Preventing Back Injuries in Healthcare Settings
Healthcare workers often experience musculoskeletal disorders (MSDs) at a rate exceeding that of workers in construction, mining, and manufacturing.1 These injuries are due in large part to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring, and repositioning patients and working in extremely awkward postures. The problem of lifting patients is compounded by the increasing weight of patients to be lifted due to the obesity epidemic in the United States and the rapidly increasing number of older people who require assistance with the activities of daily living.2,3
Direct and indirect costs associated with back injuries in the healthcare industry are estimated to be $20 billion annually.4 Additionally, nursing aides and orderlies suffer the highest prevalence (18.8%) and report the most annual cases (269,000) of work-related back pain among female workers in the United States.5 In 2000, 10,983 registered nurses (RNs) suffered lost-time work injuries due to lifting patients. Twelve percent of nurses report that they left the nursing profession because of back pain.6
As our nursing workforce ages (average age 46.8 years) and we face a critical nursing shortage in this country (an expected 20% shortage by 2015 and 30% by 2020), preserving the health of our nursing staff and reducing back injuries in healthcare personnel is critical. The National Institute for Occupational Safety and Health (NIOSH) has a comprehensive research program aimed at preventing work-related MSDs with major efforts to reduce lifting injuries in healthcare settings. NIOSH's research with diverse partners has already made great strides in developing and implementing practical intervention strategies, with further progress expected.
The first research effort was a comprehensive lab and field study to identify safer ways to lift and move nursing home residents by removing the excessive forces and extreme postures that can occur when manually lifting residents. Historically, the caregiver has used his or her own strength to provide manual assistance to the resident. NIOSH conducted a large field study to determine if an intervention consisting of mechanical equipment to lift physically dependent residents, training on the proper use of the lifts, a safe lifting policy, and a preexisting medical management program would reduce the rate and the associated costs of the resident handling injuries for the nursing personnel in a real world setting.7
During the 6-year period, from January 1995 through December 2000, 1,728 nursing personnel were followed before and after implementation of the intervention. After the intervention, there was a significant reduction in injuries involving resident handling, workers' compensation costs, and lost work day injuries. When injury rates associated with patient handling were examined, workers' compensation claims rates per 100 nursing staff were reduced by 61%; Occupational Safety and Health Administration (OSHA) recordable injury rates decreased by 46%; and first reports of employee injury rates were reduced by 35%. The initial investment of $158,556 for lifting equipment and worker training was recovered in less than 3 years on the basis of post-intervention savings of $55,000 annually in workers' compensation costs and potentially more quickly if indirect costs (lost wages, cost of hiring and retraining workers, etc.) are considered. This is significant given that cost is an often cited barrier to purchasing lifting equipment. Another advantage of lifting equipment is the reduction in the rate of assaults on caregivers during resident transfers—down 72%, 50%, and 30% on the basis of workers' compensation, OSHA recordable incidents, and the first reports of injury data, respectively.
More information on this study can be found in the NIOSH publication Safe Lifting and Movement of Nursing Home Residents. Based on the successes achieved in the long-term care industry, NIOSH is undertaking a six-year longitudinal research study to evaluate the effectiveness of a "best practices" safe patient handling program at two large acute-care hospitals in the United States.
Another major study demonstrating success in reducing back injuries to health care workers was funded by NIOSH through a cooperative agreement. The study examined the long-term effectiveness of a safe lifting program with the primary objective to reduce injuries to healthcare workers resulting from manual lifting and transferring of patients..8 The safe lifting programs, which used employee management advisory teams (participatory-team approach), were implemented in seven nursing homes and one hospital. The eight facilities varied in the available number of beds and number of nursing personnel. In this study, manual lifting and transferring of patients was replaced with modern, battery operated, portable hoists, and other patient-transfer assistive devices. Ergonomics committees with nearly equal representation from management and employees selected the equipment and implemented the safe lifting programs.
Injury statistics were collected post-intervention for 51 months and were compared with 37 months of pre-intervention data. The results were compelling. The number of injuries from patient transfers decreased by 62% (range = 3979%), lost work days by 86% (range = 5099%), restricted workdays by 64% (96% decrease to 17% increase), and workers' compensation costs by 84% (range = 5399%). Overall, the eight facilities experienced decreases of 32% in all injuries, 62% in all lost work days, 6% in all restricted work days, and 55% in total workers' compensation costs. The program produced many intangible benefits including improvements in patient comfort and safety during transfers and patient care. The nursing personnel perceived that their backs were less sore and that they were less tired at the end of their shifts. More pregnant and older workers were able to perform their regular duties and stay on the job for a longer period.
Despite the obvious advantages to using lifting equipment, schools of nursing continue to teach, and nurses' licensure exams9 continue to include, outdated and unsafe manual patient handling techniques. This is due in large part to outdated books and curricula which promote unsafe patient handling practices. To address this, a team of experts from NIOSH, the American Nurses Association, and the Veterans Health Administration developed and evaluated an evidence-based training program on safe patient handling for educators at schools of nursing. The study found that when using the curriculum, nurse educator and student knowledge improved significantly as did the intention to use mechanical lifting devices in the near future.10,11 The curriculum module, which won the 2008 National Occupational Research Agenda (NORA) Partnership Award, is ready for broad-scale dissemination across nursing schools to reduce the risk of MSDs among nurses.
Looking ahead: Beginning in 2009, NIOSH will conduct a project aimed at improving safety while lifting and moving bariatric patients. In healthcare settings, the term "bariatric" is used to refer to patients whose weights exceed the safety capacity of standard patient lifting equipment (300 lbs), or who otherwise have limitations in health, mobility, or environmental access due to their weight/size.12 Compared to the non-obese population, obese individuals require more frequent and extensive healthcare due to obesity-related health problems, and healthcare personnel are encountering hospitalized and critical-care bariatric patients on an increasingly frequent basis.13,14,15 In the extreme, such patients can weigh over 1,200 pounds. The upcoming NIOSH project will evaluate bariatric patient handling practices at multiple hospitals, including intervention programs and health/safety outcomes, in order to identify and promote evidence-based best practices.
