p45-53w32
10/4/06
12:33 pm
Page 45
learning zone CONTINUING PROFESSIONAL DEVELOPMENT Page 45 Manual handling risk management: critical care beds and support systems
Page 54 Moving and handling multiple choice questionnaire
Page 55 Read Amy Bartlett’s practice profile on infection control
Page 56 Guidelines on how to write a practice profile
Manual handling risk management: critical care beds and support systems NS338 Griffiths H (2006) Manual handling risk management: critical care beds and support systems. Nursing Standard. 20, 32, 45-53. Date of acceptance: June 28 2005.
Summary This article examines the reduction of manual handling risk to nurses through discussion of the technical and ergonomic features of critical care beds and support systems. It describes the features of different types of manual handling equipment, in particular trolleys, beds and patient platform support surfaces.
Author Howard Griffiths is clinical practice tutor, School of Health Science, University of Wales, Swansea. Email:
[email protected]
Keywords Accident prevention; Lifting; Occupational health and safety; Patients: positioning; Risk management These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.
Aims and intended learning outcomes This article, which is a follow-up to ‘Positioning critically ill patients in hospital’ (Griffiths and Gallimore 2005), focuses on the technical and ergonomic features of critical care beds and support platforms and their role in reducing manual handling risk to nurses. Nursing students and nurses new to critical care settings should regard items such as trolleys, beds and patient platform support surfaces as pieces of manual handling equipment, just as they would a hoist. The reader is advised to search the literature for information on small handling aid products and hoist equipment, because these are not reviewed in this article. After reading this article, you should be able to: NURSING STANDARD
Identify the clinical risks to the patient when using critical care beds and/or support platform surfaces to move and handle patients. Discuss ways to reduce your back care risks and the risk to others when using critical care beds and/or support platform surfaces to reposition patients. Select appropriate moving and handling equipment and small aids for repositioning a critically ill patient in the critical care environment.
Introduction There is a link between patients’ perception of safety and comfort and the manual handling technique employed by nursing staff (Kjellberg et al 2004). The Manual Handling Operations Regulations 1992 (Health and Safety Executive (HSE) 1992) and its updated guidance (HSE 1998) require workers to be taught how to recognise potentially hazardous manual handling operations, the purpose and function of risk assessment, safer handling practice and safe systems of work. Jones et al (1999) and Hignett (2003) suggest that interventions predominantly based on technique training have no impact on working practices or injury rates. Multifactorial interventions, that are founded on a risk assessment programme, are more likely to succeed in reducing risk in patient handling activities. The nature of the load is thought to be an important risk factor in manual handling together with environmental variables such as the height of the furniture and cramped workspaces that may affect the posture of patient handlers (Engkvist 2004). Non-neutral spinal postures – where the spine is rotated or flexed forward – april 19 :: vol 20 no 32 :: 2006 45
p45-53w32
10/4/06
12:33 pm
Page 46
learning zone moving and handling pose a significant risk for work-related back injuries (Elford et al 2000). Petzall et al (2000) found dissatisfaction among nursing staff about their working posture, and concerns that hospital beds were unsuitable for performing nursing tasks, such as feeding or helping patients with their hygiene needs. The aim of ergonomics is to ensure that tasks, equipment, information and the environment suit each worker (HSE 2003). Engels et al (1998) suggest that an ergonomic-focused course may improve the posture of nurses. An ergonomic approach to managing risk can significantly reduce manual handling injuries (Owen et al 2002). Improved ergonomics in the workplace is likely to be the main way to prevent lower back pain among nurses (Yip 2001). Where large equipment is too expensive for the organisation, purchasing small handling aids such as roller sheets, glide sheets, hand blocks and bed ladders can help to reduce manual handling risk. The Self-reporting Work Illness Survey of 1995 (HSE 2006a) found that nurses have one of the highest rates of musculoskeletal disorders – an estimated rate of 5.8 per cent compared with the average 2.5 per cent. Research on the cost/benefit analysis of investing in manual handling equipment is scant, although the financial cost of staff sickness has been estimated in a variety of occupational groups (HSE 2006b). One study identified factors that may reduce stress on nurses’ backs (Caboor et al 2000), and concluded that the use of variable height beds can influence working postures and reduce task demands, leading to decreased compression and shear forces on nurses’ backs. Walls (2001) concluded that there was no real risk reduction of back injury to staff when using electric beds compared with manual beds in those tasks undertaken by orthopaedic nurses caring for a disabled patient. There is, however, emerging consensus that an ergonomic approach reduces the risk of back injury in the workplace (Hignett 2005). The majority of manufacturers categorise their beds as medical/surgical beds, critical care/highdependency beds, and bariatric beds. Bariatrics is when the body mass index is greater than 30 (Kuczmarski and Flegal 2000). Most critical care beds have therapeutic and ergonomic features to benefit patients and staff. Bariatric and critical care beds have a higher safe working load (SWL) than those designed to be used in the ward setting as indicated in the manufacturers’ manuals. Automated profiling beds have a variable height facility and can be folded in three sections. These beds can help reduce the risk of manual handling 46 april 19 :: vol 20 no 32 :: 2006
injuries to nursing staff, but they may pose an increased clinical risk to the patient. For example, one medical device alert notice (Medicines and Healthcare products Regulatory Agency (MHRA) 2004a) refers to an adverse incident in which a confused patient fell out of bed and ended up with her head on the foot-operating control, thereby activating the platform lowering function which crushed the patient. Similarly, bed rails that have twin bar designs carry a high risk of trapping the patient between the widely spaced horizontal rails (MHRA 2004b).
