While new health care design requirements are common, a recently introduced group of requirements addresses critical safety issues that too many people who plan, design and equip health care facilities or approve capital budgets for their construction might not even think about — those involving caregiver safety and the safe movement of patients and residents.

In fact, the problems and consequences these new requirements address had grown so urgent that the Health Guidelines Revision Committee (HGRC) of the Facility Guidelines Institute (FGI) decided it must act. In April 2007, it established a specialty subgroup on patient movement to address these problems in the Guidelines for Design and Construction of Health Care Facilities.

The results — a collaborative effort of designers, providers, researchers and regulators — can be found in Section 1.2-5 of the 2010 Guidelines, published on Jan. 12, 2010, by the American Society for Healthcare Engineering (ASHE) of the American Hospital Association (AHA).

Problems addressed

There was growing concern among HGRC members about the increasing disparity between the many reasons patients must be moved and mobilized regularly, and the ability of caregivers to accomplish these moves safely (both for the patient and caregiver) and efficiently.

Their mandate can be seen in the following three ways:

1. Do something about the sky-high injury rate among nurses and aides. This is one of the highest rates of any industry, according to a 2005 article on "Devastating Injuries in Healthcare Workers: Description of the Crisis and Legislative Solution to the Epidemic of Back Injury from Patient Lifting" in the Journal of Long-Term Effects of Medical Implants (Volume 15, Issue 2).

In 2008 alone, more than 36,000 health care workers were injured by lifting and transferring patients, according to the U.S. Bureau of Labor Statistics. Another survey found that 83 percent of nurses continue to work despite back pain, and 60 percent fear a disabling back injury, according to the Journal article.

And injury to patients often accompanies injury to care staff. In social terms, there is a need to bring work-safety protections for health care workers in line with those of most other industries. Twelve percent of nurses say they have left the profession "for good" because of back pain, according to the 2006 book Safe Patient Handling and Movement: A Practical Guide for Health Care Professionals, edited by Audrey Nelson.

In economic terms, given the drastic shortage of nurses and their indispensable role in health care delivery, nurses and other trained caregivers can no longer be considered expendable. The HGRC actions coincide with legislative efforts on behalf of nurses to demand safer working conditions, which imply mechanical "lifting" and '"transferring" equipment to take most of the risk out of moving patients.

2. Consider that patients' general condition often deteriorates markedly during hospital stays because they don't get moved frequently enough or early enough. Many nursing home ad­ministrators, for instance, note that residents usually return from a hospital stay in worse condition, albeit without the acute condition for which they were hospitalized.

This deterioration, euphemistically referred to as "immobility-related adverse events," collectively includes anything from decubitus ulcers (bed sores), pneumonia and blood clots (deep vein thromboses or "DVTs") to muscle and bone loss, increased insulin resistance and reduced cardiac output.

In addition to such serious or even fatal clinical consequences, these outcomes result in the need for prolonged and expensive recovery after discharge, which might have been avoided or at least mitigated had patients been mobilized sooner and more frequently.

3. Improve the woeful inefficiency of staff inadequately equipped for wrestling ever-larger patients within or between care platforms. Some nurse leaders regard such operational inefficiencies as among the worst of any industry. It doesn't have to be that way.

All of these views point to the need for better and safer ways of lifting and transferring patients — helping them move between the primary perches within their environment (bed, chair and toilet); getting them back on their feet and walking; simply retaining the range of motion in their limbs; or moving them on and off the many rest surfaces, exam tables and transport devices they may use during a stay. Additionally, there are the tasks of helping patients with personal hygiene, wound care, therapy and rehabilitation. Collectively, all this is referred to as "patient handling" and/or "patient movement."

Rigorous biomechanical research conclusively demonstrates that manually lifting patients is almost categorically unsafe. Without necessary mechanical assists, health care workers and patients are less safe, care is less adequate, performance is inefficient and patients are therefore at increased risk of suffering immobility-related adverse events.

