safe patient handling and mobility safe patient handling and mobility

This supplement was funded by anunrestricted educational grant fromHill-Rom. Content of this supplementwas developed independently of the sponsor and all articles haveundergone peer review according toAmerican Nurse Today standards.

Safe Patient

Handling and

Mobility

Current Topics in

Safe Patient

Handling and

Mobility

Supplement to

www.AmericanNurseToday.comSeptember 2014

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility 1

Safe patient handling andmobility: A call to actionMuch more must be done to enhance safety forpatients and caregivers. By Melissa A. Fitzpatrick, MSN, RN, FAAN

A confluence of demographicand economic trends ispushing us toward the per-

fect storm:• Today’s nursing workforce isaging. The average age of theAmerican registered nurse is44.6.

• The patients we serve are heav-ier than ever.

• Experts predict increases in pa-tient acuity, age, and comor-bidity.

• Staffing issues continue to causeconcern. Some experts projectthe United States will be shortabout 250,000 nurses over thenext 10 to 12 years.

• Economic imperatives require usto move patients through thehealthcare delivery system morequickly to shorten stays and en-hance financial reimbursement.

Any one of these trends iscause for concern. All of themoccurring at once is cause foralarm—and a call to action.Imagine older nurses lifting heav-ier, older, and sicker patients. Ob-viously, all parties are at greaterrisk for injury.In too many cases, nurses contin-

ue to deliver care “the way we’vealways done it.” For many, thismeans doing the heavy lifting need-ed to mobilize patients manually inan attempt to avoid the many se-quelae of immobility—decreasedcardiovascular, pulmonary, integu-mentary, and psychological func-tioning, to name a few.

While the intentions of manualpatient mobilization may be honor-able, the effects are far from opti-mal for all involved. There’s no suchthing as “safe lifting” when we useour bodies as the lifting mechanism.Old-school teachings about safebody mechanics have been proveninvalid, and many of us must un-learn them. As nurses, we mustchange our mindset and get in thehabit of using safe patient handlingand mobility (SPHM) technology tokeep both our patients and our-selves safe from harm.How many times have you or a

colleague suffered an injury toyour back, shoulder, or both duringmanual patient handling? Howmany colleagues have we lost toour profession because of a career-ending injury? How many millionsof dollars are spent on workers’compensation claims for employeeswho’ve had patient handling andmobility injuries? Caregiver injuriesadversely affect staff morale,staffing levels, and, ultimately, pa-tient safety. Such injuries havemade headlines in many communi-ties and are top of mind for health-care leaders. Legislatures have tak-en on the issue, and in 2013 theAmerican Nurses Association(ANA) supported a federal bill toeliminate manual patient handling,including lifting, transferring, andrepositioning patients. That sameyear, ANA published national inter-professional standards to guidecaregiving teams of nurses, physi-cal therapists, nursing assistants,

transportation orderlies, and othersin implementing the standards andcreating a culture of safety in theirorganizations. However, only 11states have enacted SPHM lawsand these laws vary significantly.Much more work needs to be doneto enhance safety for patients andcaregivers.This special report provides a

helpful resource to caregivers asthey continue to practice SPHM—orto embark on their SPHM journey ifthey’re not already on it. Nationalexperts share their perspectives andbest practices to align people,processes, and technology to setthe course for action. I’d like tothank all of the authors who’ve con-tributed to this special report forsharing their expertise and strate-gies, which we hope will be imple-mented where you work. Pleasetake these best practices to heartand engage your colleagues to dothe same. And please join all of usat Hill-Rom on our mission to ensureSPHM. Much is at stake, and noth-ing is more important than yourhealth and well-being—to enableyou to continue doing what onlynurses can do. We’ve never need-ed nurses more than we do now.

Selected referencesAmerican Nurses Association. Safe Patient Han-dling and Mobility: Interprofessional NationalStandards. Silver Spring, MD: Author; 2013.

Buerhaus PI, Auerbach DI, Staiger DO. The recentsurge in nurse employment: causes and implica-tions. Health Aff (Millwood). 2009;28(4):w657-68.

Melissa A. Fitzpatrick is vice-president and chiefclinical officer at Hill-Rom.

2 Current Topics in Safe Patient Handling and Mobility September 2014 www.AmericanNurseToday.com

Current Topics in Safe PatientHandling and Mobility

CONTENTS

1 Safe patient handling and mobility: A call to action By Melissa A. Fitzpatrick

“The way we’ve always done it” is no longer an acceptable rationale for manual patient handling andmobilization. We must change our mindset and embrace appropriate technology to keep ourselves and our patients safe from harm.

4 Elements of a successful safepatient handling and mobilityprogram By John Celona

To build a successful program, identifyyour facility’s specific needs, design theprogram, obtain leaders’ and nurses’commitment, and provide effectiveeducation and training.

7 Transforming the culture: The key to hardwiring earlymobility and safe patient handling By Kathleen M. Vollman and Rick Bassett

Accomplishing early patient mobility and safe handling requires a culture change, deliberate focus, staffeducation, and full engagement.

11 Standards to protectnurses from handling and mobility injuries By Amy Garcia

Learn about ANA’sinterprofessional nationalstandards on safe patienthandling and mobility, developed by a panel ofinterdisciplinary experts.


Supplement to

www.AmericanNurseToday.com September 2014

13 Implementing a mobility assessmenttool for nurses By Teresa Boynton, Lesly Kelly, and Amber Perez

The authors describe a nurse-driven tool youcan use at the bedside to evaluate yourpatient’s mobility level and guide decisionsabout patient lifts, slings, and othertechnology.

17 The sliding patient: How to respondto and prevent migration in bed By Neal Wiggermann

Pulling patients up in bed carries a high risk of caregiver injury. Find out how to preventpatient migration and manage it safely when it occurs.

20 Prepare to care for patients of size By Dee Kumpar

Nearly a third of patient-handling injuriesinvolve bariatric patients. Handling andmobilizing these patients safely requires skilland specialized technology.

23 Developing a sling management system By Jan DuBose

Disposable or launderable slings? In-house or outsourced laundering? These and other key decisionsrequire input from all departments involved.

26 Making the business case for a safe patient handling and mobility program By John Celona

The author explains three approaches to justifying a safe patient handling and mobility program and presents a decision-analysis case study.

Since safe patient handlingand mobility (SPHM) effortsbegan more than a decade

ago, data show dramatic reduc-tions in caregiver injuries after asafe patient handling and mobility(SPHM) program is implemented.So why doesn’t every healthcarefacility have one?The first reason is cost. An

SPHM program requires a sub-stantial outlay. Second, SPHMprogram results have been incon-sistent. Tales abound of equipmentbought but not used because it’stoo much trouble to fetch it fromthe closet, or because no one canlocate the necessary sling. Finally,SPHM program value costs areclear but benefits are hard toquantify.This article addresses these is-

sues by laying out the basic ele-ments of a successful SPHM pro-gram. These elements can bedivided into two broad cate-gories—determining out what youneed and making it happen. (SeeSimplifying the equation.)

Determining what youneed Start by estimating how many pa-tients on a given unit are totally


Elements of asuccessful safe patienthandling and mobilityprogramProgram success hinges on leaders’ and nurses’commitment. By John Celona, BS, JD

dependent on the nurse to lift ormobilize them. Then estimate howmany patients on the unit needpartial assistance with mobility ac-tivities, such as toileting or movingfrom bed to chair.For each patient category, esti-

mate the numbers and types ofmobilization each will need overthe course of an average stay.Types of mobilization includeboosting, turning, moving frombed to chair, assisting with ambu-lation, and so on. For these cate-gories and frequencies of mobi-lization tasks, figure out how muchand what types of equipment areneeded to eliminate variation inpractice and standardize how tosafely accomplish the task.In practice, most people devel-

op rules of thumb or use intuitionand experience rather than calcu-lating the four types of informationdescribed above. Also, vendors ofhandling and mobility equipmenthave experience in determining re-quired equipment. I’ve observed three different ap-

proaches to supplying the equip-ment needed to mobilize patients:• installing overhead lifts—ceilingtracks to which lifting slings areattached

• using portable lifts—floor-mounted structures for mobiliz-ing patients that can be movedaround as needed

• going the “equipment light”route—using a low-tech systemthat combines slide sheets, limblifters, and slide boards to mo-bilize patients instead of usingceiling-mounted or portablefloor lifts.Any of these approaches will

work to mobilize patients andreduce caregiver injuries if thehealthcare organization can getstaff to use them.

Compliance rateWhen designing and implement-ing an SPHM program, the compli-ance rate is the key variable anorganization is driving. The com-pliance rate is defined as the num-ber of mobilizations for whichSPHM equipment is actually used,divided by the number of mobiliza-tions for which it should be used.The compliance rate is critical be-cause it drives program benefits.A rate of 0% means the equipmentis never used and isn’t producingbenefits. A rate of 100% meanscaregivers are using the equipmentevery time they should be, creat-ing the maximum possible valuefrom the SPHM program.A small level of investment in

SPHM equipment makes little dif-ference in the compliance rate orprogram results. Without the rightamount or type of equipment

available, an organization can’tstandardize a new mobilizationprocess, so the equipment getsused for relatively few mobiliza-tions. With higher investment lev-els, using the equipment becomespart of caregivers’ routine, so thecompliance rate goes up.

Making it happenA successful SPHM program re-quires leadership commitment,nursing commitment, and an edu-cation and training plan. Leader-ship commitment is needed to ap-prove SPHM equipment purchase,design of training plans, and timeaway from duty for training. Suchcommitment is best obtained bycreating a business case to de-scribe the proposed SPHM pro-gram and quantify its total costsand benefits, including return oninvestment (ROI). (See “Making


Simplifying the equation This diagram shows in broad strokes how a healthcare organization can develop and imple-ment a safe patient handling and mobility program.

Determining what you need

the business case for a safe pa-tient handling and mobility pro-gram” in this report.) The entire nursing staff must be

committed, especially the chiefnursing officer, who has to ap-prove the time required for stafftraining and education. Nursingcommitment should be easy to getif the business case has identifiedthe program’s potential for reduc-ing caregiver injuries, increasingstaff availability for duty due to in-jury reduction, and improvingnursing retention and satisfaction. An education and training plan

addresses which SPHM technolo-gy is purchased, installed, and de-ployed and when and where it’sinstalled and deployed; who getstrained, at what level of training,and when training takes place;and how program data will betracked and monitored to deter-mine if it’s achieving the intendedresults. In many cases, training ac-counts for half or more of totalSPHM program costs.

Levels of expertiseThree levels of expertise in usingSPHM equipment and methods exist:• A facility champion can “trainthe trainers” and aid programdesign and revision (adjustingthe deployed equipment ortraining if needed). To be effec-tive, this person needs both ex-tensive training and experience.

• A super user (such as a unitpeer leader at the VeteransHealth Administration) can trainother caregivers in the unit andanswer questions. Reaching thislevel of expertise requires in-depth training.

• A general caregiver knowshow to use SPHM technologyand methods but may not bequalified to train others.