We all have a vested interest in taking care of those who help take care of us and our families when we need medical attention. It is likely that the implementation of the research presented here will significantly reduce injuries and illnesses for healthcare workers and increase the quality of patient care. In turn, reducing MSDs among nurses may help address the critical issues of nurse recruitment and retention.
As we contemplate further research, we would like to hear about your experiences with lifting equipment and practices in medical settings. Additionally, your thoughts about retooling student nursing curriculum as well as your opinions on state laws regulating safe patient handling and movement would be appreciated.
—Jennifer Bell, Ph.D.; Jim Collins, Ph.D., MSME; Traci L. Galinsky, Ph.D.; Thomas R. Waters, Ph.D., CPE
Dr. Bell is a research epidemiologist in the Analysis and Field Evaluations Branch in the NIOSH Division of Safety Research.
Dr. Collins is (Captain, U.S. Public Health Service) is the Associate Director for Science for the NIOSH Division of Safety Research.
Dr. Galinsky (Captain, U.S. Public Health Service) is a research psychologist in the NIOSH Division of Applied Research and Technology.
Dr. Waters is a research safety engineer in the Division of Applied Research and Technology.
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Comments
I borke my back ,over 30 years ago. Over the years I have learned many things about people like me. In general, we are not told we will NEVER BE THE SAME ! We are NOT told much of anything. Until M.D._s are REQUIRED to tell people like me the complete 9 yards,Training is a waist of time & money. All that is done is try to prevent lawers from getting involved. The commen head cold is the #1 reason for E.R. visits---#2 is related to BACK PAIN. People like me have no-one to talk to. We don't know who the BAD DOC_s are, etc. I'd love to hear your reasons for that.
Posted 9/22/08 at 3:05 pm
Work-related back injuries are a serious problem and account for nearly 20 percent of all injuries and illnesses in the workplace. All healthcare professionals need to be informed of the risks and prevention of workplace-related back injuries. NIOSH recently worked with its partners to ensure that nursing school training materials contain the latest evidence-based research on safe patient lifting and back injury information. Research studies have shown that a large fraction of work-related back pain can be prevented by ergonomic design of the workplace and use of assistive equipment.
NIOSH was created by the Occupational Safety and Health Act to examine ways to prevent injuries in the first place recognizing that once an injury has occurred there can be permanent damage. As such, NIOSH research in this area focuses on the use of ergonomic workplace design to prevent injury and/or re-injury. The Agency for Healthcare Research and Quality (AHRQ) funds studies on the effectiveness of injury treatment methods.
Posted 9/23/08 at 3:15 pm
I work in Employee Health and handle our Worker's Comp claims, consequently I have seen a few musculoskeletal injuries over the years. I have been instructing our staff on how to use the battery operated patient lifts and lateral transfer air mattress devices the hospital purchased.
The staff is extremely enthused about the equipment during the demonstrations and then never use it on the units. The equipment is kept buried in a closet with commodes, scales, electronic blood pressure cuffs ect. Unfortunately our facility has a policy that hallways must be kept clear.They feel that the time they take to get the equipment they could have had the patient manually moved. Equipment must be easily accessible and visable or staff will not use it! We need to start worrying less about how a hallway looks. Use of patient moving devices is a safety issue,not only will their use reduce employee injuries but can prevent potential patient injuries.
Posted 9/24/08 at 4:47 pm
Despite the fact that mechanical lifts and lateral transfer devices can make a huge impact on improving the safety of both health care staff and patients, a broader program is required to overcome the barriers and cultural resistance to using mechanical patient lifts.
Many healthcare organizations have dedicated resources on back injury prevention with little resulting improvement. Research has shown that in order for safe patient/resident lifting programs to be successful they must not only incorporate mechanical lifting equipment and repositioning devices and training in the use of these devices, but it requires a change in the workplace culture that can be facilitated with a written safe patient lifting policy, top management support, nursing management support on each unit, and patient lifting algorithms that identify how patients with different conditions and weight bearing ability should be lifted.
Details on establishing a comprehensive safe patient handling and movement program can be found at:
Posted 9/25/08 at 11:09 am
I understand the reasoning for implementing safe lifting practices in healthcare; however, due to the increase in obesity and the older adults who need assistance, it is hard to perform these tasks with minimal assistance and poorly maintained or out of date equipment. How can we get healthcare institutions to open their eyes to the fact that employees are getting injured and they could probably purchase new and improved equipment with the Workman's comp funds they have paid out?
Posted 9/25/08 at 8:37 am
NIOSH conducted an intervention trial in six nursing homes that included a business case and cost-benefit analyses (cost to implement the program was balanced with the workers' comp savings) that are described in the DHHS (NIOSH) Publication Number 2006-117, Safe Lifting and Movement of Nursing Home Residents, and the peer-reviewed publication, An evaluation of a "best practices" musculoskeletal prevention program in nursing homes, in Injury Prevention, August 2004.
The NIOSH numbered publication (on page 6) also cites Tiesman et al., 2003, Nelson et al., 2003, and Garg 1999 as other intervention trials on safe patient lifting that have included cost-benefit analyses.
