Lifting human bodies in healthcare settings, or "patient handling," has become a hot-button issue for occupational ergonomics. Health care businesses, regulators, researchers, and employees are all beginning to reach the same conclusions on the issue:
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there are a significant number of injuries occurring;
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the injuries can be severe and life altering for the employee, and expensive and wasteful for the employer;
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many of these injuries are avoidable;
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there are proven methods to reduce these injuries; and,
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aside from ethical and moral reasons, there are concrete economic reasons to control the problem.
Scope of the Problem
Patient handling is on the radar for good reason. According to the Bureau of Labor Statistics (BLS), lifting is the principle work activity leading to an employee injury in the nursing home industry. The incidence rate of injuries in that industry, measured as the number of injuries per 100 full time workers, is over 13, more than two times greater than the private industry rate of about six. Health services and hospitals, industries that require patient handling, also show higher injury rates than private industry, at just less than eight and just over eight, respectively. To put this in perspective, these rates are higher than those, for example, in trucking services, logging, or construction industries.
"Nursing home patients generally require more care and handling as they age, while patients in hospitals and health care settings are typically improving, and thus becoming more mobile and self-sufficient with time," observes Gary Orr, a private consultant and board member on the Board of Certification in Professional Ergonomics. "That’s one explanation as to why nursing homes have higher incidence rates than other health care industries."
It’s estimated that a back injury occurs every 30 minutes among health care workers in America. Eighty-seven percent of nurses report low back pain, 38 percent of nurses suffer back pain or injuries severe enough to require time off work at some point in their career, and 44 percent of the injured are unable to return to their nursing positions.
A growing body of research indicates that lifting and transferring patients is the most common cause or precipitating factor in low back pain among nursing home workers. Researcher Arun Garg, Ph.D., CPE, professor at the University of Wisconsin, Milwaukee, found in a study of three nursing homes over a three-year period that patient handling accounted for 84 percent of all reported injuries, 86 percet of all lost or restricted work days, and 81- to 93 percent of workers’ compensation costs.
Lifting a patient presents significant issues that typical lifting jobs don’t. A human body is a flexible, large, awkward, heavy load, often weighing hundreds of pounds. Add to that the potential for a patient to be in pain, uncooperative, unpredictable, or even combative or abusive, and you have a lifting task that exposes caregivers to risks well beyond the heavy weights alone.
Compounding the lifting/transfer risk, consider that 92 percent of nurses and aides, according to BLS, are female. Research, including NIOSH (1991 Revised NIOSH Lifting Equation, and the 1981 NIOSH Work Practices Guide) and Liberty Mutual Insurance Company data (the "Snook Tables"), indicates that smaller females will have trouble safely lifting items 50 pounds or more under good conditions, let alone adult patients weighing 90 pounds or more.
“If you walked into a warehouse and asked someone to lift a 200 pound box, they would almost certainly seek a lift-assist device of some kind. Yet, in the healthcare industry, workers are routinely expected to move and lift similar weights [patients] that are even more difficult to handle,” reflects Mary Matz, MSPH, Project Manager for the Veterans Administration (VA) Safe Patient Handling and Movement Research Project.
Subjective survey-based research shows that nurses and nursing aides believe that certain patient handling activities are the most likely tasks in their daily routine to cause low-back pain. Taking a more objective approach, Martz and her VA colleagues completed task and biomechanical analyses of some of those patient handling tasks that were perceived as high risk. They broke each task into its component tasks and analyzed each one in detail. Applying biomechanical analysis to laboratory simulations of these tasks, the researchers concluded that these high-risk lifting tasks simply cannot be done safely without some sort of patient handling device such as lifting equipment or lateral transfer aids.
Arun Garg agrees. "After going through the literature and looking at the jobs, we realized the job is so stressful that the only way of reducing the risk for these people is by eliminating manual lifting and transferring," he said.
