Preventing musculoskeletal injuries requires proactive approach
EHPs try variety of old and new methods to control a pervasive problem
(Editor’s note: This is the first of a two-part series on preventing and managing musculoskeletal injuries among hospital health care workers. This month, Hospital Employee Health presents several approaches that front-line occupational health experts are taking to help prevent injuries. Next month, we take a look at how modified-duty return-to-work programs are benefiting both injured HCWs and the hospitals that employ them.)
While it seems that most government regulations affecting health care workers in recent years have to do with bloodborne or airborne pathogens, musculoskeletal injuries remain the most pervasive and costly problem hospital employee health practitioners face.
Sixty-two percent of Hospital Employee Health subscribers responding to the 1996 reader survey indicated that musculoskeletal injuries are the major occupational injury/illness concern for hospital employees today.
Data issued by the U.S. Department of Labor’s Bureau of Labor Statistics (BLS) show that in 1994, nearly two-thirds of workplace injuries and illnesses were disorders associated with repeated trauma to the upper body, with these cases increasing 10% over 1993 figures. Nursing aides and orderlies are among the 10 occupations with the largest number of injuries and illnesses involving days away from work, according to the BLS, and sprain and strain were the leading types of injury and illness.1
Four years ago, the U.S. Occupational Safety and Health Admini-stration (OSHA) announced a proposed rule-making for a federal ergonomics standard designed to help prevent work-related musculoskeletal disorders. A proposed standard was slated to be released in 1994, but a year later, only a draft proposal had been issued. (See related story in HEH, July 1995, pp. 85-92.) Now it appears that issuance of a final standard is speculative at best. OSHA spokes-woman Lola DeGroff says development of an ergonomics standard was aborted for at least a year when the political climate in Washington squelched OSHA’s regulatory efforts.
"During the last fiscal year, there was a rider on our appropriations bill that precluded us from doing anything on a standard; our hands were really tied for a year. Now we’re developing a proposal to look at where we go from here," DeGroff says.
Meanwhile, OSHA and the National Institute for Occupational Safety and Health (NIOSH) are co-sponsoring a national conference in January 1997 that will bring together representatives from business, government, labor, and academia to share information about effective workplace ergonomics programs.
DeGroff says the conference is not a poor second to a federal standard, but "a way of providing some outreach and enlightening people on the subject."
In many hospitals, musculoskeletal injuries account for the greatest amount of lost work time and represent the most expensive workers’ compensation claims.2 Because many EHPs manage their hospitals’ workers’ compensation cases, the responsibility for reducing those claims and preventing injuries becomes theirs, as well.
Most practitioners agree that taking a proactive approach is a necessary first step.
"[Being] reactive is too late," says Gabor Lantos, MD, PEng, MBA, an occupational health physician who is president of Occupational Health Management Services, a hospital occupational health consulting firm in Toronto and Barrie, Ontario, Canada.
Lantos says any proactive program will reduce injury rates and workers’ compensation claim costs by about 50%, but he cautions that taking a one-sided approach to injury prevention and management results in a return of the problem just a few months down the road.
"There are no quick fixes with any one specific intervention, but rather what is needed is the comprehensive approach of an in-house occupational health service program that starts from initial orientation and preplacement medical through primary care involvement, rehabilitation if needed, and modified-duty return-to-work programs," he explains.
Some programs focus on "Band-Aid solutions" such as using back belts (see Lantos’ letter, p. 142), which he says can actually be dangerous, and ergonomics assessments, which are insufficient as isolated programs. No change will be effective and sustaining in the long run unless it is part of a program that involves the whole organizational structure and climate.
Comprehensive programs include the following components, Lantos says:
• Back education. This can be presented by the occupational health nurse, a physiotherapist, or anyone knowledgeable about back biomechanics. It could include both general information and specific suggestions for employee groups based on their job tasks.
• Mechanical lifting devices. These are scarce in some hospitals due to budget constraints, but at least one per floor is recommended. (See related story in Hospital Employee Health, July 1994, pp. 81-86 for an extensive discussion of lifting devices and teams.)
• Replacement of hand-cranked patient beds with electrically raised and lowered beds.
• Active treatment and rehabilitation of injured workers. This ideally should begin as soon as possible.
• In-house workers’ compensation case management.
• Modified-duty return-to-work programs to keep employees on the job.
Ronald W. Porter, PT, director of the Back School of Atlanta, also notes the effectiveness of the comprehensive proactive approach, but says that as long as hospital employees lift patients manually, back injuries will remain a "huge percentage" of workers’ comp costs.
"Individuals are so difficult to move because they don’t come with handles on them," Porter says. "Add to that the fact that sometimes patients are confused, disoriented, or frightened, so they’re resisting the movement. Patient transfer in a hospital or nursing home is one of the most difficult things to teach people."
In addition to back injuries, many hospitals are seeing a rise in upper-extremity injuries such as carpal tunnel syndrome due to computer use, as well as shoulder- and elbow-impingement problems from lifting and repetitive activities.
Porter, who consults with hospitals and industries on injury prevention and treatment, suggests that employee education and training programs be repeated annually for the best results. For example, employees who are required to lift and transfer patients would demonstrate each year, in either a simulated or actual environment, that they know how to do so safely.
