Elements of a safe mobility program

The name Guy Fragala has been synonymous for years with ergo-nomic engineering for worker safety. During his years at the University of Massachusetts Medical Center and with the Newton-based firm Environmental Health and Engineering, he was a seminal influence on today’s “zero-lifting” campaigns in long-term care throughout the United States. Of late, though, he has broadened his approach to safer resident mobility. In a recent communication with Nursing Homes/Long Term Care Management, alluding to his development of a worker/resident safety program for customers of the equipment firm Sunrise Medical, Fragala noted, “We recognized that the technology required for a safe resident lifting program went beyond simply acquiring mechanical lifts. Resident beds are also a key piece of equipment. Electric height-adjustable beds with a wide range of up-and-down travel motion are also an important component. Programs must also address the important and necessary activity of repositioning residents in bed. The type of bed frame, bed surface, and friction-reducing devices available can be important in dealing with the risks presented by resident repositioning requirements.” In short, modern technology has broadened the options available for staff to maneuver residents safely and, by the same token, the demands for staff skills and training have intensified. Recently Fragala, now an independent consultant and senior adviser with the Patient Safety Center of Inquiry at the Tampa, Florida, Veterans Affairs Medical Center, elaborated on his full-spectrum approach in an interview with Editor-in-Chief Richard L. Peck.

Peck:How did your new, broader focus on resident mobility safety begin?

Fragala:I had spent my entire professional career on worker safety and, when I got into healthcare, realized that back injury for caregivers was the biggest occupational injury problem in long-term care. I concentrated on developing safe lifting programs, but then began to realize that the problem was much broader, that it was necessary to create a culture of safety within the organization. I spent a lot of time trying to convince people of this before they were ready for it, but lately I’m hearing many organizations say that this makes sense and they want help to achieve it.

Peck:So what are the key components of this approach?

Fragala:One key is the comprehensive resident safety assessment. I’ve seen this being applied to assessing fall risk and I thought, why not apply it to assessing need for lift assists and use of other types of equipment? What about beds? Different types of healthcare beds can do much to help improve resident handling and fall prevention. And bed surfaces—how might these in conjunction with friction-reducing devices help with resident positioning?

Peck:With the various resident classifications you use to specify individual needs—4 (total dependence), 3 (extensive assistance), 2 (limited assistance), 1 (supervision), and 0 (independent)—do you find facilities having difficulty customizing to this extent?

Fragala:Actually, these are fairly standard dependency classifications that almost everyone understands—the next step is to customize specific plans for addressing each resident’s level of need. It is not that difficult a step from a resident assessment to a specific response, and many facilities, when they think about it, acknowledge as much. The challenge for them is to give a bit more thought to lift/transfer maneuvers using the new technology available.

Peck:Are facilities moving in that direction?

Fragala:Yes, this change is happening right now. The old assessment approach involved deciding among two- or three-person transfers—basically, adding people as residents’ needs increased. But now we have not only standard lifts, including bariatric options, but stand-assist lifts, full-sling lifts, gait belts, friction-reducing devices for bed mobility, and more. Now it’s a matter of developing specific care plans and giving staff the tools and training they need to implement them.

The ultimate goal is to create that culture of safety. For this to happen, every facility needs a “champion” for the cause—that’s another key element of the new approach.

Peck:Even with champions and the best will in the world, though, what happens if a facility undergoes significant staff turn-over, as most do these days? How can training accommodate that?

Fragala:That’s why the culture of safety is so important and why champions are crucial to get it started and sustain it. But sustaining it also requires that workers’ peers become training leaders, passing along skills and knowledge to staff day to day on the job. Then it becomes “the way we do things here.”

Peck:I noted in descriptions of your approach that there is a disciplinary element for staff who persist in doing “the wrong thing,” such as single-person manual lifts of residents from floors or chairs.

Fragala:Discipline is not the focus of our approach but, as with any critical activity, you need some sort of progressive discipline to keep staff focused. Of course, when a resident falls to the floor, everyone wants to help immediately. But what we’re saying is that help should not be in the form of one person doing the lift, that there should be a plan to get help and use lift equipment. We are still moving toward zero-lifting as a goal.

Peck:Also interesting is your emphasis on getting residents involved in enhancing their own mobility to the extent possible.

Fragala:Yes, if people have functional abilities and can participate, we want them to. As an example, we’ve had many conversations of late with rehab therapists concerning use of stand-assist lifts. Research has found that use of these lifts is key to increasing resident ambulation, that once residents can be assisted to a standing position, using lifts with removable foot plates as a walker, resident ambulation can increase significantly.

Also interesting is how the stand-assist technology is evolving to accommodate the real long-term care environment. Many facility bathrooms are severely limited in space and can’t accommodate this equipment, so the base of these lifts has been redesigned and decreased three times over the past year and a half for a smaller footprint.

Peck:You’ve mentioned the variety of new equipment that is out there, but are facilities able to maintain a sufficient array of these devices to enable customized mobility programs?

Fragala:There are actually formulas for determining equipment needs, the basic factors being the resident assessments and dependency classifications for the particular facility, its geographic layout, and the possible location of different bed types and other equipment. The resident profile is the starting point.

Peck:Any concluding remarks?

Fragala:We have made a lot of progress in changing attitudes over the past few years and I think we are well positioned to create better and safer environments of care. The challenge will be to continue to develop new technologies for equipment and furnishings that will help caregivers deliver high quality of care.

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