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MORA Maine occupational research association conference 2003
Lower back injuries are highly prevalent in healthcare settings, accounting for over 70% of injuries. Risk factors include tasks like lifting patients, which can place up to 1,150 pounds of pressure on the lower back. Common injuries are low back pain, herniated discs, and strained muscles or tendons. Prevention strategies include proper lifting techniques, exercise, ergonomic adjustments to workstations, job modifications, and back injury education programs. Implementing a comprehensive ergonomic management program can help reduce injuries and their associated costs.
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MORA Maine occupational research association conference 2003
- 1. MORA Initiative:MORA Initiative: MusculoskeletalDisordersMusculoskeletal Disorders Lower Back Injuries in Health Care Settings
- 2. Prevalence of theProblem Denise Dumont, PTDenise Dumont, PT Area Manager U. S. HealthWorks Medical Group of Maine, Inc.
- 3. Resident handling tasks such aslifting and transferring cause more than 73% of back pain or strain injuries
- 4. Back Injuries The Hazard: Painand Injuries to muscles tendons, discs and other parts of the back
- 5. Who is atRisk? Workers who lift and move patients Those with jobs in : Laundries Kitchens Environmental Services Others who must lift, push, pull objects
- 6. Maine DOL: Occupation ofWorker 1997 1998 1999 2000 2001 Nurses Aides, orderlies, attendants 413 428 698 672 650 % of All Injuries 42.8% 40.8% 45.8% 42.9% 41.4% RNs 191 156 207 247 251 Health Aids 35 79 100 74 80 Maids and housemen 43 43 62 66 109 Janitors and cleaners 31 50 75 88 67 Technologists 22 45 46 43 43 LPNs 35 39 32 34 35 Cooks 25 23 33 28 25 Misc Food prep 12 23 24 32 25 Laundry 16 13 14 19 21 % of all injuries 85.4% 85.7% 84.7% 83.2% 83.2%
- 7. Types of Injuries Low Back Pain- Non-specific Herniated Discs Strained Muscles and tendons Sprained ligaments Sciatica
- 8. Issues Staffing Levelsin Health Care Facilities Turnover Mandatory Overtime Patient Population/types Violence Weights Inexperience or Lack of Training Facility Lift Policies, Ergonomics, Equipment Interventions and Their Effectiveness?
- 9. When Staff AreInjuredWhen Staff Are Injured Life discomfort from having a back injury. Medical Costs Loss of Income Stress for staff (increased paperwork, relationship with co-workers & residents' families)
- 10. When Staff AreInjuredWhen Staff Are Injured Staff Replacement Costs: Overtime Outside Agency Training & Orientation of New Staff Extra time from co-workers Recruitment
- 11.
- 12. U. S. Departmentof Labor Total Recordable Cases (000's) 0 50 100 150 200 250 300 350 Nursing & Personal Care 216 217 247 222 219 198 189 199 193 Hospitals 332 312 269 300 285 261 272 260 266 1993 1994 1995 1996 1997 1998 1999 2000 2001
- 13. 90 100 110 120 130 Lost Workday Cases(000's) Nursing & Personal Care Facilities 112 109 120 112 119 114 107 114 107 Hospitals 126 119 115 115 120 112 121 120 122 1993 1994 1995 1996 1997 1998 1999 2000 2001 U. S. Department of Labor
- 14. Maine Department ofLabor Standards Data Data from Worker’s Comp Board based on a First Report of Occupational Injury or Disease Only Lost Time Claims data available 805-806 SIC codes Disabling Cases 1997-2001 = 6675 or 1335 per year average Upward Trends Noted from year to year Total Costs $24 Million
- 15. Total Disabling Injuries MaineDOL 0 1000 2000 Total Disabling Cases 964 1050 1524 1566 1571 1997 1998 1999 2000 2001
- 16. Maine DOL: Natureof Injury Nature of Injury Sprain, Strain and Tears Most prevalent (30-43% of all injuries) 293 366 577 692 678 0 100 200 300 400 500 600 700 800 1997 1998 1999 2000 2001 Sprain, strain, tears
- 17. Maine BLS: BodyPart/Region 524 568 784 823 842 0 200 400 600 800 1000 1997 1998 1999 2000 2001 Spine Related Injuries 51-54% of all Injuries are spine related
