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Back Safety, Safe Patient Handling, & Assisted Mobility Skills

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Presentation on theme: "Back Safety, Safe Patient Handling, & Assisted Mobility Skills"— Presentation transcript:

1 Back Safety, Safe Patient Handling, & Assisted Mobility Skills
Finger Lakes DDSO New Employee Orientation April 2012

2 What is Back Safety/Safe Patient Handling(SPH)?1
A set of policies and programs designed to decrease the strain and injury on staff while they move and care for consumers Focuses on minimizing and eliminating manual lifting by using equipment instead of the caregiver’s body Legislation in NYS is passed in the Assembly and is pending in the Senate to make SPH mandatory in all healthcare facilities.

3 Why is Back Safety/Safe Patient Handling important?
Healthcare work is among the most hazardous occupations in NYS2 Back injury is the 2nd leading occupational injury3 Back injuries are expensive2 Cost of medical care Cost to pay overtime coverage Significant time is lost with injury Mandated overtime, training new staff Safe body mechanics are not enough to prevent injury3,5 Prior to SPH, stand pivot transfers were the #1 way FLDDSO staff were injured when caring for consumers Injuries of healthcare workers surpass those of construction workers, delivery services, truck drivers, maids and housekeepers, laborers, freight, stock and material movers The direct cost of an average back injury case is $19,000. Serious cases requiring surgery average $85,000 in direct costs. Indirect costs to the facility from a back injury averages between 4 and 10 times that of direct cost Prior to the SPH initiative at the Finger Lakes DDSO #1 injury – stand pivot transfer or standing transfer #2 injury – lifting an object (groceries from the van, maintenance lifting a door..) #3 injury – Bed care (rolling, scooting, boosting, reaching, holding while providing hygiene care) #4 injury – 2 person lift or 2 person reposition in a wheelchair #5 injury –1 person lift from the floor after a fall!

4 Benefits to Staff2 Decreases Injuries
Decreases Pain and Muscle Fatigue Decreases Lost Work Days Decreases Overtime Increases Morale Increases Job Satisfaction “My company/supervisor/worksite cares about me!” SPH is an investment in the employee Example: Batavia Veterans Home implemented SPH and showed 75% DECREASE in lost work days within 14 months If interested: see more at Zero Lift NY site

5 Consumer Benefits of SPH2
Improves quality of life Lowers levels of depression and “behaviors” Consumers feel more secure and less anxious when being transferred in a consistent manner Improves urinary continence Increases consumer participation in activities Increases level of daytime alertness Increases/maintains upper extremity ROM Decreases fall risk Decreases in fractures (spiral, compression) Decreases skin tears and bruising -Equipment provides a consistent and repeatable process for handling -Manual lifting can be awkward and is inconsistent between people (everyone has their own manner of holding and moving a consumer) Injury rates and negative patient outcomes Specific statistics (14 months after program started): NY State Veterans Home in Batavia - 64% decline in patient fractures - 37% decline in patient tears and bruises - elimination of lower extremity spiral fractures - 26% improvement in UE ROM

6 What About the Consumers?
Bottom line: We can not provide safe care for the consumers if we do not take care of ourselves! When do most consumer and staff injuries occur? -staff is fatigued, in pain, stressed

7 Injuries Risk Factors Proper Lifting
Back Safety Injuries Risk Factors Proper Lifting

8 Healthy Spine Image from Image from

9 Posture Purpose of the spine: Protects the spinal nerve
Demo: posture/curves Muscles support the spine Back muscles tend to be small in size Lifting muscles are larger quads and gluts Good posture relies on flexibility & core strength Stretch your low back into extension Strengthen your abs Demo & Return Demo: Standing posture (slouched vs. good) in relation to rotational ability Demo & Return Demo: Sitting posture (slouched vs. good) in relation to shoulder elevation ROM & neck rotation ROM Note the importance of abdominals in maintaining proper posture! (America’s weakest muscle) Image from:

10 Risk Factors2,3,6,7,8,9 Lack of exercise Poor posture
Lack of social support Low job satisfaction Age Lifting more than 35lbs NIOSH safe weight limit Lack of sleep Less than 8 hours Smoking Decreases body’s ability to heal Poor posture Stretches & weakens key muscles Examples: car seating, brushing teeth, washing dishes Frequency of forward flexion Typically 3,000-5,000 times/day Previous injury Known or unknown Protect yourself from these risk factors. Some risks are modifiable in a person’s lifestyle: smoking, exercise These risks do not just occur on the job, they happen at home as well… sometimes even as a result of fatigue at work

11 Microtraumas: “Unknown” Injuries
Mechanical processes Compression Shear Rotation/Twist Awkward Postures Compression from lifting consumers supine-to-sit, holding upright to stabilize Shearing  from pivot/twist transfers from 1 surface to another Rotation/Twist from lifting high-or-low “Awkward” postures  from over-reaching, flexing forward Micro-traumas can happen to our discs and tissues at any time we are using our body improperly. Injuries don’t just happen moving patients, they happen cranking beds, bending to get equipment & supplies. Image from

12 Common Injury in Spine Disc Herniation
Over time the outer layer of the disc weakens from repeated microtraumas The inner jelly of the disc bulges out of position, usually toward the back where it can put pressure on the nerve Board/Eisel: Drawing of disc structure, proximity to central cord & nerve roots, and microtraumas. “Jelly Doughnut” example Image from

13 Other Common Injuries Muscle Strain Compression Fracture
Tear in muscle fibers Pain Inflammation Tightness Tendinopathy Tenderness Related to gradual wear & tear Compression Fracture Directly related to disc health Various Locations Shoulder Rotator cuff, impingement Knees Torn cartilage, ligament issues Neck Nerve problems radiating down arm, stiffness Why do these injuries typically occur? -“easier”/”faster” to do manual lifts -Fatigue -Pain -Inflammation -Loss of ROM -Unknown previous micro-traumas -No buy-in to new techniques

14 Body Mechanics Get in the ready position Wide base of support
DO NOT DO Get in the ready position Wide base of support One foot slightly forward Firmly plant your feet Soften your knees Wear appropriate clothing and footwear Per DDSO dress code, shoes must cover toes and have flat contact with ground Make quick and jerky movements Causes strain on back muscles Twist when lifting “Keep nose and toes pointed in the same direction” Wear clothing that interferes with safe patient care Large jewelry Shoes with high heels, flip- flops Demo & Return Demo: “Ready Position,” Base of support with partners Get partners! Stand facing one another with small BOS vs. wide BOS. Give gentle pushes to the shoulder and chest to see differences in stability Staff advice on how to lift activity - include ready position, golfers bend, and importance of COMMUNICATION! - planning ahead also includes wearing the proper clothing and shoes for the job

15 Body Mechanics / Lifting
Assess the situation Know your limitations Is there equipment available to make this safer? Plan ahead and prepare the environment Clear pathway Hold the load close and firm Hips & shoulders square to load If hold is not firm- start over! With heavy objects, break up the load Communicate with other staff member and consumer Demo: Golfer’s lift to get small objects from floor Demo & Return Demo: Lifting chairs while holding it close to body and with arms outstretched

16 Chores Challenge Laundry Making beds Shoveling snow Yard work
Top loading washer & front loading dryer Making beds Shoveling snow Push, squat, do not toss over shoulder Yard work Use wheelbarrows, kneel on knee pads Carrying groceries & supplies Divide up loads, use carts on wheels Interactive!: Discussion with staff on chores that they find difficult! Active problem solving on how to assess the situation and make these chores easier! (break up loads, make it a multi-part process…)

17 SPH & Assisted Mobility Skills

18 Course Objectives Given direction by a licensed physical or occupational therapy staff, the FLDDSO new employee/trainee will demonstrate their knowledge by performing the following: General concepts for joint range of motion (not specific to a consumer) General concepts to prevent and manage decubiti (pressure sores) Safe and effective transferring and handling techniques including use of non-friction devices, rolling devices, mechanical floor lifts, sit/stand lifts and gait belts Safe and effective positioning of consumers on support surfaces (wheelchairs, beds)

19 Competencies 4.17 Lifting & Transferring 4.19 Range of Motion
3.5 Blind Trailing-Mobility Techniques for consumers with Visual Deficits Competencies get officially signed at the worksite. This class will give you the basics and will result in signature in the “Comments” section of these 3 competencies. Competency Books (fill out at end) PT signs 4.17 (page 52) and 4.19 (page 55) OT signs 3.5 (page 32) Use the following verbage in the NOTES section ONLY: “Basics covered in class. Your signature. Your DDSO title. Date.”

