edicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2013;94:17-22

FEATURED ARTICLE

Effect of a Safe Patient Handling Program on RehabilitationOutcomes

Marc Campo, PT, PhD,a Mariya P. Shiyko, PhD,b Heather Margulis, PT, MS,c

Amy R. Darragh, OTR/L, PhDd

From the aSchool of Health and Natural Sciences, Mercy College, Dobbs Ferry, NY; bDepartment of Counseling and Applied EducationalPsychology, Northeastern University, Boston, MA; cHebrew Rehabilitation Center, Boston, MA; and dDivision of Occupational Therapy, School ofHealth and Rehabilitation Sciences, The Ohio State University, Columbus, OH.

Abstract

Objective: To evaluate the effect of a safe patient handling (SPH) program on rehabilitation mobility outcomes.

Design: Retrospective cohort study.

Setting: A rehabilitation unit in a hospital system.

Participants: Consecutive patients (NZ1291) over a 1-year period without an SPH program in place (nZ507) and consecutive patients over a 1-

year period with an SPH program in place (nZ784).

Interventions: The SPH program consisted of administrative policies and patient handling technologies. The policies limited manual patient

handling. Equipment included ceiling- and floor-based dependent lifts, sit-to-stand assists, ambulation aides, friction-reducing devices, motorized

hospital beds and shower chairs, and multihandled gait belts.

Main Outcome Measures: The mobility subscale of the FIM.

Results: Patients rehabilitated in the group with SPH achieved similar outcomes to patients rehabilitated in the group without SPH. A significant

difference between groups was noted for patients with initial mobility FIM scores of 15.1 and higher after controlling for initial mobility FIM

score, age, length of stay, and diagnosis. Those patients performed better with SPH.

Conclusions: SPH programs do not appear to inhibit recovery. Fears among therapists that the use of equipment may lead to dependence may be

unfounded.

Archives of Physical Medicine and Rehabilitation 2013;94:17-22

ª 2013 by the American Congress of Rehabilitation Medicine

In health care settings, manual patient handling tasks (such astransferring a patient) result in excessive physical loads that canlead to injury.1,2 Manual patient handling has been associated withinjuries to health care providers such as nurses, physical

Presented to the Safe Patient Handling and Movement Conference of the Veteran’s Admin

istration Sunshine Health Network, March 18e22, 2012, Orlando, FL; presented as a poster to the

Combined Sections Meeting of the American Physical Therapy Association, February 8e11, 2012

Chicago, IL.

Supported by the Agency for Healthcare Research and Quality (Small Research Award, gran

no. R03 HS020723-01).

No commercial party having a direct financial interest in the results of the research supporting

this article has or will confer a benefit on the authors or on any organization with which the author

are associated.

An audio podcast accompanies this article.Listen at www.archives-pmr.org.

0003-9993/13/$36 - see front matter ª 2013 by the American Congress

http://dx.doi.org/10.1016/j.apmr.2012.08.213

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therapists, and occupational therapists.3-5 In response to high ratesof injuries of health care providers and patient falls, hospitalsacross the United States have implemented safe patient handing(SPH) programs.6-8 These programs limit the manual handling ofpatients through a combination of policies and patient handlingtechnologies.6,9-11 The primary focus of most programs is onpolicies and equipment that are designed to reduce the physicalloads associated with common patient handling tasks such astransfers, repositioning, ambulation, and arresting falls.11-13

Settings for SPH programs include acute care, rehabilitation,and long-term care, where patient lifting is common. SPHprograms have reduced the incidence of provider injuries andpatient falls.6-8,14-16 They also have decreased lost work time andreduced workers’ compensation costs.17 However, the effects ofthese programs on patient recovery and rehabilitation are rela-tively unknown.

