1 Effective Patient Mobilization Programs: Improving Caregiver and Patient Safety in an Increasingly Challenging Healthcare Environment Authors: Betty Z. Bogue, R.N., B.S.N.; Mark Santoleri, MS, CHSP About Integro Integro is an insurance brokerage and risk management firm. Clients credit Integro’s superior technical abilities and creative, collaborative work style for securing superior program results and pricing. The firm’s acknowledged capabilities in brokerage, risk analytics and claims are rewriting industry standards for service and quality. Integro maintains a robust healthcare practice, and since 2005 has pioneered a unique approach to managing risk for their healthcare clients. The firm has offices in the United States, Canada, Bermuda and the United Kingdom. Its U.S. headquarters are located at 1 State Street Plaza, 9th Floor, New York, NY 10004. 877.688.8701. www.integrogroup.com About Prevent, Inc. Prevent has 20 years of experience implementing safe patient mobilization initiatives. Its mobilization strategies and best practices solutions have resulted in an 80% reduction in mobilization injuries among caregivers at institutions that have adopted its “Get A Lift!” ® program. Prevent, Inc.’s office is located in Hickory, N. C. (www.getalift.com) Introduction Acute care nurses and other healthcare staff are at high risk for injuries, particularly musculoskeletal disorders, due to the intense physical demands of manually lifting and moving patients. Injuries may involve time away from work, but can also be life altering and career ending. Additionally, even without considering the injury risks, the intense physical demands of the job alone can lead to low morale and job dissatisfaction, further increasing the risk of staff turnover. Patients in the hospital setting who require partial or total support for their mobilization have an increased risk of injuries and complications. The physical support required to move a patient often exceeds safe lifting limits for caregivers, which reduces the frequency of mobilization; instead of lifting to transfer, patients are often slid to and from a surface. These compromises in care increase the risk to the patient for pneumonia, skin breakdown, falls and long term disability. An effective patient mobilization program determines each patient’s needs for lifting, transferring, and repositioning, and uses mechanical lifts and assist devices to meet the demand instead of relying on caregivers’ physical strength. The benefits of significant reductions in manual demands includes: lower risk of caregiver and patient injuries; possible
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Effective Patient Mobilization Programs: Improving Caregiver and Patient Safety in an
Increasingly Challenging Healthcare Environment
Authors: Betty Z. Bogue, R.N., B.S.N.; Mark Santoleri, MS, CHSP
About Integro
Integro is an insurance brokerage and risk management firm. Clients credit Integro’s superior
technical abilities and creative, collaborative work style for securing superior program results
and pricing. The firm’s acknowledged capabilities in brokerage, risk analytics and claims are
rewriting industry standards for service and quality.
Integro maintains a robust healthcare practice, and since 2005 has pioneered a unique
approach to managing risk for their healthcare clients. The firm has offices in the United States,
Canada, Bermuda and the United Kingdom. Its U.S. headquarters are located at 1 State Street
Plaza, 9th Floor, New York, NY 10004. 877.688.8701. www.integrogroup.com
About Prevent, Inc.
Prevent has 20 years of experience implementing safe patient mobilization initiatives. Its
mobilization strategies and best practices solutions have resulted in an 80% reduction in
mobilization injuries among caregivers at institutions that have adopted its “Get A
Lift!”®program. Prevent, Inc.’s office is located in Hickory, N. C. (www.getalift.com)
Introduction
Acute care nurses and other healthcare staff are at high risk for injuries, particularly
musculoskeletal disorders, due to the intense physical demands of manually lifting and moving
patients. Injuries may involve time away from work, but can also be life altering and career
ending. Additionally, even without considering the injury risks, the intense physical demands of
the job alone can lead to low morale and job dissatisfaction, further increasing the risk of staff
turnover.
Patients in the hospital setting who require partial or total support for their mobilization have
an increased risk of injuries and complications. The physical support required to move a patient
often exceeds safe lifting limits for caregivers, which reduces the frequency of mobilization;
instead of lifting to transfer, patients are often slid to and from a surface. These compromises in
care increase the risk to the patient for pneumonia, skin breakdown, falls and long term
disability.
An effective patient mobilization program determines each patient’s needs for lifting,
transferring, and repositioning, and uses mechanical lifts and assist devices to meet the
demand instead of relying on caregivers’ physical strength. The benefits of significant
reductions in manual demands includes: lower risk of caregiver and patient injuries; possible
improvement in job satisfaction; preservation of profit margins by reducing costs associated
with injuries; reduced recovery time for patients; and lower staff turnover.
