External Hand Forces Exerted by Long-Term Care Staff to Push Floor-Based Lifts: Effects of Flooring System and Resident Weight

Comparison of trunk mechanics and spatiotemporal outcomes in caregivers using a robotic assisted transfer device and a mobile floor lift

OBJECTIVE

The purpose of this study was to compare trunk mechanics, distance covered, and average instantaneous velocity and acceleration recorded with caregivers performing transfer tasks using a research mannequin with both a prototype robotic assisted transfer device (RATD) and a mobile floor lift.

DESIGN

Cross-Sectional.

SETTING

Biomechanics Lab and Human Engineering Research Laboratories.

PARTICIPANTS

Caregivers (N = 21).

INTERVENTION

Robotic Assisted Transfer Device.

OUTCOME MEASURES

Range of flexion-extension, lateral bend, and axial rotation; distance covered; average instantaneous velocity and acceleration.

RESULTS

Caregivers performing transfers using the RATD as compared to when using the moble floor lift reported significantly smaller range of trunk flexion-extension, lateral bending, and axial rotation, and reported lower pelvic based distance covered and slower average instantaneous velocity and acceleration (P < 0.001).

CONCLUSION

The design and usability of a RATD indicates design driven mobility advantages over clinical standard mobile floor lifts due to its ability to expand the workspace while further reducing risk factors for low back pain. While the concept is promising, further testing is required to address limitations and confirm the concept for clinical applications.

Lauren M, Cooper R, Bendixen R, Koontz AM, Cooper RA. Clinical and Ergonomic Comparison Between a Robotic Assisted Transfer Device and a Mobile Floor Lift During Caregiver-Assisted Wheelchair Transfers

BACKGROUND

The robotic assisted transfer device was developed as an updated lift technology to reduce adjustments in posture while increasing capabilities offered by transfer devices. The purpose of this study was to compare the trunk biomechanics of a robotic assisted transfer device and a mechanical floor lift in the transfer of a care recipient by a caregiver during essential transfer tasks.

METHODS

Investigators enrolled 28 caregiver/care recipient dyads to complete 36 transferring tasks. Surface electromyography for the back muscles and motion data for trunk range of motion were collected for selected surfaces, phase, and direction tasks using a robotic assisted transfer device and a mechanical floor lift.

RESULTS

Robotic assisted transfer device transfers required significantly smaller range of trunk flexion (P < 0.001), lateral bend (P < 0.001), and axial rotation (P = 0.01), in addition to smaller distance covered (P < 0.001), average instantaneous velocity (P = 0.01), and acceleration (P < 0.001) compared with a mobile floor lift. The robotic assisted transfer device transfers required significantly smaller peak erector spinae (left: P = 0.001; right: P < 0.001) and latissimus dorsi (right: P < 0.001) and integrated erector spinae left (P = 0.001) and latissimus dorsi right (P = 0.01) electromyography signals compared with the floor lift.

CONCLUSIONS

The robotic assisted transfer device provides additional benefits to mobile floor lifts which, coupled with statistically lower flexion, extension, and rotation, may make them an appealing alternative intervention.

Shock-absorbing flooring for fall-related injury prevention in older adults and staff in hospitals and care homes: the SAFEST systematic review

BACKGROUND

Injurious falls in hospitals and care homes are a life-limiting and costly international issue. Shock-absorbing flooring may offer part of the solution; however, evidence is required to inform decision-making.

OBJECTIVES

The objectives were to assess the clinical effectiveness and cost-effectiveness of shock-absorbing flooring for fall-related injury prevention among older adults in care settings.

REVIEW METHODS

A systematic review was conducted of experimental, observational, qualitative and economic studies evaluating flooring in care settings targeting older adults and/or staff. Studies identified by a scoping review (inception to May 2016) were screened, and the search of MEDLINE, AgeLine and Scopus (to September 2019) was updated, alongside other sources. Two independent reviewers assessed risk of bias in duplicate (using Cochrane's Risk of Bias 2.0 tool, the Risk Of Bias In Non-randomized Studies - of Interventions tool, or the Joanna Briggs Institute's qualitative tool).

