1. SHARP Getting to ZeroLift & Staying There. WA State Nursing Home Initiative to Reduce WMSDs B Silverstein, K Rockefeller, N Howard, J Kalat, NL Polissar, S Liao http:/www/lni.wa.gov/sharp Safety & Health Assessment and Research for Prevention Washington State Department of Labor & Industries

2. SHARP US Nursing Homes 1.5 million older adults are in US nursing homes 75% with dementia, increase in acuity 1.2 million care givers (480,000 CNAs) Combine this with –poor pay –minimal long term benefits –insufficient training –insufficient recognition and support for difficult job Equals –high turnover and high injury rates

3. SHARP Nursing Assistant Work: Major Task Categories n = 2674 observations at 16 facilities

4. SHARP

5. TRANSFERS Moving person from one surface to another Bed to wheelchair/wheelchair to bed Wheelchair to toilet/toilet to wheelchair

6. SHARP REPOSITIONING

7. SHARP RESULTS: Spinal loading during transfer & repositioning tasks, Marras et al 1999 Lift

8. SHARPSHOULDER 1 2 3TRUNK 1 2 4 LOAD 1 2 3 4 X Combined Exposure Score Range: 2 to 28

9. SHARP Combined Exposure Score – Activities of Resident Handling

10. SHARP Implementing ZeroLift Environments: (Owen & Garg 1992, Garg 1996) Eliminate awkward heavy lifting by using transfer equipment Train/retrain entire staff with demonstration, hands-on and feedback Environment where use of equipment is expected, encouraged, enforced Employee participation in all aspects Injury investigation & follow-up Measure success

11. SHARP WA State Hazard Impact Partnerships: ZeroLift Initiative Industry, labor Partners: Industry, labor, government 274 nursing homes, 258 “free standing” Washington Health Care Association (WHCA) 204 nursing homes 1996: offer $1,000 rebate if purchase lift devices Getting to ZeroDeveloped Getting to Zero video, training materials Newsletters Work on annual SHARP survey of members UFCW,SEIU (10%)-supportive, not active

12. SHARP WA State Hazard Impact Partnerships: ZeroLift Initiative government Partners: Industry, labor, government Workers compensation program, state OSHA program, safety & health research program At request of industry-evaluated total lifts and sit- to-stand lifts-> FAQ publications WC premium discounts (15%) in 6 counties for implementing zero lift environment->(36/47) Education campaign on using job modification funds for lifts for injured workers ($5,000 per job) Evaluate effectiveness of efforts

13. SHARP COMMITMENT Management team understands & supports zero-lift philosophy Allocates resources –Money for start-up & on- going –Staff time Visibly engaged Accountable

14. SHARP INVOLVEMENT Involve employees Safety committee, task force, working group Nursing, staff development, therapy, laundry, maintenance Communication plans Roles & responsibilities Accountability Use data

15. SHARP POLICIES & PROCEDURES Integrated into existing operations “It’s the way we do things here” New employee orientation Information shared with potential residents & families

16. SHARP ENFORCEMENT Need consequences for behavior –Clear –Fair Instead of “blame” investigate “why”

17. SHARP TRAINING Integrate into existing staff development plans Clear educational objectives Principles of adult learning Role play, practice, coaching RETURN DEMONSTRATIONS Mentor as needed Regular “refresher” training Update training when changes ALL NURSES SHOULD BE TRAINED ON USE OF EQUIPMENT

18. SHARP “If a job is intrinsically unsafe, no amount of training will make it safe” “But while body mechanics are important, they only work when the load is reasonable…”

19. SHARP EQUIPMENT Assess your needs –Census –Acuity –Staffing –Long range Don’t forget –Laundry »Care of slings –Maintenance »Battery charged