Time out 1 List five ergonomic features found on an accident and emergency trolley that could reduce the risk of sustaining a back injury when moving or handling patients. Answer on page 52.
Accident and emergency department Several studies report that back injuries among nursing staff are related to patient transfers (Burdorf and Sorock 1997, Retsas and Pinikahana 2000, Engkvist 2004). Trolleys used in the accident and emergency (A&E) setting have different ergonomic features that may reduce the risk of back injury to staff. A trolley with variable height allows the posture of practitioners to be maintained in a near-neutral position, minimising stooping and stress on the spine. Similarly, hydraulically operated backrests greatly reduce the physical effort of placing patients in the semi-Fowler (semi-recumbent) (Figure 1) or high-Fowler (high-recumbent) (Figure 2) position on the trolley. FIGURE 1 Semi-Fowler position
FIGURE 2 High-Fowler position
NURSING STANDARD
p45-53w32
10/4/06
12:33 pm
Page 47
Some trolleys are designed to enable the patient to be changed from a supine position into an armchair (sitting-up) position. Nurses may, in the past, have had to struggle to position patients in a high-Fowler position for chest radiographs to be taken in the A&E department. The hydraulic backrest facility of some trolleys, together with their translucent X-ray mattresses, make the trolleys compatible with the use of C-arm image intensifiers – mobile X-ray machines – by radiographers. This enables the radiographer to obtain X-ray images in the A&E department without having to move the patient off the trolley. In addition, trolleys may have a full-length sliding X-ray cassette tray underneath the supporting platform to enable the radiographer to take images along the full length of the supine patient without the need for repositioning. All of these ergonomic features reduce the physical effort required by staff in handling patients. A further manual handling risk identified by A&E practitioners occurs when having to adopt a stooping posture to push patients on trolleys when the patient is being transferred out of the department. A&E trauma trolleys that have optional or integrated pop-up steering handles enable the practitioner to adopt a safer, more neutral posture. Other ergonomic improvements in the design of A&E trolleys include side-rails that can be folded and tucked so as not to leave a gap between two adjacent support surfaces. This helps to reduce the risk of accidents occurring to the patient and practitioner during large lateral transfer movements of patients across support platforms. Where there is a need to place a semiconscious patient in an emergency Trendelenburg-tilt position (Figure 3), for example, during a stomach washout procedure, the practitioner is at considerable risk of back strain when using trolleys with mechanical leverage (Hignett 2005). Certain trolleys, however, have an automated tilt facility that helps reduce this risk. Some manufacturers FIGURE 3 Trendelenburg-tilt position
NURSING STANDARD
accommodate the extra load of bariatric patients by widening the trolley and some provide the option of having a weighing scale system built into the trolley.
Time out 2 Discuss with an operating department practitioner how the operating table attachments can contribute to the safety of the patient on the operating table. Answer on page 52.
Operating theatres In operating theatres large transfer boards and lateral transfer systems are often used for patient transfers (Lloyd 1998). The handling of bariatric patients may increase the risk of injury to theatre practitioners and compromise patient safety. Bariatric patients can be moved with manual handling equipment, such as the Anderlift hoist (Europa Medical Services). This can lift patients weighing up to 227kg and enables the injured or intubated patient to be lifted, turned and transported by one carer. Traditional mobile hoists with appropriate spreader bars (part of the hoist which has the sling attached on to it) and scoop stretchers (which can be attached to the hoist) may be used to move a heavy patient in a supine position from bed or trolley onto the operating table. Frequent repositioning of patients on the operating table also increases the manual handling risk to theatre practitioners, while compromising patients’ safety because they are being placed on a relatively narrow support surface area. Manufacturers have designed day surgical trolleys that are suitable for most surgical procedures. This equipment reduces the frequency of manually handling patients, which saves nursing time and provides a faster throughput of patients. These trolleys can usually be converted into many different positions for day surgical procedures. They also have gas spring backrest adjustments and a gas spring two-way tilt facility that may be particularly useful to the recovery theatre nurse who needs to sit the patient in a semi-Fowler position. In addition, many surgical platforms have translucent X-ray mattresses and some have longitudinal movement to enable specialist imaging, such as cardiac catheterisation, cardiac pacing and fluoroscopy. In the recovery unit a hydraulic sitting-up facility on theatre recovery trolleys may reduce the strain on nurses’ backs because physical effort to move the backrest is avoided. Some of these surgical platforms can function as both operating tables and recovery trolleys, for example, the april 19 :: vol 20 no 32 :: 2006 47
p45-53w32
10/4/06
12:33 pm
Page 48
learning zone moving and handling Stryker range of surgical platforms, and the Huntleigh Timetable™ Courier (Model 152000). The Stryker Trio® Mobile Surgery Platform has a lateral tilt facility of up to 15 degrees. It allows operating table attachments, such as lithotomy stirrups or leg rests, to be put in place. It also has a removable foot section to enable the surgeon to undertake rectal or gynaecological work.
