Hospital group opposes landmark OSHA reg
Will state’s ergonomics standard prevent injuries?
California has become the first state in the nation with an ergonomics standard to protect workers from repetitive motion injuries (RMIs), but officials with the state’s hospital association charge that the new regulation will unfairly penalize hospitals while doing nothing to reduce occupational injuries among health care workers.
The California standard affects all employers with 10 or more workers. At those work sites, the regulation is triggered only when at least two employees performing identical tasks are diagnosed with RMIs within 12 consecutive months. If that occurs, employers must establish and implement programs designed to minimize RMIs. Programs must include work site evaluations, control of exposures that may have caused RMIs, and employee training. RMIs must be diagnosed by a licensed physician, and the diagnosis must show that the injury is at least 50% work-related.
The landmark standard was expected to become effective by mid-January this year, after final review by the state’s Office of Administrative Law. Not yet published, the law was adopted by the Occupational Safety and Health Standards Board of the California Occupational Safety and Health Administration (CALOSHA), culminating several years’ efforts. In 1994, the board unanimously voted down another proposal, citing cost factors and a lack of agreement on the effectiveness and scope of the measure.
The state’s difficulty in establishing a standard parallels a similar struggle on the federal front. More than four years ago, U.S. OSHA announced a proposed rule for an ergonomics standard designed to help prevent work-related musculoskeletal disorders. A proposed standard was slated for release in 1994, but a year later, only a draft proposal had been issued. Then the rulemaking process was aborted due to budget cutbacks and Washington’s restrictive political climate. (See related story in Hospital Employee Health, July 1995, pp. 85-92.)
Successful promulgation of the CALOSHA standard could be regarded as a forecast of renewed federal action. In fact, federal officials have begun re-examining workplace ergonomics issues in preparation for a new draft proposal, says OSHA spokesman Stephen Gaskill. (See related story on OSHA’s four-part plan of action, p. 21.)
"OSHA is now moving forward since we have no congressional prohibitions on us at the moment," Gaskill says. "We have always wanted to address this issue, but realistically we didn’t know if we would have an opportunity, given congressional actions. We were truly stymied, but now we are moving slowly and deliberately toward redevelopment of a standard."
The agency essentially will start over, formulating a new proposed standard based on current research published in the two years since the last draft proposal. While a final standard is years away, Gaskill says it will be "targeted and specific rather than big and broad."
OSHA has issued some 400 ergonomics-related citations to employers since 1985, "and that’s without a standard," says Gaskill, who adds that repetitive stress injuries account for one in every three workers’ compensation dollars, costing U.S. employers more than $20 billion per year. Because California is such a large and populous state, "that’s a drain on their economy," he adds.
One gray area in of concern to California hospital officials is whether patient-lifting injuries one of the most prevalent and costly musculoskeletal injuries among HCWs are considered RMIs and therefore within the scope of the new regulation.
CALOSHA spokesman Rick Rice says the question will have to be answered "down the road." Due to the major disagreements that erupted over the more specific 1994 proposal, the final version of the ergonomics rule is more general, leaving some issues open to interpretation upon enforcement.
"There is no definitive answer at this point," Rice says. "Patient lifting [injuries] could be RMIs. CALOSHA will have to develop policies and procedures for the new standard, but the issue may have to be settled on appeal [of citations]. These are uncharted waters. It’s very difficult to put a regulation on the books that will adequately address issues in every workplace."
How does rule affect hospital employees?
But officials of the California Healthcare Association (CHA) in Sacramento, which represents 456 hospitals in that state, say hospital work-related ergonomics issues already have been adequately addressed in other standards requiring workplace illness and injury prevention programs.
In addition, they maintain that the ergonomics standard was not supported by sufficient research and will do nothing to reduce worker injuries.
"The whole issue of ergonomics is so new and so difficult for occupational health professionals to address that nobody can state with any certainty that it will improve the work environment and therefore reduce injuries to workers, specifically repetitive motion injuries," says Thomas Luevano, CHA’s vice president of human resources and governance.
While noting that CALOSHA was under a 1993 legislative mandate to produce a standard, the regulation is "very premature," he says. "What should have been done is a study to determine the causation of repetitive motion injuries and, based upon that study, propose recommendations."
