This is a CE-accredited article. A PDF of instructions and post-test are available here.
by Shannon Michael Gallagher, BA; William Charney, DOH;
and Laurie D. McGinley, RN, MS, CNS-BC, APN, CBN
Author Affiliation: Mr. Gallagher is an independent consultant on safety, outcomes and lift management. Mr. Charney is the former safety coordinator for Washington Hospitals Workers Compensation Program in Seattle, Washington. He is also the author/editor of more than 10 books and dozens of articles on hospital safety systems, needle safety systems, ribavirin, and more. Mr. Charney also received the 1997 Environmental Health Award from the State of California and the 2007 Advocacy Award from the Safe Patient Handling Conference. Ms. McGinley is the Bariatric Nurse Manager at Western Bariatric Institute of Reno, Nevada. Ms. McGinley has served as Vice President and President Elect of NABN and currently serves as President. She has worked in the hospital setting as well as office based.
Funding: This CE-accredited article was supported by an educational grant from KCI.
Financial Disclosure: Mr. Gallagher, Mr. Charney, and Ms. McGinley report no conflicts of interest relevant to the content of this article.
Bariatric Times. 2010;7(12):18–23
Despite administrative efforts at acquiring specialty patient handling equipment, caregivers continue to report injuries related to lifting, turning, and repositioning patients. This is especially true when caring for patients of size. As legislative mandates are driving changes in safety and outcomes, healthcare organizations are seeking creative methods to meet such mandates. Lift teams may serve as such a strategy. This article will review and discuss the definition of a lift team, its history, and benefits to both healthcare workers and patients and provide perspective from a lift team contract service.
Obesity is a global concern that has reached epidemic proportions in the United States. In 2007 and 2008, based on measured weight and height, approximately 72.5 million adults in the United States were considered obese. The Centers for Disease Control and Prevention (CDC) behavioral risk surveillance system indicated that in 2005, only four states in the United States had obesity prevalence rates less than 20 percent, while 17 states had prevalence rates greater than or equal to 25 percent, and three states had prevalence rates of 30 percent or more. Today, the number of people classified as overweight has reached an all-time high of 68 percent of the population, with as many as 30 percent categorically considered obese. Some authors argue the percentage of individuals with overweight and obesity may be nearly 80 percent. These data suggest that healthcare facilities face pressure to prepare for the needs of patients of size. In fact, one study reveals that patients with a body mass index (BMI) greater than 35kg/m2 comprise only 10 percent of the patient population; however, handling patients with a BMI greater than 35kg/m2 was associated with 29.8 percent of injuries, 27.9 percent of lost time, and 37.2 percent of restricted time. In this study, lifting, turning, and repositioning was usually performed using biomechanics and not equipment. Therefore, with increasing body weight and weight maldistribution of both patients and their caregivers, challenges inherent in lifting, moving, and repositioning the larger, heavier patient mandates special and creative strategies to prevent injury and promote patient safety.
In addition, there are staggering statistics surrounding caregiver injury, especially as they pertain to the various disciplines of nursing. According to a 2000 report by the Bureau of Labor Statistics (BLS), healthcare workers sustain 4.5 times as many overexertion injuries as any other type of worker. In 2002, a BLS report named the combined disciplines of healthcare work as the leader for frequency of on-the-job musculoskeletal injuries.[2–5] In 2007, a BLS report named the top 10 professions most likely to receive a back injury on the job. This top 10 list included certified nursing assistants, licensed vocational nurses, registered nurses, physical therapists, radiology technicians, and health aides as separate categories, saturating the list with healthcare workers. With very little improvement in healthcare worker injury rates, it seems that the only numbers that change in the BLS data are the years.
The cause of injuries is no mystery. Researchers have identified manual lifting, transferring, and repositioning of patients as the causes of musculoskeletal injury among healthcare workers, and these tasks become increasingly difficult and dangerous with bariatric patients. The use of lift equipment has been shown to decrease the rate of injury to patients and staff members; however, many facilities still do not provide adequate equipment and many staff members still do not use equipment provided, often due to storage, maintenance, or training issues.
In this article, we will review and discuss the lift-team model, an intervention that has proven to be effective in addressing both safe patient handling compliance and patient/caregiver injury, as well as the associated liability costs.