- 18. Maine BLS: Event Leadingto Injury 67-72% of all injuries Event Leading to Injury 1997 1998 1999 2000 2001 Overexertion in Lifting 193 261 408 462 501 Fall to floor 82 80 99 105 146 Overexertion Holding, carrying, turning object52 66 96 121 73 Overexertion in pulling/pushing objects46 52 107 93 81 Overexertion, UNS 85 59 64 83 64 Overexertion, NEC 69 74 107 50 38 Nonclassifiable 76 53 57 46 46 Bending/climbing/reaching/twisting 57 38 51 57 60
- 19. Prevalence Large WCInsurance Company Data Includes Medical Only claims as well as Lost time claims Total Claims : 8768 805 and 806 SIC Codes only Nursing & Personal Care Facilities: 46% Hospitals: 54% of claims
- 20. Demographics 1456 Employerswith Approximately 33,108 Total Employees Age : Average and Median = 40 8768 Total Injuries or 3.7% Injury Rate 16.5 % incurred $0 Spans 7 year history of Claim numbers Spans 4 years of Claims Cost Data
- 21. Case Costs $17,335 $16,879 $4,145 $5,163 $0 $5,000 $10,000 $15,000 $20,000 Average CaseCost Median Case Cost Nursing & Personal Care Facilities Hospitals
- 22. Occupation 65% 20% 15% Professional (RN/RT) Technical (LPN,Techs, Admin) Service (CNA, Dietary, Housekeeping)
- 23. Average Cost PerClaim Medical Only vs Indemnity Claims $0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 Medical Only Claims Indemnity Claims Medical Only Claims $712 $712 $565 $565 Indemnity Claims $8,596 $4,606 $3,991 $5,546 $3,293 $2,074 2001 Ave WC Cost/claim 2001 Ave Medical Cost/Claim 2001 Average Indemnity 2002 Ave WC Cost/claim 2002 Ave Medical Cost/Claim 2002 Average Indemnity
- 24. Complex Problem Worker’s CompensationCosts General Health Insurance Disability Medical Community OSHA Regulations UnionsADA Aging Workforce Employee Health and Wellness Job Accommodation FMLA EEOC Competition Downsizing Turnover
- 25. THE SPINE TheVertebrae
- 26.
- 27. THE NERVES andSPINAL CORD
- 28.
- 29. Awkward Joint PositionsAwkwardJoint Positions and Posturesand Postures Risk Factors for LBP Bending and leaning Excessive reach especially with weight Heavy lifting Static awkward positions Twisting Constant sitting
- 30. Poor Physical ConditionPoorPhysical Condition It is not always the work that causes injury, it is the lack of physical condition to perform the work
- 31. ERGONOMICS IS AN INEXACTSCIENCE
- 32. Unnecessary Strain Can BeCaused by: Excessive Reaching Prolonged Static Positions Awkward Postures Repetitive Motions Bending and Twisting Faulty Ergonomic Workstations
- 33. The mechanics ofthe spine and lifting The amount of force you place on your back in lifting may surprise you!
- 34. The Forces Involved Whenyou add in the average weight of 105 pounds for the upper torso, you see that lifting a ten pound object actually puts 1,150 pounds of pressure on the lower back.
- 35. The Forces Involved Ifyou are 25 pounds overweight, it would add an additional 250 pounds of pressure on your back every time you bend over.
- 36. The lifting solution Wide base of support Object in center of stance Neutral spine Butt down Grasp object with both hands Hug the load Raise with head and shoulders first Slow and smoothly Keep spine in neutral Once standing, move your feet in the direction you are going to move in, do not twist Repeat to put load down
- 37. The message is…. TAKECARE OF YOUR BACK ……And it will take care of you Exercise daily Get the proper amount of sleep/rest Eat right Do not ignore your signs and symptoms Limit your exposures during “heavy” lifting Get Help with heavy or bulky objects If you must bend, do it properly Avoid twisting at the waist when moving objects Always be aware of your environment and watch where you are going Work with your environment not “in it”
- 38. Job Accommodation Does theFunctional Capacity of the Injured Worker Meet the Physical Demands of the Job? If Yes Assign Job If No Modify Job or Improve Worker Tolerance
- 39. Accommodations Possibilities Restructurejobs- Reassign parts of jobs Alter Physical Facilities Acquire or modify equipment or device Modify Work schedules Provide readers or interpreters Reassignment of Employee (last resort) Experts on Accommodation #1 the disabled person #2 the rehab professional
- 40. Improve Worker Tolerance Gradual exposure to unaccustomed work Restrict overtime Gradual increase in weight lifted/ forces Gradual increase to Cardiovascular demands Monitor Progress!