Time out 3 Discuss with experienced nursing staff in the intensive care setting which ergonomic features of the beds are advantageous for patients to regain their independence during transfer from bed to chair. Answer on page 52.
Intensive care Nurses are involved in the frequent repositioning of patients to improve their lung ventilation and provide pressure area care. Immobility increases the risk of pulmonary complications (Fink et al 1990). Where alveoli collapse in the lung, atelectasis develops leading to reduced lung compliance (Raoof et al 1999). Immobility exacerbates the accumulation of mucus in the lungs, with pooled secretions culminating in respiratory infections. Regular turning of patients has been advocated as a means of reducing atelectasis and mobilising pulmonary secretions, thereby reducing the risk of respiratory tract infections (MacIntyre et al 1999). In 1967 the term ‘rotational therapy’ was used by Keane, who hypothesised that frequent automatic turning of patients prevented pulmonary complications by improving mobilisation of pulmonary secretions (Sahn 1991). Some manufacturers have designed beds specifically for the purpose of achieving rotational therapy, repositioning and management of the immobile or heavy patient, for example, Pegasus Atlas™ tilt and turn frame (Pegasus 2006). These beds were not specifically designed for intensive or critical care settings; nevertheless, they help to reduce the risk of back injury by reducing the amount of patient handling by nursing staff. Certain beds have a lateral tilt facility to enable postural therapy to be undertaken by the physiotherapist. An additional useful ergonomic feature available with some critical care beds is the turn assist (Hill-Rom’s TotalCare® SpO2RT® Pulmonary Therapy System). This helps to reduce back strain for nurses during routine nursing 48 april 19 :: vol 20 no 32 :: 2006
procedures such as changing linen or inspection of the patient’s skin. This feature has air bladders in the mattress surface which inflate, thereby assisting the patient to turn on the bed. There is a control panel on the side rail of the bed which enables the patient to be tilted into left, right or centre position. This feature is beneficial in critical care settings where frequent patient turning is required (Fragala and Owen 2002). Positioning the patient in a prone position is claimed to have a therapeutic benefit by improving lung oxygenation in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) but is not suitable for all patients (Griffiths and Gallimore 2005); hence continuous lateral rotation therapy (CLRT) is used. It is thought that ALI and ARDS are significant problems in critically ill patients in intensive therapy with mortality rates of 50 to 70 per cent (Monchi et al 1998). ARDS is a life-threatening condition in which inflammation of the lungs and accumulation of fluid in the alveoli lead to low blood oxygen levels (Medline Plus 2005). CLRT involves using specially designed beds allowing axial rotation with some beneficial effects on oxygenation (Staudinger et al 2001). Welch (2002) notes that phrases such as CLRT and kinetic therapy are used indiscriminately and interchangeably to describe the mechanical side to side turning of patients. The United States Centers for Disease Control and Prevention has suggested that a bed that tilts up to 40 degrees provides CLRT while kinetic therapy relates to beds that turn 40 degrees or more (Rance 2005). This is relevant because a 40 degree turn is needed to be clinically effective (Basham et al 1997, Welch 2002). Kinetic therapy is usually indicated for the aggressive treatment of pulmonary complications associated with immobility, atelectasis, pneumonia or ARDS. Specially designed beds use low air loss technology which turns the patient by inflating and deflating cushions, achieving turning arcs of 40 to 90 degrees. Kinetic therapy is effective in the prevention of hospital-acquired pneumonia and has been shown to reduce the incidence and severity of both pneumonia and lower respiratory tract infection, thus decreasing ventilator days, length of stay and healthcare costs (Gentilello et al 1988, Fink et al 1990, Sahn 1991, deBoisblanc et al 1993). The function of kinetic therapy is not only to prevent skin breakdown and movement of mucosal secretions in the airway passages, but also to encourage adequate perfusion/ventilation and oxygen gas exchange throughout the lungs of the critically ill patient (McLean 2001). Kinetic therapy should not be used as a primary means of stabilising cervical spine fractures, but only to prevent complications of bed rest once the cervical spine is stabilised by cervical traction, NURSING STANDARD
p45-53w32
10/4/06
12:33 pm
Page 49