Why feedback is importantFeedback is crucial for trackingand monitoring the SPHM programto determine how well it’s working.Successful programs use two typesof feedback. Compliance ratemonitoring gives some reassurancethat caregivers actually are usingSPHM technology when theyshould be. Such monitoring maybe done indirectly by requiring an-nual staff certification to ensurethey know how to use the equip-ment. Direct methods include ob-serving the unit to see if caregiversuse appropriate SPHM methods.Some newer types of equipmentcome with devices to measure howmany times they’re used.

Program result monitoring, onthe other hand, depends on SPHMprogram goals. These vary by facility but may include reducedcaregiver injuries from patienthandling, decreases in pressure ulcers and patient falls, increasedpatient and staff satisfaction, andimproved staff retention. The busi-ness case and ROI for the SPHMprogram should identify whichprogram results create the mostvalue. Methods for monitoringthese results should be created ifthey don’t already exist.Most SPHM programs monitor

workers’ compensation costs fromcaregiver injuries related to pa-tient handling. Usually, this neces-sitates connecting incidence dataon the types and causes of injuries(such as on the OccupationalSafety and Health Administration’sForm 300) with costs associatedwith those injuries (found in theworkers’ compensation system). Any equipment strategy (over-

head lifts, portable lifts, “equip-ment light” or a combination) candrive a high compliance rate andfavorable program results. But us-

ing more efficient lifting methodsand equipment might yield addi-tional program benefits from timesavings. Stanford University Med-ical Center compared the averagetime for a chair-to-bed transfer using ceiling lifts vs. portable lifts. On average, a ceiling-lifttransfer was completed before theportable-lift transfer even began.These data were used to justifyceiling lift installation in Stanford’snew hospital. Monitoring SPHM program re-

sults and comparing them againstthe potential results quantified inthe business case are crucial forensuring the program is workingas designed and the organizationis realizing the projected ROI.When results vary from the rangesidentified in the business case, thecause must be identified and re-medial action must be taken. Understanding and implement-

ing the essential elements of anSPHM program will help you en-sure that your organization’s pro-gram is successful and can trulyachieve better outcomes for care-givers and patients. 8

Selected referencesDepartment of Veterans Affairs, Veterans HealthAdministration. VHA Directive 2010-032. SafePatient Handling Program and Facility Design.June 28, 2010. www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2260. AccessedJuly 3, 2014.Hodgson MJ, Matz MW, Nelson A. Patient han-dling in the Veterans Health Administration: fa-cilitating change in the health care industry. JOccup Environ Med. 2013;55(10):1230-7.

John Celona is a principal at Decision AnalysisAssociates, LLC, in San Carlos, California. He isthe author of Decision Analysis for the Profes-sional, 4th ed.


A valuable resource for establishing asafe patient handling and mobility pro-gram is Implementation Guide to the SafePatient Handling and Mobility Interprofes-sional National Standards, available atwww.nursesbooks.org/SPHM-Package.

Early mobility in the intensivecare unit (ICU) is critical to apatient’s short- and long-term

recovery. Studies show early mo-bility programs result in more venti-lator-free days, fewer skin injuries,shorter ICU and hospital stays, re-duced delirium duration, and im-proved physical functioning.But accomplishing early mobili-

ty requires significant coordina-tion, commitment, and physical ef-fort by the multidisciplinary team.How do we balance the benefitsof early mobilization against thepotential risk of staff or patient in-jury during the mobilization activi-ty? Part of the solution to ensuringsafe mobilization of critically illpatients is to view mobilizationalong a continuum based on pa-tient readiness, progression basedon goals, strategies to preventcomplications, and assessment ofactivity tolerance. This view keepssafety at the forefront.Within the ICU, barriers to ear-

ly mobility may include clinicians’knowledge deficits and fears, in-sufficient human and equipment

resources, patients’ physiologic in-stability, lack of emphasis on thevalue and priority of mobilizingpatients, and the ICU culture relat-ed to mobility. A 2014 internation-al survey of early mobilizationpractices in 833 ICUs found only27% had formal early mobilityprotocols, 21% had adopted mo-


Transforming theculture: The key tohardwiring earlymobility and safepatient handlingCulture change requires deliberate focus, staffeducation, and full engagement. By Kathleen M. Vollman, MSN, RN, CCNS, FCCM, FAAN, and Rick Bassett, MSN, RN, APRN, ACNS-BC, CCRN

bility practices without a protocol,and 52% hadn’t incorporated ear-ly mobility into routine care prac-tices. Barriers to implementation ofmobility initiatives included com-peting staffing priorities, insuffi-cient physical therapy staff, andconcern about patient and care-giver injury. The study found that astandardized protocol may pro-mote successful implementation ofan early mobility program.

Importance of a culturechange Sustaining any clinical improve-ment initiative requires an organi-zational culture change. Baselineassessment of the current culture aswell as early engagement of teammembers is the starting point. In2012, the authors led a VHA, Inc.critical care improvement team col-laborative of 13 ICUs from eightorganizations to implement safeand effective early patient mobilityin the ICU. Efforts focused onelements central to sustainablechange. First, team membersacquired key knowledge to under-stand why ICU mobility is impor-tant. Next, strategies for organiza-tional, leadership, and clinical staffengagement were discussed. Topromote the transition in practiceand the required culture change,ICU clinicians needed guidance.An organizational developmenttool was designed to help teamscreate an effective culture change.Although it was adapted specifical-ly to integrate with early patientmobility efforts in the ICU, this toolcan be applied to other settings.(See Learning progression for pa-tient mobility.)Three elements are crucial to

successfully implementing and sus-taining an improvement initiative:• Team members must understandand be able articulate what’sbeing proposed. To help themunderstand, they must receiveevidence-based literature andother relevant information.

• Team members must grasp whythe initiative is important to thepatient, themselves, and the or-ganization. Clinicians typicallyrespond favorably to changewhen they can connect it toreal impacts.

• The leader of the initiative must


Learning progression for patient mobility This diagram shows the four stages of staff learning regarding early patient mobility andsafe patient handling.

1

2 3

4

Right type of support, right time

To progress to the next level: Educate regardingevidence and progressive mobility continuum, use scenarios to build problem-solving skillsaround contingencies and high-risk patients.Leverage physical therapy in teaching nursesspecific skills.

STAGE 2: Conscious,unskilled

“I care now, but I feel clueless.”

• Staff are receptive toprogressive mobility concepts.

• Staff may be fearful of process and risks.

STAGE 3: Conscious,skilled

“I know but need support andextra time to execute.”

• Staff are ready to put progressivemobility into daily practice.

• Staff are motivated by sense ofefficacy and success/failureexperiences.

STAGE 1: Subconscious,unskilled

“I don’t know why I should careabout patient mobility.”

• Staff are unclear on purposebehind progressive mobility.

• Old paradigms andassumptions around immobilityare present.

STAGE 4: Subconscious,skilled

“I am skilled and can help others.”

• Staff skillfully put progressivemobility into daily practice.

• Further staff learning isenhanced by teaching andmentoring others.

To support process:educate staff regardinghow to effectivelymentor, coach. Exapnd role:storyteller, champion,and mentor.

SkilledUnskilled

Cons

cious

Subc

onsc

ious

Cons

cious

ness

© 2010 Brandwene Associates

To progress to the next level:Overcome staff's emotional andintellectual barriers by usingstorytelling and evidence,engage in discussions andaddress positive/negative aspectsof immobility. Include sources(evidence and experience)outside the organization as well.

To progress to the next level:Coach and mentor staff duringexecution. Encourage throughfailure experiences (such aspatient not tolerating mobility),and build sense of competenceby recognizing successes.

define the role of each teammember and discipline. Under-standing team roles creates asolid platform on which the cul-ture change builds.

Four stages of learningTo learn a skill or concept, a per-son progresses through fourstages, according to a learningmodel attributed to AbrahamMaslow. This model can be ap-plied to clinicians learning aboutsafe patient handling and mobility(SPHM).

Stage 1: Subconscious,unskilled In this stage, team members areunaware of how little they knowand don’t realize a change is nec-essary. Also, they may have fearsand misconceptions about thechange. For example, some criti-cal care clinicians believe reposi-tioning or mobilizing critically illpatients threatens the security ofvital tubes and lines. But with theproper knowledge, training, andresources, staff can mobilize andreposition ICU patients safely with-out jeopardizing tubes and lines.In one study, 1,449 activity events(such as sitting up in bed, sittingin a chair, and ambulating) wereperformed with mechanically venti-lated patients; fewer than 1% ex-perienced adverse events. As partof the culture change, misconcep-tions about SPHM need to be ad-dressed through education andcoaching. Once the purpose ofSPHM is defined clearly and mis-conceptions have been addressed,team members are ready to moveon to stage 2.

Stage 2: Conscious,unskilled In the conscious, unskilled stage,

team members understand whySPHM is important but don’tknow how to accomplish it. Al-though open to new learning,

they may have fears about specif-ic processes or actions involvedin patient mobilization. For in-stance, they may fear certain


Decision tree for mobilizing hemodynamicallyunstable patients This diagram helps clinicians determine whether and when an intensive care unit patient isready to begin mobility activities.

Begin in-bed mobility techniquesand progress to out-of-bedmobility as the patient tolerates.

No

No

No

No

Screen for mobility readinesswithin 8 hours of admission to theICU and daily and initiate in-bedmobility strategies as soon aspossible.

Is the patient hemodynamicallyunstable with manual turning?• O2 Sat ≤ 90% • New-onset cardiac arrhythmias

or ischemia• HR < 60 or >120• MAP < 55 or >140• SBP < 90 or >180• New or increasing vasopressor

infusion

Yes

Begin in-bed mobility techniquesand progress to out-of-bedmobility as the patient tolerates.

Yes

Yes

Yes

Allow the patient a minimum of10 minutes of rest betweenactivities and then try again todetermine tolerance.

Is the patient stillhemodynamically unstable afterallowing a 5- to 10-minuteadaptation after position changebefore determining tolerance?

Have activities been spacedsufficiently to allow rest?

Has the manual position turn orhead-of-bed elevation beenperformed slowly?

Initiate continuous lateralrotation therapy via a protocol totrain the patient to tolerateturning.

Try the position turn or head-of-bed maneuver slowly to allowadaptation of cardiovascularresponse to the inner-earpostiion change.

KeyHR: heart rateICU: intensive care unitMAP: mean arterial pressureSBP: systolic blood pressureO2 sat: oxygen saturation

© 2012 Kathleen Vollman-Advancing Nursing LLC.

types of mobilization activitiescan cause hemodynamic instabili-ty. Education and practical appli-cation experiences can help themovercome this fear. Another wayeducators can break through suchbarriers is to use a decision treethat incorporates the latest scien-tific knowledge to help cliniciansminimize the hemodynamic im-pact or retrain patients to toleratemovement. (See Decision tree formobilizing hemodynamically un-stable patients.) A critical resource used with

the VHA team was a nurse-driven,evidence-based multidisciplinaryprogressive mobility continuumtool that addresses mobility phas-es and corresponding interven-tions. The team received educationon the tool and how to apply it in

practice. The tool provided a visu-al foundation to guide safe mobili-ty practices, create consistency,promote team communication, andenhance processes.Numerous studies show that ed-

ucation, skill building, and proto-cols may not be enough to createsustainable change. Using strate-gies to evaluate available nursingresources and systems that canproduce change makes it easierfor clinicians to provide the rightcare for the right patient at theright time while balancing theseneeds against caregivers’ needsfor safety.

