Back Safety,
Safe Patient Handling,
& Assisted Mobility Skills
Finger Lakes DDSO
New Employee Orientation
April 2012
What is Back Safety/Safe Patient
Handling(SPH)?1
• A set of policies and programs designed to
decrease the strain and injury on staff while
they move and care for consumers
• Focuses on minimizing and eliminating manual
lifting by using equipment instead of the
caregiver’s body
• Legislation in NYS is passed in the Assembly and
is pending in the Senate to make SPH
mandatory in all healthcare facilities.
Why is Back Safety/Safe Patient
Handling important?
• Healthcare work is among the most hazardous
occupations in NYS2
• Back injury is the 2nd leading occupational injury3
• Back injuries are expensive2
▫ Cost of medical care
▫ Cost to pay overtime coverage
• Significant time is lost with injury
▫ Mandated overtime, training new staff
• Safe body mechanics are not enough to prevent
injury3,5
• Prior to SPH, stand pivot transfers were the #1 way
FLDDSO staff were injured when caring for
consumers
Benefits to Staff2
Decreases Injuries
Decreases Pain and Muscle Fatigue
Decreases Lost Work Days
Decreases Overtime
Increases Morale
Increases Job Satisfaction
“My company/supervisor/worksite cares about
me!”
• SPH is an investment in the employee
•
•
•
•
•
•
•
Consumer Benefits of SPH2
• Improves quality of life
• Lowers levels of depression and “behaviors”
▫ Consumers feel more secure and less anxious
when being transferred in a consistent manner
•
•
•
•
•
•
•
Improves urinary continence
Increases consumer participation in activities
Increases level of daytime alertness
Increases/maintains upper extremity ROM
Decreases fall risk
Decreases in fractures (spiral, compression)
Decreases skin tears and bruising
What About the Consumers?
• Bottom line:
▫We can not provide safe
care for the consumers if
we do not take care of
ourselves!
Back Safety
Injuries
Risk Factors
Proper Lifting
Healthy Spine
Image from
http://www.orlandocaraccidentlawyerblog.com/20
09/08/
Image from www.squidoo.com
Posture
• Purpose of the spine:
▫ Protects the spinal nerve
▫ Demo: posture/curves
• Muscles support the spine
▫ Back muscles tend to be small in
size
▫ Lifting muscles are larger quads
and gluts
• Good posture relies on flexibility &
core strength
▫ Stretch your low back into
extension
▫ Strengthen your abs
Image from:
http://davidsalse.files.wordpress.com/2011/
06/posturesitting.jpg
Risk Factors2,3,6,7,8,9
• Poor posture
▫ Stretches & weakens
key muscles
▫ Examples: car seating,
brushing teeth, washing
dishes
• Frequency of forward
flexion
▫ Typically 3,000-5,000
times/day
• Previous injury
▫ Known or unknown
Lack of exercise
Lack of social support
Low job satisfaction
Age
Lifting more than 35lbs
▫ NIOSH safe weight
limit
• Lack of sleep
▫ Less than 8 hours
• Smoking
▫ Decreases body’s ability
to heal
•
•
•
•
•
Microtraumas:
“Unknown” Injuries
• Mechanical processes
▫ Compression
▫ Shear
▫ Rotation/Twist
▫ Awkward Postures
Image from http://www.sandiego-spine.com/2010/degenerative-spine.png
Common Injury in Spine
• Disc Herniation
▫ Over time the outer layer
of the disc weakens from
repeated microtraumas
▫ The inner jelly of the disc
bulges out of position,
usually toward the back
where it can put
pressure on the nerve
Image from http://www.backpainhelptoday.com/wpcontent/uploads/2010/12/Hdisc1.jpg
Other Common Injuries
• Muscle Strain
▫ Tear in muscle fibers
▫ Pain
▫ Inflammation
▫ Tightness
• Tendinopathy
▫ Pain
▫ Tenderness
▫ Related to gradual
wear & tear
• Compression Fracture
▫ Directly related to disc
health
• Various Locations
▫ Shoulder
 Rotator cuff, impingement
▫ Knees
 Torn cartilage, ligament
issues
▫ Neck
 Nerve problems radiating
down arm, stiffness
Body Mechanics
DO
• Get in the ready position
▫ Wide base of support
▫ One foot slightly forward
▫ Firmly plant your feet
▫ Soften your knees
• Wear appropriate clothing
and footwear
▫ Per DDSO dress code,
shoes must cover toes
and have flat contact
with ground
DO NOT
• Make quick and jerky
movements
▫ Causes strain on back
muscles
• Twist when lifting
▫ “Keep nose and toes
pointed in the same
direction”
• Wear clothing that interferes
with safe patient care
▫ Large jewelry
▫ Shoes with high heels, flipflops
Body Mechanics / Lifting
• Assess the situation
▫ Know your limitations
▫ Is there equipment available to make this safer?
