The Egress Test is a powerful defense against both patient injury and liability.

According to the US Bureau of Labor Statistics, among private industries in the closing decade of the 20th century that employed 100,000 or more employees, nursing assistants ranked as high as number 3 on the list of all occupations for nonfatal injuries. Nurses ranked in the top 30% of all occupations for nonfatal injuries. The most common strain was back strain, followed by cervical and shoulder strain. This is a profound statement when one considers that in most metros, the health care industry is the largest private employer. Literally, these producers are putting their spines on the line. The statistics and preventive measures designed to reduce them have created a valuable pool of knowledge for the physical therapist.

Given the high injury rates of health care providers, practical screening tools have been developed that can be easily applied. Many previous screening tools have been cumbersome—requiring PTs and other health care professionals to observe patient function, quantify that function to a final score, then reflect that safety score to a comparative scale. Still other tools became impractical, since the caregiver must follow a number of questions and arrows expressed upon multipage algorithms and then apply that result to the specific patient.

Effective transfer equipment and screening tools share some common traits. If transfer equipment and screening tools are not simple in application and readily accessible, they become ineffective and place the caregiver at great risk for injury. It is critical for any clinical decision criteria to be simple and easily remembered. For this reason, multipage decision tools and algorithms with complex pathway arrows will always fail clinically.

Peers in more than 300 professional accreditation agency events reviewed the Egress Test™, created as part of an overall safety program that I developed in more than a decade of clinical experience. Many of the concepts are based upon both clinical experience and actual deposition review, addressing safety issues in the safe management of patients classified as bariatric. This test involves screening tools developed to be easily remembered and practical at the bedside. It was developed to provide an actual response to basic questions posed by prosecuting attorneys in the courtroom. Some of the questions that attorneys pose in depositions were also provided.

The Egress Test provides the answers that PTs need to have for a defensible position (in this context, physically, not legally) prior to the mobilization of those weak relative to body mass and, therefore, avoid a potential injurious event and subsequent litigation. It addresses the most common aspect of decision failings that cause falls to occur during the initial transfer attempts and gait of the bariatric patient. The thought process is also examined to resolve specific reoccurring scenarios during debut transfer of the bariatric patient postoperatively.

Legal Analogy

Participants are asked to place themselves in the witness box of a courtroom, where they are called upon to testify regarding the patient’s fall that resulted in serious injury. The prosecuting attorney will ask the question, “How did you know that you could safely transfer this patient from the bed to the bedside commode?” The witness will typically stall at this point, because the obvious becomes very apparent. Currently we have no formal process, so we use an ad hoc “get-up-and-go” approach. The question is typically answered poorly or indirectly.

“Uh, well, we, um, put a gait belt on him, and then three of us held onto the belt, and all of a sudden down he went.” The attorney will typically fire back a question like, “With all six hands of the guarding caregivers?”

“Yes.”

“When did the fall actually take place?”

“Let’s see. Well, I recall the patient became unsteady when he lifted his advancing leg in the second step toward the commode.”

“Was there anything you could have done to prevent the fall?”

For the physical therapist, the mandatory therapy consult is evidence of the lack of an adequate screening process. It is likely that bariatric patients not in a hospital scenario are not being adequately screened. The only possible defense any caregiver can give is that the transfer activity was previously observed, or the documentation exists that supports the patient’s ability to complete the transfer task safely. The attorney can point out that, since this was a debut transfer, you could not have possibly known that the task could be performed safely. For a jury, the injury seems obvious when the plaintiff’s attorney points out the mismatch in caregivers, failings in functional independence, measures to estimate percentages of assistance, and failure to indicate transfer equipment.

There is no adequate defense, even for a therapist, unless you have tested endurance at the time of the debut transfer. The only possible defense the accused witness could provide to satisfy a jury would be to state, “I attempted the transfer because the patient demonstrated sufficient reps of activity to simulate the transfer prior to the actual attempt while still at the bedside.” Reps are evidence of consistency that provide the caregiver with a defensible position in a debut transfer event. The Egress Test provides evidence through progressive repetitions to demonstrate endurance and consistency required for a defensible work environment.

The Egress Test

Purpose: To incorporate a safe progression in the debut transfer activity through repetition for a safe and defensible patient transfer.

If during the Egress Test the patient demonstrates difficulty or need for physical assistance beyond guarding techniques, the patient is indicated for a mechanical conveyance, and adherence to the Left Free Zone is strictly observed. The basic test is divided into three components:

• 1) three reps of sit-to-stand, the first rep being a 1-inch partial clearing weight-bearing test;

• 2) three steps of marching in place (utilizing any baseline assistive devices); and

• 3) advance step and return each foot.

Phase One: Three Reps of Sit-to-Stand

The first rep in sit-to-stand progression is actually a clearing test in which the patient elevates from and clears the support surface by only 1–2 inches. The purpose of the clearing rep is to verify the patient’s weight-bearing ability and ability to perform the task without physical assistance.

The clearing test allows the therapist to pause, request feedback, and verify that all participants are safe in the initial rep. If the patient requires assistance beyond cues and guarding techniques, then that patient is indicated for a mechanical conveyance until such time as the patient demonstrates consistent performance through therapeutic referral. The patient then completes two subsequent full sit-to-stand reps to demonstrate leg press ability. This is also critical as evidence that the patient will be able to rise from the target surface in the return effort.

Phase Two: Three Steps of Marching in Place

There are situations where a patient may have sufficient strength to raise a leg from the floor and advance it toward the target surface, but surprisingly, that same leg may lack the strength to support the patient’s entire body weight. It is critical to test that the patient is able to demonstrate both the strength to elevate each leg, and that each leg has the strength to support the patient’s total body weight during the single leg stance.

Marching in place at the starting surface allows the therapist to test consistency and redirect the patient back to a sitting posture through the safe use of guarding techniques should the patient become unable to complete the task. Too many patients fall or become stranded midtransfer because the endurance of the activity had not been tested prior to leaving the starting surface. Again, it is important to emphasize that if the patient requires any assistance beyond cues and guarding techniques, then that patient is indicated for a mechanical conveyance until such time as the patient demonstrates consistent performance through therapeutic referral.

Phase Three—Advance Step and Return Each Foot

Before a 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 surface, the patient is asked to advance one leg forward and then return it back to the starting position. The task is repeated for the other leg.

Should a patient be unable to retreat a leg, the caregivers cue the patient to shift backward onto the trailing leg and sit. Note that the patient always has a trailing leg touching the standing surface for possible retreat in this last endurance test. If the patient requires any assistance greater than cues and guarding techniques, then the patient is indicated for mechanical conveyance until such time as the patient demonstrates consistent performance through therapeutic referral.

Test Advantages

The Egress Test is simple to recall and provides a defensible work environment at the transfer workstation. It builds in evidence through repetitions at the bedside in the debut of transfer activity, particularly following gastric bypass surgery. Should a caregiver find himself in the courtroom in a litigious event, at least the caregiver who has had a patient complete the Egress Test is in a position to answer the question, “How did you know that this patient could perform this transfer”?

The answer would be something such as, “I performed the transfer because the patient had demonstrated sufficient strength and endurance at the bedside prior to leaving the edge of the bed. He or she performed three leg presses demonstrating weight-bearing without assistance, marched in place demonstrating antigravity strength in each leg and the ability to hold his body weight in a single leg stance, and demonstrated an ability to advance step and retreat to the target surface prior to the transfer.” This therapist has a very defensible position.

While the focus of this article is to provide a defensible work environment, the greater purpose of the Egress Test is to make our jobs safer for both our patients and ourselves. It reminds the therapist to avoid the obsolete and traditional, “One, two, three, stand,” scenario. The Egress Test reminds therapists that patients who demonstrate difficulty and require physical assistance beyond guarding is indicated for mechanical conveyance. In other words, stated simply, it prevents patient and therapist injuries.

Mike Dionne, PT, is a bariatric specialist at Choice Physical Therapy in Gainsville, Ga. He can be contacted at mdionne@bariatricrehab.com.