Industrial ERG

CHAPTER 15 ERGONOMICS IN THE HEALTHCARE INDUSTRY

LEARNING OBJECTIVE

Students will be able to identify causes of work-related musculoskeletal disorders (WMSDs) within the healthcare industry. They will be able to identify the key contributors to those WMSDs and solutions to reduce the potential WMSDs. They will also be able to identify the resource guides for patient care.

INTRODUCTION

The healthcare industry is huge and continues to grow at an astounding rate. Nurses and nursing aides are 2 of the top 15 professions that suffer from work-related musculoskeletal disorders (WMSDs) (Workplace Health Promotion, n.d.). In 2011, 50% of nurses and nurse aide's injuries and illnesses were contributed to WMSDs (Bureau of Labor Statistics, 2011). WMSDs associated with healthcare workers in the hospital healthcare industry and in the home healthcare industry were examined. Key contributors to WMSDs among healthcare workers are from repositioning patients in bed, turning patients, transferring patients from a bed to a gurney, pushing beds or gurneys far distances, transferring patients from a chair to a toilet, and transferring patients from a wheelchair to a vehicle. This chapter explores what causes and/or contributes to WMSDs among healthcare workers and preventive measures that can be implemented to reduce the potential for WMSDs in the healthcare industry.

Healthcare workers are presented with many ergonomic challenges. In a healthcare environment, workers can work long hours and healthcare workers' duties involve being physically active for up to 16 h a day. They twist their bodies in awkward position throughout their day to deliver patient care. A trend shows nursing aides, orderlies, and attendants have the highest rates of WMSDs reported injuries through 2007–2011. In 2007, patient lifting injuries were reported for every 10,000 healthcare workers. Twenty-one employees suffered a lifting injury. WMSDs are one of the leading contributors for lost workday injury and illness cases.

ERGONOMIC RISK FACTORS/CONTRIBUTING FACTORS CAUSING HEALTHCARE INJURIES

Key factors contributing to WMSDs among healthcare workers are from repositioning patients in bed, manual lifting, turning patients, transferring patients from a bed to a gurney, pushing beds or gurneys far distances, transferring patients from a chair to a toilet, and transferring patients from a wheelchair to a car. Other risk factors that contribute to healthcare injuries are overexertion from quickly responding to patients in need, lifting more than 20 lifts/shift, lifting patients alone, lifting uncooperative patients, and moving bariatric patients. Also, there are issues with using certain pieces of medically related equipment such as pipettes and even the process of dealing with medical records. These topics are discussed in the following sections.

Patient Handling

In healthcare setting, healthcare workers routinely use manual lifting methods in life-threatening situations. Manual fore/aft lifts tend to put a high level of compression forces on the rear-facing worker, and the front-facing worker positions their body in an awkward position to transfer patients from one surface to another surface. The manual chicken or drag lift is used in healthcare setting to assist a patient after falling on the floor and repositioning the patient. The manual chicken or drag lift can cause lower back injuries, shoulder dislocation, and strain on the spinal cord. The manual cradle lift or basket lift is performed when healthcare providers put one hand under the patient's thigh, and one hand is placed on the back of the patient to ensure the patient positioning. The manual cradle lift or basket lift puts high levels of force on the spinal disc of the healthcare workers and repeatedly caused the lifters to bend their bodies in an awkward position. The manual three-person lift is used when transporting patients from a bed to a stretcher. A high level of stress is put on the spinal disc, neck, shoulders, and back of the worker when the worker bends forward at the waist to lift patients. The manual three-person lift puts excessive stress on the backs of the lifters because the weight of the patient is not equally distributed when the lifters reposition the patient. The manual belt lift is commonly used to lift patients up from falling on the ground. There is usually one person pulling on the transfer belt that puts excessive strain on the lifter's lower back and another person squats next to the patient assisting the standing worker by guiding the patient to a standing position, which can cause lower back strain. The manual blanket lifts are used in emergency situations when medical treatment is needed quickly for the patient. When using the manual blanket lifts method, three to five workers put excessive strain on their lower back, shoulders, and wrist. The manual two-person through arm lift or towel lift is used to reposition patients. The workers will position a towel under a patient's thigh to use as a sling to reposition the patient. Force is applied to the patient's thighs, arms, and shoulders. The manual one-person through arm lift is used to reposition a patient in bed. This lift puts strain on the workers' shoulder, back, and arms because the healthcare workers are unable to use their legs as leverage. The manual Australian shoulder lift is also used to reposition patients in bed. The healthcare workers position one hand under the patient's waist or thigh and the other hand on the patient's back for support. The healthcare worker's shoulder is placed under the patient's where the arm connects to the shoulder. All of these high-risk manual patients handling lifting method are the last resort method in safely handling patients. A safer alternative to manual patient handling would be to use ergonomic-friendly mechanical lifting equipment.

The Occupational Safety and Health Administration (OSHA) has produced a guidelines document on patient handling in nursing homes. It is entitled “Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders” (OSHA). The following discussion on patient handling comes from that document.

Excerpts from Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders

Assessing the potential for work to injure employees in nursing homes is complex because typical nursing home operations involve the repeated lifting and repositioning of the residents. Resident lifting and repositioning tasks can be variable, dynamic, and unpredictable in nature. In addition, factors such as resident dignity, safety, and medical contraindications should be taken into account. As a result, specific techniques are used for assessing resident lifting and repositioning tasks that are not appropriate for assessing the potential for injury associated with other nursing home activities. An analysis of any resident lifting and repositioning task involves an assessment of the needs and abilities of the resident involved. This assessment allows staff members to account for resident characteristics, while determining the safest methods for performing the task, within the context of a care plan that provides for appropriate care and services for the resident. Such assessments typically consider the resident's safety, dignity, and other rights, as well as the need to maintain or restore a resident's functional abilities.