• Plan ahead and prepare the environment
▫ Clear pathway
• Hold the load close and firm
▫ Hips & shoulders square to load
▫ If hold is not firm- start over!
• With heavy objects, break up the load
• Communicate with other staff member and
consumer
Chores Challenge
• Laundry
▫ Top loading washer & front loading dryer
• Making beds
• Shoveling snow
▫ Push, squat, do not toss over shoulder
• Yard work
▫ Use wheelbarrows, kneel on knee pads
• Carrying groceries & supplies
▫ Divide up loads, use carts on wheels
SPH & Assisted Mobility Skills
Course Objectives
• Given direction by a licensed physical or
occupational therapy staff, the FLDDSO new
employee/trainee will demonstrate their knowledge
by performing the following:
▫ General concepts for joint range of motion (not
specific to a consumer)
▫ General concepts to prevent and manage decubiti
(pressure sores)
▫ Safe and effective transferring and handling
techniques including use of non-friction devices,
rolling devices, mechanical floor lifts, sit/stand lifts
and gait belts
▫ Safe and effective positioning of consumers on support
surfaces (wheelchairs, beds)
Competencies
• 4.17 Lifting & Transferring
• 4.19 Range of Motion
• 3.5 Blind Trailing-Mobility Techniques for
consumers with Visual Deficits
• Competencies get officially signed at the
worksite. This class will give you the basics and
will result in signature in the “Comments”
section of these 3 competencies.
Range of Motion (ROM)
= The available movement at a joint
ROM deficits are commonly seen in:
▫ Consumers with cerebral palsy (high tone)
▫ Consumers who have had a stroke (high tone)
▫ Consumers with arthritis (cartilage less pliable)
Benefits of Joint Movement
▫
▫
▫
▫
Increased comfort and flexibility
Increased circulation and nutrition to joint
Maintenance of ADLs (dressing, bathing, etc.)
Greater ease for staff to perform skin/hygiene care
ROM Programs
• ROM is performed by staff when muscle and/or
joint tightness:
▫ Interferes with cleanliness and hygiene care
▫ Interferes with dressing
▫ Causes pain and discomfort
• Formal programs may be provided by OT/PT
▫ Found in the IPOP
▫ Require further consumer specific training by
the therapist
Keys to Remember
• Your approach matters:
▫ Quiet voice, dim lights, firm, but gentle touch, after a
warm bath/shower
• Always tell the consumer what you are doing
• Surround the joint
▫ One hand on each side of the joint
▫ Only range one joint at a time
• Full hand control
▫ Keep fingers together, flat surface
▫ Fingertips can bruise; avoid claw hands
• Smooth and controlled
▫ Never push into restrictions
▫ Never bounce
▫ Move slowly: fast jerks can increase tone and cause
injury
ROM Terms to Know
• Adduction
• Flexion
▫ Moving the body part
▫ To bend
towards midline
• Extension
▫ “ADD”ing to the body
▫ To straighten
• Internal Rotation
• Abduction
▫ Rotation towards the
▫ Moving the body part away
center of the body
from midline
• External Rotation
▫ Abduct means to take
▫ Rotation away from the
away!
center of the body
• Flexion
• Extension
Images from HEP2go.com
• Abduction
• Adduction
Images from HEP2go.com
• Internal Rotation
• External Rotation
Images from HEP2go.com
Decubitus Ulcers
“Pressure Ulcers” “Bed Sores”
• Risk factors
▫ Boney areas of the body
 Tail bone, heel, ankle, hip, elbow, back
▫ Prolonged pressure
 Healthcare best practice requires repositioning at
least every two hours!
