Vol. 15 Issue 13
Introducing The Egress Test
A simple screening tool to predict safety of bariatric patient transfers
With the current dramatic growth in the general population toward significant size, health professionals will begin to see not only a higher number of patients of large size, but also the same patients more often. The bariatric geriatric patient population is currently surviving at a phenomenal rate, resulting in health care providers seeing the same patient more frequently through chronic admissions.
The Need: A Simpler Tool
According to the U.S. Bureau of Labor of Statistics, among private industries in the 1990s that employed 100,000 or more employees, nursing assistants ranked as high as number three on the list of all occupations for non-fatal injuries. Nurses ranked in the top 30 percent of this list.
The most common injury sustained was strain. The most common variety was back strain, followed by cervical and shoulder strain. This is a profound statement considering that in most areas, health care is the largest private employer. These providers are literally putting their spines on the line.
Given this prevalence, easily applied practical screening tools are essential. Many previous screening tools have been cumbersome, requiring professionals to observe patient function, quantify that function in a final score, then reflect that safety score on a comparative scale. Still other tools become impractical, since the caregiver must follow a number of questions and arrows expressed upon multi-page algorithms, then apply that result at bedside.
Successful transfer equipment and screening tools share common traits. If transfer equipment and screening tools are not simple and readily accessible, they become ineffective and place the caregiver at great risk for injury. Multi-page decision tools and algorithms with complex pathway arrows will always fail clinically. It is critical for any clinical decision criteria, then, to be simple and easily remembered.
Presenting the Egress Test
The Egress Test is part of an overall safety program I developed over a decade of clinical experience, which has been peer reviewed at more than 300 professional accreditation agency events. Many of the concepts are based upon clinical experience and actual deposition reviews addressing safety issues in the management of those of significant size.
The Egress Test includes practical screening tools and provides the answers caregivers must have to maintain a defensible position against questions posed by litigators in the event of an injury and resulting lawsuit.
It addresses the most common aspect of the decision failings that cause falls to occur during initial transfer attempts and gait mobilizations of the patient of size. The entire process is examined to resolve specific recurring scenarios at bedside.
Your Day in Court
Imagine finding yourself in the witness box, after being called upon to testify regarding the fall of a patient that resulted in a catastrophic injury.
The prosecuting attorney asks you, "How did you know you could safely transfer this patient from the bed to the bedside commode?"
The witness usually stalls at this point, because the obvious becomes apparentcurrently we have no formal process to predict a safe transfer, so we use an ad hoc "get-up-and-go" approach. This question is typically answered poorly or indirectly:
"Well, we put a gait belt on the patient, and three of us were holding the belt when the patient fell down."
Prosecutor: "Was that with all six hands of the guarding caregivers?"
"When did the fall actually take place?"
"I recall that the patient became unsteady when he lifted his advancing leg in the second step toward the commode."
The defense attorney counters with, "This was a debut first-time transfer postoperativelyhow could you know that the patient could perform the task safely?"
The witness has no answer. To the jury, the risk of injury seems obvious after the prosecuting attorney points out the mismatch of caregivers, the failings in functional independence measures to estimate the percent of assistance, and the failure to indicate transfer equipment.
Estimate Endurance With Reps
Ninety-five percent of patients postop gastric bypass are discharged home in four days or less. The first postop transfer often occurs when a patient requests to use the bedside commode. The typical first bed-to-bedside commode transfer requires three to five total steps, with a similar number of steps to return to the bed. For the caregiver at the bedside, this event usually occurs prior to any therapeutic referral.
The majority of patients post-gastric bypass do not require a therapy evaluation. In facilities that do require mandatory evaluation, beyond an initial grace period common in new surgical programs, the mandatory therapy consult is evidence of the lack of an adequate screening process in that facility. It is likely, then, that patients of size not on the surgical floor are not being adequately screened.
Ultimately, unless the transfer activity was observed previously, or unless documentation exists that supports the patient's ability to complete the transfer task safely, there is no adequate defense in the above courtroom scenario. The only acceptable retort would be, "I attempted the transfer because the patient demonstrated sufficient reps of activity to simulate the transfer beforehand."
Reps are evidence of consistency that provide the caregiver with a defensible position in a debut transfer event. The Egress Test provides this evidence.
Safety First for Patient, Caregiver
The Egress Test is simple to recall and provides a defensible work environment at the transfer workstation. It builds in evidence through repetitions at bedside, particularly following a gastric bypass. Should you find yourself in a courtroom later, using the tool will put you in a position to answer the question, "How did you know that this patient could perform this transfer?"
Your response would then be, "The patient demonstrated sufficient strength and endurance at bedside prior to having left the edge of the bed. He performed three leg presses demonstrating weightbearing without assistance; he marched in place, demonstrating anti-gravity strength in each leg and the ability to hold his bodyweight in single leg stance; and he demonstrated an ability to advance step and retreat to the target surface prior to the transfer."
The ultimate purposes of The Egress Test, however, are to make our jobs safer and to protect our patients. It reminds caregivers to avoid the obsolete and traditional "one, two, three, let's stand" scenario.
It also reminds caregivers that patients who require physical assistance beyond guarding are indicated for mechanical conveyance, which is a major step toward preventing both patient and caregiver injuries.
For more information about The Egress Test and/or The Bariatric Safety Kit, visit www.bariatricrehab.com
Michael Dionne is owner and founder of Choice Physical Therapy in Gainesville, GA, which specializes in managing the patient of significant size. He is a frequently invited presenter on bariatric rehab at APTA conferences.
The Egress Test
Purpose: To facilitate the safe progression of a patient's debut transfer through repetitions.
Test 1: Three reps of sit-to-stand. The first rep in this progression is actually a clearing test, in which the patient elevates from and clears the support surface by only one to two inches. The purpose of the clearing rep is to verify weightbearing ability and that the patient is able to perform the task without physical assistance. The clearing test also allows the guarding caregivers to pause and request feedback verifying that all participants are safe during the initial rep.
If the patient requires assistance beyond cues and guarding techniques, then that patient is indicated for mechanical conveyance until a time when he demonstrates consistent performance through therapeutic referral.
The patient then completes two subsequent full sit-to-stand reps to demonstrate consistency of physical antigravity performance. The total sit-to-stand progression demonstrates leg press ability and is critical to evaluate the ability to rise from the target surface, such as a bedside commode, during the return effort.
Test 2: Three steps of marching in place. There are situations in which a patient may have sufficient strength to raise a leg from the floor and advance it toward the target surface, but that same leg may lack the strength to support the patient's entire bodyweight. So it is critical to test both the strength required to elevate each leg, and the ability of each leg to support the patient's total bodyweight during a single leg stance.
Marching in place at the starting surface allows caregivers to test consistency and to redirect the patient back to a sitting position through the safe use of guarding techniques, should the patient become unable to complete the task. Too many patients fall or become stranded mid-transfer because endurance had not properly been tested prior to leaving the starting surface.
Test 3: Advance step and return each foot. Before the patient is allowed to step away from the starting surface to the target surface, a last test of endurance and function must be performed. There are both orthopedic and neurological causes that may render a patient unable to step backward.
While guarding positions are maintained at the bed's edge or starting surface, the patient is requested to advance one leg forward and then return it to the starting position. The task is repeated in the other leg.
Should a patient be unable to retreat a leg, the caregivers cue the patient to shift backwards onto the trailing leg and sit. Note that the patient always has a trailing leg touching the starting surface for possible retreat in this last endurance test.
If, during any part of the Egress Test, the patient demonstrates difficulty or need for physical assistance beyond cues and/or guarding techniques, that patient is indicated for mechanical conveyance.