Sacrificial lamb’ stance is killing healthy backs

Successful program reduces lifting injuries, costs

Preventing patient-handling injuries among health care workers requires a major attitude shift from "caring till it hurts" to "caring for the caregiver," says the creator of a model program for reducing back injuries in health care institutions.

"It’s ironic in the caregiving setting that we end up hurting our own bodies to take care of patients," says Beth Stowell, MPH, COHN-S, division manager for health care at Maine Employers Mutual Insurance Co. (MEMIC), a mutually held state insurance fund in Portland. "The sacrificial lamb’ attitude of the caregiver leads us to do whatever we perceive we have to do to serve patients, but if we don’t put better policies and procedures in place, tomorrow we could be in the position of not being able to help patients."

Cutting costs by 50%

Stowell presented her successful program for reducing patient-lifting injuries among HCWs, along with related costs, in a poster session at the recent annual conference of the Association of Occupational Health Professionals in Healthcare, held in Orlando, FL.

Formerly a safety consultant for a large hospital system, Stowell says the comprehensive "caring for the caregiver" program can reduce a hospital’s workers’ compensation costs for back injuries by at least 50% within a year or two, depending upon the institution’s size and level of commitment.

The plan was spawned by the Occupational Safety and Health Administration’s (OSHA) 200 Program, a pilot project unique to Maine. A voluntary compliance program introduced in 1992 for the state’s 200 worst injury-producing industries, it allowed employers to either devise prevention programs based on their own data or face wall-to-wall inspections and costly fines. Hospital systems and nursing homes were among the offenders that chose to participate.

While the 200 Program has ceased to operate, Stowell continues to assist health care facilities in reducing back injuries and workers’ comp costs through a successful multifaceted approach that emphasizes several key components: data analysis to determine risky lifts, a no-manual-lift policy, ergonomic team training, the use of mechanical lift devices, and top management commitment. Return-to-work programs must be in place for injured workers, as well.

Comprehensive assessment needed

In addition to considering OSHA regulations, the program examines a facility’s safety management, safety committee practices, and employee involvement.

While patient lifts and transfers are the most frequent causes of back injuries, "we almost always found that health care institutions did not have written programs on how to address injuries and how to assess transfers," Stowell tells Hospital Employee Health. "Our approach is very comprehensive because it’s not just assessing the patient; it’s also assessing the environments in which transfers take place, the caregiver, and the available equipment."

To help facilities evaluate their hazard controls and safety management practices, Stowell adapted an OSHA audit tool called the Program Evaluation Profile (PEP), customizing it for patient-handling criteria. (See PEP form, p. 31.) Shaded areas on the form reflect program elements related to reducing patient-handling injuries, and Stowell accompanies the form with documentation relating to each shaded area. (See box, p. 30, for examples of how "employee participation" is described relative to patient handling. See editor’s note at end of article for information on how to obtain documentation and examples for other criteria.)

Using the PEP as a self-evaluation tool, hospitals can assess which areas of their back safety program might be inadequate and how to write effective policies and procedures for reducing patient-handling injuries.

Written policies and procedures banning manual lifts are essential for reducing injuries and associated costs, Stowell emphasizes. The type of mechanical lift devices to be purchased depends upon a facility’s patient population, but she says most hospitals generally need some type of hydraulic device to lift patients from the floor, as well as for bed-to-chair and bed-to-toilet transfers. Emergency rooms should be equipped with lifts installed with overhead tracking, so lift devices need not be wheeled into crowded, hectic areas. Equipment for home health aides, who often are elderly and work where administrative controls and assist devices are lacking, is crucial as well.

"The point is that we must find out where the risky lifts are," she says.

Nurses resistant to change

To eliminate those risks, team training is essential for educating front-line health care workers about ergonomic risk factors so they can troubleshoot hazardous situations. Stowell recommends ergonomic teams tailored to different employee groups involved in lifting, such as groups for nurses, maintenance workers, food service personnel, and laundry workers.

"Nursing needs its own team because they have a cultural attitude that has to be changed, but they are very resistant to this type of change due to their sacrificial lamb mindset," she says. "Nurses often don’t admit they have a [back injury] problem and have trouble identifying risky job tasks even though most of the injuries are occurring there."

One way to convince nurses of the need for ergonomic problem solving is to show them the successes achieved with that approach in other departments and to involve the hospital’s physical therapy professionals, Stowell suggests.

Nurses also accept using mechanical lift devices when the devices are presented as a quality-of-care issue for patients instead of a means of protecting their own health.

"When we tell nurses that patients experience 90% fewer skin tears when we handle them with mechanical lifts vs. manual lifts where we practically rip people’s armpits off, they are more willing to do it," she notes. "That’s how deep their care till it hurts’ culture goes."