Posted 9/25/08 at 11:04 am
Thank you for pushing this important issue forward. I am an Occupational Health Nurse in Maryland. At my last place of employment I was unable to convince my hospital management to commit any financial resources to safe patient lifting, even though I could show direct costs for back injuries related to moving patients. I brought in quality equipment for demonstrations, I gave presentations to senior management, I circulated articles regarding best practices, all to no avail.Our State Legislature passed a safe patient lifting bill last year that required all hospitals to form a safe patient lifting committee, and develope policies, but the bill fell short of requiring actual mechanical devices (in the case of this hospital, they passed out gait belts). There is also no oversight to see that it will be implemented, and no penalty for not complying. Because OSHA has not promulgated a standard, there is no fear of federal regulation. Joint Commission does not look at employee injuries as part of it's environment of care inspection process. Even "Magnet" status will only start to look at some types of employee injuries as part of it's application process in the coming year (but not back injuries). If we are to improve the working environment for healthcare workers, it seems NIOSH may need to lead the way by pushing OSHA to promulgate standards to protect us. Best practice recommendations will not be enough.
Posted 9/25/08 at 10:39 am
NIOSH is considering research that will evaluate the impact of the nine safe patient handling state laws to evaluate the effectiveness of each of the state laws to better inform pending Federal legislation. Links to each state law are provided below.
Three states have passed legislation supportive of, but not requiring, safe patient and/or resident handling:
Six states have passed legislation requiring safe patient and/or resident handling policies, and/or programs, and/or patient lifting equipment:
Language in three areas: 1. Grant funding Art 1, Sec 6, Sub 3, pp 25-26; 2. main body of wording Art 2, Sec 23. 182.6551 to Sec 25. 182.6553, pp 48-51; and 3. study ways for workers' comp insurers to recognize compliance in premiums and for on-going funding Art 2, Sec 36, and work groups on safe patient handling and equipment Sec 37, pp 58-59.
Additionally, the national bill HR 378 "Nurse and Patient Safety and Protection Act of 2007" was introduced into the House of Representatives in January 2007. The bill remains in committee. For links to the status, complete history, and text of HR 378, go to http://thomas.loc.gov.
Posted 9/29/08 at 5:46 pm
This was a very interesting article and great information, but is it in the actual job description for nurses or health care providers to physically try to lift or move patients? I know that it is something that we learn in nursing school (body mechanics) but if a nurse were to say to administration "I can not physically move this patient", do you think that she/he would be terminated?
Posted 9/27/08 at 8:28 pm
NIOSH is a research agency and we do not have the expertise or information to answer your specific question. We are aware that workers are expected to perform essential job tasks and in certain cases patient lifting may be an important or essential part of a nurse's duties. When selecting a place of employment, nurses and other healthcare professionals should evaluate whether facilities have a safe patient handling and movement program (SPH&M) with proper lifting equipment as a determining factor for where they want to work. Since there is a shortage of nurses, it is in the best interests of the facility to provide a safe patient handling environment with the proper equipment and resources to protect the workforce.
A factsheet on health care workers from the U.S. Equal Employment Opportunity Commission (EEOC) website may provide additional information.
Posted 10/1/08 at 1:33 pm
One thing I would like to add about back injury and nurses: As caretakers, we need to learn to take care of ourselves. If we are in poor physical condition because we have not taken "care" of ourselves, the likelihood of back injury increases.
Posted 9/29/08 at 12:30 pm
Injuries to the back are one of the most prevalent and costly work-related musculoskeletal disorders in the United States. Low-back pain adversely affects 1,000,000 workers in the United States every year and is responsible for more lost work days than any other musculoskeletal disorder.
Posted 10/1/08 at 5:25 am
I am graduate student currently enrolled in a Risk Assessment course. I as wondering if home healthcare workers were considered in the assessment of back injuries among healthcare staff and nurses because I would think that not all patients that have to be moved by healthcare workers are just in hospitals and long term facilities. The article appears to be only focusing on healthcare facilities and not other forms of long term care.
Posted 10/11/08 at 11:18 pm
Although home healthcare workers have been studied less extensively than workers in institutional settings, empirical evidence has been obtained which indicates that patient handling is a significant risk factor for back pain and other muscuoloskeletal symptoms in home settings. Home care aides typically provide a variety of services which include housekeeping, and may include personal care (bathing, dressing) and assistance with moving and transferring (patient handling). All of these tasks are characterized by risk factors for musculoskeletal symptoms, including forceful exertions and awkward postures (Baron and Habes, 2004; Galinsky et al., 2001). Results of a survey of home care workers conducted by NIOSH indicate that patient handling is associated with musculoskeletal symptoms, after adjusting for several other factors, including worker age, weight, non-work-related physical activities, smoking, medical conditions, work durations, and non-work-related caretaking of children and disabled family members (Waters et al., 2006). Ergonomic strategies for improving patient handling safety in home care settings are described in Parsons et al. (2006 a and b).
Additionally, NIOSH is conducting a community-based participatory intervention study to develop educational materials to assist home care workers to work more safely. These materials include information on how to avoid unsafe lifting.
References:
Baron, S. & Habes, D. (2004). NIOSH Hazard Evaluation and Technical Assistance Report # 2001-0139-2930. Alameda County Public Authority for In Home Supportive Services. Alameda County, California. Cincinnati, OH: Centers for Disease Control and Prevention (National Institute for Occupational Safety and Health).
Galinsky, T.L., Waters, T., and Malit, B. (2001). Overexertion injuries in home health care workers and the need for Ergonomics. Home Health Care Services Quarterly, 20, 57-73.
Parsons, K., Galinsky, T.L., and Waters, T. (2006a). Suggestions for preventing musculoskeletal disorders in home healthcare workers. Part 1: Lift and transfer assistance for partially weight-bearing home care patients. Home Healthcare Nurse, 24, 158-166.
Parsons, K., Galinsky, T.L., and Waters, T. (2006b). Suggestions for preventing musculoskeletal disorders in home healthcare workers. Part 2: Lift and transfer assistance for non weight-bearing home care patients. Home Healthcare Nurse, 24, 227-234.
Waters, T., Collins, J., Galinsky, T.L., Caruso, C. (2006). NIOSH research efforts to prevent musculoskeletal disorders in the healthcare industry. Orthopaedic Nursing, 25, 380-389.
