United Stated Department of Labor
Occupational Safety and Health Administration
Office of Training and Education
Guy Fragala, Ph.D., PE, CSP
TABLE OF CONTENTS
Previous Approaches for Improvement
New Directions for Improvement
Reviewing Successful Programs
Success Story # 1
Results from VISN-Wide Deployment of a Back Injury Prevention Program
Success Story # 2
Intervention Program for Transferring Residents in Nursing Homes
Success Story # 3
Long Term Effectiveness of Zero-Lift Programs in Seven (7) Nursing
Homes and One (1) Hospital
Success Story # 4
An Ergonomic Back Injury Prevention Program at Masonic Home and Hospital
Success Story # 5
Successfully Reducing Back Injuries and Workers' Compensation Costs
at Lawrence and Memorial Hospital
Success Story # 6
Addressing the Worker's Compensation Crisis at Edinburg Hospital
Success Story # 7
Limit Liability with Lift Programs
Success Story # 8
Implementation of the EC Legislation on Lifting and Manual Handling
Healthcare organizations have begun implementing ergonomic management
programs focusing on reducing risks associated with patient handling.
It is valuable to review these stories to see the level of improvement
that can be achieved and learn what are some of the key factors which
contributed to successes in reducing occupational injury rates. The successful
programs documented in this publication blend effective utilization of
lifting aid devices into the process of providing patient care along with
a management program to facilitate integration of these changes effectively
into the workplace. A diverse collection of success stories has been included.
The purpose of this publication is to provide the reader with a brief
summary of the program implemented and a demonstration of the level of
improvement actually achieved. Some of the stories provide a basic structure
of the program process others highlight some of the key elements necessary
for a successful program in a more narrative fashion. Prior to the success
story presentations, some background material is offered regarding the
magnitude of the problem, previous prevention strategies which have been
unsuccessful, and what new directions are necessary for improvement. Much
of the material in this background information is taken from an article
by the author to be published in a future issue of the Journal of the
American Association of Occupational Health Nurses.
Musculoskeletal disorders experienced by workers in the healthcare industry
have been, and remains, a major problem (Engkvist, 1992; Harber, 1988;
Hignett, 1996; Jensen, 1990; Khuder, 1999; Ljungberg, 1989; Pheasant,
1992). Reviewing trends related to occupational injury experience, a steady
decrease would be observed in total cases beginning in 1992. However,
a closer review of these statistics focusing on healthcare workers who
are involved in direct patient care, does not demonstrate an improving
trend. Data available from the Bureau of Labor Statistics substantiates
occupational back injuries as a major problem (Bureau of Labor Statistics,
2000). In 1998 there were 1,730,500 lost time occupational injuries reported
in the United States. Forty-four percent of these were strains and sprains,
with the majority involving the back. 10.5% of the total number of occupational
back injuries suffered in this country, when considering all of industry,
were caused by moving and assisting healthcare patients. In reviewing
work related musculoskeletal disorders involving time away from work for
1998 by occupation, as cited in the Bureau of Labor Statistics data, the
occupation leading the list is nursing aides, orderlies and attendants,
and registered nurses are at number six. Sixty-six percent of all injuries
suffered by nursing aides and orderlies were strains and sprains whereas
59% of all injuries suffered by registered nurses were strains and sprains
(Bureau of Labor Statistics, 2000). When considering the event leading
to an occupational injury within nursing and personal care facilities,
overexertion specifically from lifting is a major contributing factor.
In fact, the incidence rates calculated for overexertion as the cause
for injuries in nursing and personal care facilities are four times higher
than the national average for all industry. These rates rank as the fourth
worst when considering all of the hundreds of industries, which report
information to the Bureau of Labor Statistics. Back injuries among nurses
and nursing aides and others involved in direct patient care is a major
problem which must be addressed. It is the intention of this publication
to present a collection of research projects and case studies where injury
rates have been reduced following implementation of an ergonomic management
Previous Approaches for Improvement
Traditionally, healthcare organizations have attempted to improve the
back injury problem through body mechanics training programs where workers
are taught proper lifting technique. Research has demonstrated that this
approach has not been effective (Anderson, 1980; Brown, 1972; Buckle,
1981; Daltroy, 1997; Daws, 1981; Dehlin, 1976; Harber, 1994; Lagerstrom,
1997; Owen, 1991; Snook, 1978; Stubbs, 1983). Suggested reasons why this
approach has been ineffective include:
- Trying to encourage proper lifting technique requires behavior modification.
Behavior modification is difficult to achieve and even if it is achieved,
new behaviors are often short lived. Most times workers will revert
back to old behavior styles.
- Optimum theoretical principles are taught in a classroom setting.
When workers move into the patient care environment, it is often very
difficult to apply these theoretical principles.
- There may not be optimum principles, which universally apply to all
workers because of differences among people. With the wide variety of
possible situations it is often difficult to prescribe a one best way
- Even if there were a best way to conduct a manual lift, because of
the loads involved; there is no safe way for a worker to manually lift
a dependent patient.
New Directions for Improvement
To achieve improvement related to reducing musculoskeletal disorders among
healthcare workers involved in direct patient care, difficult and demanding
jobs must be redesigned applying the principles and concepts of ergonomics.
High-risk jobs must be changed and modified and a strategy for redesigning
jobs as follows is suggested:
- Can the need to do the high-risk activity be eliminated, such as
by eliminating a bed to chair transfer using a bed which converts into
a chair configuration?
