Patient Handling in a Patient Handling in a Military Treatment Military Treatment

FacilityFacility

Ergonomics ProgramErgonomics Program

MAJ Myrna CallisonMAJ Myrna Callison

What you will get What you will get from this presentationfrom this presentation

Magnitude of the ProblemMagnitude of the Problem VHA ProgramVHA Program WRAMC ProjectWRAMC Project ChallengesChallenges StrategiesStrategies Future Research NeedsFuture Research Needs

Patient HandlingUUSSAACCHH

PP

PPMM

ProblemProblem

WMSDs affect 1.7 million workers WMSDs affect 1.7 million workers every year and account for 1/3 of all every year and account for 1/3 of all reportable injuries (Frymoyer, 1997)reportable injuries (Frymoyer, 1997)– 60,000 will result in permanent disability60,000 will result in permanent disability– Back pain – most common Back pain – most common

musculoskeletal problemmusculoskeletal problem– 60 to 80% of the workforce will 60 to 80% of the workforce will

experience some type of LBPexperience some type of LBP

Low Back DisordersLow Back Disorders

Account for 27% of all nonfatal Account for 27% of all nonfatal occupational injuries involving days occupational injuries involving days away from work in the US (NORA, 2002)away from work in the US (NORA, 2002)

Economic costs Economic costs – Average compensation claim: $8,300 (twice Average compensation claim: $8,300 (twice

the average cost of $4,075 for all other the average cost of $4,075 for all other compensable claims combined)compensable claims combined)

– 1995: Total expenditures for WC claims for 1995: Total expenditures for WC claims for LBP – estimated at $8.8 billion (Shaw, 2001)LBP – estimated at $8.8 billion (Shaw, 2001)

Lost days away from workLost days away from work

BLS, 1994BLS, 1994

Type of injuryType of injury # of cases# of cases % resulting % resulting in back in back injuryinjury

Repetitive MotionRepetitive Motion 705,800705,800 32%32%

LiftingLifting 367,424367,424 65%65%

Pushing/Pulling ObjectsPushing/Pulling Objects 93,32593,325 52%52%

Holding/Carrying or Turning Holding/Carrying or Turning ObjectsObjects

68,99268,992 58%58%

Industries with Highest Incidence Rates of Injuries/Illnesses Industries with Highest Incidence Rates of Injuries/Illnesses

from Overexertion Resulting in Days Away from Workfrom Overexertion Resulting in Days Away from Work IndustryIndustry Annual average Annual average

employment (in employment (in thousands)thousands)

Incidence Rate Incidence Rate (per 10,000 (per 10,000

workers)workers)

# of cases# of cases

Nursing and Nursing and personal care personal care facilitiesfacilities

1,6481,648 318.0318.0 41,88441,884

Air Air transportation, transportation, scheduledscheduled

607607 306.7306.7 16,30916,309

Travel trailers Travel trailers and campers and campers (manufacturing)(manufacturing)

2222 303.7303.7 635635

Bottled/canned Bottled/canned soft drinks soft drinks (manufacturing)(manufacturing)

9595 255.6255.6 2,5122,512

Coal miningCoal mining 112112 235.6235.6 2,6092,609

BLS, 1994

Magnitude of the ProblemMagnitude of the ProblemNumber of Clinic VisitsNumber of Clinic Visits

Back InjuriesBack InjuriesEnlisted Health Care Enlisted Health Care

SpecialistsSpecialists

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

1997 1998 1999

Male

Female

Total

Source: DMSS

Nursing is a Nursing is a High Risk OccupationHigh Risk Occupation

Second only to heavy industry, such as Second only to heavy industry, such as coal mining (Abenhaim, et.al. 1988)coal mining (Abenhaim, et.al. 1988)

12% nurses leave the profession each 12% nurses leave the profession each year due to chronic/acute back injuries year due to chronic/acute back injuries and pain (Charney, et.al, 1991)and pain (Charney, et.al, 1991)

Over 52% nurses complain of chronic Over 52% nurses complain of chronic back pain lasting more than 14 days back pain lasting more than 14 days within the past 6 months (TerMat, 1993)within the past 6 months (TerMat, 1993)