In bed and out-of-bedactivitiesStrategies to promote patient andcaregiver safety during mobiliza-tion can be divided into two basiccategories—those used when thepatient is in bed and those usedwhen the patient is out of bed. In-bed mobility encompasses reposi-tioning activities, lateral-rotationtherapy, tilt-table exercises, andbed-chair sitting. Modern critical-care beds should be capable of ro-tating the patient continuously, cre-ating a tilt table through the use ofa reverse Trendelenburg positionand an adjustable footboard, pro-gressing the body through thehead elevation–foot down positionto a chair, and ultimately assistingthe patient with standing. Thesefeatures reduce the risk of patientand caregiver injury and make iteasier to perform mobility actions.For in-bed repositioning from

side to side and moving up, usinga breathable glide sheet and spe-cially designed foam wedgeshelps reduce shear and friction forthe patient and help prevents in-juries to caregivers because theyrequire a pulling rather than liftingmotion. In one study, implementa-tion of this turn-and-position systemreduced hospital-acquired pres-sure ulcers by 28% and reducedstaff injuries by 58%. Lifts can beused for some in-bed mobility ac-tivities and are effective duringambulation and the transition fromin-bed to out-of-bed activities.

Stage 3: Conscious, skilledStage 3 learning focuses on imple-menting the change, with attentionto fine-tuning the process. Coach-ing, mentoring, and maintainingengagement are critical. In previ-ous stages, much effort was ex-pended in educating and training

staff. During the transition fromstage 3 to stage 4, the skills andknowledge required for the SPHMinitiative must become “hard-wired” or ingrained into care-givers’ subconscious. This requiresdeliberate, focused energy on con-tinued engagement. However,staff energy, resource availability,and competing priorities may posebarriers to sustaining the change. Throughout stage 3, positive

feedback, motivation, and sharingof successes and challenges areimportant for driving continual im-provement and culture change.These goals can be accomplishedin various ways. Here are someexamples: • Networking with other organi-zations in various stages of thepractice change can be ex-tremely useful. It allows collabo-rative identification and sharingof challenges, struggles, effec-tive strategies, and success sto-ries. This process creates syner-gistic energy among the teammembers, helping to motivatethem and accelerate thechange.

• Within the VHA mobility collab-orative network, teams sharedreward strategies. One teamgave out M&Ms® when “caughtin the act” of Moving and Mo-bilizing patients. Such momentspresent crucial coaching oppor-tunities. For example, after amobility event, staff can huddlebriefly to discuss the event andwhat, if any, improvementscould be made to make theprocess more effective.

Stage 4: Subconscious,skilled During this stage, the practice andculture changes are well on their


(continued on page 25)

In-bed mobility encompasses

repositioningactivities lateral-rotation

therapy, tilt-table exercises, and

bed-chair sitting.

The intense focus on safe pa-tient handling and mobility(SPHM) in acute and long-

term care has yielded a valuablebenefit for nurses and other health-care workers—a decrease in stafflifting injuries for the first time in30 years. Nonetheless, nurses stillsuffer more musculoskeletal disor-ders than employees in the manu-facturing, construction, and ship-building industries.Many employers and nurses be-

lieve lifting injuries can be pre-vented by using proper body me-chanics and that lifting equipmentis warranted only for obeseadults. But the evidence contra-dicts this notion. The National In-stitute of Occupational Safety andHealth calculates maximum loadsfor manual lifting, pushing,pulling, and carrying using arange of variables. Typically, amaximum load for a box with han-dles is 51 lb (23 kg)—lower whenthe lifter has to reach, lift near thefloor, or assume a twisted or awk-ward position. Of course, patientsdon’t come in simple shapes orhave handles. They may sit or liein awkward positions, move unex-pectedly, or have wounds or de-vices that interfere with lifting. Al-though proper body mechanicsand good lifting technique are im-portant, they don’t compensate for

most patients’ weight.A patchwork of regulations with-

out teeth contributes to a hazardousenvironment for caregivers andpatients. Congress passed the er-gonomic standard of the Occupa-tional Safety & Health Administra-tion in 2000 but rescinded it in2001 before the regulations couldtake effect. Only 10 states havelaws requiring comprehensiveSPHM programs, typically targetingacute and long-term care settings.

ANA standardsThe American Nurses Association(ANA) recognized the need for astandard of care that applies to allhealthcare disciplines and encom-passes the entire continuum of care.In 2012, ANA convened an inter-professional group of subject matter

experts to develop standards. Par-ticipants included representatives ofpatients; nursing; surgery; therapy;biomedical engineering; risk man-agement; architecture; law; acute,long-term, home health, and hos-pice care; the military; Departmentof Defense; certain governmentagencies; vendors; and profession-al associations.In 2013, ANA published Safe

Patient Handling and Mobility: In-terprofessional National StandardsAcross the Care Continuum. Previ-ous documents referred to safe pa-tient handling and movement. Theworkgroup changed the terminolo-gy from movement to mobility todistinguish patient-initiated mobilityfrom movement accomplished byothers. Also, nurses use the wordmobility differently than physical or


Standards to protectnurses from handling andmobility injuriesLearn about ANA standards that help safeguard both nurses and patients. By Amy Garcia, MSN, RN, CAE

occupational therapists. The termi-nology change is designed toalign our practices with patients’needs and highlight new researchon the importance of early andprogressive mobility in the inten-sive care unit. The workgroup alsochose the term technology to de-scribe all lifts, slings, slide sheets,computer programs, and otheritems used to promote patient mo-bility. It decided that the termhealthcare recipient is more inclu-sive than patient for general use.

A closer look at thestandards The eight ANA standards arecomplemented by substandards,examples, resources, and metricsfor evaluation.

Standard 1: Establish a cultureof safety. This standard calls forthe employer to establish a com-mitment to a culture of safety. Thismeans prioritizing safety overcompeting goals in a blame-freeenvironment where individuals canreport errors or incidents withoutfear. The employer is compelled toevaluate systemic issues that con-tribute to incidents or accidents.The standard also calls for safestaffing levels and improved com-munication and collaboration.Every organization should have aprocedure for nurses to reportsafety concerns or refuse an as-signment due to concern about pa-tients’ or their own safety.

Standard 2: Implement and sus-tain an SPHM program. This stan-dard outlines SPHM program com-ponents, including an assessment,written program, funding, andmatching the program to the spe-cific setting. Evaluating the physi-cal requirements of a task or role

is an important step toward mini-mizing risk to patients and nurses.

Standard 3: Incorporate er-gonomic design principles to pro-vide a safe care environment.This standard is based on the con-cept of prevention through design,which considers the physical lay-out, work-process flow, and use oftechnology to reduce exposure toinjury or illness. Healthcare facili-ties should consider diverse per-spectives, including those of nurs-es and therapists, when planningfor construction or remodeling.

Standard 4: Select, install, andmaintain SPHM technology. Thisstandard provides guidance in se-lecting, installing, and maintainingSPHM technology. It emphasizesthe importance of investing in ap-propriate amounts and types ofSPHM technology to meet theneeds of patients in the organiza-tion’s specific environment.

Standard 5: Establish a systemfor education, training, and main-taining competence. This stan-dard outlines employee (and vol-unteer) training and educationneeded to participate in the SPHMprogram. Education should bemultidisciplinary and include docu-mented demonstration of compe-tency before the employee usesSPHM technology.

Standard 6: Integrate patient-cen-tered SPHM assessment, plan ofcare, and use of SPHM technolo-gy. This standard focuses on the pa-tient’s needs by establishing assess-ment guidelines and developing anindividual plan of care. It also ad-dresses the need to establish an or-ganizational policy on the rights ofpatients or family members who in-

sist on manual handling. It outlinesthe importance of using SPHM tech-nology in a therapeutic manner,with the goal of promoting inde-pendence. Nurses working in reha-bilitation or assisted-living settingsmay believe using lifts or other tech-nology limits the patient’s independ-ence, but selecting SPHM techn-ology to be used in a progressivemanner can provide support and asense of safety as the patient gainsor regains independent movement.For example, a patient may needfull-body lift technology immediatelyafter surgery, but then progress to asit-to-stand lift for bedside toiletingand then to technology that sup-ports ambulation.

Standard 7: Include SPHM inreasonable accommodation andpost-injury return to work. Thisstandard promotes an employee’searly return to work after an injuryand use of differently abled work-ers through a comprehensiveSPHM program.

Standard 8: Establish a compre-hensive evaluation system. The fi-nal standard calls for a compre-hensive evaluation system for eachSPHM program component, withremediation of deficiencies.The appendix of Safe Patient

Handling and Mobility providesan extensive list of resources formeeting each standard. To orderthe ANA book and the accompa-nying Implementation Guide to theSafe Patient Handling and Mobili-ty Interprofessional National Stan-dards, visit www.nursesbooks.org/SPHM-Package. 8

Visit www.AmericanNurseToday.com/Archives.aspx for a list of selected references.

Amy Garcia is chief nursing officer for CernerClairvia, specializing in workforce issues and wasthe technical writer for the SPHM standards.


A patient’s mobility status af-fects treatment, handlingand transfer decisions, and

potential outcomes (includingfalls). Hospital patients spend mostof their time in bed—sometimescoping with inadvertent negativeeffects of immobility. Assessing apatient’s mobility status is crucial,especially for evaluating the riskof falling. Yet no valid, easy-to-administer bedside mobility as-sessment tool exists for nursesworking in acute-care settings.Various safe patient handling

and mobility (SPHM) technologiesallow safe transfer and mobiliza-tion of patients while permittingmaximum patient participationand weight-bearing (if indicated).A mobility assessment helps identi-fy the SPHM technology needed toensure safe activities while takingthe guesswork and uncertainty outof deciding which SPHM technolo-gy is right for which patient.Because mobility is so impor-

tant during hospitalization, mem-bers of a Banner Health multidisci-plinary SPHM team determinednurses should take a more activerole in assessing and managingpatient mobility. We concluded itwas crucial to develop and vali-date a tool that nurses can useeasily at the bedside to assess apatient’s mobility level and the

need for SPHM technology. Forboth patient and staff safety, a pa-tient’s mobility level must be linkedwith use of SPHM technology.When used consistently, appropri-ate technology reduces the risk offalls and other adverse patient out-comes associated with immobility.(See The link between patient im-mobility and staff injuries.)

Communication barriersHistorically, mobility assessments

and management have been un-der the purview of physical thera-pists (PTs) through consultations.But the entire healthcare teamneeds to address patient mobility.Nurses conduct continual surveil-lance of patients and their pro-gress, but typically they haven’tperformed consistent, validatedmobility assessments. Instead,they’ve relied on therapy servicesto determine the patient’s mobilitylevel and management.


