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Back Injury Prevention:
Safe Patient Handling

Extent of the problem

Back injuries are part of a larger category of work-related injuries known as musculoskeletal disorders (MSDs). MSDs are defined by the U.S. Department of Labor as injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and/or spinal discs. (MSDs do not include disorders caused by slips, trips, falls, motor vehicle accidents, or similar accidents.)

In healthcare, most MSD's are the result of overexertion related to repeated manual patient handling activities, often associated with transferring, and repositioning patients. According to CDC's National Institute for Occupational Safety and Health (NIOSH), nurses and related patient care occupations, have high rates of back, shoulder and other MSD injuries.

The Bureau of Labor Statistics reports more than 130,000 lost-time cases of work-related back pain, carpal tunnel syndrome, tendonitis, sprains, strains and tears associated with the Healthcare and Social Assistance sector (HCSA). More than 50 percent of the MSDs reported for nurses, aides and assistants were back injuries.

Organizations are taking steps to improve safe patient handling and movement, reduce workers' musculoskeletal disorders (MSDs), such as back injuries, and create an improved safety culture in healthcare workplaces.

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Musculoskeletal Disorders (MSDs) - Risk Factors

Inherent risks
Providing assistance with transfer, positioning, mobilizing, and supporting patients in ambulation is a routine part of the daily patient care. This assistance can be further complicated when sicker patients are more physically dependent or are tethered by tubes and other devices to fixed outlets and utilities. Additionally, organizational factors such as staffing, workload, design of the care environment, and lack of mechanical lift assist devices can also have a huge impact on MSDs among healthcare personnel.

Repetitive trauma
MSDs (such as back injuries) related to patient handling are rarely caused by a single, well-defined incident. The root cause is often the specific incident coupled with years of repetitive micro-trauma. The repetitive nature of tasks performed by caregivers increases the potential for MSDs - particularly awkward postures, bending and lifting excessive loads. Because of the slow and progressive onset, internal weakening and damage, the condition may be ignored until the symptoms become severe and lead to a disabling injury.

In 2012, CDC declared that more than one third (37.5 percent) of the adult population in the U.S. are obese, posing significant lifting hazards for caregivers and prompting new tools and equipment to ensure safe patient handling. Obesity of the caregiver and an aging caregiver workforce also contributes to the risk of injury.

None of these factors operates alone - typically it is a combination of factors that lead to injury.

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Cost Considerations

The annual cost of work-related MSD's is very high
It is estimated that the direct and indirect costs associated with occupational back injuries and other MSDs nationally is between $24 billion and $64 billion annually, with $20 billion of that attributed to the health care industry, according to NIOSH. Back injuries in nursing account for the majority of these costs, with over three quarters of a million working days lost and an estimated 40,000 nurses reporting illnesses from back pain each year. OSHA has provided data to add to the business case for safe patient handling in their hospital safety web site.

Direct and indirect costs
Direct costs include workers' compensation, medical treatment, and vocational rehabilitation. Indirect costs, while much harder to quantify, are estimated to be four to seven times higher than direct costs. These costs include decreased employee morale, continual employee hiring and training, use of replacement workers, overtime, incident reporting and other paperwork, increased costs of workers' compensation insurance, and increased costs of employee healthcare, particularly for employers who are self-insured.

Patient harm
Inadequate solutions for patient lifting and movement also result in costs to the patient, both physically and psychologically. For example, the manual lifting of patients can result in patient harm from skin tears and bruising as patients are dragged across surfaces. Lifting dependent patients under the arm to transfer them can result in injuries to their shoulders or upper arms. Falls from inadequate support during transfer or ambulation are a common problem that can be reduced by proper lifting techniques and the use of suitable equipment. Psychological distress is created when caregivers are obviously straining to move a patient who may become anxious and fearful of falling. The use of assistive patient handling equipment and devices, explaining procedures to the patient and enlisting their cooperation can reduce patient harm, increase their safety and comfort, and enhance their sense of dignity.

Regulations, legislation and guidelines

The Occupational Safety and Health Administration (OSHA) continues to cite and fine employers for occupational musculoskeletal hazards under their "General Duty Clause" that requires employers to provide workers with a workplace that is "free from recognized hazards." OSHA has classified overexertion injuries from lifting people as workplace hazards. OSHA explicitly recommends the use of assistive technology and notes that enforcement can be applied in healthcare settings wherever patient handling occurs. OSHA has a full web page on
Safe Patient Handling.

The National Institute for Occupational Safety and Health (NIOSH) provides guidelines for safe lifting and movement of patients as well as safe patient handling training. NIOSH provides web-based training entitled, "Safe Patient Handling and Movement" as well as a full curriculum for a 1-2 day training for nurses titled Safe Patient Handling Training for Schools of Nursing.

The Joint Commission addresses ergonomic hazards related to patient handling with expectations that healthcare organizations will address these hazards by utilizing patient lift equipment and lateral transfer devices in compliance with its Environment of Care standard and by incorporating recognized best practices in their facilities. Also, surveyors may review OSHA Injury and Illness records and then ask about preventative measures taken for the most frequent and/or costly types of injury, many of which are musculoskeletal disorders.

Legislation and National Policies. The United Kingdom, Australia, and Canada have instituted national "no lift" policies that banned manual patient handling techniques instead of mandating the use of assistive devices to move and lift patients. Although there is no federal legislation in the U.S, many states have already passed legislation to address this issue. For example, California legislation enacted in October 2011, (AB 1136) requires employers to adopt a patient protection and health care worker back and musculoskeletal injury prevention plan, including a safe patient handling policy, trained lift teams and the use of lift devices.

