Wheelchairs are a common type of medical equipment used to transport an individual in a seated position, with the purpose of increasing mobility for a person with functional impairments. In this article, health care expert and physical therapist Christian Mongrain discusses the types of wheelchairs, their maintenance, industry standards, and the types of accidents and injuries that can occur from improper use or care.
Wheelchair Components & Safety - Expert Overview
For some individuals, a wheelchair is a temporary means of going from point A to point B. For others, a wheelchair is a necessary piece of equipment for out-of-bed positioning and mobility. It is important that a reasonable wheelchair be selected to adequately accommodate the occupant’s needs as determined by assessment of the user’s height, weight, range of motion, tone, functional mobility, precautions, and comorbidities.
Wheelchairs are described by their size, function, and accessories. Seat width is the primary descriptor of wheelchair size, and weight capacity is a consideration when choosing a size. Wheelchairs can be powered by battery (electric) or by the user or care provider (manual). Powered wheelchairs have a motor to propel and steer the wheelchair, and to position the seat and/or accessories. Most powered wheelchairs are controlled by hand with a joystick, but some custom powered chairs have other mechanisms such as a straw or head plate to enable a user to control the wheelchair by their breath or head position. Non-powered wheelchairs rely on human power to propel, maneuver, and position the chair and accessories. Users commonly self-propel wheelchairs with their hands, but depending on user functional ability and features of the wheelchair, he/she may use foot propulsion.
For occupants with specific positioning needs, there are wheelchairs that have features to accomplish weight shifting (tilt-in-space and reclining), and accessories for extremities (elevating leg rests and arm rests). These features may be used to accomplish pressure relief, maintenance of precautions (to unload an extremity or prevent a fall), or patient comfort. Additional positioning considerations include the seat in relation to the wheels (vertical height and anterior/posterior position) which can affect balance and stability.
Wheelchairs are further identified by accessories. Custom seat backs and cushions may be chosen to accommodate an individual’s balance and/or pressure relief needs. In their simplest form, wheelchair footrests are stationary in one position. However, wheelchairs with footrests that elevate, telescope, swing-away, or removable footrests may be selected to address individualized needs. Similarly, arm rests can be affixed, or have features enabling removal or repositioning to accomplish lateral transfers to/from the chair. Additional safety accessories include: anti-tip bars, brake lever extensions, positional cushions, head rests, and seat belts.
Wheelchair Inspection & Maintenance
Wheelchairs are commonly constructed of a metal frame and footrests, fabric seat and seat back, rubber tires, and plastic or metal wheels. Wheelchairs require regular maintenance and inspection. Manufacturers commonly recommend that evaluations be performed at least monthly on most components, with tires and seat cushion/cover needing attention weekly to ensure the wheelchair can function safely and effectively. Due to the significance in user safety, wheelchair brakes should be inspected prior to each use. Signs of failure in manual or electric wheelchairs include but are not limited to: spinning or fluttering casters on the wheels, sagging or torn seat cushions, damaged or broken wheel spokes, brakes that stick or don’t work properly, and any unusual noises coming from the frame, wheels, or brakes. Neglecting to act on these indicators of component failure can result in a hazardous condition for the wheelchair occupant.
Regulations / Standards
Wheelchairs are classified as Durable Medical Equipment (DME), and are regulated by the U.S. Food and Drug Administration (FDA). Medical Device Reporting (MDR) regulation (21 CFR 803) outlines mandatory requirements for manufacturers, importers, and device user facilities to report certain device-related adverse events and product problems to the FDA. When evidence suggests a wheelchair may have contributed to a patient death or serious injury, or when a wheelchair malfunctions and reoccurrence of the malfunction would likely contribute to death or serious injury, device manufacturers and importers are required to submit adverse event reports to FDA.
When a patient incident occurs involving a wheelchair, it is the responsibility of the health care provider to report the incident to the wheelchair manufacturer or to the FDA if the manufacturer is unknown. Accurate and timely reporting of device events enables the FDA to issue warnings and/or recalls for products that pose a risk to consumer health. Medical Device Reports are researchable on the FDA website, in the category titled “Manufacturer and User Facility Device Experience (MAUDE).” This database contains mandatory reports filed by manufacturers and importers since 1996, and all mandatory user facility reports since 1991.
Investigating Incidents Involving Wheelchairs
Wheelchair incidents are often due to mechanical failure, or user/provider error. There are numerous sources for mechanical failures including assembly, lack of maintenance, overloading, or manufacturer defect. Timely inspections of wheelchairs and their accessories can identify potential hazards. Once identified, the wheelchair must be removed from service until appropriate maintenance can be performed.
Safe wheelchair use requires an understanding of the wheelchair functions and limitations. Users and/or providers must apply wheelchair brakes for stability during transfers and when parked on sloped surfaces. Accessories such as foot rests or leg rests must be repositioned or removed prior to stand pivot transfers to or from the wheelchair to reduce risk for trip and fall. Wheelchairs are not to be used on escalators or surfaces with excessive slopes or terrains. If the wheelchair is used for occupant seating during vehicle transit (such as an ambulette or wheelchair van), proper anchoring and securement of the wheelchair is essential to prevent an incident. Safe handling techniques are required to prevent incident when traversing elevations including curbs and ramps.
Proper wheelchair size and accessories to address the individualized needs of the user can reduce the risk for incident including falls, tip-overs, pressure injuries, and mechanical failures. If a wheelchair is too small for the occupant, pressure from the arm rests can restrict circulation and entry/exit resulting in pressure injury during use or fall during transfer. Improper fitting (including seat position) and user error (such as unevenly loading the chair with supplies or medical equipment) can lead to tip overs.
User/provider error can lead to mechanical failure. An investigation of the device, records, and witness statements can help determine the cause of the incident. Aside from inspection and upkeep of the wheelchair, user safety is essential to proactively avoiding accident or injury. Practicing basic wheelchair safety like setting the wheel locks (in manual wheelchairs) or turning off the power (in electric wheelchairs) before transferring the occupant, and lifting the footplates before getting in/out of the chair can prevent adverse events from occurring. The health care experts at Robson Forensic can analyze the causation behind these types of wheelchair mishaps and the relevant standards of care.
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Doctor of Physical Therapy & Health Care Administration Expert
Dr. Mongrain is an expert in the continuum of care provided to patients in health care settings. He is experienced in creating and implementing injury prevention training for patients and employees, managing policies in compliance with state and federal guidelines, and performing root cause analyses of patient incidents. He applies his expertise to forensic casework involving patients who have suffered acute injuries or negative health outcomes associated with the care or supervision provided within the health care system.