20 Range of Motion (ROM) ROM deficits are commonly seen in:
= The available movement at a joint ROM deficits are commonly seen in: Consumers with cerebral palsy (high tone) Consumers who have had a stroke (high tone) Consumers with arthritis (cartilage less pliable) Benefits of Joint Movement Increased comfort and flexibility Increased circulation and nutrition to joint Maintenance of ADLs (dressing, bathing, etc.) Greater ease for staff to perform skin/hygiene care Example: adequate ROM for cleaning elbow crease/groin…

21 ROM Programs ROM is performed by staff when muscle and/or joint tightness: Interferes with cleanliness and hygiene care Interferes with dressing Causes pain and discomfort Formal programs may be provided by OT/PT Found in the IPOP Require further consumer specific training by the therapist

22 Keys to Remember Your approach matters:
Quiet voice, dim lights, firm, but gentle touch, after a warm bath/shower Always tell the consumer what you are doing Surround the joint One hand on each side of the joint Only range one joint at a time Full hand control Keep fingers together, flat surface Fingertips can bruise; avoid claw hands Smooth and controlled Never push into restrictions Never bounce Move slowly: fast jerks can increase tone and cause injury Over time, you will learn the tricks of the consumers you are working with on a regular basis. For consumers that are new to you, take time and communicate appropriately. ROM is vital for day-to-day activities Demo: Don and doff coats with partners Partner imitate having spasticity in arms (best with one arm tight or try two) Remember to start with the most difficult side first

23 ROM Terms to Know Adduction Flexion
Moving the body part towards midline “ADD”ing to the body Internal Rotation Rotation towards the center of the body External Rotation Rotation away from the center of the body Flexion To bend Extension To straighten Abduction Moving the body part away from midline Abduct means to take away! Demonstration of the terms at various joints (1-2 per direction)

24 Flexion Extension Images from

25 Abduction Adduction Images from

26 Internal Rotation External Rotation Images from

27 Decubitus Ulcers “Pressure Ulcers” “Bed Sores”
Risk factors Boney areas of the body Tail bone, heel, ankle, hip, elbow, back Prolonged pressure Healthcare best practice requires repositioning at least every two hours! Fragile skin Decreased circulation Diabetes, other vascular diseases Poor nutrition May have adequate intake, but poor absorption Demo: Start discussion on decubiti while staff is sitting in chairs Staff will begin to feel effects of improper positioning (indicate that they aren’t allowed to reposition during the whole discussion on decubiti) Seating examples Shower chair without foot support Sit on folded thick/quilted sling Sit on backwards seat cushion (abductor pommel) Sit on upside down cushion Sit on hard seat pan Sit on seat belt buckle Tilt in space without headrest Sit on objects, ie. keys, tools

28 Decubitus Ulcers Risk Factors continued… Friction Shearing
Repeated movement across a surface Shearing Body tissue moves over top the skin which has adhered to the support surface Example: bare legs on a vinyl car seat on a hot day Moisture & heat Sweat Incontinence Bowel and bladder Caustic to skin

29 Decubitus Ulcers Most are preventable by
Keeping the skin clean and dry Changing position at least every 2 hours Properly using support surfaces that relieve pressure seat cushions, mattresses… Assuring clothing is not a risk factor avoid jeans, avoid nylon pants, ensure footwear is ON when in wheelchair

30 Discussion points on seating demo
Tell us about how you feel after being on improper seating during the short discussion Remember that consumers sit in positions for up to two hours at a time Make sure consumers are seated appropriately! Fragility of consumer skin even before seating concerns

