Incentives, lifting devices cut back injuries to nurses

One of the best methods for eliminating costly back injuries in health care settings is to stop lifting patients. No lifting equals no back injuries, the experts say. But how do you go about it? Isn’t lifting an unavoidable job for health care workers? Not at all, say leaders at two institutions that have successfully eliminated manual lifting through the use of mechanical lifting devices and incentive programs. The equipment and incentive payments may be costly, but they’re nothing compared to the high cost of the back injuries you prevent, they say.

An institution that has made progress in reducing back injuries is Beverly Enterprises Inc., with headquarters in Fort Smith, AR. One of the nation’s largest nursing home operators with 408 facilities nationwide, Beverly recently adopted specific measures to reduce back injuries for employees involved in lifting nursing home residents. The improvements came as part of a settlement agreement with the Occupational Safety and Health Administration (OSHA). The company agreed to establish a training program and purchase mechanical lift equipment even though officials there thought they already had an effective ergo-nomic program in place, reports Jim Zoesch, director of safety and loss control.

The issue is a hot topic for risk managers at all health care facilities because transfer injuries and other musculoskeletal injuries can happen in any setting. According to the American Nurses Association (ANA), back injuries affect up to 38% of all nurses; and lifting, transferring, and repositioning patients are the most common tasks that lead to injury. In fact, in a recent survey by ANA, 60% of nurses cited disabling back injuries as their top health and safety concern on the job.

OSHA settlement spurs more action

The settlement applies to all Beverly Enterprises facilities within federal OSHA jurisdiction, according to a report from OSHA. The agreement settles citations issued by OSHA to five Pennsylvania nursing homes following a 15-month investigation that began in May 1991 in response to complaints that workers were suffering back injuries related to lifting and transferring residents. The agency found that the company’s injury and illness records revealed numerous musculoskeletal injuries sustained by nursing assistants that resulted in extensive lost work time and restricted work duty.

The Service Employees International Union, District Local 1199P and Local 668, which represent workers at the Pennsylvania facilities, also signed the settlement agreement. Under terms of the settlement agreement, Beverly agreed to withdraw its contest of the citations and OSHA agreed to withdraw the proposed penalties.

Zoesch says Beverly already was in the process of purchasing mechanical transfer equipment for every facility but accelerated that program as part of the OSHA settlement. By providing the equipment and education on how to avoid manual lifting, the company hoped to dramatically reduce the incidence of back and other musculoskeletal injuries. The most common injury at all Beverly facilities was musculoskeletal injury from patient transfers, he says.

It soon became obvious to Beverly leaders that simply providing the means to avoid manual transfers weren’t enough, Zoesch says. The company had to find a way to persuade employees to use the lift devices. "What really has changed in the last year is we have implemented a companywide incentive program that focuses on preventing lost time injuries," he says. "As a result, lost time injuries are down 12% over last year. About two-thirds of our facilities complete each quarter without a lost-time injury."

Beverly sets aside funds for each facility to use in celebrating its success. After each quarter, the facility submits its OSHA log of injuries to the headquarters, where Zoesch reviews it and confirms that there were no lost time injuries. Then he informs the facility of how much money it has to spend on a celebration, which will vary depending on the size and location of the facility.

Beverly advises the local facility’s safety committee to come up with ideas on how to celebrate and then let the staff make the final decision. The celebrations range from the typical pizza party to more unusual rewards, such as buying monogrammed lab coats for all the staff to wear at work. "We’re finding that success breeds success," he says. "We’ve got facilities that have gone all three quarters without lost time, but we have one that is working on five years and another working on 10 years."

Close review of all transfer injuries

Zoesch says the lifting devices and similar strategies are key to reducing musculoskeletal injuries and their associated costs, but he says they will be of limited use without some type of incentive program that gets the employees to actually use them. Though Beverly hands out cash to facilities with good results, the investment is well worth it when the injuries decrease, he says. "Twenty-five years ago, I thought incentives were a total waste. My position was that we pay you a day’s wages for a day’s work, and that’s it," he says. "But I’ve really seen in this industry that we’re beating people on the head all the time with requirements and you have to give them some pats on the back when they’re successful."

Beverly employs other strategies as well, such as having Zoesch review all transfer injury claims sent to its third-party administrator. For every transfer injury claim, Beverly sends e-mail to the facility’s director of operations and asks for an explanation of how the injury happened and what is being done to prevent recurrences. "That has created a high level of awareness, a sense that we take transfer injuries very seriously," he says. "They know they’re going to be asked about it, so they investigate them right away instead of just accepting it as another injury."

