Inspectors trained in general duty clause actions
The U.S. Occupational Safety and Health Administration (OSHA) is ready to begin citing employers that fail to identify and reduce ergonomic hazards, OSHA administrator John L. Henshaw tells Hospital Employee Health.
This summer, OSHA inspectors received training on general-duty enforcement, including how to conduct investigations and develop documentation. The "general duty" clause of the Occupational Safety and Health Act requires employers to keep the workplace free of serious hazards.
Yet tough talk from the head of OSHA isn’t convincing to critics, who say an ergonomics regulation is still necessary. There have been no ergonomics citations issued since the agency announced its "comprehensive approach" last spring.
"This is smoke and mirrors," explains Bill Borwegen, MPH, occupational health and safety director of the Service Employees International Union (SEIU).
Henshaw promised action as OSHA geared up its National Emphasis Program, which is targeting nursing homes with the highest injury rates.
The agency will issue the final guideline for patient handling in nursing homes by the end of the year, Henshaw says.
Although the draft guideline does not specifically address the hospital environment, many of the recommendations are applicable. And OSHA still expects action from employers on ergonomics, he adds.
"In my mind, employers who have total disregard for identifying risk and controlling risk and allowing individuals to get hurt . . . are the ones we need to focus our efforts on," Henshaw explains. "Those are the ones that would be candidates for 5A1 [enforcement]."
He notes that the guidelines are voluntary and employers won’t be required to follow any specific recommendations. "All we’re asking is that they have some [way to] identify hazards and reduce them," he says.
OSHA has been buoyed by its success in the Beverly case, in which the agency cited a nursing home chain, Beverly Enterprises of Fort Smith, AK, for ergonomics hazards under the general duty clause. The case was settled last year, about 10 years after the citations were issued.
"We had significant input from our solicitors who have seen the successes and failures in bringing forth 5A1 cases," Henshaw says of the agency’s new enforcement strategy. "Now having this kind of procedure developed, we will be more successful in bringing 5A1 cases forward and prosecuting those who have disregarded their obligations under the law."
OSHA created a "comprehensive approach" to ergonomics as an alternative to a regulatory standard, which was overturned by Congress in 2001. The plan includes industry-specific voluntary guidelines and emphasizes consultation. While political pressure remains for an enforceable standard, Henshaw insists that’s not necessary.
"We don’t need legislation to force us into anything," he says, referring to a bill introduced in the U.S. Senate to mandate an ergonomics rule.
"I firmly believe the process we’re undertaking now is going to be much more effective than any other process," he says. "We can accomplish much more in a shorter time frame and achieve more lasting results — reducing ergonomic injuries and [putting] less burden on what I would call a pretty fragile economy."
What does OSHA expect from hospitals? Some guidance can be found in OSHA’s draft ergonomics guideline for nursing homes. (Go to http://www.osha.gov/ergonomics/guidelines/ nursinghome/index.html.)
The document, which contains information from the safe patient-handling manual issued by the Veterans Health Administration (VHA), includes algorithms and a resource guide that explains different types of ergonomic equipment.
Borwegen criticized the guidelines as too vague. "They don’t provide a useful recipe for employers," he says. "It’s not a how-to guide. When you get into control strategies, they become very vague."
For example, OSHA does not address how to determine the proper number of lifts to serve a patient population.
OSHA broadly emphasizes the importance of management commitment, assessment of tasks and work sites, and control methods to reduce risk. The draft guidelines include a training matrix, indicating which employees need inservice programs and what topics should be included.
Yet there’s one type of training that OSHA does not recommend: Employers can’t resolve ergonomics hazards simply by teaching better body mechanics. "OSHA recommends that manual lifting of residents should be minimized in all cases and eliminated when possible," the guidelines state. "Minimizing and, where possible, eliminating resident lifting is the primary goal of the ergonomics process in the nursing home setting and of these guidelines."
Since patient-handling is very similar in the hospital setting, the same concept applies to them, says Guy Fragala, PhD, PE, CSP, director of environmental health and safety at the University of Massachusetts Medical Center in Worcester.
Tasks have to be redesigned, with the use of ergonomic equipment. "Management needs to understand that and accept that. That’s an important statement," he says.
The myth that good body mechanics can prevent injury is widespread. "One of the problems is that the health care professionals, including nurses, have been taught that if you lift safely, you won’t get hurt," says Arun Garg, PhD, CPE, professor and chair of the industrial and manufacturing engineering department at the University of Wisconsin-Milwaukee. "There’s no such thing. You’ve got 200-pound and 300-pound patients. You just can’t lift them safely. That’s where we need a change in attitude.
"In that regard, I think the manufacturing industry has done a better job," says Garg, who is also an ergonomics consultant. "Now you don’t go into a plant and see people lifting 200-, 300-pound objects. But in the health care environment, we continue to see that."
In fact, hospitals have some advantages when it comes to reducing ergonomic injuries, Fragala says.
They can purchase beds that have built-in features to assist in repositioning or transfer. In reviewing data from seven hospitals, Fragala found that repositioning patients in bed was the activity that was responsible for the most injuries.
"We need to work more on solutions [to repositioning]. It is a difficult task," he says. "It’s something that has to be done quite often. The best route to solution may be to prevent the person from sliding down in bed."
OSHA may eventually issue a guideline that is specific to hospitals. (The next two guidelines will cover grocery retailers and the poultry industry.) The nursing home guideline states, "These voluntary guidelines are intended for nursing and personal care facilities only. Other employers with similar work environments, such as hospitals and home health care providers, may find the information provided useful. Care should be taken, however, to ensure that distinctive circumstances found in different work environments are taken into account in developing ergonomic solutions for specific workplaces."
Hospitals have a wider range of patient conditions — and a greater number of solution options, Fragala says.
Hospitals also have a significant history of success in controlling musculoskeletal injuries through ergonomic interventions, Garg notes. "The employees who I have talked to at places where they have implemented these kinds of devices don’t know how they would survive without them," he says.