Objectives

1. Objectives • Describe how to apply the nursing home guidelines to develop a process to protect workers. • Discuss the benefits of implementing an ergonomics process. • Identify and analyze problem jobs in nursing homes. • Recognize practical solutions to address problem jobs.

2. Nursing Home Guidelines • The nursing home industry is the first industry that OSHA selected for ergonomics guidelines.

3. Problem Defined • MSDs accounted for 33% of all cases • Of the six occupations representing 26% of the cases two were healthcare workers (this group includes laborers, janitors and truck drivers) • Nurses aids, orderlies, and attendants had one of the highest incidence of injuries resulting in lost time (overexertion 56% STF 20%)

4. Loss Source • Health Care Associates are sustaining strains and sprains to their back from overexertion due to resident handling.

5. Health Outcomes from Exposure to Risk Factors Excessive exposure to risk factors result in musculoskeletal disorders which include: Low back pain Sciatica Rotator cuff injuries Epicondylitis

6. NIOSH Injury Prevention Research • 1728 nurses over 6 year period • Impact of Intervention involving Best Practices: mechanical lifting devises and training

7. NIOSH Injury Prevention Research • Results • More than 60% Reduction in WC injuries • Initial cost of intervention Program $159K • $55K Annual Savings • Cost recovered in less than 3 years

8. OSHA Perspective OSHA will use the OSH Act’s General Duty Clause to address ergonomic hazards in nursing homes. The General Duty Clause describes the employer's obligation to "furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees."

9. Nursing Homes Guidelines Recommendations • Manual lifting of residents be minimized, and eliminated when feasible • Employers develop a process for systematically addressing ergonomics issues

10. Ergonomics Process • Provide management support • Involve employees • Identify problems • Implement solutions • Address reports of injuries • Provide training • Evaluate ergonomic efforts

11. Management Support

12. Employee Involvement • Submitting suggestions or concerns • Discussing workplace and work methods • Participating in design of work, equipment, procedures, and training • Evaluating equipment

13. Identify Problems

14. Implement Solutions • Effective solutions involve: • Workplace modifications that • Eliminate hazard and • Improve work environment

15. Addressing Reports of Injuries • Limit severity of injuries • Improve treatment of injuries • Minimize disability or permanent damage • Reduce claims and costs

16. Training

17. Risk Factors in Nursing Homes Guidelines • Force • Repetition • Awkward postures

18. Transferring resident from bathtub to chair Transferring resident from chair to bed Making bed with resident in it Transferring resident from chair to bed Transferring resident from chair to toilet Undressing resident Repositioning resident in chair Lifting resident up in bed Feeding bed-ridden resident Examples of Resident Handling Jobs

19. Force • Examples of excessive force include: • lifting or transferring heavy residents • unexpected or abrupt forceful motions • stopping resident falls or lifting them off the floor after a fall

20. Repetition • Examples of repetitive activities include: • repeated repositioning in bed • numerous transfers to and from beds, chairs or commodes without rest breaks

21. Awkward Postures • Examples of awkward posture are: • Dressing or undressing residents • providing in-bed medical care • repositioning or turning residents in beds

22. Other Areas Where Injuries May Occur • Housekeeping • Kitchen • Laundry

23. Identifying Problem Jobs • To obtain information, analyze and review • Injury and illness logs • Workers’ compensation reports • Accident and near-miss reports • Insurance company reports • Employee interviews • Workplace observations

24. Identifying Problems for Resident Lifting

25. NIOSH Lifting Equation • Calculate a RWL for Lifting • Considers: • Location of object lifted • Frequency of lift • Distance object is lifted • Coupling (handle) • Twisting

26. NIOSH Lifting Guide • RWL=51*HM*VM*AM*FM*CM • Under ideal conditions the maximum recommended weight limit is 51 lbs

27. NIOSH Lifting Equation • So what’s the problem with using this equation when it comes to handling people?

28. NIOSH Lifting Equation • Maximum Recommended Weight limit is 35 lbs for handling residents • Assumptions • Dependent patients >35 lbs • Independent or partially weight bearing residents <35 lbs

29. Patient Handling Scenarios • 2 nurses helping patient to stand from chair • Patient weighs 180lbs • Can assist partially (about ½ his weight) • 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.

30. 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.

31. Patient Handling Scenarios • 4 nurses about to move a fully dependent patient from bed to chair • Patient weighs 250lbs • 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.

32. Patient Handling Scenarios • 1 nurse about to move a fully dependent patient from bed to chair • Patient weighs 100lbs • 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.

33. Identifying Problem Jobs – Other Activities • Activities Other than Resident Lifting and Repositioning: • Bending to make beds or feeding residents • Lifting food trays above shoulder level or below knee level • Pushing heavy carts • Bending and manually cranking an adjustable bed

34. Identifying Problem Jobs – Other Activities (Cont’d) • Job Assessment • Observing employees performing a task • Discussion with employees activities and conditions that they associate with difficulties • Checking injury records

35. Resident Assessment • Level of assistance • Size and weight • Ability and willingness to understand and cooperate • Rehabilitation plan • Medical conditions impacting choice of methods • Other factors

36. The Resident Assessment Instrument Lift Program Policy & Guide Appendix A Settlement Agreement Beverly Enterprises & OSHA Patient Care Ergonomics Resource Guide Centers for Medicare & Medicaid Services Resident Assessment Protocols

37. Resident Assessment Protocol - Continued • Patient Care Ergonomics Resource Guide Flow Charts: • Transfer to and from: bed to chair, chair to toilet, chair to chair, or car to chair • Lateral Transfer to and from: Bed to Stretcher, trolley • Transfer to and from: chair to stretcher

38. Resident Assessment Protocol - Continued • Patient Care Ergonomics Resource Guide Flow Charts: • Reposition in Bed: Side-to-Side, Up in Bed • Reposition in Chair: Wheelchair and Dependency Chair • Transfer a Resident Up From the Floor

39. Resident Assessment Example- Continued • Level of Assistance? • Can the resident bear weight? • Does the resident have upper extremity strength? • Is the resident cooperative? • Weight? Height? • Other factors? • BMI exceeds 50 go with Bariatric algorithms

40. Flowcharts in the Guidelines • Questions are placed in a diamond • Actions are placed in a rectangle Use full-body sling lift and 2 or more caregivers Is the patient cooperative?

47. Resident Assessment Example • Fred is an 80 year old resident at a nursing home. • He weighs 156 pounds and is 5’9” tall. • He has dementia and a history of falls. • Although some days he is cooperative, on other days he is combative and fearful. • When he is cooperative, he can bear weight. Otherwise he resists standing. • He is to be out of bed every day in a chair.

48. Resident Assessment Example- Continued • Level of Assistance • Dependent • Can the resident bear weight? • No, because the resident is not always cooperative • Does the resident have upper extremity strength? • No, because the resident is unreliable for using his upper body strength

49. Example of Assessing A Resident Cont’d • Patient level of cooperation and comprehension • No, unpredictable • Weight - 156 lbs, Height 5’9” • Other factors • history of falls • transfer to and from bed to chair

50. Example of Assessing A Resident Cont’d • Selection of equipment and method of transfer : • Use full body sling with two caregivers