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Service Delivery Innovation Profile

Scoring System Helps Choose Approaches and Devices for Safely Moving Patients, Leading to Fewer Staff Injuries and Lost Work Days


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Snapshot

Summary

Bay Pines Veterans Affairs Healthcare System's Safe Patient Handling Program uses a scoring system to help staff make appropriate choices in the number of staff needed and in the selection of assistive devices for lifting, moving, and/or repositioning patients. The safe patient handling score, which is obtained each time a patient needs to be moved or repositioned, is based on six attributes related to the patient's physical and mental status. The resulting score corresponds to recommended approaches and devices. The program significantly reduced staff injuries and nearly eliminated lost and restricted staff work days associated with these injuries at Bay Pines. In addition, other Veterans Health Administration sites have also experienced significant reductions in staff injuries since implementing the program.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of staff injuries, injury incident rates, and lost and restricted staff work days due to injury.
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Developing Organizations

Bay Pines Veterans Affairs Healthcare System; Veterans Health Administration
Bay Pines Veterans Affairs Healthcare System is located in Bay Pines, FL.end do

Date First Implemented

2009
The Veterans Healthcare Administration Safe Patient Handling Program was officially implemented in 2008, and the scoring system was developed at Bay Pines and implemented in 2009.

Problem Addressed

Nurses, nurse aides, and orderlies commonly suffer work-related musculoskeletal injuries, with many injuries being due to lifting, transferring, and/or repositioning patients. Yet, few hospitals employ proactive strategies to reduce injuries in the shortage-prone nursing profession.
  • A common problem: Nurses report roughly 40,000 back-related injuries each year,1 and between 35 and 80 percent of nurses sustain back injuries at some point during their career as a result of  lifting patients.2 Nearly 20 percent of nursing aides and orderlies also suffer from work-related back pain.3 Injuries often result from lifting, transferring, and repositioning patients, sometimes in awkward or tight spaces. The problem has been exacerbated by the increasing number of overweight/obese patients and elderly patients requiring assistance with activities of daily living.3 At Bay Pines VA Health System, most musculoskeletal injuries among staff resulted from moving patients, with registered nurses being the most likely to be injured. 
  • Unrealized potential of prevention strategies: Approximately 12 percent of nurses report that they left the nursing profession due to back pain.3 Given the national nursing shortage (with shortages expected to reach 20 percent by 2015 and 30 percent by 2020),3 the need to keep bedside nurses free from injuries is vital. Yet, few hospitals employ proactive strategies to do so.

What They Did

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Description of the Innovative Activity