Posted 10/16/08 at 2:05 pm
We have often heard advice on how to bend at the knee, use proper body mechanics, and strenthen our backs. Unfortunately, none of this advice will ever make the manual lifting of a 250 pound person safe, and in fact, it perpetuates the myth that we are somehow partly to blame when we become injured. Employers are responsible to provide a safe working environment for their employees. This includes the structure, policies, administrative support, staffing, and equipment necessary to perform a job safely.
American hospitals will eventually have to deal with this issue, but the question remains, how long will it take, and how many will be injured before that happens.
Posted 10/16/08 at 11:42 am
I want to know if there is a correlation between MSD-injuries and stress? Is there evidence about it? I did a risk assessment with 70 nurses (homecare): how do they perceive their job (interesses, tired, risks, autonomy, ...? wellbeing - MSD injuries.
Posted 10/21/08 at 4:29 am
There is a lot of research on this topic. You may want to contact the Netherlands Organisation for Applied Scientific Research - TNO, specifically Pauline Bongers.
Some studies have shown that psychosocial work factors, such as lack of control over work planning, are risk factors for musculoskeletal symptoms in home health care workers, especially when combined with physical risk factors such as strenuous postures (e.g., Brulin et al., 1998, Johansson, 1995).
References:
Brulin, C., Gerdle, B., Granlund, B., Hoog, J., Knutson, A., and Sundelin, G. (1998). Physical and psychosocial work-related risk factors associated with musculoskeletal symptoms among home care personnel. Scandinavian Journal of Caring Sciences, 12, pp 104-110.
Johansson, J. (1995). Psychosocial work factors, physical work load and associated musculoskeletal symptoms among home care workers. Scandinavian Journal of Psychology, 36, 113-129.
Posted 10/27/08 at 2:07 pm
I am an occupational therapist working in a large health care organization 15,000 associates (multiple hospitals and outpatient centers). I would like to know what other organizations are documenting in their job descriptions regarding the expected lifting demands for nurses and patient care assistants. I am working to lower our RN/PSA lifting requirements and require utilization of lift/transfer equipment for safe patient handling.
Feedback please.
Posted 11/5/08 at 11:54 am
Have you identified the hopitals for your 2009 bariatric study? I'm currently in the process of implementing a safe patient handling/movement program in a major teaching healthcare setting in Atlanta, one of which is a bariatric center for excellence. Are you interested in dialoging with me about Emory Hospitals being part of your research initiative?
Posted 11/5/08 at 1:12 pm
Thank you for your interest. We will contact you directly to discuss a potential collaboration.
Posted 11/10/08 at 9:39 am
IMPACC WorkSmart Injury Prevention Analysis of MSD Variances/ Claims at St Luke's Regional Medical Center in Sioux City, IA across all nursing areas has been significantly reduced since 2005.
--From 2005 through end of 3rd Qtr 2008
We have seen a reduction in MSD claims across all nursing areas at St Luke's by 64%. (Low back and Shoulder most common variance/ claims reported).
We have seen a significant reduction in the severity of claims across all nursing areas such as;
1) We have seen a 91% reduction of MSD claims reported that required Restricted duty in nursing areas at St Luke's
2) Days on restricted duty have been reduced by 98% since 2005, with only 27 days of nurses on restricted duty thus far in 2008 through 3 quarters. That is Working Smart!!
3) The best is saved for last as we have seen a 100% reduction in lost time claims and days away from work across all nursing areas in 2008!! The only lost time claims we have had at St Luke's in 2008 was from 2 slip/ falls claims of workers not involved in patient care.
These outstanding IMPACC WorkSmart "Industrial Athlete" program outcomes at St Luke's were possible by many factors such as;
1) Purchase of new Safe Patient Handling Equipment by the Employee Grants Committee which is headed by employees of St Luke's to improve workers safety and the health/ safety and well being of our patients we serve at St Luke's!!
2) Since 2006 St Luke's has offered a year round Health Challenge (through the Employee Health and WELLness Dept which I am a part of) to improve the health, wellness and injury prevention of the workers at St Luke's. This has made a HUGE improvement in our numbers since 2006 as workers are getting healthier in their lifestyle choices!!
3) Since 2001 I have led a 30 minute WorkSmart section at St Luke's every other week at new employee orientation discussing; WorkSmart posture and body mechanics principles, worksmart stetching, principles of workplace ergonomics, self care techniques to treat and prevent headaches, lower back pain, tendonitis, etc... EHW Dept also has a 30 minute section where we discuss our Health Challenge, importance of early reporting, and many others.
4) We have worked with Admin, Mgt and Sup of St Luke's and the nursing floors, along with employees to improve the ergonomics, choose SPHE and improve the safety at St Luke's.
5) Since Jan 2007 I have instructed approx 270+ nursing, radiology, respiratory therapy, and rehab staff with the Safe patient handling equipment and WorkSmart posture and body mechanics, and WorkSmart stetching at St Luke's.
6) Each week of Orientation (every other week) I lead a Safe patient handling equipment training class for all nursing, rehab, radiology employees at St Luke's.
7) We attend Dept staff meetings throughout the year to review SPHE, worksmart stretching and self cares, posture/ body mechancis and ergo principles specific to their work areas.
8) We have had gait belts in all patient rooms that are wipe down for infection control purposes too since early 2007 after I trained all employees again in the IMPACC WorkSmart injury prevention program in 2006.
9) We are now training WorkSmart Champions/ Coaches for each nursing floor to lead in this WorkSmart effort at St Luke's
10) I am training all nursing, and radiology students at our St Luke's College of Nursing and Radiology on the safe patient handling equipment, stretching and posture/ body mechanics. This was started in the last two months.
Posted 11/5/08 at 6:11 pm
At the heart of most muscular skeletal disease problems, affecting health care workers in a number of positions from hospital to long term care, is that safety for the health care worker is considered the workers active responsibility and not a built in or passive factor.