RESULTS

Of the 22 included studies, 20 assessed the outcomes (three randomised controlled trials; and seven observational, five qualitative and five economic studies) on novel floors (n = 12), sports floors (n = 5), carpet (n = 5) and wooden subfloors (n = 1). Quantitative data related to 11,857 patient/resident falls (nine studies) and 163 staff injuries (one study). Qualitative studies included patients/residents (n = 20), visitors (n = 8) and staff (n = 119). Hospital-based randomised controlled trial data were too imprecise; however, very low-quality evidence indicated that novel/sports flooring reduced injurious falls from three per 1000 patients per day on vinyl with concrete subfloors to two per 1000 patients per day (rate ratio 0.55, 95% confidence interval 0.36 to 0.84; two studies), without increasing falls rates (two studies). One care home-based randomised controlled trial found that a novel underlay produces similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to those of a plywood underlay with vinyl overlays and concrete subfloors. Very low-quality data demonstrated that, compared with rigid floors, novel/sports flooring reduced the number of falls resulting in injury in care homes (26.4% vs. 33.0%; risk ratio 0.80, 95% confidence interval 0.70 to 0.91; three studies) and hospitals (27.1% vs. 42.4%; risk ratio 0.64, 95% confidence interval 0.44 to 0.93; two studies). Fracture and head injury outcomes were imprecise; however, hip fractures reduced from 30 per 1000 falls on concrete to 18 per 1000 falls on wooden subfloors in care homes (odds ratio 0.59, 95% confidence interval 0.45 to 0.78; one study; very low-quality evidence). Four low-quality economic studies concluded that shock-absorbing flooring reduced costs and improved outcomes (three studies), or increased costs and improved outcomes (one study). One, more robust, study estimated that shock-absorbing flooring resulted in fewer quality-adjusted life-years and lower costs, if the number of falls increased on shock-absorbing floors, but that shock-absorbing flooring would be a dominant economic strategy if the number of falls remained the same. Staff found moving wheeled equipment more difficult on shock-absorbing floors, leading to workplace adaptations. Staff injuries were observed; however, very low-quality evidence suggests that these are no less frequent on rigid floors.

LIMITATIONS

Evidence favouring shock-absorbing flooring is of very low quality; thus, much uncertainty remains.

CONCLUSIONS

Robust evidence is lacking in hospitals and indicates that one novel floor may not be effective in care homes. Very low-quality evidence indicates that shock-absorbing floors may be beneficial; however, wider workplace implications need to be addressed. Work is required to establish a core outcome set, and future research needs to more comprehensively deal with confounding and the paucity of hospital-based studies, and better plan for workplace adaptations in the study design.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019118834.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 5. See the NIHR Journals Library website for further project information.

The SAFEST review: a mixed methods systematic review of shock-absorbing flooring for fall-related injury prevention

BACKGROUND

Shock-absorbing flooring may minimise impact forces incurred from falls to reduce fall-related injuries; however, synthesized evidence is required to inform decision-making in hospitals and care homes.

METHODS

This is a Health Technology Assessment mixed methods systematic review of flooring interventions targeting older adults and staff in care settings. Our search incorporated the findings from a previous scoping review, MEDLINE, AgeLine, and Scopus (to September 2019) and other sources. Two independent reviewers selected, assessed, and extracted data from studies. We assessed risk of bias using Cochrane and Joanna Briggs Institute tools, undertook meta-analyses, and meta-aggregation.

RESULTS

20 of 22 included studies assessed our outcomes (3 Randomised Controlled Trials (RCTs); 7 observational; 5 qualitative; 5 economic), on novel floors (N = 12), sports floors (N = 5), carpet (N = 5), and wooden sub-floors (N = 1). Quantitative data related to 11,857 patient falls (9 studies), and 163 staff injuries (1 study). One care home-based RCT found a novel underlay produced similar injurious falls rates (high-quality evidence) and falls rates (moderate-quality evidence) to a plywood underlay with vinyl overlay and concrete sub-floors. Very low-quality evidence suggested that shock-absorbing flooring may reduce injuries in hospitals (Rate Ratio 0.55, 95% CI 0.36 to 0.84, 2 studies; 27.1% vs. 42.4%; Risk Ratio (RR) = 0.64, 95% CI 0.44 to 0.93, 2 studies) and care homes (26.4% vs. 33.0%; RR 0.80, 95% CI 0.70 to 0.91, 3 studies), without increasing falls. Economic evidence indicated that if injuries are fewer and falls not increased, then shock-absorbing flooring would be a dominant strategy. Fracture outcomes were imprecise; however, hip fractures reduced from 30 in 1000 falls on concrete to 18 in 1000 falls on wooden sub-floors (OR 0.59, 95% CI 0.45 to 0.78; one study; very low-quality evidence). Staff found moving wheeled equipment harder on shock-absorbing floors leading to workplace adaptations. Very low-quality evidence suggests staff injuries were no less frequent on rigid floors.