This white paper provides an overview of the healthcare industry’s readiness to change patient
mobilization protocols in an increasingly challenging healthcare environment; describes the
mounting pressures for change; and shares lessons learned over 20 years of implementing and
developing patient mobilization programs. A fictitious patient-case scenario is used to illustrate
best practices for effectively improving the safety of the healthcare workplace and showcase
strategies for achieving the safest healthcare workplace possible.
An Increasingly Challenging Healthcare Environment
The healthcare environment is becoming increasingly challenging. The US population, including
patients and caregivers, is expanding and aging. There are 315 million people in the United
States, and by 2030, more than 70 million U.S. residents will be 65 years or older.[Anderson_2014]
According to the Agency for Healthcare Research and Quality, individuals aged 65 years or older
make up approximately 35% of all hospital stays. [AHRQ_2014] Additionally, in 2008, it was
estimated that nurses born between 1955 and 1959 made up the largest proportion of working
nurses. [Stokowski_2008] Therefore, approximately one-third of the current 2.8 million RNs will reach
retirement age by 2020. [Anderson_2014] Healthcare organizations must make accommodations to
the work environment to serve aging workers and older patients.
Additionally, patients and caregivers are becoming heavier. As U.S. obesity rates continue to
escalate, the exposure to injuries in the healthcare setting increases. According to the 2012
National Health Interview, approximately 35% of the general population is overweight and 28%
is obese.[CDC_2014] A large survey of RNs found that rates were similar among nurses, with almost
54% being overweight or obese. [Miller_2008] Furthermore, 91% of all nurses are women. [US
Census_2013] It is estimated that the demands of supporting patients who require partial or total
support for mobilization results in a cumulative weight lifted at 1.8 tons in an 8-hour period. It
is well known that women generally have less upper body strength than men, which further
increases the risk of injury or exacerbations of older injuries and other age-related health
conditions. [Heidkamp_2012] To help attract and retain staff needed to provide patient care, the
healthcare workplace will need to significantly reduce the physical demands of the care
practice. [Heidkamp_2012]
In 2015, the turnover rate for acute care bedside RNs increased to 17.2% from 16.4%. [NCi_2016]
The turnover rate for certified nursing assistants was even higher at 23.8%, exceeding all other
positions. The nursing workforce continues to shrink right at a time when the healthcare
marketplace is rapidly expanding to include an additional 30 to 34 million patrons through the
Affordable Care Act of 2010 (ACA), [Anderson_2014] placing additional burden on an already taxed
system. The impact of these changes on healthcare organizations will be significant, resulting in
increased physical workloads. Paperwork (the ACA’s regulations alone are anticipated to add
190 million additional hours of paperwork annually);[Anderson_2014] increased risk of monetary and
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regulatory penalties associated with quality indicators; mounting dissatisfaction and burnout
among experienced healthcare workers; and increasing staff turnover and its associated costs
further compound the burden on the U.S. healthcare system.
The average cost of turnover for a bedside RN ranges from $37,700 to $58,400, with the
average hospital losing $5.2 to $8.1 million. [NSi_2016] When an RN is severely injured on the job,
these costs can be even higher, including the costs of workers’ compensation (i.e., lost wages
and medical expenses) and the replacement of staff. According to 2011 Occupational Safety &
Health Administration (OSHA) estimates, 50% of all nursing injuries in the hospital were
musculoskeletal injuries related to patient handling, with cost per injury averaging $15,600.
[OSHA_Safe Patient Handling Pamphlet] Between 2006 and 2011, the indemnity costs alone for hospital
workers’ compensation claims averaged $9,000 to $12,000, with the latter being for injuries
associated with patient handling. [OSHA_Facts_2013] The number of injuries in the hospital workplace
is twice as high as in all other industries, illustrating the hazards of this workplace. [OSHA_Safe Patient
Handling Pamphlet] To help retain staff, particularly older and more experienced staff, and ensure the
healthcare demands of the growing and aging population can be safely met, major changes
need to occur to significantly reduce the physical demands of this workplace.
The Impact of Never-Events
As of 2008, Medicare no longer reimburses acute care hospitals for treatments related to
hospital-acquired pressure ulcers and patient falls, both of which are considered “never-
events” or injuries that should not happen during a hospital stay. Safe patient-handling
programs ensure higher quality care for patients and protect profit margins related to hospital-
acquired events. Increased mobilization of patients reduces the risk of pressure ulcers and falls,
which are injuries considered never-events by the Centers for Medicare & Medicaid Services.
Hospitals receive no reimbursement for care provided as a result of a never-event; thus, it
behooves healthcare organizations to make every effort to prevent these events from
happening.