Educational programs focus on the correct way to lift a patient, however most injuries are not part of a planned lift but are related to a reflex to protect the patient from further injury once a fall is already in progress. Gait Belts have been handed out with little or no training as a (cure all) for reducing staff injuries at a minimal cost and mechanical devices have been removed from the hallways for safety and the door are locked to avoid tampering with medical supplies also a safety measure.
Unfortunately for the health care staff, these factors compound and become a "set up for failure". When safety is not a passive built in factor, and healthcare workers are blamed as being, the cause and reason they are injured, people become afraid to report injuries on the job and that is an oppressive frame of mind.
There are a great number of health care workers who have had their fingers and wrists dislocated by Gait Belts as well as other muscular skeletal injuries associated with the use of them. Health Care workers may be injured a little less often but this still should not be acceptable. Safety should never be an active responsibility where you have to impose on others to help keep yourself safe.
Posted 1/3/09 at 2:40 pm
The article notes that
Surveys in dental journals have reported back pain rates as high as 70% for dentists, with 33% retiring early due to back disability. An as-yet unpublished survey of Registered Dental Hygienists in the state of Wisconsin found 92% of respondants reporting pain severe enough to miss work, with 42% reporting regular pain severe enough to interrupt sleep habits. 25% reported job changes as a result of pain. Similar statistics have been consistently reported for over 60 years, since the advent of sit-down dentistry.
Are there other specialty areas within health care that have similar exposures?
Posted 1/13/09 at 3:41 pm
Data from the Bureau of Labor Statistics (note: the NAICS code for Healthcare and Social Assistance is 62) show that in the healthcare industry, those working in ambulance services, other ambulatory healthcare services, nursing care facilities, nursing and residential care facilities, community care facilities for the elderly, general medical and surgical hospitals, and hospitals had the highest rates of overexertion injuries in both 2007 and 2006. The category "Offices of Dentists" does not contain data due to a small sample size. However, injuries and symptoms may be prevalent in the dental industry, as suggested by Mr. Books' mention of surveys reported in dental journals. Posting the references on the blog will allow others to locate the data.
NIOSH research has focused on patient handling because it is associated with the highest injury rates (nursing aides, orderlies, and attendants had a MSD rate of 252 cases per 10,000 workers—a rate more than seven times the national MSD average for all occupations). In addition to lifting, pushing, pulling, carrying and work in awkward or extreme bent postures can also contribute to back pain and injury. More information on preventing back injury can be found on the NIOSH Ergonomics and Musculoskeletal Disorders topic page.
Posted 1/15/09 at 2:43 pm
The above text quotes that the training and equipment changes implemented at eight facilities over 51 months, "Overall, the eight facilities experienced decreases of 32% in all injuries," This is remarkable.
However 68% of the prior injuries still occurred. This in the light of active participation, in training to reduce injuries, can this imply that once the spotlight shifts away from this intense project, that the numbers will return to prior levels, because these rates of injury are acceptable to the institutions where these people are employed.
These injuries "musculoskeletal disorders (MSDs) at a rate exceeding that of workers in construction, mining, and manufacturing" described are often life altering, accumulative, and end in career changes, debilitation, or both also this often includes life long pain. All these insults to the body and still this will be compounded by many factors, at the top of the list is legal cost to attempt to recover whatever losses have occurred both past and future. Add to this, medical bills denied by workman's comp carriers that because "100% medical care" is not covered before or after injury, future employers must consider this additional cost, with any experienced personnel as well as how much damage can this potential employee still endure. The same is true with professional athletes but we consider their compensation is written into their contract.
We need to find an alternative that does not require active thinking and pulling coworkers away from their patients to create a "safer environment". If the Auto industry or any other major manufacturer were to request a 2-4 year degree, often called a journeymen or engineer, to perform a high-risk job like this, what would their pay and compensation be?
Why is there a shortage of new nurses?
References
Garg, A. (1999). Long-term effectiveness of "Zero-Lift Programs" in seven nursing homes and one hospital. U.S. Department of Health and Human Services, National Institute for Occupational Safety and Health, Contract Report No. U60/CCU512089-02.
State of Washington [2006]. An act relating to reducing injuries among patients and healthcare workers. Retrieved January 14,2008, from http://www.leg.wa.gov/pub/billinfo/2005-06/Pdf/Bill Reports/House/1672.HBR.pdf
Posted 1/16/09 at 6:45 pm
The equipment/devices for the healthcare industry to avoid MSDs to workers is out there. Evidence based studies have proven that in spades!!! - how many more studies do you need to convince the industry that injuries can be reduced to insignificant levels? Even if there were hundreds more (studies that is) the impact would be little. It'll have to be legislated into effect?
The real problem is the nature of Risk Management—it is insurance oriented and not prevention and education oriented. Why is that? Well, partly because it is simply the accepted paradigm - people have made lifelong careers out of it and there is a whole micro-economy built around it. Think about it... healthcare work related MSDs make up a huge part of your local State's Worker's Comp Claims. It involves local/state/federal governments (part one of the micro-economy). That means budgets have to be allocated for administrative purposes/programs/information/assistance—Like NIOSH for example. Taxes have to be collected (part two of the micro-economy). Then there are the insurance companies. They make money off these injuries—what, you say? Sure, they offer a needed service and they make a profit from it (part three of the micro-economy). The hospitals and healthcare systems gladly pay the insurance companies because by law they are required to provide worker's compensation insurance (part four of the micro economy—y'all know there's an Executive with a staff to handle what's called Risk Management, right? Well he's the one that buys the insurance)
The only thing that is going to break the Paradigm is this thing called indirect costs. The insurance companies just raise the rates over time and absorb the rising costs. But there are costs to the healthcare provider that are just now really coming into focus i.e. retention/recruitment—in year 2000 it cost around $100,000 to hire a nurse to replace someone who was injured—it was close to $150,000 to hire a specialty nurse—and this was for just one employee. Meanwhile the executives look at purchasing newer Safe Patient Handling Equipment as a balance sheet liability! (Safe Patient Handling is not billable) Granted the manufacturers of such equipment in the past may have poorly juxtaposed the cost of equipment capital vs. human capital - but to be honest the people crunching the numbers have a hard time seeing the causal relationship. And anyways ask any accountant and they'll quickly point out that such equipment goes in the liability column.