habilitation Medicine

18 M. Campo et al

Rehabilitation services, in particular, are substantially impactedby SPH programs.18,19 In traditional rehabilitation settings, nurses,physical therapists, and occupational therapists provide assistancewith patient functional mobility (eg, ambulation and transfers),retraining patients to walk and transfer by lifting them and guardingthem manually. In rehabilitation settings with SPH programs, theyuse advanced patient handling equipment to support or lift thepatient while they guide these activities, particularly when patientsare very heavy and/or dependent.19,20Although therapists are athigh risk for injuries and work-related pain,3,4 opinions on SPHprograms in rehabilitation are mixed. Among therapists, a beliefpersists that using patient handling equipment in rehabilitation mayimpede recovery.18 These devices were designed primarily forpassive patient movement and not rehabilitation,21 potentiallylimiting their usefulness as rehabilitative tools. A study of stand-assist devices, for example, found that equipment-assisted trans-fers were preferable to a poorly executed manual transfer butstill did not promote normal movement patterns. The samestudy also found that equipment may promote passive participationin the transfer.22

Arnold et al23 reported positive effects of SPH equipment onrehabilitation. They found that patients with stroke who underwentrehabilitation under an SPH program had greater improvements inmobility FIM scores than did patients with stroke who underwentrehabilitation without the program. The study, however, was basedon a small sample of patients (nZ94) with a single diagnosis.

In our own qualitative work examining the use of SPH equip-ment in rehabilitation, therapists in facilities with established SPHprograms described advantages to using the equipment duringpatient care.18,19 In addition to increased staff and patient safety,therapists reported that patients demonstrated increased participa-tion and activity, and therapists were able to mobilize bariatric andmedically complex patients earlier in the rehabilitation process.19

However, they also identified important limitations of the devices(eg, sling design and equipment maneuverability) as well aslimitations in device usage (depending on patient, environment, andactivity characteristics).

These initial studies provide some evidence for the usefulnessof SPH programs in rehabilitation, particularly for addressingfunctional mobility and for mobilizing patients who require themost assistance. However, given the design and sample sizelimitations of these studies, more formal evaluations, based onlarger and representative samples, are warranted.

The number and scope of SPH programs are increasing. TheVeteran’s Administration, for example, has recently implementeda large-scale initiative to implement SPH programs in all theVeteran’s Administration inpatient facilities.24 In addition, as of2012, 10 states had enacted some form of SPH legislation, withsome requiring full SPH programs in facilities.25 Other laws weredemonstration initiatives designed to promote SPH programs andincrease adoption. Considering the number and scope of SPHprograms, and the fact that they fundamentally alter patient care,there is an urgent need to examine the effect of SPH programs onpatient functional mobility in rehabilitation. The purpose of thisstudy was to determine the effect of an SPH program on patientfunctional mobility outcomes, as measured by the FIM.

List of abbreviations:

BMI body mass index

SPH safe patient handling

Methods

Study participants

This was a retrospective cohort study of patient rehabilitationoutcomes before and after the implementation of an SPH program.We obtained data from the electronic medical records of 1315patients admitted to the rehabilitation unit of a large hospital centerin Massachusetts. Any patients who died during rehabilitation orwho had a stay of 2 days or fewer on the rehabilitation unit wereexcluded from the study. The purpose of excluding patients withshort stays was to eliminate unstable patients who were likelytransferred out of the recuperative services unit shortly afteradmission. Based on this criterion, 23 patients were excluded (10 in1 group and 13 in the other group). An additional patient wasdropped from the analysis because of an unusually prolongedhospital stay (140 days, z scoreZ9.3). The final sample comprised1291 patients. The materials and methods of this project wereapproved by the institutional review boards of Hebrew Rehabilita-tion Center, Mercy College, and The Ohio State University.

Intervention

Intervention (SPH) and comparison groups (No-SPH) occurredhistorically within the same hospital at 2 different time periods. Thecomparison group was composed of 507 patients admitted torehabilitation between July 2005 and July 2006, prior to theimplementation of the SPH program. The intervention group wascomposed of 784 patients admitted to rehabilitation between April2008 and April 2009. We did not consider any patients admittedbetween August 2006 and March 2008 to allow the program to befully implemented. This provided therapists with time to becomecomfortable with the equipment and allowed them to fully transi-tion into the work environment with new practices and standards.

