Importance of lift teams to nurses

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research abstract A lift team was implemented at an urban medical center in the pacific northwest to reduce employee injuries. The lift team consisted of a lift technician and a nursing assistant both trained in lifting techniques. The trial lasted 1 year. Data on employee injuries and day versus night injuries before and during lift team implementation are presented. results do not show the same reduction in employee injuries described by previous authors. possible explanations are related to the use of the lift team and policy development.

Preventing Employee Injury implementation of a lift Team

by Pamela J. Springer, PhD, RN, Bonnie K. Lind, PhD, Johanna Kratt, MS, Ed Baker, PhD, and Joanne T. Clavelle, MS, RN, NE-BC, FACHE

I n 2006, the Bureau of Labor Statistics (BLS) re- ported 1,183,500 non-fatal occupational injuries re- sulting in lost time from work. Non-licensed health

care workers experienced the third highest number of lost workdays due to injuries, with 526 workers injured per 10,000 (BLS, 2008a). In this same year, employee lifting injuries represented a significant number of the total claims for health care workers. Tasks such as lift- ing, turning, and ambulating patients are associated with musculoskeletal strains and back injuries, accounting for more than 30% of all lost-time cases (Caska, Pat- node, & Clickner, 1998; Haiduven, 2003). Nurse aides, orderlies, and attendants suffered 27,590 musculosk- eletal disorders, being surpassed only by occupations requiring heavy physical labor (e.g., miscellaneous laborers and freight, stock, and material movers). In the same year, registered nurses (RNs) reported 9,200 musculoskeletal disorders, the fifth highest occupation (BLS, 2008b). Nursing personnel are thus one of the oc-

cupational groups at highest risk for sustaining muscu- loskeletal injuries.

Caska et al. (1998) described three primary reasons for work-related injuries among health care workers: or- ganizational factors, environmental factors, and personal factors. Organizational factors may include lack of time, insufficient lifting equipment, unavailability of additional personnel to assist with lifting or moving tasks, and pres- sure to complete assigned work. These organizational factors are heightened by the current nursing shortage. According to the Health Resources and Services Admin- istration (HRSA), health care facilities throughout the United States are operating with vacancy rates around 8.5% and these are predicted to increase significantly (HRSA, 2006). Environmental factors include confined space and inaccessible or inoperable lifting equipment. The most common personal factor associated with back injury is previous back strain or injury (Caska et al.). However, heavier patients and an aging nursing work force should also be considered (Allen, 2008; Collins, Wolf, Bell, & Evanoff, 2004; O’Malley et al., 2006). Two of every three adults are overweight, and it is estimated that one fourth of the overweight population is actually obese (Humphreys, 2007). In 2004, the average age of nurses was 46.8 years, with 41% being 50 or older (up

About thE Authors Dr. Springer is Associate Dean, College of Health Sciences/Chair, Depart- ment of Nursing; Dr. Lind is Associate Research Professor; Ms. Kratt is a student; and Dr. Baker is Director, Center for Health Policy, Boise State University, Boise, ID. Ms. Clavelle is Vice President, Patient Care Services/ CNO, St. Lukes Regional Medical Center, Boise, ID.

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from 33% in 2000). As nurses age, many are not physical- ly able to engage safely in patient-handling tasks (Harper & Pena, 1994).

PhIlosoPhy of A lIft tEAm Some authors view patient lifting as a specialized

skill that should not be considered “routine” and per- formed by all nursing personnel. Charney (1997) states, “. . . lifting patients is considered a specialized skill per- formed by expert professional patient movers who have been thoroughly trained in the latest techniques, rather than a hazardous random task required by busy nurses” (p. 300). This philosophy has led some health care or- ganizations to implement specially trained “lift teams” to move patients. Several authors have reported substan- tial reduction in employee injuries as a result of lift team implementation (Caska et al., 1998; Caska, Patnode, & Clickner, 2000; Charney, 1997; Charney & Gasterlum, 2001; Charney, Zimerman, & Walara, 1991; Davis, 2001; Guthrie et al., 2004; Hefti et al., 2003; O’Malley et al., 2006).

rEvIEw of thE lItErAturE rEgArdIng lIft tEAms

The lift team trials reported in the literature ranged from 8 months to 6 years. Charney (1997) described a multi-institution study of lift team implementation show- ing a 69% reduction in employee lifting injuries. Hefti et al. (2003) also showed a decrease in lost workdays and restricted workdays ranging from 57% to 95% after the introduction of a lift team. Several authors examined cost savings realized with a lift team, including reduc- tions in employee injuries and workers’ compensation claims. With a lift team, Charney et al. (1991) reported 1-year savings of $65,000 and a 72% reduction in work- ers’ compensation dollars. Hefti et al. reported $45,815 in overall savings. In another 1-year study, Charney and Gasterlum (2001) reported workers’ compensation costs decreased from $224,000 before a lift team to $14,000 after lift team implementation. These facilities, like most that reported significant injury reduction, implemented policies forbidding nurses from lifting patients (“no lift policies”) and employed lift teams that were available by pagers and answered calls from nursing staff for lifting assistance.