Nursing is a Nursing is a High Risk OccupationHigh Risk Occupation

Based on workers’ compensation claims for back Based on workers’ compensation claims for back injuries, nursing aides and practical nurses were injuries, nursing aides and practical nurses were ranked fifth and ninth, respectively among all ranked fifth and ninth, respectively among all occupations (BLS, 1994)occupations (BLS, 1994)

It is estimated that up to 20% of nursing transfers It is estimated that up to 20% of nursing transfers to different jobs are associated with back injury risk to different jobs are associated with back injury risk (Owen, 1989)(Owen, 1989)

Moving patients in bed and transferring patients Moving patients in bed and transferring patients out of bed were responsible for 29% and 24% of out of bed were responsible for 29% and 24% of low back injuries, respectively (Vasiliadou, et.al. low back injuries, respectively (Vasiliadou, et.al. 1995)1995)

What We Know So FarWhat We Know So Far

Most injuries are cumulative in nature.Most injuries are cumulative in nature.

Patient care space deficits increase risk Patient care space deficits increase risk by forcing the nurse into awkward by forcing the nurse into awkward positions.positions.

Many nursing tasks far exceed the Many nursing tasks far exceed the threshold guidelines (such as NIOSH lift threshold guidelines (such as NIOSH lift equation)equation)

Nursing IssuesNursing Issues

Current workforce Current workforce shortageshortage

Increasing optionsIncreasing options Decreasing enrollmentDecreasing enrollment Aging workforceAging workforce InjuriesInjuries

InterventionsInterventions

ApproachesApproaches– Body mechanics, education and training Body mechanics, education and training

in lifting techniques, or in lifting techniques, or – Solely purchasing patient lift devices.Solely purchasing patient lift devices.

Over the past 20 years, efforts to Over the past 20 years, efforts to reduce work-related injuries in nursing reduce work-related injuries in nursing have been largely unsuccessful.have been largely unsuccessful.

VHA PROGRAMVHA PROGRAM

Key Program ElementsKey Program Elements

Ergonomic Systems ApproachErgonomic Systems Approach Safe Patient Handling & Movement Safe Patient Handling & Movement

PolicyPolicy Back Injury Resource Nurses Back Injury Resource Nurses

(BIRN’s)(BIRN’s) After Action Review ProcessAfter Action Review Process Safe Patient Handling & Movement Safe Patient Handling & Movement

Source BookSource Book Lifting Equipment Resource GuideLifting Equipment Resource Guide

Patient Care Equipment

Full Body Sling Lifts (Powered/Non Full Body Sling Lifts (Powered/Non Powered)Powered)

Lateral Transfer AidsLateral Transfer Aids Powered Stand Assist & Powered Stand Assist &

Repositioning LiftsRepositioning Lifts Stand Assist & Repositioning AidsStand Assist & Repositioning Aids Transfer ChairsTransfer Chairs Dependency/Geri ChairsDependency/Geri Chairs Gait BeltsGait Belts

24 Hour Patient Handling 24 Hour Patient Handling StudyStudy

Walter Reed Army Medical Walter Reed Army Medical CenterCenter

ObjectivesObjectives

Describe patient handling demands based Describe patient handling demands based on patient and nursing staff population on patient and nursing staff population and staff physical exertion that occurs on and staff physical exertion that occurs on inpatient units during a 24 hour periodinpatient units during a 24 hour period

Describe the physiological effect of Describe the physiological effect of transfers on discomfort level based on transfers on discomfort level based on patient dependency level, nursing and patient dependency level, nursing and patient population demographics, transfer patient population demographics, transfer characteristics and type of shift.characteristics and type of shift.

Patient Handling SurveyPatient Handling Survey

Subject Population: Approximately Subject Population: Approximately 300 nursing personnel volunteers 300 nursing personnel volunteers from Walter Reed Army Medical from Walter Reed Army Medical Center inpatient units.Center inpatient units.

Patient Handling StudyPatient Handling StudyProcessProcess

Complete demographic survey and Complete demographic survey and baseline body diagram at the start of baseline body diagram at the start of shift.shift.

