Guy Fragala Ph.D., PE, CSP, CSPHP Senior Advisor for Ergonomics, Patient Safety Center of Inquiry (P05, Friday, Lower NZI Room, 8.30-9.30)

1. Safety Solutions to Create
Safer Environments
Presented by:
Guy Fragala Ph.D., PE, CSP, CSPHP

2. Caregivers at Risk Helping Patients

3. Problem in Need • Caregiver Back Injuries
of Solutions
Musculoskeletal
disorders among
healthcare workers
delivering direct
care to patients
continues to be a
major problem
requiring help and
effective solutions

4. Occupations at Risk for Strains
and Sprains
Total Musculoskeletal Disorders 592.5
Nursing aids, orderlies and attendants 49.1
Truck drivers 43.9
Laborers, non-construction 36.6
Assemblers 19.7
Janitors and cleaners 14.0
Registered nurses 12.4
Stock handlers and baggers 11.3
Construction laborers 10.8
Number (in 1,000s) of work related musculoskeletal disorders
involving time away from work by occupation. BLS

5. Reviewing Statistics
• Incidence Rate for Overexertion Injuries is
Four Times Higher Than the National Average
(Bureau of Labor Statistics 2000)
• Highest Rate of Musculoskeletal Disorders
Among and More than Seven Times the
National Average for All Occupations
(Bureau of Labor Statistics 2009)

6. For release 10:00 a.m. (EST)
Wednesday, November 9, 2011
• The rate of nonfatal occupational injury and illness
cases requiring days away from work to recuperate
was 118 cases per 10,000 full-time workers in 2010,
statistically unchanged from 2009,
• The MSD incidence rate for nursing aides,
orderlies, and attendants increased 10 percent to an
incidence rate of 249 cases. This occupation also
had a 7 percent increase in the number of MSD
cases.
(Bureau of Labor Statistics 2011)

7. REPOSITIONING IN BED
A problem in healthcare facilities that
very much needs solutions

8. How Bad is the Problem of
Musculoskeletal Disorders
Suffered by Healthcare
Workers Resulting from
Repositioning Patients in
Bed?

9. Manual Techniques Taught
• Drag up bed - one nurse • Australian lift up bed

10. Traditional Manual Patient
Repositioning Techniques
• Highest occupational risk task determined in
biomechanics laboratory study
(Marras 1999)
• Even with draw sheets and sliding sheets peak
low back compression exceeded NIOSH action
level of 3400 newtons in 25% OF 418 trials
(Skotte &Fallentin 2008)

11. Is the Task Safe with Two Caregivers?
• This doesn’t work • Neither does this

12. Nursing Injury Studies
• Lifting Patient Up in Bed
– 48% Injury Rate
(Harber 1985)
– 29% Injury Rate
(Vasiliadou 1995)
Both number one on list in studies

13. Frequency Demands
• Forty Percent of Critical Care Unit Caregivers
Performed Repositioning Tasks More Than Six
Times Per Shift (Harber et al)
• Highest Frequency Physically Demanding Task
Reported (Vasiliadou et al)

14. Other Studies
• 50% of nurses required to do
repositioning suffered back pain
(Smedley 1995)
• High Physical Demand Task
– 31.3% up in bed or side to side
– 37.7% transfers in bed
(Knibbe 1996)

15. Seven Hospital, Two-Year Study
• Number one injury causation
activity: Repositioning Patients
in bed (Fragala 2003)

16. Injuries to Hospital Workers
Activity Reported Injuries Percentage Rank
Repositioning Patient (Includes 153 17.9 1
turning and lifting patient up in bed)
Object Lifting 109 12.7 2
Lifting Patient (not further specified) 102 11.9 3
Transfer Bed/Chair 97 11.3 4
Transporting Patient 94 11.0 5
(wheelchair/stretcher/bed)
Push/Pull Object 89 10.4 6
Aggressive Patient 70 8.2 7
Lateral Patient Transfer 49 5.7 8

17. Why Do Patients Need
Repositioning?
• Medical Diagnosis
• Physical Condition
• Comfort
• Benefits to Healing
• Maintain Healthy Tissue

18. Studying the
Problem Further
• Seeking to
formulate effective
solutions with
input from
caregivers.
• Ideas for the best
solutions come
from those who
perform the task
repeatedly each
day.