study PurPosE An urban medical center in the Pacific Northwest

decided to implement a lift team to reduce employee injuries and increase support to the nursing staff. The medical center partnered with the nursing department at a local university for program evaluation. The purpose of this study was to determine the effect on employee injury rates when a lift team was introduced without implemen- tation of a no lift policy.

mEthods This study was undertaken at a 350+ bed medical cen-

ter in the Pacific Northwest. The study received approval from the human subjects review boards of the medical center and the university that evaluated the project.

Description of the Lift Team Two lift teams were formed. Each team included a

nurse aide (CAP) and a second lift team member. The facility’s philosophy was one of ensuring patient needs were always met first. This philosophy was the basis for the decision to have one of the lift team members be a certified nurse aide; the certified nurse aide could meet basic patient needs (e.g., toileting, fluid intake, or vital signs). All lift team members received training in ergo- nomics from the medical center physical therapy depart- ment and were hired and supervised by the internal trans- port office.

Four medical and surgical units were selected to use the lift teams. Each team served two units by mak- ing rounds and moving patients hourly on each unit. The lift teams began each hour by checking with the charge nurse on the unit to identify patients needing the most assistance with moving. The charge nurse categorized the immobility of patients using an in-house scale ranging from 0 to 3 (0 = totally independent in moving; 1 = as- sistance needed to get out of bed; 2 = assistance needed from one person to turn and ambulate the patient; and 3 = 2-person lift required). Those patients with a score of 3 were automatically visited by the lift team and helped to move in bed, to a chair, or to the bathroom every 2 hours. If time allowed, other patients were also assisted to a chair and the bathroom or moved in bed. In addition, nurses could access the lift team for assistance by call- ing the main transport dispatch center and having the lift team paged. Each unit had its own lifting equipment read- ily available on the floor. The lift team was introduced to the staff on the units via staff meetings. Nurses were told the lift team would move patients who were categorized as being the most immobile. Also, nurses were asked to call the lift team for turning and ambulation activities for all patients.

Data Collected The lift teams operated from February 19 to Decem-

ber 31, 2007. To allow for a pre-post comparison, pre-data were initially collected from February through December 2006. This was later expanded to include 3 full years of pre-data to minimize seasonal personnel fluctuations.

Acuity, census, and length of stay data were collect-

Employee lifting injuries are costly to institu- tions. A variety of strategies have been used to reduce or prevent injuries, including no lift policies, lifting equipment, and lift teams. This research demonstrates the importance of re- viewing injury data over time to ensure a more accurate representation of the effectiveness of programs.

Applying research to Practice

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ed. Acuity level was collected from all patients twice a day with a tool developed for use by the facility. Acuity was measured on a scale of 1 to 3 (the higher the number, the higher the acuity). Census was defined as the number of patients present at midnight. Census was calculated per unit or floor. Length of stay was the number of days (in- cluding partial days) from admission to discharge. Data regarding acuity level and census were collected before lift team implementation and during the year of lift team implementation.

Nursing time saved was collected. This was assumed to be the amount of time the lift team registered work- ing directly with patients. It was time the nurses would have spent making these moves. Lift team members used handwritten diaries to collect this information, which was entered into a spreadsheet each evening. The data were collected by the lift team supervisor, and files were sent to the researchers monthly for analysis.

Lifting injuries and restricted workdays for RNs and CAPs were also collected. A lifting injury was defined as any injury that an RN or CAP reported to have occurred at the time of moving a patient as captured on an Occupa- tional Safety and Health Administration 300 Log (www. osha.gov/recordkeeping/new-osha300form1-1-04.pdf). Data related to employee injuries were collected by the institution, de-identified, and sent to the researchers. RN and CAP lifting injuries were tallied during three time pe- riods: prior to lift team implementation, during lift team implementation for hours the lift team worked, and dur- ing lift team implementation for hours the lift team was not on duty. Restricted workdays were defined as time spent on either the home unit with restricted work duties (i.e., no lifting) or a different unit performing non-direct patient care duties.

Analysis Stata software (version 10) was used for all analy-

ses. Mean patient acuity, census, and length of stay for each month were compared for February to December 2006, prior to lift team implementation, and February to December 2007, when the lift team was in place. Means were compared using independent samples t tests. Due to the small sample size, tests were repeated using the non- parametric Mann-Whitney U test, which uses ranks rather than actual data values. Results did not differ between the two tests.