The incidence of pressure ulcers in the ICU has been reported to range from 10% to 41%,
[Cooper_2013] and it is estimated that 2.3 to 7 hospital patients per 1,000 patient days suffer falls.
[Hitcho_2004] Numerous care practices increase the risk of these negative outcomes, including the
inability of caregivers to provide adequate manual support for patient transfers and
repositioning; long emergency department (ED) waits requiring patients to lie prone for long
periods of time without repositioning; and use of rudimentary equipment, such as bed sheets
or slide boards to transfer patients.
A 2004 study reported that patients who fall have hospital charges that are $4,200 higher than
patients who do not fall. [Hitcho_2004] Reducing patients’ fall exposure is challenging due to
numerous causative factors; however, use of proactive approaches can reduce this risk. One
such approach is use of reliable assist devices to provide necessary mobilization support and to
increase the frequency of mobilization.
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The estimated cost associated with treating one stage 4, hospital-acquired pressure ulcer is
approximately $130,000.[Brem_2010] Risk factors for hospital-acquired pressure ulcers include
older age, immobility, shearing and friction, and exposure to moisture and heat. A frequently
performed care practice in the hospital setting is using a bed sheet to laterally transfer patients
or to position them up in bed. When patients are moved in this manner, their body weight
presses down on the outer layer of their skin, causing it to stick to the sheet. When the sheet is
slid, the outer skin layer is moved quickly because of its connection to the sheet, but the deeper
skin tissues will move slower than the outer layer, stretching the deep tissue and blood vessels.
This effect on the skin is called shear. Repetitive shearing permanently damages the blood
vessels that sustain all layers of the skin, and the reduction of nourishment to the tissue results
in a pressure ulcer, which can be catastrophic.
To meet the demands of an expanding healthcare market; recruit and retain experienced
nurses; reduce the risk of injury to patients and employees; and enhance financial efficiencies in
hospital settings, mandating a safer method for supporting patients to lift, transfer and
reposition in bed will have to occur. The methods needed to dramatically improve patient
mobilization are already available, feasible, and have been proven to dramatically improve the
safety of healthcare environment.
Healthcare Industry Readiness and the Mounting Pressure for Change
In the early 1990s, OSHA published the final bloodborne pathogens standard in response to the
significant health risks associated with occupational exposure to blood and other potentially
infectious materials. This initiative dramatically improved the safety of the healthcare
workplace. As an example, acquisition of hepatitis B dropped from 10,721 in 1983 to 384 in
1999; [AHC Media_2010] safety in this area has continued to evolve and improve. Healthcare
workers’ exposure to bloodborne pathogens before OSHA’s initiative mirrors the risk of
musculoskeletal injuries healthcare providers currently face from handling patients who require
total or partial assistance with their mobilization. However, while all hospitals and healthcare
facilities have implemented effective, bloodborne pathogen exposure control plans, the
number of hospitals that have successfully reduced the manual demands placed on caregivers
pales in comparison.
In 1990, the Americans with Disabilities Act (ADA) was signed into law. This legislation required
organizations to provide reasonable accommodations, if necessary, to enable people with
disabilities to have an equal right to employment. Because of the healthcare sector’s intense
physical demands, it has one of the highest rates of injuries in the workplace; however, per the
ADA, healthcare employers cannot ask job applicants if they have any physical limitations
preventing them from performing the job, but they can administer a pre-placement physical
test that mirrors job demands. To reduce the risk of hiring employees who would exacerbate an
existing injury or be at high risk of sustaining injuries, the healthcare industry began exploring
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what a pre-placement test would require, but this effort has fallen short. In many of these
screening tests, lifting specifications have been unrealistic, indicating workers would only
occasionally be required to lift 30 to 50 pounds; however, as stated above, the manual
demands of the healthcare workplace are much greater. [Nelson_2004]
Several pioneers in safe patient handling, including Arun Garg, Bernice Owens, Audrey Nelson,
Thomas R. Waters, and Guy Fragala, have researched the impact of manual demands on
caregivers and worked to increase awareness of the impact of lifting, transferring, and
positioning patients. Multiple professional and governmental organizations have also promoted
the need for change in patient handling, including OSHA, the Veterans Administration, JCAHO,
the American Nurses Association, and the American Nurses’ Credentialing Center through its
Magnet Recognition Program. To date, eleven states have enacted laws or regulations for safe
patient handling and in December 2015, U.S. Congressman John Conyers and Senator Al
Franken re-introduced legislation on Safe Patient Handling & Mobility with H.R. 4266 and S.
2408.