CONCLUSION

Evidence favouring shock-absorbing flooring is uncertain and of very low quality. Robust research following a core outcome set is required, with attention to wider staff workplace implications.

TRIAL REGISTRATION

PROSPERO CRD42019118834 .

Assessment of Muscle Activation of Caregivers Performing Dependent Transfers With a Novel Robotic-Assisted Transfer Device Compared With the Hoyer Advance

OBJECTIVE

The purpose of this study was to compare muscle activity in caregivers while using a novel robotic-assisted transfer device (Strong Arm) to a clinical standard of care (Hoyer Advance).

DESIGN

A quasi-experimental design was used in which 20 caregivers (33 ± 15 yrs old) performed transfers with three surfaces (toilet, bench, and shower chair) with the Strong Arm and Hoyer Advance. Transfer completion time (seconds), peak percentage surface electromyography (EMG), and integrated EMG of the bilateral erector spinae, latissimus dorsi, pectoralis major and anterior deltoid were measured.

RESULTS

Caregivers required less transfer time when transferring from wheelchair to surface using the Hoyer Advance (P = 0.011, f = 0.39). For the lower back, significantly lower peak percentage EMGs were found using Strong Arm in 50% and for the integrated EMG in 25% of the cases, with the remaining cases showing no significant differences. For the shoulder, significantly lower peak percentage EMG values were found using Strong Arm in 19% of transfers and lower integrated EMG was found in 25% of transfers when using the Hoyer Advance, with the remaining cases showing no significant differences.

CONCLUSION

Although back muscle activation during Strong Arm transfers is statistically, but not clinically, lower, additional features that couple with significantly lower muscle activation make it an alternative to the clinical standard for further research and possible clinical applicability.

A comparison of floor surfaces for injury prevention in care settings: impact forces and horizontal pulling force required to move wheeled equipment

Shock-absorbing flooring is one potential solution to prevent fall-related injuries. No standards exist to characterize shock-absorbing healthcare flooring. This study explores two mechanical tests for impact force reduction and horizontal force required to move wheeled objects. An appropriately designed rubber underlay can reduce peak impact by 25% compared with 1% with standard vinyl.

INTRODUCTION

Severe falls often occur in hospitals and care homes. Shock-absorbing flooring is one potential solution to prevent fall-related injuries; however, no standards exist for characterizing flooring as an injury prevention measure. Shock-absorbing flooring use in high-risk settings may influence both patients (injury-saving potential) and staff (manoeuvring equipment). We aimed to explore two tests to characterize floors, to determine shock absorbency and horizontal pulling force required to move wheeled objects.

METHODS

Mechanical testing was performed according to the Canadian Standards Association Z325 Hip Protectors document. This test was developed for hip protectors but is applicable to compliant surfaces that form part of the floor. Tests were performed on commercially available floor materials (suitable for care settings) to assess the force required to initiate movement of a wheeled object across the floor. We explored the relationships between horizontal force required to pull wheeled objects, impact force, floor thickness, and core material.

RESULTS

Considerable differences were identified between floor samples in their ability to reduce the peak impact force (range 0.7-25%). A peak force reduction of up to 25% can be achieved with a specially designed rubber underlay. Horizontal pulling force increased with floor thickness but was lower for rubber floors. There was no direct relationship between impact attenuation and horizontal pulling force. Whilst thickness and core material explain some variations (66.5% for wheel movement; 82.3% for impact), other unmeasured factors clearly influence floor performance.

CONCLUSIONS

These results can inform the development of flooring and the establishment of standards needed to underpin practice, research, and development in this field.

Low-impact (compliant) flooring and staff injuries

Introduction: Low impact flooring (LIF) has shown potential for reducing fall-related injuries for older people in residential care or hospital environments. However, the increased rolling resistance when moving equipment on these floors has raised concerns that staff injuries may increase.Methods: LIF was trialled on one Older Persons Health ward for 2.5 years. Reported staff injuries were monitored during and following the trial. Numbers of staff injured on the LIF ward were compared with three other similar and adjacent OPH wards without LIF for the duration of the trial ('concurrent control' evaluation). At the trial conclusion the LIF ward moved to a different hospital that had standard flooring. This enabled a further 'during and after' evaluation where numbers of staff injured from the LIF ward during the trial were compared with those reported afterwards by the same ward staff without LIF.Results: There was no difference in the numbers of staff injured in the LIF ward compared with the concurrent control wards (28 LIF vs 30 control; p = 0.44). The number of staff with injuries in the LIF ward also did not significantly alter when those staff moved to a new ward without LIF (45 after vs 28 before; p = 0.11).Conclusion: There was no change in the numbers of staff with injuries during the LIF trial in an Older Persons Health ward. This small study suggests LIF appears safe for both patients and staff.Implications for rehabilitationFalls in hospital are common with patient injuries occurring in approximately 20-30% of falls.Low impact (compliant) flooring may reduce fall-related injuries in hospitals and residential care.Low impact flooring has an increased rolling resistance, which has the potential to increase staff injuries when moving equipment.This study found no change in the number of staff injured during a low impact flooring trial providing some reassurance that these floors are safe for staff.