19. REPOSITIONING PATIENTS IN BED
Your Input is Appreciated
1. What is your occupation?
2. What type of unit do you work on?
3. During a normal workday how many
patients, on average, are you responsible for
providing care to?
4. During a normal workday how many of your
patients, on average, require your assistance
to be pulled up in bed?

20. REPOSITIONING PATIENTS IN BED
(continued)
5. During a normal workday how many of your
patients, on average, require your assistance to be
turned in bed or be repositioned side to side in
bed?
6. Are there any characteristics about a patient which
make them more likely to need help repositioning?
7. Why do you reposition patients in bed?
8. Is there a need for devices which will automatically
or mechanically reposition patients in bed?

21. Answering Questions
• Demands on caregivers to reposition
patients
• Patient characteristics related to
repositioning
• Why caregivers reposition patients
• Solutions caregivers want

22. Respondents
Occupation n
Registered Nurses 313
RN Critical Care Unit 61
RN Intensive Care Unit 77
RN General Medical 112
Other Units* 63
Licenses Practical Nurses 30
Nursing Aids 87
Other Occupation 27
(Missing) 2
Healthcare workers 459
* Other Units include telemetry, orthopedics, imcu, nursing home, float,
oncology, ER, radiology, neurology, pacu, long term care, endoscopy, sds,
ambulatory, ed, rehab tcu

23. Number of Patients Requiring
Pulling up in Bed
12
10
Number of Patients/day
8
6
4
2
0
care
RN
CU pulling up
R NI CC
U
S
R N GM N
R N LP id
in gA
N ur s

24. Number of Patients Requiring
Pulling up in Bed
Patients Pull Up
n Mean SD Min Max Mean SD Min Max
All Respondents 459 7.74 6.26 0 41 6.04 5.42 0 40
Registered Nurses 313 5.87 5.19 0 41 4.81 3.81 0 22
RN Critical Care Unit 61 3.05 1.85 1 10 3.49 2.75 0.5 16
RN Intensive Care Unit 77 2.51 2.53 0 22 4.44 4.79 1.5 22
RN General Medical 112 7.48 4.94 0 41 4.67 2.53 0 16
Licenses Practical Nurses 30 10.02 8.56 3 40 7.83 6.70 3 38
Nursing Aids 87 11.83 4.96 4 35 8.11 5.75 0 35

25. Number of Patients Requiring
Repositioning
12
10
Number of Patients/day
8
6
4
2
0
care
RN
N ICU U reposition
R CC S
RN GM LP
N
R N
g Aid
in
N urs

26. Number of Patients Requiring
Repositioning
Patients Reposition
n Mean SD Min Max Mean SD Min Max
All Respondents 459 7.74 6.26 0 41 5.09 4.88 0 40
Registered Nurses 313 5.87 5.19 0 41 4.40 3.78 0 22
RN Critical Care Unit 61 3.05 1.85 1 10 2.93 2.65 0 16
RN Intensive Care Unit 77 2.51 2.53 0 22 4.27 4.69 1 22
RN General Medical 112 7.48 4.94 0 41 4.09 2.53 1 16
Licenses Practical
Nurses 30 10.02 8.56 3 40 6.60 5.57 2.5 30
Nursing Aids 87 11.83 4.96 4 35 5.81 5.16 0 35

27. Solution Strategies
• Eliminate the need to perform the high risk
activity.
• Redesign the task to eliminate components of
the high risk task.
• Minimize the frequency of the high risk task.
• Make Optimum Use of Equipment Features to
Facilitate
• Reduce risk through application of an aiding
device.