Employee lifting injuries were analyzed using inde- pendent sample t tests for average monthly injuries dur- ing the months prior to implementing the lift team and during the months the lift team was in place. RN injuries were analyzed separately from CAP injuries. A Poisson regression model was fit for the number of RN injuries per month. Poisson models are designed to model out- come data based on discrete counts. Independent vari- ables in the model were patient acuity and census, and an indicator for whether the lift teams were implemented. “Month” was the unit of analysis. Total RN hours worked was included in the model as the exposure variable (i.e., the amount of exposure reflected in each observation). A goodness-of-fit statistic was calculated after fitting the model to assess whether the Poisson model was appropri- ate for these data. The average number of days employees were on restricted duty or transferred out of their home units was analyzed using independent samples t tests.

All analyses included data from March through De- cember of each year. Data for January and February were excluded from the pre-lift team period because the lift team was implemented in late February and, as a result, no lift team data were available from January or February for comparison.

rEsults Acuity, Census, and Length of Stay

Acuity, census, and, to a lesser extent, length of stay can affect staffing levels and the likelihood of employee injuries. The analysis began by examining whether these factors changed between before implementation and dur- ing implementation. The average acuity was significantly higher for 2007 than 2006, and the average census per floor was lower in 2007 than in 2006 by an average of 1.5 patients each month. Average length of stay did not differ between 2007 and 2006 (Table 1). The period in 2006 before implementation is not comparable to the lift team period in 2007 in terms of acuity and census, and the analyses that are adjusted for these factors should be given the most consideration.

The lift teams worked an average of 8 to 10 hours per day. It was assumed when the project was proposed this might be credited as nursing time saved. However, a review of staffing patterns revealed the presence of the lift team had no impact on unit staffing. Nonetheless, one could argue that the patients received higher quality care

Table 1

Comparison of mean monthly Patient Acuity, Census, and length of stay before and during the lift team

Before Lift Team (2006) During Lift Team (2007)

n m sd n m sd p

Acuity 10 2.75 0.147 10 3.01 0.038 < .001

Census 10 24.61 0.798 10 22.97 0.821 < .001

length of stay (days) 10 4.79 0.491 10 4.73 0.235 .74

146 AAoHn JournAl

due to frequent moves and nurses having more time to devote to other aspects of patient care.

Lifting Injuries The number and rate of RN injuries varied greatly

between 2004 and 2007, increasing from a low of 10 in 2004 to a high of 20 in 2006 and then falling to 12 in 2007 during lift team implementation (Table 2 and Fig. 1). CAP injuries also showed significant variability, with a minimum of 2 in 2006 and 2007 and a maximum of 6 in 2005 (Table 3 and Fig. 2).

The total number of days employees spent on re- stricted duty was also assessed from March through De- cember of each year, adjusted for the number of RN and CAP hours worked. For RNs, the rate was lowest in 2004 at 5.4 days per 1,000 hours worked. There was a slight increase each year except 2006, when the rate jumped to 21.3. The rate fell to 6.8 during implementation of the lift team, but this was higher than the 2004 and 2005 rates. CAPs showed a different pattern, with a rate of 32.1 days per 1,000 hours worked in 2004, which dropped to 15.2 in 2005. There was a slight increase in restricted days between 2006 and 2007 during lift team implementation (Fig. 3).

If the lift teams were having an effect on injury rates, one would expect to see the greatest impact during the daytime hours, when the lift teams were working. For RNs, injuries were more likely to occur during night hours

than daytime hours in most years. The number of daytime injuries was steady at 7 in 2005, 2006, and 2007. The re- duction in RN injuries in 2007 is due to fewer nighttime injuries (Fig. 4). CAPs, on the other hand, had higher injury rates during the daytime. The number of daytime injuries was fairly steady at 1 to 2 per year in all years except 2005, when 5 daytime injuries occurred (Fig. 5).

Poisson regression models were created to assess whether the presence of the lift teams affected the num- ber of RN or CAP injuries after adjusting for differences in acuity and census. The outcome variable was the num- ber of injuries per month, and the unit of measurement was 1 month. In the RN injury model, none of the inde- pendent variables showed a significant relationship to the number of employee injuries. In the CAP injury model, patient acuity was strongly related to CAP injury, with a doubling of risk of injury for each 0.1 increase in acuity (incidence rate ratio = 2.04, SE = 0.54, p = .006). (The incidence rate ratio is the ratio of the incidence of CAP injuries during lift team implementation to the incidence of CAP injuries prior to lift team implementation.) Lift team presence showed a trend toward being protective; the incidence rate ratio was 0.21, indicating an approxi- mately 80% reduction in risk of injury (p = .06). This

Table 2

registered nurse Injuries

Year Number of

Injuries Injury Ratea

2004 10 119.4

2005 15 173.2

2006 20 220.2

2007 12 119.5 aCalculated using the Occupational Safety and Health Administration 300 Log formula: injury rate = number of injuries 3 200,000/total hours worked.

