Objectives
• Describe how to apply the nursing
home guidelines to develop a process
to protect workers.
• Discuss the benefits of implementing
an ergonomics process.
• Identify and analyze problem jobs in
nursing homes.
• Recognize practical solutions to
address problem jobs.
Nursing Home Guidelines
• The nursing home
industry is the first
industry that OSHA
selected for
ergonomics
guidelines.
Problem Defined
• MSDs accounted for 33% of all cases
• Of the six occupations representing
26% of the cases two were healthcare
workers (this group includes laborers,
janitors and truck drivers)
• Nurses aids, orderlies, and attendants
had one of the highest incidence of
injuries resulting in lost time
(overexertion 56% STF 20%)
Loss Source
• Health Care Associates are sustaining
strains and sprains to their back from
overexertion due to resident
handling.
Health Outcomes from
Exposure to Risk Factors
• Excessive exposure to risk factors
result in musculoskeletal disorders
which include:
– Low back pain
– Sciatica
– Rotator cuff injuries
– Epicondylitis
NIOSH Injury Prevention
Research
• 1728 nurses over 6 year period
– Impact of Intervention involving Best
Practices: mechanical lifting devises and
training
NIOSH Injury Prevention
Research
• Results
– More than 60% Reduction in WC injuries
– Initial cost of intervention Program
$159K
– $55K Annual Savings
– Cost recovered in less than 3 years
OSHA Perspective
OSHA will use the OSH Act’s General Duty Clause
to address ergonomic hazards in nursing homes.
The General Duty Clause describes the
employer's obligation to "furnish to each of his
employees employment and a place of
employment which are free from recognized
hazards that are causing or are likely to cause
death or serious physical harm to his
employees."
Nursing Homes Guidelines
Recommendations
• Manual lifting of residents be
minimized, and eliminated when
feasible
• Employers develop a process for
systematically addressing
ergonomics issues
Ergonomics Process
•
•
•
•
•
•
•
Provide management support
Involve employees
Identify problems
Implement solutions
Address reports of injuries
Provide training
Evaluate ergonomic efforts
Management Support
Employee Involvement
• Submitting suggestions or concerns
• Discussing workplace and work
methods
• Participating in design of work,
equipment, procedures, and training
• Evaluating equipment
Identify Problems
Implement Solutions
• Effective solutions
involve:
– Workplace
modifications that
• Eliminate hazard
and
• Improve work
environment
Addressing Reports of
Injuries
• Limit severity of
injuries
• Improve treatment
of injuries
• Minimize disability or
permanent damage
• Reduce claims and
costs
Training
Risk Factors in Nursing
Homes Guidelines
• Force
• Repetition
• Awkward postures
Examples of Resident
Handling Jobs
• Transferring resident
from bathtub to chair
• Transferring resident
from chair to bed
• Making bed with
resident in it
• Transferring resident
from chair to bed
• Transferring resident
from chair to toilet
• Undressing resident
• Repositioning resident
in chair
• Lifting resident up in
bed
• Feeding bed-ridden
resident
Force
• Examples of
excessive force
include:
– lifting or transferring
heavy residents
– unexpected or abrupt
forceful motions
– stopping resident falls
or lifting them off the
floor after a fall
Repetition
• Examples of repetitive
activities include:
– repeated repositioning
in bed
– numerous transfers to
and from beds, chairs
or commodes without
rest breaks
Awkward Postures
• Examples of awkward
posture are:
– Dressing or undressing
residents
– providing in-bed
medical care
– repositioning or turning
residents in beds
Other Areas Where Injuries
May Occur
• Housekeeping
• Kitchen
• Laundry
Identifying Problem Jobs
• To obtain information, analyze and
review
– Injury and illness logs
– Workers’ compensation reports
– Accident and near-miss reports
– Insurance company reports
– Employee interviews
– Workplace observations
Identifying Problems for
Resident Lifting
NIOSH Lifting Equation
• Calculate a RWL for Lifting
• Considers:
– Location of object lifted
– Frequency of lift
– Distance object is lifted
– Coupling (handle)
– Twisting
NIOSH Lifting Guide
• RWL=51*HM*VM*AM*FM*CM
• Under ideal conditions the maximum
recommended weight limit is 51 lbs
NIOSH Lifting Equation
• So what’s the problem with using this
equation when it comes to handling
people?
NIOSH Lifting Equation
• Maximum Recommended Weight
limit is 35 lbs for handling residents
• Assumptions
– Dependent patients >35 lbs
– Independent or partially weight bearing
residents <35 lbs
Patient Handling Scenarios
• 2 nurses helping
patient to stand from
chair
• Patient weighs 180lbs
• Can assist partially
(about ½ his weight)
– 2 nurses need to lift
90lbs
– 45lbs > 35lb RWL
Use lift or a sit-to-stand
device
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
Patient Handling Scenarios
• 1 nurse needs to
raise a patient’s leg
off the bed for wound
care
• Patient weighs 300lbs
(leg is ~16% of total
body weight)
– 47lbs > 35lb RWL
Use lift with limb sling or limb
positioner
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
Patient Handling Scenarios
• 4 nurses about to
move a fully
dependent patient
from bed to chair
• Patient weighs 250lbs
– 4 nurses need to lift
250lbs
– 62.5lbs > 35lb RWL
Use lift
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
Patient Handling Scenarios
• 1 nurse about to
move a fully
dependent patient
from bed to chair
• Patient weighs
100lbs
– 1 nurse needs to lift
100lbs
– 100lbs > 35lb RWL
USE LIFT!
