One major source of injury to healthcare workers is musculoskeletal disorders (MSDs). In 2010, nursing aides, orderlies, and attendants had the highest rates of MSDs. There were 27,020 cases, which equates to an incidence rate (IR) of 249 per 10,000 workers, more than seven times the average for all industries. This compares to the all-worker days-away from work rate of 34 per 10,000 workers. The rate for construction laborers was 85.0, and for laborers and freight, stock and material movers the IR was 154.9, still far lower than that of nursing aides and orderlies. In 2010, the average incidence rate for musculoskeletal disorder (MSD) cases with days away from work increased 4 percent, while the MSD incidence rate for nursing aides, orderlies, and attendants increased 10 percent.
These injuries are due in large part to overexertion related to repeated manual patient handling activities, often involving heavy manual lifting associated with transferring, and repositioning patients and working in extremely awkward postures. Some examples of patient handling tasks that may be identified as high-risk include: transferring from toilet to chair, transferring from chair to bed, transferring from bathtub to chair, repositioning from side-to-side in bed, lifting a patient in bed, repositioning a patient in chair, or making a bed with a patient in it.
Sprains and strains are the most often reported nature of injuries, and the shoulders and low back are the most affected body parts. The problem of lifting patients is compounded by the increasing weight of patients to be lifted due to the obesity epidemic in the United States and the rapidly increasing number of older people who require assistance with the activities of daily living.
The consequences of work-related musculoskeletal injuries among healthcare staff are substantial. Along with higher employer costs due to medical expenses, disability compensation, and litigation, injuries also are costly in terms of chronic pain and functional disability, absenteeism, and turnover. As many as 20% of healthcare staff who leave direct patient care positions do so because of risks associated with the work. Direct and indirect costs associated with only back injuries in the healthcare industry are estimated to be $20 billion annually. In addition, healthcare employees, who experience pain and fatigue, may be less productive, less attentive, more susceptible to further injury, and may be more likely to affect the health and safety of others.
Industries where patient handling tasks are performed include:
- Long-Term Care (includes facilities that provide skilled or non-skilled nursing care);
- Acute Care – (includes hospitals, out-patient surgical centers, and clinics);
- Home Healthcare workers; and
- Others – such as physical therapists, radiologists, sonographers, etc.
Some examples of areas of a facility that may be identified as high-risk include: bathing rooms, extended care wings, and diagnostic units (e.g., radiology, emergency department, spinal unit, orthopedics department).
Given the increasingly hazardous biomechanical demands on caregivers today, it is clear the healthcare industry must rely on technology to make patient handling and movement safe. Patient transfer and lifting devices are key components of an effective program to control the risk of injury to patients and staff associated with lifting, transferring, repositioning or movement of patients. Essential elements of such a program include management commitment to implement a safe patient handling program and to provide workers with appropriate measures to avoid manual handling; worker participation in the assessment and implementation processes and the evaluation and selection of patient handling devices; a thorough hazard assessment that addresses high risk units or areas; investment in equipment; care planning for patient handling and movement; training for staff; and program review and evaluation processes. The education and training of healthcare employees should be geared towards assessment of hazards in the healthcare work setting, selection and use of the appropriate patient lifting equipment and devices, and review of research-based practices of safe patient handling.
The use of assistive patient handling equipment and devices is beneficial not only for healthcare staff, but also for patients. Explaining planned lifting procedures to patients prior to lifting and enlisting their cooperation and engagement can increase patient safety and comfort, and enhance their sense of dignity.
Patient handling-related injuries and illnesses in hospitals are a serious and costly problem. In March 2006, Washington State Governor Christine Gregoire signed new legislation requiring hospitals to implement a safe patient handling program. A Safe Patient Handling Steering Committee organized to help hospitals implement safe, cost effective patient-handling program. The goal of the steering committee is to assist with and disseminate information about every aspect of the implementation of the new legislation. Please visit the steering committee’s Web page at: www.WashingtonSafePatientHandling.org .
SHARP has also begun an exciting new project aimed at evaluating the effectiveness of these safe patient handling programs to prevent work-related injuries. Initial site visits to Washington hospitals were completed in 2007. Findings from the research will be posted as they become available, but please also see the reports below from past SHARP studies on patient handling-related injuries.
Solutions to Safe Patient Handling
Manual handling of patients is hazardous for both healthcare staff and patients. The Washington State House of Representatives Commerce and Labor Committee asked the Labor & Industries to form a task force with representation from labor and business to examine issues related to safe patient handling in healthcare. Sectors of the healthcare environment included in this study were: hospitals, nursing homes, home healthcare, home care, hospice and pre-hospital medical services.
SHARP reviewed the literature on patient and staff safety related to handling patients, as well as Washington State workers’ compensation claims data for related injuries, rates and costs. Several facilities in each healthcare sector were visited to obtain information about successes and barriers to implementing safe lifting programs.
There is a close relationship between patient safety and staff safety. Patients are increasingly older, heavier and often sicker. These patients are being cared for by skilled healthcare workers who are also getting older. This has contributed to the problem of recruiting and retaining qualified or experienced staff. Musculoskeletal injuries, especially of the back, also continue to be a problem in this industry.
A review of the 2003 compensable back injury claims rates from the Washington State Workers’ Compensation data found:
- The workers’ compensation healthcare sector insured by Labor & Industries had a rate of 3.9 times greater than the rate for all other industry sectors combined.
- The self-insured healthcare sector had a rate of 1.5 times higher than the rate for all other industry sectors combined.
Findings From Study Site Visits
Lifting Patients in Hospitals
- The challenge of retaining staff stems from the aging of current licensed staff and the inadequate numbers being trained to meet future demands.