Here's the punchline... There are studies out there that point out the tremendous cost savings enjoyed by healthcare providers who implement Safe Patient Handling!!! Maybe this approach will have more effect on forcing a change. But in the meantime changes will be slow and then ever increase at rapid pace as we shift into a new thought paradigm on how to think about Risk Management for the Healthcare Provider.
Posted 1/17/09 at 12:43 am
Can you please provide references to how recommendations apply to emergency medical technicians (EMTs). As an occupation, they are frequently required to: -Carry more than 50 lbs of unbalanced equipment up stairs; -Move patients weighing more than 150 lbs with only 2 providers from ground-to-stretcher (or chair) and bed-to-stretcher without assistance devices which seems to violate both the weight and angle guidelines that I have seen; -Carry more than 200 lbs down multiple flights of stairs (equipment + patient).
While other professions have a reasonable expectation of calling for help in a timely manner; the current prevalent model of 2 EMTs does not readily allow for waiting for assistance.
Any guidance would be appreciated!
Scot Phelps
Associate Professor of Emergency Management School of Health & Human Services Southern Connecticut State University
Posted 1/30/09 at 1:37 pm
NIOSH has not examined the unique situations faced by EMTs. Laurel Kincl in Oregon and Steve Lavender at The Ohio State University have both conducted research on manual handling for EMTs. A few references are provided below.
Posted 2/2/09 at 2:39 pm
what do you recommend for a weight capacity of ceiling mounted patient lifting tracks for tertiary teaching hospitals—people at the hospital I am working for are unsure what the maximum capacity of patient they expect to be admitted.
Posted 2/15/09 at 11:58 pm
Thank you for your comment. Equipment vendors should be contacted for specifications on equipment design and capacity.
The highest patient weight we have seen mentioned in the literature is 1100 pounds, though such patients are rare. Data on rates of obesity and morbid obesity in the general U.S. population can be found in the following article:
Ogden, C., Carroll, M., and Curtin, L. (2006). Prevalence of overweight and obesity in the United States, 1999-2004. Journal of the American Medical Association, 295, 1549-1555.
Posted 2/17/09 at 9:21 am
Manual Lifts are great but they are bulky and like Carole said there are rules about keeping halls clean... That's why the hospitals need to invest more in ceiling lifts and tracks..... They are great!
Posted 4/8/09 at 3:37 pm
There is a place for both floor-based and ceiling-mounted lifting devices. Floor-based lifts can be used where there are no overhead tracking systems. Ceiling-mounted lifts are easier to use, require less physical effort to use, and are always available, but can only be used where the tracks have been installed.
Posted 4/10/09 at 9:24 am
In your response to post #4, you stated that NIOSH is considering research to look at the effectiveness of safe patient handling legislation that has been enacted in 9 states. Have you decided to go forward with this research, and how, and from whom, will you solicit input?
Posted 6/3/09 at 11:41 am
The potential research mentioned above would likely come from the NIOSH extramural research program. Currently, there are no projects funded on this topic but we encourage interested parties to apply for funding by mechanisms available and described under "Funding Opportunities." Proposals are funded annually based on availability of funds, relevance of the proposed work to the NIOSH mission, and the quality of the science proposed.
Posted 6/5/09 at 4:35 pm
Comment 4 states "Additionally, the national bill HR 378 "Nurse and Patient Safety and Protection Act of 2007" was introduced into the House of Representatives in January 2007. The bill remains in committee. For links to the status, complete history, and text of HR 378, go to http://thomas.loc.gov
Is this bill still being worked on? I tried the link and searched for both the bill # HR 378 and well as the name you've listed in parentheses. I am unable to find any information regarding this proposed bill. I am interested in more information regarding this new proposed Act.
Posted 7/13/09 at 2:15 pm
On May 13, 2009, House Resolution (H.R.) 2381 "Nurse and Health Care Worker Protection Act of 2009" was introduced into the U.S. House of Representatives of the 111th Congress by U.S. Representative John Conyers, Jr., Democrat, Michigan District 14, and co-sponsored by Representative Lynn C. Woolsey, Democrat, California District 6. More information can be found by searching Bill Number H.R. 2381 at http://thomas.loc.gov.
Posted 7/16/09 at 8:53 am
There is a lot of discussion here about electical lifting devices, what about electical bed movers for patient transfer? How common is this equipment in US hospitals?
Posted 7/22/09 at 3:10 am
Does anyone have link to information on state laws passed and state laws enacted regarding Safe Patient Handling
thank you
Posted 7/23/09 at 5:37 pm
For more information on injured Nurses, the Work Injured Nurses Group (WING) can be found at www.wingusa.org . The site lists important links regarding H.R.2381 as well.
