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Even as U.S. senators pressured the Occupational Safety and Health Administration (OSHA) to act on ergonomics, two new models emerged for implementing ergonomics programs. They offer to fill a void left by the demise of ergonomics regulation and provide a possible basis for voluntary health care guidelines.
As of March, a year after Congress rescinded the ergonomics standard, OSHA still had not announced its new approach to ergonomics. Sen. Edward M. Kennedy (D-MA), chairman of the Senate labor committee, and two other leading Democrats from the Senate, Tom Harkin of Iowa and Paul Wellstone of Minnesota, asked OSHA for information related to its ergonomics efforts. In the House, four Democrats urged President George Bush to issue a new standard. Many observers expect the agency to rely on voluntary guidelines and education rather than creating a new regulation.
It’s not yet clear whether OSHA will create industry-specific guidelines. But the health care industry already can benefit from two new guides that provide a tailored approach to reducing patient handling injuries.
The Veterans Health Administration published its guide on Safe Patient Handling and Movement, a document that provides detailed information on how to match ergonomic equipment to patient needs, how to analyze risks, and how to monitor the success of a program.
Meanwhile, the lengthy settlement between OSHA and Beverly Enterprises of Fort Smith, AK, produced a basic guide that could be adapted at other long-term care facilities. It also contains information that could be useful to hospitals building a patient care ergonomics program.
"I don’t think any of us know what OSHA’s going to do, but we do know that we need to do something about the serious problem of musculoskeletal disorders (MSDs) among health care workers," says Guy Fragala, PhD, PE, CSP, a leading ergonomics expert and director of environmental health and safety at the University of Massachusetts Medical Center in Worcester.
"These guides will help transfer a lot of the knowledge as to how to implement an effective ergonomics program," he says.
The Veterans Affair’s (VA) step-by-step approach guides hospitals as they assess ergonomic needs and match patient-handling criteria to lifting aids. "There have been ergonomic analyses done in patient handling and movement, but there has never been a guideline such as this," says Mary Matz, MSPH, project manager of the Safe Patient Handling and Movement Research Project at the VA Patient Safety Center of Inquiry in Tampa, FL.
The guide helps hospitals focus their resources on the most injury-prone tasks. But Matz also notes that getting input from employees is an essential component. "We asked nursing staff and nurse managers, What do you see as your biggest problem?’ We took that into account in determining ergonomic controls appropriate for each patient care unit," she says.
Under the now-defunct OSHA standard, hospitals would have been required to respond to musculoskeletal injuries as they occurred. But the VA’s Patient Safety Center of Inquiry in Tampa came up with a proactive approach. It based its analysis of the risk of injury on extensive research conducted by ergonomic experts, as well as surveys of its own staff and a review of MSD injuries.
Hospitals should identify their highest-risk units and give them priority for resources, equipment, and training, says Audrey Nelson, PhD, RN, FAAN, center director.
"It’s very important to identify high-risk units. This is a mistake many people make. They have a small budget, and they try to spread it too thin," she says. "By focusing on your highest-risk units, it allows you to prioritize your time and resources."
Rehab and spinal injury units are examples of high-risk areas. But other factors may contribute to injury risk. For example, patients with unpredictable or combative behavior or with cognitive impairments can unwittingly contribute to staff injuries. Frequent twisting or turning or repositioning patients without proper aids can lead to injuries.
"Not all high-risk tasks are lifts or transfers," Nelson says. "People get that in their mind in the beginning, and they neglect other tasks that may have [contributed to long-term stress]."
Purchasing the right kind of equipment is a first step. But how do you make sure employees use the equipment when it’s needed? The VA guide provides patient assessment criteria and algorithms to help health care workers identify the injury-prone tasks and the patients’ needs for transfer assistance.
"You want to match the patients’ needs to the solution you’re using," Fragala says. "Different units may have different solutions for different tasks."
Hospitals can begin by classifying patients according to their level of dependency and ability to bear weight. A patient who can partially assist is defined as someone who needs no more than 50% physical assistance of a nurse while performing the transfer. A dependent patient needs more than 50% assistance or is unpredictable in the amount of assistance offered.
The assessment also must take into account medical conditions and other factors. For example, a post-surgical patient may not be able to tolerate a sling.
"You have two basic classifications of lift: The full-body sling lift and the stand-assist lift, Fragala explains, one of the authors of the VA guide. "The criteria for matching those lifts to a patient are dependency level and weight-bearing capability. Someone who is totally dependent with no weight-bearing capability would require a full-sling lift. If someone has some weight-bearing capability, then the stand-assist lift can be used."
There may be reasons why patients could not use a lift. "Are they likely to have problems with their skin? Can they not bend certain joints? In that case, you may need to manually transfer them from a bed to a stretcher," Fragala says. "To aid such transfers, you would look at these powered lateral-assist devices or friction-reducing lateral-assist devices."
The patient-handling guide offers algorithms to help health care workers make choices about the best ergonomics equipment. (See assessment criteria and sample algorithm.)
Once the program has been implemented, its effectiveness should be monitored. The VA guide offers formulas for determining the cost impact of patient-handling injuries. "It’s important to set realistic goals for your patient care ergonomics program," Nelson says.
Borrowing an idea from the Department of Defense, the VA began conducting "After Action Reviews," enabling staff to gather in teams to discuss the root cause of injuries, or even of a near miss.
The reviews are designed specifically for frontline staff, Matz notes. "If there are recommendations that need to be made, the supervisor needs to be made aware of them. But they are not involved in the initial brainstorming and recommendation-making process."
"It’s empowering staff. It’s giving them responsibility for their own safety," she says.
(Editor’s note: The VHA’s Safe Patient Handling and Movement guide is available on-line: www.patientsafetycenter.com/products.htm.)