Applied Ergonomics for LTC

Applied Ergonomics for LTC
University of Oregon, Labor Education and Research Center (LERC) and Oregon Occupational Safety and Health Administration (OR-OSHA) This material has been made possible by a grant from the Oregon Occupational Safety and Health Division, Department of Consumer and Business Services

Acknowledgements Materials for this presentation material made possible by Oregon OSHA Veterans Health Affairs SAIF Corporation HumanFit Bay Area Hospital, Coos Bay, OR Oregon Nurses Association (ONA) University of Oregon, Labor Education and Research Center Back Injury Resource Nurses (BIRN) National Institute of Occupational Safety and Health (NIOSH)

Introduction Today’s workshop will cover Ergonomic concepts
Risk factors for musculoskeletal injury Elements of an ergonomics program SRH Case studies

Learning Objectives By the completion of this class you should be able to: List 4 risk factors for musculoskeletal injury Describe 4 action steps that can reduce your risk of injury during resident handling activities Identify effective solutions to prevent injuries in for number of common resident handling activities

What is Ergonomics? Worker Task/job
Environment Purpose: To review the definition of ergonomics: Emphasis: Ergonomics is the fit between the worker, the job and the work environment. It is important to stress that ergonomics is adapting the workplace, rather than adapting the worker. Many people believe that ergonomics is just making the worker more fit through fitness training, such as stretching and strength training. For some people, body mechanics is their idea of ergonomics. These activities are important for staying healthy and preventing injury but research has shown that body mechanics and fitness alone are ineffective approaches to injury prevention. Action Point: explain the above point to the group and ask them why fitness alone can not prevent injury. They should be able to point out that no matter how fit you are, there are many situations in Fire and EMS that require workers to use lift heavy loads, such as very heavy Residents being removed from a crowded bedroom or bathroom. Ask them to come up with two or three other examples. Such as repetitive activities, and activities requiring awkward postures. The goal of ergonomics is to design the job to fit the worker NOT make the worker fit the job

What kinds of Injuries are Musculoskeletal Disorders (MSDs)?
Acute injuries Happen immediately due to overload Can become chronic Re-injury possible Strains, sprains, disc herniations Chronic injuries Pain or symptoms lasting more than a month Cumulative trauma Happen over time Difficult to cure

Cumulative Trauma/Injury
Activity microtrauma (small tears) irritation to tissue produces scar tissue Keeps repeating as long as activity continues results in:  flexibility  strength Function *INJURY* adhesions form tears combine

Nurses/CNAs report here
The Cumulative Effect Fatigue Continued exposure to risk factors Discomfort Nurses/CNAs report here Pain Risk of injury is increased with increased exposure, greater intensity and a combination of factors Injury Disability Time

Terms for Disorders Work-related Musculoskeletal Disorder (WRMSD)
Cumulative Trauma Disorder Repetitive Strain Injury Overexertion or Overuse Injury Types of disorders Strains and sprains Rotator cuff injuries Disc herniations Carpal Tunnel Syndrome Bursitis, tendonitis Sciatica Purpose: Introduce terms for cumulative traumas Emphasis: There are many names for musculoskeletal injuries but they all refer to the same types of injuries. These are not ‘acute’ injuries such as a fracture due to a fall. Action Points: Ask the class if they are familiar with these terms. Ask them to provide examples of a few of these types of injuries. For example, carpal tunnel syndrome, tendonitis at the elbow, shoulder bursitis. Would a lumbar disc herniation be an example of a cumulative trauma injury? Why or why not?

Why is Manual Resident Handling so Hazardous?
Physical demands of the work Job exceeds physical demands of individuals Poor equipment and facility design Poor work practices Individual characteristics Age, past injuries, physical condition, leisurely activities

What are the Risk Factors for Musculoskeletal Disorders?
Excessive force Awkward postures Prolonged postures Repetition Purpose: Begin the discussion of risk factors Emphasis: There are known risk factors that are related to the incidence of musculoskeletal disorders. (read through list). We will discuss these in more detail in the following slides. Action point: There is a risk factor handout that goes with this section. The handout has the risk factors listed and for some of the risk factors there is space for the workers to write down examples. Have the class write in examples of tasks they do on the job that has the risk factor after you review each risk factor is with them. Give them about 3-4 minutes to complete the handout. Then, ask the class to tell you their examples of each risk factor and write their responses on the board. Plan on 10 minutes for this exercise.