The SPH program consisted of administrative policies, equip-ment, and a decision-making algorithm. Under this program,patients with a body mass index (BMI) >35 required a pread-mission consultation to select bariatric lift equipment. For allpatients admitted, regardless of BMI, all staff members exceptphysical and occupational therapists were required to use patienthandling equipment with 2 exceptions: patients could be manuallyhandled if they required only close supervision or contact guard orin the event of emergencies. For physical and occupational ther-apists, the requirement was to use equipment if a task required>15.9 kilograms (35 pounds) of effort or if a patient requiredanything more than minimal assistance. A level of 15.9 kilogramswas based on recommendations from the National Institute ofOccupational Safety and Health.26 The program was designed togive therapists more latitude when working on rehabilitationactivities while still reducing the risk from excessive loading.

Equipment included floor- and ceiling-based dependent patientlifts, sit-to-stand assists, motorized hospital beds, ambulationaides, multihandled gait belts, and powered shower chairs.Therapy staff members were trained in the use of equipment uponhiring and were required to pass competency evaluations. Therapyunits had “peer leaders” who were available for consultation.

Outcome measure

The outcome measure was the functional status of patients asdetermined by the mobility portion of the FIM. Admission FIM

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Safe patient handling effects on rehabilitation 19

scores were determined by the lowest score observed by any inter-disciplinary member of the care team in the first 3 days followingadmission. Discharge FIM scores were determined by a similaralgorithm in the 3 days prior to discharge. The FIMmeasure consistsof 18 items, each rated on a 7-point scale by health care professionals(usually physical therapists, occupational therapists, and speechpathologists), where a score of 1 indicates total dependence anda score of 7 indicates complete independence.

The FIM categories and individual items are described infigure 1. In the current study, we defined the mobility FIM as thetotal of the 2 locomotion and the 3 transfer subscales. Thesesubscales were chosen because function in these activities was themost likely to be affected by the use of SPH devices in rehabili-tation. The FIM has demonstrated good reliability. In a meta-analysis including 11 studies, Ottenbacher et al27 found pooledmedian reliability coefficients of .95 for both interrater and test-retest statistics. In a systematic review, Glenny and Stolee28

found internal consistency values for the total FIM ranging from.88 to .97 and values for the motor domain of the FIM rangingfrom .86 to .98. The FIM has also demonstrated good construct29

and criterion validity.30,31 Therapy staff members were trained inFIM administration and were certified upon hiring. They wereretrained every 2 years thereafter.

Statistical analysis

Statistical analyses were conducted using SPSS Statistics v. 19a andIntercooled STATA v. 12.b We examined univariate statistics,distributional plots, and outliers for all variables. To establishbetween-group equivalence, we compared the intervention andcontrol groups on a number of demographic characteristics,including age, length of stay, and diagnosis. Group equivalence wasevaluated with independent sample t tests for continuous variablesand chi-square tests of association for categorical variables.

To evaluate the main research question of the effect of the SPHprogram on patient outcomes in rehabilitation, we used a linear

Fig 1 The FIM categories. The FIM includes 6 categories and 18

individual items, each rated from 1 to 7 by rehabilitation staff. The

mobility FIM is the sum of all the transfer and locomotion items.

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regression model. The primary predictor was group, coded asa dummy variable (0ZNo-SPH, 1ZSPH), and the outcome wasdischarge mobility FIM scores. We considered baseline mobilityFIM scores, age (in years), length of stay (in days), and impairmentcodes (diagnosis) as potential confounders and effect modifiers.The FIM includes 17 impairment/diagnostic codes, with eachhaving several subcategories. We recoded impairments into 1 of thefollowing diagnostic groups: orthopedic, neurologic, cardiopul-monary, and medical complexity/debility impairments. The largestgroup (complexity/debility) was designated as the reference group.All continuous predictors were mean centered. Regressionassumptions, including linearity, homogeneity of variance, homo-scedasticity, normality, and absence of multicollinearity, wereassessed graphically and statistically. Heteroscedasticity was notedin plots of residuals and statistical tests (Breusch-Pagan/Cook-Weisberg; P<.01). To account for the departure from the homo-scedasticity assumption, we used the robust SEs to calculate Pvalues, SEs, and confidence intervals (HC3).32 Multivariate outlierswere assessed through the plots of residuals and Cook’s distance.