Ergonomics teams also should evaluate lift devices before hospitals purchase them, and Stowell routinely tells vendors to leave their equipment at hospitals for a two- to three-week trial period.

"Employees who are doing the lifting have to determine what type of mechanical lift to use in a facility, not administration or anyone else. The people who are doing the work should choose what they’re going to work with. The ergono mics team knows how many lifts they need to do, what kind of lifts, who they need to lift, and how often," she states.

Hospitals that participate in the comprehensive program can expect a significant effect on the bottom line. At a small regional hospital in northern Maine, medical and indemnity costs from lifting injuries fell from more than $75,000 in 1993 to less than $5,600 in 1997, with corresponding decreases in patient-handling injury lost-time incidents. (See graphs, above and below right.)

With top management commitment to the goal of eliminating lifting injuries, workers at all levels were involved in the process. Stowell helped identify hazards through an in-depth loss analysis. Interventions included establishing a lift injury prevention (LIP) team — a reference to the fact that past efforts to eliminate lifting injuries were merely "lip service," she notes. The LIP team established procedures for assessing potential movement for newly admitted patients and for making those moves with mechanical assist devices. A no-manual-lift policy was the program’s cornerstone.

Stowell notes that changes don’t occur overnight. Employee training and equipment purchases took place over three years. The process was considered part of a quality assurance program, so when two injuries occurred in 1996 due to nurses violating lifting protocols, the LIP team was reactivated.

Another regional hospital in Maine was plagued by patient-lifting injuries and significant lost time, despite a strong safety management system. A comprehensive injury management system was developed, and an ergonomic team recommended policies and procedures based on prohibiting manual lifts. Nursing staff were trained in using mechanical lifts, and full compliance was achieved within six months. Workers’ compensation costs were slashed from $112,600 in 1996 to $1,495 in 1998.

Stowell warns that hospitals often experience increased injury incidents as money spent on injuries decreases.

"The reason is almost any time you implement an ergonomics program, you raise the consciousness level and let people know you want to hear about what’s going on. That means you’ll see an increase in incidents, but the dollars actually will go down," she explains. "I always tell top management at the beginning not to overreact if they see an increase in incidents. The goal is to have early intervention, and the dollar cost goes down due to the decreased severity of incidents."

The commitment of top management is essential, she emphasizes. "They must want to solve this problem, and they must allow the ergonomic teams to problem-solve."

The program has been so successful that it was presented to OSHA compliance officers so they could address patient-lifting injuries in nursing homes as part of the agency’s 1996 Nursing Home Initiative.

[Editor’s note: For more information on implementing the patient-handling injury reduction program or on use of the PEP as a self-assessment tool, call Beth Stowell at (207) 791-3484.]

Example of PEP Documentation: Employee Participation

(Standard type represents OSHA documentation. Italic type represents examples of customized criteria related to patient-handling injuries as assessed by a manager at an individual hospital.)

1. Worker participation in workplace safety and health concerns is not encouraged. Incentive programs are present that discourage reporting of incidents, injuries, potential hazards, or symptoms. Employees/employee representatives are not involved in the safety and health program.

Health care workers are not cognizant of injuries related to lifting and moving clients. Not requesting help to assist transfer even when injured. Not using mechanical lifts. Not reporting moderate soft-tissue injury due to transfers/lifting.

2. Workers and their representatives are involved in the safety and health program and inspection of work areas, and are permitted to observe monitoring and receive results. Workers’ and representatives’ right of access to information is understood by workers and recognized by management. A documented procedure is in place for complaining of hazards or discrimination and receiving timely employer responses.

Health care workers participate in safety committee where transfer/lift injury trending is discussed. Each unit/department is given responsibility to address hazards of transfer/lifting. Lifting limit is stated. Health care worker transfer/ lifting behavior is not part of safety audit.

3. Workers and their representatives participate fully in developing the safety and health program and conducting training and education. Workers participate in audits, management- or third-party-conducted program reviews, and in collecting samples for monitoring purposes. They have the necessary training and education to participate in such activities. Employer encourages and authorizes employees to stop activities that present potentially serious safety and health hazards.

Health care workers are empowered with education to solve ergonomic problems and authority to choose mechanical transfer/lift/assist devices. Health care workers are actively involved in accident investigations. They write transfer/lifting policies and procedures to address ergonomic hazards on their particular unit/department. Health care workers demonstrate behaviors consistent with policies and procedures. All health care workers are authorized to alter care plans. Employees are rewarded for suggestions for improving safety.

Source: MEMIC Safety Services, Portland, ME.