28. Studying the Problem Further
• Seeking solutions
• Input from caregivers
• Involving the Patient

29. What is the Central and Most Important
Furnishing in the Care Environment?
• The Bed
• Why?
• Can we address many of our patient handling
challenges with proper bed selection for our
Patients and Residents?

30. Finding Solutions
• What are the safe patient handling challenges
we can address with proper bed system
selection?
• How do Healthcare Facilities currently make
decisions about bed selection and who is
involved?
• How should Healthcare Facilities make
decisions about bed selection and who should
be involved?

31. Develop a Process for Bed Selection
• Who should be involved in the process?
• Understand your patient and resident
population.
• What are the required features for all your
beds?
• What options and modifications will you
require to address the needs of individual
patients and residents?

32. Patient Handling Challenges
• Bed egress unassisted
• Bed egress with assistance
• Bed egress total lift and transfer
• Repositioning in bed
• Delivering care in bed

33. Bed Systems
• Not just a bed but a
Bed System
• Two Major
components
• The Bed Frame
• The Bed Surface

34. Solving Problems With Bed Systems
• What can be accomplished with bed frames
• What can be accomplished with bed surfaces
• How do frames and surfaces work together to
enhance quality of care

35. Frame Design
• Facilitate bed egress
• Reduce migration in bed
• Provide position changes of patient
• Facilitate repositioning when required
• Facilitate access for care delivery
• Provide comfort
• Provide safety

36. Reducing the Frequency
• Can we improve how we keep the patient
properly positioned in bed
• Can we change postures without repositioning
• Can we consider less frequent repositioning
• Can we better involve the patient in the
repositioning activity
• Proper Bed System selection
36

37. Bed Frames
37

38. Reducing the Need to Reposition
• Head of Bed Articulation Pushes Patient Down
in Bed
• Patient Requires Pulling Back to Head of Bed
• Movement Over Bed Surface Creates Shear
• Pulling Patient Up in Bed Difficult and
Demanding
• How Does the Head of the Bed Articulate?
• Can Articulation Mechanism be Redesigned?

39. Head of Bed Articulation

40. Can Migration be Minimized

41. Investigate Articulation Action

42. NEW BED FRAME FEATURES
• Full and reverse Trendelenburg positioning
provides versatile, clinical abilities
• Comfort chair recliner-type functionality
• Four-section sleep surface for an array of 770 Bed
therapeutic positions
• Extraordinary travel range – from 7" low
height (Model 790 & 795 low height is 9")
for resident safety to 30" high height for
caregiver convenience.
• Sleep surfaces are 35" wide and either 76"
or 80" long 790 Bed
• Six-function pendant makes adjustments
easy for both resident and caregiver
• 500 lbs maximum weight capacity
795 Bed
42

43. Task Redesign Solution
Gravity Assist Repositioning
• Integrated into the existing central room
furnishing, the bed
• Easy to achieve with one touch of the bed
control
• Quantifiable reduction of force and effort
required from the caregiver
• Reduced risk of injury to the patient
43

44. Head Down Gravity Assist
44

45. Gravity Assist Improvement
• Measured force to reposition 200 lb
mannequin 12 inches by varying head down
angle Blue is total work at 0 head down
• Area under force vs. distance chart is total
Repositioning without Slide Sheet
work
120 Yellow is total work at 6 head down
Better
100
80
0 Degrees w/o SS
Force (lbs)
4 Degrees w/o SS
60 6 Degrees w/o SS
8 Degrees w/o SS
12 Degrees w/o SS
40
20
0 45
0 2 4 6 8 10 12 14

46. Impressive Results Applying
Gravity Assist
• By increasing Work to Reposition 200 lb Resident 12 inches
1600 100%
the angle to 6 1400 90%
from 4 results 1200 80%
Work (in*lb)
1000 70%
in 3 X work 800 60%
Work (Actual)
% Work vs. 0 Degrees
600 50%
reduction 400 40%
– 49% for 6
200 30%
0 20%
0 degrees 4 degrees 6 degrees 12 degrees
– 16% for 4 Head Down Angle
Work to
Reposition % Reduction
Angle (in*lb) in Work
0 degrees 1507 0%
4 degrees 1265 16%
6 degrees 769 49%
12 degrees 499 67%
46

