Operations, Patient Care

Fresh Perspectives on Safer Patient Lifting and Moving

Issue 10 and Volume 42.

Lifting and moving are among the most important but dangerous endeavors in which EMS providers engage. The consequences of a misstep can be devastating and long-lasting.

Consider the case of a healthy paramedic in a large municipal service. He was a former kickboxer and avid weightlifter at the time of his injury.

On the day he was injured, he was taking a patient down a flight of stairs on a flexible Reeves stretcher. As he and his partner were descending the stairs, the patient moved, causing the EMS crew and patient to fall. The paramedic sustained a serious injury to his back.

Due to the typical “I don’t need help, I’m here to help you” attitude of an EMS provider, the paramedic chose to continue working and not allow his injury to properly heal. As a result, his pain worsened until he could no longer sleep.

The constant fatigue, coupled with chronic pain, caused negative changes in how he was perceived by his colleagues and supervisors.

Eventually, his extended time on disability forced him into retirement. Today, following five operations, he’s largely confined to a mobility scooter with a service dog to help him perform basic tasks.

In 2014, there were over 21,000 EMS providers treated in hospital EDs, with over one-third being the result of overexertion of the provider. Half of that number was from lifting and moving the patient.1 These numbers from the Centers for Disease Control and Prevention (CDC) don’t include the injuries sustained from lifting and moving that aren’t seen in EDs.

According to U.S. Department of Labor, the risk of injury among EMS providers is more than three times greater than risks among other private industry occupations (349.9/10,000 vs. 122.2/10,000).2

These numbers have remained largely consistent over the course of the last 10 years, and the lack of improvement suggests that it’s time for a change in our archaic system.

In this article, we begin by discussing a possible reason behind our significant injury rates. We then discuss possible changes in three separate domains that, if implemented, could serve to decrease the incidence of injury among EMS providers.

The Lifting Equation

In 1994, the National Institute for Occupational Safety and Health (NIOSH) published a revised lifting equation consisting of six factors, including the load constant, the distance the object is from the person who’s lifting and the vertical height the object is lifted. This equation was later revised to have greater application to other industries, including healthcare. When calculated out, the revised equation equals approximately 35 lbs.3,4

This number may seem shockingly low because the weights EMS providers routinely lift on a call easily may be double, triple, or even quadruple this weight. (See Table 1.) Such great weight, when it’s lifted call after call and year after year, may be why injury rates in EMS have remained unacceptably high.

Furthering this point, a 1999 study published by the Journal of Applied Ergonomics showed that even with a cooperative 110-lb. (50 kg.) patient (who had no use of his legs), the compression force exerted on the spine far exceeded the recommendations set by NIOSH of approximately 3,400 newtons, above which the risk of a lower back injury is increased by over 40%. The newton (N) is the International System of Units (SI) derived unit of force. It measures the force that produces an acceleration of 1 meter per second squared on a mass of 1 kilogram.

In a two-person traditional hook lift, the maximum compression forces on the spine averaged out to about 4,702 N for each provider while lifting and 4,513 N while lowering; the lifting movement is over 1,300 N greater than the NIOSH recommendation. (See Figure 1.)


Figure 1: Two-person hook lift

When the single-person “hug” technique for lifting the patient is performed, the total newtons of compression on the spine rises to 6,336.3 N for the lifting portion and 6,007.9 N for the lowering portion. (See Figure 2.) Both of these numbers are nearly double the NIOSH recommendations.


Figure 2: Single-person “hug” technique for patient lifting

It’s notable that these figures pertain to a patient who, although a paraplegic, was cooperative and weighed only 50 kg.5,6 We know from experience that the patients EMS providers regularly encounter, even for routine lift assists, can weigh double or triple this amount.

Coupled with variations in patient mental status, physical condition, and the awkward locations in which we find patients, the compression forces exerted on the spine on a shift-to-shift basis likely far exceed the numbers seen in this study.

As we’ve seen in the case study in the introduction and from the numbers presented, a change in how we handle lifting and moving is clearly needed. In the following section, we will discuss three controls: 1) administrative; 2) engineering; and 3) behavioral.7

These controls have been successfully implemented by the nursing industry to minimize lower back injury among providers, and will hopefully be implemented in our own industry soon.