Bay Pines Veterans Affairs Healthcare System's Safe Patient Handling Program uses a scoring system to help staff make appropriate choices in the number of staff needed and in the selection of assistive devices for lifting, moving, and/or repositioning patients. The safe patient handling score, which is obtained each time a patient needs to be moved or repositioned, is based on six attributes related to the patient's physical and mental status. The resulting score corresponds to recommended approaches and devices. Key program elements include the following:
  • Assessment based on six patient attributes: Each time a patient is moved or repositioned, a direct care unit staff member (usually a nurse, nursing assistant, radiologist, or physical therapist) uses a scoring system incorporating six items related to the patient's physical and mental abilities. Staff members assign a score of 0, 1, or 2 for each item and add the scores to obtain a "safe patient handling score." The safe patient handling score ranges from 0 (no assist) to 4 (needs full assist), and, once a patient reaches a score of 4, he or she is considered fully dependent (as explained in the next main bullet below) and further scoring is discontinued. In the event the patient is combative, uncooperative, or staff members are unable to obtain a score, the patient is considered a 4. (Note: The use of the word "assessment" is not part of the process because this indicates a higher scope of practice; the hospital allows anyone involved in direct patient care to obtain a score.) The six items cover the following areas:
    • Patient mobility: Patients receive a score of at least 1 if their mobility is impaired; in determining the score, the clinician considers recent changes, such as anesthesia use or change in mental status, that have affected mobility over the last 24 hours.
    • Lower extremity strength/ability to bear weight: Patients who can stand on both legs receive a score of 0. If they can only bear weight on one leg, they receive a score of 1; if they cannot bear weight, they receive a score of 2. If they can stand but experience a low level of function or strength in the lower extremities, they receive a score of 1.
    • Upper extremity strength/hand grasp: Patients who have strong use of both arms and hands receive a score of 0. If they have partial function, they receive a score of 1 or 2 based on the level of upper extremity weakness and the ability to grasp objects such as a handrail. Patients who are only able to use one arm and grasp receive a score of 1. 
    • Ability to understand directions/follow commands and willingness to cooperate: Patients with cognitive difficulties and/or who are forgetful or unwilling to assist with their transfer receive a score of 1 or 2 based on their level of mental capacity. Combative patients receive a score of 4 (requiring a full assist, with no additional scoring necessary). 
    • Height and weight: Patients who weigh more than 200 pounds and/or who are over 6 feet tall and have decreased mobility and require assistance receive a score of 1, indicating that larger patients are more difficult to lift, move, and reposition. Large patients who can move independently receive a score of 0. 
    • Medical or mental conditions: Conditions that may affect a patient's ability to transfer or reposition warrant a score of 1 or 2, depending on their severity. Among others, these conditions include dizziness, shortness of breath, medical instability, fractures, recent major surgery, chest pain, and stage IV pressure ulcers. The staff member conducting the assessment checks with frontline staff for pertinent information prior to assigning this score. (Note: Staff members do not double-count; for example, hip replacement patients receiving a score of 1 to reflect impaired lower extremity function do not receive an additional score of 1 to reflect hip replacement as a medical condition.)
  • Determining total score and associated level of assistance: Staff members use an algorithm that translates the total score into recommended approaches for lifting and repositioning, including the use of assistive devices. Staff members are instructed never to lift over 35 pounds. Staff members reference a laminated equipment selection chart posted in various places around the unit to guide selection of assistive equipment. Available devices vary by unit; for example, the operating room does not allow ceiling lifts because of the surgical equipment and lights already installed in the ceiling. The algorithm provides the following score-based advice: 
    • No help (for those with a safe handling score of 0): This patient is ambulatory, alert, and oriented, and hence does not need assistance. Clinicians may stand near the patient to supervise ambulation if needed. Suggested equipment could include a walker, trapeze, or grab bar for self-assist, with staff standby for safety.
    • Coaching (1): This patient can generally move or reposition on his/her own, but may need cues and/or coaching. Suggested equipment could include a walker, trapeze, or grab bar, with staff offering verbal cues and minimal assist such as light touch. 
    • Minimal help (2): This patient has limited ability to bear weight, a reliable sense of balance, and is able to offer some assistance with transfer/repositioning. For this patient, clinicians should provide coaching or use light touch to aid with standing, pivoting, or sitting. Clinicians may also use a chair with removable arms until the patient can transfer independently. Additional suggested equipment could include a slide board, roller boards, or friction-reducing sheets for lateral transfers.
    • Moderate help (3): This patient has an unreliable ability to bear weight and/or lacks strength or mental capacity to participate in lengthy moving and repositioning tasks; the patient only offers minimal assistance with transfer but remains cooperative. (If staff members have to lift over 35 pounds, the patient is considered a full assist, with a score of 4.) For this patient, clinicians can consider a variety of assistive devices depending on patient needs, including ambulation slings, air assisted lateral transfer devices, powered sit-to-stand devices, reposition slings, lift commode seats, or ceiling lifts.
    • Dependent (4): This patient has minimal or no mobility and/or may be combative or confused. Two or three clinicians should participate in assisting the patient, and consideration should be given to using a seated or supine body sling. Suggested equipment includes a ceiling lift with a full body sling and reposition slings, limb holders when elevating an extremity, bathing and hygiene slings, and air assisted lateral transfer devices (for non-combative patients). Floor lifts should be avoided for combative patients, because the lifts may tip over.
  • "Badge buddies" for quick reference: A summary of the levels of assistance (called a "badge buddy") hangs on staff badges for quick reference, providing score categories and associated devices to be considered. The badge buddy lists a physical description of the patient for each score level on one side and suggested equipment on the other side.  
  • Communication of score to staff: The patient's safe handling score is communicated in several ways, including the following:
    • Transfer card: The patient's safe handling score is marked on a blue dot located on the "BAY Pines Express" card, an informational card placed in the patient's chart that travels with the patient each time the patient leaves the unit. The cards contain other relevant patient care information such as allergies, monitoring or support needed (e.g., oxygen and fall injury risk), and do not resuscitate status. The score helps staff identify how much assistance the patient needs to participate in procedures, transfers, and repositioning. 
    • Handoff sheet: The score also appears on the handoff sheet used by nurses to communicate patient information at shift changes and during intra-facility or external transfers. 
  • Staff safety huddles to review incidents: Each time an injury or "near miss" (an unsafe handling event) occurs, the safe patient handling coordinator reviews the event with an accident review board and provides suggestions for interventions. In addition, a hospital team called the Peer Leaders for Unit Safety holds a "safety huddle" to review the circumstances surrounding the event and discuss how patient care should have been handled differently to protect safety. The safety huddle is conducted in a "nameless, blameless" environment for transfer of information only, and unit and staff names are not revealed. The committee documents its recommendations and presents them to the unit leader, who shares them with frontline staff and the unit supervisor. The supervisor or nurse manager completes the documentation, advises the coordinator when and how the information was discussed on the unit, and makes additional unit-specific recommendations as needed.