Excessive Forces Common activities contributing to excessive force:
Lifting and carrying Pushing and pulling Reaching to pick up loads Prolonged holding Pinching or squeezing Purpose: To introduce and explain excessive forces Emphasis: High forces occur when excessive strength must be used to accomplish a task. Action Points: Ask if other examples come to mind.

Awkward Postures Common risky postures: Kneeling all day
Working overhead Kneeling all day Reaching to pick up loads Twisting while lifting Bending over to floor/ground Working with wrist bent Purpose: To introduce and explain awkward postures Emphasis: An awkward posture is any uncomfortable position. For each joint, anything that is out of ‘anatomical position’ is considered awkward, especially when you hold the position for a prolonged period of time. Action Points: Ask class to provide specific examples from there work.

Prolonged Postures Standing or sitting for long periods of time
Holding arms in fixed positions for extended periods

Repetitive Motions Common problem to look for:
Same posture or motions again and again can be very frequent over short period of time can be less frequent but repeated over time injury time Purpose: Introduce and explain the concept of repetitive motions Emphasis: Repetitive motions can be motions that are repeated either at a high frequency over a short period of time as shown in this top example or low frequency but repeated over a long period of time as shown in the bottom example. The one that is of most concern for emergency service workers is the latter since most tasks are not repeated several times in a minute but more risky tasks are repeated several times in a shift. An example may be lifting the gurney with a Resident into the medic unit. The top example represents a job such as manufacturing, or computer keyboarding, where a worker might use the same hand movements hundreds or more times a day and the time until injury manifests is relatively short. The lower example is more like the jobs performed by fire/EMS personnel, since most tasks are not repeated several times in a minute but more risky tasks are repeated several times in a shift through a working career. A good example of this type of repetition would be lifting the gurney with a Resident into the medic unit. Action Points: Ask the class how this relates to their work injury time

Common Problems Leading to MSDS
: Poorly Designed Equipment Does not have a good grip Too heavy Hard to use Uncomfortable Bad condition Wrong tool/equipment for the job Purpose: Introduce and discuss direct pressure and poorly designed equipment Emphasis: Direct pressure or poorly designed equipment or tools is when tools or equipment that you use causes discomfort because of the way the tool or equipment is held. Direct pressure on any part of the body can compromise blood flow and therefore compromise the soft tissues. Action Points: Ask for examples for their jobs.

Common Problems Leading to MSDs
Poor work organization In adequate scheduling Lack of planning Poor communication among staff and other resident stakeholders Poor work practices Purpose: Introduce the concept of work organization as it relates to ergonomics Emphasis: Work organization is also a risk factor for MS injury. This include the way in which departments are organized and administered. Action Points: Ask for examples of work organization changes that might reduce the risk of MS injury. For example, crews of 4 rather than 3 reduce the loads carried by having 4 people lift instead of 3. Are there other examples? Are these types of ergonomic changes practical? Why or why not? Identify barriers and ask how can they move beyond the barriers?

When is an Activity Likely to Become an Injury?
Activity performed frequently You do the activity a long time Work intensity is high There are a combination of risk factors Purpose: Introduce the idea of combined factors Emphasis: These factors alone, time, frequency and intensity do not make an activity risky. When an activity is frequent, lasts a long time, is intense and combines risk factors, then it is more likely to eventually become an injury. These are important to remember when you are doing a hazard assessment. Action Points: Ask the group what these terms mean.

