Safety Solutions to Create Safer Environments

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Guy Fragala Ph.D., PE, CSP, CSPHP
Senior Advisor for Ergonomics, Patient Safety Center of Inquiry
(P05, Friday, Lower NZI Room, 8.30-9.30)

Published in: Health & Medicine, Business
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Safety Solutions to Create Safer Environments

  1. 1. Safety Solutions to Create Safer Environments Presented by:Guy Fragala Ph.D., PE, CSP, CSPHP
  2. 2. Caregivers at Risk Helping Patients
  3. 3. Problem in Need • Caregiver Back Injuriesof SolutionsMusculoskeletaldisorders amonghealthcare workersdelivering directcare to patientscontinues to be amajor problemrequiring help andeffective solutions
  4. 4. Occupations at Risk for Strains and SprainsTotal Musculoskeletal Disorders 592.5 Nursing aids, orderlies and attendants 49.1 Truck drivers 43.9 Laborers, non-construction 36.6 Assemblers 19.7 Janitors and cleaners 14.0 Registered nurses 12.4 Stock handlers and baggers 11.3 Construction laborers 10.8Number (in 1,000s) of work related musculoskeletal disorders involving time away from work by occupation. BLS
  5. 5. Reviewing Statistics• Incidence Rate for Overexertion Injuries is Four Times Higher Than the National Average (Bureau of Labor Statistics 2000)• Highest Rate of Musculoskeletal Disorders Among and More than Seven Times the National Average for All Occupations (Bureau of Labor Statistics 2009)
  6. 6. For release 10:00 a.m. (EST) Wednesday, November 9, 2011• The rate of nonfatal occupational injury and illness cases requiring days away from work to recuperate was 118 cases per 10,000 full-time workers in 2010, statistically unchanged from 2009,• The MSD incidence rate for nursing aides, orderlies, and attendants increased 10 percent to an incidence rate of 249 cases. This occupation also had a 7 percent increase in the number of MSD cases. (Bureau of Labor Statistics 2011)
  7. 7. REPOSITIONING IN BEDA problem in healthcare facilities that very much needs solutions
  8. 8. How Bad is the Problem ofMusculoskeletal DisordersSuffered by HealthcareWorkers Resulting fromRepositioning Patients inBed?
  9. 9. Manual Techniques Taught• Drag up bed - one nurse • Australian lift up bed
  10. 10. Traditional Manual Patient Repositioning Techniques• Highest occupational risk task determined in biomechanics laboratory study (Marras 1999)• Even with draw sheets and sliding sheets peak low back compression exceeded NIOSH action level of 3400 newtons in 25% OF 418 trials (Skotte &Fallentin 2008)
  11. 11. Is the Task Safe with Two Caregivers?• This doesn’t work • Neither does this
  12. 12. Nursing Injury Studies• Lifting Patient Up in Bed – 48% Injury Rate (Harber 1985) – 29% Injury Rate (Vasiliadou 1995) Both number one on list in studies
  13. 13. Frequency Demands• Forty Percent of Critical Care Unit Caregivers Performed Repositioning Tasks More Than Six Times Per Shift (Harber et al)• Highest Frequency Physically Demanding Task Reported (Vasiliadou et al)
  14. 14. Other Studies• 50% of nurses required to do repositioning suffered back pain (Smedley 1995)• High Physical Demand Task – 31.3% up in bed or side to side – 37.7% transfers in bed (Knibbe 1996)
  15. 15. Seven Hospital, Two-Year Study• Number one injury causation activity: Repositioning Patients in bed (Fragala 2003)
  16. 16. Injuries to Hospital Workers Activity Reported Injuries Percentage Rank Repositioning Patient (Includes 153 17.9 1turning and lifting patient up in bed) Object Lifting 109 12.7 2Lifting Patient (not further specified) 102 11.9 3 Transfer Bed/Chair 97 11.3 4 Transporting Patient 94 11.0 5 (wheelchair/stretcher/bed) Push/Pull Object 89 10.4 6 Aggressive Patient 70 8.2 7 Lateral Patient Transfer 49 5.7 8
  17. 17. Why Do Patients Need Repositioning? • Medical Diagnosis • Physical Condition • Comfort • Benefits to Healing • Maintain Healthy Tissue
  18. 18. Studying theProblem Further• Seeking to formulate effective solutions with input from caregivers.• Ideas for the best solutions come from those who perform the task repeatedly each day.
