Denise Henry, RN, BSN, Director of Quality Management, Gail Connolly, Safe Patient Handling Coordinator, and Robin Shields, RN, Women & Infants Hospital, Providence, RI., describe a safe handling simulation developed by them to improve bariatric patient experience.

The importance of Safe Patient handling in the healthcare environment is needed for patients and healthcare providers. This article discusses the method used by Providence, Rhode Island’s Women & Infants Hospital.

 The Bureau of Labor Statistics has long identified nurses, aides, orderlies, and attendants as high-risk occupations for strains and sprains as a result of repeatedly lifting patients who are irregularly shaped, unpredictable, physically limited, and/or heavy.1

Healthcare workers are generally at risk when moving a patient of relatively low or moderate weight, and that risk is magnified by the increasing weight of patients due to the obesity epidemic in the United States.2 Weight is not the only issue; girth provides its own challenges. Caregivers struggle to mobilize patients who fit poorly into recliners and beds. Manual lifting techniques, body mechanics, and back supports have been some of the more common approaches to injury prevention throughout the United States, but those interventions have not been effective at reducing caregiver injury rates.3 Safe patient handling (SPH) refers to the use of engineering controls, transfer aids, or assistive devices, whenever feasible and appropriate, instead of manual lifting to perform the acts of lifting, transferring, and/or repositioning health care patients and residents.

More recently, use of assistive equipment has evolved, and has been implemented into common healthcare practices. In 2006, Rhode Island legislative findings made reference to nine cases in which the use of lift equipment decreased injuries by 65-95%.4 What followed was the state of Rhode Island enacted safe patient handling legislation (Section 23-17-59) to protect caregivers while handling their patients. The regulation called for the maximum reasonable reduction of manual lifting, transferring, and repositioning of all or most of a patient’s weight, except under emergency, life-threatening, or otherwise exceptional circumstances. The legislation also required that SPH education and training be provided annually, or as needed.5

Purpose

Women & Infants Hospital (W&I), a specialty hospital in Providence Rhode Island, caters to women and newborns. With over 8500 births per year6, there are a significant number of challenging patients, where bariatric size is compounded by pregnancy. To comply with Safe Patient legislation, W&I introduced assistive lift equipment and training in the hope of improving safety and quality for caregivers, as well as their patients. Equipment vendors served as the industry experts for the initial training. They offered equipment demonstrations that were simple in concept. Vendors effectively demonstrated the value of using assistive equipment for lifting and mobilizing patients. Learners practiced their physical dexterity in operation of the equipment. A second wave of educational training was provided as a computer based safe patient handling module which was convenient and complimented the first training.

In 2008, W&I reported as many as 41 patient handling incidents. The administration needed to evaluate potential flaws in the original training, noting the lack of a shift in practice. Thus in 2009, a Safe Patient Handling (SPH) Coordinator was hired who was responsible for identifying safety needs within the institution and initiating unit-based risk assessments. It was in her purview to train staff on the use of air transfer devices, lift equipment, as well as the importance of incident reporting. As a result of these efforts, a reduction from 41 injury occurrences to 22 was noted the following year. Despite an initial calm in safe patient handling data, by 2010 the number of injuries swelled to 42. Although equipment use had been encouraged, a sustained demonstrated utilization of the equipment had not become the culture within the institution. There continued to be a gap between knowledge of functionality and the practicality of equipment use. Additionally, when equipment was utilized, a disconnect existed. Staff exhibited a one dimensional view which was the function of the equipment only. Complicating factors related to equipment utilization should include: the patient physical assessment, an environment assessment, and clinician-patient interaction. These important components were not being considered or addressed. Bridging these aspects required creative approaches to the educational schema. The hospital needed to consider ways to engage employees to improve their practices. The organization then turned its efforts towards implementing a simulation program.

Methods

Simulation was introduced into the W&I culture in 2009. Over the course of one year, the department had developed a reputation of excellence within the institution, being viewed as innovative, creative, and progressive. These were characteristics which had been noted to be synonymous with the growing SPH program. The simulation and safe patient handling program would provide an opportunity to incorporate staff experiences into an interactive, immersive exploration of the mounting patient handling incidents. During initial planning stages, scenario development considerations were focused on all units and departments throughout the organization. A patient fall was chosen because it could occur in any of these areas.

The creation of an educational program was built on an actual incident, one where a bariatric patient had fallen in a cramped bathroom, blocking herself in the room. To provide the necessary realism, the group consulted with a local artist to create a shell to be worn by any actor which possessed the characteristics necessary to present a patient with a body mass index (BMI) >40. The result of these efforts was the W&I girth suit, the first of its kind. This suit was capable of transforming any educator into a bariatric transferable challenge.The educational plan brought together small employee groups representing multiple operational units, varying levels of experience, and different professional licenses. Groups discussed procedures related to assessment of any fallen patient and their environment. Afterwards, they were trained to operate the patient floor lift and slings, and trained on the equipment’s indications and contraindications.

The creation of an educational program was built on an actual incident, one where a bariatric patient had fallen in a cramped bathroom, blocking herself in the room.
The use of a girth suit during simulation really emphasized any weaknesses related to utilization of equipment with the bariatric population, as well as patient rapport. Image Credit: Women and Infants Hospital.

Immediately following the training, employees practiced using the equipment to care for a 105 pound static manikin who had fallen in an open space. Caregivers were observed to determine their ability to assess the patient and environment, select and apply the correct sling, and operate the lift properly. Next, participants were asked to manage an actor-patient, wearing the girth suit, in a confined bathroom space. The actor responded to cues given by the caregiver staff. Caregivers were studied for their ability to assess the patient, consider the environment, operate the equipment, interact with the patient, and problem solve in front of the patient, functioning as a team. Finally, a debriefing session was provided to facilitate discussion, allowing participants to reflect on their experience and assess their own ability to care for patients safely and effectively.