The resident assessment should include examination of factors such as:

· the level of assistance the resident requires;

· the size and weight of the resident;

· the ability and willingness of the resident to understand and cooperate; and

· any medical conditions that may influence the choice of methods for lifting or repositioning.

These factors are critically important in determining appropriate methods for lifting and repositioning a resident. The size and weight of the resident will, in some situations, determine which equipment is needed and how many caregivers are required to provide assistance. The physical and mental abilities of the resident also play an important role in selecting appropriate solutions. For example, a resident who is able and willing to partially support their own weight may be able to move from his or her bed to a chair using a standing assist device, while a mechanical sling lift may be more appropriate for those residents who are unable to support their own weight. Other factors related to a resident's condition may need to be taken into account as well. For instance, a resident who has recently undergone hip replacement surgery may require specialized equipment for assistance in order to avoid placing stress on the affected area. A number of protocols have been developed for systematically examining resident needs and abilities and/or for recommending procedures and equipment to be used for performing lifting and repositioning tasks. The example presented here is as follows:

Patient Care Ergonomics Resource Guide

Safe Patient Handling and Movement is published by the Patient Safety Center of Inquiry, Veterans Health Administration, and the Department of Defense. This document provides flowcharts (Figures 15.1–15.6) that address relevant resident assessment factors and recommends solutions for resident lifting and repositioning problems. This material is one example of an assessment tool that has been used successfully. Employers can access this information from www.patientsafetycenter.com. Nursing home operators may find another tool or develop an assessment tool that works better in their facilities.

Figure 15.1  Transfer to and from: bed to chair, chair to toilet, chair to chair, or car to chair (The Patient Safety Center of Inquiry (Tampa, FL). Veterans Health Administration & Department of Defense. October 2001. Adapted from Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders (OSHA, 2009))

Figure 15.2  Lateral transfer to and from: bed to stretcher, trolley (The Patient Safety Center of Inquiry (Tampa, FL). Veterans Health Administration & Department of Defense. October 2001. Adapted from Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders (OSHA, 2009))

Figure 15.3  Transfer to and from: chair to stretcher (The Patient Safety Center of Inquiry (Tampa, FL). Veterans Health Administration & Department of Defense. October 2001. Adapted from Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders (OSHA, 2009))

Figure 15.4  Reposition in bed: side-to-side, up in bed (The Patient Safety Center of Inquiry (Tampa, FL). Veterans Health Administration & Department of Defense. October 2001. Adapted from Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders (OSHA, 2009))

Figure 15.5  Reposition in chair: wheelchair and dependency chair (The Patient Safety Center of Inquiry (Tampa, FL). Veterans Health Administration & Department of Defense. October 2001. Adapted from Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders (OSHA, 2009))

Figure 15.6  Transfer a patient up from the floor (The Patient Safety Center of Inquiry (Tampa, FL). Veterans Health Administration & Department of Defense. October 2001. Adapted from Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders (OSHA, 2009))

The nursing home operator should use an assessment tool that is appropriate for the conditions in an individual nursing home. The special needs of bariatric (excessively heavy) residents may require additional focus. Assistive devices must be capable of handling the heavier weight involved, and modification of work practices may be necessary. A number of individuals in nursing homes can contribute to resident assessment and the determination of appropriate methods for assisting in transfer or repositioning. Interdisciplinary teams such as staff nurses, certified nursing assistants, nursing supervisors, physical therapists, physicians, and the resident or his/her representative may all be involved. Of critical importance is the involvement of employees directly responsible for resident care and assistance, as the needs and abilities of residents may vary considerably over a short period of time, and the employees responsible for providing assistance are in the best position to be aware of and accommodate such changes.

The recommended solutions presented in the following pages are not intended to be an exhaustive list, nor does OSHA expect that all of them will be used in any given facility. The information represents a range of available options that a facility can consider using. Many of the solutions are simple, common sense modifications to equipment or procedures that do not require substantial time or resources to implement. Others may require more significant efforts. The integration of various solutions into the nursing home is a strategic decision that, if carefully planned and executed, will lead to long-term benefits. Equipment must meet applicable regulations regarding equipment design and use, such as the restraint regulations from the Centers for Medicare and Medicaid. In addition, administrators should follow any manufacturers' recommendations and review guidelines, such as the FDA Hospital Bed Safety Workgroup Guidelines, to help ensure patient safety (FDA, 2006).

Management should also be cognizant of several factors that might restrict the application of certain measures, such as residents' rehabilitation plans, the need for restoration of functional abilities, other medical contraindications, emergency conditions, and residents' dignity and rights.

The procurement of equipment and the selection of an equipment supplier are important considerations when implementing solutions. Employers should establish close working relationships with equipment suppliers. Such working relationships help with obtaining training for employees, modifying the equipment for special circumstances, and procuring parts and service when needed. Employers will want to pay particular attention to the effectiveness of the equipment, especially the injury and illness experience of other nursing homes that have used the equipment. The following questions are designed to aid in the selection of the equipment and supplier that best meets the needs of an individual nursing home.

· Availability of technical service – Is over-the-phone assistance, as well as onsite assistance, for repairs and service of the lift available?

· Availability of parts – Which parts will be in stock and available in a short time frame and how soon can they be shipped to your location?

· Storage requirements – Is the equipment too big for your facility? Can it be stored in close proximity to the area(s) where it is used?

· If needed, is a charging unit and backup battery included? What is the simplicity of the charging unit and space required for a battery charger if one is needed?

· If the lift has a self-contained charging unit, what is the amount of space necessary for charging and what electrical receptacles are required? What is the minimum charging time of a battery?

· How high is the base of the lift and will it fit under the bed and various other pieces of furniture? How wide is the base of the lift or is it adjustable to a wider and lockable position?

· How many people are required to operate the lift for lifting of a typical 200-lb person?