"Every year, people should have to demonstrate that they can perform certain skills. It’s sort of a recertification," says Porter. "With patient transfer and lifting, we have verbally given people a set of rules but have not made them check off on being able to perform those activities. Human beings tend to get a little lazy and forgetful."
Injury prevention education also needs to include lifestyle factors, Porter notes.
"A number of things can fatigue muscles and cause them to go into spasm or irritate them, such as improper exercise activities, lack of rest, or being under stress," he explains.
Worker education programs must emphasize the importance of physical fitness in preventing injuries, with hospitals offering employees such exercise incentives as health club membership discounts or after-hours use of the physical therapy department’s exercise equipment.
Another predictor of workplace injuries is an employee’s level of work satisfaction, Porter says.
"People who are unhappy with their jobs are more than twice as likely to incur an on-the-job back injury. One of our goals when we do training programs is to try to convince workers that they are the most valuable [resource] to their employer," he states.
Finally, Porter suggests that employers use functional capacity evaluations (FCE) to help ensure that workers are not placed in jobs in which they are likely to injure themselves. To administer an FCE, employers need an accurate job description that details the physical tasks the job requires. Then, through the use of simulated tasks, such as lifting and moving objects of different weights, employees are "matched" to jobs that require certain levels of physical strength, endurance, flexibility, and coordination.
"Functional evaluations can be very advantageous for matching people to jobs and reducing injury risks," Porter notes.
At Mercy Medical Center in Redding, CA, hiring is contingent upon passing an FCE as well as other portions of the pre-employment physical, says Sandra Anberg, FNP, BSN, RN, CS, employee health coordinator at the 1,100-employee facility.
"We want to be fair to employees, but we don’t want to put them in a place where they can’t perform," Anberg says.
Applicants are sent to an off-campus "Fit for Work" program, where they are evaluated according to the physical-demand portion of their job description. Depending upon the job, they may be required to spend 45 minutes pushing, pulling, lifting, and walking on a treadmill. Even applicants for desk jobs undergo FCEs designed to ensure they are capable of performing their work demands.
About 30 tests are administered monthly. In the past 10 months of the program, about five applicants have failed their FCE. Those who fail the test are told they can reapply for the position in 90 days, which gives them a chance to become more physically fit, says Anberg, adding that word of the tests has gotten around the community.
"If people can’t work very hard, they know better than to come and apply here," she says. "It isn’t a cake-walk anymore. With the restructuring in facilities, people are having to work a lot harder."
Each FCE costs about $40, but the fee is worth it, Anberg adds.
"If you look at it from the standpoint of the cost of one back injury, with MRIs and consultations and surgeries, it’s roughly $30,000 that workers’ compensation has to pay," she notes.
Although it is too soon to evaluate the effectiveness of FCEs in reducing workers’ comp costs overall, Anberg says the combination of FCEs and the hospital’s modified-duty program has drastically reduced lost work days.
Workers’ comp costs have been reduced significantly at Hoag Memorial Hospital Presbyterian in Newport Beach, CA, where Vicky McGavack, RN, employee health manager, reports about a 70% reduction from Oct. 1, 1995, through Sept. 30, 1996, over the same period the year before for costs of injuries affecting the low back and shoulder. The number of such injuries has been cut in half.
McGavack credits her ergonomic assessment program and educational efforts for much of that success. While back injuries plague most hospitals, McGavack says lifting teams, mechanical lifting devices, and employee training had been effective in minimizing that problem. However, upper-extremity cumulative trauma disorders such as carpal tunnel syndrome became a nightmare at her hospital. The ergonomics program she implemented in June 1995 specifically targeted those disorders and cut them from 24 in 1995 to three so far this year, with a huge reduction in workers’ comp costs. (See workers’ compensation analysis, inserted in this issue.)
"We were having problems with people at computer work stations. They were coming over in droves; it was out of control," she explains. "We wanted to get a handle on it because those injuries were very costly, with people usually ending up being off work and unable to do their jobs."
First, McGavack had to educate managers about the importance of allowing workers to report to employee health at the first sign of an upper-extremity disorder, such as a twinge or tingle.
"People had been coming in with symptoms when they were already in the acute phase of disease, and this does not happen overnight," she says. "They probably were working in an improper work station for months or even years. They were so acute that they had to be sent out for care because there was nothing preventive we could implement and it was too late for any kind of nursing care. They needed to be evaluated by a physician and get physical therapy."
Once the acute cases were managed, McGavack became proactive. She took over for a hired ergonomist who had been doing little more than supplying products such as wrist rests, and she began to examine work stations with the help of the hospital’s physical therapist.
"It was a matter of educating myself about what a work station should look like. I figured out it was not rocket science but common sense, especially if you’re a nurse and know how the body needs to be positioned when you’re sitting down and working all day," she says.
Now she can evaluate work stations on her own, providing products when needed, adjusting existing equipment, and educating employees one-on-one. In some of the larger departments, knowledgeable employees have been designated as work station evaluators, as well.