We considered an interaction between group and baselinemobility FIM scores to assess a potential differential effect oftreatment for patients admitted to the hospital at different levels ofinitial function. Plausible interactions between SPH group andage, group and length of stay, and group and diagnosis were alsoevaluated. Based on a significant interaction between group andbaseline mobility FIM scores (PZ.02), the Johnson-Neymantechnique was used to determine regions of significance.33

Specifically, we wanted to identify levels of baseline mobilityFIM scores that were associated with differential effects of theSPH program on the discharge scores.

Results

Demographic characteristics by group are described in table 1. Thegroups were comparable in their admission mobility FIM scores.The groups differed in terms of age (tZ2.67; PZ.01) and length ofstay (tZ2.11; PZ.03). The distribution of impairment codes wasdifferent between the groups (c2Z23.81; dfZ3; P<.01). TheNo-SPH group had a greater proportion of patients with neurologic(c2Z14.0; dfZ1; P<.01) and cardiopulmonary impairments(c2Z4.4; dfZ1; PZ.04). The SPH group had a greater proportionof patients with medical complexity and/or debility impairments(c2Z11.7; dfZ1; P<.01). Both groups had roughly equal propor-tions of patients with orthopedic impairments.

Figure 2 represents a graphical summary of mean mobilityscores for each group at admission and discharge. No significantdifference was noted in the change in mobility FIM score fromadmission to discharge between the groups (tZ�.75; PZ.45).

Based on our regression model (table 2), there were nostatistically significant differences between the groups indischarge mobility FIM scores, except for patients who had highadmission mobility scores. Those patients performed better withSPH. The Johnson-Neyman significance region for admissionmobility was 15.1 and higher (No-SPH: nZ107; SPH: nZ138).This translates to a significant difference between the No-SPH andSPH groups when admission mobility scores were 15.1 or higherbut not when admission mobility scores were lower. For example,for subjects with admission mobility FIM scores of 16, the pre-dicted mean difference in discharge mobility FIM scores was .85,with subjects in the SPH group scoring higher after controlling forcovariates (BZ.85; 95% confidence intervalZ.11e1.57).

Table 1 Demographic and baseline factors

Factor No-SPH SPH P

Number of subjects (n) 507 784

Number of excluded

subjects (n)

10 14

Age (y)

Mean � SD 82.3�9.1 80.9�10.7 <0.01*

Median (IQR) 84 (78e89) 83 (75e88)

Length of stay (d)

Mean � SD 20.9�11.6 19.4�12.9 0.03*

Median (IRQ) 18 (14e26) 16 (11e24)

Mobility FIM at admission

Mean � SD 12.4�4.3 12.4�3.6 0.67*

Median (IQR) 12 (10e15) 12 (11e14)

Impairment group, n (%)

Orthopedic 188 (37.1) 294 (37.5) 0.88y

Neurologic 54 (10.7) 40 (5.1) <0.01y

Cardiopulmonary 94 (18.5) 111 (14.2) 0.04y

Medical complexity/

debility

171 (33.7) 339 (43.2) <0.01y

Abbreviation: IQR, interquartile range.

* Independent samples t test (unequal variances).y c2 test of association.

Fig 2 Mean mobility FIM scores at admission and discharge by

group. The bars represent the mean mobility FIM scores at admission

and discharge by group. The error bars represent 95% confidence

intervals (CI) of the mean mobility FIM scores.

20 M. Campo et al

Discussion

The purpose of this study was to determine the effect of the SPHprogram on rehabilitation mobility outcomes in a large and diversesample of patients. Our main finding was that for the majority ofpatients, both patient handling practices yielded similar functionalmobility outcomes. Differences emerged for a subgroup of patientswith high mobility FIM scores at admission. Higher functioningpatients appeared to do better with SPH. The difference in dischargemobility FIM scores between groups for patients with highadmission mobility FIM scores was close to 1 point. We areunaware of any studies of the minimum clinically importantdifference for the mobility FIM. Studies using the motor FIM(which includes all the 13 mobility and self-care categories) havefound minimum clinically important difference values of 11 pointsand 17 points.34,35 The 1-point difference found in the present studyrefers only to the mobility FIM scores, for which a total score of 35is possible. Clinically, a 1-point difference in the overall score maynot be meaningful. The difference could potentially result frommeasurement error or other sources of variation.

