Capstone: building a safe patient handling program

This last lesson puts the course together. A safe patient handling program is not a lift, a policy or a training day. It is a system in which every patient is assessed, the assessment points to a method, the equipment for that method is there and working, staff know how to use it and are expected to, and someone checks the results and fixes what is not working. Lesson 2 listed the elements of such a program and showed how far Northbridge's old policy fell short. Lessons 3 to 11 covered each element in turn.

The capstone follows Grace and the 3 East team through a year of building the program on one unit. 3 East is a 30-bed surgical unit with a steady flow of patients who are mobile before surgery, dependent for a day or two afterwards, and then quickly mobile again. Lesson 11's availability audit found it was the weakest of the three units checked. By the end of the lesson you should be able to plan the same work for a unit, a long-term care home area or a home care team of your own.

The program cycle

Grace uses a simple cycle to plan the work. The steps are the same as in any occupational health and safety program, and they match the elements in Lesson 2.

Step 1: commit and organize

A program needs people who are responsible for it. On 3 East, Grace started by agreeing on roles with Sarah MacLeod's counterpart, the 3 East unit manager, and the director of surgery:

• A leader. The unit manager is accountable for the program on 3 East, including equipment, training time and follow-up. Grace, as the hospital's safe patient handling coordinator, provides expertise and data.
• A working group. The unit's working group reports to the JHSC and its patient handling working group. It has two nurses, two personal support workers, a physiotherapist, a porter, the unit's educator and the manager. Half its members do the moves every day.
• Peer leaders. Six staff, at least one on every shift and rotation, are trained as peer leaders. They coach colleagues at the bedside, run the routine equipment inspections and are the first contact when something goes wrong.
• Time. Peer leaders get two hours a month away from patient care for program work, and the working group meets monthly for the first six months.

Commitment also means saying out loud what the program expects. The director of surgery and the manager told staff at the launch meeting that manual lifting of all or most of a patient's weight would no longer be accepted on 3 East, that equipment would be provided to make that possible, and that no one would be blamed for taking the time to use it.

Step 2: assess the unit

Before buying anything, the working group collected four kinds of information.

• Injury and near-miss data. Over the previous two years, 3 East had 14 patient handling injury reports, 5 WSIB claims and 3 lost-time cases. Most were during repositioning in bed and the first time a patient got up after surgery.
• A staff survey. Staff were asked which tasks they found hardest, how often they lifted by hand and why, and what got in the way of using equipment. The top answers were that the lift was too far away and often flat, that there were not enough slings, and that there was no time.
• A patient mobility census. For two weeks, nurses recorded each patient's mobility level at the start of every day shift, using the assessment tool from Lesson 3.
• A walk-through. Grace and a peer leader looked at every room, bathroom and storage area, measured clear floor space and doorways, and checked whether ceiling track could be installed.

Step 3: plan equipment and space

The mobility census told the group how many patients at each level the unit usually had, and so how much equipment it needed. Grace turned the census into equipment numbers with a short script, using the planning ratios from Lesson 11.

import math
# 3 East patient mobility census: patients at each level at the start of day shift
# (level 1 = fully dependent ... level 4 = independent), 14 days
census = {
    1: [3, 4, 2, 3, 5, 4, 3, 2, 3, 4, 3, 5, 4, 3],
    2: [5, 6, 5, 7, 6, 5, 6, 5, 6, 7, 5, 6, 6, 5],
    3: [9, 8, 10, 8, 9, 10, 9, 9, 8, 9, 10, 8, 9, 9],
    4: [11, 10, 11, 10, 9, 10, 11, 12, 11, 9, 10, 10, 10, 11],
}
peak = {lvl: max(days) for lvl, days in census.items()}
avg = {lvl: sum(days) / len(days) for lvl, days in census.items()}
for lvl in census:
    print(f"level {lvl}: average {avg[lvl]:4.1f}, peak {peak[lvl]}")

# plan for the peak, using ratios of about 1 device per 8 patients who need it
floor_lifts = max(2, math.ceil(peak[1] / 8))         # at least 2: one each end
standing_aids = max(1, math.ceil(peak[2] / 8))
slings = 2 * (peak[1] + peak[2])                      # two per patient: one in use, one in laundry
slide_sheets = peak[1] + peak[2] + peak[3]            # one stays with each patient who needs it
print(f"\nfloor lifts {floor_lifts}, sit-to-stand aids {standing_aids}, "
      f"slings {slings}, slide sheets {slide_sheets}")

level 1: average  3.4, peak 5
level 2: average  5.7, peak 7
level 3: average  8.9, peak 10
level 4: average 10.4, peak 12

floor lifts 2, sit-to-stand aids 1, slings 24, slide sheets 22

On a typical day, about nine patients on 3 East needed a full lift or a standing aid, rising to twelve at peak. The unit had one floor lift and no sit-to-stand aid. The plan added a second floor lift, a sit-to-stand aid, a full stock of slings in each size, and slide sheets for every patient who needed repositioning. The working group also asked for ceiling lifts in the four rooms nearest the nursing station, where the sickest post-operative patients are placed, which biomedical engineering and facilities confirmed could be installed.

Space and storage followed Lesson 11: two equipment alcoves with chargers, one at each end of the corridor, made from a former linen room and an unused nourishment room. Sling hooks were labelled by size. Every room got a hook for a slide sheet at the head of the bed.

The working group also wrote down how the method for each patient would be communicated: the mobility level and method on a sign at the head of the bed and in the care plan, updated at every reassessment, and a line on the shift huddle sheet for any patient whose level had changed.

Step 4: train and coach

Training on 3 East was built around the equipment the unit actually had and the patients it actually saw.