· Does the lift activation device (pendant) have remote capabilities?

· How many sizes and types of slings are available? What type of sling is available for optimum infection control?

· Is the device versatile? Can it be a sit-to-stand lift, as well as a lift device? Can it be a sit-to-stand lift and an ambulation-assist device?

· What is the speed and noise level of the device? Will the lift go to floor level? How high will it go? Based on many factors, including the characteristics of the resident population and the layout of the facility, employers should determine the number and types of devices needed. Devices should be located so that they are easily accessible to workers. If resident lifting equipment is not accessible when it is needed, it is likely that other aspects of the ergonomics process will be ineffective.

If the facility can initially purchase only a portion of the equipment needed, it should be located in the areas where the needs are the greatest. Employers should also establish routine maintenance schedules to ensure that the equipment is in good working order. The following are examples of solutions for resident lifting and repositioning tasks.

1. Description: Powered sit-to-stand or standing assist devices.

2. When to Use: Use when transferring residents who are partially dependent, have some weight-bearing capacity, are cooperative, can sit up on the edge of the bed with or without assistance, and are able to bend hips, knees, and ankles. Transfers from bed to chair (wheel chair, Geri, or cardiac chair), or chair to bed, or for bathing and toileting. Can be used for repositioning where space or storage is limited.

3. Points to Remember: Look for a device that has a variety of sling sizes, lift height range, battery portability, handheld control, emergency shut-off, and manual override. Ensure device is rated for the resident weight. Electric-/battery-powered lifts are preferred to crank or pump type devices to allow smoother movement for the resident, and less physical exertion by the caregiver ( Figure 15.7 ).

Figure 15.7  Powered sit-to-stand or standing assist devices (Adapted from Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders (OSHA, 2009))

1. Description: Portable lift device (sling type); can be a universal/hammock sling or a band/leg sling.

2. When to Use: Lifting residents who are totally dependent, are partial- or non-weight bearing, are very heavy, or have other physical limitations. Transfers from bed to chair (wheel chair, Geri, or cardiac chair), chair or floor to bed, for bathing and toileting, or after a resident fall.

3. Points to Remember: More than one caregiver may be needed. Look for a device with a variety of slings, lift-height range, battery portability, handheld control, emergency shut-off, manual override, boom pressure-sensitive switch, that can easily move around equipment, and has a support base that goes under beds. Having multiple slings allows one of them to remain in place while resident is in bed or chair for only a short period, reducing the number of times the caregiver lifts and positions resident. Portable compact lifts may be useful where space or storage is limited. Ensure device is rated for the resident weight. Electric-/battery-powered lifts are preferred to crank or pump type devices to allow a smoother movement for the resident, and less physical exertion by the caregiver. Enhances resident safety and comfort ( Figure 15.8 ).

Figure 15.8  Portable lift device (sling type); can be a universal/hammock sling or a band/leg sling. (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Variable position Geri and cardiac chairs.

2. When to Use: Repositioning partial- or non-weight-bearing residents who are cooperative.

3. Points to Remember: More than one caregiver is needed, and use of a friction-reducing device is needed if resident cannot assist to reposition self in chair. Ensure use of good body mechanics by caregivers. Wheels on chair add versatility. Ensure that chair is easy to adjust, move, and steer. Lock wheels on chair before repositioning. Remove trays, footrests, and seat belts where appropriate. Ensure device is rated for the resident weight ( Figure 15.9 ).

Figure 15.9  Variable position Geri and cardiac chairs. (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Ambulation assist device.

1. When to Use: For residents who are weight bearing and cooperative and who need extra security and assistance when ambulating.

2. Points to Remember: Increases resident safety during ambulation and reduces risk of falls. The device supports residents as they walk and push it along during ambulation. Ensure height adjustment is correct for resident before ambulation. Ensure device is in good working order before use and rated for the resident weight to be lifted. Apply brakes before positioning resident in or releasing resident from device ( Figure 15.10 ).

Figure 15.10  Ambulation assist device (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Ceiling-mounted lift device.

2. When to Use: Lifting residents who are totally dependent, are partial- or non-weight bearing, are very heavy, or have other physical limitations. Transfers from bed to chair (wheel chair, Geri, or cardiac chair), chair or floor to bed, for bathing and toileting, or after a resident falls. A horizontal frame system or litter attached to the ceiling-mounted device can be used when transferring residents who cannot be transferred safely between two horizontal surfaces, such as a bed to a stretcher or gurney while lying on their back, using other devices.

3. Points to Remember: More than one care giver may be needed. Some residents can use the device without assistance. May be quicker to use than portable device. Motors can be fixed or portable (lightweight). Device can be operated by handheld control attached to unit or by infrared remote control. Ensure device is rated for the resident weight. It increases residents' safety and comfort during transfer ( Figure 15.11 ).

Figure 15.11  Ceiling-mounted lift device (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Devices to reduce friction force when transferring a resident such as a draw sheet or transfer cot with handles to be used in combination slippery sheets, low friction mattress covers, or slide boards; boards or mats with vinyl coverings and rollers; gurneys with transfer devices; and air-assist lateral sliding aid or flexible mattress inflated by portable air supply.

2. When to Use: Transferring a partial- or non-weight-bearing resident between two horizontal surfaces such as a bed to a stretcher or gurney while lying on their back or when repositioning resident in bed.

3. Points to Remember: More than one caregiver is needed to perform this type of transfer or repositioning. Additional assistance may be needed depending upon resident status, for example, for heavier or noncooperative residents. Some devices may not be suitable for bariatric residents. When using a draw sheet combination use a good hand-hold by rolling up draw sheets or use other friction-reducing devices with handles such as slippery sheets. Narrower slippery sheets with webbing handles positioned on the long edge of the sheet may be easier to use than wider sheets. When using boards or mats with vinyl coverings and rollers use a gentle push and pull motion to move resident to new surface. Look for a combination of devices that will increase resident's comfort and minimize risk of skin trauma. Ensure transfer surfaces are at same level and at a height that allows caregivers to work at waist level to avoid extended reaches and bending of the back. Count down and synchronize the transfer motion between caregivers ( Figure 15.12 ).

