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Changes in Functional Independence Measure Ratings Associated with a Safe Patient Handling and Movement Program (CE)
Safe patient handling and movement (SPHM) programs are effective in reducing healthcare worker injuries. However, the perception among rehabilitation personnel that SPHM equipment promotes patient dependence and adversely affects functional outcomes is one barrier to implementing successful programs. This barrier is particularly evident in acute inpatient rehabilitation facilities, where functional independence is the primary goal. The purpose of this retrospective cohort study was to evaluate this perception. Functional Independence Measure (FIM) ratings were collected from 94 patients with a diagnosis of stroke. Forty-seven patients were admitted 1 year prior to implementation of the SPHM program (Group 1), and 47 were admitted to the facility over a period of 1 year (Group 2) 18 months after program implementation. Group 2 obtained equal or better discharge mobility FIM ratings than Group 1, who received care without the SPHM equipment. This study suggests that SPHM programs do not impede functional outcomes in stroke patients.
Healthcare professionals consistently rank among the most commonly injured occupational groups in the nation (Bork et al., 1996; Campo, Weiser, Koenig, & Nordin, 2008; Cromie, Robertson, & Best, 2000; Marras, Davis, Kirking, & Bertsche, 1999; Nelson, Collins, Siddharthan, Matz, & Waters, 2008). Data from the U.S. Department of Labor Bureau of Labor Statistics (BLS) indicate that healthcare support occupations rank first among all professions in terms of sustaining on the job musculoskeletal injuries involving days away from work (BLS, 2009). The occupational group that includes rehabilitation nurses and other professional healthcare occupations ranks seventh among occupational groups suffering lost work days from musculoskeletal injuries (BLS, 2009). In addition, a growing body of evidence demonstrates significant injury rates among rehabilitation professionals (Bork et al., 1996; Campo et al.; Cromie et al.; Darragh, Huddleston, & King, 2009).
In response to these high injury rates, many healthcare organizations have implemented safe patient handling and movement (SPHM) programs that use mechanical and nonmechanical devices to assist with patient mobility tasks. Despite their role in significantly reducing work-related musculoskeletal disorders (WMDS; Collins, Wolf, Bell, & Evaonoff, 2004; Hunter, Branson, & Davenport, 2010; Sedlak, Doheny, & Jones, 2009; Zadvinskis & Salsbury, 2009), these programs are not widely implemented and may be met with resistance. The rehabilitation community in particular may resist implementation of SPHM programs (Darragh, Campo, & Olson, 2009; Daynard et al., 2001; Nelson, Harwood, Tracey, & Dunn, 2008; Saracino, Schwartz, & Pilch, 2009). Rehabilitation professionals, especially physical and occupational therapists, describe lifting or transferring dependent patients as one of the most problematic job factors in terms of WMSDs (Bork et al., 1996; Darragh, Huddleston, & King, 2009). Therapists reported using a variety of strategies to reduce physical strain, including adjustable height beds, gait belts, slide boards, and changes in posture and body mechanics (Cromie et al., 2000).
SPHM Programs in Rehabilitation
Experts in the field of SPHM have stated that rehabilitation professionals believe the use of SPHM equipment can contribute to functional decline or loss of patient independence (Nelson, Harwood, Tracey, & Dunn, 2008). Therapists have reported fears that using equipment delays independence in patients (Darragh, Campo, & Olsen, 2009). This fear may be partly due to the historical perception that lift systems include only passive lifts. In spite of anecdotal evidence of improved outcomes with use of newer active patient mobility systems, there is currently little evidence to support or refute this belief. The lack of evidence supporting SPHM in regard to rehabilitation outcomes, particularly on acute medical rehabilitation units, has led to wariness of SPHM equipment in this setting.
Rehabilitation professionals are viewed as experts in patient-mobility tasks, and their views can be highly influential to other caregivers. Because of this leadership role, it is imperative to replace the misconceptions with evidence-based knowledge and understanding regarding staff risk and rehabilitation outcomes.
Functional Independence Measures
Patients’ functional abilities are measured systematically in rehabilitation settings. The most common tool used to measure function is the Uniform Data System for Medical Rehabilitation’s (UDSMR®) FIM™ instrument (FIM; UDSMR, 1997). The FIM instrument is an 18-item, 7-level functional assessment tool designed to evaluate the level of assistance required by a person with a disability to perform basic life activities (Hamilton, Laughlin, Fiedler, & Granger, 1994; Linacre, Heinemann, Wright, Granger, & Hamilton, 1994). FIM is a trademark of UDSMR, a division of UB Foundation Activities, Inc.