Outcomes and Results

The program was piloted prior to roll out, utilizing the Safety Director and the Director of Quality Management. Feedback from the trial was fruitful and as a result of this exercise the identified benefits of the safe patient handling program using simulation improved two-fold. First was the administrative support that was received. The Safety Director believed that the knowledge gained from this exposure allowed him to be more passionate when discussing the need for more equipment with hospital administration. His experience allowed him to verbalize the challenges in a way that helped open the eyes of the administrators, being more receptive to make safe patient handling equipment more readily available to staff.

Secondly and of equal importance was advancing a sensitivity awareness among the staff when working with the bariatric population. This ground breaking work was fully embraced as a quality initiative by the Director of Quality Management. She believed through her simulation experience she gained a fuller understanding and heightened awareness of the challenges the bariatric clientele face and how interactions during a stressful exposure played a major impact on the overall psyche. This exercise proved to be an opportunity to positively impact both staff education and patient satisfaction.

An important, yet unanticipated finding from the Simulation SPH program became a longitudinal staff awareness related to safety and quality of patient care. Their thinking shifted from past and present to future thinking. Staff were evolving, becoming proactive rather than reactive in the care they provided to the bariatric patient. In 2009, staff performed their duties in accordance with their previous experiences and knowledge. Challenging patients requiring transfers, repositioning or assistance to ambulate were cared for by primary nurses with the assistance of colleagues, if required, as the situations presented.

Toward the end of 2010 and into 2011, caregivers became more educated about patient handling equipment and the resources available to assist them. The SPH Coordinator served as a necessary resource, often being called when caregivers were unsure of how to safely handle an admitted physically demanding patient. With the patient situation managed, the team would then debrief the case, determining what information could have been communicated in advance to make the process more efficient. It was recognized that height, weight, and mobility status were the keys to preparedness. It was critical that private healthcare providers be included as part of the team. Incorporating this group was the first line for gathering and sharing vital patient information in advance and would become the measure of successfulness for care provision. This practice would provide staff the opportunity to mobilize equipment ahead of time and direct additional resources as required to meet the patient’s needs.

By 2013, active staff participants and the SPH Coordinator had established a climate of preparedness, and engaged in forward thinking and reporting. An example of a report would include the following: “We will be receiving a patient three weeks from now. She will be having a robotic hysterectomy surgery. She is 5 feet tall, 395 pounds, and uses a wheelchair at home”. This sample would begin the creation of a Special Needs Care Plan. This practice would be initiated for any bariatric patient entering the hospital system. This plan would include an equipment list matching the patient’s needs, and one would follow the patient throughout their course of care. Additionally, it became a common practice to simulate any high-risk task in advance, prior to exposing patients to any harm.

Conclusions

The use of simulation was engaging, and it provided a robust learner experience that extended beyond the technical operation of the equipment. The equipment, caregivers, patient, and environment provided elements of complexity that required participants to use their collective training, experiences, and critical thinking skills to carry out their tasks. Additionally, use of the girth suit provided an effective means to expose staff attitudes and behaviors related to bariatric sensitivity. Since simulation was introduced, institutional data regarding SPH incidents stabilized (see table 1), and may be suggestive of SPH equipment utilization and training.

Limitations

Simulation made a tremendous impact on patient handling practices at W&I but we want to identify that it was an integral part of a broader, multi-faceted SPH program. This encompassed a SPH Coordinator, SPH Committee, unit assessments, incident reporting, SPH Tip of the Month, SPH Equipment & Resource Manual, equipment trials, a NetLearning module, and an Annual Care New England SPH Symposium. Much of what was learned through simulation was incorporated into the program, thus it was difficult to isolate the effects of pure simulation on our incident data.

Future Research

The frequency and duration, in which patient handling equipment was used, whether actual or simulated, may have played a factor in the caregiver’s skill and comfort level over time. The development of formal evaluation tools is necessary to measure staff proficiency and long-term learning retention. Further research is indicated to validate this Simulation/SPH program model for adoption.

About the Authors

Denise A. Henry RN, BSN, MS, RLNC, CPHQ has been a nurse for 32 years with years of experience with planning, training, evaluating and sustaining many safety program initiatives. For the past 15 years she has been in the Quality Management Department at Women & Infants Hospital of Rhode Island and the past eight as the Director of Quality Management.

Gail Connolly, MBA, PT, ATC, CSPHP is in her seventh year as the Safe Patient Handling Coordinator at Women & Infants Hospital. Gail is the Chair of the W&I Safe Patient Handling Committee and she also serves as the Chair of the Care New England Safe Patient Handling Committee, and Co-Chair of the Bariatric Task Force.

Robin Sheilds RN has 23 years of experience as a Registered Nurse in Maternal-Child Health with five years focused as a research nurse in simulation based medical education.

References

  1. Bureau of Labor Statistics. http://www.bls.gov/news.release/osh2.nr0.htm (accessed 8/30/12)
  2. CDC Congressional Testimony Safe Patient Handling Lifting Standards for a Safer American Workforce http://www.cdc.gov/washington/testimony/2010/t20100511.htm
  3. Evidence-Based Practices for Safe Patient Handling and Movement http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No3Sept04/EvidenceBasedPractices.html
  4. RI Legislative Findings 23-80-2 (e) http://webserver.rilin.state.ri.us/BillText06/HouseText06/H7386.pdf
  5. Rhode Island General Laws 23-17-59 Safe Patient Handling. http://www.lawserver.com/law/state/rhode-island/ri-laws/rhode_island_general_laws_23-17-59
  6. Care New England 2012 Annual Report. http://www.carenewengland.org/about/upload/ARFINALlow.pdf