Figure 15.12  Devices to reduce friction force when transferring a resident (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: 

1. Convertible wheelchair, Geri, or cardiac chair to bed; beds that convert to chairs.

2. When to Use: For lateral transfer of residents who are partial- or non-weight bearing. Eliminates the need to perform lift transfer in and out of wheelchairs. Can also be used to assist residents who are partially weight bearing from a sit-to-stand position. Beds that convert to chairs can aid repositioning residents who are totally dependent, non-weight bearing, very heavy, or have other physical limitations.

3. Points to Remember: More than one caregiver is needed to perform a lateral transfer. Additional assistance for lateral transfer may be needed depending on the resident's status, for example, for heavier or noncooperative residents. Additional friction-reducing devices may be required to reposition a resident. Heavy-duty beds are available for bariatric residents. Device should have easy-to-use controls located within easy reach of the caregiver, sufficient foot clearance, and wide range of adjustment. Motorized height-adjustable devices are preferred to those adjusted by crank mechanism to minimize physical exertion. Always ensure device is in good working order before use. Ensure wheels on equipment are locked. Ensure transfer surfaces are at same level and at a height that allows caregivers to work at waist level to avoid extended reaches and bending of the back ( Figure 15.13 ).

Figure 15.13  Convertible wheelchair, Geri, or cardiac chair to bed; beds that convert to chairs (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Transfer boards – wood or plastic (some with movable seat).

2. When to Use: Transferring (sliding) residents who have good sitting balance and are cooperative from one level surface to another, for example, bed to wheelchair, wheelchair to car seat or toilet. Can also be used by residents who require limited assistance but need additional safety and support.

3. Points to Remember: Movable seats increase resident comfort and reduce incidence of tissue damage during transfer. More than one caregiver is needed to perform a lateral transfer. Ensure clothing is present between the resident's skin and the transfer device. The seat may be cushioned with a small towel for comfort, may be uncomfortable for larger residents. It's usually used in conjunction with gait belts for safety depending on resident status. Ensure boards have tapered ends, rounded edges, and appropriate weight capacity. Ensure wheels on bed or chair are locked and transfer surfaces are at same level. Remove lower bedrails from bed and remove arms and footrests from chairs as appropriate ( Figure 15.14 ).

Figure 15.14  Transfer boards (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Lift cushions and lift chairs.

2. When to Use: Transferring residents who are weight bearing and cooperative but need assistance when standing and ambulating. Can be used for independent residents who need an extra boost to stand.

1. Points to Remember: Lift cushions use a lever that activates a spring action to assist residents to rise up. Lift cushions may not be appropriate for heavier residents. Lift chairs are operated via a handheld control that tilts forward slowly, raising the resident. Residents need to have physical and cognitive capacity to be able to operate lever or controls. Always ensure device is in good working order before use and is rated for the resident weight to be lifted, can aid resident independence ( Figure 15.15 ).

Figure 15.15  Lift cushions and lift chairs (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Stand-assist devices can be fixed to bed or chair or be freestanding. There is a variety of such devices on the market.

2. When to Use: Transferring residents who are weight-bearing and cooperative and can pull themselves up from sitting to standing position. Can be used for independent residents who need extra support to stand.

3. Points to Remember: Check that device is stable before use and is rated for resident weight to be supported. Ensure frame is firmly attached to bed, or if it relies on mattress support that mattress is heavy enough to hold the frame, can aid resident independence.

1. Description: Scales with ramp to accommodate wheelchairs; portable-powered lift devices with built-in scales; beds with built-in scales.

2. When to Use: To reduce the need for additional transfer of partial- or non-weight bearing or totally dependent residents to weighing device.

3. Points to Remember: Some wheelchair scales can accommodate larger wheelchairs. Built-in bed scales may increase weight of the bed and prevent it from lowering to appropriate work heights ( Figure 15.16 ).

Figure 15.16  Scales with ramp (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Gait belts/transfer belts with handles.

2. When to Use: Transferring residents who are partially dependent, have some weight-bearing capacity, and are cooperative. Transfers such as bed to chair, chair to chair, or chair to car; when repositioning residents in chairs; supporting residents during ambulation; and in some cases, when guiding and controlling falls or assisting a resident after a fall.

3. Points to Remember: More than one caregiver may be needed. Belts with padded handles are easier to grip and increase security and control. Always transfer to resident's strongest side. Use good body mechanics and a rocking and pulling motion rather than lifting when using a belt. Belts may not be suitable for ambulation of heavy residents or residents with recent abdominal or back surgery, abdominal aneurysm, and so on. Should not be used for lifting residents. Ensure belt is securely fastened and cannot be easily undone by the resident during transfer. Ensure a layer of clothing is between residents' skin and the belt to avoid abrasion. Keep resident as close as possible to caregiver during transfer. Lower bedrails, remove arms and foot rests from chairs, and other items that may obstruct the transfer. For use after a fall, always assess the resident for injury prior to movement. If resident can regain standing position with minimal assistance, use gait or transfer belts with handles to aid resident. Keep back straight, bend legs, and stay as close to resident as possible. If resident cannot stand with minimal assistance, use a powered portable or ceiling-mounted lift device to move resident ( Figure 15.17 ).

Figure 15.17  Gait belts/transfer belts with handles (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Electric-powered height-adjustable bed.

2. When to Use: For all activities involving resident care, transfer, repositioning in bed, and so on, to reduce caregiver bending when interacting with resident.