For the majority of the patients in this study, the SPH programresulted in similar or even slightly better mobility outcomes. Thismay mitigate concerns of therapists who fear that SPH programsmay lead to dependency and interfere with recovery of functionalmobility. Very small group differences may have been missed.However, our model was powered adequately to detect even smallclinically relevant differences. In our previous research, therapistsexpressed concerns that the use of equipment may be a hindrance torehabilitation, especially for higher functioning patients.18 In thecurrent study, the SPH program did not demonstrate an adverseimpact on mobility. The focus of the current study was on an SPHprogram. Future research should evaluate the equipment itself andthe efficacy of specific pieces of equipment in rehabilitation.

Our previous work also suggested that SPH programs may beparticularly useful for complex and low-functioning patients.18,19

Therapists in these previous studies reported that SPH equip-ment increased the options for therapeutic activities and allowedthem to mobilize patients earlier. We found no evidence of anadvantage for this subgroup of patients. Outcomes for patientswith lower admission mobility scores were similar in both groups.

An unanticipated finding is that comparable functionaloutcomes for the SPH group may have been achieved in a shorterlength of a hospital stay. Length of stay was not the primaryanalysis, however, and there were important group differences thatmay have influenced these results. More research should be con-ducted to determine the potential impact of SPH programs onlength of stay.

The findings of the current study contrast with those ofArnold,23 who found that an SPH program resulted in bettermobility outcomes for patients with stroke. Although our studyfound an improvement with SPH for a subgroup of patients, forthe majority of patients, there were no statistically or clinicallyrelevant differences. There were many differences in studymethods and populations that may have accounted for the differ-ence. The equipment and policies in the individual programs weredifferent. In addition, in the current study, we looked at a muchlarger, broader patient population with a variety of diagnoses.

Study limitations

To the best of our knowledge, this is the first study to evaluate theefficacy of the SPH program in a large and diverse sample ofpatients from a large urban hospital. Analyses of individual ratherthan aggregated data allowed us to account for important personalcharacteristics, such as age, length of stay, and diagnosis that havedirect implications on functional outcomes and can interfere witheffects of the SPH practices. Further studies should includemultiple hospital sites to ensure that effects are equivalent acrossdifferent hospital settings.

Another strength of the study related to the setting and theprogram implementation. This program included clear guidelinesfor equipment use. The program at this facility was implemented

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Table 2 Linear regression model of discharge mobility FIM scores

Variables Format Unstandardized B P 95% CI* Standardized b

Admission mobility FIM Mean centered 0.87 <0.01 0.74 to 1.01 0.49

Group 0ZNo-SPH, 1ZSPH 0.10 0.76 �0.53 to 0.73 0.01

Age (y) Mean centered �0.08 <0.01 �0.12 to �0.05 �0.12

Length of stay (d) Mean centered 0.03 0.12 �0.01 to 0.06 0.05

Diagnosis

Medical complexity/debility Reference

Orthopedic diagnosis 0ZNo, 1ZYes 2.63 <0.01 1.94 to 3.33 0.19

Neurologic diagnosis 0ZNo, 1ZYes �1.17 0.11 �2.61 to 0.27 �0.04

Cardiopulmonary diagnosis 0ZNo, 1ZYes 0.21 0.65 �0.71 to 1.13 0.01

Abbreviation: CI, confidence interval.

* CIs generated with robust SEs (HC3).

Safe patient handling effects on rehabilitation 21

relatively quickly, and no elements of the program were availablefor patients in the No-SPH group. All elements of the programwere available in the SPH group.

