Comparison of Provider Experience with Two Patient Examination Tables

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1 Proceedings of the Human Factors and Ergonomics Society 2016 Annual Meeting 593 Comparison of Provider Experience with Two Patient Examination Tables Amro Abdelrahman 1, Denny Yu 1, 2, Tara Cohen 3, Susan Hallbeck 1, Sandra Woolley 4 1 Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA 2 School of Industrial Engineering, Purdue University, West Lafayette, IN, USA 3 Human Factors Department, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA 4 Occupational Safety, Systems Quality Office, Mayo Clinic, Rochester, MN, USA Medical care providers recognize nonadjustable examination tables in clinics as a barrier to comprehensively and safely providing routine healthcare for disabled, elderly and obese patients. The aim of this study was to understand how the availability of the adjustable examination table may affect the medical care provider s perception of the quality of care provided to patients who need physical assistance. Fifty providers answered questionnaires to report their perceptions of two different examination tables usability. The first one is a mid-century industrial designed table and the other adjustable and ADA compliant, as used in a community health clinic. Before implementation of the new adjustable examination table, 34 medical care providers provided feedback on their experiences with nonadjustable examination tables. A second survey was administered approximately six months after implementation of the new adjustable examination tables to 16 medical care providers (with 2 indicating participation in the prior-toimplementation survey) for their feedback on experiences with the new adjustable examination tables. Providers reported significantly (p<0.05) more comfort in getting typical patients (27%), bariatric patients (50%), and geriatric patients (30%) into a sitting position when they used the adjustable examination table compared to the nonadjustable examination table. Providers considered the adjustable examination tables to have a more ideal width (60%) and length (64%) to accommodate a wider variety of patients than the nonadjustable examination tables. Providers also considered the adjustable table (33%) easier to use and preferable to the nonadjustable table. This research showed how the adjustable examination table improves healthcare provider experience to provide access to healthcare for patients with disabilities with better ergonomics and greater safety for both patients and providers. Copyright 2016 by Human Factors and Ergonomics Society. DOI / INTRODUCTION Nonadjustable-height examination tables are one of the health care barriers for disabled, elderly, and obese patients in health care settings (Amy, Aalborg, Lyons, & Keranen, 2006; Tara Lagu, Iezzoni, & Lindenauer, 2014; Mudrick & Schwartz, 2010; Rosen & Schneider, 2004; Stillman, Frost, Smalley, Bertocci, & Williams, 2014). During site assessments on a sample of healthcare clinics in one state, Frost et al reported that 64%-80% of the clinics were not equipped with adjustable-height examination tables. A similar study reported that less than 10% of outpatient practices have adjustable-height examination tables. Although federal regulatory laws (the Americans with Disabilities Act [ADA] of 1990 and Section 504 of the Rehabilitation Act of 1973) have been implemented to ensure that health care settings must be accessible to patients with disabilities, physical barriers like nonadjustable examination tables persist in many healthcare settings and can impact both patient and provider safety (T. Lagu, Griffin, & Lindenauer, 2015). Patients with disabilities not only perceived the nonadjustable examination table as a barrier to equal health care access but also as an unsafe and scary experience, limiting their willingness to go to healthcare clinics (Story, Schwier, & Kailes, 2009). Although patient apprehensions about height adjustability of examination tables as a barrier and major safety concern has been demonstrated in the literature, provider perception regarding the usability of different examination tables has not been studied yet. Patient handling has been identified as a significant contributor to musculoskeletal injuries. Musculoskeletal injuries have been significantly reported among healthcare workers mainly due to patient handling without ergonomic medical equipment. The consequences can be devastating on the provider health and career (Pompeii, Lipscomb, Schoenfisch, & Dement, 2009). Typically, only one provider is placed in a given examination room and is responsible for caring for the patient. This includes tasks such as assisting patients onto/off the examination table. Without accessible examination tables, providers are not able to assist patients with accessing the examination table, particularly those patients who need physical assistance (e.g., disabled, elderly, and/or obese patients). Inaccessible examination tables may put patients at a high risk of falling and providers at high risk of back or other musculoskeletal injuries (Engkvist, Hjelm, Hagberg, Menckel, & Ekenvall, 2000; Fragala, 2016; Smedley, Inskip, et al., 2003). Those risks may limit providers in their ability to provide adequate healthcare to patients who required physical assistance.

2 Proceedings of the Human Factors and Ergonomics Society 2016 Annual Meeting The purpose of this study was to evaluate provider perception regarding the usability of two different patient examination tables, in an effort to determine the impact of adjustable examination tables on medical care provider safety and healthcare delivery. Understanding the usability of medical equipment can help us to design a better ergonomic work environment for the successful treatment/triage of patients. Provider opinions on the examination table will provide useful feedback to continuously improve the quality of the examination room equipment and ensure that patients always receive the highest standard of care regardless of their disability status. This approach will help a clinic s medical staff to work efficiently to treat the greatest number of patients on a given day, while maintaining the highest standard of patient and provider safety. METHODS A total of 50 providers from a community health clinic participated in the study to evaluate their perceptions of the usability of two different examination tables. The medical providers included physicians, physician assistants, nurse practitioners, nurses and medical assistants. Thirty-four providers provided feedback on their experiences with the nonadjustable examination tables and 16 providers responded to a survey based on the new adjustable examination tables. The nonadjustable-height examination table: The dimensions of the wooden nonadjustable-height examination table are 5 x2 x2 6" with 7" high footrest. Once on the half circle footrest (i.e., shallow footrest with radius of 1 and 0.6"), the patient must be able to turn around to sit down. Once the patient has turned around, the distance between the footrest and top surface of the table is 24.8" for nonadjustable-height examination table. When the patient is asked to step down from table, depending on the patient s height, there is a drop of between 3.3" to 9.7" for the 95th to the 5th percentile individual, respectively, for the wooden nonadjustable examination table. The table width is 24 inches and the table length is 59.6 inches (Figure 1). Figure 1: The industrial designed wooden nonadjustable examination table in clinic examination room. The adjustable examination table: The adjustable-height examination table used in this study was Midmark 623 Barrier-Free Power Examination Table (Midmark Corporation. Dayton, Ohio, U.S.A.). The dimensions of the adjustable examination table are: 28.38" x 59.5" with minimum and maximum heights equal 18" and 37", 594 respectively. The length with footrest extended: 77.5" with pelvic tilt of 7 degrees. There were hand and foot controls available to adjust the table height and to control the orientation of the table back rest. The back part of the table was pneumatically adjustable from zero to 90. (Figure 2) Figure 2: The industrial designed adjustable examination table in clinic examination room. Study procedure: In the years prior to the study, a community healthcare clinic was equipped with the old nonadjustable examination tables. Before installation of new adjustable tables, participants completed a questionnaire regarding their perceptions of the usability of the nonadjustable examination table. Specifically, the questions were focused on addressing the impact of the old table on providing health services to patients. After the implementation of the new adjustable examination table, training was provided to the medical care providers on the use of the new adjustable examination table. Six months after the implementation of the new adjustable examination table in the clinic, medical providers were asked follow-up questions. Follow-up questions were composed of the same questions from the original questionnaire used before implementation of the new adjustable examination table as well as additional questions aimed at getting feedback regarding the new adjustable examination table. Dependent variables Self-reported questionnaires were completed by medical providers. This questionnaire assessed the provider s perception of the usability of two different examination tables and was developed by a team of human factors and ergonomic experts. The questionnaire was designed using short visual analogue scales (VAS). Seven questions were common to the pre- and postimplementation of the new adjustable examination table as shown in Figure 2. Participants completed each question based on a subscale on a 20 point visual analogue scale (VAS) (from 0 as not comfortable, not ideal, or very hard to use; to 20 as very comfortable, ideal, or very easy to use, respectively).

3 Proceedings of the Human Factors and Ergonomics Society 2016 Annual Meeting 595 your field would be when using this table to examine patients? 6 In comparison to other patients table I have worked with, this table is: (0 = not ideal, 20 = Ideal) Statistical analysis: Data were processed and analyzed using SPSS (v22, IBM Corp., Armonk, NY). All categorical independent variables, each question on the questionnaire, were expressed as percentages of the total number of providers, and the continuous independent variables were expressed as mean (M) ± standard deviation (SD). The differences in the dependent variables between the two provider groups (i.e., nonadjustable-height examination tables and adjustable-height examination tables) were tested using t-tests. The dependent variables which filled only by the providers after using the adjustable-height examination tables were expressed in mean ± SD. Alpha was set to Figure 2: Seven questions on provider perceptions of whether it is easier or harder to transfer and provide care for patients with examination table. This part has been filled by the providers of the two groups of clinics. The second part of the questionnaire was only asked after the implementation of the new adjustable examination table and contained six VAS questions (Table 1). Table 1: Additional questions on the post-implementation questionnaire Question Question stem No. 1 How comfortable do you feel with the amount of the time it takes to get a typical patient into sitting position on the table? 2 How comfortable do you feel with getting pediatric patients into setting position on the table? 3 In general, patients appear to be comfortable with getting into sitting position on the table: (0= disagree, 5= agree) 4 The patient exam table does everything I need it to do (moves appropriately, functions properly etc.): (0 = Never, 20 = Always) 5 How comfortable do you think other providers in RESULTS A total of 50 providers completed the questionnaires before and after the implementation of the new adjustable examination table. The demographic data from participants (i.e., medical care providers) in the clinics with the new adjustable examination table are summarized in Table 2. Regarding the data after implementation of the new adjustable examination table, most of the providers were nurses and most of their work was considered to be ambulatory (87%). Geriatric and bariatric patients together represented about 48% of their daily patient load. The mean percentage of the patients who needed physical assistance during their appointment represented 5% of the patient total (Table 2). Table 2: Descriptive statistics for 16 medical provider participants from the clinic equipped with the adjustable examination table. % Mean % Standard Deviation Count % Role Nurse Other Physician Pediatric Bariatric Geriatric Ambulatory Patients Per Day Patient Need to Assist 5 8 Self-reported questionnaire: part 1 Provider perception of the usability of each examination table was determined using unpaired t-tests and findings are summarized in Figure 3. Medical providers reported that the adjustable examination tables significantly (p<0.05) improved their comfort in getting patients into a

4 Proceedings of the Human Factors and Ergonomics Society 2016 Annual Meeting 596 sitting position compared to the nonadjustable table (27% for typical patients, 50% for bariatric patients, and 30% for geriatric patients older than 65 years old). Providers reported the adjustable examination table were more comfortable (18% improvement) in getting patients in wheelchairs into sitting position than the nonadjustable examination table but this difference did not reach the statistical significance level (p=0.1). On a scale from 0 (not ideal) to 20 (ideal), providers considered the adjustable examination table significantly better in width (6-point difference) and length (7-point difference) than the nonadjustable examination table. Providers also reported that the adjustable examination table was significantly (33%) easier to use than the nonadjustable exam table (Figure 3). Figure 3: Comparison of the provider perception between the nonadjustable examination table and the adjustable examination table using unpaired t-test. A strike represents p- value < On a scale from 0 (disagree) to 5 (agree), providers agreed that patients felt more comfortable on the adjustable examination table. Additionally, on a scale from 0 (never) to 5 (always), providers rated the adjustable examination table 4 out of 5 in doing everything the provider needed with respect to its movement and functionality. On a scale from 0 (not comfortable at all) to 20 (very comfortable), providers rated the adjustable table 17 and 16, in other words very favorable, in the amount of the time it took to get typical patients and pediatric patients onto the table, respectively. When providers were asked how they consider the adjustable examination table in comparison to the nonadjustable examination table, on a scale from 0 (not ideal) to 20 (ideal ), on average, providers rated the adjustable examination table as a 17 out of 20 (Table 3) Table 3: Descriptive statistics for the second part of the questionnaire which had been filled by16 participants of the second group of the clinic with the adjustable examination table. Questions Mean Standard Deviation Missing Comfort with amount of Time Comfort getting pediatric Patient comfort with the adjustable Exam table functionality Comfort of other providers using the adjustable examination table Comparison of the adjustable examination table to the nonadjustable examination table DISCUSSION This study investigated medical providers perception with respect to the use of two examination tables in providing healthcare for a variety of patient categories (Table 2). Each provider who worked in clinics equipped with the adjustable examination tables were responsible for seeing about 10 patients per day. Patients older than 65 years represented more than a third of their daily patients, while bariatric patients (e.g., obese patients) represented 12%. Both geriatric and bariatric patients represent a vulnerable group who may need physical assistance in addition to disabled patients in wheelchair. While providers in the new clinic reported that only about 5% of patients were in need of physical assistance, this number was most likely underestimated, because of the implementation of the new examination table. Patienthandling activities have been significantly positively associated with risk for lower back pain. Specifically, literature has identified that providers with the highest risk of back pain were those who have to assist patients from the floor to seated positions on the table (Smedley, Trevelyan, et al., 2003). This study was limited in measuring this reduction in patient handling issues, and future studies are needed to quantify the reduction of patient-handling activity after the implementation of the new adjustable examination table in other clinics to quantify how this ergonomic intervention may reduce body parts discomfort and pain among medical staff providing medical care to disabled patients. In this study, providers reported that the adjustable examination table was more comfortable and easy to use for delivering standardized healthcare when treating different patient types compared to the nonadjustable examination table (Figure 3). The fixed height and the small footrest of the original examination table increased the difficulty of independent transfer and made it impossible for many people with mobility disabilities to become appropriately situated for examination. This situation required medical staff to help the patients get onto/off the table. The alternative is to be examined in their wheelchairs or on the exam room couch which lead to less than the optimal healthcare and represents one of the main reasons for back pain among healthcare workers (Fragala, 2016; Hignett, 2003). Providing an

5 Proceedings of the Human Factors and Ergonomics Society 2016 Annual Meeting 597 ergonomically adjustable table can lower the rate in which providers must physically handle patients without mechanical aids. The results of this study showed that providers were very satisfied with the adjustable examination table as it enabled timely, efficient, and practical treatment and examination of all patients (Table 2). Furthermore, the adjustable examination tables were found to increase patient comfort as perceived by the providers (Table 3). This notable improvement in comfort may help to mitigate fear or discomfort in patients visiting clinics for medical care (Story, et al., 2009). Results presented in the current study measured the medical staff perception in healthcare settings regarding the usability of an adjustable patient examination table. Overall findings indicated that the adjustable table was more userfriendly from a provider perspective than patient exam tables used in the past, however these findings are not without limitations. First, the sample size utilized in this study was small, unbalanced, and non-paired. Continuous implementations of the new adjustable examination table in various clinics with follow-up studies are needed. Doing this would increase sample size and allow for the inclusion of more providers with different specialties, creating more generalizable data. Further, participants were not matched between the two groups of the clinics, but this concern has been minimized because the providers in the second group with the new adjustable examination table had also previously practiced on the nonadjustable examination table and we were able to compare their perception in providing healthcare to different patients. During this study, we did not connect the provider perception with the patient risk outcomes like falls, pain, or inequality of healthcare delivery for patients with disabilities. However, the current study did identify an increase in provider perceived patient comfort, with respect to disabled patients after the implementation of the new adjustable patient examination table. In conclusion, the adjustable examination table had better dimensions and adjustability which improved medical staff experience (i.e., comfort and usability) in providing health services to different groups of patients, including those with disabilities. Both patient and provider perceptions and the risk outcome measures from using two types of examination tables in delivering healthcare are needed to address the critical ergonomic concerns. Longitudinal research to measure patient risk outcomes (i.e., fall risk; injury risk, worsen patient condition, pain, etc.) and provider musculoskeletal risk (i.e., body parts pain, discomfort or strain, injury, etc.) from the new adjustable examination table are also needed to comprehensively understand how applied ergonomics could improve both patients and provider safety. This approach of assessing the usability of the examination table could be also applied to other clinic medical equipment (e.g., patients lifts, radiologic equipment) to make clinics more accessible to patients with disabilities and more functional for practicing providers. White and African-American obese women. Int J Obes (Lond), 30(1), doi: /sj.ijo Engkvist, I. L., Hjelm, E. W., Hagberg, M., Menckel, E., & Ekenvall, L. (2000). Risk indicators for reported over-exertion back injuries among female nursing personnel. Epidemiology, 11(5), Fragala, Guy. (2016). Reducing Occupational Risk to Ambulatory Caregivers. Workplace Health & Safety. doi: / Hignett, S. (2003). Intervention strategies to reduce musculoskeletal injuries associated with handling patients: a systematic review. Occup Environ Med, 60(9), E6. Lagu, T., Griffin, C., & Lindenauer, P. K. (2015). ENsuring access to health care for patients with disabilities. JAMA Internal Medicine, 175(2), doi: /jamainternmed Lagu, Tara, Iezzoni, Lisa I., & Lindenauer, Peter K. (2014). The Axes of Access Improving Care for Patients with Disabilities. New England Journal of Medicine, 370(19), doi: doi: /nejmsb Mudrick, N. R., & Schwartz, M. A. (2010). Health care under the ADA: a vision or a mirage? Disabil Health J, 3(4), doi: /j.dhjo Pompeii, L. A., Lipscomb, H. J., Schoenfisch, A. L., & Dement, J. M. (2009). Musculoskeletal injuries resulting from patient handling tasks among hospital workers. Am J Ind Med, 52(7), doi: /ajim Rosen, A. B., & Schneider, E. C. (2004). Colorectal cancer screening disparities related to obesity and gender. J Gen Intern Med, 19(4), doi: /j x Smedley, J., Inskip, H., Trevelyan, F., Buckle, P., Cooper, C., & Coggon, D. (2003). Risk factors for incident neck and shoulder pain in hospital nurses. Occup Environ Med, 60(11), Smedley, J., Trevelyan, F., Inskip, H., Buckle, P., Cooper, C., & Coggon, D. (2003). Impact of ergonomic intervention on back pain among nurses. Scand J Work Environ Health, 29(2), Stillman, M. D., Frost, K. L., Smalley, C., Bertocci, G., & Williams, S. (2014). Health care utilization and barriers experienced by individuals with spinal cord injury. Arch Phys Med Rehabil, 95(6), doi: /j.apmr Story, Molly Follette, Schwier, Erin, & Kailes, June Isaacson. (2009). Perspectives of patients with disabilities on the accessibility of medical equipment: Examination tables, imaging equipment, medical chairs, and weight scales. Disability and Health Journal, 2(4), e161. doi: References: Amy, N. K., Aalborg, A., Lyons, P., & Keranen, L. (2006). Barriers to routine gynecological cancer screening for

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