Caregiving - A Look At No-Manual Lift Programs 
 
By Betty Bogue
Prevent, Inc. 
 
Some experts believe that mechanical lifts can significantly reduce employee MSDs and also cut back on injuries to patients.

While long term care facilities have had access to mechanical lifts for a number of years, the technology has often been viewed as too cumbersome and impractical for everyday use. Many of these mechanical devices have fallen into disrepair or have been simply gathering dust in storage buildings or basements.

But increased financial exposure from employee and resident transfer-related injuries, along with the advent of the Occupational Safety and Health Administration's new ergonomics rule, has spurred a renewed interest in the utility of mechanical lifts.

Indeed, in facilities where no-manual-lift programs have been initiated-in which all patient lifts are accomplished using mechanical equipment-the impact on both the quality of patient care and the safety of healthcare workers has been significant.

A study of 106 nursing facilities that employed no-manual lift policies for a 12 month period showed a 97 per cent reduction in lift-transfer injuries to workers compared with the previous 12 months. The research further revealed a positive impact on 13 of the 24 quality indicators monitored by annual surveyors. Because mechanical lifts enabled staff to safely move more patients over a given period of time, the no-manual-lift policy had the effect of increasing patient activity, thus reducing urinary tract infections and the probability of pressure ulcers, while enhancing toileting programs and helping to increase patient appetites. A no-manual-lift environment enables a single healthcare worker to safely lift-transfer any resident in a long term care facility without help.

Another study in 88 long term care facilities compared the number of falls occurring with lift patients 12 months prior to the initiation of the no-manual-lift program with the 12-month period following implementation. The research revealed a 48 percent reduction in such falls for the 12 months after the program was initiated. This correlates with a study reported in Rehabilitation Nursing (May/June 1997), which found that most falls can be attributed to attempts by patients to get up independently (for example, attempting to toilet themselves when sufficient help is not available). With the use of mechanical lifts, however, a single staff member is physically able to help toilet a patient, thus increasing the likelihood that help will be available.  
 
Savings Vs. Costs 
This is not to say that switching to a no-manual-lift program is easy or inexpensive. Providing the necessary equipment and training to redesign a facility's lift-transfer process can require a substantial up-front investment as well as other on-going costs. But the payoff can be calculated in terms of the reduction of musculoskeletal disorders (MSDs) and complaints-especially the lower-back injuries incurred during standard manual lift-transfers. According to the U.S. Department of Labor, facilities can save an average of $27,700 each time a severe MSD is prevented. Thus, the argument can be made that money already being spent of MSDs in the form of workers' compensation costs can be shifted to pay for the implementation of a no-manual lift program to prevent such injuries.

However, managing the up-front capital expense for the necessary equipment and training remains a barrier for many facilities.

One viable option is hiring a loss-prevention service that enables a facility to implement a no-manual- lift program without the purchase of capital equipment. This is a service that includes the use of the necessary mechanical lifts and associated equipment as well as the ongoing educational components needed to maintain and enhance the use of the mechanical lifts. The annual fee for such a service includes all additional slings that are needed as well as lift-maintenance costs.

Another financial option is for a facility to purchase all the necessary mechanical lifts and supplies and to designate a part time staff member to develop and oversee the processes of installing the no-manual-lift program. Ongoing equipment costs will include the replacement of damaged slings as well as the addition of specialty slings and lifts as patient acuity changes. Maintenance of the mechanical lifts is also an ongoing expense. Average annual cost of maintaining the mechanical lifts varies by vendor.  
 
Implementing A Program 
Installing a no-manual-lift policy at a long term care facility requires strong cooperation from nurses and certified nurse assistants (CNAs). It is also vitally important to dispel potential barriers that may cause resistance to the program among healthcare workers. 
 