Nursing as a profession, and especially nursing homes, have been on the front lines in terms of research on safe lifting and moving practices, and in translating research into practice to minimize injury among their personnel.

Unfortunately, EMS has largely lagged behind in these vital areas of patient care and occupational safety; as a result, our rates of injury have remained unacceptably high.

The peer-reviewed journal, The Online Journal of Issues in Nursing, published a three-pronged, evidence-based approach for reducing musculoskeletal injury among providers.7

The first prong is “administrative controls,” which entails the implementation of policies and protocols from management that would minimize the risk of injury during the performance of strenuous lifting and moving tasks.

The second prong is “engineering controls,” which is the use of patient handling technologies to limit strain on providers while performing lifting and moving tasks. The third prong is “behavioral controls,” which is the improvement in education regarding proper lifting techniques and maintenance of a healthy lifestyle so these tasks can be performed efficiently and safely.7

All of these factors are currently deficient in EMS, and if there’s any hope of minimizing injury and implementing a culture of safety, improvements in these three areas are imperative.

Administrative Controls

The CDC reports that roughly 2 out of 3 American adults are considered overweight (i.e., body mass index [BMI] > 25) and more than one-third of American adults are obese (i.e., BMI > 30).8

Because of the increased cardiovascular, pulmonary and musculoskeletal risks associated with being overweight or obese, EMS providers are encountering these patients with ever-increasing frequency and, as such, administrative procedures pertaining to these patients must be changed from the bottom up.

A policy should be created that empowers dispatch personnel to ascertain the estimated weight of the patient so adequate resources and personnel can be sent to the scene.

Next, every state EMS office should create a protocol for dealing with obese patients. (See Figure 3, p. 45.) This protocol would include the number of providers sent to a scene based on patient weight, specialized equipment that must be utilized, and the designation of safety officers who can oversee or assist in removing the patient from his or her home and into the ambulance.


Removing obese patients from their homes can carry equal levels of risk to EMS personnel as extricating a patient from their vehicle; so, similar safeguards must be put into place.

As with any protocol, special reports justifying deviation from the protocol must be filed and if it’s ruled that no justification exists or there’s a pattern of neglecting the protocol, remediation and re-education must occur. If that doesn’t alleviate the issue, penalties should be put in place.

Although repercussions for lifting and moving infractions may seem harsh, the reality is that overestimating how much you or your partner can lift can result in injury to both you and the patient. As with any error in patient care, safeguards must be put into place.

Behavioral Controls

One of the pitfalls of the current EMS education system is that lifting and moving isn’t seen as a topic worthy of consideration. Although continuing education opportunities are filled with classes on topics like emergency cricothyrotomy and even ultrasonography, one would be hard-pressed to find even a single class on the topic of lifting and moving, despite the fact that this task is performed on a daily basis.

An examination of the 212-page document, National Emergency Medical Services Education Standards: Emergency Medical Technician Instructional Guidelines 2009, revealed only four pages containing information regarding safety, lifting and wellness-that’s 1.88% of the entire document.9

The “Lifting and Moving Patients” section of these four pages defines three types of movements: 1) emergency; 2) urgent; and
3) non-urgent. However, outside of stating common sense safety measures such as “communication” and “keeping weight close to your torso,” no substantive discussion of how to perform these moves exists, forcing instructors to teach from their own subjective experiences rather than an empirically grounded and objective source.9

Unfortunately, lifting and moving tends to get buried in the vastness of the national education guidelines, resulting in instructors focusing on topics that have been problematically characterized as “more important.”

Our early training experience demonstrates that, of the 150 hours required to become an EMT-B, approximately 20 minutes were spent on learning the concepts of lifting and moving. Yet, research has shown that the three most common causes of injury are force (i.e., the weight of a patient and/or equipment), repetition, and awkward positioning.10

These three factors show the danger of inadequate education regarding lifting and moving: A provider who’s been improperly taught how to lift will lift patients who exceed his or her ability (i.e., force), will perform movements incorrectly (i.e., awkward positioning), and will repeat the incorrect movements (i.e., repetition)-a trifecta that raises the risk of injury to the provider.10

Research has also shown that, in order to prevent this, the provider must remain conscious of the lifting and moving process throughout the call. For instance, using one strap to carry the first-in bag can be dangerous if the provider doesn’t consciously keep their back straight, which illustrates the importance of maintaining a consciousness of good body mechanics for the entirety of a call.

