Safe Patient Handling Program

The physical stresses and exertion involved in caring for patients can lead to back injuries and other musculoskeletal issues.

Musculoskeletal injuries include damage to muscles, ligaments, tendons, nerves, bursae, joints, and cartilage, including intervertebral discs. Symptoms of damage can include:

• Pain or swelling.
• Numbness, burning, or tingling sensations.
• Loss of mobility around particular joints.

These injuries generally result from the long-term cumulative physical effort of patient transfers as well as acute effects resulting from incidents during transfers. They may also develop from a "peak load." Peak loads occur when a one-time task or event requires the body to perform above its capacity.

An ergonomic approach to patient handling, part of an overall program to reduce musculoskeletal injuries, can benefit caregivers and employers alike.

A health and safety policy is the commitment by the employer to provide and maintain a safe workplace.

When the workplace parties develop an ergonomic approach to patient handling, they will develop terms of reference that set forth how the workplace will function in approaching this problem and reach its goal of reduced injuries.

In general, a safe patient handling program will involve the following steps:

• Approval and commitment by management to develop and implement a patient handling program.
• Develop a joint program committee with input from management, workers, union (if present), health and safety committee, etc.
• Perform a needs analysis.
• Create and standardize patient assessment criteria.
• Develop decision trees to standardize actions.
• Determine which controls are needed to implement specific tasks or patient needs.
• Institute a "no-lift" policy, where possible.

The needs analysis should review and document, on an ongoing basis, the causes of injuries that occur during patient handling. Including caring for aggressive patients and residents. Document the number of injuries and all the relevant details needed to eliminate hazards and develop work practices that will ensure prevention.

The committee performing the needs analysis should be represent the entire facility - all areas, shifts, and all groups of workers who have experienced musculoskeletal injuries or those who are likely to be handling patients as part of their work.

It may help to use a survey to gain the input of workers. If needed, prepare a questionnaire that can be completed anonymously.  Ask for details about hazards and for suggested solutions. Questions can include the topics of workload, tasks, frequency, available assistive devices, and work environments that the workers perceive as high risk.  

The committee should analyze the data from the questionnaire combined with their own investigation, observations, and experiences. Gather injury and incident inspection data.

This information is needed to determine high-risk activities and to establish baseline injury data to which future injury data can be compared (e.g., compare injury frequency after a mechanical lift is installed versus before).

Conduct a site visit to observe each work environment or area.  The goal is to evaluate injury data and to match it to equipment and space issues, physical layout, storage availability, maintenance or repair issues, and staffing.

Yes. Carefully analyze the number of patients or residents assigned to staff members, the number and duration of tasks required for these specific clients, and the time allotted to caregivers in order to assess the workload. Excessive workloads can be hazardous to clients as well as to caregivers.

In-patient handling, there is a distinction between a patient transfer and a lift.

• A transfer is a dynamic effort in which the client aids in the transfer and is able to bear weight on at least one leg.
• A lift involves moving a client who cannot bear weight on at least one leg. Lifts should always involve mechanical lifting devices.

Injuries to caregivers during patient transfers usually occur when a transfer suddenly becomes a lift. Therefore, assessment of the client's capabilities becomes a critical component of any patient-handling program. Clients who might suddenly lose their balance must be identified to determine whether two caregivers are necessary for the transfer or whether a mechanical device is necessary.

The relative sizes of the caregiver and the client must be considered when determining the need for additional staff to aid in a transfer or the need for a mechanical lift. The weight and height differences may make mechanical assistance necessary.

An assessment of the individual patient must be performed to determine the proper transfer method and to clearly outline the client's degree of mobility and physical impairment.

Patient assessment criteria may include:

• How much assistance does the patient require?
• What is the weight bearing capacity of the patient?
• Does the patient have enough upper body strength to support their weight during the transfer?
• Is the patient cooperative, and can they understand instructions?
• Is the patient able to cooperate with each lift, or does this change each time (e.g., time of day)?
• Are there physical characteristics that should be noted (height, weight, age)?
• Are there special circumstances such as injuries, presence of tubes, history of falls, osteoporosis, fractures, pressure ulcers, splints, history of spasms, etc.?

This information must be clearly communicated to all staff that may care for the client including staff that may be filling in for workers who are ill or on vacation.

Appropriate symbols and codes can communicate whether the client is capable of an unassisted transfer, can bear his or her weight on at least one leg during an assisted transfer, or requires a mechanical lift.

The ability of the patient to communicate with the caregiver to either identify physical limitations or to aid in the transfer will also determine the need for a mechanical lift.

Mechanical lifts should be available in all situations where the patient or resident cannot bear weight on at least one leg.

The adequate number, variety, and placement of mechanical lifts will need to be determined by the committee undertaking an ergonomic analysis of the workplace.