The VA researchers also took injury incidence and severity data and identified patient care units with the highest risk for injuries due to patient-handling tasks. They found characteristics of such high-risk units included having a high proportion of dependent patients who are frequently moved in and out of bed, such as in nursing home and spinal cord injury units. Accordingly, these units were determined to derive the most benefit from use of patient-handling equipment.
Culture and Confounders
Although patients may be difficult to lift, transfer, and otherwise assist, it must always be remembered that the patient is also the client, and that client — possibly your own mother, father, brother, sister, or spouse — deserves the highest level of care and respect possible. This critical fact may be one of the issues that confound an easy solution to the problem. For example, many industrial workers are taught to let a falling load fall rather than trying to catch it and risk injury. Replacing damaged product, as the argument goes, is cheaper and preferable to an injured employee. When that "load" is a human being, this argument loses validity.
There may also be an element of acceptance among nursing professionals, the people responsible for most patient handling tasks in health care and nursing home facilities. "Before I was back-injured, I realized [nursing] carried a risk of injury but believed as I had been taught, that keeping fit and using good body mechanics with patient lifting would protect me," says Anne Hudson, RN, BSN, BIN. (“BIN,” she jokes, stands for "Back Injured Nurse.") She believes that many nurses simply accept such injuries as part of their jobs, and don’t question the outcomes until it’s too late, even if it means they will permanently lose their job or end their career. Expressing frustration with her career-ending injury, she says, "I also naively believed that, being in health care, employers would take care of their injured nurses and keep them working."
The Bottom Line
The we’ve-always-done-it-this-way attitude, which in the case of patient handling appears to exist among employees and employers alike, is a common barrier to business improvements of any kind, and can only be overcome with a persuasive case for change. Most proactive business decisions are driven by financial information — the bottom line — and implementing advancements in patient handling is no different.
There are a number of compelling financial reasons to implement controls that will reduce patient-handling injuries, including significant reductions in direct injury costs, lost work days and productivity losses, and the costs of replacement hiring and training.
"The physical stress caused by manual patient handling is one of the major reasons for the high turnover rates among nursing assistants in nursing homes," notes Gary Orr. Putting this in financial terms, Arun Garg says, "We figured out that, conservatively, it cost us $300 to find and train a new nurse aide. If your turnover is over 100 people a year," as it was in the facilities he studied, "you’ve pretty much paid for the equipment." In addition, Garg states that, "You’ve also paid for the equipment if you prevent just one injury." And preventing injuries is exactly what happens when ergonomics principles are applied to patient handling.
Controlling the costs and consequences of poor ergonomics in patient-handling tasks can take many forms, from a "Zero-Lift" policy to procedural approaches that mix handling skills training with lift-assist devices. Depending on the size and scope of the organization and its patient handling requirements, different levels of intervention will produce varying degrees of improvement.
Garg and his colleagues implemented "Zero-Lift Patient Transfer Programs" in eight nursing home facilities and realized the following compelling results over a three to five year period:
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62% decrease in injuries
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86% decrease in lost workdays
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64% decrease in restricted workdays
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84% decrease in workers’ compensation costs
Hope Tiesman, MSPH, epidemiologist for the Patient Safety Center of Inquiry reports that the results of “Evaluation of a Ceiling Mounted Patient Lift System in a Long-Term Care Unit” will be published soon. The researchers studied the effects of a ceiling mounted patient lift system over a year period. The ceiling mounted patient lift system is a patient lifting device permanently attached to the ceiling on a series of tracks and can track to all areas of a room. According to Tiesman, “We did see significant reductions in injuries and in injury severity, as measured by reductions in restricted duty days, and lost days.”
The economics are becoming very clear.
Thanks to Gary Orr, CPE, Anne Hudson, RN, BSN, Arun Garg, Ph.D. CPE, Mary Matz, MSPH, and Hope Tiesman, MSPH for their assistance with this article.
This article originally appeared in The Ergonomics Report™ on 2002-04-01.