1. Points to Remember: Device should have easy-to-use controls located within easy reach of the caregiver to promote use of the electric adjustment, sufficient foot clearance, and wide range of adjustment. Adjustments must be completed in 20 s or completed in 20 s or less to ensure staff use. For residents that may be at risk of falling from bed, some beds that lower closer to the floor may be needed. Heavy-duty beds are available for bariatric residents. Beds raised and lowered with an electric motor are preferred over crank-adjust beds to allow a smoother movement for the resident and less physical exertion to the caregiver ( Figure 15.18 ).

Figure 15.18  Electric-powered height-adjustable bed (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Trapeze bar; hand blocks and push up bars attached to the bed frame.

2. When to Use: Reposition residents that have the ability to assist the caregiver during the activity, that is, residents with upper body strength and use of extremities, who are cooperative and can follow instructions.

3. Points to Remember: Residents use trapeze bar by grasping bar suspended from an overhead frame to raise themselves up and reposition themselves in a bed. Heavy-duty trapeze frames are available for bariatric residents. If a caregiver is assisting, ensure that bed wheels are locked, bedrails are lowered, and bed is adjusted to caregiver's waist height. Blocks also enable residents to raise themselves up and reposition themselves in bed. Bars attached to the bed frame serve the same purpose. This may not be suitable for heavier residents and can aid resident independence ( Figure 15.19 ).

Figure 15.19  Trapeze bar (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Pelvic lift devices (hip lifters).

1. When to Use: To assist residents who are cooperative and can sit up to a position on a special bedpan.

2. Points to Remember: Convenience of device may reduce need for resident lifting during toileting. Device is positioned under the pelvis. The part of the device located under the pelvis gets inflated so the pelvis is raised and a special bedpan put underneath. The head of the bed is raised slightly during this procedure. Use correct body mechanics, lower bedrails, and adjust bed to caregivers' waist height to reduce bending ( Figure 15.20 ).

Figure 15.20  Pelvic lift devices (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Height-adjustable bathtub and easy-entry bathtubs.

2. When to Use: Bathing residents who sit directly in the bathtub, or to assist ambulatory residents climb more easily into a low tub, or easy-access tub. Bathing residents in portable-powered or ceiling-mounted lift device using appropriate bathing sling.

3. Points to Remember: Reduces awkward postures for caregivers and those who clean the tub after use. The tub can be raised to eliminate bending and reaching for the caregiver. Use correct body mechanics, and adjust the tub to the caregiver's waist height when performing hygiene activities. Increases resident safety and comfort ( Figure 15.21 ).

Figure 15.21  Height-adjustable bathtub (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Shower and toileting chairs.

2. When to Use: Showering and toileting residents who are partially dependent, have some weight bearing capacity, can sit up unaided, and are able to bend hips, knees, and ankles.

3. Points to Remember: Ensure that wheels move easily and smoothly; chair is high enough to fit over toilet; chair has removable arms, adjustable footrests, safety belts, and is heavy enough to be stable; and that the seat is comfortable, accommodates larger residents, and has a removable commode bucket for toileting. Ensure that brakes lock and hold effectively and that weight capacity is sufficient ( Figure 15.22 ).

Figure 15.22  Shower and toileting chairs (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Toilet seat risers.

2. When to Use: For toileting partially weight-bearing residents who can sit up unaided, use upper extremities (have upper body strength), are able to bend hips, knees, and ankles, and are cooperative. Independent residents can also use these devices.

3. Points to Remember: Risers decrease the distance and amount of effort required to lower and raise residents. Grab bars and height-adjustable legs add safety and versatility to the device. Ensure device is stable and can accommodate resident's weight and size ( Figure 15.23 ).

Figure 15.23  Toilet seat risers (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Bath boards and transfer benches.

2. When to Use: Bathing residents who are partially weight bearing, have good sitting balance, can use upper extremities (have upper body strength), are cooperative, and can follow instructions. Independent residents can also use these devices.

1. Points to Remember: To reduce friction and possible skin tears, use clothing or material between the resident's skin and the board. Can be used with a gait or transfer belt and/or grab bars to aid transfer. Back support and vinyl padded seats add to bathing comfort. Look for devices that allow for water drainage and have height-adjustable legs, may not be suitable for heavy residents. If wheelchair is used, ensure wheels are locked, the transfer surfaces are at the same level, and device is securely in place and rated for weight to be transferred. Remove arms and foot rests from chairs as appropriate and ensure that floor is dry ( Figure 15.24 ).

Figure 15.24  Bath boards and transfer benches (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Grab bars and stand assists; can be fixed or mobile.

Long-handled or extended shower heads or brushes can be used for personal hygiene.

2. When to Use: Bars and assists help when toileting, bathing, and/or showering residents who need extra support and security. Residents must be partially weight bearing, able to use upper extremities (have upper body strength), and be cooperative. Long-handled devices reduce the amount of bending, reaching, and twisting required by the caregiver when washing feet, legs, and trunk of residents. Independent residents who have difficulty reaching lower extremities can also use these devices.

3. Points to Remember: Movable grab bars on toilets minimize workplace congestion. Ensure bars are securely fastened to wall before use ( Figure 15.25 ).

Figure 15.25  Grab bars and stand assists (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Height-adjustable shower gurney or lift bath cart with waterproof top.

2. When to Use: For bathing non-weight-bearing residents who are unable to sit up. Transfer resident to cart with lift or lateral transfer boards or other friction-reducing devices.

3. Points to Remember: The cart can be raised to eliminate bending and reaching to the caregiver. Foot and head supports are available for resident comfort, may not be suitable for bariatric residents. Look for carts that are power-driven to reduce force required to move and position device ( Figure 15.26 ).

Figure 15.26  Height-adjustable shower gurney (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Built-in or fixed bath lifts.