Although the need for change in patient handling practice has been promoted by many
organizations, direct care workers’ risk of injuries during patient mobilization has not shown
significant reductions because the number of hospitals working to significantly reduce their
employees’ risks of injuries during patient mobilization have not greatly increased. Reluctance
to change this healthcare practice may be attributed to several factors, including the recession,
which began impacting U.S. financial markets in 2007; the unknowns and fears associated with
the financial impact of the ACA; and the lack of confidence in implementing an effective and
feasible change in the healthcare workplace. However, the pressure for change will continue to
mount with the drive to expand services to a much larger market, including an increasingly
older market that is being cared for by aging caregivers.
The Benefits of Safe Patient Mobilization
Despite the increasing challenges of the healthcare market, Healthcare organizations can thrive with long-range plans that focus on retaining and protecting healthcare workers. One of the known drawbacks of the healthcare environment is that it is physically demanding. By implementing a best-practices approach to patient mobilization and supporting and developing these approaches on an ongoing basis, healthcare organizations can significantly reduce the manual demands placed on their staff, thereby improving caregiver and patient safety; reducing direct and in-direct hospital costs; increasing worker and patient satisfaction; and enhancing work efficiencies.
Illustrating Best Practices for Patient Mobilization
To more fully understand the application, feasibility and many benefits of adopting a best-practices model for patient mobilization, a fictitious patient-case scenario is used to illustrate the present-day care model from a patient’s transport and admission to the ED through
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hospital discharge. This same patient scenario is then used to reflect a care model that includes best practices for patient mobilization. The case scenario, all names, and incidents portrayed in this scenario are fictitious. This example is used to illustrate the vision of a safer health care environment.
Present Day Care Model – A Patient Case Scenario
Janet is a 74-year-old RN who retired after a long career at a local hospital. After having an early
dinner, she began experiencing jaw and arm pain. She took an aspirin and called 911. She was
then transported to the ED by the emergency medical service (EMS). Janet’s health history was
unremarkable except for chronic back pain. Although she had been physically active before the
event, the pain she was experiencing limited her mobility and required the emergency medical
technicians (EMTs) and ED nurses to slide her from the gurney to the ED cart using a sheet.
After an electrocardiogram, portable chest radiograph, and blood work, a computed
tomography (CT) scan was completed. The CT scan required another lateral transfer, which was
performed by two caregivers who used the bed sheet to slide her to and from the examination
table and ED cart.
On return to the ED, a change in Janet’s heart rhythm was noted. The staff quickly transported
her to the cardiac catheterization lab, where she was once again laterally transferred to and
from the ED cart with a sheet. After the procedure, she was admitted to the intensive care unit
(ICU) by stretcher, where two nurses slid her from the stretcher to her bed using the sheet.
Throughout the night, Janet’s vital signs were monitored, staff repositioned her in bed, and she
received a bedpan for toileting.
The next morning, as part of the early mobilization protocol, two nurses provided weight-
bearing assistance to slide her to a seated position on the side of the bed. Later in the day,
Janet’s activity progressed to involve a transfer to the bedside commode and chair. Although
Janet was able to bear weight for transfers, her illness and the imposed bed rest reduced her
strength and she required weight-bearing support to stand and transfer. On returning to her
bed, Janet became weak and her knees buckled, causing her to suddenly drop to the floor
despite assistance. Evaluation by the nurse noted swelling in the left arm. No other areas of
concern were noted. Janet was provided support to stand up and get onto her bed. To rule out
a fracture, she was taken to radiology, where lateral transfers were again performed using a
bed sheet to slide her between surfaces. A fracture of her left arm was diagnosed and
appropriate measures for healing were completed.
Janet was sore and her movement was limited due to her casted arm; thus, staff members were
required to provide the support needed to position her in bed and slide her to a seated position
on the side of the bed. Once in an upright position, staff used a gait belt to bring her to a
standing position and to stabilize her while walking, providing manual support as needed to
prevent another fall.
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Janet’s hospital stay was longer than expected due to the fracture from her fall and from the
development of a stage 3 decubitus ulcer. The ulcer resulted from Janet lying prone for several
hours before being transferred to the in-patient unit and from frequent shearing of her skin
during transfers and positioning. Her arm healed without complications, but the pressure ulcer
required a hospital readmission for antibiotics and debridement before it completely healed.
Additionally, a nurse was injured when providing Janet with weight-bearing support, which
resulted in additional medical costs and loss of workdays for the hospital. Janet recognized after
her hospital discharge that the care she received did not differ much from the care she
provided prior to her retirement.
Improving the Safety of the Healthcare Environment
Best Practice: Addressing Culture Change
The first step toward improving the safety of patients and caregivers in healthcare
environments is recognizing that workplace culture surrounding patient mobilization needs to
change. Once leaders are confident with that goal, best practices can be applied to patient
mobilization protocols and tailored with increasing experience to ensure outcomes and
preservation of healthcare dollars are optimized.
