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*Note:
OSHA is currently involved in rulemaking
concerning employee protection against Ergonomic hazards which may influence the following recommendations.
Many
residents are totally dependent on staff members to provide for their
activities of daily living (ADL), such as dressing, bathing, feeding, and
toileting. Each of these activities involve multiple interactions with
handling or transferring of residents and could result in employee injury.
In addition, recent trends are seeing hospitals sending sicker, more
dependent patients, to nursing homes for care, in an attempt to cut rising
hospital costs.
Click
on the area for more specific information.
Common
safety and health topics:
Ergonomics
Ergonomics is the science of fitting the job to the worker. When
there is a mismatch between the physical requirements of the job and the physical capacity
of the worker, work-related musculoskeletal (WMSDs) disorders can result. |
Hazard
Ergonomic hazards are
not effectively addressed in the safety and health program.
- Resulting in musculoskeletal
disorders, increased injury costs, higher turnover rates,
increased sick/injured days, and staffing shortages.
Example Controls
OSHA recommends that employers address ergonomic issues
in their facility's Safety and Health Program, see Nurses Station Safety
and Health Program Section.
OSHA is currently involved in rulemaking
for Ergonomics
which also addresses ergonomic programs.
Additional Information
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Resident Handling Program
According to the
Bureau of Labor Statistics in 1994, nursing home workers suffer most
injuries (51.2 percent) when handling residents. Fifty-eight percent
of their injuries are strains and sprains. While back injuries account
for 27 percent of all injuries in the private sector, in nursing homes
they account for 42 percent of all injuries. Of the 10 occupations
with the largest number of injuries and illnesses, nursing aides and
orderlies are exceeded only by truck drivers and non-construction
laborers. Back
injuries average more than $8,400 each, in Worker's Compensation expenses.
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Hazard
Potential risk factors for
ergonomic injuries in resident
handling include:
- Overexertion; trying to stop a patient from falling
or picking patient up from floor or bed.
- Multiple lifts per shift (more than
20; ref. OSHA Framework Document).
- Lifting alone/no available staff to help.
- Lifting un-cooperative, confused patients.
- Lifting patients that cannot support their own
weight.
- Patient weight.
- Expecting employees to
perform work beyond their physical capabilities.
- Distance to be moved, and the distance the patient
is from the employee, (it is more stressful to reach away from the body to lift or pull a
patient).
- Awkward postures required by
the activity.
- Ineffective training of
employees in body mechanics and proper lifting techniques.
Example Controls
It is recommend that resident
handling injuries be addressed in the nursing home safety and health
program.
Areas that should be addressed in a resident
handling safety and health program are:
Management
Leadership/Employee Participation:
- Management
Leadership should demonstrate a commitment to reduce or eliminate resident
handling hazards through establishing a written program that addresses
issues, such as:
- Continued training of employees in injury prevention.
- Methods of transfer and lifting to be used by all staff.
- Compliance with transfer and lift procedures.
- Procedures for reporting early
signs and symptoms of
back pain and other musculoskeletal injuries.
- Employee
Participation should include:
- Complaint/suggestion program which includes
employee reports of unsafe working conditions.
- Prompt reporting of signs
and symptoms as well as injuries.
Workplace
Analysis to identify existing and potential resident handling hazards and
find ways to correct these hazards. Changes are then implemented to correct the most
stressful of resident transfers. These changes are continually evaluated to
reduce risk of injury. Periodic screening surveys are used to help identify
stressful tasks and hazards.
Accident
and Record Analysis:
Records of injuries and illnesses
should be analyzed to identify
patterns of injury that occur over time, enabling the hazards to be
addressed and prevented. This
includes reviewing OSHA 200 logs, OSHA 101 forms and Workers'
Compensation reports.
Hazard
Prevention and Control including implementing
administrative and
engineering controls.
- Administrative controls: Provide for adequate
staffing, assessment of resident needs, and restricted admittance
policies.