▫ Fragile skin
▫ Decreased circulation
 Diabetes, other vascular diseases
▫ Poor nutrition
 May have adequate intake, but poor absorption
Decubitus Ulcers
• Risk Factors continued…
▫ Friction
 Repeated movement across a surface
▫ Shearing
 Body tissue moves over top the skin which has
adhered to the support surface
 Example: bare legs on a vinyl car seat on a hot day
▫ Moisture & heat
 Sweat
▫ Incontinence
 Bowel and bladder
 Caustic to skin
Decubitus Ulcers
• Most are preventable by
▫ Keeping the skin clean and dry
▫ Changing position at least every 2 hours
▫ Properly using support surfaces that relieve
pressure
 seat cushions, mattresses…
▫ Assuring clothing is not a risk factor
 avoid jeans, avoid nylon pants, ensure footwear
is ON when in wheelchair
Discussion points on seating demo
• Tell us about how you feel after being on
improper seating during the short discussion
• Remember that consumers sit in positions for
up to two hours at a time
▫ Make sure consumers are seated appropriately!
▫ Fragility of consumer skin even before seating
concerns
Cushion 101
• Used for pressure relief, comfort, and positioning
• Positioning cushions have:
▫ Bump in front to separate legs
▫ Soft well in the back for tailbone
• Check to make sure they are in properly
▫ Hand sweep to check front and back
• Check the labels
▫ Often labeled front and back
• Do not assume the cover is on the cushion
correctly
Wheelchair parts
Pelvic Positioning Belt
Hand Rim
Rear Anti-Tippers
Front Castor
All WCs used by consumers at the
FLDDSO must have:
•
•
•
•
•
2 working brakes (wheel locks)
Pelvic positioning belt (seat belt)
Rear anti-tippers
Arm rests
Foot rests
▫ may be removed inside buildings for people who
foot propel, must be replaced prior to
transportation
• Tilt chairs must have headrests
*Any exceptions are found in the IPOP
Wheelchair Maintenance & Care
• Frequent cleaning necessary for function
▫ Not just for night shift
▫ Cleaning should occur as chair gets soiled
 Especially following meals
▫ Upholstery should be wiped down
▫ More to come with Personal Care Skills course…
• If the wheelchair is broken or missing parts, DO
NOT bring consumer to day program or outings
▫ Cannot be transported in that condition
▫ Immediately contact OT, PT, house or program
managers
Soft Goods Maintenance & Care
• “Soft Goods” include:
▫ Wheelchair Cushion
Covers
▫ Canvas and Mesh
Slings
▫ Non-friction sheets for
bed repositioning
▫ One-way (anti-slip)
devices
▫ Gait belts
• Washing
▫ Hand wash
▫ Machine wash: lukewarm
water & detergent
▫ Garment bag may be
used
▫ **DO NOT USE BLEACH**
• Drying
▫ All soft goods MUST be
hung or laid flat to dry
▫ **DO NOT PUT IN THE
DRYER**
Bed Mobility
and Positioning
Keys to Bed Mobility and Positioning
• COMMUNICATION
▫ Always talk to the consumer to tell them
what you are doing; ask them to help if they
can assist
▫ Always talk to the other staff person
• Don’t forget good body mechanics
• If the task is unsafe or difficult, is there
equipment that would make it safer and easier?
If you aren’t sure, ask a PT or OT!