Posted 7/24/09 at 6:50 pm
I left nursing in 2004 due to back problems. I had already had a lumbar laminectomy and had began having difficulties with cervical vertebra. In Nursing it was my feeling that a nurse should have the appearance of health and stamina. I know that if you didn't, you were looked upon by management as a workers comp case ready to happen. We were in the begining phases of implementing lift equipment and evaluating injury related to lifting and moving patients. We were monitoring this through our Quality / Risk Dept. and had chosen indicators to measure improvement and compliance. This being a new concept we had some difficulty with in education and buy in from the staff. Remembering the days of the old hoyer lifts, it was much easier and faster to use manual lifting maneuvers. There were usually one hoyer per floor and finding it was as difficult as getting a second person to assist you in using it. The issue after getting the new equipment was remembering how to use it and still finding someone to assist you in the use of the product. It was about saving time and manpower. I was already injured from years of physical abuse in nursing. Now I find myself unemployed with years of experience as a skilled nurse from everything to bedside nursing to risk management and infection control, educaton as a preseptor and in teaching new technology to the staff nurses from computerized nursing documention and e-mar to any and all new equipment including lift equipment and monitoring for compliance to an abundance of wound management and developing and revising nursing standards. I am the average age of a retired nurse, but I loved it. I never collected workers comp. I just figured it was part of the job.
Posted 8/03/09 at 2:06 pm
I appreciate the comments from those individuals about the equipment being tucked away and not utilized in their facilities. Our acute care hospital and acute rehab have implemented a Safe Patient Handling and Movement program over the past 18 months. This was a huge undertaking, but we are starting to see the benefits. We have learned some important lessons as we have rolled this out in our facility. We had to have administration backing and a policy that prohibited the manual lifting of dependent patients in all but life threatening circumstances. We have worked very closely with Employee Health and all patient care staff get 2.5 hours of hands on training on the equipment, techniques, back safety and policy.
This has really helped. We still have to make rounds and post updates in our hospital newsletter frequently to remind staff of the equipment and policy. It is definitely a 2-3 year process for buy-in, education and ongoing transition to a "Culture of Safety". Don't give up, just like anything new it takes time and persistance!
Posted 8/04/09 at 11:47 am
I am curious as to why there are so many nurses getting injured on the job. There are other professions such as EMT's Physical and Occupational therapists that lift, transfer and reposition patients all day long. I don't quite understand the "zero lift policy" if a resident is in a nursing home, as part of providing quality care one should try to maintain the residents abilities, not decrease it by putting everyone in a mechanical lift where they don't use their muscles. Another concern is that short-term rehab residents are there to get stronger. If nurses aides are using a mechanical lift for all transfers mean while therapists are trying to teach the patient to be independent, the length of stay will be much longer costing the resident perhaps their house.
If body mechanics/ergonomic training are effective in many professions then one should look into why it's not effective in the nursing profession. I strongly feel a combination of ergonomic training along with mechanical lifts and having the staff follow the facilities policies and procedures on patient handling will reduce the number of injuries.
Posted 10/22/09 at 12:58 pm
All healthcare personnel, including physical therapists and rehabilitation nurses, are at high risk of musculoskeletal injuries from patient handling. EMTs and physical and occupational therapists likely have high rates of back injuries because they lift, transfer, and reposition patients all day long. For that reason, it is important to incorporate lifting technology into the work they do. Body mechanics/ergonomic training have not been shown to be effective in other professions when not incorporated into a comprehensive ergonomics program that includes use of technology when available. A safe-lifting policy (also referred to as "no-lift," "zero-lift," "no manual lift," or "safe patient lifting policy") is one part of a comprehensive approach to preventing musculoskeletal injuries to healthcare workers (Collins, 2006). The purpose of a safe-lifting policy is to provide a clear understanding of the elements of a safe patient handling and movement program, to define the roles and responsibilities for all affected staff (healthcare administrators, supervisors, frontline caregivers, therapy staff, maintenance personnel, and housekeeping staff) and to provide a reference for review when questions arise. A sample of a safe lifting policy is available in the appendix of the book "Safe Patient Handling and Movement – A Practical Guide for Health Care Professionals."
Physical therapy tasks tend to be of longer duration than typical transfer tasks, which increases exposure to excessive spinal loads during therapy tasks. A discussion of injury risk in rehabilitation personnel is provided in a recent article by Nelson et al. (2008b). They also cited research in which a significant percentage of injured therapists stopped performing or altered treatments that aggravated their own symptoms, raising concerns about the impact of patient handling injuries on the quality of rehabilitative treatment (Cromie et al., 2000).
There has been reluctance to use mechanized equipment in physical therapy/rehabilitation, due to concerns that it might impede therapeutic progress and thereby reduce patients' functional status and independence (Nelson et al., 2008b). Nelson et al. point out that there is a lack of evidence on which to base such concerns. Use of patient handling equipment has been shown to be effective in improving rehabilitation outcomes (i.e., it speeds recovery and is adaptable to patient needs). Use of equipment or technology likely improves the quality of care afforded to patients (Nelson et al., 2008a).
Nelson et al. encourage further development of mechanized methods for simultaneously administering physical therapy while reducing exertion and injury risk for therapy/rehabilitation personnel. Examples of such methods and ongoing research to evaluate their effectiveness are described by Baptiste et al. (2008) and Rockefeller (2008).
References
Baptiste, A., McCleerey, M., Matz, M., and Evitt, C. (2008). Proper sling selection and application while using patient lifts. Rehabilitation Nursing, 33, 22-32.
Collins, James W. (2006). Safe Lifting Policies. Chapter 10 in "Safe Patient Handling and Movement - A Practical Guide for Health Care Professionals." Audrey Nelson, Editor, Springer Publishing Company.
Cromie, J., Robertson, V., and Best, M. (2000). Work-related musculoskeletal disorders in physical therapists: Prevalence, severity, risks, and responses. Physical Therapy, 80, 336-351.
Nelson A., Collins J., Siddharthan K., Matz M., and Waters T.(2008a) Link between safe patient handling and patient outcomes in long term care. Rehabilitation Nursing 33(1).
Nelson, A., Harwood, K., Tracey, C., and Dunn, K. (2008 b ). Myths and facts about safe patient handling in rehabilitation. Rehabilitation Nursing, 33, 10-17.
Rockefeller, K. (2008). Using technology to promote safe patient handling and rehabilitation. Rehabilitation Nursing, 33, 3-9.