  19. 19. REPOSITIONING PATIENTS IN BED Your Input is Appreciated1. What is your occupation?2. What type of unit do you work on?3. During a normal workday how many patients, on average, are you responsible for providing care to?4. During a normal workday how many of your patients, on average, require your assistance to be pulled up in bed?
  20. 20. REPOSITIONING PATIENTS IN BED (continued)5. During a normal workday how many of your patients, on average, require your assistance to be turned in bed or be repositioned side to side in bed?6. Are there any characteristics about a patient which make them more likely to need help repositioning?7. Why do you reposition patients in bed?8. Is there a need for devices which will automatically or mechanically reposition patients in bed?
  21. 21. Answering Questions• Demands on caregivers to reposition patients• Patient characteristics related to repositioning• Why caregivers reposition patients• Solutions caregivers want
  22. 22. Respondents Occupation n Registered Nurses 313 RN Critical Care Unit 61 RN Intensive Care Unit 77 RN General Medical 112 Other Units* 63 Licenses Practical Nurses 30 Nursing Aids 87 Other Occupation 27 (Missing) 2 Healthcare workers 459* Other Units include telemetry, orthopedics, imcu, nursing home, float,oncology, ER, radiology, neurology, pacu, long term care, endoscopy, sds,ambulatory, ed, rehab tcu
  23. 23. Number of Patients Requiring Pulling up in Bed 12 10Number of Patients/day 8 6 4 2 0 care RN CU pulling up R NI CC U S R N GM N R N LP id in gA N ur s
  24. 24. Number of Patients Requiring Pulling up in Bed Patients Pull Up n Mean SD Min Max Mean SD Min MaxAll Respondents 459 7.74 6.26 0 41 6.04 5.42 0 40 Registered Nurses 313 5.87 5.19 0 41 4.81 3.81 0 22 RN Critical Care Unit 61 3.05 1.85 1 10 3.49 2.75 0.5 16 RN Intensive Care Unit 77 2.51 2.53 0 22 4.44 4.79 1.5 22 RN General Medical 112 7.48 4.94 0 41 4.67 2.53 0 16Licenses Practical Nurses 30 10.02 8.56 3 40 7.83 6.70 3 38Nursing Aids 87 11.83 4.96 4 35 8.11 5.75 0 35
  25. 25. Number of Patients Requiring Repositioning 12 10Number of Patients/day 8 6 4 2 0 care RN N ICU U reposition R CC S RN GM LP N R N g Aid in N urs
  26. 26. Number of Patients Requiring Repositioning Patients Reposition n Mean SD Min Max Mean SD Min MaxAll Respondents 459 7.74 6.26 0 41 5.09 4.88 0 40 Registered Nurses 313 5.87 5.19 0 41 4.40 3.78 0 22 RN Critical Care Unit 61 3.05 1.85 1 10 2.93 2.65 0 16 RN Intensive Care Unit 77 2.51 2.53 0 22 4.27 4.69 1 22 RN General Medical 112 7.48 4.94 0 41 4.09 2.53 1 16 Licenses Practical Nurses 30 10.02 8.56 3 40 6.60 5.57 2.5 30 Nursing Aids 87 11.83 4.96 4 35 5.81 5.16 0 35
  27. 27. Solution Strategies• Eliminate the need to perform the high risk activity.• Redesign the task to eliminate components of the high risk task.• Minimize the frequency of the high risk task.• Make Optimum Use of Equipment Features to Facilitate• Reduce risk through application of an aiding device.