- Can the high-risk activity be redesigned using devices such as mechanical
- Can the high-risk activity be improved through risk reduction using
some type of lifting aid device, such as a gait belt with handles or
friction reducing sheet?
In order to effectively integrate new and improved job design into the
process of delivering care within healthcare facilities, a basic structure
or process can contribute to the level of improvement achieved. A simple
structure for the ergonomic management process is as follows:
- Identify jobs and job tasks which stress body parts beyond limits.
- Identify and develop solutions to change these task demands.
- Use a well thought out process to implement these changes into the
- In addition to reviewing job design, also review the design of the
physical work environment to remove barriers, minimize travel and consider
Below is a collection of success stories highlighting the process implemented,
key ingredients, and what results were achieved. The presentation format
for each success story is not exactly the same since approaches to the
process may have not been implemented with the same structure. A program
summary for each success story is offered along with improvements achieved.
STORY # 1
||Veterans' Health Administration (VHA) VISN8
||Nursing and Personal Care Facilities – SIC code 805
||Total 15,000, staff in 23 high risk units 800
Through the identification of patient care units presenting a high level
of occupational risk to workers, a targeted back injury prevention program
was developed and implemented. The program integrated the concept of ergonomics
into a program to redesign high risk activities.
Workers involved in providing patient care in high risk units were suffering
over 85% of reported injuries. This resulted in disability to workers
and high workers' compensation costs
An Ergonomic Management Program was implemented in six (6) Veterans'
Administration Medical Centers within VISN8. Program development was started
in January 2001 and the study data collection ran from January 2002 until
December 2002. Program design included implementation of a nine (9) step
process as follows:
- Step 1 Collect Baseline Injury Data
Injury data should focus on injuries related to patient handling and
movement. Each clinical unit should gather and record their individual
information. Data should minimally capture a description of the incident
including; the patient care activity performed at the time of the injury,
time of the incident, unit/location where incident occurred, body parts
effected, days of work lost and modified duty days.
- Step 2 – Identify High Risk Units
Using baseline data on the incidence and severity of injuries identify
the high risk units at the facility. Eventually, every unit may be included
in the ergonomic management program, but prioritization is important
to effectively allocate available resources. High risk units will normally
have the highest incidence of patient handling injuries, the most work
days lost, and the highest concentration of staff on modified duty.
- Step 3 – Obtain Pre-Site Visit Data on High Risk Units
Normally some type of multidisciplinary team will be involved in program
implementation. Prior to visits at the unit, unit specific information
can be collected by staff and submitted to the site visit team prior
to their visit. Generally the site visit team will evaluate injury data,
equipment issues, space issues, storage availability, and maintenance
and repair issues. Other factors such as patient population and staffing
information are needed to determine unit characteristics that will influence
- Step 4 – Identify High Risk Tasks
It is important to identify and assess staff perceptions of high risk
tasks. The highest risk tasks are likely to vary between patient care
units depending on patient characteristics, availability of equipment,
physical layout and work organization.
- Step 5 – Conduct Team Site Visit for Ergonomic Assessment
Following identification of high risk units from historical data, the
Ergonomics Assessment Team conducts an onsite evaluation. This site
evaluation serves to recognize the many direct and indirect factors
that may contribute to risk potential and with staff input, to identify
potential solutions that will serve to minimize risk of injury to the
caregivers and patients.
- Step 6 – Risk Analysis
Risk Analysis involves careful review of the base line injury data,
pre-site visit data, identification of high risk tasks, and observational
data from the site visit. Through Risk Analysis high risk situations
or job tasks are identified. In this step a determination is made as
to what changes are required for improvement.
- Step 7 – Formulate Recommendations
Recommendations should be achievable and simple. When developing recommendations
it is necessary to factor in constraints such as fiscal resources, administrative
support, and environment. Generally solutions fall into two categories,
engineering controls and administrative controls.
- Step 8 – Implementation of Recommendations
Implementation of Recommendations will involve changes to the workplace.
To enhance chances for success, a well thought out process needs to
be developed. If engineering solutions such as new furnishings and patient
lifting aid equipment are to be introduced, programs for educational
awareness and detailed training are necessary. An implementation team
must be recruited and this team will formulate a plan where each member
of the team understands their role in the plan. The implementation team
will be the group responsible to integrate recommendations formulated
into the operational activities at the facility. Included in the implementation
team are peer leaders who are directly involved in patient care. In
this case, they were called Back Injury Resource Nurses or BIRN
nurses. They were responsible to provide ongoing support to the program
- Step 9 – Monitor Results and Continuously Improve Safety
on the Unit
A system for monitoring and evaluation should be developed to determine
what successes and failures have occurred so appropriate adjustments
can be considered as necessary. The monitoring and evaluation system
is also critical to maintaining an adequate level of interest and attention
for the program. The monitoring function also requires a system for
data collection similar to risk assessment. It must be determined what
information will be useful in the evaluation process.
|Injury Incidence Rate
|Modified Duty Days
|Lost Work Days
Results from VISN-Wide Deployment of a Back Injury Prevention
Program for Nurses, conducted by Patient Safety Center, Tampa, Florida.