How do you find solutions?
Job Tasks Solution Hazards Solution Form SRH team Ergonomic Risk Analysis Needs Assessment Formulate solutions Solution Purpose: Emphasis: So once you have identified and prioritized the risky jobs and hazardous tasks have been identified, these hazards need to be addressed. The people charged with finding solutions to the identified hazards must brain storm a list of potential solutions that can be taken to the command staff. This could be done in conjunction with an ergonomics team, the equipment selection committee, a shift crew, the safety committee, the training crew or even an individual. It is also important for the department to decide how to manage the flow of information on solutions. There are potentially many solutions that could reduce the hazards. Action Point: Solution

musculoskeletal injury
Proper body mechanics Fitness & wellness Engineering controls/ Equipment improvement Work practice controls Risk of musculoskeletal injury Administrative controls Personal protective equipment

Choose Effective Solutions
Most Effective Engineering Tools/equipment Workplace design Administrative Job rotation Number of workers Work practices Changing bed height Behavioral Body mechanics Stretching/Fitness PPE Emphasize that some solutions are more effective than others. Behavior solutions, such as body mechanics and stretching programs are generally NOT effective and should only be used as a last resort. Least Effective

Preventing MSDS First Choice: Engineering Controls
Eliminate or reduce primary risk factors Use resident handling equipment, such as, ceiling and portable floor lifts, air assist transfer devices, and mechanical sit to stand lifts Must match equipment use with Resident dependency (physical and cognitive abilities) Type of lift, transfer or movement Number of staff available

Preventing MSDS Second Choice: Administrative Controls
Reduce employee exposure to primary risk factors Ergonomics training Policy & procedures that define good work practices Staffing and overtime practices Job rotation

Preventing MSDS Second Choice: Work Practice Controls
Reduce employee exposure to primary risk factors by using best work methods: Plan work organization Use good housekeeping practices Use adjustments on equipment Get help when needed Eliminate unnecessary movements Don’t use broken equipment Remember – it’s the employee’s responsibility to use good work practices and follow the organizations’ safe resident handling policy and procedures

Preventing MSDs Second Choice: Work Practice Controls
Neutral spine posture - 3 Curves make your spine strong and minimize physical stress It is important to KEEP THESE CURVES when moving, bending and lifting Neutral spine is the reason body builders can lift so much weight without injury Cervical Thoracic Lumbar Purpose: Explain neutral spine. Emphasis: Neutral spine reduces stress to the bones, discs, muscles, ligaments. Many disc herniations occur due to fracture of the vertebral endplate. This can happen when the spine is overloaded. Neutral spine posture distributes the load to the vertebrae and reduces the chance of an end fracture or disc herniation. Neutral spine is the place where the spine is most stable and least likely to be injured. The reason the lumbar lordosis is so important is that this part of the spine bears most of the body weight plus the weight of whatever load is being lifted and carried. Action Point: none. Using good body mechanics is important, even when using equipment, but alone body mechanics will NOT prevent MSDs

Conduct Ergonomic Risk Assessment
Recognizing hazards is the first step toward injury prevention Job analysis performed by people with ergonomics training Ergonomics team Safety committee members Line personnel Purpose: Introduce the concept of Job Hazard Assessment Emphasis: Before you can come up with solutions, you must do an assessment to understand the hazard. Recognizing the hazards is the first step toward injury prevention. With some training, line personnel can perform a hazard analysis or you can have the ergonomics team or safety committee members complete hazard analyses. Let them know that this topic will be covered in greater depth in another module. Action Points: none

Reduce Your Risk of MSDs?
What Can You Do to Reduce Your Risk of MSDs? The following materials from the Safe Resident Handling in Health Care Guide, and made possible by a grant from Oregon OSHA, Department of Consumer and Business Services, Used with permission from Oregon Nurses Association, UO LERC and Bay Area Hospital, Coos Bay, OR

Plan and Prepare – It only takes a minute but can save a career
Risk Assessment steps Assess the resident Assess & prepare the environment Get necessary equipment & help Perform the Resident care task, lift or movement safely Discuss what is the current practice for assessing residents. Discuss VA algorithms for patient handling. Plan and Prepare – It only takes a minute but can save a career

Assess the Resident Goal:
To assess if resident status (physical and cognitive abilities) has changed and to determine the safest method to transfer or move the resident. Compare assessment with resident handling orders or instructions in the Resident's Care Plan and ensure that staff are alerted to changes in resident status.