Posted 10/24/09 at 9:24 am
Do you have any numbers on the use of lifting devices (in hospitals, factories, etc.?
Posted 11/22/09 at 9:32 pm
There are no concrete data available for this topic. Many Nursing homes have 1 or 2 lifts but few have best practices programs. I am only aware of a handful of acute care hospitals with best practices programs. Many have a lift or two but only a few with hundreds of lifts. The VA recently received 300 million dollars to put a lift over every VA bed in the country. We are on the front end of a huge paradigm shift where lift implementation is dramatically increasing. The more important issue is the implementation of comprehensive programs that include lifting equipment, management support, written policies, and management support.
Posted 12/9/09 at 7:01 am
Where do gait belts fall as part of a safe patient handling program?
Minnesota has enacted a statute (MN Statute 182.6553 and 182.6554) with the goal of minimizing manual lifting of patients. The question of are facilities still going to be able to use gait belts keeps coming up.
Several prominent facilities have made the determination that gait belts are not considered safe patient moving equipment and have 35lb. lifting limits to back this. Research indicates that gait belts do not prevent injuries but many lifting algorithms still include them as an assistive device for moving patients. What does NIOSH say?
Posted 11/22/09 at 9:32 pm
Gait belts are wide, fabric belts worn around the patient's waist, with sewn-in fabric handles that are grasped by the caretaker. They are helpful assistive devices for some patient handling tasks, but they are not designed for lifting patients. Gait belts, as their name suggests, were designed to help stabilize weight-bearing patients during ambulation. In addition, patient handling algorithms developed by the Veterans' Administration Patient Safety Center include the use of gait belts to assist with transfers in some circumstances. For example, they can be used to assist partially weight-bearing patients to stand and pivot or to assist a non weight-bearing patient who has upper extremity strength while s/he is initially learning to do a seated transfer with a seated transfer aid, such as a transfer board. The algorithms can be found in the document "Assessment Form and Algorithms" under "Algorithms for Safe Patient Handling and Movement" at the following website:
http://www1.va.gov/visn8/patientsafetycenter/safePtHandling/default.asp
Posted 12/9/09 at 6:59 am
Many emergency dental care providers suffer from back pain and injury due to sloughing over all day.
Posted 1/18/10 at 1:00 am
When implementing Safe Patient Handling Programs the challenge is to keep the ratio of equipment to patients at a reasonable level to keep the equipment accessible. The NIOSH publication "Safe Lifting and Movement of Nursing Home Residents" gives an equipment ratio. However, the next challenge is to purchase enough slings to keep the equipment accessible and not to over purchase slings which is quite costly.
Is there any documentation on an appropriate ratio of slings to patients or residents?
Posted 1/28/10 at 11:06 pm
There are a couple of options to consider regarding slings that should be discussed carefully with your lifting equipment vendor. Where infection control is a concern, disposable slings have proven to be an effective solution and in some cases these slings can be billed to the patient. An alternative choice is washable non-disposable slings. You should have at least two of each size sling per piece of equipment to handle a range of different sized patients and to have a back up sling when soiled slings are being laundered. As noted, slings are expensive so care should be taken to carefully track and maintain your inventory of washable slings. At one nursing home serving as a study site in our research, slings were being laundered offsite at a commercial laundry and were frequently lost. The nursing home solved the problem by buying a washer and dryer to put in the nursing home that was dedicated to laundering only slings.
Posted 2/5/10 at 12:41 pm
I find it unsettling that there are no articles on helping the nursing staff that work in the home with lifting issues. I can not find anything that regulates safety for the indidual who works in the home with total care patients who for some reason or another are not in nursing homes, convelascence centers, or other controlled environments where there is one person doing all the care and no one to call upon for help should the need arise. I work as a certified nursing assistant with total care patients. I do know how to use a lift and but I find that it is often hard to get a patient set in the sling with no help especially if they are obese or lack any mobiltiy at all to help off set their own weight. I am currently dealing with constant back pain due to work related stress on my back, hips, shoulders and arms. Quiting work is not an option for me. I would like to see articles written that address the in home patient and their special nursing requirements. OSHA needs to set lifting guidelines for home health workers as the population continues to age and people cannot afford nursing home care you are going to see a need for more skilled workers in the private sectors. I fear that you will find a shortage of people who will continue to train and work in this area. I have been working in this field 5 years and hope to leave it when my training to become a medical assistant is over due issues such as this.
Posted 1/31/10 at 11:13 am
At this time there are no laws or even OSHA guidelines specifically for the home healthcare worker related to lifting tasks. NIOSH published suggestions on equipment that is suitable for home use (see references below), but those publications don't include patient lifting algorithms that identify how patients with different conditions and weight bearing ability should be lifted. I would suggest that the VA algorithms (see Assessment Form and Algorithms below) should apply in home settings. These algorithms for many transfer situations require more than one caretaker, even when equipment is used. I suggest it would be advisable to request a conference with the home care agency and the patient/family, using the algorithms to determine and arrange proper methods for patient handling in the home, including more than one caretaker when appropriate.
Parsons, K., Galinsky, T., Waters, T. (2006). Suggestions for Preventing Musculoskeletal Disorders in Home Healthcare Workers, Part 1: Lift and Transfer Assistance for Partially Weight-Bearing Home Care Patients. Home Healthcare Nurse. 24 (3), 158-164.
Parsons, K., Galinsky, T., Waters, T. (2006). Suggestions for Preventing Musculoskeletal Disorders in Home Healthcare Workers, Part 2: Lift and Transfer Assistance for Non–Weight-Bearing Home Care Patients. Home Healthcare Nurse. 24 (4), 227-234.
"Assessment Form and Algorithms" under "Algorithms for Safe Patient Handling and Movement" at the following website: http://www1.va.gov/visn8/patientsafetycenter/safePtHandling/default.asp
Posted 2/1/10 at 3:31 pm