Complete one coupon for each patient Complete one coupon for each patient transfer performed throughout their shift.transfer performed throughout their shift.

Research staff were stationed on each Research staff were stationed on each ward for the entirety of the study to ward for the entirety of the study to provide confidentiality and answer any provide confidentiality and answer any nursing staff questions.nursing staff questions.

Patient Handling SurveyPatient Handling SurveyDemographic SurveyDemographic Survey

Patient Handling StudyPatient Handling StudyCoupon booksCoupon books

ResultsResults

Staff DemographicsStaff Demographics  Military Civilian including

ContractorPercentage/Mean of Total Reporting

Population

% Of total staff 46 % 54%  

% Female 42% 85% 64%

% Male 58% 15% 36%

% Reporting Discomfort

40% 60% 55%

Mean Age 29 years 40 years 35 years

Demographics include 175 staff members that completed the demographic survey. Approximately 283 nursing personnel were on duty giving a 62% response rate.

        

Percent of discomfort in neck/shoulder, upper/lower back, upper extremity

and lower extremity as result of reported causes.

Reported Cause of Discomfort

Pe

rce

nt

70

60

50

40

30

20

10

0

Discomfort Location

Neck/Shoulder

Upper/Lower Back

Upper Extremity

Lower Extremity

 Percent of total transfers on 5 units with most responses

that are lateral and non-lateral transfers 

Transfer Category

non lateral transferlateral transfer

Pe

rce

nt120

100

80

60

40

20

0

UNIT

ICU/CCU

(28 transfers)

General Surgery

(21 transfers)

Med/Surg

(72 transfers)

SICU

(23 transfers)

MICU

(33 transfers)

ConclusionsConclusions

Military personnel were younger Military personnel were younger than their civilian co-workers.than their civilian co-workers.

More than 50% of transfers required More than 50% of transfers required greater than moderate exertion.greater than moderate exertion.

Repositioning in bed transfers were Repositioning in bed transfers were more than twice as frequent as the more than twice as frequent as the 22ndnd most often performed transfer. most often performed transfer.

Conclusions Conclusions

More than 50% of all lateral transfers, More than 50% of all lateral transfers, including repositioning and bed to bed, including repositioning and bed to bed, required moderate or greater physical required moderate or greater physical exertion while less than 20% of all other exertion while less than 20% of all other transfer types combined required transfer types combined required moderate or greater physical exertion.moderate or greater physical exertion.

64% of lateral transfers required greater 64% of lateral transfers required greater than 13 minutes to perform. 10.7% of all than 13 minutes to perform. 10.7% of all other transfers required greater than 13 other transfers required greater than 13 minutes.minutes.

Intervention Phase Intervention Phase

Nursing supervisor trainingNursing supervisor training Back injury resource nurse Back injury resource nurse

assignment and trainingassignment and training Nurse/assistant trainingNurse/assistant training Equipment solutionsEquipment solutions Command/leadership supportCommand/leadership support Follow up surveys Follow up surveys

ChallengesChallenges

Data GatheringData Gathering– Ability to identify high risk areas within facilityAbility to identify high risk areas within facility

UnderreportingUnderreporting– BeliefsBeliefs

Buy-in Buy-in – Command/leadership (Field of Dreams)Command/leadership (Field of Dreams)– Employees (Culture)Employees (Culture)

FundingFunding Patient/Family AcceptancePatient/Family Acceptance Patient Management PracticesPatient Management Practices

StrategiesStrategies

Command/Leadership SupportCommand/Leadership Support Identify champions within the facilityIdentify champions within the facility IdentificationIdentification

– Tasks, UnitsTasks, Units– Current practices as compared to best practicesCurrent practices as compared to best practices

Risk AssessmentRisk Assessment Equipment SelectionEquipment Selection Involve employees in processInvolve employees in process Education/TrainingEducation/Training PolicyPolicy

Future Research NeedsFuture Research Needs

Acute care facilityAcute care facility– TasksTasks– UnitsUnits

Low cost interventionsLow cost interventions Home care needsHome care needs Standardization of assessments and Standardization of assessments and

proceduresprocedures