Assess the Resident This brief observation includes assessment of the resident’s: Ability to provide assistance Physical status – ability to bear weight, upper extremity strength, coordination and balance Ability to cooperate and follow instructions Medical status – changes in diagnosis or symptoms, pain, fatigue, medications When in doubt, assume the resident cannot assist with the transfer/ repositioning

Assess & Prepare the Environment
Ensure that the path for transfer or movement is clear and remove obstacles and clutter that constrain use of good posture and access to the Resident, e.g., bed tables, and chairs trip hazards, e.g., cords from medical equipment slip hazards , e.g., spilled beverages or other fluids on the floor

Assess & Prepare the Environment
Consider safe handling of medical devices, such as catheters, intravenous tubing, oxygen tubing, and monitoring devices Ensure good lighting. Adjust equipment, such as beds to correct working height to promote good postures Keep supplies close to body to avoid long reaches

Get Necessary Equipment & Help
Get the correct equipment and supplies for the task as determined in the Resident Care Plan and after the Resident Assessment in Step 1 Get additional help as required Ensure that Equipment is in good working order Devices such as gait belts and slings are in good condition and the correct size The resident is wearing non-slip footwear if they are to be weight bearing

Perform Resident Care Task, Lift or Movement Safely
Explain the task to the resident – agree on how much help he or she can give during the task Position equipment correctly, e.g., height between a stretcher and bed is equal Apply brakes on equipment and furniture used Lower bed rails when necessary You should receive training on correct use of equipment, resident assessment and safe work practices before handling Residents

Perform Resident Care Task, Lift or Movement Safely
Coordinate the task as a team (nurses and Resident) Have the Resident assist as much as possible Use good body posture – keep work close to the body and at optimal height Know your physical limits and do not exceed them Follow your organizations safe Resident handling policy and procedures

What else can you do? Report ergonomic problems to your supervisor
Apply back injury prevention principles to your off -the-job activities Report any physical problems early – leads to a quicker recovery

Safe Resident Handling Program: Applied Ergonomics for Nurses and
Case Studies Safe Resident Handling Program: Applied Ergonomics for Nurses and Health Care Workers

Case Studies Case study 1: Repositioning resident in bed
Case study 2: Transfer from chair to bed Case study 3: Transfer from bed to stretcher Case study 4: Transfer from wheelchair to bed Case study 5: Making a bed & repositioning resident in bed Case study 6: Resident ambulation and fall recovery

Ergonomic Analysis Form
Potential Risk Factors and Body Regions Root Causes Observed (Reason) Possible Solutions Repetitive Forward bend of torso >60 coupled with twisting and side bending back Lifting bags from floor. Dirty linen bags Weighing about 20 lbs each Consider carts for garbage and soiled laundry with spring load bases that reduce reach and force required to load and unload bags.

Case Studies Remember – what you are about to practice is not a substitute for specific training on safe use of resident handling equipment Not all resident handling equipment available is shown in the video Always follow the Resident handling policy at your facility

Case Study 1 Repositioning Resident in Bed
What Did You See? Identify primary risk factors for MSDs Identify hazards that may cause slips, trips, falls or other acute or traumatic injuries Determine the cause or the primary risk factors and hazards observed Determine a safer way to perform the task Ask participants not to look at the power point handout for each case until after working on that case.

Task Risk Factors & Hazards Cause Injection of medication Back bent & twisted coupled with static posture Trip Hazard Bed too low Rail up Bed table obstructs access Phone on bed – cord on floor Dispose of needle Back bent Neck bent backwards Long reach (arm overhead)

Task Risk Factors & Hazards Cause Reposition resident Back bent & twisted Neck bent backwards Forceful exertion– back and shoulder Bed too low Rail up Resident weight Resident did not assist

Case Study 1 Repositioning Resident in Bed:
The Safer Way Assess the Resident Has upper extremity strength, can sit unaided, is non-weight bearing, cooperative (consider medical status etc.) Assess the Environment Move bed table and phone, raise bed, lower rail when administering injection Raise bed and lower bed rails before moving resident