Implementing amobility assessmenttool for nurses A nurse-driven assessment tool reveals the patient’smobility level and guides SPHM technology choices. By Teresa Boynton, MS, OTR, CSPHP; Lesly Kelly, PhD, RN; and Amber Perez, LPN, BBA, CSPHP

In many cases, though, a PT’sassessment doesn’t translate tomeaningful actionable items fornurses. What’s more, PTs don’t al-ways adequately communicate apatient’s SPHM needs to otherhealthcare team members. For ex-ample, confusion surrounds termi-nology typically used by PTs, suchas numeric mobility levels (1+, 2+,indicating a one-person or two-person assist, respectively) as wellas ranges (minimum, moderate, ormaximum assist by one or morehealthcare workers). Also, PTs areconsulted only for a limited num-ber of patients and at differentpoints during the hospital stay.Nurses, for their part, aren’ttrained in skilled therapy tech-niques and may be ill prepared tomobilize patients safely duringroutine daily activities.In addition to communicating

potential risk to other healthcareteam members, mobility assess-ment can identify technology need-

ed to perform SPHM. Especially ifPTs aren’t available, nurses mustrely on their own judgment tomove and mobilize patients safely.But they may be uncertain as towhich equipment to use for whichpatients. While a total lift may beused with many patients, such alift doesn’t maximize the patient’smobility potential.

Current mobilityassessment options Although tools to assess mobilityand guide SPHM technology selec-tion are used in hospitals, their val-ue for the bedside nurse may belimited or inappropriate with manypatients in acute-care settings.SPHM algorithms from the Depart-ment of Veterans Affairs have beenvaluable as training and decision-making tools in determining whichSPHM technology to consider forspecific tasks. But these can behard to use at the bedside. Also,they assume the patient’s mobilitystatus is known and don’t providequick guidance in determining apatient’s overall mobility level.(See Limitations of common mobili-ty assessment tools.)


The link between patient immobility and staffinjuries Patient immobility poses the risk of injury to healthcare workers. Nurse workloads continue torise as patient acuity levels increase and hospital stays lengthen. This situation increases pa-tients’ dependence on nurses for assistance with their mobility needs.

What’s more, nursing staff frequently rely on the patient or a family member to report thepatient’s ability to stand, transfer, and ambulate. But this information can be unreliable, espe-cially if the patient has cognitive impairment related to the diagnosis or medications or if he orshe has experienced unrecognized decreased mobility and deconditioning from the disease orinjury that necessitated hospitalization.

To decrease the risk of caregiver injury, nurses should assess patient mobility and use safepatient handling and mobility (SPHM) technology.

Limitations of common mobilityassessment tools Several of the mobility assessment tools discussed below already are in use, buteach has certain drawbacks.

The Timed Get Up and Go Test starts by havingthe patient stand up from an armchair, walk 3meters, turn, walk back to the chair, and sit down.But it gives no guidance on what to do if the pa-tient can’t maintain seated balance, bear weight,or stand and walk.

The Quick 5 Bedside Guide tool, developed bya registered nurse and physical therapist (PT),was the basis for a research project on what be-came known as the Quick 3. This tool takes thepatient through three functional tasks but doesn’tfully address patient limitations. Nor does it rec-ognize weight-bearing limitations or address theissues or abilities of an ambulatory patient. Also,it provides only limited recommendations forSPHM technology.

The Egress test, also developed by a PT, is usedin hospital settings. It starts with the patient per-forming three repetitions of sit-to-stand, at thebedside, marching in place, and advance step andreturn with each foot. But it’s tailored to PTs anddoesn’t address how the patient performs bed mobility or comes to a standing po-sition. Also, it gives only limited guidance for nurses on use of SPHM technologyand isn’t appropriate for certain patients (such as those unable to weight bear onone or both legs).

Nurses aren’t trained in

skilled therapytechniques and may be ill

prepared to mobilize patients

safely during routine daily

activities.

Banner MobilityAssessment Tool At Banner Health, we developedthe Banner Mobility AssessmentTool (BMAT) to be used as a

nurse-driven bedside assessmentof patient mobility. It walks thepatient through a four-step func-tional task list and identifies themobility level the patient can

achieve (such as mobility level1). Then it guides the nurse to therecommended SPHM technologyneeded to safely lift, transfer,and mobilize the patient. (See


Banner Mobility Assessment Tool for nurses Nurses have found that the Banner Mobility Assessment Tool (BMAT) is an effective resource for performing a bedside assessment of patientmobility.

Fail = Choose most appropriateTest Task Response equipment/device(s) Pass

Assessment Sit and shake: From a semi-reclined Sit: Patient is able to follow MOBILITY LEVEL 1 Passed Assessment Level 1 position, ask patient to sit upright and commands, has some trunk strength; • Use total lift with sling and/or Level 1 = Proceed Assessment of: rotate* to a seated position at side caregivers may be able to try weight- repositioning sheet and/or straps. with Assessment • Trunk strength of bed; may use bedrail. bearing if patient is able to maintain • Use lateral transfer devices, such Level 2.• Seated balance Note patient’s ability to maintain seated balance longer than 2 minutes as roll board, friction-reducing

bedside position. (without caregiver assistance). device (slide sheets/tube), or Ask patient to reach out and grab your Shake: Patient has significant upper air-assisted device.hand and shake, making sure patient body strength, awareness of body in Note: If patient has strict bed restreaches across his/her midline. space, and grasp strength. or bilateral non-weight-bearing

restrictions, do not proceed with the assessment; patient is MOBILITY LEVEL 1.

Assessment Stretch and point: With patient in Patient exhibits lower extremity MOBILITY LEVEL 2 Passed Assessment Level 2 seated position at side of bed, have stability, strength and control. • Use total lift for patient unable to Level 2 = Proceed Assessment of: patient place both feet on floor (or stool) May test only one leg and weight- bear on at least one leg. with Assessment • Lower extremity with knees no higher than hips. proceed accordingly (e.g., • Use sit-to-stand lift for patient who Level 3.

strength Ask patient to stretch one leg and stroke patient, patient with can weight-bear on at least one leg.• Stability straighten knee, then bend ankle/flex ankle in cast).

and point toes. If appropriate, repeat with other leg.

Assessment Stand: Ask patient to elevate off bed or Patient exhibits upper and lower MOBILITY LEVEL 3 Passed Assessment Level 3 chair (seated to standing) using assistive extremity stability and strength. • Use non-powered raising/stand aid; Level 3 AND no Assessment of: device (cane, bedrail). May test with weight-bearing default to powered sit-to-stand lift assistive device• Lower extremity Patient should be able to raise buttocks on only one leg and proceed if no stand aid is available. needed = Proceed

strength for off bed and hold for a count of five. May accordingly (e.g., stroke patient, • Use total lift with ambulation with Assessment standing repeat once. patient with ankle in cast). accessories. Level 4.

Note: Consider your patient’s cognitive If any assistive device (cane, • Use assistive device (cane, walker, Consult with ability, including orientation and CAM walker, crutches) is needed, crutches). physical therapist assessment if applicable. patient is Mobility Level 3. Note: Patient passes Assessment Level when needed

3 but requires assistive device to and appropriate. ambulate or cognitive assessmentindicates poor safety awareness; patient is MOBILITY LEVEL 3.

Assessment Walk: Ask patient to march in place at Patient exhibits steady gait and good MOBILITY LEVEL 3 MOBILITY LEVEL 4Level 3 bedside. Then ask patient to advance balance while marching and when If patient shows signs of unsteady gait MODIFIED Assessment of: step and return each foot. stepping forward and backward. or fails Assessment Level 4, refer INDEPENDENCE• Standing balance Patient should display stability while Patient can maneuver necessary turns back to MOBILITY LEVEL 3; Passed = No • Gait performing tasks. for in-room mobility. patient is MOBILITY LEVEL 3. assistance needed

Assess for stability and safety awareness. Patient exhibits safety awareness. to ambulate; use your best clinical judgment to determine need for supervision during ambulation.

Always default to the safest lifting/transfer method (e.g., total lift) if there is any doubt about the patient’s ability to perform the task.

Banner Mobility Assessment Toolfor nurses.)

Implementing BMATThe BMAT was created in our hos-pital’s electronic medical record(EMR) in a way that guides thenurse through the assessmentsteps. Patients are determined tohave a mobility level of 1, 2, 3,or 4 based on whether they passor fail each assessment level. Edu-cational tools and tip sheets areused to train nurses and supportstaff on what technology to consid-er for patients at each level.

Communication tools also areused. For instance, a sign outsidethe patient’s room indicates his orher mobility level, instantly tellinganyone passing by or entering ifthe patient can ambulate inde-pendently or if SPHM technologymust be used. To stay current onthe patient’s mobility status (for in-stance, at handoffs, after proce-dures, with medication changes,or after a potentially tiring therapysession), nurses are expected tocomplete the BMAT on admission,once per shift, and with the pa-tient status changes. The BMATalso is linked to Banner’s fall as-sessment risk in the EMR.Throughout BMAT implementa-

tion, we recognized that identify-ing a patient’s mobility level andfall risk score are pointless unless

appropriate interventions are im-plemented and the outcomes eval-uated. Nurses need to be empow-ered and able to recognize theconnection between these assess-ments and choice of interventions,including SPHM technology. Here’s an example of BMAT in

action at Banner: A 35-year-oldmale was admitted to a surgicalfloor late in the evening. He was6'2" tall and weighed 350 lb(158 kg). He didn’t want to use abedpan, but his nurse wasn’t com-fortable getting him up to use thebathroom because he hadn’t beenevaluated by physical therapy,and a PT wasn’t available in theevening. A nurse passing bywho’d used the BMAT (which had-n’t been formally rolled out Ban-ner-wide at that time) came in andassessed the patient; the assess-ment found him at mobility level 3.He was transferred to the toilet us-ing a nonpowered stand aid. Bothpatient and nurse were relievedand happy.

A step in the rightdirectionAs a quick bedside assessmenttool, the BMAT is a step in the rightdirection. It’s part of a broad pro-gram of increased staff awareness,education, and training around pa-tient assessments, preventing staffinjuries and patient falls, andachieving better patient outcomes.Initial evidence from a validationstudy completed at one Banner hos-pital supports the BMAT as a validinstrument for assessing a patient’smobility status at the bedside.As we work toward customizing

actions and interventions to meetindividual patient needs, we contin-ue to evaluate which additional as-sessment components or fall inter-ventions or precautions are needed

or require greater focus. Althoughwe know nurses should be more in-volved in assessing mobility thanthey have been historically, we rec-ognize the value of involving andcommunicating effectively with allmembers of a good interdiscipli-nary team to help reduce patientfalls and staff injuries caused bypatient handling. 8

Selected referencesDionne M. Practice Management: Stand and de-liver. Physical Therapy Products. March 2005.www.ptproductsonline.com/2005/03/stand-and-deliver/. Accessed June 30, 2014.