47. Bed Positioning Aid
47

48. Solutions With Surface Design
• Redistributes Pressure
• Reduces Moisture
• Can Facilitate Turning
• Influences Repositioning Frequency
• Wound Prevention and Treatment
• Provides Comfort
48

49. How Often Should a Patient be Turned
• Every four hours?
• Every two hours?
• More frequently?
• New research supports possible less frequent
repositioning when applying appropriate
pressure redistribution surface.
(reference American Journal of Nursing 2009)

50. Non-Powered Surfaces
• Foam Type and Density
• Foam Surface Cut and
Layout
• Foam and Air Cells
Combined

51. Good Foam Surface
• Single-ply, therapeutic high-
density foam mattress, which
encourages envelopment and
redistributes pressure. Combines
quality, comfort and value.
• Incorporates sloped heel section
to redistribute pressure in
delicate heel and lower leg areas
• Available in flat construction style
or with raised sidewalls

52. Better Foam Surface
• Soothing, Visco memory foam in heel
slope for delicate heel section.
Optional TEMPUR material for heel
section.
• Firm perimeter and Tru-fit sizing help
meet FDA/HBSW guidelines
• Strategically located mattress base
cuts promote easier flexing during
bed frame articulation - reduces wear
and tear to help extend mattress life
• Optional raised sidewall available
• Soft, yet highly resilient foam gently
cradles head and torso sleeping
section

53. Best Foam Surface
• Dynamic non-powered pressure
relieving mattress replacement.
• Firm perimeter provides added
stability during resident care/
transfer and help support
resident safety
• Incorporates sloped heel section
to redistribute pressure in
delicate heel and lower leg areas
• Tubular foam cylinders provide
comfort and pressure
redistribution

54. Foam and Air Cell Surface
• The P.R.O. Matt Plus is a non-
powered convertible alternating
pressure mattress replacement
system featuring our P.R.O.
(Pressure Relief Optimization)
technology. This mattress
replacement system allows
healthcare providers to provide
optimal interface pressures
through controlled air cell
inflation for at-risk residents and
treatment for Stage I and II
pressure ulcers. The P.R.O. Matt
Plus may also be indicated for
additional therapeutic
intervention based on resident’s
specific assessment.

55. Powered Surfaces
• Number of Cells and Zones
• Alternating Pressure
• Low Air Loss
• Customization of Surface

56. SURFACE OPTIONS ADDING POWER
• Non-powered convertible alternating
pressure mattress replacement system
featuring P.R.O. (Pressure Relief
Optimization) technology
• Four zones (head, shoulder, torso and foot)
• High resiliency foam topper provides
maximum pressure relief
• Treatment for Stage I and II pressure ulcers
• Dimensions: 80"L x 36"W x 7"H
• Meets flammability standards including
Federal 16 CFR 1633, Cal 117 and Boston IX-
II
• 500 lbs. maximum weight capacity

57. CairTurn RT
Lateral Rotation Therapy
Benefits
• Highly specialized quilted therapy pad reduces friction
and shear force while providing moisture relief without
drying out patients skin
• “Autofirm” mode provides maximum air inflation
designed to assist both patient and caregiver during
patient transfer and treatment
• Advanced design turning therapy cells provide optimal
turning therapy
• Six turn cycle times and eight therapy settings maximize
patient compliance, healing and lateral rotation options
• Preset optimal turn of 30° offers safe, comfortable
rotation for both organ drainage and pressure relief
• Quiet, comfortable, easy to set up and use and
incorporates both rotation and floatation therapy