Table 3

nurse Aide Injuries

Year Number of

Injuries Injury Ratea

2004 3 67.6

2005 6 205.4

2006 2 63.6

2007 2 55.4 aCalculated using the Occupational Safety and Health Administration 300 Log formula: injury rate = number of injuries 3 200,000/total hours worked.

figure 2. nurse aide injuries (CAP) prior to implementation of lift team (2004 to 2006) and during implementation of lift team (2007). All years reflect march through december only.

figure 1. registered nurse (rn) injuries prior to implemen- tation of lift team (2004 to 2006) and during implementation of lift team (2007). All years reflect march through decem- ber only.

147April 2009, vol. 57, no. 4

may indicate that although the number of CAP injuries did not change after implementation of the lift team, given the higher patient acuity and census, perhaps an increase in CAP injuries would have been seen had the lift team not been present.

dIsCussIon Results do not indicate strong evidence that imple-

mentation of the lift team reduced the number of employ- ee injuries (RN or assistive personnel) related to patient handling. Although injuries were lower in 2007 during lift team implementation than in 2006, injuries in 2004 and 2005 were similar to or lower than those seen during lift team implementation.

Injury findings from this study are not representative of the findings of other authors (Charney, 1997; Hefti et al., 2003). Previous studies have primarily examined the year of lift team implementation compared to 1 previous year. In this study, a 1-year pre-post comparison of injuries would have revealed a similar decline in RN injuries as well as in restricted duty days. It was after more in-depth analysis spanning 4 years and controlling for census and acuity that the researchers discovered no significant dif- ference in employee injuries related to the use of the lift team. It is possible that other hospitals implemented lift teams after a period with high rates of employee injuries, and perhaps regression to the mean accounts for the lower employee injury rate after lift team implementation.

Most lift teams in the reviewed literature were avail- able via paging rather than routine rounds on floors (Charney, 2004). Additionally, most facilities implement- ed a no lift policy at the time the lift team was introduced (Charney, 1997). Anecdotal evidence obtained from RNs and lift team members indicated the RNs and CAPs did not wait for the lift team to make rounds or did not want to “bother” the team. Indeed, some RNs actually wanted to complete patient care before the lift team made rounds. Although this is a testament to the desire to deliver high- quality care and to pride in the care delivered, it may have contributed to more injuries. The facility did not attempt to implement no lift policies simultaneously with imple- mentation of the lift team. The addition of a solid policy

against lifting patients may have increased the odds of the lift team being called.

Formal evaluation and analysis of the level of satis- faction with patient care and the work environment was not part of this project’s scope. However, anecdotal in- formation indicated the lift team was popular with staff and patients. Despite the lack of positive outcomes relat- ed to employee injuries, anecdotal reports from nursing leader interviews indicated strong support for the model and continuation of the program. Although the program continued, changes were made to the lift team staffing model requiring flexible schedules depending on patient volumes. Data continue to be collected on musculoskel- etal injuries and the relationship of injuries to lift team use.

APPlICAtIons And ImPlICAtIons Thorough analysis of lift team programs is essen-

tial. Previous research into the effectiveness of lift teams showed a decrease in the number of employee injuries. The current study revealed no change in employee in- juries when adjusted for acuity and census and when compared over a 4-year period. When implemented, the

figure 3. transfer or restricted duty days over 1,000 hours worked prior to implementation of lift team (2004 to 2006) and during implementation of lift team (2007). All years in- clude march through december only. rn = registered nurse; CAP = nurse aide.

figure 5. nurse aide injuries by day (8:00 a.m. to 6:00 p.m.) or night (6:01 p.m. to 7:59 a.m.) occurrence prior to imple- mentation of lift team (2004 to 2006) and during implemen- tation of lift team (2007). All years include march through december only.

figure 4. registered nurse injuries by day (8:00 a.m. to 6:00 p.m.) or night (6:01 p.m. to 7:59 a.m.) occurrence prior to implementation of lift team (2004 to 2006) and during implementation of lift team (2007). All years reflect march through december only.

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institution did not use a no lift policy, a decision that could have limited the effectiveness of the lift team. A process monitor to ensure the lift team was being used as envisioned could have strengthened the implementa- tion. For this institution, the partnership with the univer- sity assisted in a thorough analysis. When evaluating the effectiveness of programs, health care facilities should consider partnering with a local university and examin- ing data collected over longer periods to ensure sound decision making.

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