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Physical Examinations IV

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JoVE Science Education Physical Examinations IV

Accessibility to Clinical Care for People who use Wheelchairs

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Using Point of Care Ultrasound to Augment Acquisition of Physical Exam Skills: Organs

Science Education (Physical Examinations IV)

Using Point of Care Ultrasound to Augment Acquisition of Physical Exam Skills: Organs

Physical Exam Considerations for People who use Wheelchairs

Science Education (Physical Examinations IV)

Physical Exam Considerations for People who use Wheelchairs

Accessibility to Clinical Care for People who use Wheelchairs

Overview

Source: Yetsa Tuakli-Wosornu^1,2, Jaideep Talwalkar¹; ¹Yale School of Medicine, ²University of Pittsburgh

In the United States, 25% of the general population suffers from one or another type of disability. Ambulatory disabilities, or mobility impairments, represent the most common subcategory, comprising 14% of the country's populace. Different mobility-assistive devices, ranging from canes to scooters, enable increased independence and improved quality of life for those suffering from mobility impairment. Wheelchairs or wheeled mobility devices are the most important among these, and an estimated 2.7 million people in the US use manual and powered wheelchairs annually. In the future, these numbers will increase due to rising chronic health conditions and an aging population. People who use wheelchairs often experience barriers to medical services in healthcare settings due to generalized disability stigma, inaccessible medical settings, inadequately trained clinic staff, and the inability of healthcare providers to understand all of their patients' needs.

Section 504 of the 1973 Rehabilitation Act and the 1990 Americans with Disabilities Act (ADA) are federal civil rights legislations that protect US citizens with disabilities from discrimination, and mandate appropriate accommodation(s) be provided to ensure equal access, opportunities, and care in all sectors of society, including healthcare. Those with mobility impairment who use wheelchairs are therefore protected under law, and must be afforded equal access to clinical care for the prevention and treatment of illness, injury, and disease. Despite the laws, many clinical settings still struggle to provide such an inclusive environment. The US Department of Justice and Department of Health and Human Services' Access to Medical Care for Individuals with Mobility Disabilities summarizes practical strategies that healthcare settings should adopt to create an accessible, ADA-compliant clinical environment. Reviewing and implementing these and other strategies are essential if clinical practices are to offer people who use wheelchairs the same level of care as those who do not.

Most details related to the medical care for people who use wheelchairs are no different than for people without a disability. Such elements of the physical examination will not be reviewed in this video in order to emphasize points where care is often lacking or must be approached differently. Given the prevalence of mobility impairment, the protocol described below should be a standard practice in medical settings, rather than an exception in specially designed office spaces.

Procedure

1. Creating an Accessible Clinic

When patients make an appointment, they should be asked whether they will need assistance during the examination because of their wheelchair use or disability. If they answer yes, more information should be collected about their disability, the type of wheelchair they have, the usual method for transfer (including assistive equipment needed such as a transfer board, a lift, etc.), and if they require assistance for transfers, changing clothes, and any other task during the clinical encounter.
They should also be reminded that there is no obligation for them to bring someone to help during the exam. The clinic employees are fully trained and will be able to assist them throughout the entire encounter.
There should be multiple accessible parking spots that are in close proximity to the entrance of the clinic, and they must be spacious enough to accommodate ramps along with vehicles. Also, be mindful that many patients depend on public transportation, which can make it difficult to arrive on time. In such cases, medical organizations should consider allowing flexibility for arrival times.
In order to reach the entrance of the building and clinic, there should be an alternative to steps, such as an accessible elevator and/or a ramp.
When the patient opens the door to 90-degrees, an accessible doorway should have a clear opening width of at least 32 inches. Also, the door opening system should not involve tight twisting, pinching, or grasping. Ideally, automatic door-opening systems with a wireless push-button or wave controls should be used.
Once inside, hallways in the clinic must be clear and should have an appropriate width of at least 36 inches to allow free movement of the wheelchair, with enough turning space so that the patient can turn right or left easily.
There should be a restroom with accessible features, including the door entrance, enlarged toilet stalls, faucet controls, and grab bars near the toilet.
The front desk or check-in kiosk (which is often too high for a person who uses a wheelchair) should ideally be set at a universally accessible height, between 28-34 inches to enable easy interactions with the front desk staff.