2. When to Use: Bathing residents who are partially weight bearing, have good sitting balance, can use upper extremities (have upper body strength), are cooperative, and can follow instructions, useful in small bathrooms where space is limited.

3. Points to Remember: Ensure that seat rises so resident's feet clear tub, easily rotates, and lowers resident into water, may not be suitable for heavy residents. Always ensure lifting device is in good working order before use and rated for the resident weight. Choose device with lift mechanism that does not require excessive effort by caregiver when rising and lowering device ( Figure 15.27 ).

Figure 15.27  Built-in or fixed bath lifts (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Use of carts.

2. When to Use: When moving food trays, cleaning supplies, equipment, maintenance tools, and dispensing medications.

3. Points to Remember: Speeds process for accessing and storing items. Placement of items on the cart should keep the most frequently used and heavy items within easy reach between hip and shoulder height. Carts should have full-bearing wheels of a material designed for the floor surface in your facility. Cart handles that are vertical, with some horizontal adjustability, will allow all employees to push at elbow height and shoulder width. Carts should have wheel locks. Handles that can swing out of the way may be useful for saving space or reducing reach. Heavy carts should have brakes. Balance loads and keep loads under cart weight restrictions. Ensure stack height does not block vision. Low-profile medication carts with easy-open side drawers are recommended to accommodate hand height of shorter nurses ( Figure 15.28 ).

Figure 15.28  Carts (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Work methods and tools to transport equipment.

2. When to Use: When transporting assistive devices and other equipment.

3. Points to Remember:

1. Oxygen tanks: Use 

· small cylinders with handles to reduce weight and allow for easier gripping. Secure oxygen tanks to transport device.

· Medication pumps: Use stands on wheels.

· Transporting equipment: Push equipment, rather than pull, when possible. Keep arms close to the body, and push with whole body and not just arms. Remove unnecessary objects to minimize weight. Avoid obstacles that could cause abrupt stops. Place equipment on a rolling device if possible. Take defective equipment out of service. Perform routine maintenance on all equipment.

· Ensure that when moving and transporting residents, additional equipment such as oxygen tanks and IV/medication poles are attached to wheelchairs or gurneys or moved by another caregiver to avoid awkwardly pushing with one hand and holding freestanding equipment with the other hand ( Figure 15.29 ).

Figure 15.29  Transport equipment (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Filling and emptying liquids from containers.

2. When to Use: In housekeeping areas when filling and emptying buckets with floor drain arrangements.

3. Points to Remember: Reduces risk of spills, slips, speeds process, and reduces waste. The faucet and floor drain is used in housekeeping. Ensure that casters don't get stuck in floor grate. Use hose to fill bucket. Use buckets with casters to move mop bucket around. Ensure casters are maintained and roll easily ( Figure 15.30 ).

Figure 15.30  Liquid transfer equipment (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Filling and emptying liquids from containers.

1. When to Use: In dietary when pouring soups or other liquid foods that are heavy.

2. Points to Remember: Reduces risk of spills and burns, speeds process, and reduces waste. Use an elevated faucet or hose to fill large pots. Avoid lifting heavy pots filled with liquids. Use ladle to empty liquids, soups, and so on, from pots. Small sauce pans can also be used to dip liquids from pots. If the worker stands for more than 2 h/day, shock-absorbing floors or insoles will minimize back and leg strain. With hot liquids, ensure a splash guard is included ( Figure 15.31 ).

Figure 15.31  Liquids (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Select and use properly designed tools.

2. When to Use: When selecting frequently used tools for the kitchen, housekeeping, laundry, and maintenance areas.

1. Points to Remember: Enhances tool safety, speeds process, and reduces waste. Handles should fit the grip size of the user. Use bent-handled tools to avoid bending wrists. Use appropriate tool weight. Select tools that have minimal vibration or vibration damping devices. Implement a regular maintenance program for tools to keep blades sharp and edges and handles intact. Always wear the appropriate personal protective equipment.

1. Description: Spring-loaded carts that automatically bring linen within easy reach.

2. When to Use: Moving or storing linen.

3. Points to Remember: Speeds process for handling linen, and reduces wear on linen due to excessive pulling. Select a spring tension that is appropriate for the weight of the load. Carts should have wheel locks and height-appropriate handles that can swing out of the way. Heavy carts should have brakes ( Figure 15.32 ).

Figure 15.32  Spring-loaded carts (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Equipment and practices for handling bags.

2. When to Use: When handling laundry, trash, and other bags.

3. Points to Remember: Reduces risk of items being dropped, and speeds process for removing and disposing of items. Receptacles that hold bags of laundry or trash should have side openings that keep the bags within easy reach and allow employees to slide the bag off the cart without lifting. Provide handles to decrease the strain of handling. Chutes and dumpsters should be positioned to minimize lifting. It is best to lower the dumpster or chute rather than lift materials to higher levels. Provide automatic opening or hardware to keep doors open to minimize twisting and awkward handling ( Figure 15.33 ).

Figure 15.33  Laundry carts (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Tools used to modify a deep sink for cleaning small objects.

2. When to Use: Cleaning small objects in a deep sink.

3. Points to Remember: Place an object such as a plastic basin in the bottom of the sink to raise the work surface. An alternative is to use a smaller porous container to hold small objects for soaking, transfer to an adjacent countertop for aggressive cleaning, and then transfer back to the sink for final rinsing. Store inserts and containers in a convenient location to encourage consistent use. This technique is not suitable in kitchens/food preparation.