Context of the Innovation

A large integrated health system housed within the U.S. Department of Veterans Affairs, VHA provides health care services to approximately 5.6 million veterans each year (out of the roughly 7.6 million veterans enrolled in the system). The nine-facility Bay Pines VA Healthcare System provides comprehensive health care services, including medical, surgical, rehabilitative, and psychiatric inpatient services; long-term medical and psychiatric care; and outpatient services in a variety of specialties. Serving veterans in the southwest part of coastal Florida and inland, Bay Pines has 397 beds and 8 outpatient clinics. In fiscal year 2010, Bay Pines provided care to nearly 98,000 veterans and had nearly 1.3 million outpatient visits. In 2006, the national VHA office emphasized the need to address safety issues related to patient handling and urged individual VHA health systems to design and implement programs to address this problem. The chief nurse executive at Bay Pines responded by encouraging staff to develop such an initiative. In response, the staff developed a team called Back Injury Resource Nurses. In 2008, when VHA officially launched the national program, this team expanded its focus to preventing all musculoskeletal injuries.

Did It Work?

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Results

At Bay Pines, the program significantly reduced staff injuries and nearly eliminated lost and restricted staff work days associated with these injuries. Other Veterans Health Administration (VHA) sites have also experienced significant reductions in staff injuries since implementing the program. 
  • Significantly fewer injuries: Since implementing the program, injuries due to the lifting or repositioning of patients have decreased by nearly 78 percent at Bay Pines, from an incident rate of 581.2 in 2006 (2 years before implementation) to 128.3 in 2011. The 2011 figure is well below the 331.6 incident rate for the VHA region that includes Bay Pines. By 2012, the incident rate fell to 45, making Bay Pines the number one program in the nation for all VHA Level 1A complexity facilities for second consecutive year. (The "incident" rate is calculated as the number of incidents divided by the number of productive staff hours, multiplied by 20,000,000; the 20,000,000 figure represents hours worked by fee-based staff not on regular payroll.) Other VHA facilities that have adopted the program have seen an average 33-percent decline in staff injuries due to lifting/repositioning since implementation. 
  • Many fewer lost and restricted staff days: At Bay Pines, lost staff days due to injuries from patient lifting, moving, and repositioning have nearly been eliminated, falling from 420 in 2007 (the year before implementation) to just 3 in 2010. The number of restricted staff days also decreased markedly, from 395 in 2007 to 15 in 2010. 

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of staff injuries, injury incident rates, and lost and restricted staff work days due to injury.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Assigning coordinator: A staff nurse assigned to work on special projects (who had suffered an injury herself) was reassigned to serve as the safe patient handling coordinator.
  • Obtaining education: The safe patient handling coordinator (along with coordinators from other VHA institutions) attended training sessions on safe patient handling provided by the VHA during annual national meetings. Training focused on basic concepts, policy development, hands-on equipment use, and implementation processes.
  • Forming committee: The chief nurse executive and coordinator expanded the former Back Injury Resource Nurses team to include staff from all areas and address all types of musculoskeletal disorders. This new team (called the "Peer Leaders for Unit Safety" team, or PLUS) included physicians, back injury resource nurses, acute care nurses, the patient safety officer, and clinicians and staff from various departments involved in moving patients, including physical therapy, radiology, emergency medicine, nuclear medicine, and rehabilitation.
  • Creating scoring system and associated algorithm: The team reviewed VHA's national safe patient handling algorithms, which they realized were complicated and led to low staff adherence. The team then gathered evidence from 27 published sources to inform the development of a new algorithm and scoring system. The team applied the scoring system to real patient cases to see how well it worked during a 60-day period and then revised and refined the system over a period of months.
  • Communicating system to staff: Team members called unit peer leaders who are located on each unit, communicated, and role modeled the program concepts to peers. Staff also viewed demonstrations on how to use the various assistive devices, and the Safe Patient Handling Program information was integrated into new employee education.
  • Pilot testing and subsequent rollout: Select units pilot tested the system for 60 days, during which staff provided feedback about its usefulness and applicability. Program developers also assessed scoring accuracy, with data collection revealing an accuracy rate of 99.6 percent. After the test, the system was rolled out across Bay Pines and then at a few other VHA institutions. In 2012, the scoring system will be rolled out nationally to all VHA facilities.