History of the Lift Team
Birth of the lift-team model. Experts recognized that manual lifting, transferring, and repositioning patients are tasks most commonly associated with back injuries among healthcare personnel. In fact, some researchers consider these injuries epidemic in proportion because not only are these activities stressful on the body by placing unacceptable lateral, shearing, and compression force on the spine, but nurses are older and heavier and patients are heavier and require more assistance. One study explains that nurses lift an average of 1.8 tons per shift worked. Further, Haidaven described organizational obstacles to safe handling, such as lack of available lifting aids, time pressure to perform tasks, and lack of available personnel. These compounding factors have led to numerous crises in healthcare including widespread caregiver injury, nursing shortages, and quantifiable adverse clinical outcomes.[15,16] Therefore, in an effort to manage these risks, the concept of the lift team was born.
In 1991, a study on lift teams was conducted at San Francisco General Hospital, San Francisco, California, a 250-bed, acute-care, urban facility. This study revealed statistically sound evidence suggesting the efficacy of lift teams. For the first time, researchers were able to quantify the relationship between the lift team and reduction of staff injuries, lost work days, and workers’ compensation insurance as set in premiums. Since that time, a number of peer-review studies have shown significant decreases in economic and humanistic costs using the lift-team model. Additionally, nurses have expressed a high level of satisfaction with the lift-team model.
Defining the lift-team model. The lift-team concept was developed to absorb the work identified as being most dangerous to nursing staff members, specifically lifting, turning, and transferring immobile patients. Lift teams are composed of at least two individuals, determined to be at low risk for musculoskeletal injury and trained in the use of the wide variety of safe-patient-handling equipment and accessories available. The sheer number of options presented by contemporary equipment make selection of the proper hardware difficult for those who might not use it on a daily basis, regardless of training. By mobilizing patients more often, lift teams reduce length of stay; however, the lift team is not intended to be used for patients who are ambulating independently. For example, a cooperative patient with improving upper body strength would not warrant a lift-team rotation. When a patient is determined to be a candidate for lift team attention, the nursing staff coordinates with the lift team to ensure that the patient receives regularly scheduled rotations and spontaneously scheduled lifts and transfers until the patient is able to ambulate independently. Some facilities that have implemented lift teams include the following: Tampa General Hospital, Kaiser Permanente, Mayo Clinic, John Muir Health, University of California Davis Medical Center, University of California San Diego Medical Center, University of California Los Angeles Medical Center, and University of Chicago Medical Center. Successful lift-team implementations have reduced patient injuries by 70 percent, employee injuries by 88 percent, lost workdays by 90 percent, and have increased morale by 97 percent.
All members in a lift team should be familiar with the facility’s lift equipment and practices. The team aspect allows lift teams to perform equipment-assisted lifts, turns, transfers, and rotations efficiently because no time is spent waiting for the assistance of additional caregivers, a situation that often plagues nursing staff members. Familiarity with the equipment is instilled in training and is continually reinforced in practice, ensuring that lift equipment is accessible, properly used, and in proper working order. This eliminates difficulties surrounding proper selection of equipment and accessories, such as slings and bands. In addition, a primary hurdle for caregivers using equipment is storage. Simply, if a piece of equipment is difficult to locate or retrieve from storage, a lift may be performed manually due to time constraints. The lift team, who regularly use equipment on the floor, is responsible for knowing the exact location and condition of equipment.
Perhaps the most important statement to keep in mind when considering lift teams is this: Lifting is a skill, rather than a random task. This is, perhaps, the shift in perception necessary to take the necessary steps to protect patients and caregivers and, in turn, improve the previously mentioned BLS data.
Evidence of Lift Team Success
Rethinking Lift Teams
Since the initial introduction of the lift-team concept in 1991, much has transpired in healthcare, particularly the advancement of lift equipment technology, the increasing number of patients of size, and the widening dialogue surrounding caregiver injury in the context of the nursing shortage. These factors have led many innovators to rethink lift teams. The logical place to begin rethinking of the lift-team concept is with a critical question: “What is the advantage of a relatively small number of highly trained support staff over a facility-wide comprehension and implementation of safe patient handling practices?” Certainly, an informed response to this question is that these approaches are not mutually exclusive. The true advantages of the lift team cannot be realized without the support and cooperation of the nursing staff members. Staff members, in turn, benefit from the proper use of the lift team by regaining time lost to physically demanding, repetitive activities—time that could be devoted to patient care.