(Nelson, Fragala, Matz, 2003).
|Missouri and Illinois
||BJC Health System
St. Louis, Missouri
||Nursing and personal care facilities – SIC code 805
||460 direct patient care staff at 6 sites
The program was implemented in six nursing homes and is based on three
- A zero-lift policy that uses state-of-the-art equipment to assist
with patient transfers,
- Training in the use of patient transferring equipment
- A medical management program.
Direct patient care staff responsible for assisting dependent residents
were at a high risk for occupational injuries. Identified high risk activities
included: transfers in and out of bed; in and out of bath tubs, showers
and whirlpools; on and off toilets; repositioning in bed; and lifting
a resident who has collapsed from the floor.
This study examined the effectiveness of the ergonomic management injury
prevention program by contrasting the injury, disability, and injury related
cost experience of a cohort of nursing aides, orderlies, and assistants
for a thirty-six month pre-intervention (1995-1997) and a thirty-six month
post-intervention (1998-2000) intervention period in six nursing homes.
The intervention program implemented was a best practices injury prevention
program which included state of the art lifting equipment to assist nursing
staff with resident transfers, a training program for nursing staff on
how to use the lifting equipment, and a medical management program. The
prevention program contained primary and tertiary prevention elements.
The primary prevention was based on the use of modern resident lifting
equipment and manual lifting methods, employing lifting aid devices, that
have been shown in laboratory studies to reduce the physical stresses
exerted by CNA's when transferring residents. The tertiary prevention
was a medical management program that insured that quality healthcare
was provided to injured workers and also allowed for light or restricted
duty for workers being rehabilitated. This allowed injured workers to
return to work in a prompt and safe manner.
Training was an important part of this program. It was delivered to all
nursing, maintenance, and physical therapy department personnel. Training
was delivered upon initial department orientation, whenever there was
a change in job assignment, equipment or process, or if there was a change
in procedure. Training was refreshed during annual safety training orientation.
Nursing personnel were trained on the recognition of type of transfer
required for each resident, the purpose of the safe-lifting procedure
and the correct use of each type of lifting equipment. Maintenance personnel
were trained how to inspect lifting equipment, what to inspect on each
piece of equipment, the frequency of inspection and tag out procedures
for damaged equipment. Physical Therapy personnel were trained on the
capabilities and limits of lifting equipment; the correct use and purpose
of each type of lifting equipment, the purpose and policies of these zero-lift
policies, and suggested classification of residents. A zero-lift policy
implemented, attempted to eliminate all manual lifting where possible.
All charge nurses on each shift were trained on all aspects of the zero-lift
policy. The resident transferring program targeted the most back stressing
resident handling tasks performed by CNA's. These included; resident transfers
for toileting, bed to chair transfers, transfers to showers, bathtubs,
whirlpools, and for weighing residents.
Depending on the level of assistance required by the resident, there
were two types of mechanical lifts and several devices such as walking
belts and gait belts used to assist with manual transfers. The zero-lift
policy established requirements for the methods of transferring residents
and was used to insure that all residents had been evaluated for transfer
needs and that medical personnel responsible for performing resident transfers
were trained on the correct procedure to transfer each resident. The complimentary
element of the prevention program was the medical management program aimed
at minimizing the cost and impact of worker disability. The objective
of the program was to provide quality medical care to injured workers
and provide modified duty programs that allowed workers to return to work
as quickly and safely as possible.
(Lifting related injuries are three year totals. Injury rates and costs
are an annual average)
|Lifting Related Injuries
| Injury Incidence Rate
| Injury Costs
Intervention Program for Transferring Residents in Nursing
Homes, (Collins, Wolf, Hsiao, 2002).
STORY # 3
|Seven nursing homes located in four (4) different states,
hospital in Canada
||Study conducted by National Institute for Occupational Safety and
||Nursing and personal care facilities – SIC code 805
Hospitals – SIC code 806
Zero-lift programs were implemented by replacing manual lifting and transferring
of patients with modern, battery operated portable lifts and other patient
transfer assist devices. The program reduced injury rates significantly
and produced many intangible benefits including improvements in patients
comfort and safety during transfers and patient care.
Both management and the employees believed that manual lifting and transferring
of patients were the most hazardous tasks in their facilities. This belief
was confirmed by injury statistics including number of injuries, lost
work days and workers' compensation cost. The targeted tasks included
lifting and transferring patients from bed to wheelchair, wheelchair to
bed, bed or wheelchair to toilet, toilet to bed for wheelchair, lifting
patients off the floor, bed or wheelchair to bathtub, shower chair or
gurney and back, weighing patients, and bathing. In addition, some nursing
homes also targeted repositioning in bed and wheelchair.
The primary objective of this study was to reduce injuries to healthcare
workers resulting from manual lifting and transferring patients. Zero-lift
programs using employee management advisory teams termed as a participatory
approach were implemented in seven (7) nursing homes and one (1) hospital.
A zero-lift program was implemented by replacing manual lifting and transferring
of patients with modern battery operated portable lifts and other patient
transfer assisting devices. Ergonomics committees with nearly equal representation
from management and employees selected the equipment and implemented the
zero-lift programs. Injury statistics were collected during post-intervention
for 51 months and were compared with pre intervention data for 37 months.
Two key elements for a successful ergonomics program were identified as
management commitment and worker participation.
Management Commitment Includes Providing Financial and Organizational
Financial Resources Include:
- Providing a safe workplace
- Appropriate patient transfer devices and other equipment
- Adequate staffing to manage the ergonomics program
Organizational Resources Include:
- Providing an ergonomics coordinator
- Adequate staff
- Assigning responsibilities
- Training, monitoring, feedback to employees
- Injury investigation and medical management
Key Elements of Worker Participation Include:
- Identifying the most stressful job tasks
- Evaluation of suggested solutions to problems including patient transferring
procedures and devices
- Selecting the most effective procedures and devices, participation
in implementation of the program
- Input on injury investigation making employees equal partners where
they will take ownership of the program as much as possible
Management's Role in Worker Participation Includes:
- Encourage worker participation so that they will feel confident and
- Emphasize positive reinforcement
- Appreciate and respect employees for achieving small goals
- Seek workers input prior to any decision making
- Good communication where information and feedback are provided in
a timely manner
- Address workers' problems and concerns
Engineering Controls Implemented
The primary patient transferring devices used in the eight (8) healthcare
facilities were different types of battery operated portable lifts, both
full-sling lifts and stand-assist lifts were used. In addition, the hospital
and four (4) of the nursing homes used walking belts with handles, shower
chairs, shower gurneys, ramp type weighing scales, and devices to reposition
patients in bed. The hospital also installed a few ceiling mounted hoists.
All nursing homes except one had modern bathing facilities. The equipment
supplied to the eight (8) healthcare facilities came from different manufacturers.
As a result of implementation of this program the following results
||SUMMARY OF PERCENT DECREASES IN
NUMBER OF INJURIES PER YEAR
|B & C
||SUMMARY OF PERCENT DECREASES IN
LOST WORKDAYS PER YEAR
|B & C
||SUMMARY OF PERCENT DECREASES IN
RESTRICTED WORKDAYS PER YEAR
|B & C
* denotes increase
||SUMMARY OF PERCENT DECREASES IN
WORKERS' COMPENSATION COSTS PER YEAR
|B & C
Long Term Effectiveness of Zero-Lift Programs in Seven
(7) Nursing Homes and One (1) Hospital, (Garg, 1999).
STORY # 4
||Masonic Home and Hospital
||Nursing and personal care facility – SIC code 805
Facility identified high risk units, purchased lifting aid devices and
introduced an ergonomic management program. This resulted in reduced injury
claims and cost and also generated a financial credit for their next workers'
Insurance records indicated that in 1992 there were 1,025 workdays lost
as a result of occupational injuries involving patient handling tasks.
This was a major contributor to the $628,511 incurred workers' compensation
Risk Identification and Assessment
The effort at Masonic Home was championed by the Assistant Director of
Human Resources who realized the magnitude of the back injury problem
at the institution. In order to develop necessary awareness with administration,
risk management staff from the Workers' Compensation Trust provided strong
support with data collection and highlighted opportunities for financial
savings if improvements could be made. Insurance records indicated that
in 1992 there were 1,025 workdays lost as a result of occupational injuries
involving patient handling tasks. This was the major contributor to $628,511.
incurred Workers' Compensation cost. To begin the process for improvement,
an initiation team was formed. The team included three certified nursing
aids, one from each shift, three licensed nurses, one from each shift,
a representative from Rehabilitation Services, representation from Quality
Assurance and Risk Management, the Safety Officer, the head of Education
and In-Service Training, and the team leader was the Assistant Director
of Human Resources. An ergonomics expert and a loss prevention representative
from the Connecticut Hospital Association Workers' compensation Trust
served as ad-hoc members of the initiation team. As the team investigated
the occupational injury problem, they realized that the educational programs
they have been using to train personnel in lifting techniques were ineffective
in improving their experience, particularly among nursing aids and there
back injury problems were growing worse. A number of brainstorming sessions were held with staff members
to determine what was considered to be the high risk jobs. In the data
collection process, the focus was to determine by area where patient care
staff were at the highest risk for occupational injuries. From information
learned in the pilot study done at another location, many felt that resident
handling tasks would be identified as high risk occupational activities.
The Workers' Compensation Trust provided a basis to enlist better administrative
support by which engineering improvements such as state of the art lifting
equipment could be provided to the facility at a reduced cost if it were
determined appropriate in the formulation of recommendation. In addition,
a financial incentive beyond reduction in Workers' Compensation experience
was offered to the facility. If performance could improve over a six month
period there would be a financial reward. A system was set up where by
if staff back injuries related to resident handling tasks could be reduced
by at least 30% over a six month period, once the selected ergonomics
management program had been implemented, a five percent credit would be
granted on Masonic Homes' annual Workers' Compensation premium paid. For
Masonic Homes and Hospital this would be a significant amount. Their annual
insurance premium was approximately $660,000 and the resulting refund
would be $33,000. This provided further incentives among administration
to back the program. Through facility tours and brainstorming sessions
high risk areas were identified. These activities did achieve necessary
by –in from administration and other important staff plus the team
moved on in their process.
At this point, the Director of Quality Management became involved in
the process as data was analyzed. The team found no correlation between
things like staffing patterns or long shifts to the rate of injuries.
The team also realized that although new aides were correctly trained
in lifting techniques, when they got out on the floors and worked with
experienced aides new lifting techniques were introduced that may not
have been the best. It was found that the new recently trained aides were
not using techniques as taught in the classroom training programs. Because
many of the team members were front line workers, not supervisors, they
were better able to identify what exactly was causing back injuries in
the risk analysis process. One floor on the skilled nursing unit was identified
as having higher than normal injury rates for the facility. This high
risk unit was referred to as the SNF floor and identified as a top priority
for the improvements to be determined.
Formulation of Recommendations
The team working with nurse managers and patient care staff consulted
further with their insurance carrier. At this time the Workers' Compensation
Trust had further developed their pilot ergonomics management program
by which they would contribute to the purchase of engineering controls
of lifting aid equipment, Masonic Homes took advantage of this program
and obtained new mechanical lifts. In addition, gait belts which are a
fabric belt which staff place around the patient's waist to help them
walk were also issued. The use of the belts would essentially put handles
on residents. These belts had occasionally been used in the past on people
by physical therapist, but had not been used by staff nurses and certified
nursing aides. Recommendations were formulated; now the task remained
as to how to effectively implement the program.
Lifting aids had been suggested within the facility in the past; however,
there were problems with getting people to use the equipment. The Initiation
Team now became an Implementation Team or a Continuous Quality Improvement
Team and they appointed contact people on each unit who were responsible
for making sure staff felt comfortable using the new equipment. Continuous
Quality Improvement Team members also toured the facility and spoke at
staff meetings, particularly those team members who were Certified Nursing
Assistants themselves. They urged their fellow workers to use this new
equipment. The equipment was accepted and monitoring of the program was
Measuring and Assessing
One of the key monitors selected for measuring effectiveness of the
program was Workers' Compensation assessments for back injuries. Prior
to initiation of the program, an assessment for a representative four
month period was $174.412. After the program had been initiated, the assessment
for a similar period was down to $4,500 as a result of a dramatic decrease
in back injuries associated with patient handling tasks. Since the program
was initiated there was only one patient handling related back injury
reported among the entire 876 person workforce. This was a CNA who didn't
use a proper lift device on a designated patient. Lost days associated
with patient handling injuries were reduced from the 1992 figure of 1,025
to 81 in 1993. Overall incurred Workers' Compensation costs for 1993 were
reduced to $142,995 down from the $628,511 in 1992.
Masonic Home decided to further mechanize their operation through the
purchase of additional lifting aid equipment. Lifting aid equipment has
now become an integral part of the process for care and Masonic Home is
experiencing significant financial rewards for the improvements they have
made. Masonic Home did qualify for the credit on their Workers' Compensation
Premium and the amount was $33,000 toward their 1994 cost.
|Annual Lost Work Days
|Injury Assessments Four Month Period
|Incurred Annual Workers' Compensation Costs
An Ergonomic Back Injury Prevention Program at Masonic
Home and Hospital, (Fragala, 1995)
STORY # 5
||Lawrence and Memorial Hospital
New London, Connecticut
||Hospital – SIC code 806
To protect its employees from the risk of occupational back injuries,
Lawrence and Memorial Hospital eliminated high risk manual patient transfers
by purchasing lifting aid equipment. This equipment was integrated into
patient care through an effective ergonomics implementation plan.
An analysis conducted by in-house staff determined that traditionally
the main approach to controlling back injuries from patient lifting was
trying to teach nurses how to apply body mechanics. It was determined
that training alone had been ineffective in reducing back injuries at
Lawrence and Memorial Hospital. Patient handling tasks were determined
to be a problem because of the requirements of these tasks. These tasks
were determined to be beyond what is considered a reasonably acceptable
risk. Handling patients was recognized as much more difficult and unpredictable
than handling and lifting a compact box or container.
Step 1 – Risk Identification and Assessment
In this first step the objective is to identify what is perceived to
be the high risk areas or activities within the facility. Also, this
initial activity begins to bring awareness to the problem and starts
preliminary thinking for directions to be taken for solutions. A high
level of involvement created throughout the organization can help establish
buy-in for the program and makes everyone feel as though they have had
a part in the program development. A three month data collection period
was established from September 1992 through December 1992. The objective
was to collect data from nurses who actually perform the task to be
evaluated and thus allow nurses to feel that they had an early opportunity
to have input in the program development. Prior to the data collection
activity, a meeting was held with Nurse Managers to enlist their support
in gathering information from their staff. Nurse Managers were asked
to hold brainstorming sessions with staff members to gather information
and a back injury questionnaire was sent out to all nursing staff. From
the data gathered, four main reasons were identified as perceived to
be important when considering causes which contribute to back injuries
due to lifting patients. They were:
- Low staffing levels
- No time to wait for help, that is, rushing to the next patient,
late lunch, or getting near the end of a work shift.
- Current lifting aid equipment available to assist in patient lifts
is difficult to use and not readily available when needed.
- The nature of the work itself is difficult even when adequate staff
are available such as three or four nurses to assist in a lifting
task; someone is still at risk for injury.
It was recognized that the hospital had begun redesigning
some tasks such as using stretchers with adjustable height, sliding
boards for lateral transfers, and employing gait belts when transferring
a patient. However, opportunities for greater improvement were identified
related to patient handling tasks where the objective would be to eliminate
the lift where possible using effective engineering controls.
- Step 2 - Risk Analysis
Through risk analysis actual loss data and injury experience records
are analyzed to determine specific actual high risk areas for comparison
with what was determined to be perceived high risk. In this process
an analysis was done on back injuries due to patient lifting for the
nursing department for the calendar year 1992. Results of the analysis
identified four floors to have the highest injury occurrence rates.
The Orthopedic Unit was found to have the highest number of lost work
days and restricted workdays and Medical Surgical was found to have
the highest number of back injuries due to patient lifting. On the Orthopedic
Unit fifty percent of the back injuries were due to boosting patients
ups in bed and fifty percent due to chair to bed transfers. On the Medical
Surgical Unit chair to bed transfers were again identified as a high
risk activity with fifty percent of injuries attributable to this activity.
The cost of an individual back injury was analyzed and it was determined
that a common back injury usually resulted in three weeks of missed
work. A point was raised that this single estimate is conservative and
it is possible for a single back injury case to cost the hospital anywhere
from $50000 to $100,000, possibly even more. In this step, it was recognized
that case management had been effective in decreasing the number of
lost workdays in the past. However, there was much opportunity to focus
improvement activities on prevention efforts, the goal to prevent injuries
from happening in the first place.
- Step 3 – Formulation of Recommendations
Once problems were identified and priorities set as to which units or
floors needed attention, work began on redesigning high risk activities.
Through a categorization of the patient population on the Orthopedic
Unit and the Medical Surgical Unit it was determined that if two types
of patient lifting aid devices were obtained, many of the unacceptable
job tasks could be changed. The devices identified were a standing and
repositioning lifting aid with a commode attachment and a full body
sling lift with a bed scale attachment. Although funds had not been
budgeted for expenditures such as patient lifting aid equipment, support
from senior management had been established and when the request for
funds to purchase these engineering controls was made, the request was
approved and funds were provided through a contingency fund to purchase
needed patient lifting aid devices.
- Step 4 – Implementation
The best ideas in the world can fail if they are not accompanied by
a good implementation plan. Once recommendations have been formulated
and it has been determined what to do, the process by which changes
are made and the new ways of doing things implemented are keys to overall
success. At Lawrence and Memorial Hospital a well thought-out implementation
plan was a prime contributor to the overall success of this program.
Education and training are critical parts of any implementation plan.
Two sets of educational awareness programs were developed. The first,
for management staff of direct patient care workers. Management needed
to be convinced of the requirement for equipment and understand what
an important role mechanical lifting aid equipment plays in the overall
back injury prevention program for the hospital. The second set of educational
awareness sessions was given to direct patient care staff. Nurses needed
to be in-serviced in the philosophies of an ergonomic program and why
the mechanical lifting aid equipment was being introduced into their
worksites. Beyond the educational awareness sessions, training programs
were done utilizing a train-the-trainer approach. Key operators were
identified as those who would be trained to instruct other direct patient
care staff in the use of patient lifting aid equipment. These people
were identified through buttons so that nursing staff knew who the key
operators were in case there were questions. Key operators were extensively
trained and they were sent to nursing floors to train staff. All staff
who were trained signed an acknowledgement form, to add an element of
accountability regarding learning the skills to operate the new equipment.
Other issues important in implementation were covered in an implementation
plan for the facility. This written implementation plan provides an
example for other facilities and is presented below.
- Step 5 – Measure and Assess
An important part of any undertaking is to satisfy the customers. In
this case, one of the customer groups would be staff who uses the new
patient transfer equipment. A satisfaction survey was distributed to
staff and overall, staff were very pleased with performance of the new
equipment. To further establish buy-in, part of the survey requested
their input on recommendations to improve the lifting aid equipment,
and staff were very enthusiastic about offering ideas. From the perspective
of an administrator, satisfied staff is important. In addition, how
has injury experience changed as a result of the new program? After
a six-month period data was gathered to present to senior management.
The monitoring system put in place to measure the impact of the back
injury prevention program included data on injury experience, days lost
resulting form occupational injuries, restricted days resulting from
occupational injuries, costs associated with occupational injuries,
in addition to the satisfaction data.
TABLE 1 UNIT
1/1/92 – 12/31/92
1/1/93 – 9/30/93
|# lost work days
| # restricted days
| Replacement costs
TABLE 2 UNIT
1/1/92 – 12/31/92
1/1/93 – 9/30/93
|# lost work days
|# restricted days
TABLE 3 WORKERS'
INTERVENTION Year 2
TABLE 4 ALL
PATIENT CARE AREAS
|Patient Transfer Incidents
|Lost Time Claims
Successfully Reducing Back Injuries and Workers' Compensation
Costs at Lawrence and Memorial Hospital, (Fragala, Santamaria, 1997).
STORY # 6
||Hospital – SIC code 806
Through integration of an effective ergonomic management program into
a facility-wide quality improvement activity, occupational injury experience
was improved. This resulted in a significant cost savings for the organization.
A review of occupational injury data demonstrated that back injuries attributable
to patient lifting tasks were a significant contributor to total injury
experience. This was resulting in significant increases to workers' compensation
premiums for the organization.
Edinburg Hospital in Edinburg aggressively pursued the development and
implementation of an ergonomic-based back injury prevention program. The
director of quality improvement and the director of physical therapy coordinated
their efforts and enlisted other appropriate personnel in the institution
to attack this problem. Consistent with techniques of problem solving
being used in many healthcare organizations, a quality improvement process
was used to address the issue of occupational back injuries. The directors
of physical therapy acted as a team leader and the director of quality
improvement as a team facilitator and have launched the beginnings of
what is expected to be a successful ergonomic-based injury prevention
program. With the team leader and the team facilitator in place, additional
team members were added to include representation from administration,
nursing, infection control, radiology, the rehabilitation unit and a physician
Opportunity for Improvement
With the quality improvement team in place, the initial task was to define
an opportunity for improvement. As a result of work in their initial meetings,
the team developed a statement for opportunity for improvement as follows:
"To decrease risk of patient and staff injury during patient transfers
by providing a more efficient, ergonomically effective and safe patient
With the opportunity for improvement defined, the team began to assess
their current situation through initial data analysis. A review of the
data for calendar year 1993 revealed that there were 13 back injuries
attributable to patient lifting tasks. These resulted in a direct cost
of $61,090.31. Cost implications were identified as a critical measure
in the improvement process. Other costs related to this issue were Workers'
Compensation premiums. It was found that because of past experience for
calendar year 1994 Workers' Compensation premiums had increased by $118,206.
This resulted in a total premium for 1994 or $740,756, a significant expenditure
for this institution. These Workers' Compensation premiums and the direct
costs associated with occupational back injuries related to patient handling
tasks presented an opportunity for significant cost savings.
Analysis of Causes
In order to attempt to improve the situation, causation related to patient
care handling injuries was studied. Figure 1 represents the cause and
effect diagram resulting from the team's effort. From the cause and effect
diagram, root causes were determined to be:
- Lack of transfer equipment
- Staff fatigue combined with poor technique
- Patient medical status and lack or cooperation with transfer
- Poor assessment process for present assistance needed by patient
After a study of root causes, the team was lead to solutions which involved
redesign of high risk patient transfers. In order to accomplish this,
the team realized that effective patient handling devices must be obtained.
An action plan was determined as follows:
- January, 1993 – Review the literature on equipment available
- July, 1993 – In-service the safety committee and administration
once a vendor of choice was selected on chosen equipment.
- January, 1994 – Purchase equipment and develop an orientation
throughout the facility on lifting aid devices.
Lifting aid equipment was purchased and the program
implemented in February 1994. The team determined that in addition to
programs for senior administration, educational awareness was required
throughout the facility. It was also identified that there was a need
for training key operators who would participate in the changes of methods
in handling and transferring patients. Measurement began immediately.
One injury did occur in the third month, April, when an operator conducted
a patient transfer not using the lifting equipment provided. After the
injury to a key operator, the team realized that additional ground work
would be required to better implement Step 3 in the action plan. There
was a need to redefine the responsibility for key operators within the
facility. In order to maintain interest and enthusiasm for the program,
two additional training sessions were held for key operators. This was
done in June, the fifth month of the program. In redefining the responsibility
of key operators, the team developed a mission statement. The mission
statement was developed for those who would be affected most directly
by the changes to take place as a result of the solutions to be implemented.
That is, for personnel directly involved in patient handling tasks. The
mission statement developed was as follows:
"Our mission as key operators is to reduce risk
of patient and staff injury during patient handling tasks by providing
a more efficient and ergonomically effective and safe mechanism through
education, encouragement and recognition/rewards program."
At the same time in June, a modification was made to the overall system
to better identify patients who require lifting aid devices. After this
five-month period, the team established redefined goals as follows:
- To review and modify the role of key operators within 30 days.
- To re-establish needs to appropriately measure trends and evaluate
outcomes of changes in patient handling to the overall safety program.
- To design four major processes that would be applicable to all departments
hospital-wide with regard to patient handling techniques.
- A long-term performance goal to reduce injury to staff by at least
50% in the next six-month period and to reduce the occurrence of injuries
related to patient handling and transfers by in excess of 90% in the
same six-month period.
In order to better train staff in new patient handling techniques, train-the-trainer
sessions were done. Following these sessions, training was given to staff
Results as of October 1994 are displayed in Table 1. There has been a
significant savings in the direct costs associated with occupational injuries.
The facility has also considered the impact of indirect costs which include
sick, time, orientation and training to replace injured employees, overtime
for staff and other activities which effect operational revenues. Safety
professionals have estimated that these indirect costs may be from four
to ten times in excess of direct costs.
|| COST OF BACK INJURIES DUE TO
| # of
| Indirect Cost (X4)
|| Total Cost
|# of Case Still Open and Receiving Workers'
SUMMARY OF IMPROVEMENTS FROM ERGONOMIC MANAGEMENT
|Direct cost of back injuries due to patient handling
Figured on annual basis
Addressing the Workers' Compensation Crisis at Edinburg
Hospital. (Fragala, Read, Kelley, 1995).
STORY # 7
||Diamond Insurance Group, insuring three (3) skilled nursing facility
chains which were Heritage Enterprises, Dynamic Healthcare, and Christian
||Nursing and personal care facilities – SIC code 805
||Multiple locations 1,000 plus
Through the implementation of a limited lift policy, OSHA recordable
injuries, lost work days, and total workers' compensation claims and costs
were reduced for a number of long term care facilities.
It was recognized that lost work days due to injury and illness for skilled
nursing facilities were 2.5 times the average for all private industry
in the United States. The high rate of these on-the-job injuries was traced
to largely three (3) basic tasks: Manual lifting, transferring and repositioning
A typical limited lift policy (LLP) implementation consists of four distinct
- Evaluation and Introduction (Phase 1)
During this first phase, the facility's current mechanical
lifting equipment and patient acuity are evaluated; nursing staff get
to examine various brands of equipment available on the market; and
lifting equipment is then ordered based on acuity, facility layout,
and staff input. This is also the phase in which questions and concerns
are addressed via programs and equipment introductions aimed at staff
members, individual patients, patients' council, admissions coordinators,
patients' families, and physicians.
- Education and Assessment (Phase 2)
At this point, care giving staff are educated on the policy
directives and safe use of the lifting equipment. Qualified personnel
assess each patient for the safest method of transfer, and this is posted
via a coding system (to maintain patient privacy) in the patient's room.
As appropriate, caregivers should communicate perceived changes in a
patient's condition to the charge nurse for possible transfer-status change. Equipment checklists are implemented into the
maintenance department with vendor contact information to ensure the
lifts are operational and safe for use at all times. Sling-laundering
instructions and checklists are given to the laundry department to ensure
slings are in safe condition after every laundering.
- Front-line Employee Involvement (Phase III)
Specific front-line nursing staff are selected by the
director of nursing to serve as the "product champions." These individuals
are schooled to assist with training of new employees and to provide
feedback on the equipment itself. They also handle all staff and patient
issues related to the equipment. The product champions are perhaps the
most integral part of the policy besides the equipment itself with regard
to employee "buy-in" and compliance.
- Program Evaluation and Appreciation (Phase IV)
In this final phase, the administrator, director of nursing,
and product champions complete audits of the equipment, patient acuity
and concerns, and staff issues. Once recommendations based on the audits
are implemented, staff are treated to a thank-you party for their assistance
in implementing the LLP. Providers should continue the audits on a quarterly
basis to ensure ongoing success.
COMPARATIVE RETURNS ON INVESTMENT OF LIFTS FOR
THREE SNF CHAINS
2001 – 2002
||Percent decrease in OSHA
recordable resident handling
|Percent decrease in lost workday
injuries related to
|Percent decrease in total
Workers' Compensation claims
|Percent decrease in total
Workers' Compensation claims
| Dynamic Health Care
| Christian Homes
Source: Diamond Insurance Group
Pre and post-policy year comparison information from limited lift audits
Limit Liability with Lift Programs (Moreno, 2003)
STORY # 8
|Outside the United States, England
||Wigan and Leigh NHS Trust
||Nursing and personal care facilities – SIC code 805
Hospitals – SIC code 806
||10,000 plus – involves workers from 30 trusts throughout the
Through the introduction of an ergonomic approach aimed at improving
all aspects of work systems including the implementation of a policy with
appropriate management support, equipment and training, and sustaining
intervention over a long period of time, lost time from occupational injuries
was significantly reduced.
A study conducted by the National Audit Office concluded that there might
be an excess of one million reported occupational accidents in the national
health system each year contributing to a high level of worker disability
and placing a serious financial burden on the healthcare system.
In January of 1993, England introduced the EC Legislation on Lifting
and Manual Handling which stated all hazardous manual handling tasks are
to be avoided wherever possible. If hazardous manual handling tasks are
unavoidable, they must be assessed in advance. Once they are assessed,
action should be taken to remove or reduce the risk of injury. A safe
manual handling policy, incorporating training and assessment, must take
place. Dangers and hazards must be identified and equipment provided for
safer working practice for staff and caregivers. Before any moving and
handling procedure can be performed, the nurse should undertake a full
risk assessment, completing the appropriate documentation. As a result
of these regulations, facilities in England have experienced a reduction
in injuries among caregivers.
To measure the impact of the EC Legislation, a study was conducted by
the National Audit Office where 30 acute trusts, a grouping of healthcare
facilities, were surveyed. It was found that with the implementation of
an ergonomic program in 1994 through 1995, lost work hours from patient
moving and handling injuries dropped by 84%. Pre-intervention more than
11,635 hours of work were lost at the Wigan and Leigh NHS Trust in 1993-1994
because of occupational injuries. Over 6,720 of these hours were due to
injuries caused by moving and handling of patients. Under the direction
of the health and safety advisor at the Trust, the group took advantage of
a free equipment assessment offered by a lift manufacturer. A moving and
handling coordinator was appointed to undertake a detailed audit of manual
handling activity and related issues. An action plan was developed and
equipment purchased. The results were dramatic yielding the 84% decrease
in lost work hours, thus saving 5,638 hours or work. Once the program
was implemented, good injury experience was maintained and the yearly
costs in absenteeism resulting from lifting and handling injuries have
been reduced by a factor of 97.5%. The moving and handling coordinator
appointed was a nurse with over thirty years experience who played a key
role in persuading staff to change their practice and use new equipment.
Initially, there was a common misconception among staff that using equipment
to move patients took longer. Staff soon began to realize that once they
were skilled and confident with using equipment, it actually was a lot
quicker. The ergonomic approach meant that hospitals had to improve all
aspects of their work systems. This involved trusts implementing a policy
with appropriate management support, equipment and training, and sustaining
intervention over a long period of time.
TABLE 1 SUMMARY OF INJURY EXPERIENCE IMPROVEMENT RELATED TO HANDLING
|Work Hours Lost
| Cost of Absenteeism
Implementation of the EC Legislation on Lifting and Manual Handling in
England (Logan, 1996), (Waters, 1997), (Gaze, 1997)
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