Following are some of the most common challenges raised by workers prior to conversion to no-manual-lift programs at the 106 nursing facilities studied:

• It won't work because it will take too much time.
• Residents will refuse the use of mechanical lifts.
• Mechanical lifts are old chain-and-metal contraptions, we don't have enough, they don't stay charged, they don't always work, they are not safe, there are not enough slings, and you have to turn the resident to get them on the sling and lift them to get them off.
• How do you know who is supposed to use it?
• They trained me once but half the people I work with do not know how to use it.
• Mrs. Jones just had hip surgery on her one leg, she is combative, obese, and the lift does not work on her.
• The bathrooms are too small, the resident rooms are too crowded, and we can't store the lifts in the hall.

Implementation and maintenance of a successful no-manual-lift program first requires a commitment from all staff, and it must begin with the top managers. The doubts stated above are critical challenges that must be resolved to ensure healthcare workers' compliance with the change.  
 
Versatile Equipment Available 
For greater efficiency, all the mobile mechanical lifts that were selected for the 106 facilities in the study have a remote-controlled frame, and most have a remote- controlled base. In addition, all are battery-powered and lift in excess of 350 pounds. A successful no-manual-lift program demands mechanical lifts that are easy to move, fit under low beds, straddle mattresses on the floor, lift high enough for whirlpools, have a wheel base that fits standard bathroom doors, and have the capacity to pick patients up off the floor. 
 
There are two types of transfers that are used with an effective no-manual-lift program. The "total lift" is used to transfer patients who are unable to assist in any way. The "stand lift" is for those who can bear weight on at least one leg but who require a stand pivot transfer. Any patient who can provide 50 percent or more assistance with the transfer is not considered a lift candidate. The number of mechanical lift devices needed is determined by building layout, acuity of patients, and staff work patterns. 
 
The sling, which attaches to the frame of a mechanical lift device, supports the weight of the patient during a lift-transfer. To accommodate physical bodies affected by age and disease, an adequate number and variation of sling styles are needed. Bilateral amputees, for example, require their own slings, while patients who weigh in excess of 250 pounds will require specialized slings. 
 
When implementing a no-manual-lift program, all documentation, redesigned care processes, and enforcement of the policy and procedure must be integrated within regulatory guidelines. A critical example is patients' rights. Prior to implementation of a no-manual-lift program, the policies and procedures involved must be presented in writing to patient representatives and to patients themselves. Patients must be given ample time to discuss what the program provides and have an opportunity to view a demonstration of the function of the lifts. Education of the patient population is key to reducing resistance to mechanical lifts.  
 
Broad Scale Education 
Implementing and maintaining a no-manual-lift program involves almost every department in a facility. The laundry department must be aware of the special handling of the slings that is necessary. Maintenance personnel must be trained on simple problem solving with the function of the lifts. The housekeeping department is responsible for scheduling the regular cleaning of the equipment. Admissions must be aware of notifying new patients of the no-manual-lift policy and procedure.

After redesigning and creating all the necessary support processes and educating staff, patients, and patients' representatives on the "mechanics", a facility can begin the slow process of initiating the no-manual-lift program. When a no-lift program begins, caregivers must realize that it will be slow going until they become proficient at using the mechanical-lift devices.

More than 10,000 CNAs in the United States have been asked how long it takes to become time efficient with this equipment, and the answers vary from "the first time I used it" to "six months." Changing work processes involves time.  
 
Monitoring Compliance 
Monitoring compliance of the use of lifts is an ongoing challenge and key to a successful program-a lift is no good if it is not being used. To reinforce and support lift use, training needs and support processes must be monitored on an ongoing basis. Caregivers, for example, must work out such procedures as training on specialty slings, creating processes for difficult patients, assessing sling availability, gauging battery change schedules, and orienting new hires.

Implementing and maintaining a successful no-manual-lift program is possible, if not easy. The cost savings and the impact on quality of care reflect the benefits. There may soon be a day when every nursing facility will no longer permit employees to manually lift or transfer patients. 
 
Betty Z. Bogue, R.N., B.S.N., is president of Get a Lift!®, Prevent, Inc., Hickory, NC.
Reprinted with permission of the American Healthcare Association, Provider magazine, copyright American Healthcare Association.