Lifting with and without equipment. The term physically demanding, repetitive activities was once reserved for the manual lifting, turning, transferring, or repositioning of patients, but new solutions inherently present new problems. The lifting problem is not solved simply by introduction of lifting equipment alone, as not all lifting equipment is equally safe by design or use. For example, according to a study by Marras of Ohio State University, 27 percent of facilities implementing zero-lift interventions, with nurses performing lifts, actually saw a rise in complaints of back pain. This is due to the fact that certain uses of safe patient handling equipment exceed the safe limit of anterior/posterior shear in the upper lumbar vertebrae (L3 and above) from pushing and pulling activities. Specifically, the highest levels of anterior/posterior shear resulted from one caregiver maneuvering small-wheeled floor lifts in tight quarters on a carpet surface. This is in contrast to ceiling lifts, which pose no additional threat to the caregiver as additional control is required to maneuver the patient. In light of this data, Marras concluded that the ceiling lift is the best option. Interestingly, these tests were conducted with simulated patient weights of 125, 160, and 360 pounds, which demonstrated that weight had a much less significant effect on anterior/posterior shear (with a range of less than 200 Newtons, none surpassing the safe limit) than equipment-lifting method (with a range of more than 600 Newtons, even exceeding hazardous levels), suggesting two important points. First, certain mobility challenges facing the bariatric community have unexplored solutions in proper equipment choice and use. Second, merely purchasing lift equipment does not protect patients and caregivers to the degree that use lift team will. After all, even textbook use of state-of-the-art equipment in a zero-lift situation necessitates a fair amount of physical effort to properly place slings and bands without causing skin shear, especially with the bariatric population.
While the conclusions drawn by Marras champion the merits of the ceiling lift, caregivers recognize the fact that these systems are not always accessible or practical, often necessitating the more difficult floor lift and/or transfer system. In these situations in particular, the lift team is an effective alternative to a manual lift performed by the nursing staff members, especially when more than one person is required to safely perform the lift. While nursing staff members with the proper training may prove quite capable of safe patient handling, their specialty is nursing care. Essentially, time spent performing physically demanding, repetitive activities limits the nurses’ time spent on patient care, both in terms of hours in the day and in terms of days lost to injury. In the age of efficient, specialized labor, it is irrational to insist that nurses continue to perform tasks that have been proven to be hazardous to their musculoskeltal health.
Employee safety and satisfaction. The idea of specialty staff members performing specialty services in a contemporary hospital may seem like an affront to corporate ideology, which dictates maximum efficiency, usually accomplished by minimizing the number of staff. During the 1990s, cost constraints catalyzed hospital restructuring, increasing nurses’ individual responsibilities while decreasing their collective authority. This model, resulting from managed care, reduced Medicare reimbursement, and private sector purchaser initiatives. Left in its wake were fewer nursing staff members responsible for larger numbers of higher acuity patients. This persists in many facilities, despite the fact that multiple studies insist on the higher quality, lower long-term costs, better outcomes, and even lower mortality rates associated with lower patient-to-nurse ratios.[29–33] Additionally, employee satisfaction increases as the number of patients per nurse decreases, and there is an almost perfect correlation between employee satisfaction and patient satisfaction.[33,34]
While there has been significant push-back on the issue of increased staffing to meet mandated ratios, the lift-team option offers a compromise. Lift teams save nurses an average of 1.5 hours per shift, allowing nurses more time for direct patient care. With this model, more nursing hours can be devoted to patient care with little or no increase in facility headcount, all while protecting nursing staff members and patients from injury, which directly effects institutional liability. Furthermore, a study by Peter D. Hart Research Associates35 found that active nursing respondents to a survey about the biggest problems with nursing overwhelmingly cited understaffing (39%) and stress and physical demands of the job (38%)—two problems ameliorated by the lift-team concept.
The humanitarian aspect of the lift team, protecting patients and caregivers alike, is certainly compelling. However, the most decisive question with regard to use of lift teams is often, “Can our facility afford lift teams?” This is a legitimate concern, but data from facilities properly implementing lift teams upend this question, replacing it instead with, “Can our facility afford not to utilize lift teams?”
