 2-hour training course twice a year for care staff is only a semi-effective educational tool for the proper usage of lift equipment. At the end of the day when the care staff have a lift team in their facility every day, that is a resource provided to them 24/7 for an active and continual training program. With the lift team, at no point do the caregivers feel that the lift equipment is intimidating or that they do not know how to use it because they have a resource. If there is a new piece of equipment, or if there is a patient that needs special positioning, the nurse feels comfortable knowing that there is someone who will support them in moving and caring for that patient.

Stanford's minimal lift program was mentioned previously. Stanford has a very successful minimal lift program, yet on site they have a patient mobility specialist, which is essentially the same thing as a safe patient handling expert. Again, this is where we come into the verbiage of what do we call each “type” of program. It really does not matter what we call it. It just has to be that we are encouraging the healthcare providers to utilize the equipment, and if they do not feel comfortable using it, how do we make them comfortable at all times.

Ms. Bunke: I do believe it depends on the facility. It can be successful and I have also worked with facilities where they have tried it and stopped using it. I think a big piece of it is the education that you do upfront. Is it a 30-minute in-service or is it a 2-hour education session where you talk about the culture and what you do when a physician says not to use a specific piece of equipment, or when the patient refuses to be lifted with a lift, or when a coworker is resistant. The initial and ongoing education is crucial.

I also think that in this discussion we are looking at this situation as we would have looked at it 10 years ago, when equipment was not used very often and therefore caregivers did not remember how to use it. I am working in hospitals where nurses are using the ceiling lifts and mobile lifts every single day and they are very good at it. I am not discounting lift teams, but I have also seen a lot of success in hospitals and long-term care facilities that do not have lift teams, and the caregivers have no hesitation on how to use the lift and use it appropriately.

Dr. Seidl: Excellent point and I think it reinforces a point made earlier—that there is not one solution that is a perfect fit for every facility. I would like to get back to the evidence for a minute. As we talked a bit about evidence a few minutes ago, Dr. Charney's name came up a couple of times. As you all know, he started writing about healthcare worker injury and the concept of the lift team in the early 1990s. In healthcare, we know that it often takes a long time to translate research evidence into practice, so slow progress is not unique to safe patient handling. Could someone comment about the challenges of translating evidence about safe patient handling in the bariatric population, or in any patient population for that matter, into clinical practice? In other words, what are some challenges that you have seen or experienced that might make translation difficult?

Mr. Race: There are a number of issues and misconceptions that go along with the utilization of the equipment with care staff. One is that nursing staff is reluctant to use equipment due to the fact that they believe it will take too long or that the equipment doesn't work, or the fact that they “have been doing this for 30 years.” Culture change is absolutely a key element of a safe patient handling program. If a facility simply implements equipment and negates to address the culture change aspect, they will continually be playing catch up.

I also believe that culture change needs to be from the top down and the bottom up. A facility must have buy-in from every single person in the facility and incorporating them into the program is vital. Even though you may not believe that bio med should be part of your safe patient handling program, they do play a part in it. We are talking about batteries needing to be charged or slings needing to be maintained, and of course slings needing to be washed. So we must also include environmental services into the planning and rollout process of the safe patient handling program. We need to look at this as an entire facility-wide program. This is not just addressing the nursing staff or just the PTs.

Dr. Seidl: What I hear in your response is that a reason for slow integration may be due to the logistical complexity and the involvement of so many different people and departments. In your experience, what are the types of roles that traditionally drive a safe patient handling program? Has it been nursing? Has it been PT?

Ms. Short: I think it really depends on the hospital. For our hospital, it was more occupational health and employee health. For other hospitals, it is safety directors. Sometimes it is physical therapists. Sometimes it is the nursing director. Sometimes it is CEOs. I really think it depends on the facility.