• Every staff member who moves patients, including porters, physiotherapists and float staff, attended a two-hour hands-on session before the launch, practising each move on each device with a partner as the patient.
• Training covered the mobility assessment, the care plan sign, pre-use checks, sling selection and fit, each device, falls and controlled lowering, and what to do when equipment fails.
• Each person's competence was checked on the unit by a peer leader within a month, using a short checklist, rather than assumed from attendance.
• New staff are trained during orientation and checked before they work alone. Everyone has a yearly refresher, and new equipment always comes with training.

Coaching matters more than the classroom. Peer leaders spent the first weeks after the launch on the floor, helping colleagues with their first uses of the new equipment, answering questions on night shift and spotting problems early. When staff saw a respected colleague use a lift for a boost that they would once have done by hand, the habit started to change.

Step 5: use every day

The program only works if it changes what happens at the bedside, every shift. The 3 East routine became:

• Assess every patient on admission, every day shift and whenever their condition changes, especially after surgery and before the first time up.
• Put the mobility level and method on the bedside sign and say it at the shift huddle.
• Bring the equipment to the bedside before the move, check it, and use it, even when it seems quicker not to.
• Report any problem with equipment, any move done by hand and any near miss, so the working group can see what is getting in the way.

The charge nurse checks bedside signs on rounds, and peer leaders do short observation audits each month, watching a sample of moves and noting whether the method matched the plan.

Step 6: measure

The working group measured both the process (whether the program was being followed) and the outcomes (whether injuries fell).

• Process measures: the share of patients with a current mobility assessment and bedside sign, the share of observed moves that used the planned method, availability audit times (Lesson 11), slings at par level, and equipment repair times.
• Outcome measures: patient handling injury reports, WSIB claims, lost-time cases and lost days, staff survey results, and patient outcomes such as falls and pressure injuries, which a good program also tends to reduce.

Grace compared the year before the program with the first full year after it. Because the number of hours worked changes from year to year, she used rates per 100 full-time equivalents (FTE), as in HSE-390.

# 3 East: patient handling injuries, year before and first year after the program
before = {"reports": 8, "claims": 3, "lost_time": 2, "lost_days": 61, "fte": 46.0}
after  = {"reports": 6, "claims": 1, "lost_time": 0, "lost_days": 0,  "fte": 47.5}

def per_100_fte(n, fte):
    return 100 * n / fte

for key in ("reports", "claims", "lost_time"):
    b = per_100_fte(before[key], before["fte"])
    a = per_100_fte(after[key], after["fte"])
    print(f"{key:10} {b:5.1f} -> {a:5.1f} per 100 FTE")
print(f"lost days {before['lost_days']} -> {after['lost_days']}")

# process measures from monthly audits in the first year (share of checks passed)
process = {"current assessment and sign": [0.62, 0.78, 0.86, 0.91],
           "observed moves used planned method": [0.55, 0.71, 0.83, 0.88],
           "lift at bedside within 2 minutes": [0.33, 0.67, 0.83, 0.92]}
for name, q in process.items():
    print(f"{name:35} " + "  ".join(f"Q{i + 1} {v:.0%}" for i, v in enumerate(q)))

reports     17.4 ->  12.6 per 100 FTE
claims       6.5 ->   2.1 per 100 FTE
lost_time    4.3 ->   0.0 per 100 FTE
lost days 61 -> 0
current assessment and sign         Q1 62%  Q2 78%  Q3 86%  Q4 91%
observed moves used planned method  Q1 55%  Q2 71%  Q3 83%  Q4 88%
lift at bedside within 2 minutes    Q1 33%  Q2 67%  Q3 83%  Q4 92%

The results were encouraging but needed careful reading. Lost-time cases fell from two to none and WSIB claims from three to one, a real improvement in the most serious outcomes. Injury reports fell only a little, from 8 to 6, and Grace was glad of that: part of the program was to encourage reporting of strains and near misses before they became injuries, so a steady number of reports with fewer serious cases is what a working program often looks like. The numbers on one unit are also small, so a single bad week can change them. The process measures showed steady improvement every quarter, which gave the working group more confidence that the outcome changes were not just chance.

Step 7: review and improve

Every quarter, the working group reviews the data and reports to the JHSC and its patient handling working group, and once a year the whole program is evaluated and the policy reviewed. On 3 East, the first annual review found three problems still to fix:

• The night shift's audit scores lagged behind days, because two of the six peer leaders worked days only. A night peer leader was added.
• Patients going home were still being helped into cars by hand at the front entrance. A swivel cushion and a transfer board were added to the discharge cart, with a short training session for staff and volunteers.
• Two of the four ceiling lifts had been installed, but the other two were delayed by funding. The committee put them first on the next capital budget.

Grace then re-ran the gap analysis from Lesson 2, this time for the hospital program as a whole. The score had risen from 6 of 28 to 23 of 28. The elements still only partly in place were design review for renovated space, equipment maintenance in home care, and return to work after injury, which became the priorities for the next year.

Keeping it going

Many programs start well and fade. Equipment wears out and is not replaced, peer leaders move on, new managers arrive who were not there at the launch, and old habits return when the unit is busy. The programs that last share some features:

• They are built into normal work: the assessment is in the chart, the sign is part of the bed, equipment checks are part of the shift, and the budget includes slings and batteries every year.
• They have a named owner at every level, from the unit peer leader to a senior leader.
• They keep measuring and reporting results, so that leaders see the value and staff see that their reports lead to action.
• They involve frontline workers in every decision, from choosing equipment to writing procedures.
• They link safe patient handling with patient goals such as early mobility, fall prevention and skin care, so that it is seen as good care, not an extra.