Cost/benefits of lift teams. According to Bill Borwegen of Service Employees International Union (SEIU), facilities have realized savings of up to $10.00 for every dollar invested in lifting, transfer, and repositioning devices. This figure seems outlandish at first glance, but is very real in context. For example, after implementing a successful safe patient handling program, Stanford University Medical Center reported a five-year net savings of $2,184,613 on their initial investment of $807,010 in capital. While impressive, this still does not fit the 10-to-1 claim made by Borwegen until considering that many experts maintain that the indirect costs incurred from a lack of a safe patient handling program are 4 to 7 times higher than the direct costs (the net). Applying the conservative side of this multiplier (four times) to the Stanford University Medical Center figure, we arrive at a contextual defense of Borwegen’s 10-to-1 claim: $8,738,452-to-$807,010. This indirect, or “soft,” cost benefit is not at all lost on Stanford, which recognizes both employee retention and pressure ulcer prevention as significant soft-cost savings areas of its commendable program.
Nurse turnover not associated with retirement often results from job dissatisfaction and workplace injury, factors that the lift team has the power to abate. This is evidenced by nurse surveys taken at Tampa General Hospital (TGH), Tampa, Florida, a facility using lift teams. Here, nursing staff members stated: “My back no longer hurts at the end of the day,” and “I love the lift team. It was one good asset when considering employment at TGH.” This is important to remember when considering a report on turnover from Veteran’s Health Administration (VHA), which asserts that it costs approximately 100 percent of a nurse’s salary to fill a vacated nursing position. This report also explained that a 600-bed facility with a 20-percent turnover rate—the current average—and an average nursing salary of $46,000—will spend $5,520,000 annually in replacement costs.
Yet another significant indirect cost benefit of the lift team can be found in wound care and pressure ulcer prevention. Wound care nurses working with lift teams can schedule regular repositions and rotations essential to the prevention of hospital-acquired pressure ulcers without sacrificing time that would otherwise be spent dressing and treating wounds. In the current “never event” climate that denies Medicare reimbursement for avoidable pressure ulcers acquired during a patient’s stay. The term never events refers to specific types of adverse event identified by the Centers for Medicare and Medicaid Services (CMS). In terms of acute care and pressure ulcer formation, in October 2008, a CMS directive was introduced, which explained that when a patient is admitted to a facility and does not have a pressure ulcer noted on admission, based on this directive, the patient should not develop a pressure ulcer. In order for the pressure ulcer to be considered unavoidable, the facility should have taken all precautions to prevent pressure ulcer development. The implementation of a lift team is an effective prioritization of hospital-acquired pressure ulcer prevention. Celona et al of Stanford University Medical Center, reported an ulcer treatment savings of $1,761,000, approaching the $1,789,000 workers compensation savings for the same period, and clearly demonstrating the gravity of the situation.
It is important to note that this approach by Stanford University Medical Center depends upon facility-wide staff training in the use of lift equipment and peer leadership. This model incurred $850,000 in total training expenses, surpassing the $807,010 equipment cost. While this program is effective both in terms of patient/caregiver safety and return on investment (ROI), it presents two disadvantages when compared to the lift-team model. First, lifts are still performed by nursing staff members responsible for direct patient care, which means that they are still exposed to the new hazards of lifting equipment and their time is divided. Second, the facility-wide training model is initially too costly for facilities that do not have the same resources as Stanford University Medical Center, especially if their turnover rates are high. These facilities stand to benefit from the lift-team model because intensive training is focused on the lift-team staff, while general nursing staff members receive training in the utilization of the lift team (communication and algorithms), rather than in the use of the wide variety of complex lifting equipment available. By focusing safe patient handling efforts on a relatively small number of specialists, high levels of proficiency may be maintained with relatively lower training costs. Additionally, the high-volume, high-risk issues of safe patient handling can be placed squarely where the risk can be managed with a high degree of oversight, as opposed to the caregiver-lift model, which necessitates facility-wide change each and every time the safe patient handling program requires change for the better.
The wealth of data suggesting positive outcomes associated with the lift-team model, with a design for removing nurses from the physical burden of lifting tons of weight each day, begs the question, “Why has this model not yet been implemented more widely?” Unfortunately, this disconnect between research and practice is not atypical, in fact, it is to be expected. According to Balas and Boren, it takes an average of 17 years for new knowledge generated by randomized clinical trials (RCT) to be incorporated into practice, and even then, the application is highly uneven. 2011 marks the 20th year since the first lift team, an idea that has come of age by proving itself indispensable time and again. Utilizing a contract service to fulfill the requirements of a lift team is another option hospitals can consider. See A New Approach to Lift Teams: Utilizing a Contract Service
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Category: Clinical Nursing Education Series