Professional Documents
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Abstract
Personal support workers (PSWs) are health care workers that assist those in need with day-to-day activities. While PSWs work in a variety of settings, such as long-term care facilities and hospitals, this Request for Proposal (RFP) focuses primarily on those that provide in-home care to patients. One group that PSWs regularly provide service to is seniors. In many cases, these seniors need help transitioning from one position to another (i.e. bed to wheelchair). PSWs assist this movement by performing patient transfers. This RFP focuses on the risk of PSWs developing musculoskeletal disorders while performing these patient transfers. Musculoskeletal disorders (MSDs) are injuries to the muscles, ligaments and/or surrounding bone structures that do not develop from a singular event [1]. Factors that influence the development of MSDs include posture, mechanical load and psychosocial wellbeing [2][3]. As well, this community faces a heightened risk due to career-specific factors, such as funding and standardized training [4]. Health care professional, such as PSWs, report one of the highest rates for development of MSDs [5]. This RFP seeks solutions to help reduce the likelihood of PSWs developing MSDs. Potential solutions should seek to both minimalize the physical factors, while also being more accessible for PSWs with regard to the career-specific issues. Reference designs to current patient transfers aids are included to illustrate current industry standards, although the design team should not feel limited to any such design. Stakeholders related to this need will be outlined, identifying their particular design concerns. Finally, design requirements will be provided in order to create a design space for potential solutions. [1] Ontario Personal Support Worker Association. (2010) OPSWA. [Online]. HYPERLINK "http://opswa.com/Articles/What-is-a-PSW-.aspx" http://opswa.com/Articles/What-is-a-PSW-.aspx [2] T R Hales and B P Bernard, "Epidemiology of work-related musculoskeletal disorders," Orthopedic Clinics of North America, vol. 27, no. 4, pp. 670-709, 1996. [3] M. Hagberg and B. Silverstein et al., Work Related Musculoskeletal Disorders (WMSDs). London, UK: Taylor & Francis, 1995. [4] Isik Urla Zeytinoglu and Margaret A. Denton et al., "Self-Reported Msuculoskeletal Disorders Among Visiting and Office Home Care Workers," Women & Health, vol. 31, 2000. [5] Kirsten (OPSWA Communications Liaison) Ballantyne, [Interview]. January 2013. [6] Bureau of Labor Statistics, Table 12: Number and median days of nonfatal occupational injuries and illnesses with days away from work involving musculoskeletal disorders by selected occupations, 2001, March 2003.
T215903 ESC102 Request for Proposal 2 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
Table of Contents
Abstract .................................................................................................................................................... 1 1 Introduction ..................................................................................................................................... 3 2 Key Definitions ................................................................................................................................ 3
2.1 Community ................................................................................................................................................ 3 2.2 Quality of Life ........................................................................................................................................... 3 2.3 Need ............................................................................................................................................................. 3
4 Stakeholders .................................................................................................................................... 5
4.1 Personal Support Workers .................................................................................................................. 5 4.2 Senior Clients ........................................................................................................................................... 6 4.3 Canadian Government (Provincial and Federal)......................................................................... 7 4.4 Manufacturers.......................................................................................................................................... 7 4.5 Hospitals and Nursing Homes ............................................................................................................ 7
T215903 ESC102 Request for Proposal 3 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
1 Introduction
This Request for Proposal (RFP) focuses on the Personal Support Worker (PSW) community within the City of Toronto, and their need for a product to reduce the risk of developing musculoskeletal disorders. PSWs, alternatively recognized as home care workers [1], provide assistance to those that need help with day-to-day activities. PSWs provide care in a number of different settings, such as long-term care facilities, group homes, and hospitals [2]. In particular, this RFP will focus on PSWs that work inhome care for clients, working within the residence of the client themselves. The risk of developing a musculoskeletal disorder poses a serious quality of life issue to PSWs as it affects both their physical wellbeing and ability to work. This RFP will outline the mechanics behind the development of musculoskeletal disorders in PSWs, specifically in relation to patient transfers, and why this issue is especially prevalent in the PSW community. An examination of stakeholders will be completed, detailing their connections to this issues and particular interests with regards to a solution. An analysis of current products used for patient transfers will be included, discussing their advantages and shortcomings. Finally, this information will be synthesized to provide design requirements for a potential solution.
2 Key Definitions
2.1 Community
The American National Institute for Health defines a community to be a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings [3]. This community which this RFP focuses on is the Personal Support Worker (PSW) community. Under the general definition, this community is defined by its social ties (collective organizations such as the Ontario Personal Support Worker Association and the Community Care Access Centre), common perspectives related to a shared career, and joint action with regards to that career.
2.3 Need
Need is defined by the Merriam-Webster dictionary as a physiological or psychological requirement for the well-being of an organism [6]. Relating this definition to the PSW community and the given definition for quality of life, we identify the need to decreasing the risk of musculoskeletal disorders relating to patient transfer. The specifics of this need and its relation to quality of life are discussed in Section 3.
T215903 ESC102 Request for Proposal 4 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
3 Problem Specifics
This RFP focuses on the occurrence of musculoskeletal disorders amongst PSWs as a result of patienthandling activities, specifically patient transfers. Musculoskeletal disorders (MSDs) refer to a range of disorders of the soft tissues and their surrounding structures not resulting from an acute or instantaneous event [3]. The need of the PSW community is to reduce the risk of MSDs occurring, in order to improve their quality of life
3.2.1 Posture
Postures at the extreme end of ones range of motion often require muscle force to maintain the extended position. Alternatively, non-extreme postures may still result in abnormal gravity loading or musculoskeletal geometry, adding stress to the system separate of the mechanical load. Presence of these conditions in any combination increases the likelihood of an MSD occurring [5].
T215903 ESC102 Request for Proposal 5 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
3.3.2 Training
Education for PSWs within Ontario is comprised of a two-semester college program. No registration exam is required and likewise, no certification is provided upon completion of this program. Additionally, there is no individual regulating body for PSWs in the workforce [2]. These requirements are very relaxed when compared to those for a similar career, such as a Registered Practical Nurse (RPN). In Ontario, prospective RPNs must complete a postsecondary nursing course and pass a series of nursing exams [11]. The lack of well-defined requirements for training PSWs can result in an increased likelihood of developing an MSD. Untrained personnel performing patient-handling activities perform significantly worse than those who have received training, when evaluated by a teaching professional [12]. The Ontario Personal Support Worker Association has identified improper performance of these activities as a primary source of injury [14].
4 Stakeholders
Due to the nature of the need being addressed, a number of different groups can be viewed as stakeholders. Each stakeholder group is analyzed to determine their concerns and interests regarding potential solutions.
T215903 ESC102 Request for Proposal 6 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers Personal support workers, as the primary users of any solution, are the most important stakeholders in this project. According to a survey done by the Canadian Research Network for Care in the Community collaborated with PSNO and OCSA [14], 26% of PSWs in Ontario reported occupational health safety issues as a reason they would stop working as a PSW (See Figure 2). According to an interview with a currently employed PSW working with the Carefirst Seniors and Community Association, proper prevention of back strain can reduce discomfort felt after performing a patient transfer [19]. Helping PSWs prevent and reduce the occurrence of MSDs is the primary objective of this design. The training and education required for PSW qualification constitute a constraint on the design. The Ministry of Health and Long Term Care Personal Support Worker Training Standards (1997), issued by the OCSA (Ontario Community Support Association) in 2009 [15], outlines one possible qualification for a PSW certificate. The lack of thoroughly defined training standards for the operation of transfer aids increases the risk of injury. Additionally, the lack of both a unified regulatory body and reliable funding makes it difficult for some PSWs to acquire up-to-date equipment [2] [14]. As a result, the PSWs primary concerns regarding solutions are ease of operation, costs, and reduction of MSDs risk.
Figure 2: Analysis of various factors that would persuade PSWs to quit their jobs [14]. Factors related to development of MSDs include Lack of Ongoing Training, Occupation Health Safety Issues, and Dissatisfaction w/ Work Conditions
Another concern of senior clients is the comfort level they experience during the transfer itself. This represents a design criterion, as different types of aids can have different perceived levels of comfort [13].
T215903 ESC102 Request for Proposal 7 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
4.4 Manufacturers
As the creators and implementers of any proposed solution, the manufacturers have a unique set of concerns regarding said solutions. The manufacturers deal with the production of the solution, and as such must adhere to the applicable standards and codes (See Section 6.2.1). The criteria that directly affect the manufactures are the production cost, size and weight of the solution. Additionally, any material-related requirements will impact the manufacturers stake in the solution. While such considerations are of a lower priority than those of the PSWs and their clients, potential solutions should still consider these factors.
5 Reference Designs
There are currently a number of different devices used by PSWs to aid in patient transfer. This section outlines the most common devices available to PSWs: how they help to decrease the risk of MSDs, their advantages and disadvantages. One additional device, the Hoyer lift, will also be examined. The Hoyer lift is rarely used by PSWs, but is an industry standard in other medical establishments for patient transfers.
T215903 ESC102 Request for Proposal 8 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
A) B) C)
D)
E)
Figure 3: Examples of various transfer aids. A) Draw Sheets. B) Slider Sheets. C) Transfer Belts. D) Slide/Transfer Board. E) Turning Disks. All Photos credited to [18].
The advantage of these sheets is that they are intuitive to use and easy to manufacture, while still being effective in transferring patients. Using sheets also reduces the force required to move patients [18]. The disadvantages of the sheets are that cannot be used to transfer patients over any gaps. Draw sheets and slider sheets are less compatible with certain transfers, such as bed-to-wheelchair transfers [18]. Furthermore, two caregivers are required to perform a safe sheet transfer [20].
T215903 ESC102 Request for Proposal 9 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers are suitable only for those patients who can power themselves by sliding or rolling along the board with guidance from a knowledgeable caregiver [18]. The advantage of transfer boards is that they dont require any lifting on the part of the PSW; moreover some patients may be able to transfer themselves. When a PSW needs to assist with such a transfer, it takes much less force than a manual lift [18]. The problem with transfer boards is that surfaces must be at an equal height for an easy transfer. Usage also requires the patients assistance in most cases, making the transfer board impractical. In addition, use of the boards may still require the PSW to work with awkward postures, increasing the risk of developing an MSD [18].
6 Design Requirements
This section outlines the design objectives, constraints and criteria to which any proposed solution for this RFP should adhere. These requirements will help create a design space.
T215903 ESC102 Request for Proposal 10 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
Criteria
Force Applied to PSW Affordability
Metric(s)
Force applied: Newtons Cost: $CDN
Target Metric(s)
Less is better. Given constraint <1000N (see above) Cheaper is better
1 2
The choice of constraint depends on if the solution is intended to be reusable or not. As PSWs that provide in-home care are sometimes required to work in multiple locations within a short period of time, this constraint allows the PSW to make use of the solution in different locations without undue strife.
T215903 ESC102 Request for Proposal 11 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers funding [14] Allows PSWs to use device in multiple locations, as required by their job Reduces risk of injury due to improper use [14] Analyzes the patients stake in a solution Determines the average amount of time before a solution must be replaced.
Portability
Dimensions: Meters Weight: Kilograms Required instruction time4: Hours Holistic measurement5 Avg. product lifespan: years
Note: The solution must still be large enough to properly assist in patient transfer. Meeting the size criterion is secondary to the high-level objectives of safely transferring the patient. 4 This refers to the amount of time required, on average, for a PSW to be properly instructed in the safe use of the solution. 5 Note: Patient comfort should be ideally measured by surveying test patients, and rating their perceived comfort levels while being transferred for example, the survey shown on page 302 of the following study [13]. 6 Note: This criterion does not apply to any solutions that are designed to be disposable.
T215903 ESC102 Request for Proposal 12 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
T215903 ESC102 Request for Proposal 13 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers From: 2013-01-30 Good evening, The protocols and technologies in place can certainly be improved. Many company's are coming up to date and using computerized documentation programs and also telephone callin systems for signing in and out of clients homes (home care) and or for messaging systems. All institutions/facilities/residences would very much benefit from up to date technology if they have not yet implemented it. Equipment PSWs use is a rough subject. New facilities usually carry all brand new equipment. But private run facilities and or home care may not have up to date(older) or safe equipment. Or they may not have enough equipment. Due to funding or personal finances. The PSW role was a grey area in the health care field. Now it is becoming much more black and white but PSWs desperately need a governing body so all standards and practices are universal. That is the goal. It protects, most importantly, the patients/clients and as well as the PSWs. As for back injuries, many injuries of all kinds happen because of unsafe equipment or improper use. Education is a must! Learning how to safety assist transfers and how to safety use the transferring devices is so important. Body mechanics! Even a brand new piece of equipment can result in injury if a PSW does not use proper body mechanics. Knowing the equipment they are using is also important. PSWs are not to use any new equipment or use any old equipment unless they properly know how to. A supervisor or trainer is to sign off that the PSW can use it safety and correctly. From that point on the PSW is able to provide care with those devices themselves, unless... it is a lift or other device that requires 2 PSWs to use safely. Its called a "2 person transfer". I hope I managed to answer your questions? Regards, Kirsten To: 2013-01-31 Good morning, Thank you once again. Using the information given in your answers, my group has been able to begin framing our RFP. If it isn't too much trouble I do have one follow-up question. Most importantly, is there an average price range for the equipment that PSWs use? And if so, what is it? If it's different for different types of equipment, I'd be interested in knowing all the various ranges. Thanks again for your time,
From: 2013-01-31
T215903 ESC102 Request for Proposal 14 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
Good morning, I personally do not know the price ranges for the equipment used. I'm assuming since there are so many transfer devices, from hand held to mechanical, that the price range is very wide. Certain medical and home care medical shops do specialize in supplying some of these. If you google it I am sure you will find some information. I'm glad I could help, Kirsten Ballantyne OPSWA Communications Liaison
T215903 ESC102 Request for Proposal 15 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
T215903 ESC102 Request for Proposal 16 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
T215903 ESC102 Request for Proposal 17 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
T215903 ESC102 Request for Proposal 18 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
T215903 ESC102 Request for Proposal 19 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
T215903 ESC102 Request for Proposal 20 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers An immobilizing device shall be provided for mobile hoists. When tested in accordance with 5.6 a maximum movement of 10 mm in any direction is allowed. 5.6 Test methods for immobilizing device (brakes) To ensure that the requirement described in 5.5 above is fulfilled, a hoist shall be positioned on a 1 slope with the immobilizing device(s) activated. The maximum load shall be applied to the hoist in the most adverse position. 5.7 Requirements for moving forces The maximum forces required for moving the hoist shall be as follows when tested with the maximum load on the hoist: a) starting/turning: 160 N b) driving (pushing/pulling): 85 N 5.8 Test methods for moving forces The test shall be carried out on a flat, smooth and horizontal steel plate. The hoist shall be loaded with the maximum load (3.24) with the lifting arm set to obtain the maximum reach. The castors shall be set at 180 to the direction of pulling/pushing. Using a dynamometer, a starting force is gradually applied to the push handle until the hoist begins to move. Repeat five (5) times. The highest force noted during these tests shall be recorded as the starting force. The starting force shall be applied and recorded as follows: a) in the forward direction b) in the backward direction c) in the direction that begins to turn the hoist. 5.9 Instructions for use This clause specifies information required for mobile hoists additional to that specified in 4.11. The manufacturer shall provide the following information as a minimum: - daily check list - functional dimensions, including: a) the height of the base, in accordance with figure 4; b) the maximum/minimum external/internal width, in accordance with figures 5 and 6; c) the under-base clearance, in accordance with figure 4; d) the maximum and minimum hoisting reach (see figure 7 for example); e) the hoisting range in relation to the hoisting reach, in accordance with figure 7; f) the turning radius; g) the total mass of the hoist excluding body support unit; h) the number of parts and the identification of those parts into which the hoist can be disassembled; i) the mass of the heaviest part of the hoist.
T215903 ESC102 Request for Proposal 21 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
T215903 ESC102 Request for Proposal 22 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers 5.2 Manufacturers instructions 5.2.1 Prior to purchasing a new medical device, health care facility personnel shall review the manufacturers instructions to ascertain that the recommended decontamination procedures (a) are device specific, legible, and understandable; (b) clearly indicate which parts need to be disassembled, and provide clear disassembly instructions (including illustrations where necessary); (c) can be achieved, given the resources of the facility; (d) are in accordance with the intended use of the device; (e) state whether or not the device is immersible; (f) specify the necessary materials (i.e., detergents, enzymatic solutions, etc.) and equipment for proper cleaning and maintenance of the device; and (g) specify if there is a limit to the number of times the device can be reprocessed, or if reprocessing will contribute to degradation of the medical device. Note: See CAN/CSA-ISO 17664 for additional information on the information that manufacturers should supply. Written confirmation that the reprocessing instructions have been validated shall be obtained from the device manufacturer. 5.2.2 If the instructions are unclear, incomplete, or inadequate, the manufacturer shall be contacted for clarification or additional information. If clear, validated instructions are unavailable for a device, it shall not be purchased unless the health care facilitys risk management, biomedical engineering, and infection prevention and control personnel provide written confirmation that the device can be reprocessed and reused based on internally-developed procedures. Note: Facilities that are not able to obtain the relevant instructions can report problems to the following: (a) Health Canada at (i) 1-800-267-9675; (ii) mdpr@hc-sc.gc.ca; or (iii) www.hc-sc.gc.ca/dhp-mps/compli-conform/prob-report-rapport/mavprfmdrioevraim_tc-tm_e.html (b) Medical Devices Canada (MEDEC) at 1-866-58-MEDEC. 5.2.3 All manufacturer information shall be received and maintained in printed form (e.g., in binders, manuals, or monographs) or in electronic format, or both, so as to facilitate device maintenance, as well as staff training and education. 5.3 Initial processing All newly purchased, non-sterile devices shall be inspected and decontaminated before further processing or use. Critical devices shall be sterilized. Depending on their intended use, semi-critical and non-critical devices shall be cleaned and disinfected as appropriate. Notes: (1) Many newly purchased devices are received non-sterile from the manufacturer and require cleaning prior to disinfection and sterilization. Anti-corrosive and anti-rusting agents such as oils, greases, or waxes are sometimes applied to the device by the manufacturer in order to protect it during shipping. Such agents will interfere with sterilization if not removed. Manual washing is in some cases necessary to remove these agents; consult the manufacturers instructions for initial cleaning. Questions on procedures should be referred to the manufacturer. (2) Guidance on reprocessing of heat-sensitive devices requiring sterilization or high-level disinfection should be soughtfrom the manufacturer.
T215903 ESC102 Request for Proposal 23 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
Appendix F -- References
[1] I. U. Zeytinoglu and M. A. Denton et al., "Self-Reported Musculoskeletal Disorders Among Visiting and Office Home Care Workers," Women & Health, vol. 31, 2000. [2] Ontario Personal Support Worker Association, "What is a PSW?," 2010. [Online]. Available: http://opswa.com/Articles/What-is-a-PSW-.aspx. [Accessed 30 January 2013]. [3] K. M. MacQueen and E. McLellan et al., "What Is Community? An Evidence-Based Definition for Participatory Public Health," American Journal of Public Health, vol. 91, no. 12, pp. 1929-1938, 2001. [4] D. Felce and J. Perry, "Quality of life: Its definition and measurement," Research in Developmental Disabilities, vol. 16, no. 1, pp. 51-74, 1995. [5] B. Zhao, Perceptions of Quality of Life and Use of Human, 2004. [6] Merriam-Webster, "Need - Definition," 2013. [Online]. Available: http://www.merriamwebster.com/dictionary/need?show=0&t=1360945280. [Accessed 20 January 2013]. [7] T. R. Hales and B. P. Bernard, "Epidemiology of work-related musculoskeletal disorders," Orthopedic Clinics of North America, vol. 27, no. 4, pp. 679-709, 1996. [8] Bureau of Labor Statistics, Table 12: Number and median days of nonfatal occupational injuries and illnesses with days away from work involving musculoskeletal disorders by selected occupations, 2001, U.S. Department of Labor, 2003. [9] M. Hagberg and B. Silverstien et al., Work Related Musculoskeletal Disorders (WMSDs), London: Taylor & Francis, 1995, pp. 5,6,146-155. [10] W. S. Marras and G. G. Knapik et al., "Lumbar spine forces during manoeuvring of ceiling-based and floor-based patient transfer devices," Ergonomics, vol. 52, no. 3, pp. 398-397, March 2009. [11] S. M. McGill, "The Biomechanics of Low Back Injury: Implications on Current Practice in Industry and the Clinic," Journal of Biomechanics, vol. 30, no. 5, pp. 465-475, 1997. [12] S. J. Bigos and M. C. Battie et al., "A Prospective Study of Work Perceptions and Psychosocial Factors Affecting the Report of Back Injury," Spine, vol. 16, no. 1, 1991. [13] J. A. Johansson, "Psychosocial work factors, physical work load and associated musculoskeletal symptoms among home care workers," Scandinavian Journal of Psychology, vol. 36, pp. 113-129, 1995. [14] K. Ballantyne, Interviewee, Communications Liaison, Ontario Personal Support Worker Association. [Interview]. 29-31 January 2013. [15] College of Nurses of Ontario, "Become a Nurse in Ontario - How to Apply," 01 January 2013. [Online]. Available: http://www.cno.org/en/become-a-nurse/new-applicants1/ontario/. [Accessed 06 February 2013]. [16] T. Yonetsuji and Y. Takebe et al., "A Measurement and Evaluation Method of a Support System to Teach How to Improve Transferring Patients," in Proceedings of the 2011 IEEE International
T215903 ESC102 Request for Proposal 24 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers Conference on Robotics and Biomimetics, Phuket, Thailand, 2011. [17] A. Garg and B. Owen et al., "A biomechanical and ergonomic evaluation of patient transferring tasks: bed to wheelchair and wheelchair to bed," Ergonomics, vol. 34, no. 3, pp. 289-312, 1991. [18] J. Lum and J. Sladek et al., "Ontario Personal Support Workers in Home and Community Care: CRNCC/PSNO Survey Results," Toronto, 2010. [19] W. Zhang, Interviewee, Carefirst Seniors & Community Services Association. [Interview]. 10 February 2013. [20] Ontario Community Support Association, "PSW Standards," 2009. [Online]. Available: http://www.ocsa.on.ca/userfiles/PSW_Training_Standards.pdf. [Accessed 10 February 2013]. [21] A. Laupacis and K. Born, "Ontario's Plan for Personal Support Workers," 10 May 2012. [Online]. Available: http://healthydebate.ca/2012/05/topic/community-long-term-care/personal-supportworkers. [Accessed 10 February 2013]. [22] Government of Ontario, "Ontario Regulation 79/10," 2010. [23] Workers' Compensation Board of British Columbia, Transfer Assist Devices for Safer Handling of Patients: A Guide for Selection and Safe Use, 2006 ed. ed., British Columbia, 2006. [24] B. R. Hegner and J. F. Needham, Assisting in Long-Term Care, 4 ed., Clifton Park, New York: Delmar Thomson Learning, 2002, p. 245. [25] S. Thompaon, "Manual handling 2 - repositioning a surpine patient using a slide sheet," 12 January 2009. [Online]. Available: http://www.nursingtimes.net/nursing-practice/student-nurses/manualhandling-2-repositioning-a-supine-patient-using-a-slide-sheet/1963080.article. [26] C. Lawrie, "Leading the way: Ontario campaigns against influenza," The Safe Angle, vol. 4, no. 1, January 2002. [27] C. M. Magistro and R. W. Bohannon, How To Use a Patient Lifter: A Positioning and Transfer Guide, Sunrise Medical. [28] "Preferred Health Choice," [Online]. Available: http://www.phconline.com/Hoyer_Lift_Supply_s/44.htm. [29] Sunrise Medical, Hoyer Hydraulic Patient Lifters: User Instruction Manual & Warranty. [30] Canadian Standards Association, Hoists for the transfer of disabled persons - Requirements and test methods, 2003. [31] Canadian Standards Association, Decontamination of reusable medical devices, 2009. [32] Canadian Centre for Occupational Health and Safety, 2005.