2. Accessible Waiting and Exam Rooms

Most in-person waiting rooms include a few rows of chairs, organized to best accommodate patients. However, an inclusive waiting room should be large enough to accommodate people with various types of mobility devices (e.g., a scooter, a wheelchair, a cane, a crutch, a walker, a rollator, etc.). In addition, besides chairs, there should be designated spaces where a seated person's device can fit easily.
There are physical standards for achieving accessibility in the medical environment. For instance, at least one exam room in a clinic space should meet the accessibility specifications listed below. Additional rooms may be needed based on the population being served.
1. A clear space that is at least 30 inches x 48 inches next to the exam table with access to the entryway is important. This makes it possible to complete a side transfer to the exam table. More space may be needed if using a portable patient lift or stretcher.
2. Additionally, the exam table must have an adjustable height so that transfers can be completed. Exam tables should lower to the height of the wheelchair seat, 17-19 inches from the floor, and also include items to stabilize the patient during the transfer, such as straps or adjustable support rails with gripping surfaces.
3. There also should be additional space between the wall and the table. This is useful for staff assisting in patient transfer.
4. Open floor space is needed at the end of the table. Ideally, the patient should have enough space to complete a 180-degree turn requiring either 60 inches in diameter or a 60 inches by 60 inches T-shaped space.
5. The clinic room should offer accessible routes to connect to the common areas in the clinic.
6. Doorways should be accessible, and there must be adequate space to allow for maneuvers on both sides of the door. Make sure that these areas do not have objects such as chairs or equipment that may impede clearance.
An issue that many patients bring up is that their wheelchair or mobility devices are commonly removed from the room by staff, which makes them feel stranded. The wheelchair should not be removed from the examination room without asking the patient, unless the patient wishes for it to be removed.
For clinics that complete gynecological exams or mammography studies, the necessary accessible equipment should be available for the patients. For example, in an accessible mammography machine, the height can be adjusted, and it also allows wheelchair clearance below the camera unit.
For the adjustable height exam table, there should be padded leg supports to help complete a gynecological exam for individuals who cannot move or support their legs.

3. Communicating with the Patient

Throughout the encounter, ask the individual about their needs and/or how the staff person can be of assistance.
During an encounter with a patient who uses a wheelchair, it is of paramount importance to create an inclusive environment. The healthcare team needs to prioritize creating a culture of understanding and respect. Much of this occurs through the use of appropriate verbal and non-verbal communication by all staff of the healthcare organization, as described below:
1. If a patient were to arrive at the clinic with a relative or friend, the care team needs to speak directly to the patient. This demonstrates respect and prevents paternalistic interaction during the visit.
2. During the encounter, like all encounters, standing over a patient can be intimidating and potentially hinder the patient-doctor connection or cause discomfort to the patient as they need to look upwards constantly to have a conversation. Providers should try to sit down in front of the patient at eye level and then initiate a conversation with them.
3. After the patient is roomed, the first medical staff interacting with the patient should review how the medical team can assist them during this visit. Specifically, they should review what support they need for transfers and changing clothes.
4. Responsible communication starts by asking the patient about their preferences for addressing them, such as patient-first or identity-first language. An example of person-first language is a patient with paraplegia, and an example of identity-first language is a paraplegic person.
5. Be sure to emphasize abilities and not limitations. For example, in conversation with the patient, family, and other healthcare providers, as well as in chart documentation, instead of saying "confined to a wheelchair, use the phrase a person who uses a wheelchair.
6. Avoid using language that suggests the lack of something like the term unable to walk and instead say a person with an ambulatory disability. Emphasize the need for accessibility, not the disability. An example of this would be replacing the term handicapped parking with accessible parking. Rather than using offensive language like crippled, lame, or deformed, use words like a person with a physical disability.
7. Try to avoid language that implies negative stereotypes such as a normal person and instead say a person without a disability, a non-disabled person, or an ambulant person. It is not appropriate to portray people with disabilities as inspirational because of their disability, as is the case when saying, "they have overcome their disability."