20. SHARP EQUIPMENT

21. SHARP LIFTING EQUIPMENT FOR PEOPLE HANDLING Total body –Manual (hand-operated) –Mechanical (battery)

22. SHARP MORE EXAMPLES TOTAL LIFTS Hand-operated Mechanical

23. SHARP LIFTING EQUIPMENT FOR PEOPLE HANDLING Ceiling lifts

24. SHARP LIFTING EQUIPMENT FOR PEOPLE HANDLING Partial weight bearing Instead of pivot transfer Sit-to-stand lifts

25. SHARP EQUIPMENT FOR LATERAL TRANSFERS & REPOSITIONING Lateral –Low friction –Air assisted Mechanical Chairs & beds Ceiling lifts Trapeze

26. SHARP ASSESS EACH HANDLING TASK RESIDENT ENVIRONMENTCAREGIVER The best assessment is specific to that patient and that caregiver, and is done just before the task is to be performed. Adapted from OHSAH PATIENT/RESIDENT CEILING LIFT PROGRAM Focus on functional mobility

27. SHARP MEDICAL CASE MANAGEMENT Incidents are investigated Active case management Light-duty jobs available Medical community knows of zero-lift program

28. SHARP ZeroLift Initiative: Effectiveness Evaluation H1: Premium Discount homes will have higher ZeroLift scores & greater decrease in WC rates H2: WC rates decrease more for nursing homes with more developed ZeroLift environments Rate of decrease in back claims greater in nursing home industry than all industries Evaluation Research supported in part by NIOSH (# OH03749)

29. SHARP Effectiveness EvaluationMethods Effectiveness Evaluation: Methods Employer surveys: yearly x 4 86%, 95%, 91%, 81% participation No difference in participation by group site visits to study sites year 1 & year 2 12 premium discount (6 counties) 12 job mod (1 very large county) 12 comparison (rest of the state) Monitor workers compensation claims rates for back and shoulder disorder claims

30. SHARP Premium Discount Group Gets More Equipment P<0.01

31. SHARP Survey 3 Employer Self Rating of ZeroLift Elements

32. SHARP Management: What do YOU think are the biggest barriers to reducing injuries related to resident handling? Staffing –Management stability –Nursing assistant turnover Equipment Residents –Acuity –Dementia Training Funding

33. SHARP NAC Survey: Perceived Risk of Injury Compared to other NACs doing a job like mine, how likely is it I will be hurt doing my job?

34. SHARP NAC Survey: Beliefs about using electric lifts (n=159)

35. SHARP NAC Survey: Want me to use equipment to handle residents

36. SHARP NAC Survey: How important is it to me what these people want?

37. SHARP NAC Survey: Agreement with statements

38. SHARP

40. Claims Incidence RateClaims Incidence Rate Claims Incidence Rates Compensable Back Injuries with Source =Other Person

41. SHARP

42. Bigger effect on lost time?

43. SHARP Important Predictors Hand crank lifts per # NAC, residents ** Residents per NAC *** Non-profit versus For-profit status NAC turnover *** Management turnover Premium Discount group: yes/no *** Region Training score Enough Equipment* Mgmt commitment* S&H Committee-discuss prevention*** ** p<0.05, ***p<0.01

44. SHARP Barriers to preventing back injuries High management turnover High Nursing Assistant turnover Changing ownership Changing regulations Changing resident characteristics Payment systems Management turnover NAC turnover Bankruptcy Larger % of PD nursing homes are “for- profit” Organization Beliefs about risk, residents and time

45. SHARP Barriers: Changing Markets Job Growth Nursing homes 3.6% 1987-92, 2.7% 1992-97 Home Health 16.5% 12.4% Experienced CNAs move to Home Health or Hospitals Turnover staff: 74-400% involvement in care planning decreases turnover (30% if over advice, 50% if attend care plan meetings, Banaszak-Hall, 1996 )

46. SHARP Recommendations (a)  Better pay, good benefits and social support for NACs  Improved management skills  Provide accessible resident transfer devices  Involve NACs in plan of care, distribution of workload decisions, injury investigation  Enforce resident handling policies by eliminating barriers, not blaming  Training/retraining (include managing difficult residents)

47. SHARP onclusion Conclusion ZeroLift Programs can prevent injuries, protect patients and staff, and save money If Management commitment, employee involvement & stability are present