Source: Waters, T. When is it Safe to Manually Lift a Patient? AJN 2007; 107(8): 53-58.
Identifying Problem
Jobs – Other Activities
• Activities Other than
Resident Lifting and
Repositioning:
– Bending to make beds
or feeding residents
– Lifting food trays
above shoulder level
or below knee level
– Pushing heavy carts
– Bending and manually
cranking an
adjustable bed
Identifying Problem
Jobs – Other Activities (Cont’d)
• Job Assessment
– Observing employees performing a task
– Discussion with employees activities and
conditions that they associate with
difficulties
– Checking injury records
Resident Assessment
 Level of assistance
 Size and weight
 Ability and willingness to understand



and cooperate
Rehabilitation plan
Medical conditions impacting choice
of methods
Other factors
Resident Assessment
Protocols
Patient Care
Ergonomics
Resource Guide
Resident Assessment
Protocol - Continued
• Patient Care Ergonomics Resource
Guide Flow Charts:
– Transfer to and from: bed to chair, chair
to toilet, chair to chair, or car to chair
– Lateral Transfer to and from: Bed to
Stretcher, trolley
– Transfer to and from: chair to stretcher
Resident Assessment
Protocol - Continued
• Patient Care Ergonomics Resource
Guide Flow Charts:
– Reposition in Bed: Side-to-Side, Up in
Bed
– Reposition in Chair: Wheelchair and
Dependency Chair
– Transfer a Resident Up From the Floor
Resident Assessment
Example- Continued
• Level of Assistance?
• Can the resident bear weight?
• Does the resident have upper
extremity strength?
• Is the resident cooperative?
• Weight? Height?
• Other factors?
• BMI exceeds 50 go with Bariatric
algorithms
Flowcharts in the Guidelines
• Questions are placed in a diamond
• Actions are placed in a rectangle
Is the patient
cooperative?
Use full-body sling lift and
2 or more caregivers
Resident Assessment Example
• Fred is an 80 year old resident at a nursing
home.
• He weighs 156 pounds and is 5’9” tall.
• He has dementia and a history of falls.
• Although some days he is cooperative, on
other days he is combative and fearful.
• When he is cooperative, he can bear
weight. Otherwise he resists standing.
• He is to be out of bed every day in a chair.
Resident Assessment
Example- Continued
• Level of Assistance
– Dependent
• Can the resident bear weight?
– No, because the resident is not always
cooperative
• Does the resident have upper
extremity strength?
– No, because the resident is unreliable for
using his upper body strength
Example of Assessing
A Resident Cont’d
• Patient level of cooperation and
comprehension
– No, unpredictable
• Weight - 156 lbs, Height 5’9”
• Other factors
– history of falls
– transfer to and from bed to chair
Example of Assessing
A Resident Cont’d
• Selection of equipment and method
of transfer :
– Use full body sling with two caregivers
Problem Solving Strategy
Change in philosophy:
• Lifting techniques are still important but no longer the only key
elements.
• Elimination or modification of lifting activities is more effective.
Use task analysis and patient assessment.
• Use engineering solutions (such as patient lifts, friction-reducing
devices, or transfer belts to reduce risk of injury).
• Standardized processes for equipment, sling and staff selection.
Engineering Solutions
• Involve a physical
change to the way
a job or task is
conducted or
physical
modifications to
the workplace.
Work Practice Solutions
• Involve the way
work is done and
do not involve a
physical change to
the workplace.
Example of Solutions in
Guidelines
•Description
•When to Use
•Points to Remember
Factors That May Affect
Solutions
• Resident’s rehabilitation plan
• Need to restore resident’s functional
abilities
• Medical contraindications
• Emergency situations
• Resident dignity and rights
Resident Lifting and
Repositioning Solutions
Floor-Based Sling Lift
Resident Lifting and
Repositioning Solutions Continued
Sit-to-Stand Lift
Resident Lifting and
Repositioning Solutions Continued
Ambulation Assist
Resident Lifting and
Repositioning Solutions Continued
Lateral Sliding Aid
Resident Lifting and
Repositioning Solutions Continued
Transfer Board
Resident Lifting and
Repositioning Solutions Continued
Electric Bed
Resident Lifting and
Repositioning Solutions Continued
Weighing Scale with
Ramp
Solutions for Other Than
Resident Lifting
Front-Loading Washers
and Dryers
Equipment Considerations
Equipment:
• Maintenance
• Availability
• Utilization
• Capability
Examples of Equipment
Questions - Continued
• Is the equipment too big for my
facility?
• Can it be stored in close proximity to
the area (s) where it is used?
• If needed, is a charging unit and
back up battery included?
Case Studies
Resources
• www.oshainfo.gatech.edu