- 41. Distribution by Hourof Shift 12.30% 10.20% 10.10% 8.80% 7.30% 6.90% 6.40% 5.60% 7.80% 0% 2% 4% 6% 8% 10% 12% 14% 1st 3rd 5th 7th 9th
- 42. Nature of Injury 50.90% 8.80% 8.30% 7.70% 3.20% 0.02 1.90% 0%10% 20% 30% 40% 50% 60% Sprains, Strains Cut, Laceration Contusion, Bruise Fracture Multiple Injuries Hernia Rupture Nervous System East
- 43. FIT FOR WORK “StretchingPrograms” Warm-up exercises Stretching exercises All major muscle groups Performed in standing position Ten minutes to complete Flexibility tests Injured workers can perform the program Progression: Isometrics (Strengthening)?
- 44. Work Site Visits/Evaluations Patient education/ understand their work Ergonomic evaluation & recommendations Job task analysis /ADA Risk analysis Communications/ close the loop Build relationships
- 45. BACK SCHOOLS Quiz Introduction: Prevalence of back problems, issues, etc.. Teach functional Anatomy & Physiology of the spine Understand different types of back disorders: Disc herniations,muscle strains, arthritis, joint stiffness, etc. Explain risk factors: Poor postures, body mechanics, physical fitness, ergonomic considerations Describe diagnostics and treatments: X-rays, MRIs, manipulation, encourage active forms of treatments and early mobility Proper lifting and body mechanics Prevention: work site problem solving, discussion, Activities of daily living
- 46. PREVENTATIVE EDUCATIONAL PROGRAMS Back Schools CTDSchools VDT training FIT FOR WORK Stretching Program Ergonomics training Supervisor Work Injury Management Customized programs
- 47. Back Injuries inHealth Care Settings A Long Term Care Provider’sA Long Term Care Provider’s PerspectivePerspective Susanne Heeschen, RNC Director of Operations Sandy River Health Care Systems
- 48. Who Are We? Maine based Long Term Care Provider Present in 12 Communities Throughout Maine 777 Skilled Nursing Beds 215 Assisted Living Beds One Outpatient BI Rehab Program Two Adult Day Care Programs
- 49. Employee Profile TotalEmployees 1535 Total Nursing Employees 1032 (67%) Total Employees age 50 and Over 445 (29%) Total Nursing Employees age 50 and Over 259 (58% 0f all employees age 50 & over)
- 50. Safety Management Profile 2002 65% of total incidents First Aid 29% of total incidents Medical Only 6% of total incidents Lost Time 75% of total incidents Nursing 31% of total incidents Strains 14% of all incidents Resident Behavior
- 51. Other Data 2001 200220012002 Total Claims 211 227 7% inc. Total $$ 389,717 333,006 14.5% dec. Ave$/injury 1847 1467 20% dec. Total Spr/Str 130 146 12% inc. Ave$/Spr-Str 2162 1983 8% dec. Exp Mod .90 .84 ( 2003 .78 )
- 52. What Makes ADifference? Culture Commitment to Prevention Safety Committee Tracking and Trending Training Equipment-Availability and Use Effective Occupational Health Services Claims Management Early Return to Work Efforts
- 53. Challenges Nature ofPatient Care in LTC Settings Keeping Staff Current in Their Practices Funding Aging Workforce Healthcare Worker Shortage Health Care Practices of Workers
- 54. A Management Process toImprove Outcomes in Healthcare Applying Guy Fragala, PhDGuy Fragala, PhD Director of Environmental Health and SafeDirector of Environmental Health and Safe University of Massachusetts Medical CentUniversity of Massachusetts Medical Cent
- 55. G ood EngineeringSolutions G ood M anagem ent Program The Ergonom ic M anagem ent Process Reduced Loss and Im proved Outcom es
- 56. A Simple Lookat an ERGONOMIC APPROACH 1. Identify jobs and job tasks which stress body parts beyond limits. 2. Develop solutions to change these task demands. 3. Implement these changes in the work place. 4. Review the design of the physical work environment to remove barriers, minimize travel and consider spacial relations.
- 57. Initiation Team Members Safety and health function Human Resources/Workers’ Compensation Manager or supervisor Rehab or therapy specialist Direct care staff Senior administrator Who else? Who will champion?
- 58. Scope of theProblem Cure world hunger Feed a few hungry people
- 59. What are Occupational InjuriesCosting You? Direct cost Indirect cost How are you paying?