Case Study 1 Repositioning Resident in Bed:
The Safer Way Get Necessary Equipment & Help Friction reducing device (slippery sheet) & two nurses or CNAs Perform the Task Safely Coordinate the move Use good posture Have resident assist

Case Study 2 Transfer from Chair to Bed
What Did You See? Identify primary risk factors for MSDs Identify hazards that may cause slips, trips, falls or other acute or traumatic injuries Determine the cause or the primary risk factors and hazards observed Determine a safer way to perform the task

Task Risk Factors & Hazards Cause Assisting resident from chair to bed Forceful exertion – back Back bent & twisted Resident weight Resident not capable of bearing full weight Resident not assessed Chair too low

Task Risk Factors & Hazards Cause Assisting resident onto bed Forceful and sudden exertion – back Back bent & twisted Neck bent backwards Resident not capable of full weight bearing Resident not assessed Repositioning in bed Forceful exertion – back Bed too low

Case Study 2 Transfer from Chair to Bed: The Safer Way
Assess the Resident Partial weight bearing, cooperative, has upper extremity strength and can sit unaided Assess the Environment Move bed table, lower head of bed; lower bed rail using good posture

Case Study 2 Transfer from Chair to Bed: The Safer Way
Get Necessary Equipment & Help Powered Sit-to-Stand device Only one caregiver needed Perform the Task Safely Apply equipment brakes when raising or lowering resident Raise bed before lifting resident’s legs Use good posture Have Resident assist

Case Study 3 Transfer from Bed to Stretcher

Task Risk Factors & Hazards Cause Positioning stretcher in room Back bent and twisted Sharp corners or protruding edges on furniture (risk of soft tissue contusion) Poor posture or bodymechanics Moving furniture in constricted space Preparing transfer Back bent Long reach (arm overhead) Passing IV bag and tubing over bed

Task Risk Factors & Hazards Cause Performing transfer Extreme forceful exertion – back and shoulders Back bent Neck bent backwards Extreme bending of knee (on bed) coupled with force Extended reach to grasp drawsheet Forceful grip (poor hand hold) Resident weight/ shape Resident unable to assist Stretcher higher than bed height Width of stretcher and bed Use of drawsheet to move resident

Task Risk Factors & Hazards Cause Moving stretcher Forceful exertion - back and shoulder Back bent and twisted Neck bent backwards and twisted Arms extended away from body Pushing and pulling stretcher on carpeted surface Lack of holder on stretcher for O2 tank Lack of steering control on stretcher Stretcher too low

Case Study 3 Transfer from Bed to Stretcher: The Safer Way
Assess the Resident This is a Bariatric resident who cannot assist with the transfer Assess the Environment Move furniture from of work area before bringing stretcher into room

Get Necessary Equipment & Help Air assisted friction-reducing device & three caregivers Pass IV bag around resident Stretcher has holder for IV and Oxygen tank Larger wheels and steering assist mechanism

Perform the Task Safely Coordinate the preparation and transfer Work heights equal and equipment/bed brakes applied Use good posture Adjust stretcher height for movement to allow good posture 2nd person required to guide front of stretcher only

Case Study 4 Transfer from Wheel Chair to Bed

Task Risk Factors & Hazards Cause Preparing to assist the resident Forceful exertion - back Back bent Neck bent backwards Holding resident’s leg while adjusting foot rest Adjusting leg supports/ foot rests Assisting resident from wheelchair to bed Forceful exertion – back Back bent & twisted resident not capable of full weight bearing Resident weight Resident not assessed

Task Risk Factors & Hazards Cause Assisting resident onto bed Forceful and sudden exertion – back Back bent & twisted Neck bent backwards Resident not capable of full weight bearing Resident not assessed Wheel chair away from bed

Task Risk Factors & Hazards Cause Repositioning in bed Forceful exertion -back Back bent & twisted Neck bent backwards Bed too low Bed rail up Head of bed partially raised Resident does not assist

Case Study 4 Transfer from Wheel Chair to Bed: The Safer Way
Assess the Resident Partial weight bearing, cooperative, has upper extremity strength and can sit unaided Assess the Environment Move bed table, raise bed, raise head of bed, lower bed rail using good posture