Ms. Muir: Unfortunately, costs seem to be the biggest motivator. When you convince a facility that the Workers Compensation Board costs and premiums can be affected, that is how you can get the board of directors onboard. The bottom line is saving dollars. The staff, however, they have a different goal. They think about whether or not this is going to be easier, and maybe I won't be going home with pain at the end of the day. Or if I already have a chronic injury and I am 47 years old and been doing this job for a long time, then the motivation for them is they want you to feel better at the end of your day.

As we mentioned earlier, what I find with nurses in particular is that you sometimes have to tell them is what is best for the patient. Then, they are going to feel more comfortable and be more motivated to adopt a behavior. One of the things that you will see, however, is that there are a lot of people who do not feel the motivation to make the change. They may feel that they are physically capable to do it their old way.

Ms. McGinley: In a facility where I used to work, leadership tried to incentivize things. We implemented unit-based champions on each shift, and these champions tried to reward the staff for using the appropriate tools. That approach seemed to help. There is the negative side of this, however, if there is an injury that is sustained when someone is not using appropriate equipment. Should there be repercussions? I think staff injuries can be avoided with the appropriate lift equipment. I think it is telling when you have a staff member that comes up with statements such as, “Well, we have always done it this way and it takes too long.” That is why I think that using champions or somebody else who is really invested on each shift helps because they can be the cheerleaders and they can show the benefits and reinforce the benefits of using the equipment.

Mr. Gallagher: I completely agree. I think it is very important to remember that what is both easy and hard about socially marketing a safe patient handling program is the fact that it really does hold benefits for everyone involved, from the patients and nursing staff, all the way up through management. And that makes social marketing seem easy because everyone stands to gain. In reality, that makes social marketing hard because of the wide variety of demographics and sheer number of people that must be involved in buy-in.

Ms. Short: Talking about barriers and things that are difficult as far as implementing and maintaining safe patient handling programs, I think it also is related to the inconsistency with guidelines and standards. I think it is very hard to quantify patient function, even as a physical therapist. I may describe a patient as requiring “maximal assistance,” but another therapist may go in and say, “Oh no, they only require moderate assistance.” And even if you are dealing with algorithms, you might be faced with a change in patient function from the morning to the afternoon. So even though they were able to stand in the morning, in the afternoon they may not be able to stand. As a result, it is very hard to have clear guidelines when the factors that you are trying to control for vary so much from hour to hour and from patient to patient.

Dr. Seidl: Thank you for detailing some of the complexities and challenges surrounding the implementation of safe patient handling programs. Another thing I heard a couple of times was that a specific facility has a successful program. How does a program come to be described as “successful”? What metrics or measures should facilities examine to evaluate if their program is successful? And thinking more globally, are there benchmarks or other more objective ways to evaluate and even compare organizations?

Mr. Race: In fact, I just finished a presentation about this very topic. I think that in the past we have looked at the major points being the reduction of injury to employee staff. While I agree with that 100%, I believe that just begins a long list of preventable injuries and costs to the facility. I could go into a list of 20-plus things, but the ones I think we really need to look at are employee injury and then patient injury, such as patient pressure ulcers and patient falls. We also have lost workdays, and the severity of the employee injury. Manon touched on it earlier, talking about how as the program gains momentum, the attention that you give injuries is actually heightened. Therefore, smaller or lesser injuries begin to be reported. At the end of the day, if we can catch an injury prior to it becoming a severe injury, we can reduce costs and ultimately reduce the injury rate to the employees themselves. Nursing turnover, costs to an institution, such as increases in insurance premiums or fines, the efficiency of the hospital, and patient and employee satisfaction—all of these could be measured in your program. I do think that, however, we should choose several measures and benchmarks and not just use employee injury as the only benchmark because we are talking about multifaceted programs that should be hospital wide.

