Safe Patient Handling and Movement

Purpose

This document provides guidance to perioperative professionals for developing, implementing, and maintaining an effective safe patient handling and movement (SPHM) program to reduce the incidence and minimize the severity of injuries to patients and health care workers related to performance of high-risk tasks in the perioperative environment.¹  Guidance is provided for

• establishing and sustaining a culture of safety;

• establishing a formal, systemized SPHM program;

• incorporating ergonomic design principles to provide a safe environment of care;

• selecting, installing, incorporating, and maintaining safe patient handling technology in the perioperative setting;

• establishing education, training, and competency verification in safe patient handling techniques and equipment use;

• assessing the patient and the perioperative environment and developing a plan for SPHM;

• collaborating to include reasonable accommodations for post-injury return to work within the comprehensive SPHM program; and

• establishing a comprehensive quality assurance and performance improvement program to evaluate the SPHM program.

Perioperative registered nurses (RNs) and other team members are routinely faced with a wide array of occupational hazards in the perioperative setting that place them at risk for work-related musculoskeletal disorders (MSDs).^2,3  Work-related MSDs are disorders of the muscles, nerves, tendons, ligaments, joints, cartilage, and spinal discs.⁴  The lower back, shoulder, and upper extremity are typically involved in MSDs with a gradual or chronic onset. Injuries are the result of overexertion, repetitive motion, manual lifting, and pushing and pulling.⁴  When a worker’s physical ability, task, workplace environment, and workplace culture are not compatible, there is an increased risk that the worker will develop an MSD.²  Physical stressors encountered in health care that contribute to MSDs include forceful exertions,⁵  repetitive motions,⁵  awkward postures,^6-9  static postures,^10,11  prolonged standing,^12-15  long cumulative work hours (eg, overtime, consecutive shifts),^16-20  moving or lifting patients and equipment, carrying heavy instruments and equipment, and overexertion.^2,21  Research studies have also demonstrated an association between psychosocial factors (eg, work-family conflict, workplace verbal abuse, job demands, job satisfaction) and the incidence of musculoskeletal symptoms.^22-29 

Musculoskeletal disorders are some of the most frequently occurring and costly types of occupational issues affecting nurses.^2,30-41  In 2015, RNs in the private sector reported a total of 20,360 nonfatal occupational injury and illness cases requiring days away from work, of which 8,530 (42%) were MSDs and 5,790 (28%) were back injuries.⁴² 

Ellapen and Narsigan³⁰  conducted a systematic review of 27 publications with the outcome measure of work-related MSDs among a total of 13,317 nurses. The prevalence of work-related MSDs was 71.8%. The authors concluded that nurses are vulnerable to a work-related MSDs, especially lower back pain and injury. Work-related MSDs also occur frequently in other members of the perioperative team,^20,43,47  including surgeons.^48-63  Karahan et al⁴³  conducted a qualitative study to describe the prevalence and high-risk factors for lower back pain among hospital workers. Of the 1,600 respondents, 65.8% reported experiencing low back pain, with 61.3% reporting an occurrence in the previous 12 months. The highest prevalence (77.1%, n = 509) was reported by nurses.

The perioperative setting poses unique challenges related to the provision of patient care and completion of procedure-related tasks. This highly technical environment is equipment intensive and necessitates the lifting and moving of heavy supplies and equipment during the perioperative team member’s work shift. Many of the patients undergoing surgical or other invasive procedures are completely or partially dependent on the caregivers due to the effects of general or regional anesthesia or sedation. Patients who are unconscious cannot move, sense discomfort, or feel pain, and they must be protected from injury. This may require perioperative team members to manually lift the patient or the patient’s extremities several times during a procedure.^26,64 

Nützi et al²⁶  conducted a correlational questionnaire study of 116 operating room (OR) nurses from eight hospitals to examine the prevalence of musculoskeletal problems in OR nurses. The frequency distribution of the sample showed that 66.1% of the OR nurses reported suffering from MSDs. The nurses reported pain in the lumbar region (52.7%), cervical region (38.4%), mid-spine region (20.5%), knees and legs (20.5%), and hands and feet (9.8%). Many of the respondents reported more than one pain region. The authors postulated that MSD is one of the most common causes of long-term absence from work (ie, more than 2 weeks). Nurses with MSDs incur both high direct costs for treatment and high economic costs due to their absence from work and productivity loss.

A contributing factor to the incidence of musculoskeletal injuries in health care workers is the increasing prevalence of obesity in the United States.^65,66  The National Health and Nutrition Examination Survey (NHANES), a program of the National Center for Health Statistics, Centers for Disease Control and Prevention, is a cross-sectional, nationally representative health examination of the US noninstitutionalized population that includes measured weight and height. The objective of a recently published NHANES survey was to examine the obesity prevalence for 2013-2014 and trends over the decade from 2005 through 2014, adjusting for sex, age, race/Hispanic origin, smoking status, and education. The survey’s main outcomes were the prevalence of obesity (body mass index ≥ 30) and class 3 obesity (body mass index ≥ 40).

The age-adjusted prevalence of obesity in 2013-2014 was 35% among men and 40.4% among women; the age-adjusted prevalence of class 3 obesity was 5.5% for men and 9.9% for women. For women, the prevalence of overall obesity and of class 3 obesity showed significant linear trends for increase from 2005 to 2014. There were no significant trends for men.⁶⁷  The relevance for the perioperative team is that more than one-third of all surgical patients cared for could be obese.