To lift and move safely, information is available for providers in training and their instructors. In EMS training, the topic shouldn’t be glossed over, but repeatedly reviewed throughout the period of instruction.

In the psychomotor portion of the class, while performing scenarios, body mechanic critique should be focused on, and repetition of these movements should be done weekly.

Classroom scenarios often begin with the patient on the floor and end with the student verbalizing how they’d move the patient for transport. Rather than simply verbalizing this, EMS educators should prioritize the hands-on practice of field techniques in the safe environment of the classroom.

EMS providers shouldn’t leave the classroom without demonstrating proficiency in lifting and moving, in order to prevent injury not only to themselves, but to their partners and the patient. The classroom is an optimal place to make mistakes and learn, not the field.

EMS providers are prone to work-related injuries, and developing poor lifting and moving habits is one of the quickest ways to end a career and negatively affect daily life.

Engineering Controls

As in other areas of patient care, lifting and moving has experienced a rapid expansion of technology. Alternative lifting devices such as the Binder Lift, CombiCarrier II from Hartwell Medical, the Ferno Scoop Stretcher and others have multiple handles to facilitate lifting assistance from additional responders.

Driven by industry leaders Ferno and Stryker, significant innovations in the traditional patient movement apparatus have been implemented. These innovations are designed to minimize loads on the musculature of the providers while improving patient safety and comfort.

Traditionally designed stretchers have either an X-frame or an H-frame, and the force provided by the EMS providers has typically powered it. Although this sort of stretcher has existed for decades and has proven to be effective, the strain it places on providers’ backs is unacceptably high.

Fortunately, power stretchers are now proving to be a major improvement in lifting and moving technology in regard to musculoskeletal strains and sprains among EMS providers. (See Figure 4, p. 46.) One recent study found that power stretchers result in reduced muscle activity from six different areas on the body when operated by a provider.11


Figure 4: Ferno iNX (left) and Stryker Power-PRO (right) are two widely used power stretchers

Using 16 EMS providers as subjects, electromyography (EMG) activity was measured with electrode placement at six different locations on the body (forearm flexor, bicep, middle deltoid, right descending trapezius and bilateral erector spine).

The stimulation of these muscle groups was measured when the providers operated both stretchers, and also when different amounts of weight were placed on the stretchers. Research results showed statistically significant reductions in muscle activity.11 These reductions in muscle activity may result in fewer injuries, leading to a longer career in EMS.

As with any technology, significant differences in design and capability exist between manufacturers and, as such, comparisons must be done to determine which stretcher best suits the needs of EMS providers.

In one study, Ferno showed the effectiveness of the power stretcher, specifically the iNX model. In the study, the iNX was operated in comparison to another power stretcher (Stryker Power-PRO). Each stretcher was to be loaded and unloaded with different amounts of weight into an ambulance, with each side of the ambulance (left, right front, back) tilted at 3°.12

The experiment determined that the iNX could support the maximum amount of weight (700 lbs.) at four out of the five angles. The Power-PRO was also able to support 500 lbs. and more at three out of the five positions.12

It’s notable that the power stretchers aren’t exactly the same, as they come from two different companies. However, the importance of the power stretcher is clear from the study. When incorporated as an everyday piece of equipment, this new technology can reduce provider strain and accommodate the increasing size of patients encountered in the field today.

In another study, conducted by Stryker, researchers analyzed the overall macro impact of the power stretcher. The study focused on one EMS agency in particular, Century Ambulance, which used many Power-PRO units to replace their previous manual stretchers.13

In a service with an average of 3,000 calls per year, the replacement of manual lifting with new technology-supported lifting contributed to a significant reduction in provider injuries: Lost work days due to injury were reduced from 113 to zero. Notably, stretcher-related workers’ compensation claims also went down 28% within two years.13

This makes it hard to overlook the impact that power stretchers can have on providers, as this evidence demonstrates a reduction physical strain experienced by EMS workers.

In addition, the impact of these power stretchers allowed Century Ambulance to become more comfortable with how their patients are lifted and moved in the field, decreasing manpower demands and overall costs for the company.13

The incorporation of technology in EMS has enhanced many regularly utilized devices like the stretcher, and many EMS agencies are taking advantage of the new and innovative equipment now used in the field.