Beverly also made accident prevention part of its corporate quality council to make the topic high profile with top administration. Upper management attends the quality council every month and hears an update on how the company is reducing transfer injuries.

"We also publish in our quarterly newsletter the names of all the facilities that were successful in avoiding lost time injuries," Zoesch reports. "People see that success, and those that were sitting on the fence start thinking maybe they should get in on the action, too."

No-lift environment yields fast results

Another facility taking a hard-line approach to transfer injuries is Forsyth Medical Center in Winston-Salem, NC. Forsyth became one of the first hospitals in North Carolina to begin converting to a completely lift-free environment, investing $500,000 in equipment that will help staff lift and transfer patients from beds, stretchers, wheelchairs, and even cars. The program immediately started helping prevent back injuries among staff, while increasing comfort and safety for patients, notes Kathy Avery, BSN, director of employee occupational health, which includes workers’ compensation claims.

The Get a Lift program has three main goals: To help prevent neck, back, and shoulder injuries among nurses at Forsyth and therefore reduce lost work hours, and to help recruit and retain nursing staff. Even though Forsyth has a vacancy rate of just 4.5% to 5%, well below the national average of 11%, Forsyth nursing leaders believe this extra measure will be an added benefit that can help recruit staff, Avery says. "We’ve had applicants come in from other parts of the country and ask what kind of lifting devices we use," she says. "This is an issue that nurses are recognizing more and more as a way to differentiate between hospitals where they want to work."

The new equipment includes a hydraulic system that can lift up to 880 pounds and will be available for use in every department of the hospital. Forsyth does a good number of bariatric surgeries, so it is common to have patients weighing up to 500 pounds, making every transfer potentially hazardous, Avery says. For more typical patients who are not able to sit up or walk on their own, using the new equipment will be more comfortable, safer and faster than manual lifting. It will eliminate risks to both patient and staff member by preventing falls that can occur during lifting or transferring, and reducing the number of staff needed to transfer patients.

Forsyth selected the new equipment by working closely with the physical therapy department, where staff are specially trained and experienced in transfer techniques, and also by holding vendor fairs in which manufacturers could bring equipment in for staff to try out. The staff who would use the equipment was instrumental in making the final selections, Avery says. "We got approval from administration pretty easily because they saw the cost of back injuries," she says. "We averaged about $100,000 a claim, so it wasn’t hard to convince them that we should buy the equipment."

After buying the equipment, the next question was how to educate the hospital’s 4,000 employees on how to use it. Forsyth leaders didn’t think they were equipped for that task, so they opted to use an outside educational firm. The consultants provided training 24 hours a day for two weeks to ensure that all staff were properly educated.

The new equipment arrived in June 2003 and the original plan was to implement a strict "no-manual-lifting" policy by the end of the month. But then the staff realized that the lifts would not work with about 20 of the beds in the hospital, so the deadline was extended to Oct. 30 so the beds could be modified.

The hospital now forbids staff from lifting patients manually, with some exceptions granted to physical therapists because of the nature of their work and their advanced training in transfer techniques. Even before the policy became mandatory, the addition of the lifting devices had an immediate effect on injuries, Avery says. There were 89 back injuries at the hospital in 2002 and only 14 in 2003. Staff suffered 14 shoulder injuries last year, down to four in 2003.

"We’re still analyzing the return on investment, but there is no doubt that we will save a great deal more than we spent on the equipment and training," she says. "It’s obvious that the money was well spent. With 89 back injuries last year and 14 this year, we’ve saved money on medical and indemnity, so there is no doubt. I think the equipment will pay for itself within the year."

The no-lifting policy also enables work-restricted nurses to get back on the job faster because there is no requirement for lifting. Avery says the no-lift environment has been received well by the staff, which sees this as an indication that someone cares about their welfare.

To determine when lifting aids are necessary, every patient is assessed on admission. If the patient meets certain criteria for posing a lifting hazard to staff, that chart is flagged and a special Get a Lift magnetic sticker is posted on the patient’s door. That signals the staff that all patient transfers for that patient must be done with the aid of one of the lifting devices.

Avery notes that an important part of making the program work is that there are enough lifting devices in all patient areas of the hospital. The administration avoided the typical hospital purchasing approach of "if we need 30, we can probably get by with 10," she says. "We purchased enough so that these devices are available on every floor, all the time," she says. "We’re being very strict about requiring their use, so we didn’t want staff to say that they couldn’t find one and didn’t have time to go to the seventh floor to get one. If you’re serious about having a lift-free environment, you have to provide enough tools to make that possible."