The American Nurses Association (ANA) laid the foundation for the prevention of work-related MSDs in 2003 with the release of the position statement The Elimination of Manual Patient Handling to Prevent Work-Related Musculoskeletal Disorder^68,69  and development of the Handle With Care® campaign.⁷⁰  In 2006, AORN developed the Position Statement for Ergonomically Healthy Workplace Practices.⁷¹  The National Association of Orthopedic Nurses,⁷²  the Australian College of Operating Room Nurses,⁷³  and the Association of Occupational Health Professionals⁷⁴  have also developed safe patient handling position statements.

In 2005, AORN continued its commitment to the prevention of MSDs by forming a collaborative arrangement with the National Institute for Occupational Safety and Health (NIOSH) and the ANA to discuss, design, and advance the agenda of an ergonomically healthy workplace for perioperative professionals. The AORN Workplace Safety Task Force examined current research, literature, and patient care practices to evaluate and make recommendations to promote patient and caregiver safety in a perioperative setting.⁷⁵  While there are a number of high-risk tasks specific to perioperative nurses, the task force identified seven key activities as the starting point for developing recommendations. The result of this collaboration was the AORN Guidance Statement: Safe Patient Handling and Movement in the Perioperative Setting⁶⁴  developed by AORN with the assistance of a panel of experts from the Patient Safety Center of Inquiry at the James A. Haley Veterans Administration Medical Center, Tampa, Florida; the NIOSH Division of Applied Research and Technology Human Factors and Ergonomics Research Team⁷⁶ ; and the ANA.⁶⁴ 

The Ergonomic Tools developed for this guidance document were based on previous work by Audrey Nelson, PhD, RN, FAAN; experts within the Veterans Administration; and nationally recognized researchers. The seven Ergonomic Tools for SPHM were developed based on professional consensus and evidence from research and were designed with the goal of eradicating job-related MSDs in perioperative nurses (See Recommendation 6).⁶⁴ 

In 2013, the ANA published Safe Patient Handling and Mobility: Interprofessional National Standards Across the Care Continuum.⁶⁹  The ANA’s eight core standards are:

• Establish a Culture of Safety

• Implement and Sustain a Safe Patient Handling and Mobility (SPHM) Program

• Incorporate Ergonomic Design Principles to Provide a Safe Environment of Care

• Select, Install, and Maintain SPHM Technology

• Establish a System for Education, Training, and Maintaining Competence

• Integrate Patient-Centered SPHM Assessment, Plan of Care, and Use of SPHM Technology

• Include SPHM in Reasonable Accommodation and Post-Injury Return to Work

• Establish a Comprehensive Evaluation System⁶⁹ 

The ANA standards have been adapted to meet the unique needs of the perioperative patients, team members, and environment. These standards provide an important framework⁷⁷  for health care organizations to use in implementing safe patient handling practices and provide the framework for the eight recommendations in this guideline.

The benefits of implementing an SPHM program include reduced work-related MSDs,^1,78,79  reduced risk and severity of lifting and repositioning injuries,¹  increased patient safety,^1,7979 decreased falls,¹  decreased workers’ compensation costs,^1,79,80  decreased health care worker fatigue,¹  decreased employee turnover,⁷⁸  increased health care worker morale,^1,80  and increased quality of life.¹ 

The following topics are outside the scope of this document:

• patient positioning (See the AORN Guideline for Positioning the Patient⁸¹ ),

• pressure injuries (See the AORN Guideline for Positioning the Patient⁸¹ ),

• patient skin antisepsis (See the AORN Guideline for Preoperative Patient Skin Antisepsis⁸² ), and

• mobility of postoperative patients.

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE®, EBSCO CINAHL®, Scopus®, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from 2005 through November 2017. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until January of 2018. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies. The literature review was supplemented with additional select articles following the public commenting review period.

Search terms included subject headings such as accidental falls, accidents (occupational), allied health personnel, back injuries, biomechanics, equipment safety, ergonomics, handling and movement, health care personnel, health personnel, hoists, human engineering, lifting, lifting and transfer equipment, low back pain, muscular diseases, musculoskeletal diseases, musculoskeletal system/injuries, neck pain, nursing staff, occupational diseases, occupational exposure, occupational hazards, occupational health, occupational health services, occupational safety, occupational-related injuries, operating room personnel, patient transfer, physical complaints, posture, pull, push, risk assessment, risk management, roll board, shoulder pain, stress (physiological), surgical equipment and supplies, transfer techniques, transportation of patients, weight bearing, worker’s compensation, and wounds and injuries/prevention and control.

Included were research and non-research literature in English, complete publications, and publication dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, other brief items, and publications about off-label use of devices also were excluded. Low-quality evidence was excluded when higher-quality evidence was available (Figure 1).

Figure 1

Adapted from: Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement PLoS Med. 2009;6(6):el000097.

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and three evidence appraisers. The lead author divided the search results into topics, and members of the team reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation. Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

Editor’s note: Handle With Care is a registered trademark of the American Nurses Association, Silver Spring, MD. MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands.