Transcript Ergonomics in Healthcare Ergonomic Injury Prevention

It’s broke, so let’s fix it:
Anatomy of an Injury, Fallacy of
Body Mechanics
Valerie Beecher, MS, AEP
Ergonomics – Employee Health
Danielle Wheeler-Vickery, PT
Acute Rehabilitation
SUNY Upstate Medical University
History of Patient Handling
History of Patient Handling
Quotes from nursing texts:
“Occasionally the complaint is made that a nurse has injured her
back or strained herself in some way in moving a patient. This will
generally be because she has failed to do the lifting properly.”
(Hampton, 1898, p.102)
“It is very good for strength
To know that someone needs you to be strong”
(Committee of the Connecticut Training-School for Nurses, 1906, preface verso).
“Lifting does not always require strength. It takes skill which the
nurse can readily develop once she has made good body
mechanics a habit” (Gill, 1958, p.299).
Taken from: Safe Patient Handling and Movement: A Practical Guide for Health Care Professionals,
Nelson, A. Ed. (2006).
Awkward Handling
“Compared to objects manually lifted or moved in
industrial settings, the body is heavier, more
delicate and awkward to handle”
Source: A Back Injury Prevention Guide for Healthcare Workers; Cal/OSHA
“The adult human form is an awkward burden to
lift or carry. Weighing up to 100 kg or more, it
has no handles, it is not rigid, and it is liable to
severe damage if mishandled or dropped. In bed
a patient is placed inconveniently for lifting, and
the placing of a load in such a situation would be
tolerated by few industrial workers” (“The
Nurse’s Load”, 1965, p.422).
Taken from: Safe Patient Handling and Movement: A Practical Guide for
Health Care Professionals, Nelson, A. Ed. (2006).
National Problem of Ergonomic
Injury in Healthcare Services
Top Ten Occupations for MSDs
1)
Laborers and freight, stock,
and material movers
6)
Truck drivers, light and
delivery
2)
Nursing aides, orderlies,
and attendants
7)
Janitors and cleaners
8)
Stock clerks and order
fillers
9)
Construction laborers
3)
Truck drivers, heavy and
tractor-trailer
4)
Retail salesperson
5)
Registered nurses
10) Maintenance and repair
workers
Source: US Department of Labor, Bureau of Labor Statistics, News Release, “Nonfatal Occupational
Injuries and Illnesses Requiring Days Away from Work, 2006,” November 8, 2007. Accessible at
www.bls.gov/iif/
National Problem of Ergonomic
Injury in Healthcare Services
In 2006, nursing aides, orderlies and attendants
had:
 49,480 days away from work cases
 An incidence rate of 526 per 10,000 workers,
which was more than four times the total for all
occupations.
Source: US Department of Labor, Bureau of Labor Statistics, News Release, “Nonfatal Occupational
Injuries and Illnesses Requiring Days Away from Work, 2006,” November 8, 2007. Accessible at
www.bls.gov/iif/
National Problem of Ergonomic
Injury in Healthcare Services
In 2000, ANA reported that compared to the
general workforce, nurses used 30% more sick
leave annually due to back pain.
 38% of the nursing workforce had been affected by
back injury.
 68% of disabling injuries reported by nurses were
attributable to over-exertion injuries from lifting
patients.
 98% of patient lifting was still done manually.
Source: American Nurses Association Website, NursingWorld, Jan.-Feb. 2000
National Problem of Ergonomic
Injury in Healthcare Services
 ANA estimates that 12% of nurses leave the
profession annually due to back injuries.
 >52% complain of chronic back pain.
 More than 1/3 of back injuries among nursing
personnel is associated with patient handling and
the frequency with which nurses are required to
manually move patients.
Source: American Nurses Association Website, NursingWorld, July 2008
National Problem of Ergonomic
Injury in Healthcare Services
Cost Factors
 In 1990, the annual cost of back injury ranged from $50
to $100 billion in the US
 One low back injury: $40,000
 Indirect costs outweigh direct costs 5:1
 $20 billion per year is spent annually on workers
compensation costs associated with musculoskeletal
disorders (MSDs)
 $100 billion per year is spent on indirect costs
Source: US Department of Labor, Occupational Safety and Health Administration
National Problem of Ergonomic
Injury in Healthcare Services
Reporting
 In 2006 there were over 350,000 musculoskeletal
disorders (MSDs) reported that required days away
from work.
 Many
experts believe this figure
significant under-reporting of cases.
represents
 MSDs account for 30% of all lost-workday injuries and
illnesses.
Source: US Department of Labor, Occupational Safety and Health Administration
Low Back Pain Prevalence
 Back injury is the #2 work-related
injury in the US
 Back pain is the most common
reason for filing workers comp
claims
 Low back pain (LBP) is the #2
reason why patients are seen by
an MD.
 80% of adults will experience
LBP.
 Most of the time injury to the low
back happens at work.
Source: National Institute of Occupational Safety and Health (NIOSH)
What is Low Back Pain?
 Pain that originates from the spine, muscles, nerves or
other structures in the back that can radiate into the
lower extremities, such as tingling, burning sensation,
dull or sharp ache.
 Causes weakness/imbalance in strength and flexibility
in the lower back and abdominal areas.
Low Back Pain Statistics
 15-20% of US adult
population experience back
pain every year. Out of that
number, another 15-20%
require medical care for a
minimum of 3 years.
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90% LBP resolve in 6 weeks
5% LBP resolve in 12 weeks
<1% LBP serious spinal disease
<5% LBP true nerve root pain
Source: American Academy of Orthopaedic Surgeons
Anatomy of Lumbar Spine
1) Intervertebral disc
2) Facet joints
3) Vertebral body
4) Ligaments
5) Spinous process
6) Transverse process
7) Muscles
8) Spinal cord
Causes of Low Back Pain
 Lifting of heavy objects
 Prolonged sitting
 Injury/accident
 Quick movements
 Other Causes:
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Muscle spasms
 Stenosis
Decreasing alignment
 Muscle strains/tears
Herniated Disc (HNP)
 Curvature of spine
Small fractures
 Fibromyalgia
Degenerative Disc Disease (DDD)
Low Back Pain Disorders
Herniated Disc (HNP)
 Nucleus pulposus (center of disc which is a

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
fibrogelatinous pulp) acts as a shock absorber.
Disc protrudes outside of the center (annulus
fibrosis), i.e. jelly donut when squeezed.
95% occur at L4L5 or L5S1 (center of gravity)
75% recover within 6 months
Sudden onset of LBP and radicular symptoms
in leg(s).
Facet Joints
 Occur in 40%; mainly extension and rotation
 Symptoms increase with lumbar extension “compression”
 Symptoms decrease with lumbar flexion “separates”
 Sudden attacks
 No radicular symptoms to buttocks or below knee.
Spondylolysis
Spondylolisthesis
Spondylolysis
 Stress fracture of pars interarticularis
 Repetitive flexion/extension
 LBP with occasional
radicular symptoms
past buttocks and
thighs, no neurologic
deficits
Spondylolisthesis
 “Slipping of vertebrae”
 75% have LBP
 Restrictive ROM
DDD/Spinal Stenosis
 Neurogenic claudications
 Pain/symptoms increase with
standing/walking (buttock and lower
extremity symptoms)
 Pain decreases with flexion
LBP Risk Factors
 Heavy manual lifting
 Repetitive movement: lifting/twisting
 Constant vibration
 Poor posture
 Continuous work
 Poor physical fitness
 Low pain threshold
 Weak trunk musculature
 Smoking
 Stressed/depressed
 Pregnancy
 Arthritis
Biomechanics
How does it work together?
“It’s broke…”
Past Approaches to Reducing Injury in Healthcare
Training in body mechanics and appropriate lifting techniques, i.e.
“bend your knees, not your back”.
Lectures
addressing
musculoskeletal system.
human
anatomy
and
function
of
the
Promotion of healthcare worker physical fitness.
Promotion of healthcare worker proper nutrition.
Modified from: Ergonomics, How to Contain On-The-Job Injuries in Health Care by Guy Fragala, PhD. Reprinted
with permission from Joint Commission on Accreditation of Healthcare Organizations.
Dispelling the Myth
 Education on lifting techniques and training in body
mechanics are not effective in reducing injuries.
 Research over past 35 years reveals that these efforts
by themselves have failed to reduce injury.
 Most common factor contributing to ergonomic injury in
healthcare is the caregiver’s tendency to exceed
one’s own safe lifting capacity when handling
patients, putting excess force on the spine.
Sources: Patient Safety Center of Inquiry of the Veterans Administration Medical Center
(www.visn8.med.va.gov/patientsafetycenter/) and Back Injury Prevention (www.premierinc.com)
Facts
 Early studies on body mechanics
focused on men and nursing still
consists primarily of women.
 Early body mechanics studies were
performed in controlled settings with
boxes with handles (patients are bulky
and don’t have handles!)
 Patients can be combative,
experience muscle spasms, or lose
their balance.
 A patient’s ability to assist varies.
 The environment is complex.
Sources: Patient Safety Center of Inquiry of the Veterans Administration Medical Center
(www.visn8.med.va.gov/patientsafetycenter/)
Facts
 When the lifting capacity is exceeded, there is no way
to “lift properly” or use “proper body mechanics”.
 Forces exerted on the musculoskeletal system when
caregivers perform patient-handling tasks are beyond
reasonable limits and capabilities, regardless of
technique to perform the task manually.
 Training programs fail to consider that lifting, turning,
and repositioning patients are frequently performed on
a horizontal plane, such as a bed or stretcher, requiring
the nurse to use the weaker muscles of the arms and
shoulders, rather than the stronger muscles of the legs.
Sources: Patient Safety Center of Inquiry of the Veterans Administration Medical Center
(www.visn8.med.va.gov/patientsafetycenter/)
Patient Handling
Risk Factors
 Personnel Factors:
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Staff shortage
Healthcare worker general
health factors
Poor patient handling
techniques
Repetitive tasks
End-of-shift fatigue
Lack of equipment training
Lack of time
Resistance to change
 Patient Related Factors:
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Decreased consciousness


Decreased strength and
ability to cooperate
Mental status and
combativeness
Patient size and weight
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No handles

Progression for patient

Patient/family resistance to
equipment use

Modified from Ergonomics, How to Contain On-The-Job Injuries in Health Care by Guy Fragala, PhD.
Reprinted with permission from Joint Commission on Accreditation of Healthcare Organizations.
Patient Handling
Risk Factors
 Environmental Factors:
 Confined space of patient room and bathroom
 Wet and slippery floors
 Multiple monitors, IV poles, equipment, etc. in rooms
 Equipment Factors:
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Lack of proper equipment (lateral transfer equipment,
bariatric equipment)
Broken and poorly maintained equipment
Low height of patient chairs, toilets, or high height of patient
bed
Modified from Ergonomics, How to Contain On-The-Job Injuries in Health Care by Guy Fragala, PhD.
Reprinted with permission from Joint Commission on Accreditation of Healthcare Organizations.
NIOSH Lifting Equation
 Can be used to calculate a weight limit for a lifting task
under ideal conditions.
 Based on biomechanics, psychophysics, physiology, and
epidemiology.
 Recommended weight limit is 35 pounds for most
patient-lifting tasks, but less when conditions are not
ideal.
 Reasonable to use this maximum limit to assess patient
handling when equation isn’t feasible.
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
NIOSH Lifting Equation
 Not originally used for assessing the lifting of
patients due to limitations:
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Patient unpredictability and combativeness
Patient movements while lifting can create additional
loads
 Can be used under ideal conditions as a guide
 Patient can follow directions, non-combative
 Weight a caregiver handles can be estimated
 Lifting is smooth and slow
 “Geometry” of the lift doesn’t change
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
What does this mean?
 Many patient-handling tasks that caregivers perform
are unacceptable based on a 35-pound limit.
 Few patients weigh less than 35 pounds (except in
pediatrics).
 Recommended weight limit (RWL) can assist with
identifying tasks/situations for which the use of
equipment is necessary.
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
Patient Handling Scenarios
 2 nurses helping patient
to stand from chair
 Patient weighs 180lbs
 Can assist partially
(about ½ his weight)
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2 nurses need to lift 90lbs
45lbs > 35lb RWL
Use lift or a sit-to-stand device
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
Patient Handling Scenarios
 1 nurse needs to raise a
patient’s leg off the bed
for wound care
 Patient weighs 300lbs
(leg is ~16% of total
body weight)

47lbs > 35lb RWL
Use lift with limb sling or limb positioner
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
Patient Handling Scenarios
 4 nurses about to move a
fully dependent patient
from bed to chair
 Patient weighs 250lbs
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
4 nurses need to lift
250lbs
62.5lbs > 35lb RWL
Use lift
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
Patient Handling Scenarios
 1 nurse about to move a
fully dependent patient
from bed to chair
 Patient weighs 100lbs
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1 nurse needs to lift
100lbs
100lbs > 35lb RWL
USE LIFT!
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
“…So, let’s fix it”
Change in philosophy:
Modify the job to fit the worker rather than
changing the worker to fit the job.
 Lifting techniques are still important but no longer the only key elements.
 Elimination or modification of lifting activities is more effective. Use task
analysis and patient assessment.
 Use engineering solutions (such as patient lifts, friction-reducing devices,
or transfer belts to reduce risk of injury).
 Standardized processes for equipment, sling and staff selection.
Questions?