Supine positioning
• Body position
▫ laying on their
back
• Pressure points
▫ Back, tail bone, heels, back of
head, elbows
• Use bed controls for positioning
• Pillow/support placement
▫ Under head
▫ Under knees
▫ Behind calves
 Heels floating
Image from http://www.mejaa.com/mejaa21Mar2009/pressureu
lcer-pt2-fig1.gif
Side-lying positioning
• Body position
▫ Head, neck, trunk, and hip
aligned
▫ Both legs bent at hips and
knees
• Pressure points
▫ Shoulder, hip, knees, ankles
• Pillow/support placement
▫ Under head
▫ Between knees
▫ Supporting top arm
▫ Behind back
Image from http://lifecenter.ric.org
Image from http://www.mejaa.com/mejaa21Mar2009/pressureu
lcer-pt2-fig1.gif
SPH Rolling
• Communicate with the consumer and other staff
• Equipment possibilities include:
▫ Non-friction sheets
▫ Positioning devices (Tri-turner, full body, split sheet)
▫ Grab bars (side rails, bed assist bars)
• Position the person for best mechanical advantage
▫ Bend knee opposite the direction of the roll or cross
leg over towards roll
▫ Ensure their arms are out of the way
Rolling With SPH Techniques & Devices
• Top Sheet (“Split Sheet”)
▫ Used with mechanical lifts
▫ Used for wound care, pressure relief
▫ Can be used with 1 or 2 staff members because it is
for positioning & is not a transfer out of bed
▫ Must be left on bed
 Make the bed with the Top-Sheet on
Images from
romedic.com/usa
More SPH Techniques & Devices
• Non-Friction Sheets
▫ Use: Repositioning up/down, side/side in bed, rolling for care in
sidelying
▫ Closed end of tube in the direction you are moving the consumer
 Headfoot for up/down positioning
 Sideside for lateral shift or rolling
▫ Must be used with two staff
▫ Must hold and use secondary sheet (draw sheet/cloth chux) atop
NF sheet
▫ Rules for Non-Friction Sheets
 Hands are never on the NF sheet after it is under the person
 Hands are driving DOWNWARD into the bed
 Lunge/step to move, square body towards direction you are going
 Arms/legs/trunk move as ONE unit
▫ Place and remove without turning or rolling consumer
 Tuck method in demo lab
▫ Does NOT stay on bed
Images from
romedic.com/usa
Transfers
Gait belts
• Why
Image from
▫ Consistent, firm grasping surface for staff
romedic.com/usa
▫ Provides a sense of security to the consumer
▫ Protects both parties from injury when transferring or
ambulating
• When
▫ Consumer requires assistance to maintain balance standing
or ambulating as determined by PT/OT/RN with input from
staff
• Remember
▫ NOT a lifting belt
▫ Consumer must have good sitting balance
▫ Consumer must be able to move their feet
▫
▫
▫
▫
 Should not require lifting to maintain standing position
Not intended to prevent most falls
Always hold at the handle
Make sure belt is snug but not restrictive
Be aware of location of medical concerns (tubes)
Assistance Levels
• Contact Guard
▫ Gait belt required
▫ Hands on the gait belt
▫ Used when consumer requires physical and/or directional
guidance and verbal cueing
• Stand-By Guard
▫ Gait belt frequently required
▫ Within an arms reach of the consumer, prepared to assist if
needed
▫ Used when consumer only needs occasional balance
assistance or guidance
• Range of Scanning
▫ Visual supervision
*Level of assistance determined by PT/OT/RN
▫ Documented in IPOP
Keys to Transfers with Mechanical
Devices
• COMMUNICATION
▫ Always talk to the consumer to tell them
what you are doing; ask them to help if they
can assist
▫ Always talk to the other staff person
• Don’t forget good body mechanics
• If the task is unsafe or difficult, is there
equipment that would make it safer and easier?
▫ If you aren’t sure, ask a PT or OT!