- Engineering controls: Help to isolate or remove
the hazards from the workplace, for example providing proper selection
and use of assist devices or equipment (see Resident
Handling Controls Section).
Medical Management:
A medical
management program, supervised by a person trained in the prevention of musculoskeletal
disorders, should be in place to manage the care of those injured. The
program should:
- Accurate injury and illness recording.
- Early identification and treatment of injured employees.
- "Light duty" or "no lifting" work restrictions during
recovery periods.
- Systematic monitoring of injured employees to identify when they
are ready to return to regular duty.
Training: A training program, designed and
implemented by qualified persons, should be in place to provide continual
education and training about ergonomic hazards and controls to managers, supervisors and
all healthcare providers, including "new employee" orientation. Training should
be at a level of understanding appropriate for those individuals being trained, and should
also include:
- The opportunity to ask questions of the trainer.
- An overview of the potential risks, causes, and symptoms of back injury and other
injuries.
- Ways to prevent and treat these injuries.
- Encouragement of staff physical fitness.
- Lifting guidelines for health care workers (nurse assistants, licensed practical
nurses, registered nurses) which should include:
- Never transfer residents when off balance.
- Lift loads close to the body.
- Never lift alone,
particularly fallen residents, use team lifts or use mechanical
assistance.
- Limit the number of allowed lifts per worker per day.
- Avoid heavy lifting with spine rotated.
- Training in when and how to use mechanical assistance.
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Resident
Handling Controls |
Hazard
Nursing home health care workers (especially nursing
assistants, who do a majority of the lifting in many facilities) may
develop musculoskeletal injuries such as sprains and strains from resident handling
tasks if they:
- Repeat the same motion throughout their workday (i.e.,
repeatedly cranking manual adjustments for beds).
- Do their work in an awkward position (i.e.,
reaching
across beds to lift residents).
- Use a great deal of force to perform their jobs (i.e.,
pushing
chairs or gurneys across elevational changes or up ramps).
- Repeatedly lifting heavy
objects (i.e., manually lifting
immobile residents).
- Face a combination of these risk factors.
Example
Controls
Good work practice includes
continually identifying the most hazardous tasks and
implementing engineering and work practice controls to help reduce or prevent injuries in
those tasks.
- Provide employees with assist devices and equipment
to reduce excessive lifting hazards.
- Proper equipment selection depends on the specific
needs of the facility.
For example, implement
the use of:
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- Devices such as shower chairs
that fit over the toilet, using this device can eliminate multiple transfers, saving
health care workers multiple lifts. A patient can be moved to the shower chair, toileted,
showered, and transferred back to the wheelchair.
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- Shower stalls that allow for shower chairs
to be pushed in and out on level floor surfaces. This is a standard
shower without the front lip to allow for easy access.
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- Toilet seat risers: Use
toilet seat risers
on toilets to equalize the height of wheelchair and toilet seat, making it a
lateral transfer rather than a lift up and back into wheelchair.
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- Mechanical lift equipment
to help lift patients who cannot support their own weight. Choose a lift that does not
require manual pumping to avoid possible repetitive motion disorders to
workers' arms or shoulders.
Lift equipment can be categorized into 2 main categories:
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- Lateral
transfer devices: Devices used to
laterally transfer a resident for example from bed to gurney.
They usually involve multiple staff members to help do the
lifting. This is often done with the help of a draw sheet, or
similar device. Some new lateral transfer systems do not
require any lifting by staff, and are totally mechanical. This
type of device helps prevent staff back injuries.
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- Height
adjustable electric beds
that have height controls
to allow for easy transfers from bed height to wheelchair height. These beds can be kept low to the ground for
patient safety and then raised up for interaction with staff. Avoid hand cranked
beds,
which can lead to wrist/shoulder musculoskeletal disorders such as
strain or repetitive
motion injuries.
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- Trapeze lifts:
A bar device
suspended above the bed which allows residents with upper muscle strength to help
reposition themselves. This device is particularly useful with
adjustable beds and armless wheelchairs.