She developed a symptom survey (see insert) to identify problems early and to help employees understand that repetitive-motion leisure activities such as crafts work, bowling, or piano-playing might be contributing to the problem. In conjunction with an orthopedic surgeon, McGavack also developed an upper extremity cumulative trauma pathway (see insert) to help employees improve and return to work.
When an upper-extremity disorder is suspected, workers fill out the symptom survey and McGavack arranges to assess their work station. Using the office assessment guidelines she developed (see insert), McGavack determines the employee’s main job functions and recommends ergonomic adjustments.
"Where we are now is that our numbers have significantly reduced no one has needed carpal tunnel surgery since we implemented the program in 1995, and we’re even being more aggressive on prevention now," McGavack says. "When a new employee comes through here and we do our physicals, the nurse will identify people who are going to be working at a work station. We will notify their manager that two weeks after they’re in their job we want to set up an appointment to come out and adjust their work station. We do that right at the get-go so we don’t see these people in the next three or four months saying they have neck pain or shoulder pain."
One additional approach holds promise for preventing painful musculoskeletal injuries. Under a NIOSH grant, researchers at the 6,000-worker Barnes-Jewish Hospital in St. Louis are studying the use of employee management advisory teams (EMATs), a participatory ergonomics program that has been used in manufacturing industries for some time, says Bradley Evanoff, MD, MPH, an occupational health physician and the lead researcher.
"The idea is to involve the people who are actually doing the work, both in defining the problem and coming up with the solutions, rather than getting an outside ergonomist to come in and say, Don’t do that. Change this,’ and then they take their check and leave you with the problem," Evanoff says.
In a format similar to a quality circle, small committees of four to eight employees, including management and labor, meet at first on a weekly, then bimonthly, then monthly basis. Evanoff, an ergonomist, and an occupational therapist all provide technical assistance. EMATs in the research program include separate groups for orderlies, intensive care nurses, laboratory workers, and housekeepers. Each group is provided with injury rates and accident reports for its job category.
Groups should be given a week or 10 days of training in team building and effective team action, as well as in ergonomics. Their goal is to identify musculoskeletal injury hazards, suggest solutions, and implement them.
"The theoretical advantage of this approach is that when the people who actually are doing the work come up with solutions, it’s likely that those solutions will be workable and actually implemented vs. solutions suggested by an outside person who doesn’t work there," Evanoff explains.
Realistically, the hospital follows through "unless it costs money," he jokes, "given the fiscal pressures hospitals are subject to right now."
Three categories of solutions have been proposed, with implementation varying according to how much they cost. Almost all procedural-type solutions that cost nothing have been carried out. Most of the solutions that don’t cost very much money such as purchasing new chairs or foot rests also have been carried out. However, issues involving whole areas of the hospital that need to be redesigned to eliminate hazards stand little chance of being addressed right now, Evanoff notes, but may be accomplished in years to come as old buildings are torn down and new ones built. The purchase of more expensive equipment, such as mechanical lifting devices, also has not been accomplished yet.
"I think we will see lifting-equipment purchases next year," Evanoff says, "but it takes a while for ideas generated by janitors and orderlies to percolate up to the level of the people who have the discretion to spend the money."
Results of the two-year project are starting to trickle in. The orderlies’ EMAT has been operating for longer than the other groups about one year and Evanoff reports that back injury rates during the first half of 1996 were 50% less than during the same period in 1995. Lost days due to injuries were cut by 90%. The other teams just now are beginning to implement changes, so effectiveness is difficult to measure. Evanoff says an economic analysis will be done in about six more months.
Nevertheless, the hospital EMAT experience so far is giving researchers other information.
"We’re learning what makes these EMATs successful or unsuccessful," Evanoff says. "The least-educated employees have done the best job with these teams for a variety of reasons. One is that they do the crap jobs, so it’s easier to make changes that are effective. You do almost anything, and it makes a difference. Nurses and lab workers have a lot less physically demanding jobs."
Also, nurses are used to working in committees and groups, so "for them it is one more committee responsibility; it is not as novel a thing," he adds. "Whereas for housekeepers and orderlies, it is the first time they have been asked their opinion of how things ought to change, so they’ve been really enthusiastic and committed to it."
This does not imply that EMATs won’t work with nurses and other professional groups, but nurses have demanding clinical responsibilities that make it more difficult to pull them away from the work site and into a committee meeting that supervisors do not perceive as "revenue-generating," Evanoff notes. "We’re also trained that the health of the patient clearly comes before the health of the hospital personnel, so that’s the attitude that people have."
Nevertheless, the success of the EMAT project so far has prompted Evanoff to seek approval from administrators for incorporating it into a more comprehensive ergonomics program for the 21,000-employee system that includes Barnes-Jewish Hospital. He says he is optimistic that the proactive approach he and his colleagues have taken will bring about a "decently funded" ergonomics program.
References
1. U.S. Department of Labor, Bureau of Labor Statistics. Survey of Occupational Injuries and Illnesses. Washington, DC; 1995.
2. Charney W, Zimmerman K, Walera E. The lifting team: A design method to reduce lost time back injury in nursing. AAOHN J 1991; 39:231-234.
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