Culture change is often brought up in discussions about improving the safety of patient
mobilization practices. Many institutions have purchased and provided staff with training on
the use and function of ceiling lifts, mobile mechanical lifts, and other assist devices only to sum
up the initiative by stating, “the staff just don't use the equipment—it was a waste of money.”
Over the past 20 years, observations of more than 1,000 diverse healthcare organizations, 100
of which are acute care hospitals throughout the United States that have successfully
implemented safe patient mobilization practices and dramatically reduced injuries, reveal what
has to occur to permanently change the culture of this workplace. All of these organizations
have the following attributes in common:
Mentorship to ensure new practices are adopted
Nursing Leadership sponsored the initiative
Clearly defined roles and responsibilities for administrative, nursing, and
department leaders around implementation of a new mobilization strategy
Bonus and performance reviews and organizational goals tied directly to patient
mobilization outcomes
Designation of key personnel to support the program, including a liaison position
to oversee and manage the program
Monthly review and evaluation of patient mobilization outcomes followed by
action to resolve revealed opportunities for improvement
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Defined annual, expected outcomes and considered these an organizational goal
Best Practice: Applying Best Practices
The aforementioned institutions have helped define best practices for safe patient mobilization.
Following are attributes displayed across successful acute care programs.
All employees, physicians, community participants, and partners have a clear
understanding of the expectations, roles, and responsibilities related to patient
mobilization practices.
Patients’ mobilization support needs are determined and the appropriate equipment is
used.
A defined procedure exists for communicating patients’ mobilization support needs,
which are customized by department and patient care area.
On hire, all direct-care employees complete training on patient mobilization practices;
skills are mentored and competency is verified at the point of care.
Mobilization equipment is adequate, functional, and available for use.
Any injury or incident related to patient mobilization is investigated, opportunities to
strengthen the practice are defined, and interventions are developed, implemented,
and verified as being effective to prevent another injury by the same cause.
Employees who refuse to comply with patient mobilization practices are provided
counseling and additional education and mentoring; repeat offenses result in
termination based on the organizational disciplinary practice.
All barriers to the use of equipment are identified and eliminated.
There is ongoing analysis of defined outcomes to identify opportunities to strengthen
the practice.
A Best Practice Model For Patient Mobilization – A Patient Case Scenario
Determination of the Patients’ Mobilization Support Needs
Janet is a 74-year-old RN who retired after a long career at a local hospital. After having an early
dinner, she began experiencing jaw and arm pain. She took an aspirin and called 911. When
the EMTs arrived at Janet’s home, she was seated in a chair. As part of the evaluation before
moving her, the EMTs noted she was able to sit upright, had leg strength, and could
demonstrate weight bearing on her legs. She was assisted to the stretcher, which had a
disposable air mat in place. During transport to the ED, Janet’s vital signs, symptoms,
medications, and mobility support needs were called in.
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Once in the ED, Janet was transferred to the bed using the air mat under her. The ED nurse
began the admission assessment, which included Janet’s mobilization support needs and risk
for falls and pressure ulcers. To communicate her needs to other staff members and
departments, the findings were documented on the admission assessment form and the
interdepartmental communication form.
Every hour during her wait in the ED and during her procedures, the air mat Janet laid on was
inflated for several minutes to off-load her body weight from her skin to reduce the risk of skin
breakdown. Before being admitted to the in-patient unit, per the report provided by the cardiac
catheterization lab nurse, a repositioning sling was placed on the bed per the unit’s protocols.
Once in the unit, the air mat was used to transfer her to the bed, and then stored in Janet’s
room for future use. As Janet’s hospital stay progressed, her mobilization support needs were
changed as her needs changed and communication to the healthcare team was updated
accordingly.
Practice Pearl: Determination of patients’ mobilization support needs requires observing their
ability to turn in bed, position up in bed, move from a reclined position to a seated position,
and sit upright. It also requires assessment of leg strength, including ability to bear weight on
legs, stand, balance, and ambulate. Additionally, patients’ risk for complications must be
carefully considered. In Janet’s case, her diagnosis, treatment, age, and imposed immobility
were considered when determining her mobilization needs and interventions to reduce her risk
for complications.
Knowledgeable Caregivers and Community Partners
The EMT service sent to Janet’s house was not employed by the hospital; however, as a
community partner, the hospital communicated the change to their patient mobilization
practices. Recognizing the benefits of this change, the EMT organization chose to adopt these
practices to ensure their patients received continuity of care with the hospital. To achieve this
goal, the EMTs received training on the patient mobilization practices and protocols for
meeting patients’ needs.
