Lifts and liability: Avoid workers' comp claims

The moment a nurse tries to help a heavy-set, medically fragile patient stand and walk is fraught with risk. With one miscalculation, the patient can fall, and the nurse or the patient — or both — might be seriously injured. Workers' compensation claims may be expensive and annoying.

Additionally, if the patient falls, the hospital could have a lawsuit on its hands for failing to use mechanical assist devices that are readily available. "If a patient is going to sue, they're going to say this happened because you didn't have a lift," says Sherry Taxer, RN, COHN/CM, CCM, CPDM, senior clinical risk management consultant with Medical Protective, a risk management consulting firm based in Beaverton, OR. Malpractice suits can bring unwanted publicity along with high costs, Taxer says.

Even if the patient doesn't sue, the hospital might write off costs associated with extra days in the hospital. "That would have paid for a lift," she says.

By putting the efforts of employee health and safety with risk management, you can have a much stronger safe patient handling program. You need to enlist your risk manager as a strong ally who recognizes mechanical lifts as an essential aspect of patient safety, she says. "If you can convince the risk manager, which should be a piece of cake, that safe patient handling would affect risk management, then you've now got two key players in the hospital building a program," she says.

It may sound like heresy to get rid of gait belts, which are a staple of hospitals. Gait belts are inexpensive items used by physical therapists and others to help patients ambulate after surgery. But look at them from another perspective, and you'll see the inherent risk. In a common scenario, a nurse places a gait belt on a patient who is at risk of falling. Perhaps the patient is recovering from surgery and is unsteady but needs to ambulate. What will happen if the patient begins to fall?

Louise O'Shea, RN, a patient handling consultant and president of O'Shea Associates in Chicago and Austin, TX, says, "We shouldn't think that because we have a gait belt on them that we're going to be able to save them and save ourselves. We've got to recognize that that is unacceptable."

Imagine there's an unstable refrigerator in an appliance store, suggests O'Shea. Would a worker wrap a belt around it to grab onto it in case it fell? Would anyone think that was safe? "[Hospital employees] have the assumption that by putting on the gait belt, everything is going to be all right. It's a false sense of security. And these patients are very fragile," she says.

Research has demonstrated that gait belts don't protect workers from ergonomic hazards. In one study, when a gait belt was used in a two-person lift, the load was only reduced for the person on the right side of the patient. The other health care worker experienced forces on the back that were equivalent to a single-person manual lift.1

In its ergonomic guidelines for nursing homes, the Occupational Safety and Health Administration (OSHA) recommends using gait belts for some transfers involving patients who are "partially dependent, have some weight-bearing capacity, and are cooperative." However, some ergonomic experts advise against the use of gait belts altogether. The Center for Ergonomics at the University of Wisconsin — Milwaukee did studies in their lab and found the transfer belt produced more stress on the body than not using it, says Arun Garg, PhD, CPE, director of the center, distinguished professor, and chair of industrial engineering at the university.

Instead, health care workers should use either ceiling lifts or a walk assist lift, ergonomic experts say. For example, Golvo lift from Franklin, MA-based Liko can be used with a vest-like harness to support a patient while walking.

Convincing employees not to use gait belts will be challenging, admits O'Shea. She suggests enlisting strong leaders on the floors who promote the use of new equipment. "Management has to send a clear message through those peer leaders that [using gait belts] is obsolete practice; it's dangerous practice," O'Shea says.

Hospital employees often are in a hurry, she says, "but we've got to understand that mobilizing people is fraught with danger." If they've had strokes or surgery or some debilitating disease, they are weakened, O'Shea says.

Gait belts were reasonable at their time, she says. "But now companies have provided us with alternatives and we need to move on to those alternatives, both for the safety of the patient and the employee," O'Shea says.

About 30% of Americans are obese, and the numbers are rising. From 1996 to 2004, the number of obese patients in hospitals rose by 112%. Michael Silverstein, MD, MPH, clinical professor in the Department of Environmental and Occupational Health Sciences at the University of Washington in Seattle, says, nurses and nurses' aides are among the highest-risk workers in the country, and that's without considering obesity. "You add to that the fact that patients' and workers' weights are going up, and you've got a perfect storm for workplace danger," Silverstein says.

While even lifting a 100-pound patient manually involves risk of injury, clearly the risk is magnified with obese patients. "Tremendous force is being placed on the lower back," he says.

Facilities that offer bariatric surgery need to purchase equipment that can be used safely with those patients, says Silverstein. Traditional lift equipment has a weight limit of about 450 pounds. Bariatric equipment can handle patient weight up to 1,000 pounds.

The Patient Safety Center at the James A. Haley VA Hospital in Tampa defines "bariatric" as patients who weigh more than 300 pounds and have a body mass index of 50 or greater. The center provides a bariatric toolkit for safe patient handling, including special algorithms and checklists. A sample policy provides for at least annual training, bariatric needs assessment, and a bariatric patient handling specialist. (See sample assessment criteria sheet and equipment checklist, below.)

Even hospitals that don't provide bariatric surgery must be prepared for the occasional patient who will exceed weight limits on standard equipment and create patient handling risks. Special equipment can be leased on an as-needed basis.

Silverstein suggests using a "disaster preparedness"-type model, including drills to practice how staff would assess the patient handling needs of a morbidly obese patient. "You have to think through how you're going to function as a team to manage someone of a weight of that size," he says.

A lack of adequate staff increases the risk of injury for nurses and patients. One study found a relationship between nurse staffing in nursing homes and worker injury.2 For every additional hour of nursing care provided, the injury rate declined by 16%.

Hospitals that use more temporary nurses may have higher injury and error rates, but that is not the fault of the temporary workers, says Linda H. Aiken, PhD, the Claire M. Fagin Leadership Professor of Nursing and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia. In another study, Aiken found that disparities in outcomes were related to the work environment, including staffing ratios, level of experience among the staff, and lack of a safety climate.3 "Sometimes hospitals that use a lot of supplemental nurses have poor outcomes. But it's really the deficient work environment that's associated with the adverse outcomes for patients," she says.

(Editors' note: The Bariatric Toolkit and other resources are available at www.visn8.med.va.gov/patientsafetycenter/safePtHandling/toolkitBariatrics.asp.)

References

1. Marras WS, Davis KG, Kirking BC, et al. A comprehensive analysis of low-back disorder risk and spinal loading during the transferring and repositioning of patients using different techniques. Ergonomics 1999; 42:904-926.

2. Trinkoff AM, Johantgen M, Muntaner C, et al. Staffing and worker injury in nursing homes. Am J Public Health 2005; 95:1,220-1,225.

3. Aiken LH, Xue Y, Clarke SP, et al. Supplemental nurse staffing in hospitals and quality of care. JAMA 2002; 288:1,987-1,993.