1. Description: Front-loading washers and dryers.

2. When to Use: When loading or unloading laundry from washers, dryers, and other laundry equipment.

3. Points to Remember: Speeds process for retrieving and placing items, and minimizes wear-and-tear on linen. Washers with tumbling cycles separate clothes, making removal easier. For deep tubs, a rake with long or extendable handle can be used to pull linen closer to the door opening. Raise machines so that opening is between hip and elbow height of employees. If using top-loading washers, work practices that reduce risk include handling small loads of laundry, handling only a few items at a time, and bracing your body against the front of the machine

1. when lifting. If items are knotted in the machine, brace with one hand while using the other to gently pull the items free. Ensure that items go into a cart rather than picking up baskets of soiled linen or wet laundry ( Figure 15.34 ).

Figure 15.34  Laundry machines (Adapted from Guidelines for Nursing Homes OSHA 3182-3R 2009)

1. Description: Work methods and tools to clean resident rooms with water and chemical products.

2. When to Use: When cleaning with water and chemical products and using spray bottles.

3. Points to Remember:

· Cleaning implement: use alternate leading hand, avoid tight static grip, and use padded nonslip handles.

· Spray bottles: Use trigger handles long enough for the index and middle fingers. Avoid using the ring and little fingers.

· For all cleaning: Use chemical cleaners and abrasive sponges to minimize scrubbing force. Use kneepads when kneeling. Avoid bending and twisting. Use extension handles, step stools, or ladders for overhead needs. Use carts to transport supplies or carry only small quantities and weights of supplies. Ventilation of rooms may be necessary when chemicals are used.

· Avoid lifting heavy buckets, for example, lifting a large, full bucket from a sink. Use a hose or similar device to fill buckets with water. Use wheels on buckets that roll easily and have functional brakes. Ensure that casters are maintained. Use rubber-soled shoes in wet areas to prevent slipping.

· Cleaning wheelchairs: Cleaning workstation should be at appropriate height.

1. Description: Work methods and tools to vacuum and buff floors.

2. When to Use: Vacuuming and buffing floors.

3. Points to Remember:

· Both vacuum cleaners and buffers should have lightweight construction, adjustable handles, triggers (buffer) long enough to accommodate at least the index and middle fingers, and easy to reach controls. Technique is important for both devices, including use of appropriate grips, avoiding tight grips, and for vacuuming, by alternating grip. The use of telescoping and extension handles, hoses, and tools can reduce reaching for low areas, high areas, and far away areas. Maintain and service the equipment and change vacuum bags when 0.5–0.75 full.

· Vacuums and other powered devices are preferred over manual equipment for moderate-to-long duration use. Heavy canisters or other large, heavy equipment should have brakes.

Training is critical for employers and employees to safely use the suggestions identified in these guidelines. Of course, training should be provided in a manner and language that all employees can understand. The following describes areas of training for nursing home employees, their supervisors, and program managers who are responsible for planning and managing the nursing home's ergonomics efforts. OSHA recommends refresher training be provided as needed to reinforce initial training and to address new developments in the workplace.

Nursing assistants and other workers at risk of injury. Employees should be trained before they lift or reposition residents, or perform other work that may involve risk of injury. Ergonomics training can be included with other safety and health training, or incorporated into general instructions provided to employees. Training is usually most effective when it includes case studies or demonstrations based on the nursing home's polices, and allows enough time to answer answer any questions that may arise. Training should ensure that these workers understand the following:

Training Recommendations

· Policies and procedures that should be followed to avoid injury, including proper work practices and use of equipment

· How to recognize musculoskeletal disorders (MSDs) and their early indications

· The advantages of addressing early indications of MSDs before serious injury has developed

· The nursing home's procedures for reporting work-related injuries and illnesses as required by OSHA's injury and illness recording and reporting regulation.

Training for Charge Nurses and Supervisors

Charge nurses and supervisors should reinforce the safety program of the facility, oversee reporting guidelines, and help ensure the implementation of resident and task-specific ergonomics recommendations, for example, using a mechanical lift. Because charge nurses and supervisors are likely to receive reports of injuries, and are usually responsible for implementing the nursing home's work practices, they may need more detailed training than nursing assistants on:

· methods for ensuring use of proper work practices;

· how to respond to injury reports; and

· how to help other workers implement solutions.

Training for Designated Program Managers

Staff members who are responsible for planning and managing ergonomics efforts need training so they can identify ergonomics concerns and select appropriate solutions. These staff members should receive information and training that will allow them to

· identify potential problems related to physical activities in the workplace through observation, use of checklists, injury data analysis, or other analytical tools;

· address problems by selecting proper equipment and work practices;

· help other workers implement solutions; and

· evaluate the effectiveness of ergonomics efforts.

USE OF MEDICAL EQUIPMENT

There is a wide range of equipment that is used in the medical field. Items include, but are not limited to scalpels, pipettes, needles, instrumentation/monitors, pumps of various types, IV bags, and so on. This section discusses the ergonomic risk factors associated with the use of pipettes.

Pipettes

A typical mechanical pipette, as shown in Figure 15.35, works in the following way. The user holds the pipette in a dagger grip (like an ice pick or similar tool would be held; also called reverse grip) with the index finger under a curved piece, called a finger hook, to keep the hand from sliding up the pipette. While gripping tightly, the user applies force using the hand, wrist, and arm, downward onto a pipette tip to firmly attach it to the end of the pipette. The user's thumb then extends to sit on the top of the pipette where the spring-loaded plunger is located. The thumb exerts pressure on the plunger, then releases, creating a vacuum, in order to aspirate liquid. Applying pressure to the plunger again will eject the liquid from the tip. Most mechanical pipettes have two “stops” on the plunger, one that discharges the liquid and one that is responsible for blowout, driving out any other residual liquid kept in the tip of the pipette. This, along with another trigger used to release the pipette tip from the pipette after use, again uses pressure from the thumb to work. To choose the quantity to dispense, the user twists the plunger, or for fine volume adjustments, the thumb or index finger spins a small dial to increase or decrease volume.