Approach to a solution

The right approach is to spotlight and detail the need for and building implications of assistive technology to better enable patient handling and movement. And, further, to have that technology in sufficient quantities at hand and available for use when needed.

The Guidelines address these goals by requiring the preparation of what's called a "Patient Handling And Movement Assessment" (PHAMA). Its vision is to eliminate the need for manually lifting and holding patients and to enable such patient care services to be performed "as needed" rather than "as able."

The process comprises several steps. First, health care facilities should assess the physical dependency needs of the facility's patient population by determining the degree of assistance they characteristically require in each care area being planned. Facilities should identify and quantify which mechanical assists are needed and where, as well as any storage, utilities and service requirements for equipment and accessories.

These requirements should be recorded in a newly mandated document entitled "PHAMA for Project X." This document, in turn, should be furnished to the team preparing the document known as the "functional and space program." The PHAMA can be used to inform the project's functional and space programs about dimensional and adjacency requirements, including all necessary clearances and potential architectural, structural, mechanical and utility planning and coordination issues.

The functional and space program should then be furnished to the design team so the facility may be planned, designed and constructed to accommodate those programs.

If and when needs change during the planning, design and construction process, the PHAMA and the building design can be revised as required. Finally, during project commissioning, hospitals should make sure caregiver and facilities staff know how to (and do) deploy, utilize, service and maintain the equipment, and to make necessary adjustments to verify that the facility is functioning as planned.

The Guidelines only require the preparation of a PHAMA and a functional program for each area in which patient handling will take place. The rest is recommended but not mandated. It's up to each applicant and authority having jurisdiction (AHJ) to decide how best to develop and complete a project. However, the PHAMA can be an indispensable tool for increasing staff and patient safety, and reducing the deterioration of patients that often accompanies the healing process. It can also enhance the efficiency of staff in their critical obligation to keep patients physically active or moving to whatever degree possible.

In jurisdictions that have a certificate of need (CON) or similar preliminary plan review requirement, the project PHAMA and functional program documents should be submitted along with schematic design and/or final construction documents (as required by each jurisdiction) for AHJ approval.

Assigning responsibility

The Guidelines assign responsibility for both the PHAMA and the functional program to the health care organization initiating a project, and they require the PHAMA be done as part of the pre-design-phase development of the functional program.

The appendix to the Guidelines suggests that the PHAMA be prepared by a team of experts comprised of frontline staff and care supervisors and managers; experts in risk management, safety and ergonomics; and those responsible for facility design and construction. These professionals should additionally be advised as needed by experts in therapy, infection prevention, housekeeping and maintenance and (optionally) a representative of the design team.

The Guidelines also spell out what must be done in the two-phase PHAMA process: Phase 1 includes a needs assessment and equipment recommendations; and Phase 2 lists facility-related considerations, in which the PHAMA addresses the impact of patient handling and movement needs on a building design.

This includes structural, mechanical and electrical and space considerations, as well as space requirements for care and maneuvering equipment, destination points for patient transfers and movement, sizes and types of door openings, floor finishes, and surfaces and transitions. It also includes coordination of patient handling and movement equipment installations with building mechanical, electrical and life support systems.

It further includes storage space requirements and locations, the impact of patient handling and movement equipment on the environment of care and aesthetics of care space, and infection prevention risk mitigation requirements.

Implementing a program

A PHAMA is the first step in implementing a Patient Handling and Movement Program (PHAMP). Once the specific needs have been determined in a PHAMA, these recommendations need
to be sold to administration.

The probable costs of the complete PHAMP, including equipment, accessories, storage facilities, impact on building size and design, installation, staff training, maintenance, financing, depreciation and replacement, should be established and figured into a business case for the program, with the results presented to decision-makers for approval.

The business case should incorporate not only the estimated costs but the anticipated return on investment. This should take into account estimated savings in patient care and facility operation from such analyses as anticipated worker compensation insurance savings, staff retention and retraining program savings, improved staff efficiency, faster recovery times, and both reduced readmission rates and lengths of stay for "immobility-related adverse events."