Training needs should also be assessed by the committee. Are new workers receiving appropriate training and orientation regarding safe transfer techniques, patient assessment, and the proper use of mechanical lifts? Are workers receiving ongoing in-service training and refresher training?

Workers should also be informed about the importance of appropriate footwear and clothing. Proper footwear that is slip resistant and clothing that allows unrestricted movement can significantly reduce the chance of injury in transfers. Jewellery such as necklaces or bracelets can become a hazard if the patient grabs at these objects during a fall.

The design and layout of a facility are critical in reducing risk factors for caregivers and clients.

The space and design of the patient room (including the bathroom) must allow for the free movement of the caregiver, patient, lifting devices, walkers, and wheelchairs.

The layout and space must also enable the caregiver to use proper body mechanics and transfer techniques.

Furniture should be of sufficient height to safely effect transfers. Furniture and equipment, particularly beds, should be adjustable to best ensure safe client handling.

Arms and legs on wheelchairs should be adjustable and removable. Cushions on wheelchairs should be secured so they cannot slip.

Grab bars should be sufficient in number and placement to aid transfers in the bathroom.

Commode chairs should have removable arms, legs, and footrests. A well-designed chair should also be stable and have a lap belt for the patient.

Geriatric chairs should also have removable arm and footrests to be used during transfers.

Bed rails should be light to allow operation by the caregiver with only one hand to reduce physical exertion.

Lighting should be adequate to accomplish necessary tasks. However, glare and lighting that is too bright can cause optical strain and eye stress.

Floors should be clean, but highly polished or wet floors may not provide good traction. 

The use of contracting colours that aid the visual perception of the elderly may reduce the chance of incidents during transfers or if the client is ambulatory. For example, if the seat or seat cushion is easily visible, it will help the elderly patient know where to sit. 

Wet, highly polished, or otherwise slippery floors can contribute to slip and fall hazards.

In addition to the physical layout of the workplace, equipment, staffing, and workload, the approach to the transfer or lift is a key element in reducing caregiver injuries.

Proper documentation and communication should inform the caregiver of the patient's abilities, transfer needs, physical stability, and tendency if any, towards aggressive acts.

The caregiver should anticipate what actions would be necessary if the patient loses balance or falls.

The procedure for the transfer should be clearly communicated and understood by any other worker assisting the patient.

The caregiver should assess the client, even briefly, before every transfer.  Any mechanical lifting device must also be inspected before use, including any accessories such as slings, belts, or discs.

The client should be transported at the shortest possible distance by the lifting device. The mechanical lifting device should not be used to transport the patient outside the room.

When performing transfers or lifts:

• In transfers, tighten your abdominal muscles, keep your back straight, and use your leg muscles to avoid injury.
• Do not rotate or twist the spine. Move your entire body in the direction of the transfer.
• Never grab the client under their armpits as this grip could injure the person.
• Position yourself close to the patient and make sure your footing is stable.
• Try to maintain eye contact with the client and communicate while the transfer is in progress.
• Never allow the patient to grasp you around the neck as this action could result in injury.
• Agree on the timing of the transfer with the patient and other caregiver(s) and count together.
• Assure that the path of the transfer or lift is clear from obstructions and that the furniture and aids that the patient is being transferred to are properly placed and secure.

Injury to the caregiver and patient can occur when transferring aggressive patients.

Caregivers have a legal right to know if the patient they are caring for has a history of aggressive behaviour.

Caregivers must receive proper training and have the assistance of other properly trained staff when dealing with potentially violent patients.

The reasons for patient anger and hostility can be complex. Workers should be trained to identify the signs of potential aggressive behaviour, the triggers that can lead to violent outbursts, means of de-escalating an aggressive encounter, and emergency procedures to follow if retreat from an aggressive patient is not possible or an attack occurs.

Emergency communication and security procedures and systems need to be in place before they are needed.

All aggressive incidents should be documented and reported to the supervisor and the health and safety committee.

A no-lift policy would state that all manual handling tasks are to be avoided when possible.  No-lift policies successfully reduce the risk only if the organization has the infrastructure in place (e.g., technical solutions, lifts, equipment) to support the initiative. Training is also necessary for caregivers to recognize the risk in activities, and how to follow appropriate steps to move or transfer a patient safely.

More information* is available from: 

• WorkSafeBC: Patient Handling
• Occupational Health Clinic for Ontario Workers: Patient Handling for Healthcare Workers
• US Occupational Health and Safety Administration: Safe Patient Handling

(*We have mentioned these organizations as a means of providing a potentially useful referral. You should contact the organization(s) directly for more information about their services. Please note that mention of these organizations does not represent a recommendation or endorsement by CCOHS of these organizations over others of which you may be aware.)