After being admitted to the in-patient unit, admission personnel visited Janet and made her
aware of the patient mobilization standards and gave her the opportunity to ask any questions.
All transport employees and caregivers explained to Janet how she would be mobilized and
what equipment would be used, ensuring she understood the need and justification for all
equipment and procedures.
During her stay, Janet’s family became aware of the hospital’s enhanced attention to patient
safety. They learned about mobilization practices through admission pamphlets, information
posted in highly visible areas, and explanations provided by the care staff. Additionally, before
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Janet’s hospital discharge, her mobilization needs were discussed in detail with her family,
including any necessary accommodations to ensure she would be safe in her living quarters.
Practice Pearl: All employees, community participants, and partners must understand the
purpose, protocols, and expectations of the mobilization practices and reinforce those practices
to ensure lasting culture change.
Provision of Appropriate Equipment at All Care Points
On arrival to the hospital, Janet saw a blower on the stretcher she was transported on, which
was used to inflate the air mat she was on. Staff noted the blower had been signed out on the
log, which kept track of the inventory. When transported to the imaging and cardiac
catheterization department, staff inflated the air mattress so that Janet could be easily
transferred between surfaces and positioned for the tests and treatments.
When changing Janet’s bed the first day, her repositioning sling was replaced with a fresh one. The staff informed her that the sling could be replaced with a clean one whenever needed because their unit maintained a sufficient inventory of slings to ensure they were always accessible. Throughout her hospitalization, Janet observed staff using a variety of equipment for patient
mobilization. It was evident to her that there were systems in place to ensure the equipment
was functional and available. This made her recall some of her past patient mobilization
experiences, including the crank lifts she used early in her career and the reluctance
surrounding their use due to difficulties finding slings, challenges using the equipment in
patients’ rooms, and lack of training provided on how to properly use the equipment.
Practice Pearl: To provide optimal and effective patient mobilization, mobilization equipment
must be appropriate for the task, in adequate supply, available for use, and functional at all
points of care. Additionally, it must be usable under beds and around treatment tables,
equipment, furniture, and other potential obstacles. Any identified barriers to use must be
eliminated.
Fostering Complete Culture Change and Identifying Best Practices
While Janet was hospitalized, the unit manager visited to make sure all her needs were met.
The manager asked Janet questions about her safety and about the quality of care the staff
were providing. During the conversation, Janet shared that she retired from working at that
very hospital’s ICU more than 15 years ago. She related her surprise at the use of equipment to
support her mobilization instead of the hands-on approach with which she was familiar. What
she was most curious about was the caregivers’ compliance with the use of equipment. She
stated that healthcare workers during her career were resistant to change and would often
state, “this is how we have always done it,” as the reason for not changing practices.
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The unit manager related that the hospital started the change seven years earlier. Initially, the
organization purchased ceiling lifts for the ICU beds, mobile lifts for the other patient care
areas, as well as slings and other necessary accessories, and provided hands-on training for all
staff. For a while, she stated there was a reduction in staff injuries related to patient
mobilization, but the following year the number and cost of those injuries nearly doubled. In
addition, the hospital had chosen to use disposable slings, which added substantially to costs
and quickly eliminated any cost-effectiveness of the project. The evidence from this experience
made it clear to the organization that additional changes were needed to permanently change
staff’s care practices.
The unit manager then shared that after this frustrating experience, Prevent, Inc. was
contracted to help identify and implement the necessary changes. Prior to hiring, the hospital
contacted Prevent, Inc.’s references to verify success. These healthcare organizations
reinforced that long-term success would be directly related to the hospital’s commitment to
dedicating the resources to implement and develop the patient mobilization practices. The
references also stated that the resources provided by Prevent, Inc., along with the hospital’s
investments in equipment and support, would dramatically reduce the number and cost of
patient mobilization injuries.
Janet was pleased to learn this was a nurse-led initiative and wanted to know more about the
process for changing the practice. The Unit Manager stated Prevent, Inc.’s nurses provided the
hospitals’ executives and department directors with the overall changes required to implement
safe patient mobilization practices. Many hospital departments and providers had a role in
changing this practice, including all physicians, wound care nurses, in-patient units,
rehabilitative services, operating and recovery, imaging, risk management, admissions,
biomedical, laundry, communications, marketing, infection control, and purchasing. After this
initial session, the needed department managers helped to identify action plans to integrate
and support the needed changes. A comprehensive project plan summarized area tasks,
timelines, and persons responsible to ensure the changes were made. All changes required
completion within 90 days. Throughout the development of the changes, Prevent, Inc.’s nurses
provided ongoing support and direction.