Hook ML, Devine EC, Lang NM. Using a com-puterized fall risk assessment process to tailorinterventions in acute care. In: Henriksen K, Bat-tles JB, Keyes MA, Grady ML, eds. Advances inPatient Safety: New Directions and AlternativeApproaches; vol 1. Assessment. AHRQ Publica-tion No. 08-0034. Rockville, MD: Agency for Healthcare Research and Quality; 2008.www.ncbi.nlm.nih.gov/books/NBK43610. Ac-cessed July 10, 2014.

Mathias S, Nayak US, Isaacs B. Balance in eld-erly patients: the “get-up and go” test. ArchPhys Med Rehabil. 1986;67(6):387-9.

Oliver D, Healey F. Falls risk prediction tools forhospital inpatients: do they work? Nurs Times.2009;105(7):18-21.

Oliver D, Healey F, Haines TP. Preventing fallsand fall-related injuries in hospitals. Clin GeriatrMed. 2010;26(4):645-92.

Nelson AL. Safe patient handling and move-ment: A guide for nurses and other health careproviders. New York, NY: Springer PublishingCompany, Inc.; 2006. www.springerpub.com/samples/9780826163639_chapter.pdf. Ac-cessed June 30, 2014.

Nelson A, Harwood KJ, Tracey CA, Dunn KL.Myths and facts about safe patient handling inrehabilitation. Rehabil Nurs. 2008;33(1):10-7.

Wright B, Murphy J. “Quick-5 Bedside” Guide.Franklin, MA: Liko, Inc.; 2005.

Teresa Boynton is an injury prevention andworkers’ compensation consultant, ergonomicsspecialist, and certified safe patient handlingprofessional for Risk Management at BannerHealth, Western Region, based in Greeley, Col-orado. Lesly Kelly is the RN clinical researchprogram director for Banner Good SamaritanMedical Center in Phoenix, Arizona. AmberPerez is a safe patient handling clinical con-sultant for Handicare North America based inPhoenix, Arizona.


To stay current on the patient’s

mobility status nurses are

expected to complete the BMAT on

admission, once per shift, and with

the patient status changes.

In hospital settings, where thehead of the bed (HOB) com-monly is elevated, gravity caus-

es patients to slide, or migrate,toward the foot of the bed. Nurs-es are well aware of this, asthey’re regularly required to pullpatients back toward the HOB ifthey can’t reposition themselves.

A 1995 study at one hospitalfound nurses pulled patients up inbed an average of 9.9 times pershift. More recent evidence sug-gests this activity may be evenmore common in some hospitalsand units.Studies show that pulling pa-

tients who’ve migrated in bed

carries an extremely high risk ofcaregiver injury. Less researchhas been done on the effects ofmigration on patients. This articledescribes how migration can af-fect patient outcomes, outlines rel-evant scientific evidence, and dis-cusses strategies for managingpatient migration.

The sliding patient:How to respond toand prevent migrationin bed Migration can cause negative patient outcomes andcaregiver injuries resulting from repositioning. By Neal Wiggermann, PhD


Negative effects ofmigration A 2013 study found that patientsin traditional hospital-bed designsmigrated about 13 cm (5") whenthe HOB was raised to 45 de-grees. Both bed movement andgravity cause patients to slidedown in bed over time if the HOBis kept elevated. Such migrationpresumably causes friction and

shear forces between the mattressand skin as the patient slidesagainst the bed surface. Althoughfriction and shear have beenlinked to pressure-ulcer formation,no research has evaluated whetherfriction and shear caused by mi-gration directly contribute to pres-sure-ulcer risk.As patients migrate toward the

foot of the bed, the torso eleva-

tion decreases. A pilot investiga-tion of 10 healthy subjects lyingwith the HOB at 30 degreesshowed their torso angle wasabout 30 degrees when properlyaligned with the hip indicator,compared to about 12 degreeswhen they migrated 23 cm (9")past the hip indicator.Positioning the HOB at or

above 30 degrees is intendedto reduce the risk of ventilator-associated pneumonia (VAP) be-cause torso elevation decreasesthe risk of aspirating gastric con-tents into the lungs. Once patientshave migrated farther down themattress, elevating the HOB mayno longer reduce aspiration riskbecause their torsos are flatter. Atthat point, if they’re not reposi-tioned, they may be at increasedrisk for VAP.When patients migrate down in

bed with the HOB up, they slideout away from the pivot of theHOB section and the lumbar spinegoes unsupported, causing kypho-sis. Kyphosis reduces lung capaci-ty, so respiratory function maydiminish in patients who’ve migrat-ed. Although the relationship be-tween kyphotic postures causedby migration and discomfort has-

n't been studied for hospital beds,it’s reasonable to expect migrationwould result in discomfort, espe-cially in patients with low backpain or disc herniation.

Responding to patientmigration To help prevent negative outcomesassociated with patient migration,be diligent in repositioning pa-tients who’ve migrated downward.But be aware that repositioning ismost likely to affect outcomes relat-ed to torso angle (such as VAP, re-duced lung capacity, and discom-fort)—not friction and shear linkedto pressure-ulcer development.Among patients unable to boost orreposition themselves in bed,those on mechanical ventilatorsand those with back pain may bemost in need of repositioning bythe nurse.Repositioning patients manual-

ly is associated with a high riskof musculoskeletal injury, so al-ways use repositioning aids forpatients unable to repositionthemselves. Using lift equipment,such as a ceiling-mounted or mo-bile lift, is the best way to reducehealthcare worker strain, accord-ing to the American Nurses Asso-ciation’s Safe Patient Handlingand Mobility: InterprofessionalNational Standards, which callsfor eliminating manual lifting inall healthcare settings.If lift equipment isn’t available,

use a friction-reducing sheet andplace the bed in the Trendelenburgposition (if the patient can tolerateit). If the patient is on an air sur-face, use the “max inflate” func-tion. Patients who can provide par-tial assistance should participate inmobilization by placing their feetflat on the mattress and “bridging”when being repositioned. The pa-


Considerations when purchasing hospitalbeds Before purchasing hospital beds, clinicians and hospital purchasing staff should evaluate rele-vant manufacturer claims and test data to determine how well the product performs to reducepatient migration. Keep the following points in mind.

• Migration test results may vary based on methodology, so be suspicious of marketingmaterials that don’t describe test methods.

• Consider the relevance of test conditions to their clinical application.

• Be aware that a proper experimental design can improve test result accuracy. For exam-ple, a laboratory motion-capture system produces less error than a tape measure, and alarge subject sample (10 or more) with subjects of varied heights and weights is more ac-curate than a small or homogenous sample.

• Make sure migration is reported with respect to the bed surface. Because the top sectionsof some hospital bed frames can move back relative to the floor, measuring migrationrelative to the floor rather than the bed surface can lead to the mistaken conclusion thata patient has migrated several inches less than he or she actually has.

Once patients have migratedfarther down the mattress,

elevating the HOB may no

longer reduce aspiration risk.

tient also may pull on tractionequipment, a trapeze bar, or thebed side rails, if available. However, be aware that any

method that involves manual liftingcan cause injury to the nurse. Oneresearcher found that based onthe postures adopted when han-dling patients, caregivers who liftwith forces above 16 kg (35 lb)are at increased risk of injury. Themost effective way to prevent self-injury when repositioning patientsis to use a ceiling-mounted or mo-bile lift. An air-assisted lateraltransfer device also can be usedto reposition the patient up in bed.

Preventing migrationDespite the impact of migration onpatients and caregivers, little re-search exists on how to prevent it.The bed’s contribution to migrationhas been investigated in laborato-ry studies, but patient movementhas yet to be studied.To limit migration when articu-

lating the bed, use auto-contour (aknee gatch that rises automaticallyand simultaneously as the HOBrises) to reduce migration by up to2.5 cm (1"). If the bed doesn’thave auto-contour, raise the kneegatch before raising the HOB. Be-sides limiting migration from bedarticulation, keeping the patient’sknees raised also may help limitmigration over time. Of course,these strategies can be used onlyif the patient can tolerate kneebending.Design of the bed-frame articu-

lation seems to have an even big-ger effect than auto-contour on theamount of patient migration. Forexample, across three differentbed-frame designs, mean cumula-tive movement (total amount ofsliding when raising and loweringthe HOB) ranged from 13 to 28

cm (5" to 11"). Most likely, migra-tion caused by bed movement willcontinue to decrease as manufac-turers develop beds more compati-ble with the changing geometry ofthe patient as the HOB rises. (SeeConsiderations when purchasinghospital beds.)More research is needed to

confirm indications that patientmigration toward the foot of thebed increases pressure-ulcer andVAP risk, causes patient discom-fort, and reduces lung capacity.Many tools are available to helpnurses safely reposition patientswho’ve migrated. Using auto-contour when raising the HOB orthe knee gatch may help preventmigration or slow its rate. Designof the bed’s articulation also af-fects the distance that a patientmigrates. 8


Bakker EW, Verhagen AP, van Trijffel E, LucasC, Koes BW. Spinal mechanical load as a riskfactor for low back pain: a systematic review ofprospective cohort studies. Spine (Phila PA1976). 2009;34(8): E281-93.

Bartnik LM, Rice MS. Comparison of caregiverforces required for sliding a patient up in bedusing an array of slide sheets. WorkplaceHealth Saf. 2013;61(9):393-400.

Drakulovic MB, Torres A, Bauer TT, et al.Supine body position as a risk factor for noso-comial pneumonia in mechanically ventilatedpatients: a randomised trial. Lancet.1999;354(9193):1851-8.

Eriksen W, Bruusgaard D, Knardahl S. Work

factors as predictors of intense or disabling lowback pain; a prospective study of nurses’ aides.Occup Environ Med. 2004;61(5):398-404.

Kotowski SE, Davis KG, Wiggermann N,Williamson R. Quantification of patient migra-tion in bed: catalyst to improve hospital bed de-sign to reduce shear and friction forces and nurs-es’ injuries. Hum Factors. 2013;55(1):36-47.

Lin F, Parthasarathy S, Taylor SJ, et al. Effect ofdifferent sitting postures on lung capacity, expi-ratory flow, and lumbar lordosis. Arch PhysMed Rehabil. 2006;87(4):504-9.

Marras WS, Davis KG, Kirking BC, Bertsche PK.A comprehensive analysis of low-back disorderrisk and spinal loading during the transferringand repositioning of patients using differenttechniques. Ergonomics. 1999;42(7):904-26.

Mehta RK, Horton LM, Agnew MJ, NussbaumMA. Ergonomic evaluation of hospital bed de-sign features during patient handling tasks. Int JInd Ergon. 2011;41(6):647-52.

Metheny NA, Davis-Jackson J, Stewart BJ. Effec-tiveness of an aspiration risk-reduction protocol.Nurs Res. 2010;59(1):18-25.

Michel DP, Helander MG. Effects of two types ofchairs on stature change and comfort for indi-viduals with healthy and herniated discs. Er-gonomics. 1994;37(7):1231-44.

Poole-Wilson T, Davis K, Daraiseh N, KotowskiS. Documenting the amount of manual handlingperformed by nurses in a hospital setting. Pro-ceedings of 2014 Symposium on Human Fac-tors and Ergonomics in Health Care: Leadingthe Way. Chicago, IL: The Human Factors andErgonomics Society; 2014.