31 Cushion 101 Used for pressure relief, comfort, and positioning
Positioning cushions have: Bump in front to separate legs Soft well in the back for tailbone Check to make sure they are in properly Hand sweep to check front and back Check the labels Often labeled front and back Do not assume the cover is on the cushion correctly

32 Wheelchair parts Pelvic Positioning Belt Hand Rim Rear Anti-Tippers
Participation: Have staff assess different style chairs, removing footrests, tilting… (transport chair, tilt chair, chair with multiple supports…) Rear Anti-Tippers Front Castor

33 All WCs used by consumers at the FLDDSO must have:
2 working brakes (wheel locks) Pelvic positioning belt (seat belt) Rear anti-tippers Arm rests Foot rests may be removed inside buildings for people who foot propel, must be replaced prior to transportation Tilt chairs must have headrests *Any exceptions are found in the IPOP

34 Wheelchair Maintenance & Care
Frequent cleaning necessary for function Not just for night shift Cleaning should occur as chair gets soiled Especially following meals Upholstery should be wiped down More to come with Personal Care Skills course… If the wheelchair is broken or missing parts, DO NOT bring consumer to day program or outings Cannot be transported in that condition Immediately contact OT, PT, house or program managers

35 Soft Goods Maintenance & Care
“Soft Goods” include: Wheelchair Cushion Covers Canvas and Mesh Slings Non-friction sheets for bed repositioning One-way (anti-slip) devices Gait belts Washing Hand wash Machine wash: lukewarm water & detergent Garment bag may be used **DO NOT USE BLEACH** Drying All soft goods MUST be hung or laid flat to dry **DO NOT PUT IN THE DRYER**

36 Bed Mobility and Positioning

37 Keys to Bed Mobility and Positioning
COMMUNICATION Always talk to the consumer to tell them what you are doing; ask them to help if they can assist Always talk to the other staff person Don’t forget good body mechanics If the task is unsafe or difficult, is there equipment that would make it safer and easier? If you aren’t sure, ask a PT or OT!

38 Supine positioning Body position laying on their back Pressure points
Back, tail bone, heels, back of head, elbows Use bed controls for positioning Pillow/support placement Under head Under knees Behind calves Heels floating Image from

39 Side-lying positioning
Body position Head, neck, trunk, and hip aligned Both legs bent at hips and knees Pressure points Shoulder, hip, knees, ankles Pillow/support placement Under head Between knees Supporting top arm Behind back Image from Demo: Break up into groups and demonstrate positioning with pillows, cushions, bed controls… Image from

40 SPH Rolling Communicate with the consumer and other staff
Equipment possibilities include: Non-friction sheets Positioning devices (Tri-turner, full body, split sheet) Grab bars (side rails, bed assist bars) Position the person for best mechanical advantage Bend knee opposite the direction of the roll or cross leg over towards roll Ensure their arms are out of the way Demo:

41 Rolling With SPH Techniques & Devices
Top Sheet (“Split Sheet”) Used with mechanical lifts Used for wound care, pressure relief Can be used with 1 or 2 staff members because it is for positioning & is not a transfer out of bed Must be left on bed Make the bed with the Top-Sheet on Demo only: only demo this on one person; not enough time to demo on multiple people Images from

42 More SPH Techniques & Devices
Non-Friction Sheets Use: Repositioning up/down, side/side in bed, rolling for care in sidelying Closed end of tube in the direction you are moving the consumer Headfoot for up/down positioning Sideside for lateral shift or rolling Must be used with two staff Must hold and use secondary sheet (draw sheet/cloth chux) atop NF sheet Rules for Non-Friction Sheets Hands are never on the NF sheet after it is under the person Hands are driving DOWNWARD into the bed Lunge/step to move, square body towards direction you are going Arms/legs/trunk move as ONE unit Place and remove without turning or rolling consumer Tuck method in demo lab Does NOT stay on bed Demo and Return Demo: Every staff member gets the chance to be the consumer on the bed and a staff person using the NF sheet. Images from