- 60. A 5 StepProcess STEP 1 - Risk Identification and Assessment STEP 2 - Risk Analysis STEP 3 - Develop Recommendations STEP 4 - Program Implementation STEP 5 - Measurement and Results
- 61. Step 1: RiskIdentification and Assessment Perceived high risk jobs Specific high risk job tasks Element of high risk job tasks High risk departments or areas Task intensity and duration Work postures General design of equipment and space Where do we think problems exist?
- 62. Methods to GatherData General observation Employee discussions Employee questionnaires Review of medical data Symptom surveys Quantitative evaluations Previous studies Job consistency and fatigue Brainstorming and group activities
- 63. Patient Handling Tasks Transferring patient from bathtub to chair Transferring patient from chair to bed Weighing patient Transferring patient from toilet to chair Making bed with patient in it Transferring patient from bed to chair Transferring patient from chair to toilet Undressing patient Repositioning patient in chair Making bed when patient is not in it Lifting patient up in bed Feeding bed-ridden patient Changing absorbent pad Repositioning patient in bed
- 64. Step 2: RiskAnalysis Confirm perceived problems Analyze cost data Specify high risk jobs and areas Set priorities Formal job analysis Study risk factors Quantify risk factors
- 65. Step 3: Develop Recommendations Achievable and simple Constraints Approaches Engineering Administrative
- 66. Engineering Control Strategies… the preferred control method Eliminate the need to do the hazardous activity Redesign the activity to reduce the hazard Utilize an aiding device to minimize the hazard
- 67. Basic Transfer Aids Gait belts with handles Hand slings Sliding boards Stand assist and repositioning aids on furnishings on walls self supporting
- 68. Gait/Transfer Belt with Handles What do you do? Fit the belt around the patient’s waist What happens next? Use the handles to improve your grasp What are they used for? Assisting and transferring partially dependent patients
- 69.
- 70. Lateral Transfer Aids Friction reducing lateral slide aids rigid boards flexible sheets rollers air assisted Mechanical lateral transfer aids hand cranks electric motor
- 71. Friction Reducing Lateral SlidingAids Friction Reducing Lateral Sliding Aids
- 72. Mechanical Lateral Transfer Aids What do you do? Position the device as directed What happens next? Start the motor or turn the crank to slide the patient over to the new surface What are they used for? Lateral transfers
- 73. Mechanical Lifts Portablebase full sling Portable base stand assist Ceiling mounted track Wall mounted Bathing Pool Automobile
- 74. Floor-Based Ceiling-Mounted Powered FullBody Sling Lifts
- 75. Powered Standing Assist andRepositioning Lifts
- 76. Ergonomic Furnishings Transferchair Bed improvements aiding transfers minimizing transfers minimizing repositioning Stretchers Toilets Tubs and showers
- 78. Resident Dependency Classification Height Adjustable Bed Full Sling Lift StandAssist Lift Lift Walker Stand Assist Aid Gait Belt with Handles Friction Reducing Aid 0 - Independent Recommende d Never Rarely Rarely Rarely Rarely Rarely 1 – Supervision Recommende d Rarely Occasionally Occasionally Normally Occasionally Rarely 2 – Limited Assistance Strongly Recommende d Rarely Normally Normally Normally Normally Normally 3 – Extensive Assistance Required Normally Normally Normally Rarely Rarely Always 4 – Total Dependence Required Always Never Never Never Never Always Lift Aid Equipment Determination Grid (recommended example) For a typical resident with the dependency status classification as shown, this grid indicates normal equipment requirements to conduct a safe transfer. Some residents may have special characteristics and not exactly match a typical profile. In those situations, special consideration will be required.
- 79. Step 4: Program Implementation The Implementation Team Education and training Involve everyone affected Resistance to change Policies and procedures Goals and objectives Medical management
- 80. Traditional Back Injury TrainingEfforts The comprehensive all-inclusive back school The traditional most popular approach training in lifting and body mechanics Evaluating the true effectiveness of these approaches Is it time for a change? What are the barriers to change?