  28. 28. Studying the Problem Further• Seeking solutions• Input from caregivers• Involving the Patient
  29. 29. What is the Central and Most Important Furnishing in the Care Environment?• The Bed• Why?• Can we address many of our patient handling challenges with proper bed selection for our Patients and Residents?
  30. 30. Finding Solutions• What are the safe patient handling challenges we can address with proper bed system selection?• How do Healthcare Facilities currently make decisions about bed selection and who is involved?• How should Healthcare Facilities make decisions about bed selection and who should be involved?
  31. 31. Develop a Process for Bed Selection• Who should be involved in the process?• Understand your patient and resident population.• What are the required features for all your beds?• What options and modifications will you require to address the needs of individual patients and residents?
  32. 32. Patient Handling Challenges• Bed egress unassisted• Bed egress with assistance• Bed egress total lift and transfer• Repositioning in bed• Delivering care in bed
  33. 33. Bed Systems• Not just a bed but a Bed System• Two Major components• The Bed Frame• The Bed Surface
  34. 34. Solving Problems With Bed Systems• What can be accomplished with bed frames• What can be accomplished with bed surfaces• How do frames and surfaces work together to enhance quality of care
  35. 35. Frame Design• Facilitate bed egress• Reduce migration in bed• Provide position changes of patient• Facilitate repositioning when required• Facilitate access for care delivery• Provide comfort• Provide safety
  36. 36. Reducing the Frequency• Can we improve how we keep the patient properly positioned in bed• Can we change postures without repositioning• Can we consider less frequent repositioning• Can we better involve the patient in the repositioning activity• Proper Bed System selection 36
  37. 37. Bed Frames 37
  38. 38. Reducing the Need to Reposition• Head of Bed Articulation Pushes Patient Down in Bed• Patient Requires Pulling Back to Head of Bed• Movement Over Bed Surface Creates Shear• Pulling Patient Up in Bed Difficult and Demanding• How Does the Head of the Bed Articulate?• Can Articulation Mechanism be Redesigned?
  39. 39. Head of Bed Articulation
  40. 40. Can Migration be Minimized
  41. 41. Investigate Articulation Action
  42. 42. NEW BED FRAME FEATURES• Full and reverse Trendelenburg positioning provides versatile, clinical abilities• Comfort chair recliner-type functionality• Four-section sleep surface for an array of 770 Bed therapeutic positions• Extraordinary travel range – from 7" low height (Model 790 & 795 low height is 9") for resident safety to 30" high height for caregiver convenience.• Sleep surfaces are 35" wide and either 76" or 80" long 790 Bed• Six-function pendant makes adjustments easy for both resident and caregiver• 500 lbs maximum weight capacity 795 Bed 42
  43. 43. Task Redesign Solution Gravity Assist Repositioning• Integrated into the existing central room furnishing, the bed• Easy to achieve with one touch of the bed control• Quantifiable reduction of force and effort required from the caregiver• Reduced risk of injury to the patient 43
  44. 44. Head Down Gravity Assist 44
  45. 45. Gravity Assist Improvement • Measured force to reposition 200 lb mannequin 12 inches by varying head down angle Blue is total work at 0 head down • Area under force vs. distance chart is total Repositioning without Slide Sheet work 120 Yellow is total work at 6 head downBetter 100 80 0 Degrees w/o SS Force (lbs) 4 Degrees w/o SS 60 6 Degrees w/o SS 8 Degrees w/o SS 12 Degrees w/o SS 40 20 0 45 0 2 4 6 8 10 12 14
  46. 46. Impressive Results Applying Gravity Assist• By increasing Work to Reposition 200 lb Resident 12 inches 1600 100% the angle to 6 1400 90% from 4 results 1200 80% Work (in*lb) 1000 70% in 3 X work 800 60% Work (Actual) % Work vs. 0 Degrees 600 50% reduction 400 40% – 49% for 6 200 30% 0 20% 0 degrees 4 degrees 6 degrees 12 degrees – 16% for 4 Head Down Angle Work to Reposition % Reduction Angle (in*lb) in Work 0 degrees 1507 0% 4 degrees 1265 16% 6 degrees 769 49% 12 degrees 499 67% 46