Skotte J, Fallentin N. Low back injury risk duringrepositioning of patients in bed: the influence ofhandling technique, patient weight and disabili-ty. Ergonomics. 2008;51(7):1042-52.

Vasiliadou A, Karvountzis GG, Soumilas A,Roumeliotis D, Theodosopoulou E. Occupationallow-back pain in nursing staff in a Greek hospi-tal. J Adv Nurs. 1995;21(1):125-30.

Waters TR. When is it safe to manually lift a pa-tient? Am J Nurs. 2007;107(8):53-9.

Wiggermann NE, Vangilder C, Davis K. Patientmigration toward the foot of the bed affects tor-so angle. 2014 National Teaching Institute Re-search Abstracts. http://ajcc.aacnjournals.org/content/23/3/e19.full?sid=039ddc07-4db1-4bc4-aaca-5855cc684831#sec-175. AccessedJuly 15, 2014.

Williams MM, Hawley JA, McKenzie RA, vanWijmen PM. A comparison of the effects of twositting postures on back and referred pain.Spine (Phila Pa 1976). 1991;16(10):1185-91.

Neal Wiggermann is a senior biomedical engi-neer and ergonomics specialist for Hill-Rom inBatesville, Indiana.


Be aware that any method

that involves manuallifting can cause injury

to the nurse.

Providing care for bariatricpatients is a concern forhealthcare facilities and staff

everywhere. Delayed patient mo-bilization due to fear of injury andlack of proper policy, knowledge,or equipment for handling thesepatients can lead to poor out-comes—and may pose legal andethical concerns. Specializedequipment, beds, patient lifts, andsurgical instruments must be made

available to help nurses and otherhealthcare professionals care forand support best practices forbariatric patients. (See Bariatricsby the numbers.)

Mobility mattersWhen patients can’t mobilize inde-pendently, they rely on nursing andphysical therapy staff to prevent im-mobility complications—pressureulcers, contractures, deep vein

thrombosis, muscle wasting, andpneumonia. Increased patient sizeis a significant barrier to early mo-bility, as are lack of proper equip-ment to lift and move the patient.Yet providing early mobilization

for dependent patients is challeng-ing, and when they’re large, itmay seem overwhelming. Thebariatric patient may be at evengreater risk for immobility and de-conditioning during hospitalizationbecause nurses may fear they’ll in-jure themselves while providingpatient care. Manual patient mobi-lization increases the risk of muscu-loskeletal injury to caregivers. Onestudy found that although bariatricpatients accounted for less than10% of the patient census in acute-care facilities, patient-handling in-juries involving them accounted for29.8% of staff-reported injuries.Safe patient handling and liftingrequires skill and specialized prod-ucts that support early mobility, lift-ing, and ambulation.Bariatric patients may fear

falling and may be embarrassedthat it takes four or five people tolift, move, or support them duringtoileting or out-of-bed activities.They may have moderate to se-vere mobility limitations due tobody type, decreased range ofmotion at the hip and knee, gener-alized adiposity, and location andsize of the pannus (a dense layerof fatty tissue over the lower ab-dominal area).


Prepare to care forpatients of size How to make mobilization and lifting safer forbariatric patients and staff By Dee Kumpar, MBA, BSN, RN, CSPHP

Bariatrics by the numbers In 2011, the Centers for Disease Control and Prevention reported that 69% of adults were over-weight, including 35% who were obese. Among adolescents ages 12 to 19, 18.4% were obese;among children ages 6 to 11, 18% were obese; and among children ages 2 to 5, about 12%were obese. Obesity is defined as a body mass index (BMI) of 30 to 39; morbid obesity, a BMI of40 or higher. Overweight is defined as a BMI between 25 and 29.9.

Overweight and obese persons are at increased risk for many diseases and disorders, includ-ing type 2 diabetes, hypertension, hyperlipidemia, coronary heart disease, gallbladder disease,cancer, osteoarthritis, sleep apnea, and depression.

Promoting a culture ofsafety As a nurse, you can lead the wayto creating and maintaining a cul-ture of safety by supporting andmodeling safe patient-handlingpractices on your unit. A focusedapproach to managing bariatricpatients’ mobility needs requiresthoughtful planning and knowl-edge of the technology designedto support care for these patientsthroughout their entire stay. Liftingand mobility practices can bestandardized successfully if nurseshave a voice in developing a safepatient-handling and mobility(SPHM) program and in selectingSPHM technology.

Assessing the level ofassistance needed Changing practice begins withevaluating the types of lifting andmoving tasks required. Bariatric pa-tients may need assistance withcommon activities, such as toileting,bathing, skin care, eating, sittingupright, and ambulating. To elimi-nate variations in care practices,caregivers should be clear on howto assess a patient’s mobility status.Barriers to moving independently—not the patient’s weight—should bethe main criteria for determining theneed for lift equipment.Standard categories of depend-

ency levels include:• dependent—the patient relieson the nurse or caregiver for alllifting and moving activities

• minimally to moderately de-pendent—the patient relies onthe nurse or caregiver for morethan 50% of lifting and movingactivities

• independent—the patient canperform lifting and moving ac-tivities without assistance fromthe nurse or other caregiver.

Other assessment considera-tions include:• weight-bearing capability (full,partial, or none)

• whether the patient has bilater-al upper-extremity strength

• patient’s level of cooperationand comprehension

• medications, such as vasopres-sors and paralytics

• conditions that may affectchoice of transfer technique,such as stomas, fractures, severeedema, or joint replacements.

For more information on assess-ment, read “Implementing a mobil-ity assessment tool for nurses” inthis supplement.

Patient-handlingalgorithms In 2003, the Veterans Administra-tion created algorithms to provideguidance on how to safely per-form high-risk activities related topatient handling and movement.Each algorithm specifies the sug-gested number of caregivers aswell as selection and use of ap-propriate lift equipment. To down-load these algorithms, visitwww.tampavaref.org/safe-patient-handling.htm.

Organizational guidelinesManual lifting of any patient isn’tsafe. The National Institute of Oc-cupational Safety and Health (partof the Occupational Safety andHealth Administration), recom-mends 35 lb (15 kg) as the safepatient-lifting limit for healthcareworkers. The American Nurses As-sociation (ANA) supports a policyof no manual lifting, as discussedin its 2013 book, Safe PatientHandling and Mobility: Interpro-fessional National Standards.A 2010 white paper from The

Facility Guidelines Institute, titledPatient handling and mobility as-sessment (FGI-PHAMA), providesrecommendations for the rightamount of equipment in the rightlocation based on the specificneeds of patients on each type ofunit. (The ANA publication men-tioned above cites this documentas supporting evidence on select-

ing and using lift equipment.) Forexample, we know many patientsin intensive care units (ICUs) aredependent and must rely on nursesto boost, turn, and reposition themfrequently throughout the day. FGI-PHAMA recommends 100% ceil-ing lift coverage in ICUs to ensurepatient mobilization activities canbe done without delay or injury tonurses. For medical-surgical units,FGI-PHAMA recommends 50%ceiling lift coverage, because gen-erally half the patients on theseunits depend on the nurse to lift,manage, move, and support theirambulation activities throughoutsome portion of their stay.

Challenging environmentsAdvances currently are under wayto promote safe patient handlingin other challenging hospital ar-eas, such as the operating room(OR), emergency department, out-patient areas, and ancillary units.Preplanning for patient flow andtransfer activity to and from theseunits is essential. The care teammust communicate, coordinate,and cooperate during patienttransport, lateral transfers, and


Barriers to moving independently—

not the patient’s weight—should

be the main criteria for determining

the need for lift equipment.

repositioning. With technologyavailable to prevent injury to bothcaregivers and patients, no de-partment should put staff at riskfor injury during transfer activities.

(For a case study on bariatricequipment use in the OR, seeCase study: Bariatric surgery us-ing the proper SPHM technology.)Bariatric patients present multi-

ple concerns for healthcare work-ers. We encourage all nurses tospeak up about safety and to support a SPHM workplace en -vironment. 8


American Society for Metabolic and BariatricSurgery. Estimate of bariatric surgery numbers.2014. http://asmbs.org/2014/03/estimate-of-bariatric-surgery-numbers. Accessed June 24,2014.

American Society of Bariatric Surgeons. Med-ical options for treating obesity fact sheet. Up-dated May 2014. www.asbp.org/images/PDFs/Resources/Obesity-Algorithm_FactSheet.pdf. Accessed June 24, 2014.

The Facility Guidelines Institute. 2010 HealthGuidelines Revision Committee Specialty Sub-committee on Patient Movement. Patient han-dling and movement assessments: A white pa-per. April 2010. https://www.dli.mn.gov/wsc/PDF/FGI_PHAMAwhitepaper_042710.pdf. Ac-cessed June 24, 2014.

Gallagher S. Implementation Guide to the SafePatient Handling and Mobility InterprofessionalNational Standards. Silver Spring, MD: Ameri-can Nurses Association; 2013.

Gallagher S. The Challenges of Caring for theObese Patient. Edgemont, PA: Matrix MedicalCommunications; 2005.

Ogden CL, Carroll MD, Kit BK, Flegal KM.Prevalence of childhood and adult obesity in theUnited States, 2011-2012. JAMA. 2014;311(8):806-14.

Randall SB, Pories WJ, Pearson A, Drake DJ.Expanded Occupational Safety and Health Ad-ministration 300 log as metric for bariatric pa-tient-handling staff injuries. Surg Obes Relat Dis.2009;5(4);463-8.

Schallom L, Metheny NA, Stewart J, et al. Effectof frequency of manual turning on pneumonia.Am J Crit Care. 2005;14(6):476-8.

U.S. Department of Veterans Affairs. Safe pa-tient handling and movement. Reviewed/Updat-ed April 30, 2014. www.visn8.va.gov/visn8/patientsafetycenter/safePtHandling/default.asp.Accessed June 24, 2014.

Dee Kumpar is the director for Safe Patient Handling Programs at Hill-Rom in Batesville,Indiana and a member of the workgroup forANA’s Safe Patient Handling and Mobility: In-terprofessional National Standards. She is onthe board of directors of the Association of SafePatient Handling Professionals.


Case study: Bariatric surgery using the properSPHM technology By Ronda Fritz, RN, BSN, MA

An estimated 179,000 bariatric surgeries were performed in the United States in 2013. De-mand for such surgery continues to rise. However, using safe patient handling and mobility(SPHM) technology in the operating room (OR) can be challenging because of the sterileenvironment and potential lack of knowledge about safe equipment use—especially forsuch tasks as lifting the pannus and limbs. This case study shows how one nurse was able topromote a culture of safety in the OR and how the surgeon recognized the benefits to boththe surgical team and patient. As described below, a team of experts in the hospital deter-mined how to incorporate the patient lift system to support the pannus during surgery toprotect staff from injury and enhance the surgeon’s visualization and safety.