4. Accessible Medical Equipment

A clinic with accessible medical equipment greatly improves the quality of care for patients with mobility disabilities. Staff responsible for operating and maintaining these equipment will need initial training and an annual review of the content to ensure appropriate use and storage.
Measuring the patient's weight is an important part of each medical encounter, and this can be a challenge for wheelchair users. This can be done with an accessible scale that has a ramp to accommodate a wheelchair. Follow the steps given below:
1. Direct the patient into the room with the accessible scale.
2. Follow standard office protocols used for all patients to obtain accurate weight measurements, such as removing shoes and emptying pockets. If medical devices or durable medical equipment are unable to be removed (e.g., feeding tubes, orthopedic braces), make a note of this so that consistent procedures can be used for that patient for future measurements.
3. Remove all items from wheelchair compartments and pockets.
4. While remaining in the wheelchair, the patient should move the wheelchair onto the platform of the accessible scale.
5. Note the weight recorded on the scale.
6. Note the weight of the wheelchair itself by either referring to the manufacturer's instructions or weighing the chair without the patient in it (e.g., when the patient is on the exam table later in the visit). This step does not need to be repeated at every visit if the weight of the wheelchair is saved within the patient's record.
7. Subtract the weight of the wheelchair from the weight of the patient plus the wheelchair to calculate the weight of the patient.
When a patient needs to be evaluated in the prone, side-lying, or supine position (skin evaluation, for example), transfers from the wheelchair to the exam table represent one of the most important components of the patient visit. The medical staff is responsible for assisting patients when the patient indicates that they need help.
If a patient does not require an examination while lying down, it may not be necessary to transfer the patient to the examination table. However, the exam should not be compromised for a clinician or staff convenience.
If a transfer is needed, medical staff should ask the patient about their preferred method of transfer and if they need assistance. Some individuals will be able to transfer themselves independently to the exam table. This involves the patient positioning their wheelchair alongside the examination table, locking the chair, transferring from the chair to the table using their upper extremities, and transferring back to the chair once the exam is complete.
There are different techniques for transfer when patients require assistance. However, all these methods must be directed by the patient and start with the patient positioning the wheelchair alongside the exam table and then locking the chair.
Assisted transfer to the exam table can be carried out using a gait belt for a standing transfer or a slide board for a sitting transfer.
A slide board transfer starts with the wheelchair angled 30- to 45-degrees towards the table and should be close enough that the slide board can reach from the wheelchair seat to the top of the table.
In preparation for the transfer, remove the armrest of the chair and ensure that the patient's feet are facing forward with firm contact with the ground.
Next, ask the patient to shift their weight to the hip farther away from the table and then insert, or ask if they need assistance in inserting, the slide board underneath the hip closest to the table, ensuring that at least one-third of the length of the board is placed below the hip.
The patient will then lean forward and can use their arms to help with the transfer. To prevent wrist strain, ask the patient to make fists instead of moving with open hands.
The patient can also be transferred from the wheelchair to the exam table and vice versa using a portable or ceiling lift. Safe use of a Hoyer lift requires expertise and is preferred when alternative transfer methods are not safe due to the patient's overall strength, muscle control, muscle tone, and/or body habitus.

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Disclosures

No conflicts of interest declared.

Transcript

In the United States, 25% of the general population has a disability. Ambulatory disabilities or mobility impairment represent the most common subcategory, comprising 14% of the country's populace.

People with ambulatory or physical disabilities use a range of mobility-assistive devices, from canes to scooters. Wheelchairs or wheeled mobility devices are among the most important of these, and an estimated 2.7 million people in the US use manual and powered wheelchairs annually.

People who use wheelchairs often experience barriers to medical services in healthcare settings due to generalized disability stigma, inaccessible medical settings, inadequately trained clinic staff, and the inability of healthcare providers to understand all of their patients' needs.

Section 504 of the 1973 Rehabilitation Act, and the 1990 Americans with Disabilities Act (ADA), are federal civil rights legislations that protect US citizens with disabilities from discrimination, and mandate appropriate accommodations be provided to ensure equal access, opportunities, and care in all sectors of society, including healthcare.

Those with mobility impairment who use wheelchairs are therefore protected under the law and must be afforded equal access to clinical care for the prevention and treatment of illness, injury, and disease.

The US Department of Justice and Department of Health and Human Services' Access to Medical Care for Individuals with Mobility Disabilities summarizes practical strategies which healthcare settings can adopt to create an accessible clinical environment.

Medical staff should receive appropriate training for working with patients who use wheelchairs, and operating accessible equipment through local or national disability organizations.