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- Walking belts or gait belts (with handles)
that provide stabilization for ambulatory patients by allowing workers to hold onto the belt and
support residents when walking.
Not designed for lifting patients.
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- Wheelchairs with removable
arms to allow for
easier lateral transfers. Especially useful with height adjustable
beds.
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- Sliding
boards: A slick board used under
residents to help reduce friction during transfer of resident from bed to chair or
when changing position in bed.
- Hazards of tearing or burning skin if board
is not
functioning properly.
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- Resident
care plans:
A written care plan
that describes specific resident needs, degree of assistance required, special treatments
etc. Possible scenarios include:
- Color coding of patient lift requirements for posting at bedside.
By simply looking at displayed color coding system an employee can know what kind of
assistance the resident will need with moving or transfers.
- Segregation of residents based on need so equipment and trained
staff are appropriately assigned.
- Staggered staffing to provide additional manpower for
peak periods.
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- Wheelchair
Scale or Roll on weight scale: Patients who cannot stand can be weighed in their
wheelchairs.
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Back belts: The effectiveness of
back belts in reducing the risk of back injury among healthy workers remains unproven.
- If workers falsely believe that they are protected
when wearing belts they may attempt to lift more weight than they would have without a
belt, risking potential injury (See Backbelts:
Do They Prevent Injury? (DHHS) (NIOSH) Publication No. 94-127).
For more ergonomic information see the
Nursing Home Whirlpool/Shower Module.
Additional Information
- Back
Disorders and Injuries. OSHA Technical Manual Section VII
Chapter 1.TED 1-0.15A.
- Back Facts: An OSHA training workbook to prevent
back injuries in nursing homes:
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Trips/Slips/Falls |
Hazard
Trip/slips and falls from spills or environmental hazards.
- Environmental hazards such as:
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- Lifting in confined spaces.
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- Cluttered or obstructed work areas/passageways.
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- Poorly maintained walkway
or broken equipment.
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- Inadequate staffing levels to deal with the workload,
leading to single person lifts and greater chances of falls.
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- Inadequate lighting, especially during evening
shifts.
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Example Controls
Good work practice
includes implementing
engineering and work practices controls to help prevent slips/falls such as:
- Eliminate uneven floor surfaces.
- Create non slip surfaces in toilet/shower areas.
- Use of no skid waxes and
surfaces coated with grit or waterproof footgear may also help
decrease slip/fall hazards.
- Immediate clean-up of fluids spilled on floor.
- Safely working in cramped working spaces-avoiding awkward.
positions, using equipment that makes lifts less awkward.
- Eliminate cluttered or obstructed work
areas.
- Provide adequate lighting especially during night
hours. Flashlights or low level lighting could be used when entering
resident rooms.
- Provide adequate staffing levels to deal with the workload.
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Awkward Postures
Twisting while lifting
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Awkward postures occur with twisted, hyper-extended or
flexed back positions. They are
unsafe back postures for resident lifting. More information about awkward
postures can be found in:
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Back flexion |
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Hazard
Increased potential for employee
injury exists when awkward postures are used when handling or lifting residents.
Awkward postures include:
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- Back hyperextension or flexion.
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Forces on the spine increase when lifting, lowering or handling objects with the back
bent or twisted. This occurs because the muscles must handle your body weight in addition
to the weight of the resident being lifted.
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- More muscular force is required when awkward postures are
used because muscles cannot perform efficiently.
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- Fixed awkward postures (i.e., holding the arm out straight
for several minutes) contribute to muscle and tendon
fatigue, and joint soreness.
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- To be considered a risk factor, awkward postures need to last more than 1 hour
continuously or for several hours in the workshift.
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- Reaching
forward or twisting to support a patient from behind to
assist them in walking.
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Example Controls
Good work practice
recommends avoiding awkward postures while lifting or moving
residents.
- Educate and train employees about safer lifting techniques.
- Use assist devices or other equipment when possible.
- Team lifting based on
assessment.
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