A morbidly obese patient weighing 488 lb (221 kg) with a BMI of 70 was scheduled for apanniculectomy (pannus removal) and hernia repair. The surgeon requested use of a pa-tient lift during the procedure to lift and hold the pannus. As the patient was being preppedfor surgery, the surgeon learned that the requested Böhler Steinmann pin holders, whichwould attach to the lift to support the pannus, weren’t available. He cancelled the surgeryand rescheduled it for a later date. He said he wouldn’t perform the surgery without the pa-tient lift because he didn’t want staff to hold the pannus, which weighed more than 100 lb(45 kg), for the 3 to 5 hours the surgery would take.

The panniculectomy was rescheduled. Before the operation, the nurse worked with SPHMexperts to assess how to best handle the patient and developed a plan to incorporate thepatient lift system to support the pannus during surgery, thus protecting staff from injuryand enhancing the surgeon’s visualization and safety.

The surgery was performed with use of a portable patient lift. The patient was positionedon an OR table appropriate for his size and weight and prepped in sterile fashion. The pan-nus was suspended with two Steinmann pins attached to two Böhler Steinmann pin holdersand a Golvo® 7007 lift. The patient was draped and prepped in standard sterile fashion. AnSPHM expert positioned and operated the lift during the procedure. The panniculectomy re-moved 40 lb (18 kg) of adipose tissue. When the surgery was completed, the patient wastransferred off the OR table with an air-assisted lateral transfer device.

Benefits of using the proper equipmentUsing the proper patient-handling equipment during the panneculectomy yielded the fol-lowing benefits:• No unpredictable movement of the pannus occurred while it was attached to the lift. It

was moved only when the surgeon moved the tissue or directed the SPHM expert toreposition or lift it.

• Use of the lift during the surgery enhanced patient safety.• The patient’s adipose tissue was hiding many blood vessels. Having the pannus stabilized

by the lift helped avoid unintentional vessel dissections. Estimated blood loss was 300 mL.• Use of OR staff was improved. Although six additional staff members were assigned to

assist with holding the pannus and transferring the patient off the OR table, they weren’tneeded and were released to other duties.

• No staff members were injured during the procedure. Because the air-assisted lateraltransfer device was used, no patient or staff injuries occurred during transfer from the ORtable to the bed.

• No patient injuries occurred.

Ronda Fritz is a safe patient-handling facility champion at VA Nebraska-Western Iowa Health Care System inOmaha, Nebraska. She is on the board of directors of the Association of Safe Patient Handling Professionals.

A patient mobility assessmentdetermines your new patientneeds a dependent sling.

But when you finish your admis-sion intake and reach the sling in-ventory storage site, you find noslings are available. Or perhapsyou see a sling hanging on a hookand wonder if it’s clean or dirty.If you’ve had an experience

like this, you’re probably eagerfor your workplace to adopt asafe patient handling and mobility(SPHM) program that addressesslings, among other things. Butbefore adopting such a program,a healthcare facility must performa unit assessment to evaluate:• medical conditions and mobilityneeds of its patient population

• maximum number of bariatricpatients on the unit at a giventime, and how often the unitreaches this number

• tasks performed on the unit• unit staffing• storage constraints.Other parts of an SPHM pro-

gram related to sling use includeinfection control and selection ofthe sling fabric.

Launderable vs.disposable The SPHM committee, whichoversees all aspects of the SPHMprogram, must decide if the facil-ity should use launderable andreusable slings, disposableslings, or both types. Input from

the laundry department is criti-cal. Each type of sling has bene-fits and drawbacks. (See Com-paring launderable and dis-posable slings.) If the committeechooses launderable slings,the next decision is whether tolaunder them in-house or out-

source laundering to a laundrycompany.

In-house launderingAdvantages of in-house launder-ing include:• negligible number of missingor lost slings because all slings


Developing a slingmanagement systemLearn about key decisions for this segment of an SPHM program. By Jan DuBose, RN, CSPHP

Comparing launderable and disposable slings Despite their laundering costs, launderable slings are more cost-effective than disposableslings because they’re reusable. Also, more launderable sling types are available, givinghealthcare facilities more solutions for patient transfer and lifting needs. However, theseslings raise concerns about infection control and sling sharing.

Disposable slings, on the other hand, are easier to store. With no laundering process, thesafe patient handling and mobility (SPHM) program is simpler, no slings are lost to launder-ing, and infection control is easier. On the flip side, the ever-increasing cost of replacingslings can be a financial drain even on a successful, sustainable SPHM program. Also, dispos-able sling styles are limited, which can reduce the potential success of the program by failingto address all the manual tasks required.

stay in the facility• shorter turnaround time due tobetter control of the process

• reduced sling purchase costdue to reduced inventory

• better oversight for maintainingsling standards.

Disadvantages include:• the need for a dedicated staffmember to oversee and man-age the process

• the need for space to house awasher, dryer, drying cabinet,folding surface, and storagecarts

• a properly vented environmentto avoid dampness and mold

• possible injuries to laundrystaff due to the added work-load. (See Case study: On-sitelaundry with centralized distri-bution.)

Outsourced launderingAdvantages of outsourced laun-

dering include a reduced impacton laundry staff and transfer of re-sponsibility for a smooth, success-ful process off-campus. Disadvan-tages are possible loss of slings,sling damage from industrial laun-dering methods, long turnaroundtime, and costs (determined bythe pound or item).

Fabric maintenanceWhichever laundering process ischosen, fabric maintenanceguidelines must be followed.Meeting infection-prevention stan-dards is paramount. For exam-ple, a protocol for disposing ofor treating soiled or infectedslings must be established, alongwith protocols for single patientuse of slings. Fabric integritymust be maintained to extendsling life; preserving sling qualityfor prolonged fabric reliabilityand sling longevity promotes pa-tient safety and cost-effectiveness.

If the facility has chosen to out-source its sling laundering, itmust establish a good workingrelationship with the laundrycompany, with clear and regularcommunication.

Inventory purchase andstocking of supplies A sling management process in-cludes estimating the number andsizes of slings a unit uses, pur-chasing inventory, and stockingsupplies in an organized, effec-tive way. Several factors can af-fect inventory. For instance, as theSPHM program grows, the facilitywill need more slings and acces-sories, and purchasing may beslow to catch up. The laundryservice, whether in-house or out-sourced, also may be unable tokeep up with demand. And de-spite seemingly reasonable initialexpectations, turnaround timemight become impractical as theSPHM program evolves. Also, thenumber or sizes of slings a unituses may have been estimated im-properly initially.Healthcare facilities have two

options for establishing and keep-ing a satisfactory sling inventory—periodic automatic replenishment(PAR) or centralized distribution.

PAR systemTo maintain a PAR level, thefacility must keep enough slingson hand so it doesn’t run outwhile waiting for resupply. Spaceconstraints may limit the PARlevel. PAR requires not just astorage area but also adedicated staff member, alongwith unit staff, transport staff, andlaundry staff for backup. What’smore, if specialized slings arestored on specific units, they’renot easily available on other

Case study: On-site laundry with centralizeddistribution By Deanna Watkins, MSN, RN, CSPHP

One hospital chose to build an 800-square-foot on-site laundry facility to reduce overallproduct processing costs, reduce the required product inventory, and decrease the risk ofproduct loss. The laundry facility also represented an investment in the hospital's infra-structure. Achieving return on investment was estimated to take less than 18 months.

The hospital purchased four times the estimated inventory of slings and accessories,compared to six times the inventory that offsite laundering would require. Keeping prod-ucts on-site keeps losses low and allows barcoding of all items for product managementand tracking. Also, the on-site facility custom-launders linens with the potential for futuresavings.

The hospital has a centralized process managed by the linen service of the environ-mental services department. This allows better inventory tracking and accountability. Eachunit and department has an established inventory or periodic automatic replenishment(PAR) level of lift products. PAR levels were determined by reviewing patient demograph-ics for each unit; the most difficult tasks reported by the staff; admission, discharge, andtransfer data; average patient weight; and location from where most patients are admit-ted (such as direct admit vs. postoperative).

All products are barcoded and labeled with organization identification, not unit or de-partment identification. That way, slings can be transferred with the patient as he or sheflows throughout the care continuum. This is accomplished by the linen service using alaundry cart exchange process. Carts are exchanged daily depending on product use. Spe-cialty slings and accessories (such as amputee slings) also can be acquired through thecentralized system by calling the main phone number for linen distribution.

Deanna Watkins is a nursing administrative specialist at Mayo Clinic Hospital in Phoenix, Arizona.

units. On the other hand, using aPAR system means slings will bereadily available on all shifts,which leads to better compliancewith the SPHM program.

Centralized distributionWith this system, access to slingsmay not be available when need-ed, especially on evenings,nights, weekends, and holidays.A staff member must be put incharge of maintaining central stor-age for efficient distribution, anda process for obtaining slingsmust be established. For instance,is a runner needed? If so, whosupplies the runner?Nonetheless, a well-organized

centralized distribution processcan be highly effective if commu-nication is clear and consistent.Also, lack of unit storage forslings isn’t a concern.

Sling trackingSling tracking promotes return ofslings to the proper unit. Trackingcan be handled in several ways:• Slings can be labeled with anindelible marker, barcoded, orembroidered. A simple mark-ing system can yield valuablebenefits.

• Vendors may have sling track-ing systems your facility canuse.

Support for the SPHMprogram A well-developed sling manage-ment system supports a facility’sSPHM program. The SPHM mustelicit input from units that will usethe system and from the laundrydepartment or outsourced laun-dry company to ensure all par-ties’ needs are met. It mustchoose sling styles and fabric

and put in place procedures forsling purchase, inventory mainte-nance, care, laundering, track-ing, and replacement. Once theseissues have been addressed, thefacility is ready to embark on anSPHM program that can improvepatient care and help preventstaff injuries. 8

Selected referencesThe Facility Guidelines Institute. 2010 HealthGuidelines Revision Committee Specialty Sub-committee on Patient Movement. Patient han-dling and movement assessments: A white pa-per. April 2010. https://www.dli.mn.gov/wsc/PDF/FGI_PHAMAwhitepaper_042710.pdf. Ac-cessed June 24, 2014.

Occupational Safety and Health Administration.Lift program policy and guide: Introduction to the lift program. https://www.osha.gov/CWSA-attachment/beverlyliftprogramguide.pdf.Accessed July 3, 2014.

Jan DuBose is director of Safe Patient HandlingPrograms and Services at Hill-Rom.


way to becoming firmly rootedand incorporated into caregivers’daily practice. Although the prac-tice change is becoming the newnorm, coaching and mentoringare needed to help maintain mo-mentum. Stories learned along thejourney should be used to inspireboth novice and expert clinicians.Objective evaluation of the im-

provement process should contin-ue, focusing on outcome measuresand identifying improvement op-portunities to promote refinement.Team members are now doingthings they never thought werepossible—and previously believedto be unsafe. Recently, I learned ofa ventilator patient at St. Luke’sMedical Center, Boise/Meridian(Idaho) who was receiving contin-uous renal replacement therapy(CRRT). Staff safely mobilized the

patient to the chair using the hos-pital’s mobility protocol. In manyICUs, such a patient would bebedbound. But at St. Luke’s, earlymobility is now routine practiceeven for these patients. Conversa-tion about mobility occurs in dailyrounds and often is a major focusof daily patient goals.In fact, staff members are likely

to comment that they no longer askthe question “Can we mobilize thispatient?” Instead, they ask, “Isthere a reason why we can’t mobi-lize the patient?” Key lessonslearned to promote and maintainthis cultural transformation includethe importance of testing new prac-tices on a small scale, getting regu-lar feedback of performance andoutcome data, providing sufficienteducation, and increasing care-givers’ will to mobilize patients byseeing the work in action.