43 Transfers

44 Gait belts Why When Remember
Consistent, firm grasping surface for staff Provides a sense of security to the consumer Protects both parties from injury when transferring or ambulating When Consumer requires assistance to maintain balance standing or ambulating as determined by PT/OT/RN with input from staff Remember NOT a lifting belt Consumer must have good sitting balance Consumer must be able to move their feet Should not require lifting to maintain standing position Not intended to prevent most falls Always hold at the handle Make sure belt is snug but not restrictive Be aware of location of medical concerns (tubes) Image from Decreases the chances of staff and consumers get injured Show how to guard and discuss ways to provide a safe fall  not meant to prevent fall!! Be aware of G or J tubes and colostomy bags

45 Assistance Levels Contact Guard Stand-By Guard Range of Scanning
Gait belt required Hands on the gait belt Used when consumer requires physical and/or directional guidance and verbal cueing Stand-By Guard Gait belt frequently required Within an arms reach of the consumer, prepared to assist if needed Used when consumer only needs occasional balance assistance or guidance Range of Scanning Visual supervision *Level of assistance determined by PT/OT/RN Documented in IPOP

46 Keys to Transfers with Mechanical Devices
COMMUNICATION Always talk to the consumer to tell them what you are doing; ask them to help if they can assist Always talk to the other staff person Don’t forget good body mechanics If the task is unsafe or difficult, is there equipment that would make it safer and easier? If you aren’t sure, ask a PT or OT!

47 Lifting Sling Sizing and Materials
Height Mid-head to mid-buttock for full coverage Width 2-3 finger-width of material on either side of body Weight Slings will have weight as well as sizing restrictions Check label Color Coded (most) Small= red, Medium= yellow, Large= green, XLarge= blue Materials Canvas/Quilted Dry transfers only (not for bathing) Not left under consumer Mesh ANY transfer, including bathing Typically best if IPOP requires sling to stay under consumer Dries fastest

48 Lifting Sling Check When to NOT use sling:
Frayed material on loops (even if it’s not the loop you will be using) Holes in any portion of sling Cut-off loops Evidence of previous repair (sewn) Evidence of being shrunk in washer Dusty residue from previous bleaching Report to supervisor if you take sling out of use, clearly label concern on sling Contact OT/PT Suggestion: have a place in the office for “bad” slings to be reviewed by supervisors Demo: Sling care & observation Pass around slings to class and have them determine if slings are good or bad for use; indicate why to group

49 Lifting Sling Types… Split Leg Sling
Has full trunk and separate leg extensions to support each leg Available with or without head support Can be placed & removed with consumer in chair Images from and

50 Lifting Sling Types… Full Body Sling Must stay under consumer
Ideally, it should be mesh Head control No separate pieces for legs Image from

51 Lifting Sling Types… Split Leg Hammock Sling Head control
Leg straps to support each leg Cross-through method for majority of people Cradle method for amputees or full leg coverage Images from and

52 Lifting Sling Types… Hygiene/Toileting Sling
Has wide support belt around trunk and/or waist with leg supports Allows access for hygiene care and toileting Can also be used for other seated transfers Consumer must have adequate head and neck control Images from and

53 Lifting Sling Types… Limb Strap
Secures limbs for positioning, wound care, hygiene care, dressing, bathing Can also be used for ROM and exercising Can be used in combination with other slings for optimal positioning Image from

54 Lifting Sling Types… Stand Assist Harness Trunk/waist support belt
Used with sit-stand mechanical lifts Walking Harness Sling Has body support with pelvic/leg straps Used with mobile base floor lifts or ceiling track lifts for assisted walking Images from

55 Mechanical Lifts Sit-Stand Lift Rolls on floor
Used for transfers from seated position to seated position (toileting, bathing…) Potential use in therapy Removable footplates for ambulation Image from

56 Sit-Stand Lift Consumer Requirements
Independent sitting (on edge of bed OR supported sitting in chair) Bears some weight through one or both legs Holds on with at least one hand Is an active participant in the lifting, familiar with the process May require training for consumer comfort and cooperation Moving from supine to sitting  increase risk of injury if manual rolling and sitting up has to be done (body points used for leverage, and manual lift by staff) Image from

