SENATE, No. 1294

SECTION 1. Chapter 111 of the general laws, as appearing in the 2004 Official Edition, is hereby amended by inserting at the end, the following new section:

     Section 219.  Safe Patient Handling and Movement

Definitions: As used in this section, the following words shall, unless the context clearly requires otherwise, shall have the following meanings:-

“Administrative controls” are management-dictated work practices and policies that reduce or prevent exposures to ergonomic risk factors. Administrative control strategies include (a) modification of job rules and procedures (scheduling more rest breaks), (b) job rotation or modified duties or length of shift, and (c) training workers to recognize ergonomic risk factors so they can adopt stress reduction techniques while performing their work tasks. Examples of administrative controls include a no lift policy (explained later in this article), patient care assessment protocols, and use of clinical tools such as algorithms.

“Behavioral or work practice controls” are those that involve training of staff in body mechanics, or other joint protection principles. Such techniques include manual patient lifting, training in proper use of lifting equipment/devices, and the use of unit-based peer leaders.

“Back belts” are described as breathable, lightweight bands, with double-sided pulls, which allow for different levels of pressure and tautness.

“Department” shall mean the Massachusetts Department of Public Health.

“Engineering controls” are changes made to the work environment, layout, tools, or equipment used on the job, or changing the way a job is done to avoid work-related musculoskeletal hazards. These controls are the preferred solution because they create permanent changes that eliminate risks at the identified source. An example is the use of patient handling technology, such as lateral transfer aids or hospital bed improvements.

“Health care facility”, an individual, partnership, association, corporation or trust or any person or group of persons that employs health care providers, including any hospital, clinic, convalescent or nursing home, charitable home for the aged, community health agency or other provider of health care services licensed, or subject to licensing by, or operated by, the department of public health; any facility as defined in section 3 of chapter 111B; any private, county or municipal facility, department or unit which is licensed or subject to licensing by the department of mental health pursuant to section 19 of chapter 19, or by the department of mental retardation pursuant to section 15 of chapter 19B; any facility as defined in section 1 of chapter 123; the Soldiers’ Home in Holyoke, the Soldiers’ Home in Massachusetts; or any facility as set forth in section 1 of chapter 19 or section 1 of chapter 19B.

“Lift team,” a lifting team includes two physically fit people, competent in lifting techniques, who work together to perform high-risk patient transfers.

“Manual patient handling” is broadly defined as the transporting or supporting of a patient by hand or bodily force, including pushing, pulling, carrying, holding, and supporting of the patient or a body.

“Peer safety leader” is defined as a nursing staff member who receives special training and then returns to the unit to share knowledge and skills with coworkers.

     Every licensed health care facility shall implement an evidence-based policy for safe handling and movement of patients for all shifts and all patient care personnel based on minimum ergonomic standards to reduce the injury rates associated with manual patient handling. The policy shall include requirement for training in (a) use of patient handling equipment/devices, (b) patient care ergonomic assessment protocols, (c) no lift policies, and (d) patient lift teams. The policy may include new interventions developed through evidence-based research, such as the use of unit-based peer leaders and, clinical tools such as algorithms and patient assessment protocols. 

     The basic intent of the policy shall be to provide that care providers should eliminate manual handling in virtually every patient care situation. Therefore, the policy adopted shall include a “No Lift Policy,” which constitutes a pledge from administrators that proper equipment, adequately maintained and in sufficient numbers, will be available to care providers to reduce the risks associated with manual patient handling. Successfully implemented, a “no lift” policy is an integral part of a comprehensive safe patient handling and movement program in acute care hospitals and long-term care facilities.  A "No Lift" policy shall not mean that (a) nurses should never attempt to move a patient, (b) nurses should not use lift equipment, or that (c) the policy only applies to high risk tasks associated with patient lifts, and ignores other high risk tasks.  “No lift” policies mean that manual lifting of patients shall be eliminated in all but exceptional or life threatening situations.  The policy is to include provisions that:

• Patients be encouraged to assist in their own transfers and handling aids must be used whenever possible to help reduce risk if this is not contrary to a patient’s needs.
• Manual lifting may only be continued in exceptional or life threatening if it does not involve lifting most or all of a patient’s weight.
• A “no-lift” policy does not mean health care providers will never transfer or reposition any resident manually, but rather is based on patients’ physical and cognitive status as well as medical conditions.
• Proper infrastructure be in place before a no lift policy is enforced. Infrastructure is defined as management commitment and support, availability of patient handling equipment, equipment maintenance, employee training, advanced training for resources, and a culture of safety. The culture of safety approach includes collective attitude of employees at all levels taking a shared responsibility for safety in the work environment and by doing so providing a safe environment for themselves and patients.

     Said policy for safe handling and movement of patients shall utilize patient handling equipment and devices.  Several technological solutions that research has proven to be effective in addressing high-risk tasks include: the use of height-adjustable beds and electric beds, mobile mechanical devices, the use of ceiling mounted lifts for vertical transfers, repositioning devices, lateral rotation therapy beds for turning a patient in bed, and gait belts for transferring patients from a sitting position to standing one.  Black belts, lateral transfer aids such as friction reducing slide sheets, air assisted devices or mechanical aids shall not be utilized under any circumstances.

     The policy and its implementation must address factors that act as barriers to the use of equipment, including:

• Patient aversion of the equipment
• Unstable equipment or operationally difficult to use
• Storage issues/equipment is located in an inconvenient place
• Poor maintenance and cleaning of equipment
• Time constraints
• Inadequate number of available lifts
• No training on device on floors with high turnover levels
• Space restrictions to control equipment
• Incompatible equipment purchased
• Weight limitations

Patient lift teams. To help other caregivers perform their duties, the policy shall include provisions that high risk patient handling tasks are assigned to a select few well trained nursing staff. Selection of lift team members shall be based on individuals with no prior history of a musculoskeletal injury and is dependent upon their physical strength and capabilities. Those selected shall pass a physical exam, have a radiograph of their spine, and have no history of a back injury.  Once selected, team members shall be trained on the use of mechanical lifting devices. The significance of a lift team is evident by the elimination of critical risk factors that contribute to nursing back injuries: (a) lifts that are uncoordinated, (b) unprotected personnel, (c) lifting pairs with anthropometric disparities, (d) fatigue in nurses who lift, (e) injured nurses who lift, (f) lack of using mechanical lifting devices, and (g) lifters who are untrained.

The policy shall recognize that manual patient handling and lifting techniques are not evidence-based, have been found to be unsafe for the nurse and the patient.  The "Hook and Toss" method (also known as the Drag Lift) is banned.  In addition, classes on body mechanics and/or training in lifting techniques are not known to prevent job-related injuries.  While training may improve patient handling and lifting skills in the short term, it has no impact in reducing injuries or musculoskeletal pain. A more effective approach is to educate and train nursing staff on the use of patient handling equipment emphasizing proper body mechanics. 

Clinical tools shall be implemented applying research to practice and reducing unnecessary variation in practice carefully matching equipment to specific patient characteristics. Use of patient assessment protocols and algorithms shall be utilized to provide a standardized way to assess patients and make appropriate decisions about how to safely perform high-risk tasks. Such a system shall emphasize clear communication between nurses on a unit.

Patient assessment and algorithms for safe patient handling to assist nurses in selecting the safest equipment, technique, and number of staff needed to perform safe patient handling tasks based on specific patient characteristics. The use of assessment and algorithms ensure that patients receive assistance appropriate for their functional level, thus improving safety for patients as well as staff.