Deliberate focus, fullengagement Incorporating new evidence intodaily practice isn’t enough to sus-tain a culture change to empha-size early mobility and SPHM.Such a change comes only with adeliberate focus on three key ques-tions: What are we are doing?Why are we doing it? What’s myrole? Full engagement and culturaltransformation can occur onlywhen all team members can re-spond to these questions with fullunderstanding. 8

Visit www.AmericanNurseToday.com/Archives/aspx for a multidisciplinary progressive mobilitycontinuum tool and a list of selected references.

Kathleen M. Vollman is a clinical nurse specialist,educator, and consultant with Advancing Nurs-ing, LLC in Northville, Michigan. Rick Bassett is acardiovascular clinical nurse specialist in adultcritical care at St. Luke’s Medical Center,Boise/Meridian, Idaho.

(continued from page 10)


The value of a safe patienthandling and mobility(SPHM) program is clear, but

the benefits may be difficult forsome nurse leaders to quantify.Some investment justifications areavailable from vendors of SPHMequipment, but even when welldone, they don’t give a completepicture of potential benefits—andinevitably are discounted becausevendors are in the business of sell-ing equipment. This article de-scribes how to make an independ-ent, unbiased business case for anSPHM program and presents acase study of a decision analysisprocess used at Stanford Universi-ty Medical Center.

Elements of a goodbusiness case A business case should:• describe the proposed pro-gram, such as required equip-ment and training

• quantify program costs andbenefits

• show the program’s net benefit(benefits minus costs), express-ed either as a net present valueor return on investment (ROI).

A good business case consid-

ers alternative program designsand includes projections for the re-sults if the proposed program isn’timplemented (such as increasedworkers’ compensation costs andincreased pressure ulcers). Netbenefits commonly are measuredby subtracting costs with the pro-gram in place from costs withoutthe program in place.Although preparing such pro-

jections is feasible for those with amaster’s degree in business admin-istration or a similar education,many SPHM program championshave clinical backgrounds. Hereare some possible strategies theycan use, starting with the easiestbut least facility-specific.

STRATEGY 1: Refer to apublished study The easiest but least facility-spe-cific and least accurate way toprepare an investment justifica-tion is to refer to published stud-ies. For example, the risk-man-agement study I undertook forStanford, published in the April2011 issue of Journal of Health-care Risk Management, showswhat a facility with all the ele-ments of a successful SPHM pro-gram can achieve.

STRATEGY 2:Complete a simple template The next most accurate way toprepare an investment justificationis to fill out a simple template.Most likely, your employer’s fi-nance department or capital com-mittee has a standard template forproposed expenditures. Most or-ganizations require a cost-benefitprojection for 5 years into the fu-ture. The cost part is fairly easy,and most people are familiar withpreparing budgets for what theypropose to spend. Be sure to in-clude estimates for equipment pur-chases and training time.As for benefits, the most com-

monly cited ones for an SPHMprogram are reductions in work-ers’ compensation costs and inlost or restricted staff days due topatient handling and mobility in-juries. Unless your facility alreadyhas identified these costs, you’llneed to crossmatch data from theOccupational Safety and HealthAdministration Form 300 (listingcauses of injuries and whetherthey led to lost or restricted duty

Making the businesscase for a safe patienthandling and mobility program Learn about three approaches to preparing an investment justification. By John Celona, BS, JD

days) against cost data in theworkers’ compensation system.Typically, organizations esti-

mate they’ll save 60% to 80% ofworkers’ compensation costs relat-ed to patient mobilization if theyhave an SPHM program, and willsave zero to 50% of the cost ofreplacement staff to fill in for out-of-work or restricted-duty staff (de-pending on the facility’s replace-ment staff policy). Subtractingeach year’s costs from the benefitsyields the annual net benefit. Ifyour facility’s template hasn’t builtin these costs, someone from thefinance department can help con-vert the year-by-year figures to anet present value or ROI.

STRATEGY 3: Prepare adecision analysis Preparing a decision analysis ismore difficult than referring to apublished study or using a tem-plate. But it’s facility-specific andthus provides the most completeand accurate picture. Of course, itmust be done by someone skilledin decision analysis. But for largeinvestments, the cost of the analy-sis is well worth it, because it:• delivers a highly accuratequantification of costs and ben-efits, including uncertainties

• shows worst- and best-case sce-narios for costs and benefitsand describes exactly howthese might occur

• identifies how to get more val-ue out of the SPHM program

• specifies which result measuresshould be tracked to validatethat the program is working asit should be, and pinpointswhat the values for those meas-ures should be.

Generally, a decision analysiscosts much less than 1% of theprogram cost. What’s more, it pro-duces recommendations for in-creasing program value, whichdwarf the cost of the analysis.I worked with Stanford on a de-

cision analysis for its SPHM pro-gram because it became apparentthat the simple-template approach


Influence diagram An influence diagram is a simple, graphic way of showing all items of interest and demonstrating what’s related to what. Uncertainties areshown in ovals, decisions in boxes, and the final value as a hexagon; arrows show relationships among items. This influence diagram showsall safe patient handling and mobility (SPHM) costs and benefits of interest to leaders at Stanford University Medical Center when consider-ing whether to invest in an SPHM program.

initially used there missed most ofthe value and wouldn’t justify aprogram in the new hospital underconstruction.

Case study: Standforddecision analysis At Stanford, we began by draw-ing an influence diagram to showall SPHM costs and benefits of in-terest to leaders. (See Influence di-agram.) For each cost or benefit,more detailed work explored ex-actly how to quantify the results.For example, to estimate the bene-fits of reduced staff turnover, weneeded to know:• number of nurses mobilizingpatients who would be affectedby the SPHM program

• average annual staff turnoverrate

• average cost to recruit and

train a nurse ($60K to $80K,based on a literature search)

• estimate of how much theSPHM program would reducestaff turnover.

We did similar work for eachtype of cost and benefit. Unlike us-ing a simple template or referringto a published study, the decision-analysis approach enabled us touse a range of numbers to repre-sent uncertainty regarding howsignificant the future impact mightbe. For turnover reduction, weused a range of 0% to 20%.These data were then pro-

grammed into a Microsoft Excelspreadsheet. One immediate resultwas that the total value of anSPHM program (including hard-to-quantify benefits) would amount tomore than twice the value of re-

duced workers’ compensationcosts and lost and restricted daysalone.The next step was to set each

uncertainty (such as a change inthe nurse turnover rate) to the lowvalue in the range, record the totalprogram value, set the uncertaintyto the high value in the range,and record the total program val-ue. The difference between thetwo program values was plottedon a bar chart. When the barswere sorted from highest to lowestimpact on program value, thecharacteristic tornado shape result-ed. (See Tornado chart: Key valuedrivers.)Stanford leaders were surprised

to learn that reduced staff turnoverhad the greatest potential for get-ting more value out of the SPHMprogram, possibly increasing total


Tornado chart: Key value drivers In this so-called tornado chart, the key value drivers for Stanford’s safe patient handling and mobility (SPHM) program appear at the top.Uncertainties farther down the chart (the complete chart had 40 uncertainties) don’t merit much time or attention. For example, whether35% or 50% of restricted staff time was replaced with other staff time didn’t significantly affect total program value. In reality, of course, alluncertainties are varying at the same time, rather than one at a time as shown in this chart.

Reduction on turnoverPercentage point increases in Press Ganey score

Workers’ compensation cost (baseline) growth ratePercentage of relevant staff with improved Gallup score

Percentage of ulcers in stage 1 or 2Final workers’ compensation reduction rate

Final ulcer reduction rateLost and restricted days (baseline) growth rate

Percentage of referral from improved patient satisfactionEquipment costs (based on patient mobility)

Patient volume growth rateAverage cost to treat stage 3, 4, or unstageable growth rate

Training costs (HR wages)Final replacement costs reduction rate

Time replacement factor Workers

’ compen

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program value from about $4 mil-lion to $6.5 million. As a result,Stanford decided to inform thenursing staff that it was going toput in place the SPHM tools need-ed to keep them healthy and ableto work. Stanford also surveyedstaff satisfaction improvements re-sulting from the SPHM program.Combinations of all the variablesproduce thousands of scenarios,best shown in a probability distri-bution. The probability distributionfor Stanford showed that the meanprogram value was more than dou-ble the estimate from the templateapproach. It also showed that in aworst-case scenario, the programwould still pay for itself.An easy way to show the com-

ponents of program value is totake the overall program valuefrom the base case (all uncertain-ties set to their middle value) andbreak these down into compo-

nents of cost and value. This pro-duces a so-called waterfall chart.(See Components of total SPHMprogram value.)

Outcome of the decisionanalysis Stanford’s decision analysisproduced:• a high degree of confidencethat the actual value of theSPHM program and uncertaintyin that value had been quanti-fied accurately

• a deeper understanding of howthe program would add valueand which benefits were mostimportant

• insight into how to get more val-ue from the program

• identification of which value mea-sures would need to be trackedto validate program results.

At Stanford, reductions in work-

ers’ compensation claims were ontrack (within the 60% to 80%range forecast), but baseline work-ers’ compensation costs weregrowing faster than the maximum19% annual increase forecast. Acloser look revealed that a return-to-work program had been discon-tinued, sending costs skyrocketing.Stanford quickly reinstated thatprogram. 8

Selected referencesCelona J, Driver J, Hall E. Value-driven ERM:Making ERM an engine for simultaneous valuecreation and value protection. J Healthc RiskManag. 2011;30(4):15-33.

Celona JN, McNamee PC. Decision Analysis forthe Professional. 4th ed., rev. Menlo Park, CA:SmartOrg, Inc., 2001-2007.

The Facility Guidelines Institute. 2010 Guide-lines for Design and Construction of HealthcareFacilities. Dallas, TX: Author; 2010

John Celona is a principal at Decision AnalysisAssociates, LLC, in San Carlos, California. He isthe author of Decision Analysis for the Profes-sional, 4th ed.

www.AmericanNurseToday.com September 2014 Current Topics in Safe Patient Handling and Mobility

Components of total SPHM program value This “waterfall” chart shows that the largest components of value for Stanford’s safe patient handling and mobility (SPHM) program are de-creases in workers’ compensation costs and in pressure ulcers and increased patient satisfaction. Nurse retention is a small component of totalprogram value in the base case scenario shown here (with only a 2% reduction in turnover), although it has the largest potential for increas-ing program value if turnover reduction could be pushed up to 20%.

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©2014 Liko R&D, AB. ALL RIGHTS RESERVED.188198 rev 1 06-AUG-2014 ENG – US

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