  47. 47. Bed Positioning Aid 47
  48. 48. Solutions With Surface Design• Redistributes Pressure• Reduces Moisture• Can Facilitate Turning• Influences Repositioning Frequency• Wound Prevention and Treatment• Provides Comfort 48
  49. 49. How Often Should a Patient be Turned• Every four hours?• Every two hours?• More frequently?• New research supports possible less frequent repositioning when applying appropriate pressure redistribution surface. (reference American Journal of Nursing 2009)
  50. 50. Non-Powered Surfaces• Foam Type and Density• Foam Surface Cut and Layout• Foam and Air Cells Combined
  51. 51. Good Foam Surface• Single-ply, therapeutic high- density foam mattress, which encourages envelopment and redistributes pressure. Combines quality, comfort and value.• Incorporates sloped heel section to redistribute pressure in delicate heel and lower leg areas• Available in flat construction style or with raised sidewalls
  52. 52. Better Foam Surface• Soothing, Visco memory foam in heel slope for delicate heel section. Optional TEMPUR material for heel section.• Firm perimeter and Tru-fit sizing help meet FDA/HBSW guidelines• Strategically located mattress base cuts promote easier flexing during bed frame articulation - reduces wear and tear to help extend mattress life• Optional raised sidewall available• Soft, yet highly resilient foam gently cradles head and torso sleeping section
  53. 53. Best Foam Surface• Dynamic non-powered pressure relieving mattress replacement.• Firm perimeter provides added stability during resident care/ transfer and help support resident safety• Incorporates sloped heel section to redistribute pressure in delicate heel and lower leg areas• Tubular foam cylinders provide comfort and pressure redistribution
  54. 54. Foam and Air Cell Surface• The P.R.O. Matt Plus is a non- powered convertible alternating pressure mattress replacement system featuring our P.R.O. (Pressure Relief Optimization) technology. This mattress replacement system allows healthcare providers to provide optimal interface pressures through controlled air cell inflation for at-risk residents and treatment for Stage I and II pressure ulcers. The P.R.O. Matt Plus may also be indicated for additional therapeutic intervention based on resident’s specific assessment.
  55. 55. Powered Surfaces• Number of Cells and Zones• Alternating Pressure• Low Air Loss• Customization of Surface
  56. 56. SURFACE OPTIONS ADDING POWER• Non-powered convertible alternating pressure mattress replacement system featuring P.R.O. (Pressure Relief Optimization) technology• Four zones (head, shoulder, torso and foot)• High resiliency foam topper provides maximum pressure relief• Treatment for Stage I and II pressure ulcers• Dimensions: 80"L x 36"W x 7"H• Meets flammability standards including Federal 16 CFR 1633, Cal 117 and Boston IX- II• 500 lbs. maximum weight capacity
  57. 57. CairTurn RT Lateral Rotation TherapyBenefits• Highly specialized quilted therapy pad reduces friction and shear force while providing moisture relief without drying out patients skin• “Autofirm” mode provides maximum air inflation designed to assist both patient and caregiver during patient transfer and treatment• Advanced design turning therapy cells provide optimal turning therapy• Six turn cycle times and eight therapy settings maximize patient compliance, healing and lateral rotation options• Preset optimal turn of 30° offers safe, comfortable rotation for both organ drainage and pressure relief• Quiet, comfortable, easy to set up and use and incorporates both rotation and floatation therapy
  58. 58. TurnCair™ Plus Lateral Rotation and Low Air LossBenefits• Specially designed quilted therapy pad reduces friction and shear force while providing moisture relief without drying out patient’s skin• Up to two hundred liters of airflow wicks away moisture to help prevent skin maceration• “Autofirm” mode provides maximum air inflation designed to assist both patient and caregiver during patient transfer and treatment• True 40º turn (80º arc) provides maximum benefit for wound healing and reduction of fluid in lungs• Inflatable side air bolsters provide additional patient safety• Turning done by inflation provides for a more significant turn while maintaining pressure relief• Fowler boost inflates sacral section to provide adequate pressure relief when head of bed is elevated at 25º or greater