Case Study 4 Transfer from Wheel Chair to Bed: The Safer Way
Get Necessary Equipment & Help Gait belt; crutches and trapeze bar Only one caregiver needed

Case Study 4 Transfer from Wheel Chair to Be The Safer Way
Perform the Task Safely Use good posture to apply gait belt and to adjust wheel chair foot supports Have resident assist to hold leg while adjusting foot support Do NOT lift but guide resident to a standing Have resident transfer self to bed with stand-by assist Have resident reposition self on bed

Case Study 5 Making Bed & Repositioning Resident in Bed

Case Study 5 Making a Bed and Repositioning Resident in Bed
Task Risk Factors & Hazards Cause Making bed Forceful exertion – back and shoulders (CNA turning & holding resident) Back bent & twisted in static posture (CNA turning & holding resident) Repetitive bending & twisting of back (CNA making bed) Neck bent backwards (both CNAs) Resident weight Resident unable to assist Bed too low Bed Rails up

Case Study 5 Making a Bed and Repositioning Resident in Bed
Task Risk Factors & Hazards Cause Making the bed Forceful grip - Poor hand hold (nurse turning & holding resident) Slip Hazard Using drawsheet Spill on floor Repositioning resident in bed Forceful exertion – back and shoulder Back bent & twisted Neck bent backwards & twisted Resident weight Resident unable to assist Bed too low Rail up

Case Study 5 Making a Bed and Repositioning Resident in Bed:
The Safer Way Assess the Resident This is a semi-conscious resident who is unable to assist Assess the Environment Clean up spill, have bed linens ready, raise bed and lower rails

Case Study 5 Making a Bed and Repositioning Resident in Bed:
The Safer Way Get Necessary Equipment & Help Ceiling hoist and 2 nurses or caregivers Perform the Task Safely Coordinate lift and movement Each nurse makes a side of the bed Move bed and/or use ceiling lift to reposition resident safely

Case Study 6 Resident Ambulation & Fall Recovery

Case Study 6 Resident Ambulation and Fall Recovery
Task Risk Factors & Hazards Cause Ambulating resident Trip hazards Sharp corners or protruding edges on furniture (risk of soft tissue contusion) Poor and unstable coupling (handhold) Equipment in walkway No safe way to support resident – holding wrist may cause soft tissue trauma to resident during fall

Task Risk Factors & Hazards Cause Attempting to control the resident fall Forceful exertion – back and shoulders Back bent & twisted Neck bent backwards Forceful twisting of left forearm when attempting to ‘hold’ resident during fall Resident weight coupled with sudden motion Location of resident at floor level Poor coupling –no location to securely support resident and control the fall safely

Task Risk Factors & Hazards Cause Lifting Resident from floor Forceful exertion – back and shoulder Back bent Neck bent backwards Forceful grip - Poor coupling hand hold Resident weight Resident unable to assist Location of Resident - lift from floor level No safe way to hold resident’s arms and legs. Risk of soft tissue trauma to resident

Case Study 6 Resident Ambulation and Fall Recovery:
The Safer Way Assess the Resident Can weight bear with standby assist and is cooperative The resident cannot stand without assistance after fall Assess the Environment Move IV pole and wheelchair in walkway

The Safer Way Get Necessary Equipment & Help Use gait belt for ambulation Only one nurse or caregiver needed Portable powered floor lift and two nurses or caregivers to safely lift resident from floor using equipment

The Safer Way Perform the Task Safely Improve coupling or handhold by using gait belt with handles (less grip force required) Control fall correctly using gait belt as aid (but not to ‘lift’ Resident) Maintain good posture while controlling the fall and supporting resident in floor lift sling Use of portable powered floor lift reduces injury risk for caregiver and resident

Applying your knowledge: Conducting a risk assessment

Resources National Center for Resident Safety http://www.va.gov/ncps/
Resident Safety Center of Inquiry National Institute of Occupational Safety and Health OSHA (federal) Oregon OSHA: SAIF Corporation:

Wrap up & Evaluation Final questions
Have audience fill out post assessment (white sheet). Do not separate from lavender sheet.

Applied Ergonomics for LTC

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