Resources Used and Skills Needed

  • Staffing: The program at Bay Pines includes one full-time safe patient handling coordinator.
  • Costs: Costs include the salary/benefits of the coordinator and the purchase of additional patient lifts and other assistive devices. Outfitting the nine Bay Pines facilities with a sufficient number of safe patient handling devices and providing education cost approximately $2.5 million.
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Funding Sources

Veterans Health Administration; Bay Pines Veterans Affairs Healthcare System
VHA and Bay Pines share the costs of salary and benefits for the coordinator position. VHA funded the purchase of assistive equipment and coordinator training.end fs

Tools and Other Resources

Safe Patient Handling Program algorithms are available from the program developer.

Resource guides to help hospitals establish a comprehensive safe patient handling and movement program can be found at the national Web site:
http://www.visn8.va.gov/patientsafetycenter/safepthandling/

Adoption Considerations

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Getting Started with This Innovation

  • Get system leader buy-in: Success depends in large part on securing the support of system leaders, especially because the program likely requires a meaningful financial investment in new equipment. To win this support, develop a "business case" documenting the program's potential to reduce injury-related costs, including direct medical care for injured staff and patients, long-term disability and workers' compensation, legal expenses, and staff replacement and training. These costs will very likely outweigh any needed investment in equipment.
  • Create interdepartmental team: The team responsible for program development should include representation from all hospital departments in which staff members lift, move, or reposition patients. This approach helps ensure that the scoring system and algorithm account for all patient handling needs and circumstances and include considerations that may have otherwise been overlooked.
  • Leverage existing communication programs: Use existing patient safety communication mechanisms to share the details of the new system with staff. The Bay Pines Express card is one mechanism to communicate safe patient handling needs when the patient is leaving the unit.
  • Enlist staff as role models: Recruit a team member from each unit and each shift to be on the team. Each unit should also have a trained peer leader to serve as a role model for safe patient handling concepts.

Sustaining This Innovation

  • Hold safety huddles: Review all injuries/incidents and near misses in a blame-free manner to foster a learning culture related to safe patient handling.
  • Provide ongoing education: Regularly host educational and other activities surrounding safe patient handling, including training on how to use assistive devices properly and periodic reminders about the need to use the scoring system and to share information when safety events or near misses occur. As part of this effort, share data demonstrating the program's positive impact on patient safety. These activities help to keep the program top-of-mind among busy staff.
  • Accept that culture change takes time: Gaining acceptance of any new program takes time, because staff members tend to resist change. To promote acceptance, continually communicate the organization's overriding goal for the program, which is to keep staff and patients safe.

Spreading This Innovation

As noted, the scoring system and algorithm have been implemented at other health care facilities and are available across the national VHA System.

Additional Considerations

Though the VHA implemented the Safe Patient Handling Program as a national initiative across all 153 health care systems, Bay Pines Veterans Affairs Healthcare System has become one of the nation's top performers in reducing staff injury rates, lost work days, and restricted duty work days. The safe patient handling scoring system at Bay Pines is what sets it apart from other VHA facilities, and for this reason, program developers attribute the success of the Bay Pines program primarily to the scoring system but also to the strong implementation process and staff dedication.

More Information

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Contact the Innovator

Judee Gozzard, RN, MSN, BC
Safe Patient Handling Coordinator
Bay Pines VA Healthcare System
10,000 Bay Pines Blvd.
Bay Pines, FL 33744
(727) 398-6661 Ext. 7726
E-mail: judee.gozzard@va.gov

Innovator Disclosures

Ms. Gozzard has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Footnotes

1 O'Malley P, Holly E, Davis D, et al. No brawn needed. Nurs Manage. 2006;37(4):26-34. [PubMed]
2 Ohio nurses get a lift and reduce injuries. Reflections on Nursing Leadership. 2006;Second Q.
3 Bell J, Collins J, Galinsky TL, Waters TR. Preventing Back Injuries in Healthcare Settings. NIOSH Science Blog. U.S. Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health. September 22, 2008. Available at: http://blogs.cdc.gov/niosh-science-blog/2008/09/lifting/
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 20, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 02, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: May 20, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.