To identify equipment and specific training needs for each patient care area, Prevent, Inc.’s
nurses met with focus groups and completed a walkthrough of the units. The layout of the units
and existing equipment was used to project the type and amount of equipment needed and
specific training needs.
An area that required extensive planning was the setup for onsite laundering of cloth slings and
accessories. To justify this change, Prevent, Inc. provided a cost comparison on the use of
disposable products with laundering cloth products in-house. This financial comparison
illustrated that the in-house laundering of cloth slings would be significantly less expensive.
Subsequently, staff members were hired, procedures were developed, training was provided,
commercial washers were installed, and racks were mounted to hang slings for air-drying. The
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in-house infection-control nurse reviewed the temperature and handling of soiled slings to
ensure infection-control guidelines were met within the proposed practices.
In addition to the laundering of the slings, laundry staff members were responsible for
inspecting slings with each wash, removing any slings with signs of damage, documenting these
inspections, and managing the master inventory of all products. To ensure slings and
accessories were always available for use in patient care areas, the laundry staff helped to
establish and maintain a predetermined inventory of type and size of sling and accessories for
each unit and were also responsible for pick-up of soiled slings. Ongoing evaluations of sling
availability were conducted to ensure these products were accessible and sufficiently available
to staff.
The manager noted that in the three years prior to the implementation of the program, at least
32 caregivers each year sustained injuries from helping patients with their mobilization. The
average annual cost each year for these injuries exceeded $762,000. In contrast, in the 4 years
since the program’s implementation, about 4 employees have been injured annually, with an
associated average cost of $112,000 per year. Within 3 years, reduction in costs related to
employee injuries paid for all expenses related to the program’s implementation. The manager
ended with, “Although this change didn’t happen overnight and takes ongoing focus, all of our
efforts have resulted in a much safer workplace for our employees and patients and a more
financially efficient business.”
Practice Pearls: Prior to hiring patient mobilization consultants, it is essential to verify their
experience by contacting their customers and gathering information on the following:
1. Support given to identify the needed changes to patient mobilization practices and the
expected outcomes of addressing these changes
2. Resources provided to develop leaders’ effectiveness to support the change
3. Clearly defined expectations to when equipment is to be used for patient mobilization
4. Resources used to determine and communicate patient mobilization needs
5. Strategies used to imbed triggers and reinforce change of practice into existing care
practices
6. Training resources provided during implementation and for new hires
7. Education and healthcare experience of those who provided training
8. Support provided after training to further develop caregiver competency with the use of
patient mobilization practices
9. Tools and strategies provided for ongoing evaluation and development of each unit’s
practice
10. Benchmarks and measurement tools used to analyze the effectiveness of the program
11. Cost-effectiveness of equipment recommendations, both initially and on an ongoing
basis
12. Processes implemented to ensure equipment is available and functional
13. Evidence used to support the success of the changes.
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Hands-on Staff Training and Competency Verification
Throughout Janet’s hospitalization, many of the people who provided her with services,
including the housekeeping personnel who cleaned her room daily, discussed various aspects of
the patient mobilization program with her. As a former nurse, Janet became aware that the
hospital had supported the change in the patient mobilization practice through education for all
the staff. This in turn supported and helped to strengthen the change in practice.
Janet learned from the direct-care staff that they had all completed an in-depth, hands-on
training session and continued their learning from experienced, patient mobilization nurses
who also provided support with using the equipment with their patients. All agreed that having
experienced staff in the room facilitated learning by doing and that the mentoring was
invaluable in building their competency and compliance with the use of the equipment.
Practice Pearl: All staff in all departments require training appropriate to the scope and
expectations of their jobs, with competency further developed via mentoring from hands-on,
experienced patient mobilization nurses. After training, to ensure all staff are proficient with
the new patient mobilization practices, their competency with determining and communicating
patients’ mobilization needs as well as their use of equipment to lift, transfer, and reposition
patients should be evaluated at the point of care. If weaknesses are identified, additional
training and support must be provided until competency is demonstrated.
Patient Mobilization – Using Equipment to Improve Patient Outcomes
Janet felt weak and fragile the morning after her procedure and was unable to independently
move from a lying to a seated position. To progress her mobilization, minimize shearing of her
skin, eliminate the risk of injury to her caregivers, and support her return to independence, a
total lift and repositioning sling were used to first elevate and suspend her upper body in a
semi-upright seated position. When stopping the lift, Janet’s caregivers confirmed all sling loops
were securely fastened to the device. Pausing Janet in the semi-upright position required her
abdominal muscles to tighten, a strategy used to help recondition and build her core strength.