Hospitals and clinics should adopt these strategies along with a few other wheelchair-accessible approaches to provide good quality service to all patients.

When patients who use wheelchairs book an appointment, they should be assured about the accessibility of the clinic, which can reduce anxiety and increase feelings of comfort, respect, and safety.

Accessible building entrances with an elevator or ramp and easily approachable waiting and examination rooms equipped with specific medical instruments are important.

Communication is another important aspect of creating a conducive environment for the patient.

Responsible communication starts by asking the patient about their preferences for addressing them, such as patient-first or identity-first language. An example of person-first language is "patient with paraplegia," and an example of identity-first language is "paraplegic person."

Another example of person-first language is the phrase "person who uses a wheelchair." This type of respectful communication has replaced outdated phrases like "person confined to a wheelchair" or "wheelchair-bound." Responsible verbal communication can avoid misunderstandings, and help provide quality service to the patient.

Similarly, it is essential to let the patient take the lead when it comes to activities of daily living like transfers. The clinic should play a supportive role and create space for the patient's preferences to facilitate a comfortable appointment on their terms.

Integrating these approaches into clinical practice can foster good medical care and inclusive clinical environments, empowering clinicians to both fulfill their duty of care to patients and uphold the civil law.

In this video, we will present a few strategies to optimize medical environments that serve people who use wheelchairs to promote a better culture of inclusion and equity in healthcare settings.

When a patient calls a hospital to book an appointment, the medical staffer should ask the patient whether they use a wheelchair or need any accommodations related to access, mobility,

or communication.

If the patient answers yes, then the medical staffer should ask the following questions to the patient. What type of wheelchair do you have? What is your usual method for transfer from a wheelchair to the examination table and vice versa? Do you need assistance with transfers, changing clothes, or any other task during the clinical encounter? The medical staffer should also inform the patient that it is not necessary to bring someone to help them during the exam as the medical staff is fully trained to assist persons with disabilities.

There are essential steps for medical organizations to make their clinic more accessible to people who use wheelchairs.

There should be multiple accessible parking spots that are in close proximity to the entrance of the clinic. The international wheelchair logo and braille should be included if the parking spot is ADA-compliant.

For outpatient facilities that treat people with mobility disabilities, a greater percentage of parking spots need to be designated as accessible ones. These parking spots should have enough space to allow using ramps on the vehicles.

Some patients may use public transportation to visit the hospital, and in such scenarios, the bus stop should be near to the entrance of the hospital.

It is helpful to keep in mind that the use of public transportation can make it difficult for patients to arrive on time. In this circumstance, medical organizations should consider asking if patients will be using public transportation, and allowing flexibility for arrival times.

An accessible elevator or a ramp should also be available at the entrance of the clinic.

Also, the door opening system should not involve tight twisting, pinching, or grasping. Ideally, automatic door-opening systems with wireless push-button, or wave controls should be used.

When the patient opens the door to 90 degrees, an accessible doorway should have at least 32 inches of clear opening width.

Once inside, hallways in the clinic must be clear and should have an appropriate width of at least 36 inches to allow free movement of the wheelchair, with enough turning space so the patient can turn right or left easily.

Standard front desk or check-in kiosks are often too high for a person who uses a wheelchair, so ideally, the whole front desk or at least some part of it should be set at a universally accessible height of between 28-34 inches to enable easy interaction between patients and staff .

The clinic should also have general directional signage to the closest accessible bathroom and a restroom.

The accessible bathroom and restroom should have features including automatic or easy-open door entrance, enlarged toilet stalls, accessible faucet controls, comfortable reach-range of toilet paper, and grab bars near the toilet. The placement of trash cans and paper towels should be considered, as well.

Standard in-person waiting rooms include a few rows of chairs, organized to best accommodate patients. An inclusive waiting room should be large enough to accommodate people with various types of mobility devices, such as scooters, wheelchairs, canes, crutches, and walkers, as well as service animals.

Where there are chairs, there should be designated but not segregated or separate spaces where seated persons' devices can fit with ease. Where there are coat hooks, there should be lower hooks available.

At least one exam room in a clinic space should meet the accessibility specifications for wheelchair users, although more rooms may be needed based on the population being served.