  59. 59. FlapCair™ Cellular Low Air Loss SupportBenefits In a recent independent study, the Sixty individual therapy cells help to evenly distribute FlapCair pressure mapped and patient’s weight and maximize pressure relief performed comparable to the Clinitron. Highly specialized quilted cover reduces friction and shear force while providing moisture relief without drying out patient’s skin Up to two hundred liters of airflow wicks away moisture to help prevent skin maceration Designed for healing flaps and graft sites as well as pressure ulcers Low air loss mattress replacement provides ten inches of therapeutic support “Pulsate” mode to enhance wound healing and patient comfort Lower safety mattress prevents bottoming out by remaining inflated up to 24 hours in the event of a power failure
  60. 60. Turn1000™ Bariatric Lateral Rotation and Low Air LossBenefits Improving patient outcomes and increasing patient• Specially designed quilted therapy pad reduces friction and caregiver safety. and shear force while providing moisture relief without drying out patient’s skin• Up to 200 liters of airflow wicks away moisture to help prevent skin maceration• “Autofirm” mode provides maximum air inflation designed to assist both patient and caregiver during patient transfer and treatment• Turn angle set options of ¼, ½, ¾ and “full” provides maximum benefit for wound healing and reduction of fluid in lungs• Turn set times of 10, 20, 30 and 60 minutes provide individualized patient therapy settings• Lower safety mattress provides pressure reduction by remaining inflated up to 24 hours in the event of a power failure
  61. 61. CairRails™ Risk Management Air BolstersBenefits Protect your facility from liability… And provide your patient with a safe, secure healing A bilateral side bolster solution which can environment. enhance your facilities entrapment/risk management program Transfer friendly-deflate for ease of assisted transfer or when bolsters are not required Unique contoured design allows ease of ingress/egress, while providing additional protection, comfort and supports patient compliance Promotes maximum independence by allowing caregiver to decide when added protection is required
  62. 62. Other Patient Handling Challenges• Bed egress unassisted• Bed egress with assistance• Bed egress total lift and transfer• Delivering care in bed• Patients at Risk for Falls
  63. 63. Bed Egress• What can be done to facilitate bed egress• Assisted Bed Egress• Independent Bed Egress
  64. 64. Bed System Solutions• Deluxe Assist Handles mounted on bed frame sides provide a secure hand hold to assist residents to safely stand and egress the bed• Auto Transfer Height as part of the AdvanceCare positioning package easily sets the bed frame at the optimum bed egress height for most of the population
  65. 65. Foot of Bed Egress
  66. 66. Height Adjustment Egress Assist
  67. 67. Increase Bed Surface Width • UltraWide adds nearly 20% width to the bed surface providing more space for the resident similar to conventional residential bed surface area encouraging a comfortable night’s sleep and reducing the exposure of rolling out of bed.
  68. 68. Body Center of Gravity on Bed Surface
  69. 69. Risk for Falling Out of Bed Figure 2: Average Risk for All Target Populations 60% Average Risk for All PopulationsPercent Risk of Falling due to Hip Width Contribution 50% 51% 44% 40% 30% 33% 20% 10% Benchmark 14% 36% Improvement Improvement 0% 35 inch 39 inch 42 inch
  70. 70. Under Bed Lighting • The Under bed night light provides soft lighting to the bed egress floor area adding safety for residents to exit the bed during evening hours
  71. 71. Low Beds Reduce Injury severity • Ability to be placed in a very low surface position to reduce risk of injury severity related to rolling out of bed
  72. 72. Gait Training Application

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