Instituting a PHAMP requires change, and a successful program helps providers understand the potential benefits of the program. It also helps them understand the need to adopt new ways of doing things that may differ from how they've been trained and probably how they've been doing things during their entire professional lives.

There are many recommendations in the Guidelines and its appendix about how best to approach these and other tasks. But perhaps the most useful advice in the Guidelines may be found in the very first paragraph of Appendix Section A.1.2-5, which says the following:

"Information and guidance for conducting a PHAMA can be found in the white paper entitled 'Patient Handling and Movement Assessment: A White Paper,' prepared by the 2010 Health Guidelines Revision Committee Specialty Subcommittee on Patient Movement and posted at www.fgiguidelines.org. The white paper also explains the rationale for considering patient handling equipment during the health care design and construction process; information about various types of patient handling equipment; the business case for implementing patient handling and movement programs; and strategies for implementing such programs."

FGI published this 147-page supplement, which features illustrations, explanations, charts and diagrams one can use as is or modify for use in preparing a PHAMA. It also includes additional chapters on "Establishing the Business Case for a PHAMP," "Facilitating Acceptance of a PHAMP and PHAM Technology," "A Vision of the Future of PHAMPs" and "Patient Handling and Movement Resources." The white paper is advisory and is not intended to be used as regulatory or accreditation requirements. However, because FGI wants the information to be widely disseminated, it is available for free on the FGI website.

State-by-state adoption

The effective date of the patient handling and movement guidelines depends on the location of the project. In states that adopt the latest edition of the FGI Guidelines as soon as it's published and enforce it as a code, these guidelines are already in effect. In most states, however, they will come into effect as the 2010 edition of the Guidelines is adopted in whole, in part or as modified by individual AHJs — typically a state, municipality or a federal or private agency such as the Indian Health Service or The Joint Commission.

Other AHJs write their own documents, many using the Guidelines as a model or as an authoritative reference. The best advice is to check with the AHJ.

The Guidelines are written to apply to all health care facilities, whether they are acute, ambulatory, residential long-term care or behavioral. But each AHJ decides whether to adopt the Guidelines in whole, in part or as modified, and can also decide to which types of facilities the Guidelines shall apply. Here again, the best advice is to consult the AHJ.

Change for the better

These patient handling and movement guidelines represent a change in the health care industry's way of doing things. But it is a change that should improve efficiencies, working conditions, outcomes and bottom lines.

Roger Leib, AIA, ACHA, is principal at Leib & Leib Inc., Los Angeles. He can be reached at roger@rogerleib.com. Martin Cohen, FAIA, FACHA, is principal at Martin H. Cohen, FAIA, FACHA, Southbury, Conn. His e-mail is martinhcohen@alum.mit.edu.

Sidebar - FGI keeps to its mission

To create a more formal document-writing process and to keep the Guidelines for Design and Construction of Health Care Facilities current, the Facility Guidelines Institute (FGI) was founded in 1998 as an in­dependent, not-for-profit 501(c)(3) corporation.

The primary objectives of FGI are to see that the Guidelines are reviewed and revised on a regular cycle using a consensus process carried out by a multidisciplinary group of experts from the federal, state and private sectors; to stimulate research in support of evidence-based design and construction guidelines; and to reinvest FGI's share of the net revenue derived from the sale of Guidelines documents to support the next revision cycle and to fund research that will improve future editions of the Guidelines.

FGI is primarily interested in consensus methodology and in overseeing the Guidelines revision process.

Specifically, FGI wants to make sure the Health Guidelines Revision Committee is properly funded; operates under a formal set of bylaws; has a balance of stakeholder representation from individuals with expertise or jurisdiction; uses the consensus process; requests public input in the form of proposals for change and comments on proposed changes; and reviews and revises the Guidelines on a timely basis to maintain a balance between minimum standards and the state of the art in health care design and construction practices.