Lifting Sling Sizing and Materials
Sizing
• Height
▫ Mid-head to mid-buttock for
full coverage
• Width
▫ 2-3 finger-width of material
on either side of body
• Weight
▫ Slings will have weight as
well as sizing restrictions
▫ Check label
• Color Coded (most)
▫ Small= red, Medium= yellow,
Large= green, XLarge= blue
Materials
• Canvas/Quilted
▫ Dry transfers only (not for
bathing)
▫ Not left under consumer
• Mesh
▫ ANY transfer, including
bathing
▫ Typically best if IPOP
requires sling to stay under
consumer
▫ Dries fastest
Lifting Sling Check
• When to NOT use sling:
▫ Frayed material on loops (even if it’s not the
loop you will be using)
▫ Holes in any portion of sling
▫ Cut-off loops
▫ Evidence of previous repair (sewn)
▫ Evidence of being shrunk in washer
▫ Dusty residue from previous bleaching
• Report to supervisor if you take sling out of
use, clearly label concern on sling
• Contact OT/PT
Lifting Sling Types…
• Split Leg Sling
▫ Has full trunk and separate
leg extensions to support
each leg
 Available with or without
head support
▫ Can be placed & removed
with consumer in chair
Images from Romedic.com/usa and
http://www.a3bs.com/imagelibrary/W49825M/
W49825M_01_Universal-Mesh-Sling-Split-LegMedium.jpg
Lifting Sling Types…
• Full Body Sling
▫ Must stay under consumer
 Ideally, it should be mesh
▫ Head control
▫ No separate pieces for legs
Image from http://www.a3bs.com
Lifting Sling Types…
• Split Leg Hammock Sling
▫ Head control
▫ Leg straps to support each
leg
 Cross-through method for
majority of people
 Cradle method for amputees
or full leg coverage
Images from Romedic.com/usa and
http://www.hmebc.com
Lifting Sling Types…
• Hygiene/Toileting Sling
▫ Has wide support belt
around trunk and/or
waist with leg supports
▫ Allows access for
hygiene care and
toileting
▫ Can also be used for
other seated transfers
▫ Consumer must have
adequate head and
neck control
Images from Romedic.com/usa and
http://www.hmebc.com
Lifting Sling Types…
• Limb Strap
▫ Secures limbs for
positioning, wound care,
hygiene care, dressing,
bathing
▫ Can also be used for ROM
and exercising
▫ Can be used in
combination with other
slings for optimal
positioning
Image from http://www.angelsolutions.com/
Lifting Sling Types…
• Stand Assist Harness
▫ Trunk/waist support belt
▫ Used with sit-stand mechanical lifts
• Walking Harness Sling
▫ Has body support with pelvic/leg straps
▫ Used with mobile base floor lifts or ceiling
track lifts for assisted walking
Images from Romedic.com/usa
Mechanical Lifts
• Sit-Stand Lift
▫ Rolls on floor
▫ Used for transfers from seated
position to seated position
(toileting, bathing…)
▫ Potential use in therapy
 Removable footplates for
ambulation
Image from
spin-life.com
Sit-Stand Lift
• Consumer Requirements
▫ Independent sitting (on edge of
bed OR supported sitting in chair)
▫ Bears some weight through one or
both legs
▫ Holds on with at least one hand
▫ Is an active participant in the
lifting, familiar with the process
 May require training for consumer
comfort and cooperation
Image from
http://www.accessibilityservices.net/image/Floor%20li
ft%206-sit%20to%20stand.jpg
Sit-Stand Lift Procedure
• Always use TWO staff for transfers
• Assess environment
▫ Clear path to transferring area
▫ Minimal space between transfer surfaces
• Prepare equipment
▫ Place harness snugly around the low back region
of the consumer
▫ Attach designated straps to lift
• Instruct/Assist the consumer to put their feet
on the foot plates
• Instruct the consumer to grasp the handles on
the lift
Sit-Stand Lift Procedure (cont…)
• Sit-Stand lift brakes OFF /wheelchair brakes ON
▫ Allows consumer’s weight to center itself within
supports
• Raise the consumer using remote
• Maintain contact guard while lifting and moving
▫ Staff stand on either side of consumer in lift
• Transfer to desired location
▫ Move the lift, do not push consumer
•
•
•
•
Lower the consumer onto destination seat
Buckle pelvic belt if present
Remove lift harness
Reposition as necessary
Mechanical Lifts
• Mobile Base Floor Lift
▫ Rolls on floor
▫ “Hoyer” is one brand, we
typically use Invacare
Reliant 450 lifts
Image from
Romedic.com
/usa