halo, vest or internal fixation (KCI 2006a). The risks and benefits of kinetic therapy need to be considered carefully. McLean (2001) suggests that the use of kinetic therapy can result in the patient becoming haemodynamically unstable, for example, tachycardic and/or hypotensive. Frequent change of linen may be necessary if the patient has uncontrolled diarrhoea and, because the patient is strapped onto the bed, this therapy may exacerbate conditions such as severe agitation or claustrophobia (KCI 2006a). Some beds combine CLRT with percussion therapy. Percussion may be performed by manual clapping of the chest wall over an affected area of the lung. Vibration may be applied manually by vibrating, shaking, or compressing the patient’s chest wall during expiration. Both percussion and vibration can also be performed using mechanical devices (Stiller 2000). Percussion therapy can be automated and incorporated into the mattress of these beds to deliver chest physiotherapy to aid mobilisation of lung secretions. Percussion therapy is contraindicated for patients who have sustained multiple rib fractures (Hough 2001), persistent intracranial hypertension, bronchospasm, and following cardiac surgery (KCI 2006b). There is a risk that percussion therapy may displace rib fractures leading to pneumothorax and neurovascular damage; as well as increasing intracranial pressure with multi-modality physiotherapy (Stiller 2000); and lead to movement of sputum in the lower airway that may block the lumen of the upper airway while the patient experiences bronchospasm. Percussion has been associated with cardiac arrhythmias (Hammon et al 1992, Hough 2001). Stiller et al (1996) found inconclusive evidence that vibration therapy in addition to positioning therapy, mechanical bagging and suctioning of ventilated patients failed to alter significantly the resolution of atelectasis in patients. Some beds provide a 45 degrees bilateral turn percussion and pulsating air suspension on a low air-loss pressure-relieving mattress surface, for example, the KCI’s TriaDyne® Proventa™. The pulsating air suspension helps to stimulate lymphatic flow while percussion therapy during rotation helps to mobilise secretions in the lungs (Stiller 2000, Hough 2001). The sophisticated nature of these beds, and their use in combination with small handling aids such as glide sheets, should enable the patient to be moved into position without much need for using a hoist. Specific bariatric beds offer most of the functions of other standardised critical care beds. The majority of the critical care beds offering CLRT or kinetic therapy can take a SWL above those of standardised beds but below the NURSING STANDARD
SWL of bariatric beds. Some bariatric beds differ from other critical care beds by having a wider platform dimension but may have the same SWL. The Hill-Rom TotalCare Bariatric Bed has a width of 107cm compared with the Hill-Rom TotalCare® Duo2 which has a width of 91 cm. The transfer of patients out of bed for weighing may pose a risk of falls to the patient, in addition to increasing the risk to the nurse of back strain injury. Biomechanical evaluation of assistive devices for transferring patients helps to reduce back strain in staff (Garg and Owen 1994, Zhuang et al 1999). Where monitoring the patient’s weight is important, some beds may reduce the need for lateral transfer of patients by offering a built-in weighing facility with the bed. Zhuang et al (2000) found that nursing home residents gave assistive manual handling devices high ratings with regard to comfort and safety in comparison with manual handling techniques. Critical care beds enable the patient to be placed in a variety of positions from supine to high-Fowler, as well as in a cardiac chair position (Figure 4) which aids venous return to the heart. Some beds allow the patient to be put in a chair egress position (Figure 5a), whereby the foot board is removed and the bed is put into a chair profile, to help the patient to stand from a sitting position (Figure 5b). Most FIGURE 4 Enhanced cardiac chair patient position
Reproduced with permission of Hill-Rom
FIGURE 5a Chair egress patient position
Reproduced with permission of Hill-Rom
april 19 :: vol 20 no 32 :: 2006 49
p45-53w32
10/4/06
12:33 pm
Page 50
learning zone moving and handling FIGURE 5b Chair egress patient position
Reproduced with permission of Hill-Rom
critical care beds are designed for easier access during patient transfers from bed to chair. Some beds go down to an unusually low position, for example, the Huntleigh Contoura® 885’s lowest height is 38cm. Side rails that are usually full length are halflength, and have two rails each side of the bed, at the head and foot end of the bed. This enables safer patient transfer or bed exit because there is less risk of the patient falling and staff injury when the bed is in a chair egress position. The nurse should be aware of the risk of patient entrapment between the two half-length side rails when using the profile facility on these beds. A further safety feature commonly found in beds is side rails that have a zero gap for lateral transfers. Most critical care beds enable the nurse to put the patient into a sitting position. The degree of backrest movement is variable. Some also have an optional or integrated X-ray cassette carrier to the X-ray translucent backrest, thus minimising the need to handle patients when sitting them forward during chest X-ray. The patient can be elevated from a supine to a full chair position of 65 degrees or in a chair egress position of 75 degrees. Auto-contour and auto-cardiopulmonary resuscitation (CPR) facilities enable the patient to have the backrest and knee break adjusted simultaneously during patient positioning to minimise shear forces acting on the buttocks of the patient, hence reducing the risk of pressure damage to the patient’s sacrum (Collins 1999a). They also enable the nurse to put the patient back in the supine position quickly and with little effort when CPR is required.