- Most hospitals visited in the study had at least one ceiling lift. The advantages of ceiling lifts were: easy availability, space saving, smoother handling of patients, and reduction of staff turnover.
- Both management and employees interviewed recognized that while mechanical patient handling equipment was essential, it was not sufficient without an integrated program or process.
Lifting Residents in Nursing Homes
- An increasing challenge to handling patients is the increasing number of obese and bariatric (extremely obese) residents. Some of the nursing homes did not have the capacity to admit bariatric patients.
- All the nursing homes visited in the study had some type of mechanical patient handling devices including sit/stand devices and total body lifts.
- There were no ceiling lifts observed in any of the nursing homes visited.
Lifting Patients in Home Healthcare
- Workers in the home sector face unique challenges in that the home is not often designed for ease of patient assisted transfers.
- Home sector workers often work alone and must transfer patients by themselves.
- Insurance rarely covers transfer devices. This might be what that allows patients to remain in their home and not be moved to long-term care facility.
Patient Transfers and Patient Lifts
A critical issue in ergonomic patient handling is the distinction between a patient transfer and a lift. A transfer is a dynamic effort in which the patient aids in the transfer and is able to bear weight on at least one leg. A lift involves moving a patient who cannot bear weight on at least one leg. Lifts should always involve mechanical lifting devices.
Injuries to caregivers during patient transfers usually occur when a patient transfer suddenly becomes a patient lift. Assessment of the client’s capabilities therefore becomes a critical component of any ergonomic patient-handling program. Patients who suddenly lose their balance must be identified to determine whether two caregivers are necessary to affect a transfer or whether a mechanical device is necessary.
The relative sizes of the caregiver and the patient must be considered when one is determining the need for additional staff to aid in a transfer or the need for a mechanical lift. The weight and height differences may dictate the necessity of mechanical assistance.
Patient Assessment
An assessment of the individual patient must be performed to determine the proper transfer method and clearly outline the patient’s degree of mobility and physical impairment.
Patient assessment criteria may include:
- How much assistance does the patient require?
- What is the weight bearing capacity of the patient?
- Does the patient have enough upper body strength to support their weight during the transfer?
- Is the patient co-operative, and can they understand instructions?
- Is the patient able to cooperate with each lift, or does this change each time (e.g., time of day)?
- Are there physical characteristics that should be noted (height, weight, age)?
- Are there special circumstances such as injuries, presence of tubes, history of falls, osteoporosis, fractures, pressure ulcers, splints, history of spasms, etc.?
This information must be clearly communicated to all staff that may care for the patient including staff that may be filling in for workers that are ill or on vacation. Appropriate symbols and codes can communicate whether the patient is capable of an unassisted transfer, can bear his or her weight on at least one leg during an assisted transfer, or requires a mechanical lift. The ability of the patient to communicate with the caregiver to either identify physical limitations or to aid in the transfer will also determine the need for a mechanical lift.
Mechanical lifts should be available in all situations where the patient cannot bear weight on at least one leg. The adequate number, variety, and placement of mechanical lifts will need to be determined by a joint health and safety committee undertaking an ergonomic analysis of the workplace.
Training needs should also be assessed by the committee. Are new employees receiving proper training and orientation regarding safe transfer techniques, patient or resident assessment, and the proper use of mechanical lifts? Are current staff receiving on-going in-service training and refresher training? Employees should also be informed about the importance of appropriate footwear and clothing. Proper footwear that is slip resistant and clothing that allows unrestricted movement can significantly reduce the chance of injury in transfers. Jewelry such as necklaces or bracelets can become a hazard if the patient grabs at these objects during a fall.
Proper Approach
- In addition to the physical layout of the workplace, equipment, staffing, and workload, the approach to the transfer or lift is a key element to reducing caregiver injuries.
- Proper documentation and communication should inform the caregiver of the patient’s abilities, transfer needs, physical stability, and tendency if any, towards aggressive acts. The caregiver should anticipate what actions would be necessary if the patient loses balance or falls.
- The procedure for the transfer should be clearly communicated and understood by any other staff assisting and the patient.
- The caregiver should assess the patient, even briefly, before every transfer.
- The patient should be transported the shortest possible distance by the lifting device. The mechanical lifting device should not be used to transport the patient outside the room. In transfers, tighten your abdominal muscles, keep your back straight, and use your leg muscles to avoid injury. Do not rotate or twist the spine. Move your entire body in the direction of the transfer.
- Never grab the client under his or her armpits as this could injure the client.
- Position yourself close to the client and assure footing is stable.
- Try to maintain eye contact with the client and communicate while the transfer is in progress.
- Never allow the client to grasp you around the neck as this could result in injury.
- Agree on the timing of the transfer with the client and other caregiver(s) and count together.
- Assure that the path of the transfer or lift is clear from obstructions and that furniture and aids that the client is being transferred to are properly placed and secure.
Additional Things To Know
Injury to the caregiver and patient can occur when transferring aggressive patients. Caregivers have a legal right to know if the patient they are caring for has a history of aggressive behavior. Caregivers must receive proper training and have the assistance of other properly trained staff when dealing with potentially violent patients. Depending on the level of aggression, the patient may need to be placed in a facility designed for the care of violent individuals.
The reasons for patient anger and hostility can be complex. Staff should be trained to identify the signs of potential aggressive behavior, the triggers that can lead to violent outburst, means of deescalating an aggressive encounter, and emergency procedures to follow if retreat from an aggressive patient is not possible or an attack occurs. Emergency communication and security procedures and systems need to be in place before they are needed. All aggressive incidents should be documented and reported to the health and safety committee.