Despite these strengths, a number of limitations should beconsidered to aid interpretation of the results. The facilityconfirmed that no major changes in staffing qualifications, majorhospital policies, or health insurance reimbursement practiceswere instituted following the first period of data collection, otherthan the SPH program. However, more subtle changes that wehave not considered might have taken place and should beconsidered when interpreting the results. Another importantlimitation was our inability to determine the extent of equipmentuse in the SPH group. While specific guidelines and training wereprovided, we do not have data that would indicate how closely theguidelines were followed. Although equipment was mandated forlevels of assistance more than 15.9 kilograms or anything greaterthan minimal assistance, therapists estimated the level of assis-tance and we had no way to determine how accurate they actuallywere. In addition, equipment was used by the other hospital staff,including nursing. The effect of equipment use outside of therapycould not be determined but may have played a role in the results.

There were important differences between the groups in certainpatient characteristics. For example, our demographic analysisrevealed that patients in the SPH group had more medicalcomplexity diagnoses. These differences were controlled for inour regression model. It is possible, however, that the difference incase mix influenced the results in a way that the regression modeldid not capture. Data on other factors that may have influenced theresults were unavailable. For example, we had no data on BMI.One of the primary motivations for using SPH is the ability towork with heavier and more complex patients. BMI may playa role in mobility progress,36-38 and SPH equipment may beparticularly useful for obese patients.19 Moving forward, werecommend additional studies that account for BMI and the effectit may have on patient outcomes with and without SPH.

Use of the FIM as the primary outcome measure has limita-tions that should be considered. Although it is widely accepted asa reliable, valid, and responsive assessment of patient function,39

it is limited by the potential for inconsistent and inaccuratescoring, particularly when multiple raters are involved or whenequipment is used. In addition, scoring guidelines can result in aninaccurate picture of a patient’s abilities.40 Other performance-based measures such as the 6-minute walk test and timed upand go test or other measures such as the Barthel Index might beuseful additions to studies such as these to increase the overallmeasurement reliability.

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Clinical implications

Based on the current findings, it appears that mobilityoutcomes are similar or slightly better with SPH than withtraditional rehabilitation. Therefore, concerns about SPH andfunctional progress voiced by physical and occupational ther-apists may be unwarranted. Considering the high rate ofinjuries in health care workers overall and in therapistsspecifically,3,4 these programs could potentially play a largerole in preventing injuries while allowing for effective reha-bilitation. More research, however, is needed to determine theeffect of SPH programs definitively. Other functional outcomesbeyond mobility, such as self-care, are important to examine aswell. Studies with larger sample sizes and multiple settings arealso warranted.

As related laws and initiatives related to SPH continue toevolve, rehabilitation professionals are more likely to find them-selves working in facilities with SPH programs. It is thereforeimperative that they embrace SPH, contribute to the evolution ofequipment and programs, and learn to use equipment in ways thatmaximize rehabilitative potential.

Conclusions

To the best of our knowledge, this is the first study to evaluate theeffect of an SPH program on functional mobility outcomes acrossthe full range of rehabilitation diagnoses. Patients who partici-pated in rehabilitation with an SPH program in place achievedsimilar or slightly better outcomes than did patients who partici-pated in rehabilitation without an SPH program.

Suppliers

a. SPSS Statistics v. 19; SPSS: An IBM Company, IBM Corp, 1New Orchard Rd, Armonk, NY 10504.

b. STATA IC v. 12.1; StataCorp LP, 4905 Lakeway Dr, CollegeStation, TX 77845.

Keywords

Moving and lifting patients; Occupational therapy; Physicaltherapy techniques; Rehabilitation

22 M. Campo et al

Corresponding author

Marc Campo, PT, PhD, School of Health and Natural Sciences,Mercy College, 555 Broadway, Dobbs Ferry, NY 10522. E-mailaddress: mcampo@mercy.edu.

Acknowledgments

We thank Karen Drake, PT, GCS (Hebrew Rehabilitation Center),for her assistance with data acquisition; Lena L. Deter, RN, MPH,CSPHP, Clinical Program Specialist (Hebrew Senior Life), forproviding information about the safe patient handing program; andSusan E. White, PhD, CHDA (The Ohio State University), forstatistical consultation.

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