Specific medical conditions Patients with extensive burns are nursed on specialised beds to provide comfort and 50 april 19 :: vol 20 no 32 :: 2006
minimise tissue damage. Air fluidised mattresses and low air pressure beds have been used for many years to prevent the formation of pressure ulcers (Micheels and Sorensen 1983). Some manufacturers stipulate that low air-loss mattresses may be suitable for burns patients, those undergoing plastic reconstructive surgery or for patients with one grade III or IV pressure ulcer or multiple grade II ulcers. Low air-loss mattresses work by air being gradually lost but continuously replaced in response to the patient’s weight distribution and movement (Clay 2000). Air-loss mattresses comprise segments of adjustable air-filled sections in independent zones, which can be customised to the individual patient and provide pressure relief (Arblaster 1999). Some deflate quickly from full inflation to almost zero pressure, which encourages reactive hyperaemia and maintenance of tissue nutrition and oxygenation (Schregel et al 1993). Ferrell et al (1993) found that low air-loss beds provided substantial improvement in preventing and healing ulcers compared with foam mattresses. The Pegasus Paragon 5000, Huntleigh Oasis® Fluidised Bead Bed and the Hill-Rom Clinitron® II Air Fluidised Therapy offer low pressure air-flow technology for patients with multiple pressure ulcers, intractable pain, burns or exudating wounds. There is evidence of the effectiveness of air-fluidised and low air-loss devices in treating wounds (Dolynchuk et al 2000). It was noted that a reduced heat accumulation differentiated low air-loss and air-fluidised support mattresses from other types of support surfaces. Most had low moisture retention, shear reduction and pressure reduction characteristics. The combination of reduced shearing, friction and reduced interface pressure help to reduce the risk of microscopic blood vessels in the tissue becoming occluded, thereby maintaining oxygen and nutrient supply to the tissue cells. However, the use of a low air-loss mattress is contraindicated in patients with burns who also have an unstable spinal fracture or require cervical traction according to the manufacturers since fractures can be displaced causing neurovascular and spinal cord damage. In contrast, air-fluidised therapy beds work by having a surface that moves continually as air is blown through fine particles resembling sand (Clay 2000). Fluidised beds are unsuitable for spinal cord-injured patients and those requiring long bone traction because the bed frame cannot take traction apparatus attachments. Very low interface pressures help to reduce the frequency of patient repositioning and minimise risk of pressure damage on the body’s tissue. Beds with low interface pressures reduce body movement NURSING STANDARD
p45-53w32
10/4/06
12:33 pm
Page 51
and therefore reduce friction and shearing forces associated with tissue damage on other support surfaces. Injuries such as burns and other exuding wounds may benefit from air-fluidised therapy which reduces skin maceration by blowing air through a micro-porous cover and keeping the skin dry. This helps to manage incontinence by enabling body fluids such as sweat or urine to pass through the micro-porous bed cover into the base of the bed. Air-fluidised beds have a variable fluidisation control (Clinitron® II Air Fluidised Therapy and Huntleigh Oasis® Fluidised Bead Bed), and intermittent fluidisation for patients requiring traction, or who are being weaned onto an alternative support system. In addition, a static mode facility on these bed systems facilitates nursing care, for example, by enabling more efficient CPR. This control enables deflation of the mattress and returns the patient onto the solid base of the bed, therefore enabling more efficient CPR. Manual handling accessory equipment, such as the trapeze or monkey pole can be attached to certain beds to assist with the patient’s independence. Where a patient with extensive burns requires head elevation for respiratory purposes or to stabilise or decrease intracranial pressure following head injuries, the Hill-Rom Clinitron® Rite Hite® Air Fluidised Therapy Unit may prove useful because it has a backrest to maintain the patient in the reverse Trendelenburg position (Griffiths and Gallimore 2005) to stabilise intracranial pressure. The Clinitron® II Air Fluidised Therapy can have a foam wedge placed on it to allow head elevation of up to 67 degrees. The Clinitron® Rite Hite® Air Fluidised Therapy Unit provides a combination of airfluidised therapy and low air-loss therapy on an articulating frame to assist with improved wound outcomes, treat patients with grade II or IV pressure ulcers, skin flaps, grafts and other skin disorders that require healing. Ochs et al (2005) in their retrospective comparison of airfluidised therapy with other support surfaces for nursing home residents, found the mean healing rates were significantly greater for stage III/IV ulcers on air fluidised surfaces compared with other groups (static overlays and replacement mattresses) and (low air-loss beds, alternating pressure, and powered/non-powered overlays/mattresses). Bennett et al (1989) suggest that air-fluidised beds can be used to treat pressure ulcers successfully, and Allman et al (1987) found a median decrease in total surface area of large ulcers on air-fluidised beds compared with an increase on the other beds and mattresses. NURSING STANDARD
Time out 4 List three ergonomic features of a profiling bed that could cause harm to a patient who has sustained a head and spinal injury. Answer on page 52.