57 Sit-Stand Lift Procedure
Always use TWO staff for transfers Assess environment Clear path to transferring area Minimal space between transfer surfaces Prepare equipment Place harness snugly around the low back region of the consumer Attach designated straps to lift Instruct/Assist the consumer to put their feet on the foot plates Instruct the consumer to grasp the handles on the lift

58 Sit-Stand Lift Procedure (cont…)
Sit-Stand lift brakes OFF /wheelchair brakes ON Allows consumer’s weight to center itself within supports Raise the consumer using remote Maintain contact guard while lifting and moving Staff stand on either side of consumer in lift Transfer to desired location Move the lift, do not push consumer Lower the consumer onto destination seat Buckle pelvic belt if present Remove lift harness Reposition as necessary

59 Mechanical Lifts Mobile Base Floor Lift Rolls on floor
“Hoyer” is one brand, we typically use Invacare Reliant 450 lifts Image from Ceiling Track Lift Includes ceiling mount, wall-to- wall mount, free standing frame, tension-mount Best for small rooms like bathrooms and bedrooms Image from

60 Mobile Base Floor Lift / Ceiling Track Lift
Consumer Requirements Most universal lift available, can be used on vast majority of consumers May have poor sitting balance and poor head control May have seizure disorder, osteoporosis… Unable to meet requirements for Sit-Stand Lift

61 Mobile Base Floor Lift / Ceiling Track Lift Procedure
Always uses TWO staff for transfers Assess environment Clear path to transferring area Minimal space between transfer surfaces Prepare equipment Ensure sling is in the proper position under consumer Determine and attach appropriate sling loops Mobile base floor lift brakes OFF Allows consumer’s weight to center itself within lift supports Raise the consumer using the remote

62 Mobile Base Floor Lift / Ceiling Track Lift Procedure (cont…)
Maintain contact guard while lifting and moving Protect the head and legs Transfer consumer to desired location Move the lift, do not push the consumer in sling Lower the consumer onto destination support surface Buckle pelvic belt if present Remove sling unless otherwise indicated in IPOP Reposition as necessary

63 One Person Transfer with Gait Belt
SPH Decision Tree Full Mechanical Lift (Floor or Ceiling) ^ Sit to Stand Mechanical Lift One Person Transfer with Gait Belt Independent

64 Additional Discussion & Demos
One-way devices Turning discs (cloth for seated, hard plastic for standing) Compression stocking donner / bag RoMedic Easy-Glide for sling placement and removal

65 References American Nurses Association. Safe patient handling. Accessed February Available at NYS Zero Lift Task Force. Accessed February 27, Available at Edlich RF, Winters KL, Hudson MA, Britt LD, Long WB. Prevention of disabling back injuries in nurses by the use of mechanical patient lift system. Journal of Long Term Effects of Medical Implants. 2004;14(6): Finger Lakes Developmental Disability Services Office. Injury reports. Last updated February 2012. Hignett S. Intervention strategies to reduce musculoskeletal injuries associated with handling patient: a systematic review.Occup Environ Med. 2003;60(9). Available at Bidassie B, McGlothlin JD, Mena I, Duffy VG, Barany JW. Evaluation of lifestyle risk factors and job status associated with back injuries among employees at a mid-western university. Applied Ergonomics ;41: Hoogendoorn WE, van Poppel MNM, Bongers PM, Koes BW, Bouter LM. Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine. 200;25(16): Waters T. When is it safe to manually lift a patient? AJN. 2007;107(8): Available at %20when%20is%20it%20safe%20to%20manually%20lift%20a%20patient.pdf  Nelson, A., Baptiste, A. Evidence-based practices for safe patient handling and movement. Online Journal of Issues in Nursing. 2004;9(3). Available: e92004/No3Sept04/EvidenceBasedPractices.aspx Tseng CN, Chen CCH, Wu SC, Lin LC. Effects of range-of-motion exercise programme. Pless. A closer look at the pivot transfer. Caring for the Ages. December Available at

66 Images
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