Ms. Short: For our hospital, in order to get the program started and receive funding, we needed to identify how we would measure the success of our program. A lot of it relates back to our injury cost. We have been able to reduce our injury costs by more than 90%, and we have been able to maintain those results. We also receive our experience modification factor from the state to see how we are doing compared to other hospitals. Having such a great safe patient handling program has impacted other injuries as well. As you know, injuries are repetitive over time. Someone may get injured lifting a box, but it may have nothing to do with the actual task. That type of injury is not logged into the system as a patient handling injury. We have seen over time that our program has affected not just our safe patient handling injury rate, but the overall workers' comp for our entire hospital.

But there are a lot of other benefits to programs. As far as from a nursing and patient care standpoint, we want to show that having a good safe patient handling program has helped improve our nursing retention and recruitment. We use it as a recruitment tool. You know, nurses have more time for other nursing duties. Their morale has increased. They go home at the end of the day with less pain. We conduct an annual survey each year about our safe patient handling and lifting program, and this year we added a question. We had more than 500 people respond, and I think 78% were nurses. The question we asked was, “How has the lift team impacted the physical job demand?” More than 65% of respondents stated that they experienced a decrease of 50% in their physical job demand. That is potentially huge for recruitment and retention.

Dr. Seidl: I like the last area of measurement that you mentioned. It sounds as if you are trying to capture some of the more experiential and subjective measures, not necessarily as objective as the dollar figures, but still important.

Ms. Short: Right. It is important if you want to have buy-in from the nursing staff. I hate to say it, but they really do not care how much money the hospital spends on workers' comp.

Ms. Bunke: I agree.

Ms. Muir: A lot of the studies that were done to start selling these programs 10 years ago were about the costs and the workers' compensation expenditures. I was looking at some of them before we came on the phone. Some of the 2004 publications and the lift studies in 2003 from Dr. Audrey Nelson in the United States and Canada, and all of these studies reported that you can invest this money and obtain a return on workers' comp expense reductions within 15 months to 4 years, depending on which study. So it was very much a dollar-incentive measurement that started at the grass roots. But everybody else involved at all the other levels, such as education and occupational health, certainly are interested in measuring all of the previously stated other areas.

Mr. Gallagher: I have one comment here about the metrics of a successful program. What is interesting is that in successful programs, the severity of injuries drop relative to the number of reported injuries. What happens when injury prevention becomes prioritized is that there is a perception shift surrounding reporting. This shift from the “right to report” to the “responsibility to report” model means that reporting ceases to be viewed as a retributive act and comes to be viewed as a preventative act. This means that more injuries, albeit less severe, are reported. The injury being reported today prevents another similarly qualified and trained staff member in a similar situation from suffering that same injury tomorrow.

Dr. Seidl: So what I hear you saying is that it is not necessarily just the total number of incidents, but that it is also about the proportion of low-severity to high-severity injuries within the incident reporting. Did I understand you correctly?

Mr. Gallagher: Yes, the root causes of the most severe injuries have been identified and addressed by the program. However, a key element of the program is the utilization of reporting to prevent the remainder of injuries.

Ms. Muir: We did several studies at our facility, and certainly what we saw was increased reporting because there was increased awareness. There was an exciting promotion going on, and we saw increased reporting of injury. But we absolutely saw a reduction in the costs associated with it indicating a reduction in severity.

Dr. Seidl: I agree with you. Any time a measurement outcome relies on self-report, you always run the risk that focusing attention on the topic will result in increased recognition and reporting. The interpretation of the data then becomes about whether things are really getting worse or is it just because people are now more in tune with it and therefore they report. I think what you have all described speaks to the fact that yes, reports may increase, but it is imperative to examine the nature of the reports.

We are approaching the end of this roundtable discussion, but I would like to give people the opportunity to say anything else they would like to about safe patient handling. Is there something I did not ask about that you think the readership would like to hear?

Ms. Muir: I would like to say something really positive about the future. I think what I am seeing internationally in Europe, the United States, and Canada is that all the organizations are now aware and are trying to address this problem. And moving forward in the United States, we have NIOSH, OSHA, and the ANA all making position statements and encouraging and supporting state legislation. We have really come a long way in the last 10 years and I think we are really going to go a long way in the next 10 years. I think that we are going to see the day where the nursing profession is going to be a lot safer and that we are really headed toward it. It is wonderful.