The CHA attempted unsuccessfully to introduce legislation superseding the piece that called for an ergonomics standard, so "the [CALOSHA standards] board then had to proceed under that directive to produce a standard for an issue that is so new and so difficult to address that we ended up with something that nobody can say with any assurances to the employer community will in fact reduce repetitive motion injuries," Luevano says.
New regulation objectionable’
While the defeated 1994 proposal specifically called for employers to purchase equipment and make other costly capital improvements, the new regulation does not. Nevertheless, Luevano says the CHA finds it "objectionable" as well, especially as it relates to patient-lifting injuries.
Keyboarding injuries such as carpal tunnel syndrome and many other cumulative trauma disorders clearly are RMIs, but injuries incurred in patient lifting are not, he maintains. Luevano says he has asked CALOSHA officials "repeatedly" whether the standard considers patient- lifting injuries to be RMIs but has not received a definite answer.
"It’s a wait-and-see situation. Who’s going to file the first complaint? Who is going to be the first test case? That’s how they’re going to approach this," he says.
The standard should not be applied to patient-lifting because RMIs are the result of activities performed routinely in the same manner, such as keyboarding, while "lifting patients is not done in the same manner using the same techniques," Luevano states.
RMIs resulting from keyboarding can be addressed by examining the operator’s technique and adjusting the height and angle of the keyboard or the seating arrangements, but if patient-lifting injuries are considered RMIs, "the question then becomes what do you want me to implement that will mitigate the injury categorized as an RMI by this standard? What do you want me to do that is different than what we do right now? We already evaluate [injuries] and institute controls. We already have lifting equipment. What else do you want me to do to comply with this standard? You want me to do more training? We already do training. How much more training do you want me to do?"
Back injuries from patient-lifting "will not go away," says Luevano, who attributes those injuries to two main factors: the aging work force, "many of whom choose not to use lifting equipment because it’s too time-consuming," and "the fact that we’re in an industry where a lot of manual lifting is a function of the job."
Hiring lifting teams and purchasing more lifting equipment can become cost-prohibitive, he adds, especially at a time when consumers already are complaining about the high cost of health care. In any case, not enough research exists to prove that those measures will prevent injuries, says Luevano.
For example, he points out that California hospitals purchased back support belts for workers several years ago because industry experts touted their effectiveness in preventing back injuries. Now, more current research suggests the belts don’t work. (See related story in Hospital Employee Health, September 1996, pp. 97-103.)
"That’s the problem with the ergonomics standard. They should have studied this first, and then told us what they think would work, and we would not have been so resistant," Luevano says.
We’re going to be the bad people’
As it is, the standard will not be effective, he states. "We as employers who have always complied with the intent of the law will find ourselves in the same position in a couple of years, addressing the same issue with no evidence and no research to help us understand the issue. We’re going to be touted as the bad people because employees will continue to injure themselves, and [people will think] it must be because employers are not implementing the standard, when in fact they are. We have to spend all this time and money with no evidence that it’s going to help."
But a national expert on hospital workplace ergonomics says employers have to assume more responsibility for preventing all-too-common back injuries among HCWs.
While noting that the California ergonomics standard seems to apply more to upper-extremity RMIs than it does to back injuries, Guy Fragala, PhD, PE, CSP, director of environmental health and safety and faculty member at the University of Massachusetts Medical Center’s occupational health program in Worcester, says blaming back injuries on the workers who incur them is "a poor way of viewing the problem."
"We in health care have to assume some responsibility and to admit that lifting and handling patients is a high-risk activity because the loads involved in those tasks are beyond what we can expect a normal worker to lift," Fragala says. "The aging work force could have some impact, but even a young, strong, healthy worker can’t be expected to lift some of the heavy loads involved in manually handling patients."
Lifting devices have improved greatly in recent years, he adds, making them much easier to use than earlier, more cumbersome equipment.
Nevertheless, "We can’t just provide equipment and expect the problem to go away," Fragala says. "We have to integrate the whole concept of ergonomics into the culture of the way we work in health care. We must look at the whole concept of ergonomics in assessing high-risk activities and developing a systematic plan of implementation. We have to teach health care workers how to use the new equipment and make sure it is becoming an integral part of the way they perform their work."
Although back injuries are a common occurrence, employers can take action to minimize the amount of lifting required.
"The employer can’t put the blame on the employee and say that no matter what we do, the employee won’t do the right thing," Fragala says. "The employer has to assume the responsibility."
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