Hand forces exerted by long-term care staff when pushing wheelchairs on compliant and non-compliant flooring

Purpose-designed compliant flooring and carpeting have been promoted as a means for reducing fall-related injuries in high-risk environments, such as long-term care. However, it is not known whether these surfaces influence the forces that long-term care staff exert when pushing residents in wheelchairs. We studied 14 direct-care staff who pushed a loaded wheelchair instrumented with a triaxial load cell to test the effects on hand force of flooring overlay (vinyl versus carpet) and flooring subfloor (concrete versus compliant rubber [brand: SmartCells]). During straight-line pushing, carpet overlay increased initial and sustained hand forces compared to vinyl overlay by 22-49% over a concrete subfloor and by 8-20% over a compliant subfloor. Compliant subflooring increased initial and sustained hand forces compared to concrete subflooring by 18-31% when under a vinyl overlay. In contrast, compliant flooring caused no change in initial or sustained hand forces compared to concrete subflooring when under a carpet overlay.

Feasibility of Compliant Flooring in Long-Term Care: Results from a Stakeholder Symposium

Compliant flooring aims to prevent fall-related injuries among high-risk older adults in long-term care, but uptake of compliant flooring in this setting is limited. We hosted a one-day stakeholder symposium to identify advantages and disadvantages of implementing compliant flooring in long-term care and the most pressing directions for future research from the perspective of key stakeholders. Twenty-three stakeholders representing health care, industry, and research attended the symposium. Attendees believed the most important advantages of compliant flooring were reducing injuries in residents who have fallen, potential benefits to care staff, and potential increases in quality of life for residents. Attendees perceived the most significant disadvantages of compliant flooring were financial considerations, lack of research evidence, and challenges with installation. Attendees indicated a need for additional research on cost-effectiveness and clinical effectiveness. While stakeholders perceived compliant flooring to add value to long-term care, there are significant informational and financial barriers to uptake.

Compliant flooring to prevent fall-related injuries in older adults: A scoping review of biomechanical efficacy, clinical effectiveness, cost-effectiveness, and workplace safety

Background

Compliant flooring, broadly defined as flooring systems or floor coverings with some level of shock absorbency, may reduce the incidence and severity of fall-related injuries in older adults; however, a lack of synthesized evidence may be limiting widespread uptake.

Methods

Informed by the Arksey and O’Malley framework and guided by a Research Advisory Panel of knowledge users, we conducted a scoping review to answer: what is presented about the biomechanical efficacy, clinical effectiveness, cost-effectiveness, and workplace safety associated with compliant flooring systems that aim to prevent fall-related injuries in healthcare settings? We searched academic and grey literature databases. Any record that discussed a compliant flooring system and at least one of biomechanical efficacy, clinical effectiveness, cost-effectiveness, or workplace safety was eligible for inclusion. Two independent reviewers screened and abstracted records, charted data, and summarized results.

Results

After screening 3611 titles and abstracts and 166 full-text articles, we included 84 records plus 56 companion (supplementary) reports. Biomechanical efficacy records (n = 50) demonstrate compliant flooring can reduce fall-related impact forces with minimal effects on standing and walking balance. Clinical effectiveness records (n = 20) suggest that compliant flooring may reduce injuries, but may increase risk for falls. Preliminary evidence suggests that compliant flooring may be a cost-effective strategy (n = 12), but may also result in increased physical demands for healthcare workers (n = 17).

Conclusions

In summary, compliant flooring is a promising strategy for preventing fall-related injuries from a biomechanical perspective. Additional research is warranted to confirm whether compliant flooring (i) prevents fall-related injuries in real-world settings, (ii) is a cost-effective intervention strategy, and (iii) can be installed without negatively impacting workplace safety. Avenues for future research are provided, which will help to determine whether compliant flooring is recommended in healthcare environments.