Raymond Everitt, division chief for the city of Pittsburgh EMS, reports that it will obtain power stretchers for its entire EMS fleet (13 units). With an estimated cost at $40,000 per unit installed (for a total of $520,000), Pittsburgh EMS is making the purchase with the intended goal of reducing injuries to their personnel. Although this cost to a municipal agency with a limited budget is significant, these high-technology stretchers and self-loading systems should be viewed as an asset to the city and future benefits may well outweigh the financial cost.

Everitt further reports that Pittsburgh EMS has paid 19 workers’ compensation claims related to on the job lifting and moving injuries, totaling $215,000 over the past two years.

New investments in power stretchers have the potential to markedly reduce these claims. Tri-Community South EMS in Bethel Park, Penn., has sought to improve conditions for their employees by integrating Binder Lifts, power load systems and power stretchers into their daily operations.

Nora Helfrich, the director of Tri-Community South EMS, notes, “We have had no injuries to employees since purchasing these three pieces of equipment.”

Conclusion

This work argues that a reduction in injury rates of EMS providers will be fostered by careful and considered improvements in three areas of control: administrative, behavioral, and technological/engineering. With results showing a significant decrease in injuries, services like Pittsburgh EMS are taking notice. Not only is this change financially responsible, but more importantly, it promises to lengthen the careers and ensure the continued health of EMS providers.

The EMS community needs more research devoted to the topic of proper lifting and moving in order to underscore its importance to prehospital care and to create new, safer methods of lifting and moving.

By continuing to invest time and resources in administration, education and technology/engineering, EMS systems will build better cultures and more rigorous practices of safety for their providers and patients

References

1. National Institute of Occupational Safety and Health. (Sept. 6, 2016.) Emergency medical services workers injury and illness data. CDC.Gov. Retrieved Mar. 11, 2017, from www.cdc.gov/niosh/topics/ems/data.html.

2. Maguire BJ, Smith S. Injuries and fatalities among emergency medical technicians and paramedics in the United States. Prehosp Disaster Med. 2013;28(4):376-382.

3. Waters TR, Putz-Anderson V, Garg A, Fine LJ. Revised NIOSH equation for the design and evaluation of manual lifting tasks. Ergonomics. 1993;36(7):749-776.

4. Waters TR. When is it safe to manually lift a patient? Am J Nurs. 2007;107(8):53-58.

5. Marras WS, Davis KG, Kirking BC, et al. A comprehensive analysis of low-back disorder risk and spinal loading during the transferring and repositioning of patients using different techniques. Ergonomics. 1999;42(7):904-926.

6. Zwedling D. (Feb. 11, 2015.) Even ‘proper’ technique exposes nurses’ spines to dangerous forces. National Public Radio. Retrieved Mar. 1, 2017, from www.npr.org/2015/02/11/383564180/even-proper-technique-exposes-nurses-spines-to-dangerous-forces.

7. Nelson A, Baptiste AS. Evidence-based practices for safe patient handling and movement. Online J Issues Nurs. 2004;9(3):4.

8. Flegal KM, Carroll MD, Kit BK, et al. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA. 2012;307(5):491-497.

9. National Highway Traffic Safety Administration. (January 2009.) National emergency medical services education standards. NHTSA Office of EMS. Retrieved March 2, 2017, from www.ems.gov/pdf/811077a.pdf.

10. Limmer D, O’Keefe MF. Emergency care, 13th edition. Pearson: Boston, 2016.

11. Sommerich CM, Lavender SA, Radin Umar RZ, et al. Powered ambulance cots: Effects of design differences on muscle activity and subjective perceptions of operators. Proc Hum Factors Ergon Soc Annu Meet. 2013;57(1):972-975.

12. Frederick K, Bravo I, Cartner J. (2016) Comparison of Multiple Loading Scenarios for Emergency Cots & Loading Systems. Ferno. Retrieved March 2, 2017, from www.paramedicchiefs.ca/docs/bcs-tomembers/ferno/8.4.16-Cot%20Comparison%20Gray-V2.pdf

13. Stryker Power-PRO powered ambulance cots help private EMS company reduce lost workdays from 113 to zero. (2011.) Stryker. Retrieved March 2, 2017, from http://ems.stryker.com/-/media/medical/ems/attachments/casestudies/century_ambulance_casestudy_mktlit192revc.ashx.