Author unit / section: FOD Public Services Sector/ Health Services Unit

Target audience: All FOD inspectors

• Summary
• Introduction
• Statement of the problem
  • Reduction in MSD risk achieved by profiling beds
  • Electric Profiling Beds in the community
  • Application of the Manual Handling Operations Regulations 1992 (as Amended)
  • Additional benefits of profiling beds
• Considerations when introducing electric profiling beds
  • Manual handling of profiling beds
  • Electrical issues at profiling beds
  • Entrapment risk at profiling beds
• Enforcement
• Other sources of guidance
• Appendix 1 - Summary of “The impact of profiling beds on manual handling risk and patient experience.”
  • Table 1: REBA scores and associated action levels.

Summary

This SIM provides information to assist inspectors undertaking visits looking at musculoskeletal damage and manual handling at work issues.

Introduction

1. As part of the FIT3 programme that combines sector and hazard programme work, the Public Sector Programme continues plans to address issues relating to musculoskeletal damage and manual handling at work. This links with, and is a continuation of, action towards meeting PSA and RHS Targets (of reducing levels both of ill health and days lost due to work-related incidents and causes).

2. This SIM describes the benefits of electric profiling beds  (EPBs) and how they can contribute to a reduction in MSD risk associated with person handling. It also outlines some of the issues that need to be considered when a healthcare organisation looks to introduce electric profiling beds. This SIM deals principally with NHS Trusts but recognises the scope of this guidance is applicable to social care environments.

3. These management systems inspections to control manual handling/MSD risk should be carried out at the same time as other activities and/or topic inspections wherever possible.

Statement of the problem

4. The level of manual handling related injuries reported to HSE under RIDDOR by employers with SIC92 codes 85110-85140 had been showing a steady decline from 1998/99 when it peaked at nearly 6500. It continues to remain relatively stable at around 5000 injuries reported each year.

5. The manual handling of people leads to one of the highest causes of injury to health care staff, reported under RIDDOR. The Royal College of Nurses (1996) identified that 52% of manual handling accidents involve the hospital bed. The most frequent activity being carried out at the time of injury involved moving the patient up the bed. Typically, these tasks include; sitting up a patient, moving the patient up or down the bed and turning the patient in bed.

6. Training in appropriate patient handling techniques along with the provision of suitable moving and handling aids reduces the risk of injury. However a risk of injury persists particularly in wards where there is a high level of patient dependency and therefore frequent patient handling takes place.

7. In the UK, most hospital beds are standard hydraulic, foot pump operated devices, with a flat base (mattress platform) and a pullout backrest. These are frequently referred to as King’s Fund beds as they follow the specification drawn up by the King’s Fund (an independent charitable foundation) in the 1960s.

8. Unlike the standard hydraulic beds, the bases of electric profiling beds (EPBs) are sectioned meaning that the mattress can be profiled to achieve various positions. The movement is powered and can be controlled, via a handset at the bedside, by either the patient or care staff. The height of the bed can also be adjusted under power.

Reduction in MSD risk achieved by profiling beds

9. A Comparison between standard and profiling beds using an ergonomic assessment tool (REBA: Rapid Entire Body Assessment) looked at a number of tasks involving moving patients on the bed. The study identified a significant reduction in the risk of musculoskeletal injury associated with those tasks where EPBs were provided. Appendix 1 lists the tasks examined and the reduction in REBA risk rating achieved.

10. An ergonomic risk assessment conducted on the adjustment of backrests on standard beds identified that staff at a hospital trust needed to compress the bed mattress in order to lower and raise the backrest, while overcoming frictional forces where the backrest rubs the top surface of the mattress. The ergonomic assessment suggested there is a high risk of musculoskeletal injury related to the use of the unmodified backrest. This risk is eliminated with the provision of electric profiling beds.

11. The reduction in MSD risk achieved by the introduction of EPBs can be in the main attributable to eliminating the need to manually adjust the backrest and manually raising the bed using the foot pump. In addition the ability to easily adjust bed height means that staff are more likely to appropriately adjust the height of the bed when conducting patient handling tasks or making beds.

12. Patients sitting in standard beds tend to slide down the bed and can have difficulty adjusting their position without assistance. The ability to easlily control the bed profile means that EPBs reduce the risk of patients slipping down the bed. Further, patients are able to reposition themselves from lying to sitting and vice versa without the assistance of care staff. Profiling beds promote bed mobility and patient independence. These factors mean that the number of patient handling tasks carried out by staff is reduced, further lowering the risk of injury.

13. It must be recognised that adequate training in the use of EPBs needs to be provided to maximise their benefits. A particular example would be staff awareness of the appropriate use of the knee break to prevent clients slipping down the bed.

Electric Profiling Beds in the community

14. Although EPBs are most commonly found in NHS Trusts the case for their provision within the community social care environments, particularly in nursing homes can be equally as strong.The reduction in risk achieved by their provision could be equivalent to that within an NHS acute ward.

15. When raising this issue with providers Inspectors should be mindful that small independent nursing homes may not have the same purchasing power as large NHS trusts or corporate providers of social care and so the impact of cost may be much greater.