Orthopaedics/trauma units Repositioning the patient for pressure relief may increase the risk of manual handling injury to the critical care nurse. Some critical care beds are designed to have an optional fracture frame attachment (Huntleigh’s Contoura 1080 and Hill-Rom’s Magnum® II) and traction adapter. Most critical care beds can have trapeze or monkey pole handling aids added to the bed frames to assist the patient with repositioning. However, the patient must have the upper arm strength and such movement must not be contraindicated, for example, in the case of patients with hemiparesis or hemiplegia (Mitchell and Moore 2004). Some critical care beds that have integral air-loss mattresses may not be suitable for patients with unstable spinal or cervical fractures (KCI 2006c), because the movement and change of pressure in the mattress cells may make the fracture unstable and potentially cause spinal cord damage. Kinetic therapy or CLRT beds are unsuitable for patients with sustained unstable cervical or spinal fractures, although some, such as KCI RotoRest® Delta, can be used once the fracture has been stabilised with surgical fixation, cervical traction, or halo and vest (KCI 2006a). Where a patient needs to be turned completely from a supine to a prone position then the Stryker™ rotating frame, circular bed or orthopaedic turning frame can be used while still maintaining cervical traction. The frame enables the patient to receive pressure relief and to toilet without the spine being flexed or extended. A further manual handling risk to nurses occurs during the lateral turning of a patient with hip prostheses. There is a risk of both back strain to the nurse through handling heavy loads and a risk to the patient of prosthesis dislocation if the patient’s limb is not kept abducted (Collins 1999b, Peak and Hozack 2003). If the patient has sustained a head injury without any cervical fracture, operating the knee-break facility of a profile bed may cause hip flexion, leading to increased intrathoracic pressure, and subsequently to a rise in intracranial pressure (Price et al 2003). The nurse should also be aware of the risk of hip prosthesis damage if the profiling bed is not disabled. This may lead to inadvertent excessive april 19 :: vol 20 no 32 :: 2006 51
p45-53w32
10/4/06
12:33 pm
Page 52
learning zone moving and handling knee or hip flexion and hence dislocation of the prosthesis (Peak and Hozack 2003), especially if the knee break automatically folds at the same time as the backrest moves upwards. The Immoturn® manual handling equipment enables the nurse to turn the patient laterally in a supine position on his or her side without the risk of hip prosthesis dislocation. These metal frames are designed to turn patients on their side, while lying in bed. The patient’s lower limbs are kept in abduction to prevent the hip prosthesis dislocating out of the hip joint.
Conclusion This article has reviewed some of the technical and ergonomic features of critical care beds and patient support platforms that may be encountered by nurses in a variety of settings. Such items should be introduced in staff induction training and student preparation to minimise the risk of manual handling injury, and the clinical risk of harm occurring to the patient through incorrect use of such equipment when positioning patients. Practitioners and/or managers need to consult with back care advisers when purchasing beds and moving and handling equipment to reduce the risks of manual handling accidents in the critical care setting. The cost of the initial purchasing investment will be regained in savings in back injury-associated costs to the employer NS
Answers to Time out activities Time out 1 Variable height facility. Hydraulically operated backrest. Trendelenburg/reverse Trendelenburg automated tilt facility. Side rails with zero gap. X-ray cassette holder behind the backrest. Time out 2 Prevent upper limb and lower limb peripheral nerve damage. Minimise direct pressure on the patient’s body tissue while on the operating table. Time out 3 Zero gap bed rails. Half-length side rails ease lateral transfer from bed to chair. Profiling facility enables the bed to go into a chair egress position. Variable height facility enables some beds to be lowered to a very low position. Time out 4 Trendelenburg tilt facility could lead to an increase in the patient’s intracranial pressure. The knee break when folded upwards could increase the patient’s intrathoracic and intracranial pressure. Use of the backrest may lead to displacement of any spinal fractures in the vertebrae.
Time out 5 Now that you have completed the article, you might like to write a practice profile. Guidelines are on page 56.
References Allman RM, Walker JM, Hart MK, Laprade CA, Noel LB, Smith CR (1987) Air-fluidized beds or conventional therapy for pressure sores. A randomized trial. Annals of Internal Medicine. 107, 5, 641-648. Arblaster GM (1999) An evaluative approach to selecting mattresses. Nursing Standard. 13, 42, 56-63. Basham KA, Vollman KM, Miller AC (1997) To everything turn, turn, turn… An overview of continuous lateral rotation therapy. Respiratory Care Clinics of North America. 3, 1, 109-134.
