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. Examples of Resident Handling Jobs 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

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 Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58. Use lift or a sit-to-stand device

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 Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58. Use lift with limb sling or limb positioner

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 Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58. Use lift

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 Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58. USE LIFT!

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

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 Is the patient cooperative? Use full-body sling lift and 2 or more caregivers

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

51. Change in philosophy: Lifting techniques are still important but no longer the only key elements. Elimination or modification of lifting activities is more effective. Use task analysis and patient assessment. Use engineering solutions (such as patient lifts, friction-reducing devices, or transfer belts to reduce risk of injury). Standardized processes for equipment, sling and staff selection. Problem Solving Strategy

52. Engineering Solutions Involve a physical change to the way a job or task is conducted or physical modifications to the workplace.

53. Work Practice Solutions Involve the way work is done and do not involve a physical change to the workplace.

54. Example of Solutions in Guidelines Description When to Use Points to Remember

55. Factors That May Affect Solutions Resident’s rehabilitation plan Need to restore resident’s functional abilities Medical contraindications Emergency situations Resident dignity and rights

56. Resident Lifting and Repositioning Solutions Floor-Based Sling Lift

57. Resident Lifting and Repositioning Solutions - Continued Sit-to-Stand Lift

58. Resident Lifting and Repositioning Solutions - Continued Ambulation Assist

59. Resident Lifting and Repositioning Solutions - Continued Lateral Sliding Aid

60. Resident Lifting and Repositioning Solutions - Continued Transfer Board

61. Resident Lifting and Repositioning Solutions - Continued Electric Bed

62. Resident Lifting and Repositioning Solutions - Continued Weighing Scale with Ramp

63. Solutions for Other Than Resident Lifting Front-Loading Washers and Dryers

64. Equipment Considerations Equipment: Maintenance Availability Utilization Capability

65. Examples of Equipment Questions - Continued Is the equipment too big for my facility? Can it be stored in close proximity to the area (s) where it is used? If needed, is a charging unit and back up battery included?

66. Case Studies

67. Resources www.oshainfo.gatech.edu