- 81. Step 5: Measurementand Results Select measures Improvements Quality of work life Quality of care Reporting results Ongoing efforts and interest Continuous improvement cycle
- 82. Effective Ergonomic Interventions in Healthcare Resultsof what has been achieved How was the program implemented? Key points contributing to success
- 83. Summary of Improvement fromErgonomic Management Program Masonic Home and Hospital Pre-Intervention Post-Intervention Annual lost work days 1,025 81 Injury assessments four-month period $174,412 $4,500 Incurred annual workers compensation costs $628,511 $142,995
- 84. The Champion Assistant Directorof Human Resources
- 85. Reason for Improvement 1,025lost workdays $628,511 direct cost
- 86. Risk Identification Brainstormingsessions Created buy-in Perceived high risk activity
- 87. Risk Analysis Nocorrelation with staffing patterns and injuries Existing training programs not effective Confirmed high risk units
- 88. Formulation of Recommendations EngineeringControls Mechanical lifts Gait belts
- 89. Implementation Initiation teambecame Implementation and CQI Team High interaction of team with staff Key operator/unit contact
- 90. Evaluation Lost workdays Direct cost of injury Workers comp premiums Injury incurred cost
- 91. Key Points Contributing toSuccess Establish the need Define the problem Form the team Establish top management support Provide educational awareness for buy-in Involve staff Create and follow a time line
Editor's Notes
- #26 Discussion: demonstrate with spine model how the vertebrae interlock and move segmentally. Have one of the audience come up and demonstrate neutral spine vs flexed vs extended spine and the level of play in the spine, by pressing down through the shoulders. Discuss the curves of the spine and how being overweight can accentuate the lumbar curve. Demonstrate through the use of the spine model or audience how changing the curves, changes the vertebral alignment and the stresses placed on the discs, ligaments and other structures.
- #27 Discussion: Each disc is a circular pad filled with a gelatin type substance, that is under constant pressure. The disc acts like a shock absorber between the vertebrae and allows for the smooth segmental movement that occurs when you move. You may have a relative or you may have been told that you have arthritis, degenerative joint disease or a narrowing of the joint spaces in your spine, this is due to the compression of the discs over time and the loss of volume or fluid that they contain. You can see that as you bend and extend your back part of the disc is compressed while the other part is stretched. This is why therapists are always emphasizing the maintenance of your curves and keeping your back straight while you lift. You can see if you constantly bend and twist without maintaining a neutral spine, then the wear and tear on your disc becomes more and more of an issue and the joint spaces begin to approximate or touch one another, causing wear and tear on the joint surfaces.
- #28 Discussion: If the disc becomes really irritated and inflamed, it can begin to bulge and swell, thus putting pressure on the nerve roots that come out between the vertebrae and possibly on the spinal cord. The term slipped disc, really is a misnomer, since the disc does not really slip out of place, it tends to swell and bulge and finally herniates and ruptures.
- #29 Discussion: When you move, your spine and the surrounding ligaments, muscles and tendons also must contract and stretch to allow for the movement. When we over extend ourselves, reach just a little to far, or bend and lift with just a little too much force, we end up “pulling” or injuring one of these structures. You know, you felt that twinge but thought nothing of it, it will go away. At that moment your body begins to form scar tissue to repair the area. But unfortunately our bodies do not lay the scar tissue down in a very smooth manner, so when you go to move a little too far again, you “pull” the area again, resulting in more discomfort and more scar tissue formation. Think of it, like an old sweater, where the threads become worn over time, becomes harder and harder to mend. Demonstrate: lifting object with poor mechanics from floor to overhead. Reinforce the importance of a neutral spine, the disc alignment and the stresses on the other structures.
- #34 Discussion: think of your back as a lever, with the fulcrum in the center. If you keep the fulcrum in the center, the amount of pressure exerted onto the spine equals the amount of the weight that you are lifting. Your waist acts like the fulcrum in the lever system, it is a 10:1 ratio.
- #35 Discussion: The upper torso is the area from above the waist to the shoulders, unfortunately it where most of us carry additional weight.
- #36 Discussion: As we demonstrated before, the wear and tear of the discs and surrounding tissues lead to injury over time. But with increased abdominal mass, the wear and tear is accentuated. Everyone talks about weight loss and I have certainly seen many patients that are thin with injured backs, so again what it really gets down to, is the use of correct body mechanics, working smart, knowing your lifting limits, changing your workstation to fit you and ultimately staying strong and flexible. Discussion: How are we going to improve the fulcrum placement? What do you have to do?
- #37 Discussion: demonstration. Obviously, there are times that you are not able to perform the lift entirely correct, but think before you lift, “how can I minimize my exposure to injury during this lift”. Number one priority? Get as close to the object as you can, either by widening your base of support, bending your knees more, getting your butt down, using mechanical devices or by asking for assistance. Attempt to keep your spine in a neutral position and use your arms and legs to lift the object. I do not emphasize a straight back lift, since you can lift incorrectly using a straight back and perform a hinge type of movement from the waist (demonstrate); the emphasis is on raising with head and shoulders first, keeping the spine in neutral.
- #38 Discussion: Wrap up concepts/ideas. Open answer/question session.