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Developing a Safe Patient Handling Program

Safe patient handling programs increase knowledge among both workers and employers about the prevention of MSDs and improved patient safety. Providing safe patient handling requires more than a "quick fix" or a singular solution, such as more training or simply purchasing patient lifting equipment.

The Association of Occupational Health Professionals in Healthcare (AHOP), in alliance with the Occupational Safety and Health Administration (OSHA) developed "Beyond Getting Started: A Resource Guide for Implementing a Safe Patient Handling Program in the Acute Care Setting". This guide provides sample policies, product evaluation tools and a strategic plan for initiating a program.

Components of a successful safe patient handling program:

Gain Management Support
All programs begin with management support as a key element for success. Most organizations have a basic "back injury prevention" program; however, continuing incidents of back injuries should prompt the development of a more comprehensive program. Providing senior management with information on the huge opportunity to reduce costs that will result from effective worker and patient safety improvements is a key factor in gaining support and the necessary resources for a successful program.

Effective programs may prompt increase in reporting of injuries . An effective program may initially result in increased reporting of symptoms. Though sometimes alarming, this increase in early reporting helps to ensure that measures can be taken to reduce the severity and cost of injuries. This strategy requires commitment and education of senior management and supervisory personnel as well as care givers.

Tips for enlisting leadership support:

Assess the environment and patients
An essential first step in developing your program is to perform a worksite assessment to identify the types of patients, types of movement and transfers needed, and the nature of worker injuries. With the increasing use of computers in healthcare settings, attention should also be paid to hand, wrist, neck and upper extremity stressors among workers. Obese patients will need specific attention for safe handling. You can determine the obesity prevalence in your state using CDC's Adult Obesity Facts.

Gather input and data

Data on injuries. Gather data on injuries and cost to the organization. Data from national statistics and studies, the organization's own OSHA Injury and Illness Records, internal incident reports, employee health records, and workman's compensation claims are useful.

Gather input from frontline workers. Employees who will be using the safe patient handling program on a daily basis have an understanding of clinical needs and can provide insights that will enrich the program. Including these workers in the planning process will help ensure that they have a vested interest in the program's success.

Determine a reasonable goal for the program
A comprehensive safe patient handling program combines management support, equipment use, work practices and training to reduce the risk of each patient/resident handling event. In OSHA's guideline, the goal is to "minimize manual lifting [of patients] in all cases and eliminate it when possible," (See Ergonomics for the Prevention of Musculoskeletal Disorders: Guidelines for Nursing Homes )

Specific goal-setting is a critical step in creating successful, long-lasing improvements. The organization must develop incremental, measurable goals based on its size, patient mix and the results of injury data analyses, surveys, and interviews. Read success stories for examples of successful patient handling programs.

Management approval is essential to implementing a safe patient handling program that, by its nature is complex and requires a great deal of organizational commitment and resources to be successful. As the program moves into setting specific goals and designing implementation strategies (such as beginning to purchase equipment and initiating training); it is a good time to reaffirm commitment to the goals of the program and gain concurrence on a timeline for implementation.

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Identify patient handling equipment needs
Decisions about lifting and transfer equipment should reflect the worksite assessment, including equipment currently available and the environment in which it is used. Additional equipment can be chosen for specific situations so that purchasing is targeted and effective.

Preventing MSDs, such as serious back injuries, through safe patient handling must include the use of patient lifting and transfer equipment, especially for obese (bariatric), confused or physically dependent patients. Devices to consider include: lateral slides, full body slings and lifts, stand assist and repositioning lifts, ergonomically designed beds and gait belts.

Patient Handling and Movement Assessments: A White paper (2010) provides guidance on architectural and construction issues, a strategy for developing a business case for safe patient handling, equipment evaluation forms, as well as discussion of logistical issues such as storage of equipment.

Veterans Health Administration (VHA) - Patient Safety Center has extensive resources that may be helpful in establishing a safe patient handling program, including identification and evaluation of patient handling equipment.

Establish policies and procedures
Safe patient handling policies and protocols ensure consistency with the organization's patient care policies, patient and employee injury reporting process, and return-to-work programs. Lifting assistance is a critical part of patient care and caregivers need clear direction on making decisions on which equipment to use. Patients and families need to know the organization's policy on use of equipment (for example, is equipment use mandatory). OSHA has developed a poster titled, "Need a Lift" to encourage families and patients to cooperate with lifting policies.

Develop a timeline for action and begin implementation
There is no single solution to safe patient handling. Each organization will need to develop a plan and timeline that matches their specific patient population needs and organizational goals. Getting both managers and employees "on board" is critical for success and each of these groups will need to be involved in the planning and implementation strategies. Additional lifting equipment may be required, policies and procedures need to be updated, and subsequent training and education need to be delivered. Timelines should be ambitious, but feasible; plan for success!

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Provide training
Training needs should be identified and provided for all levels of personnel. Caregivers will need "hands-on" experience with the equipment. Many manufacturers provide this training with the purchase of equipment. Planning should include training for the following groups.

Evaluate progres
Success of the program will need to be measured against the goals each organization has set. This requires ongoing monitoring and evaluation, incorporating findings into new prevention strategies. If measures are not producing the results identified in the goals, the program should be re-evaluated to determine appropriate corrective measures.

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