FIM ratings are important because they are used nationally to establish reimbursement based on burden of care for inpatient rehabilitation facilities under the prospective payment system (PPS), to measure functional outcomes for national benchmarking, and for marketing purposes (Uniform Data System for Medical Rehabilitation [UDSMR], 1990). Rehabilitation professionals fear that low FIM ratings could affect reimbursement, reputation, and ability to attract patients, which may ultimately influence their decision to implement SPHM programs. Research to determine the impact of SPHM programs on outcomes, as measured by the FIM instrument, is urgently needed.
The purpose of this study is to evaluate whether there is a difference in functional outcomes, as measured by the FIM instrument, between patients with a diagnosis of stroke treated with safe patient handling equipment compared with a similar group of patients treated without the equipment/program.
This was a retrospective cohort study. Retrospective analysis of selected FIM ratings was performed for patients with a diagnosis of stroke (ICD code 434.91), admitted to a 20-bed acute inpatient rehabilitation facility. The functional activities included in this study were toilet transfers, bed/chair/wheelchair transfers, locomotion, and stairs (Table 1). These activities were selected because they are most directly affected by use of SPHM equipment. Admission and discharge FIM ratings of the selected activities, length of stay, age, and gender were recorded for each patient. Approval from the hospital’s institutional review board was obtained for the study.
Predictor and Outcome Variables
The primary outcome in this study was the total score of the mobility elements of the FIM instrument (described below). The primary predictor of interest was group (without safe patient handling program vs. with safe patient handling program). Group 1 was every patient admitted who met the inclusion criteria (IC) from June 2005 to June 2006, prior to implementation of the SPHM program. Group 2 was every patient who met the IC from January 2008 to December 2008, after the SPHM program was in place. Data on potential confounding factors or effect modifiers including age, length of stay, and gender were also collected. Finally, the mean changes in total mobility FIM ratings and in the individual category ratings were described and compared.
All patients with ICD-9 code 434.91 (stroke) admitted to the unit during the year prior to the implementation of the SPHM program—from June 2005 to June 2006—were included in Group 1. Group 2 was every patient admitted to the unit with the same diagnosis from January 2008 to December 2008. The SPHM program was implemented in June 2006. For this retrospective study, the data were gathered in January 2009. The most recent full year of data was collected for Group 2 to allow for maximum integration of the program into daily practice on the unit.
The exclusion criteria were death or length of stay fewer than 2 days.
Safe Patient Handling Program
The safe patient handling program included several elements: equipment, training, policy formulation, and external consulting services. Equipment included passive lifts, standing and raising aides (motorized and nonmotorized), and a standing and raising aid that converts to an ambulation assist device (i.e., ¨assists to stand the patient as well as fall arrest with gait). Friction-reducing devices were included in the complement of equipment.
Eight hours of training was provided for selected super users, 4 hours of training was provided for therapeutic techniques for key clinical staff, and 2 hours of training was provided for all other professionals and support personnel on the unit.
Supporting procedures were developed to facilitate reliable availability of equipment and accessories. Policies were developed to ensure consistency across all disciplines and also provide for disciplinary action in the event of noncompliance. The program was supplemented with external consulting services.
During the time this study took place, there were no other significant changes in practices or environment. Other than the addition of SPHM equipment, no other therapeutic tools were added to the rehabilitation unit. Staffing matrices remained constant, and there were no other major procedural or policy changes.
FIM Mobility Ratings
Transfers, toilet transfers, tub transfers, locomotion, and stairs are mobility tasks that require lower extremity strength, good sitting and standing balance, ability to bear weight through at least one lower extremity, and sufficient cardiovascular endurance to complete the given task. In contrast to traditional passive lifts, the current range of equipment can facilitate functional goals by assisting with bed mobility tasks, sitting balance, sit-stand activities, pregait, and ambulation activities.
FIM as a Measurement Tool
The FIM instrument is the most widely used measure of functional independence in rehabilitation units. It has demonstrated high levels of reliability. In a meta-analysis of FIM reliability and consistency, Ottenbacher, Hsu, Granger, and Fiedler (1996) found high levels of reliability when results were pooled across 11 studies. Specifically, the authors reported mean (95% CI) reliability coefficients for interrater reliability (.92; 95% CI = .92–.93), test-retest reliability (.92; 95% CI = .91–.93), and equivalence (.89; 95% CI = .89–.91). Glenny and Stolee (2009) found internal consistency values for total FIM ranging from (a = .88–.97) and values for the motor domain of the FIM ranging from (a = .86–.98). The FIM instrument also has demonstrated good validity (Corrigan, Smith-Knapp, & Granger, 1997; Hoenig, Branch, McIntyre, Hoff, & Horner, 1999; Stineman, Ross, Fiedler, Granger, & Maislin, 2003).