Key aspects of patient assessment include:

• Ability of the patient to provide assistance.
• Ability of the patient to bear weight.
• Upper extremity strength of the patient.
• Ability of the patient to cooperate and follow instructions.
• Patient height, weight and body shape.
• Special circumstances likely to affect transfer or repositioning tasks, such as abdominal wounds, contractures, spinal injuries, orthopedic conditions, post-surgical periods, or presence of tubes, etc.
• Specific physician orders or physical therapy recommendations that relate to transferring or repositioning patients (e.g., a patient with a knee or hip replacement may need a specific order or recommendation to maintain the correct angle of knee extension or hip abduction during transfer.)

After the assessment is completed, the information shall be used to direct recommendations in regards to the proper technique, equipment, and number of staff required for performing high-risk patient handling tasks, through the use of algorithms. Within the scope of patient handling, our operational definition of an algorithm is a procedure consisting of a sequence of logical steps to determine a given task.

Algorithms shall be developed for the following high-risk tasks:

• Transfer To and From: Bed to Chair, Chair to Toilet, Chair to Chair, or Car to Chair
• Lateral Transfer To and From: Bed to Stretcher, Trolley
• Transfer To and From: Chair to Stretcher, Chair to Chair, or Chair to Exam Table
• Reposition in Bed: Side to Side, Up in Bed
• Reposition in Chair: Wheelchair or Dependency Chair
• Transfer a Patient Up from the Floor
• Bariatric Transfer To and From: Bed to Chair, Chair to Toilet, or Chair to Chair
• Bariatric Lateral Transfer To and From: Bed to Stretcher or Trolley
• Bariatric Reposition in Bed: Side to Side, Up in Bed
• Bariatric Reposition in Chair: Wheelchair, Chair, or Dependency Chair
• Patient Handling Tasks Requiring Sustained Holding of a Limb/Access
• Bariatric Transporting (Stretcher, Wheelchair, Walker)

Failure of Health Care Facility to Adopt and Implement Safe Handling and Movement of Patients Policy.  The Department of Public Health shall promulgate regulations to ensure that inspections of health care facilities determine the existence of a policy for safe handling and movement of patients for all shifts, that personnel are trained in that policy and in the use of appropriate evidence-based techniques and equipment use, that equipment is available and in adequate supply convenient to each unit, and that a lift team is available at all times.  Said regulations shall include penalties for failure to develop and implement said policy.              

SECTION 2.  Nursing Education.

Notwithstanding any other general or special law to the contrary, the board of higher education, established pursuant to section 4 of chapter 15A of the general laws, shall institute a review of nursing education in the Commonwealth focused on needs to address evidence-based strategies and expose the nursing student to technologies available to reduce risk in the workplace with a goal of modifying how student nurses are taught patient handling considering emerging scientific research, technologic innovation, and exemplary application in real work settings, methods that make patient handling safe and ergonomically sound.

SECTION 3.  Nursing Licensure.

The board of registration of nursing, established pursuant to the provisions of section 13 of chapter 13 of the general laws, shall promulgate regulations to ensure that any holder of a license issued pursuant to the provisions of sections 74, 74A of chapter 112 of the general laws, and that, pursuant to the provisions of section 81A graduates of any nursing school have been trained in evidence-based strategies that expose the nursing student to technologies available to reduce risk in the workplace with a goal of ensuring that applicants for a license or renewal of license have been taught patient handling considering emerging scientific research, technologic innovation, and exemplary application in real work settings, methods that make patient handling safe and ergonomically sound.

SECTION 4.  Nursing Home Administrators.

The board of registration of nursing home administrators, established pursuant to the provisions of sections 108 - 117 of chapter 112, shall require that applicants for a license or renewal of a license under these section shall require that certified nursing assistants or other staff providing patient care who are, or will be, employed by said administrator, shall have been trained in evidence-based strategies that expose the nursing student to technologies available to reduce risk in the workplace with a goal of ensuring that applicants for a license or renewal of license have been taught patient handling considering emerging scientific research, technologic innovation, and exemplary application in real work settings, methods that make patient handling safe and ergonomically sound.

SECTION 5.  This act shall take effect one year from the date of passage.