After this pause, Janet’s caregivers continued to lift and position her in an upright-seated
position with her legs dangling off the side of the bed. Initially, the nurse noted an increase in
heart rate and a drop in blood pressure, and Janet said that she felt dizzy and weak. The nurse
continued to support Janet with the ceiling lift and sling and within 10 minutes Janet began to
feel stronger and was able to sit upright independently. After sitting for 15 minutes, Janet was
positioned back in a reclined position with the sling and lift.
Later in the day, to continue her progressive mobilization plan, the lift and sling were used
again to engage Janet’s abdominal muscles and then position her in a seated position on the
side of the bed. This time there was no indications of dizziness or weakness and her activity was
progressed; however, before this was undertaken, Janet was informed of the procedures
involved and a nurse performed an examination to gauge her safety. During the examination, it
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was noted that Janet could maintain an upright position while seated, indicating core strength;
could lift and kick her legs against applied pressure, demonstrating leg strength; and with feet
on the floor could push her buttocks off the bed and lower herself back down, demonstrating
the ability to weight bear. Since this was her first time standing, to comply with the unit’s
protocols, a stand aid was used to reduce her risk of falling. This non-motorized assist device
required Janet to pull up to a standing position and weight bear before assuming a seated
position, and to repeat this activity sequence on her return to bed. This progression of Janet’s
mobilization was completed without skin shearing, falls, or injury to her caregivers.
When Janet questioned why she required a stand aid, the nurse explained that imposed bed
rest slows the body’s ability to respond to changes in position. Slowly progressing her activity
and providing support for safety allows her body to build her physical strength without
complications. The nurse reminded Janet of all the benefits of just standing upright, including
strengthening the quadriceps from the demand of supporting the body; cardiovascular benefits
by increasing blood volume requirements; reduced risk of pneumonia from the lungs being able
to fully expand; reduced risk of blood clots from improved blood circulation in the legs; reduced
risk of osteoporosis from increased absorption of calcium due to increased weight bearing on
the long bones; and improved overall mood from increased activity.
Practice Pearl: Reducing patients’ risk of complications during a hospital stay must include
progressing the frequency and duration of their mobilization. Evidence shows that lying down
shifts 11% of the total blood volume away from the legs and towards the chest and that
immobility can reduce overall blood volume, increasing the risk of blood clots. [Volman_2010]
Additionally, studies show that physical deconditioning related to hospital stays can negatively
impact a patient’s quality of life after hospital discharge. [Volman_2010] Using equipment to support
the continuum of mobilization protects patients and caregivers from injuries and engages the
physical response needed to sustain and improve recovery time.
The Evidence Reflects New Mobilization Practices Are Effective
On hospital discharge, Janet had no evidence of skin breakdown despite being at high risk for
this complication due to her older age, lying prone for many hours between her admission and
transfer to the in-patient unit, and numerous lateral transfers and positionings in bed. Janet
also did not fall, despite having felt dizzy and weak, and none of Janet’s hands-on caregivers
were injured while providing her with mobilization support.
On reflection after hospital discharge, Janet recognized how progressing her mobilization was
used as a therapeutic intervention to support her recovery. This focus increased her awareness
of the importance of physical activity to improve and sustain her health. She was also well
aware of how the change in the care delivery significantly reduced her risk of complications
related to immobility. Lastly, she could not help but think that if these changes were made
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during her career, she would most likely not have suffered with chronic and sometimes
debilitating back pain which forced her to leave nursing earlier than she wanted.
Practice Pearl: Evaluating outcomes by measuring against benchmarks and goals supports the
development of a successful patient mobilization program. Analysis of outcomes to strengthen
the practice includes patient and employee satisfaction surveys; audits of findings from reviews
of compliance with practice and the efficacy of support practices; investigations of incidents to
determine root cause; and implementation of appropriate interventions to reduce risk, all of
which can evolve to better meet needs and strengthen the program.
Summary
In the increasingly complex healthcare environment, organizations must find ways to attract
and retain staff and reduce negative outcomes to patients and caregivers. An often neglected
but highly effective solution is to integrate effective patient mobilization practices into patients’
plans of care. These practices can enhance healing time while reducing the length and cost of
hospital stays. Additionally, the physical demands placed on nurses and other healthcare
providers are lessened, thereby decreasing the risk of injury.
An effective patient mobilization program saves precious healthcare dollars by enabling
healthcare organizations to retain healthcare staff, including older workers; prevent costly
injuries among patients and staff; and reduce unnecessary hospital expenses.
References
AHC Media. Needlesticks, sharps injuries dropping but safety device push must continue.