16. HSCSU is aware that some of the larger social care providers use EPBS. However the extent to which social care providers already use EPBs is unclear and the HSCSU would welcome any information on this issue.

Application of the Manual Handling Operations Regulations 1992 (as Amended)

17. The Manual Handling Operations Regulations 1992 (as amended), Regulation 4(1)(a) requires employers to so far as is reasonably practicable avoid the need for employees to undertake any manual handling operations at work which involve a risk of their being injured.  Where it is not reasonably practicable to avoid such manual handling operations, employers are required to make a suitable and sufficient assessment of the manual handling operations and take the appropriate steps to reduce the risk to employees to the lowest level reasonably practicable.

18. EPBs eliminate the need for healthcare staff to undertake some patient-handling tasks.  Further the risks posed by those tasks that remain are greatly reduced. Where there is a high level of patient dependency and therefore frequent patient handling operations the provision of profiling beds is considered a reasonably practicable control measure in the management of the risk of musculoskeletal injury and as such should be provided.

19. Healthcare organisations need not provide EPBs where clients do not require assistance in bed. It is possible, for example for a Trust to provide EPBs in appropriate wards only while retaining a number of standard beds. However there are practical difficulties in ensuring that the right beds are available when and where required. Furthermore moving patients between beds introduces an unnecessary transfer with the associated risks.

20. Healthcare organisations should be undertaking generic assessments of the manual handling activities that they carry out. In hospital settings these should be done on a ward-by-ward basis. Such assessments should identify the handling aids required and should consider the need for electric profiling beds. An example of such an assessment is included in the RCN guidance 'Manual Handling Assessments in Hospitals and the community; A RCN Guide' (2003).

21. Typically orthopaedic, care of the elderly and stroke rehabilitation wards will by their nature have dependent clients and would be good examples of locations where EPBs would be required.

Additional benefits of profiling beds

22. In addition to reduction in MSD risk there are a number of benefits associated with the ability to alter the bed profile.

23. There are a number of studies that have shown that the introduction of Electric Profiling Beds has contributed toward a reduction in hospital developed pressure ulcers because:

• Patient handling operations themselves can subject the skin to shear and friction forces that can contribute to the formation of pressure ulcers.
• The tendency for patients to slide down the bed similarly applies shearing forces to the skin; this is less likely to occur in profiling beds.
• In addition the ability to position an occupant with support under the knee and calf can contribute significantly to reducing pressure on the heels of occupants as well as friction and shear on the sacrum (wedge-shaped bone consisting of five fused vertebrae forming the posterior part of the pelvis), thus reducing the risk of pressure ulcer development. 

24. A reduction in pressure ulcer incidence can represent a significant cost saving to healthcare organisations. The savings arise from amongst other things reduced length of patient stay and reduced pharmacy costs.

25. By giving patients the ability to adjust their position unaided, EPBs increase patient independence. This can lead to a significant reduction in the amount of time healthcare staff have to undertake other duties including pastoral care.

26. EPB allow better positioning of patients for eg coronary aftercare, postural drainage that can aid treatment and recovery. Similarly the beds can be profiled to better positions for nursing mothers.

27. Electric Profiling Beds generally have integral bed rails. This has a number of benefits including the certainty that the bed rails are the correct ones for the bed and that they are properly fitted. There is also the additional benefit of not needing to find storage space for the bed rails when not in use. However there is some concern that their ready availability has led to the use of the bed rails when not justified by a clinical assessment.

Considerations when introducing electric profiling beds

28. Although EPBs bring clear benefits a number of issues need to be considered prior to their introduction. Commonly electric profiling beds are provided through total bed or total equipment management schemes. SIM 07/2004/03 'Patient Handling: Making the business case' provides a case study on the benefits of such a scheme.

Manual handling of profiling beds

29. EPBs are significantly heavier than standard non-profiling beds and therefore can potentially introduce an increased risk when moving the beds. Whilst they should be relatively easy to manoeuvre on flat surfaces, locations with even shallow inclines may report some difficulty in moving the beds over any distance.

30. Some NHS Trusts have purchased bed pullers to assist in the transportation of beds. This represents an additional cost but should be able to be included in any total equipment management arrangements the organisation enters into.

Electrical issues at profiling beds

31. Hospital beds can be frequently moved, as the patient moves from ward to ward and during cleaning on wards. There is evidence that this can result in damage to the electric cables of EPBs. Further where pressure-relieving mattresses are used in conjunction to profiling beds there is a risk that the mattress power cable (particularly where it runs from the bottom of the mattress to the top of the bed) may become damaged as the bed’s profile is adjusted. Damage to the outer insulation of the cable has led to exposure of live conductors.

32. Where EPBs are provided healthcare organisations should have in place arrangements to reduce the likelihood and consequence of damage to the cables eg clipping cables to the frame of the bed, routine examination of the electrical cables and fitting of RCDs.

33. EPBs by definition require connection to a mains electrical supply. Healthcare organisations have needed to ensure that the electrical infrastructure can accommodate the additional load. In addition there may be a need to provide additional power points in the locations that beds are provided.

