Effects on Quality of Care and Work on a Novel Transfer and Repositioning Device on an Intensive Care Unit

Transcription

1 Proceedings 19 th Triennial Congress of the IEA, Melbourne 9-14 August 215 Effects on Quality of Care and Work on a Novel Transfer and Repositioning Device on an Intensive Care Unit J.J. Knibbe a, M. Onrust b, W. Dieperink b a LOCOmotion Research in Health Care, Bennekom, The Netherlands. b Department of Critical Care, University Medical Center, Groningen, The Netherlands Abstract To reduce the risk of occupational musculoskeletal disorders for nurses, a newly developed patient handling device is evaluated from the perspective of occupational health and quality of care. This sheet can replace the standard bed sheet and is used with a lifter to undertake a range of transfers and repositioning activities. It can stay under the patient and be changed at the same time as the bed linen. The novel device showed a significant reduction in physical load for the nurses, compared to regular routines with normal non-permanent slings, sliding sheets and manual transfers. This was partly due to lower biomechanical forces and partly due to the fact that some activities were eliminated as the sheet can stay under the patient at all times. It does not have to be applied and removed before and after use. The implications for the patients quality of care and safety are discussed and look promising, as no adverse events were noted and the patients' comfort seemed to improve. However, a more detailed analysis is required to assess the effects on the quality of care. Practitioner Summary: Devices such as these are promising for the daily practice of nurses. Proof from this study shows that the occupational health risk is reduced substantially in comparison to standard care and current equipment. In addition, the number of staff required for repositioning decreases, which may in turn help lightening the general workload. Furthermore the threshold to offer the patient frequent repositioning (to prevent pressure ulcers) was perceived to be lower. Keywords: ergonomic, back pain prevention, nurses, intensive care transfer-equipment 1. Introduction In hospitals multiple horizontal transfers (from stretcher to bed, repositioning on the bed, placing X-ray cassettes under a patient, weighing a patient, etc.) are performed. This is a challenge where patients are fully dependent, for example in intensive care units (ICU). The process of repositioning, although of general benefit to the patient, exposes the caregiver to an increased risk of musculoskeletal disorders (MSD). These transfers are strenuous for both nurses and patients. They may result in an increase in perceived pain for the patient, an increase in the risks of developing pressure ulcers and provocation of adverse events in ICU patients (for example cardiac arrest or ventilatory distress) (Brindle et al., 213). For nurses, these transfers provide a risk of developing occupational back-, neck- and shoulder pain (Hignett et al., 214, Knibbe and Knibbe, 212, Koppelaar et al., 211). These activities demand a considerable amount of nursing time as well, since they are often performed by multiple nurses and, if lifters are used, the sling necessary for the transfer needs to be placed under the patient before, and removed after, each transfer or repositioning activity (Knibbe and Knibbe, 212). In order to address this issue, a new patient lifting device was developed by the ICU of an academic hospital in close cooperation with the industry. It was thoroughly tested and CE-marked before it was introduced on the wards. This Maxi Transfer Sheet (TS) from ArjoHuntleigh is a lifting sling for horizontal 1