Admission FIM rating is obtained by using the lowest rating observed by any interdisciplinary member of the care team in the first 3 days following admission. The discharge FIM rating is obtained as the lowest rating observed by any caregiver for each activity within any 24-hour period within the 3 days prior to discharge. All disciplines in the facility are trained annually on FIM rating to promote scoring consistency. The functional change is obtained by subtracting the admission FIM rating from the discharge FIM rating to obtain gain (or loss) in functional independence for each of the activities analyzed. Rating of the FIM instrument is outlined in Table 2.
Data were analyzed using PASW Statistics v. 17.0. (SPSS, an IBM Company, Chicago, IL). All demographic factors, predictors, and outcomes were analyzed with descriptive statistics. Distributions of ratio-level data were analyzed with box plots that were clustered by group. Nominal-level data were analyzed with bar charts. The baseline functional status and demographic characteristics of the two groups were compared at baseline to determine if they were equivalent using the χ2 test of association or independent samples t-tests.
We compared the mean change in mobility FIM ratings from admission to discharge for the total mobility FIM and for each of the mobility FIM individual categories. To answer the research question of whether group affected the mobility FIM levels at discharge, the mean FIM mobility ratings at discharge were compared using univariate analysis of covariance (ANCOVA) with group as the fixed factor and baseline mobility FIM rating as a covariate. Age and length of stay were included as covariates because they both theoretically could have affected discharge mobility FIM ratings.
All subjects during the study period (N = 94) met the inclusion criteria. No subjects were excluded, and all data were available for every subject for all FIM categories at baseline and discharge. Forty-seven subjects were treated prior to SPHM program implementation, and 47 were treated afterward. Demographic and baseline characteristics are listed in Table 3. The groups were similar in terms of length of stay, gender ratios, and mean admission total and mobility FIM ratings. The subjects in Group 1 were significantly older than subjects in Group 2 (p = .03).
Figure 1 is a clustered bar chart representing the FIM mobility ratings at admission and discharge for each group. Both groups improved significantly from admission to discharge.
Discharge mobility FIM ratings for each group are listed in Table 4. Both the unadjusted and adjusted mean mobility FIM ratings at discharge were significantly higher in Group 2 (56.1 ± 1.47) than in Group 1 (50.9 ± 1.47). Baseline mobility FIM ratings were predictive of discharge mobility FIM ratings (F = 77.62; p < .01). Length of stay (F = 0.12; p = .73) and age (F = .35; p = .56) were not significantly related to discharge mobility FIM ratings.
Assumptions of ANCOVA were generally met satisfactorily with one notable exception: one patient in Group 1 was an outlier and had a mobility FIM rating that decreased by 12 points. Repeating the analysis without that patient did not appreciably change the p value of the F test for differences in group means. However, the adjusted mean discharge mobility FIM increased from 50.9 to 51.5 when that patient was deleted.
Overall, the mean change in mobility FIM ratings for Group 2 (21.5 ± 1.32) was significantly higher than the mean change in mobility FIM ratings for Group 1 (16.1 ± 1.53).
This increase in mobility FIM ratings was fairly consistent across FIM categories with the exception of tub transfers, for which Group 1 improved slightly more than Group 2. Table 5 lists the changes in the individual mobility FIM categories.
The Effect of SPHM on Mobility FIM Outcomes
The patients in both groups demonstrated significant improvements in mobility FIM ratings at the time of discharge from this facility. Discharge mobility FIM ratings in Group 2 (treated with the SPHM program) were higher than the discharge mobility FIM ratings in Group 1 (without the program). Group 2 improved more than Group 1 in four out of five FIM mobility categories, suggesting that mobility outcomes were better in patients treated in the SPHM environment. These effects appeared to be independent of age and initial baseline mobility FIM ratings. In addition, these effects appeared to be consistent within most of the individual categories comprised by the mobility FIM subscale.
Even relatively small FIM rating differences can have substantial clinical implications. In some cases a difference of 1 point in one of the individual categories can determine whether a patient may return home or go to a skilled nursing facility. The differences noted here may therefore have represented important clinical improvements.
Darragh and colleagues (Darragh, Campo, & Olsen, 2009) found that therapists reported being able to do more with low-functioning patients using SPHM equipment than they would have been able to do alone. SPHM equipment enables staff to get patients up earlier, more frequently, and for longer periods of time by removing caregiver fatigue as a limiting factor. The foci of SPHM programs are traditionally patient safety and worker safety. To date, however, we are not aware of studies that compare functional outcomes with and without SPHM programs. The present study suggests that a carefully designed and implemented program may not hinder and may indeed improve functional outcomes without additional therapy or treatment days. This improvement was seen in the unadjusted outcome ratings, the adjusted outcome ratings, and the change ratings.