Entrapment risk at profiling beds

34. In certain circumstances EPBs may present a risk of entrapment or crushing.  In the UK a fatal accident occurred in which an elderly patient fell under a profiling bed.  The mattress platform descended under power, crushing the patient’s head.  In addition to the handset the bed had footpedal controls and it appears that the patient fell onto the foot pedal activating the platform lowering function.  There have been a number of incidents reported in France, three of which were fatal.  Again it appears that these incidents were the result of the foot controls being accidentally activated.

35. There is also potential for entrapment on other parts of the mechanism during bed transit, cleaning and maintenance.

36. Health bodies using EPBs therefore should be able to demonstrate that they have considered the risk of entrapment.  In conducting this assessment consideration should be given to; patient needs and condition, moving and handling operations, infection control and relationship to other equipment. 

37. Potential control measures could include: leaving the mattress platform in its lowest position when the patient is unattended, disabling the foot controls (temporarily or permanently) which may be possible without affecting other functions.

38. Measures may need to be taken to prevent inadvertent activation during cleaning and maintenance.  This may require trained staff deactivating the controls and recognising the beds are fitted with battery back up (so disconnection from mains power alone may not be sufficient).

39. EPBs are considered to be medical devices and as such any issues relating to the design of profiling beds is regulated by the Medical and Healthcare products Regulatory Agency (MHRA).  HSCSU would be grateful to hear of any such concerns.

Enforcement

40. It is not possible to encompass the risks of musculoskeletal disorders rigorously within the EMM. The manual handling assessment charts (MAC) are also not appropriate for application to patient handling tasks. For inanimate load handling task reference should be made to OC 313/4 Manual Handling Assessment Tool, MAC and EMM.

41. There is evidence that the cost of provision of the beds is balanced by reduction in costs from pressure ulcer treatment and manual handling injury, particularly where healthcare organisations have negotiated contracts for the lease of EPBS and mattresses.

42. However there may be initial capital outlay required or negotiations with suppliers/manufacturers. Inspectors should allow sufficient timescales for healthcare bodies to examine the range of products available and the options that are available to them in sourcing this equipment.

43. Inspectors are requested to contact HSCSU where enforcement action on EPBs is being considered. Similarly HSCSU would be interested to learn of any case studies where provision of profiling beds has demonstrably reduced MSD injury and related sickness absence.

Other sources of guidance

• 'Better Beds for Health Care: Report of the King’s Fund Centenary Bed Project.' Kings Fund ISBN 1-85717-202-7
• 'The impact of profiling beds on manual handling risk and patient experience.' The Column,2005, 17.4, 18-21
• 'Manual Handling Assessments in Hospitals and the Community. An RCN Guide.' Royal College of Nursing, 2003 Publication Code 000 605

Date first issued: October 2007

HSCSU contact: Amanda James / Sarah Tapley

Appendix 1

Summary of "The impact of profiling beds on manual handling risk and patient experience."
The Column, 2005, 17.4, 18-21

This study identified and examined a range of the most common patient handling tasks that would be affected by the nature of the bed used. The tasks were reconstructed by manual handling trainers in a training facility and video recorded. The recordings were then analysed using the Rapid Entire Body Assessment (REBA) tool (Hignett and McAtamney 2000) to compare the musculoskeletal risk they posed to staff. 

The REBA system uses look-up tables to derive an overall score of risk based on assessment of individual body areas (trunk, neck, legs and arms), the load or force involved, the activity level and the hold on the load (coupling). Action levels based on the REBA scores can be used to determine the extent of the risk and inform action. For example, the scoring system has a maximum possible score of 15 indicating a ‘very high’ risk action level requiring immediate action. 

A more detailed picture of the comparative risks for each of the simulated operations is given when the operations are broken into component sub tasks and assessed. Table 1 summarises the results of the analysis.

Table 1: REBA scores and associated action levels.

Simulated Operation	Combined REBA Score		Action Level
	Standard Bed	Profiling Bed	Standard Bed	Profiling Bed
Transfer onto bedpan	10	4	High	Medium
Assisting out of bed	10	6	High	Medium
Feeding a patient	10	1	High	Negligible
Lying a patient down	9	1	High	Negligible
Sitting a patient up	10	1	High	Negligible
Turning a patient	10	3	High	Low

All of the six manual handling operations on standard beds were identified as being high risk, requiring immediate action to control the risk. The REBA scores were noticeably reduced when the identical manual handling operations were carried out on electric profiling beds. None of the operations on profiling beds scored higher than medium risk. The REBA scores for the operations involving the profiling beds were between 40% and 90% lower than the scores for the same operations using the standard beds. This represented a clear and substantial reduction in the level of risk.

The frequency at which the operations were carried out did not reach the four times a minute required within the REBA methodology to increase the score to very high.  However given the level of manual handling operations recorded e.g. up to 77 per shift (1 every 6.2 minutes) and a total 12991 operations over the week, the authors  considered that there may be an increased risk to carers from the cumulative effect of exposure to the manual handling risks that the REBA system potentially underestimated.