Image from
spin-life.com
• Ceiling Track Lift
▫ Includes ceiling mount, wall-towall mount, free standing
frame, tension-mount
▫ Best for small rooms like
bathrooms and bedrooms
Mobile Base Floor Lift / Ceiling
Track Lift
• Consumer Requirements
▫ Most universal lift available, can be used on vast
majority of consumers
▫ May have poor sitting balance and poor head
control
▫ May have seizure disorder, osteoporosis…
▫ Unable to meet requirements for Sit-Stand Lift
Mobile Base Floor Lift / Ceiling Track
Lift Procedure
• Always uses TWO staff for transfers
• Assess environment
▫ Clear path to transferring area
▫ Minimal space between transfer surfaces
• Prepare equipment
▫ Ensure sling is in the proper position under consumer
• Determine and attach appropriate sling loops
• Mobile base floor lift brakes OFF
▫ Allows consumer’s weight to center itself within lift
supports
• Raise the consumer using the remote
Mobile Base Floor Lift / Ceiling Track
Lift Procedure (cont…)
• Maintain contact guard while lifting and moving
▫ Protect the head and legs
• Transfer consumer to desired location
▫ Move the lift, do not push the consumer in sling
• Lower the consumer onto destination support
surface
• Buckle pelvic belt if present
• Remove sling unless otherwise indicated in IPOP
• Reposition as necessary
SPH Decision Tree
Full Mechanical Lift
(Floor or Ceiling)
^
Sit to Stand Mechanical Lift
^
One Person Transfer with Gait Belt
^
Independent
Additional Discussion & Demos
• One-way devices
• Turning discs (cloth for seated, hard plastic for
standing)
• Compression stocking donner / bag
• RoMedic Easy-Glide for sling placement and
removal
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
American Nurses Association. Safe patient handling. Accessed February 28 2012. Available at
http://www.anasafepatienthandling.org/Main-Menu/SPH-Background.aspx.
NYS Zero Lift Task Force. Accessed February 27, 2012. Available at www.zeroliftforny.org.
Edlich RF, Winters KL, Hudson MA, Britt LD, Long WB. Prevention of disabling back injuries in nurses by the
use of mechanical patient lift system. Journal of Long Term Effects of Medical Implants. 2004;14(6):521533.
Finger Lakes Developmental Disability Services Office. Injury reports. Last updated February 2012.
Hignett S. Intervention strategies to reduce musculoskeletal injuries associated with handling patient: a
systematic review.Occup Environ Med. 2003;60(9). Available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1740617/
Bidassie B, McGlothlin JD, Mena I, Duffy VG, Barany JW. Evaluation of lifestyle risk factors and job status
associated with back injuries among employees at a mid-western university. Applied Ergonomics.
2010;41:106-114.
http://www.newyorkbackinjury.com/2010/12/15/new-york-back-injury-–-risk-factors-of-back-pain/
Hoogendoorn WE, van Poppel MNM, Bongers PM, Koes BW, Bouter LM. Systematic review of psychosocial
factors at work and private life as risk factors for back pain. Spine. 200;25(16):2114-2125.
Waters T. When is it safe to manually lift a patient? AJN. 2007;107(8):53-58. Available at
http://safeliftingportal.com/safeliftinglibrary/documents/Tom%20Waters%20article%20when%20is%20it%20safe%20to%20manually%20lift%20a%20patient.pdf
Nelson, A., Baptiste, A. Evidence-based practices for safe patient handling and movement. Online Journal
of Issues in Nursing. 2004;9(3). Available:
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volum
e92004/No3Sept04/EvidenceBasedPractices.aspx
Tseng CN, Chen CCH, Wu SC, Lin LC. Effects of range-of-motion exercise programme.
Pless. A closer look at the pivot transfer. Caring for the Ages. December 2005. Available at www.amda.com.
Images
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www.HEP2go.com
www.squidoo.com
www.quickie-wheelchairs.com
www.romedic.com/usa
http://www.orlandocaraccidentlawyerblog.com/20
09/08/
http://login.npwebsiteservices.com/Tarlov_Cyst_Di
sease_FoundaAYSCXT//OurLibrary.asp
http://www.streetsie.com/manual-wheelchairdesign-production/
http://lifecenter.ric.org
www.spin-life.com
www.veteransmedicalequipmentsales.com
• http://www.a3bs.com
• http://www.backpainhelptoday.com