Bennett RG, Bellantoni MF, Ouslander JG (1989) Air-fluidized treatment of nursing home patients with pressure sores. Journal of the American Geriatrics Society. 37, 3, 235-242. Burdorf A, Sorock G (1997) Positive and negative evidence of risk factors for back disorders. Scandinavian Journal of Work, Environment and Health. 23, 4, 243-256. Caboor DE, Verlinden MO, Zinzen E, Van Roy P, Van Riel MP, Clarys JP (2000) Implications of an adjustable bed height during
52 april 19 :: vol 20 no 32 :: 2006
standard nursing tasks on spinal motion, perceived exertion and muscular activity. Ergonomics. 43, 10, 1771-1780. Clay M (2000) Pressure sore prevention in nursing homes. Nursing Standard. 14, 44, 45-50. Collins F (1999a) Preventing pressure sores in the seated patient. Nursing Standard. 13, 42, 50-54. Collins T (1999b) Fractured neck of femur. Nursing Standard. 13, 23, 53-57. deBoisblanc BP, Castro M, Everret B, Grender J, Walker CD,
Summer WR (1993) Effect of air-supported continuous, postural oscillation on the risk of early ICU pneumonia in non-traumatic critical illness. Chest. 103, 5, 1543-1547. Dolynchuk K, Keast D, Campbell K et al (2000) Best practices for the prevention and treatment of pressure ulcers. Ostomy/Wound Management. 46, 11, 38-52. Elford W, Straker L, Strauss G (2000) Patient handling with and without slings: an analysis of the risk of injury to the lumbar spine. Applied Ergonomics. 31, 2, 185-200.
NURSING STANDARD
p45-53w32
10/4/06
12:33 pm
Page 53
Engels JA, van der Gulden JW, Senden TF, Kolk JJ, Binkhorst RA (1998) The effects of an ergonomiceducational course. Postural load, perceived physical exertion, and biomechanical errors in nursing. International Archives of Occupational and Environmental Health. 71, 5, 336-342. Engkvist I (2004) The accident process preceding back injuries among Australian nurses. Safety Science. 42, 3, 221-235. Ferrell BA, Osterweil D, Christenson P (1993) A randomised trial of low-air-loss beds for treatment of pressure ulcers. Journal of the American Medical Association. 269, 4, 494-497. Fink MP, Helsmoortel CM, Stein KL, Lee PC, Cohn SM (1990) The efficacy of an oscillating bed in the prevention of lower respiratory tract infection in critically ill victims of blunt trauma: a prospective study. Chest. 97, 1, 132-137. Fragala G, Owen D (2002) Nursing Ergonomics. Take the CE Test. American Association of Critical Care Nurses. Aliso Viejo CA. Garg A, Owen B (1994) Prevention of back injuries in healthcare workers. International Journal of Industrial Ergonomics. 14, 4, 315-331. Gentilello L, Thompson DA, Tonnesen AS et al (1988) Effect of a rotating bed on the incidence of pulmonary complications in critically ill patients. Critical Care Medicine. 16, 8, 783-786. Griffiths H, Gallimore D (2005) Positioning critically ill patients in hospital. Nursing Standard. 19, 42, 56-64. Hammon WE, Connors AF Jr, McCaffree DR (1992) Cardiac arrhythmias during postural drainage and chest percussion of critically ill patients. Chest. 102, 6, 1836-1841. Health and Safety Executive (1992) The Manual Handling Operations Regulations 1992: Guidance on Regulations. HSE, London. Health and Safety Executive (1998) Guidance on the 1992 Manual Handling Operations Regulations 1998. HSE, London. Health and Safety Executive (2003) Understanding Ergonomics at Work. Reduce Accidents and Ill Health and Increase Productivity by Fitting the Task to the Worker. www.hse.gov.uk/pubns/indg90.pdf
NURSING STANDARD
(Last accessed: March 23 2006.) Health and Safety Exexcutive (2006a) Health Services. www.hse.gov.uk/healthservices/index.h tm (Last accessed: March 23 2006.) Health and Safety Executive (2006b) Muscoskeletal Disorders. www.hse.gov.uk/statistics/ causdis/musc.htm (Last accessed: March 23 2006.) Hignett S (2003) Intervention strategies to reduce muscoskeletal injuries associated with handling patients: a systematic review. Occupational and Environmental Medicine. 60, 9, E6. Hignett S (2005) Ergonomics in health and social care. In Smith J (Ed) The Guide to The Handling of People. Fifth edition. BackCare, Teddington, Middlesex, 37-43. Hough A (2001) Physiotherapy in Respiratory Care: An Evidencebased Approach to Respiratory and Cardiac Management. Third edition. Stanley Thornes, Cheltenham. Jones J, Cockcroft A, Richardson B (1999) The ability of non-ergonomists in the health care setting to make manual handling risk assessments and implement changes. Applied Ergonomics. 30, 2, 159-166. Kuczmarski RJ, Flegal KM (2000) Criteria for definition of overweight in transition: background and recommendations for the United States. American Journal of Clinical Nutrition. 72, 5, 1074-1081. KCI (2006a) RotoRest® Delta. www.kci1.com/324.asp#QL327 (Last accessed: March 23 2006.) KCI (2006b) TriaDyne® II. www.kci1.com/336.asp (Last accessed: March 23 2006.) KCI (2006c) KinAir® IV. www.kci1.com/444.asp (Last accessed: March 23 2006.) Kjellberg K, Lagerstrom M, Hagberg M (2004) Patient safety and comfort during transfers in relation to nurses’ work technique. Journal of Advanced Nursing. 47, 3, 251-259. Lloyd P (1998) The Guide to the Handling of Patients. Fourth edition. National Back Pain Association and Royal College of Nursing, Teddington, Middlesex. MacIntyre N, Helms M, Wundwerink R, Schmidt G, Sahn S (1999) Automated rotational therapy for the prevention of respiratory complications during mechanical ventilation. Respiratory Care. 44, 12, 1447-1451.