2 Proceedings 19 th Triennial Congress of the IEA, Melbourne 9-14 August 215 transfers and repositioning. The sling can be connected to a ceiling- or floor-lifter and can be left under the patient before and after the transfer or repositioning, and is comparable to regular bed linen. It is hypothesized that this permanently accessible sheet eliminates the effort of the transfer itself (performed by the lifter) and the process of placing and removing the repositioning device. Hence it saves time and reduces the ergonomic risk to the staff, with at least the same, or improved, quality of care. 2. Method A prospective case study in one single centre, with a pre-post design of the introduction of the TS on an ICU, was performed. Before the introduction of the TS the ICU s were using powered high-low beds, sliding sheets, pat slides and lifters (mobile and overhead) with normal slings. Hence, the situation was considered to be satisfactory from an ergonomic point of view. Ethical consent to perform the study was given by the METC by means of a waiver. No funding was received by the authors for this study. The following variables were measured at baseline and at follow-up (after 3 months): - Patient: subjective pain, subjective comfort, pressure ulcers and adverse events (for example cardiac arrest) - Nurse: biomechanical exposure, type of equipment used, perceived exertion, back- and neck/shoulder pain. Research instruments were: 1. Patient: TISS, VAS, RASS, Apache II & IV (to assess the incidence of adverse effects) 2. Exposure to physical (over)load of nurses (static and dynamic load) 3. Back pain prevalence of nurses 3. Frequency of activities and equipment used 4. (Subjective) quality scores First of all an integrated survey for the nurses was pre-tested. It was based on an extended and validated version of the NORDIC questionnaire (Knibbe et al., 28). Secondly a validated 24-hour patientlog was tailored for use on an ICU (Knibbe & Friele, 1999). In this log the participating nurses registered all the repositioning and transfer activities they performed during a full 24-hour period, before and after the introduction of the TS. They also noted the way these transfers were performed (equipment, number of nurses involved etc.). Thirdly biomechanical forces were measured using a calibrated MecMesin force gauge. These forces were used as input for the calculations in the 3D SSPP biomechanical model, version 6.5. Measurements were performed during transfer and repositioning activities (with and without the TS) under controlled conditions, using a subject of 7 kg and 1.7 m. Three transfers with and without the TS were studied in this way: - Horizontal transfers from bed to stretcher - Repositioning in bed - Insertion and removal of an X-Ray cassette 3. Results Pre-post data from 47 nurses and 25 patients were collected. Everyone invited chose to participate in the study. The survey data are summarised in table 1 and show a slight decrease in 12-months and 3-months back pain prevalence from 43% to 34% and 43% to 3%. Nurses rated the TS positively with a score of 8.2 (1-point scale) compared to 8.5 (ceiling lifter), 5. (sliding sheet) and 7.3 (PAT-slide). The subjective and indirect patient-scores (not in the table) improved significantly from 2.4 to 1.4 (discomfort) and 2.5 to 1.5 (pain) on a 5-point scale. No differences were found in the incidence of pressure ulcers or adverse effects (for example cardiac arrest). Table 1. Survey results before and after the introduction of the TS (Nurses N=57). Pre-intervention Post-intervention 12-months back pain prevalence 43% 34% 3-months back pain prevalence 43% 3% Evaluation of equipment (1=max) Ceiling system Sliding sheet PAT-slide TS

3 Proceedings 19 th Triennial Congress of the IEA, Melbourne 9-14 August 215 For the three transfers studied in detail (horizontal transfer from bed to stretcher, repositioning in bed sideways, turning, up in bed, and placing an X-ray cassette under the patient), we found a substantial reduction of the biomechanical exposure for the nurses compared to manual transfers, transfers with a sliding sheet and when compared to a transfer with a non-permanent sling. Table 2 contains the overall biomechanical results. The considerable range of forces when using sliding sheets and when applying and removing sliding sheets and slings is remarkable. Maximum forces above a limit of N are not recommended from an ergonomic point of view and need to be avoided under Dutch guidelines (Knibbe et al., 28). It can be seen in table 2 that the TS, lifter and most of the sliding sheet data remain below that level. It is also obvious that all manual transfers exceed that limit and need to be avoided from an ergonomic point of view. Table 2. Biomechanical load (max pull/push/lift forces measured in N and range (min-max)) for three transfers and/or repositioning activities (for five repetitions measured with a standardised patient, 7 kg, 1.7 m). TS Lifter without TS Horizontal transfer bed to stretcher Applying slings/sheet 146 N (8-39) Sliding sheets 112 N (6-34) Transfer itself 27 N (14-36) Removing slings/sheets (45-129) (19-12) Repositioning in bed Applying slings/sheet 146 N (8-39) 112 N (6-34) Transfer itself 23 N (11-43) Removing slings/sheets 111 N 78 N (45-129) (19-12) Inserting and removing X-ray cassette Applying slings/sheets 146 N 112 N (8-39) (6-34) Transfer itself 199 N (8-246) Removing slings/sheets 111 N 78 N (45-129) (19-12) Manual 658 N (34-934) 441 N ( ) 388 N ( ) Note The TS remains under the patient and therefore the load for applying and removing is zero. But of course the TS must be changed regularly. As a rule this is done when clean sheets are required: at least once every 24 hours. In that case the load is similar to applying a sling. In addition to these effects the elimination of the need to place and remove the sling, prior to and after the transfer or repositioning when using the MTS, reduces the total exposure level of the nurses significantly. This elimination effect is further increased when the total exposure on ward level per 24 hours is based on one and a maximum of two nurses. Before the TS introduction more nurses (up to four) may occasionally have been required to perform a transfer safely. Table 3 presents the effects of this elimination on the total exposure level for a 24-hour period. The total number of transfer and/or repositioning activities was reduced from 634 to

4 Proceedings 19 th Triennial Congress of the IEA, Melbourne 9-14 August 215 Table 3. Frequency of transfers and repositioning activities registered per cycle of 24 hours before and after th introduction of the MTS aggregated for the nurse population (N=47 nurses). Before TS introduction After TS introduction Horizontal transfers Applying sling/sheet/ts etc. 16 Transfer itself Removing sling/sheet/ts 16 Subtotal Repositioning in bed Applying sling/sheet/ts etc Transfer itself Removing sling/sheet/ts Subtotal Placing X-ray cassettes Applying sling/sheet/ts etc. 14 Transfer itself Removing sling/sheet /TS etc. 14 Subtotal TOTAL Note The TS remains under the patient but must be changed regularly, preferably when clean sheets are required. This was done on average a little more than once per 24 hours and this frequency is mentioned in the table under repositioning. 4. Discussion After the introduction of the TS, the back pain prevalence was reduced. No control group related this reduction directly to the introduction of the TS. However, there is a substantial reduction in the physical exposure which increases the likelihood of this relation. More research with a larger study group and a control group will permit final conclusions. The TS offers a significant reduction of the physical load for nurses and a good subjective experience for nurses. The results show a substantial difference in physical load for the nurses when using the TS, compared to the regular routines using normal slings, sliding sheets and especially the manual transfers. It is also obvious that the range in forces is substantial. This is consistent with the findings of Maertens (211) who also found considerable differences in forces especially when using sliding sheets. Although most nurses were not aware of this, a slight peak load was often measured during the start of the repositioning. More gradual and slower movements led to lower peak loads. Although our findings are similar, our results are not as obvious as the findings of Maertens. Nevertheless, this apparent range with the undesired possibility of loads in excess of safe limits underlines the need to find solutions where these larger forces will not occur, which may entail techniques that will prevent these forces from occurring at all. In our study we found that the likelihood of these forces occurring was lower when using the TS for the simple reason that some activities were no longer required, thereby eliminating the risk. Our study was limited in the sense that more variations need to be measured: different nurses, different patient sizes and weights, different types of material and equipment and different types of mattresses. This will be a topic for future research. However, these considerations are most likely of minor importance, as the reliance on human power is limited. This can be seen as an argument in favour of using the TS. For patients the results seem at least equal to the quality of care they had before the implementation of the TS. A more detailed analysis is required and is currently being undertaken. That study will be presented elsewhere. It is important to note that there were no adverse or otherwise negative results reported. We can therefore conclude that there were no indications that the patients had a negative experience with the TS. A difference was found between the technical set-up of the lifters with which the TS devices were used. The results were better when the TS was used in combination with a traverse ceiling-lifter as opposed to a single track ceiling-lifter and a mobile, floor-based hoist. Although in all situations the exposure of the nurses to physical overload was reduced significantly, the traverse system proved to be the better solution. The time 4

5 Proceedings 19 th Triennial Congress of the IEA, Melbourne 9-14 August 215 required, the perceived exertion for the nurses, and the subjective comfort for the patient, were all slightly better. This is due to the fact that with a single track system, and especially with a mobile lifter, additional and more precise positioning was sometimes required. Further research is required as the sample size was too small to assess this in more detail. Acknowledgements Equipment was partially provided by an unrestricted grant from ArjoHuntleigh. The study itself was financed exclusively by the UMCG and by LOCOmotion (first author). References Brindle, T.C., R.Malhotra, S.O Rourke, L.Currie, D.Chadwik, P.Falls, C.Adams, J.Swenson, D.Tuason, S.Watson, S.Creehan, 213. Turning and Repositioning the Critically Ill Patient With Hemodynamic Instability A Literature Review and Consensus Recommendations. J Wound Ostomy Continence Nurs. 4(3): Hignett, S., M.Fray, N.Battevi, E.Occhipinti, O.Menoni, L.Tamminen-Peter, E.Waaijer, H.J.J.Knibbe, M.Jäger, M International consensus on manual handling of people in the healthcare sector: Technical report ISO/TR ; 44(1): Knibbe, H.J.J., R.D.Friele, The use of logs to assess exposure to manual handling of patients, illustrated in an intervention study in home care nursing. International Journal of Industrial Ergonomics 4 (24), Knibbe, H.J.J., N.E.Knibbe, L.Geuze, 28. Een hap uit een gegroeide olifant, vierde nationale monitoring fysieke belasting, SOV&V, Den Haag (in Dutch). Fourth National Monitoring, Unions & Employers organizations. Knibbe, J.J., N.E.Knibbe, 212. Flying through the hospital: efficiency and safety of an ergonomic solution. Work 41: Koppelaar, E., J.J.Knibbe, H.S.Miedema, A.Burdorf, 211. Individual and organisational determinants of use of ergonomic devices in healthcare, Occup Environ Med. 68(9): pp Maertens, L., 211. Trekkracht bij gebruik glijzeil, ergonomische benadering bij procedure hogerop in bed, Hartziekenhuis, Roeselare-Menen. (in Dutch). 5