FIM as Outcomes Measure for SPHM
An important limitation of this study is the use of the FIM instrument itself. The FIM instrument can be confusing to rate when using SPHM equipment. The National Institute for Occupational Safety and Health (NIOSH) recommends that assistive devices should be used for patient handling tasks requiring more than 35 pounds of lifting (Waters, 2007). However, guidelines from UDSMR require that if any mechanical device or “lift” is used, the correct FIM rating is 1, or totally dependent regardless of how much effort the patient expends. Therefore, patients who would traditionally receive a rating of 2 (maximum assist) or 3 (moderate assist) per FIM assessment would receive a rating of 1 under UDSMR guidelines if the caregiver considers NIOSH recommendations (UDSMR & Center for Medicare and Medicaid Services, 2001). This poses a serious dilemma for rehabilitation staff because it artificially lowers the functional score and does not reflect the true level of patient function. In the current study, patients were rated by estimation of actual patient contribution to the mobility task. This meant that rating processes were more consistent between the two groups than they would have been if equipment use was rated downward automatically in Group 2. However, because there may be variability between facilities on how the guidelines are interpreted in the context of SPHM, the external validity of the current study findings and generalizability across settings is limited. Further clarification is urgently needed on rating FIM levels when using SPHM equipment.
The ability to rate actual patient function in the context of SPHM equipment is vitally important to evaluate true functional improvement. More research is needed to investigate the validity of the FIM instrument for measurement of outcomes in the context of SPHM.
As an observational, nonexperimental study, there are factors at either the facility or individual level that we could not account for. Our results should be interpreted with caution, and they should not be considered evidence of causality. That is, we cannot conclude from this study that SPHM improves outcomes. These findings suggest the need for additional studies with multiple outcomes and larger samples to explore the issue further.
There are a variety of methods available for comparing the change or gain in ratings between two groups in studies. Any approach has important limitations, particularly in an observational study in which group assignment is not the result of random selection. Criticisms of a simple analysis of change scores have been documented (Dimitrov & Rumrill, 2003; Norman & Streiner, 2008; Wainer, 1991; Wright, 2006). ANCOVA is frequently used to increase power and to account for differences in baseline status in both observational and experimental studies, but its use is more limited in observational studies. It is clear in this study, however, that Group 2 achieved slightly better outcomes than Group 1 regardless of the analytical technique.
Another limitation was the single diagnosis studied. The authors cannot assume similar findings in other diagnoses. We recommend larger studies of a variety of patient populations for which SPHM programs have been implemented. It may also be beneficial to identify other variables that may have an impact on outcomes such as overall premorbid fitness levels, body mass index, and comorbidities.
The role of caregiver experience level also should be considered in future studies. There was minimal staff turnover at the facility studied between Groups 1 and 2. The staff were therefore 1.5 years more experienced when treating Group 2. Future studies should include this as a potential confounding factor.
Conclusion and Recommendations
There is a growing body of evidence to show that SPHM programs reduce work-related musculoskeletal disorders among healthcare providers. Rehabilitation professionals often resist these programs because of fears of negative impact on their patients’ level of functional activity. The findings of this study suggest that functional outcomes are not compromised by use of SPHM equipment in the stroke population, and some areas of function may even be improved. This study underscores the potential for rehabilitation professionals to be proactive in the use of safer methods to achieve functional independence in their patients.
More work needs to be done on patient outcomes across a wider range of diagnoses and in multiple settings and locations, and further clarification is needed on appropriate FIM rating in the context of an SPHM environment. Future studies should also use multiple raters to enable inter-rater reliability to be computed in the context of SPHM.
When considering the results of this study in the context of the literature, we also recommend that any future study consider multiple outcome measures in order to account for potential differences in outcome scoring. Prospective studies should be designed so that some of the previously mentioned limitations will be less prevalent.
The authors wish to express sincere appreciation to Larisa Hagen, BSN RN, rehabilitation nurse manager, formerly at Bay Regional Medical Center, for her contribution and support in data collection and article design.
Approval was obtained from Bay Regional Medical Center’s institutional review board.
About the Authors
Margaret Arnold, PT CEES, is rehabilitation services coordinator and ergonomics program coordinator at Bay Regional Medical Center, Bay City, MI. Address all correspondence to her at firstname.lastname@example.org.
Stephanie Radawiec, DPT MHS PT , is a clinical consultant at Diligent Services, ArjoHuntleigh, a division of the Getinge AB Group, in Addison, IL.
Marc Campo, PhD PT OCS, is assistant professor in the Program in Physical Therapy, Mercy College in Dobbs Ferry, NY.
Laurette R. Wright, MPH BSN RN COHN-S, is clinical director for Diligent Services, ArjoHuntleigh, a division of the Getinge AB Group, in Addison, IL.
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