McLean B (2001) Rotational kinetic therapy™ for ventilation/perfusion mismatch. Critical Care Nursing in Europe. 1, 4, 113-118. Medicines and Healthcare products Regulatory Agency (2004a) Medical Device Alert Ref MDA/2004/042: Electrically Operated Beds. MHRA, London. Medicines and Healthcare products Regulatory Agency (2004b) Medical Device Alert Ref MDA/2004/007: Bed Rails: Twin-bar Design. MHRA, London. Medline Plus (2005) Medical Encyclopedia ARDS (Acute Respiratory Distress Syndrome). www.nlm.nih.gov/medlineplus/ency/ article/000103.htm (Last accessed: March 23 2006.) Micheels J, Sorensen B (1983) The physiology of a healthy normal person in the air-fluidized bed. Burns. 9, 3, 158-168. Mitchell E, Moore K (2004) Stroke: holistic care and management. Nursing Standard. 18, 33, 43-52. Monchi M, Bellenfant F, Cariou A et al (1998) Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis. American Journal of Respiratory and Critical Care Medicine. 158, 4, 1076-1081. Ochs RF, Horn SD, van Rijswijk L, Pietsch C, Smout RJ (2005) Comparison of air-fluidized therapy with other support surfaces used to treat pressure ulcers in nursing home residents. Ostomy/Wound Management. 51, 2, 38-68.
Nursing in Critical Care. 8, 3, 126-133. Rance M (2005) Kinetic therapy positively influences oxygenation in patients with ALI/ARDS. Nursing in Critical Care. 10, 1, 35-41. Raoof S, Chowdhrey N, Raoof S et al (1999) Effect of combined kinetic therapy and percussion therapy on the resolution of atelectasis in critically ill patients. Chest. 115, 6, 1658-1666. Retsas A, Pinikahana J (2000) Manual handling activities and injuries among nurses: an Australian hospital study. Journal of Advanced Nursing. 31, 4, 875-883. Sahn SA (1991) Continuous lateral rotational therapy and nosocomial pneumonia. Chest. 99, 5, 1263-1267. Schregel W, Hube M, Finsterwalder H (1993) Static and dynamic anti-decubitus systems for ITU care patients. Journal of Tissue Viability. 3, 4, 108-113. Staudinger T, Kofler J, Mullner M et al (2001) Comparison of prone positioning and continuous lateral rotation of patients with adult respiratory distress syndrome: results of a pilot study. Critical Care Medicine. 29, 1, 51-56. Stiller K, Jenkins S, Grant R et al (1996) Acute lobar atelectasis: a comparison of five physiotherapy regimens. Physiotherapy Theory and Practice. 12, 197-209. Stiller K (2000) Physiotherapy in intensive care: towards an evidence-based practice. Chest. 118, 6, 1801-1813.
Owen BD, Keene K, Olson S (2002) An ergonomic approach to reducing back/shoulder stress in hospital nursing personnel: a five year follow up. International Journal of Nursing Studies. 39, 3, 295-302.
Walls C (2001) Do electric patient beds reduce the risk of lower back disorders in nurses? Occupational Medicine. 15, 6, 380-384.
Peak EL, Hozack WJ (2003) Total Hip Replacement Dislocations: What to Do? http://rothmaninstitute.com/ patienteducation/joint/hip/thrdislocation.htm (Last accessed: March 23 2006.)
Yip Y (2001) A study of work stress, patient handling activities and the risk of low back pain among nurses in Hong Kong. Journal of Advanced Nursing. 36, 6, 794-804.
Pegasus (2006) Specialist Bed Frames. www.pegasusuk.com/page.asp?pagenumber=9 (Last accessed: March 23 2006.) Petzall K, Berglund B, Lundberg C (2000) The staff’s satisfaction with the hospital bed. Journal of Nursing Management. 9, 1, 51-57. Price AM, Collins TJ, Gallagher A (2003) Nursing care of the acute head injury: a review of the evidence.
Welch J (2002) How to guide: kinetic therapy. Care of the Critically Ill. 18, 6, Suppl.
Zhuang Z, Stobbe TJ, Hsiao H, Collins JW, Hobbs GR (1999) Biomechanical evaluation of assistive devices for transferring residents. Applied Ergonomics. 30, 4, 285-294. Zhuang Z, Stobbe TJ, Collins JW, Hsiao H, Hobbs GR (2000) Psychophysical assessment of assistive devices for transferring patients/residents. Applied Ergonomics. 31, 1, 35-44.
april 19 :: vol 20 no 32 :: 2006 53