In such rooms, there should be a clear space of at least 30 inches by 48 inches next to the exam table, with access to the entryway, so that it is possible to complete a side transfer to the exam table. More space may be needed if using a portable patient lift or stretcher.

Additionally, the examination table will need to have an adjustable height so that transfers can be completed.

Exam tables should lower to wheelchair seat height, 17-19 inches from the floor.

There should be additional space between the wall and table for a staffer to assist in completing a transfer if necessary.

Open floor space is also needed at the end of the table. Ideally, the patient should have enough space to complete a 180-degree turn requiring either a 60 inches diameter or 60 inches by 60 inches T-shaped space.

Many patients report feeling stranded when their wheelchair or mobility devices are placed out of reach or removed from the examination room. The wheelchair should not be removed from the examination room without the patient's consent. If it is necessary to remove the wheelchair or mobility device, it should immediately be brought back into the room once the examination is complete.

For clinics that complete gynecological exams or mammography studies, necessary accessible equipment should be available for the patients. For example, the accessible mammography machine has an adjustable height, and it also allows wheelchair clearance below the camera unit.

For the adjustable height exam table, there should be padded leg supports to help complete a gynecological exam for individuals who cannot move or support their legs.

During an encounter with a patient who uses a wheelchair, it is of paramount importance to create an inclusive environment and build a culture of dignity and respect through the use of appropriate verbal and non-verbal communication by all staff at the healthcare organization.

If a patient arrives at the clinic with a relative, friend or caregiver, first, the care team needs to ask the patient if they want to discuss healthcare matters in front of this individual. If the patient says it is ok, during the encounter, the care team needs to speak directly to the patient, as this demonstrates respect and prevents paternalistic interactions during the visit.

During the encounter, like all encounters, standing over a patient can be intimidating and potentially hinder the patient-doctor connection or cause discomfort to the patient as they need to look upwards constantly to have a conversation. Therefore, try to sit down in front of the patient at eye level and then initiate a conversation with them.

After the patient is roomed, the first medical staffer interacting with the patient should review how the medical team can assist them during this visit. Specifically, they should review what support they may need for transfers, changing clothes, and communication.

When a patient needs to be evaluated in the prone, side-lying, or supine position, transfers from the wheelchair to the exam table represent one of the most important components of the patient visit. The medical staffer is responsible for assisting patients when the patient indicates that they need or want an accommodation.

If the clinical standard of care can be administered effectively and accurately in the seated position, then it may not be necessary to transfer the patient to the examination table; however, the exam should not be compromised for the convenience of a clinician or staffer.

If the transfer needs to be performed, the medical staffer should ask the patient about their preferred method of transfer and if they need assistance.

There are different techniques for transferring when patients require assistance, but all methods start with the patient positioning the wheelchair alongside the exam table, locking the wheel brakes, and then removing or adjusting the armrest and footrest such that they do not obstruct the transfer.

Assisted transfer to the exam table can be carried out using a gait belt for a standing transfer or a slide board for a sitting transfer.

For the transfer using a slide board, the wheelchair should be angled 30 to 45 degrees toward the table and should be close enough where the slide board could bridge the gap between the wheelchair seat and the top of the table.

In preparation for the transfer, remove the armrest of the chair and ensure that the patient's feet are facing forward and have firm contact with the ground.

Next, ask the patient to shift their weight to the hip farther away from the table and then insert, or ask if they need assistance in inserting the slide board underneath the hip closest to the table, ensuring that at least one-third of the length of the board is placed below the hip. To prevent wrist strain, ask the patient to make fists instead of moving with open hands.

The patient can also be transferred from the wheelchair to the exam table and vice versa, using a portable or ceiling lift. Safe use of a hoyer lift requires expertise and is preferred when alternative transfer methods are not safe due to the patient's overall strength, muscle control, muscle tone, and/or body habitus.

Tags

Accessibility Clinical Care People With Disabilities Wheelchairs Ambulatory Disabilities Mobility Impairment Mobility-assistive Devices Healthcare Settings Disability Stigma Inaccessible Medical Settings Clinic Staff Training Patient Needs Section 504 Rehabilitation Act Americans With Disabilities Act Discrimination Accommodations Equal Access Opportunities Prevention And Treatment Of Illness And Injury US Department Of Justice Department Of Health And Human Services

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