When I first started working with bariatric clients about 10 years ago, we did not have a lift capacity that was more than 350 pounds. It did not exist in 1991. So what is that, 20 years ago? We did not have large-size beds. We did not have these things, and now we have them, and we have the research now too. We have the evidence to support the practice. We have the legislation. We are really on a good pathway.

Ms. Short: Not to be negative, because I definitely agree with you. I think there has been a lot of movement and it has been surprising to me. When I think about whether the risks have increased through the years or if we just paying more attention to it, well I really think it is both. We are definitely paying more attention to it, and it is wonderful to see all these organizations such as NIOSH, OSHA, and even state legislators involved with position statements. But when you look at the 2009 Bureau of Labor statistics data, they state that nurses increased their injuries by 5%. So even with all of this, nurses still rank sixth and nurses' aid rank first.

To me, that was very disappointing to read because this is my passion. This is what I have been doing for 11 years. I still believe that there needs to be more standards created for safe patient handling and more resources, because everybody is doing it a different way and some people are successful with what they do and some are not. I feel horrible for hospitals that do not have a lot of resources. They are looking for a manual to say, “Okay, this is what works and this is what does not work.” I hope that the future will provide more specific guidelines so all hospitals can try to standardize this very complex issue the best that they can.

Ms. Bunke: The schools of nursing are now getting on board. There are several that have incorporated safe patient handling into their program. That is a very positive change, but it needs to include more schools than have changed their curriculum thus far.

Dr. Seidl: To continue to move in a positive direction, what research should be done? What types of research questions should the healthcare community ask in order to provide institutions with some answers?

Ms. Short: Well, I think there should be an organization—a safe patient handling and movement national organization—that healthcare providers can be associated with, so there is one source of information, rather than looking through all the different journals, talking to different hospitals, and sorting through the different marketing materials. There is not one place where you can go to find the answers, and there are many answers depending on your facility. There are many books being published, but it would be nice to have some type of national organization where people could go for expert advice and to get clearer guidelines as to where to start a program.

Dr. Seidl: And maybe this type of organization could help drive research agendas?

Ms. Short: Exactly, because there is definitely a lack of research in this area. I am a clinical person. I do not have time to perform research. I have barely published anything on our program and we have been so successful. I am not a researcher, so it is very hard for me to answer that question, but it would be nice to have an organization that could address all these gaps.

We did not mention anything in this conference call about the huge gap in technology. I think we have really made huge advances compared to what I was using 20 years ago with the cranks and the chains with the Hoyer lifts. But I still think there is a huge gap in equipment. Repositioning, for example, is a huge task that nurses and healthcare professionals do every single day. To me, there is not a great solution that is very user-friendly and quick. The bed technology could definitely improve to address the repositioning aspect.

Ms. Muir: I think if readers are looking for guidelines on how to get started based on research and practice evidence, they need to look towards the U.S. Department of Veterans Affairs and the safe patient handling resources. They have been writing guidelines for their facilities and sharing these at their annual conference. I think that they do really bring a lot of new evidence to the table and that they have some really excellent guidelines to get organizations started.

Ms. McGinley: I would have to agree with Marylou. I know Marylou has worked with Audrey Nelson on certain aspects of safe patient handling. They have done some amazing things, looking at studies, coming up with guidelines, and a lot of it is available for download on the Internet.

Dr. Seidl: I think that is a good place to end in terms of where to direct people for further information. The other key points that stand out for me are the complexity of implementing and maintaining a safe patient handling team, the idea that there is not one solution that will work for every facility, and some suggestions about how to measure the outcomes of a program. I think the information discussed today will provide our readers with guidance for the development and evaluation of their own programs. Thank you again for participating in this roundtable discussion.