58. TurnCair™ Plus
Lateral Rotation and Low Air Loss
Benefits
• Specially designed quilted therapy pad reduces friction and
shear force while providing moisture relief without drying out
patient’s skin
• Up to two hundred liters of airflow wicks away moisture to
help prevent skin maceration
• “Autofirm” mode provides maximum air inflation designed to
assist both patient and caregiver during patient transfer and
treatment
• True 40º turn (80º arc) provides maximum benefit for wound
healing and reduction of fluid in lungs
• Inflatable side air bolsters provide additional patient safety
• Turning done by inflation provides for a more significant turn
while maintaining pressure relief
• Fowler boost inflates sacral section to provide adequate
pressure relief when head of bed is elevated at 25º or greater

59. FlapCair™
Cellular Low Air Loss Support
Benefits
In a recent independent study, the
Sixty individual therapy cells help to evenly distribute FlapCair pressure mapped and
patient’s weight and maximize pressure relief performed comparable to the Clinitron.
Highly specialized quilted cover reduces friction and
shear force while providing moisture relief without
drying out patient’s skin
Up to two hundred liters of airflow wicks away
moisture to help prevent skin maceration
Designed for healing flaps and graft sites as well as
pressure ulcers
Low air loss mattress replacement provides ten inches
of therapeutic support
“Pulsate” mode to enhance wound healing and patient
comfort
Lower safety mattress prevents bottoming out by
remaining inflated up to 24 hours in the event of a
power failure

60. Turn1000™
Bariatric Lateral Rotation and Low Air Loss
Benefits Improving patient outcomes
and increasing patient
• Specially designed quilted therapy pad reduces friction and caregiver safety.
and shear force while providing moisture relief without
drying out patient’s skin
• Up to 200 liters of airflow wicks away moisture to help
prevent skin maceration
• “Autofirm” mode provides maximum air inflation
designed to assist both patient and caregiver during
patient transfer and treatment
• Turn angle set options of ¼, ½, ¾ and “full” provides
maximum benefit for wound healing and reduction of
fluid in lungs
• Turn set times of 10, 20, 30 and 60 minutes provide
individualized patient therapy settings
• Lower safety mattress provides pressure reduction by
remaining inflated up to 24 hours in the event of a power
failure

61. CairRails™
Risk Management Air Bolsters
Benefits Protect your facility from liability…
And provide your patient with a safe, secure healing
A bilateral side bolster solution which can environment.
enhance your facilities entrapment/risk
management program
Transfer friendly-deflate for ease of assisted
transfer or when bolsters are not required
Unique contoured design allows ease of
ingress/egress, while providing additional
protection, comfort and supports patient
compliance
Promotes maximum independence by allowing
caregiver to decide when added protection is
required

62. Other Patient Handling Challenges
• Bed egress unassisted
• Bed egress with assistance
• Bed egress total lift and transfer
• Delivering care in bed
• Patients at Risk for Falls

63. Bed Egress
• What can be done to
facilitate bed egress
• Assisted Bed Egress
• Independent Bed
Egress

64. Bed System Solutions
• Deluxe Assist Handles mounted
on bed frame sides provide a
secure hand hold to assist
residents to safely stand and
egress the bed
• Auto Transfer Height as part of the
AdvanceCare positioning package
easily sets the bed frame at the
optimum bed egress height for
most of the population

65. Foot of Bed Egress

66. Height Adjustment Egress Assist

67. Increase Bed Surface Width
• UltraWide adds nearly 20%
width to the bed surface
providing more space for
the resident similar to
conventional residential
bed surface area
encouraging a comfortable
night’s sleep and reducing
the exposure of rolling out
of bed.

68. Body Center of Gravity on Bed Surface

69. Risk for Falling Out of Bed
Figure 2: Average Risk for All Target Populations
60%
Average Risk for All Populations
Percent Risk of Falling due to Hip Width Contribution
50% 51%
44%
40%
30% 33%
20%
10%
Benchmark 14% 36%
Improvement Improvement
0%
35 inch 39 inch 42 inch

70. Under Bed Lighting
• The Under bed night light
provides soft lighting to
the bed egress floor area
adding safety for residents
to exit the bed during
evening hours

71. Low Beds Reduce Injury severity
• Ability to be placed in a
very low surface position
to reduce risk of injury
severity related to rolling
out of bed

72. Gait Training Application