Figure 15.35  Typical mechanical pipette

Ergonomic Stressors Related to Pipetting

Thumb/Force

When pipetting, the thumb is used almost exclusively to draw out and deliver liquids as well as eject pipette tips. These tasks may be repeated hundreds of times daily and the force needed can vary, but all are significant to the total stress on the thumb. Figure 15.36 shows a representative force displacement curve documenting the strength needed to use a pipette plunger, from one repetition of aspiration to delivery (Asundi et al., 2005). Step 1 is pressing the plunger, using lateral pinch strength, to the first stop before releasing to draw out the liquid in step 3. Notice that the greatest amount of force is needed, from approximately 20–35 N (2–3.6 kg) in step 5, in order to complete the blowout of the residual liquid. Step 6 is when the plunger is released. Although these measurements appear high, they are not as high as the amount needed for pipette tip ejection. The force needed to discharge the tip from the end of the pipette can easily reach up to 8 kg of force (Fox, 1999). It is also important to emphasize that the biomechanical force within the joint of the thumb can be over nine times higher the force experienced at the tip of the thumb (Erickson & Woodward, 2001).

Figure 15.36  Force displacement curve for pipette use cycle (Adapted from Asundi et al. (2005))

All these stressors can lead to damage. One of the most common injuries for a laboratory worker using a pipette is de Quervain's Tenosynovitis. Especially with pipettes that have a longer plunger length and high plunger and tip ejection forces, this thumb injury can cause pain and swelling near the base of the thumb as well as a “sticking” sensation upon movement. If untreated, it can cause pain to travel up the thumb and, in extreme cases, into the forearm (Mayo Clinic, 2012). Other concerns are the wearing of the joint at the base of the thumb. Repetitive use can injure the carpometacarpal joint and lead to arthritis.

Hand and Wrist Movement/Repetitive Motion

Pipette grip is an important aspect to pipetting. Hand grip is normally increased when seating a new pipette tip or ejecting one, as well as during the blow out phase. Laboratory workers often pipette multiple sample aliquots while firmly holding the pipette in a static position. This can lead to decreased blood flow in the hand causing fatigue. Nerve injuries such as carpal tunnel syndrome can also occur from holding the pipette too tightly, causing the tendons of the hand to swell, compressing the median nerve in the carpal tunnel area. This can be intensified by pressure on the nerve upon bending the wrist since usually the worker's wrist is not in a neutral position while pipetting. Typical wrist position is often tilted to one side in order to aspirate and deliver aliquots of liquids. According to a study of female laboratory technicians, those who used pipettes more than 300 h/year had a risk of hand ailments five times higher than those with less exposure (Bjorksten et al., 1994).

Workstation/Awkward Postures

The task of pipetting normally entails nonneutral static postures of the head, neck, and shoulder (Lichty et al., 2011). The head might be tilted forward and down, shoulders hunched, and arm extended at shoulder height in order to effectively complete work (Figure 15.37). Body positioning such as this can compress the blood vessels, as well as restrict the flow of blood in the neck and shoulders causing weakness. This posture can also lead to nerve injuries due to the compression of the head and neck muscles as well as nerves against bones in the upper body. In addition to the awkward posture from using the pipette, normal bench top work can have many ergonomic stressors associated with it. Most pipette work requires workers to sit or stand for long periods of time in a static posture that can lead to WMSDs.

Figure 15.37  Posture of laboratory worker (Adapted photo by Ostrom)

Workstations vary depending on the work performed in a laboratory. Laboratory workers often utilize fume hoods or glove boxes to safely perform work. Unfortunately, while these workstations might mitigate the chemical or biological hazards of the work, they can possibly create ergonomic complications. Often when pipetting in a hood or glove box, reach becomes an issue. Having to fully extend the elbow and wrist to access necessary bottles or other items can lead to strain on the muscles and tendons responsible for straightening the wrist and fingers causing tennis elbow, or lateral epicondylitis (Erickson & Woodward, 2001). A worker may also have to pipette aliquots of liquid in containers while working around a hood sash or other obstruction putting strain on the shoulder and arm (Figure 15.38).

Figure 15.38  Pipetting in a hood (Adapted photo by Ostrom)

Elbow positioning is another ergonomic issue. In bench top applications, the worker naturally will place their elbow in only a few ways. One is on the bench top, as shown in Figure 15.39. Resting the elbow on this hard surface can compress the ulnar nerve in the arm against the medial epicondyle causing cubital tunnel syndrome (Erickson & Woodward, 2001). Similarly, many workers will rest their forearm against the edge of the bench top, often again creating contact stress that can restrict blood flow or cause inflammation.

Figure 15.39  Elbow resting on bench top (Adapted photo by Ostrom)

Other Personal and Contributing Risk Factors

Workload/Stress

Although many laboratory workers work in a research and development environment, production laboratories are quite common. With constant deadlines needing to be maintained, stress can contribute to WMSDs. Also, along the same line, signs of WMSDs can occur relating to inadequate recovery time. In addition, some samples such as in a radiological laboratory can only be used for a short period of time due to ALARA considerations so the worker might be rushed to complete their task. This also might elevate the risk of symptoms.

Temperature

Temperature can also be a factor. Some laboratories are temperature controlled because of the nature of the work being performed. This can reduce dexterity especially over long periods of time spent in colder temperatures. Temperature, similarly, can pose problems as a result of holding samples that come directly from a freezer, refrigerator, or heating device. All these can exacerbate ergonomic stressors.

Age

Age is also a factor. According to McGowan (2011), sensory/motor perception, strength, and movement control, as well as other physiological changes, begin to occur at age 45. These factors can impact abilities such as grasping, reaching, and overall movement.

Physical Condition/Extracurricular Activities/Prior Injuries

Ergonomic stressors can be worsened depending on a person's physical condition. Smoking, medical issues, and certain medications can restrict blood flow to the areas of the upper body, affecting the muscles and causing fatigue. Prior injuries to or extracurricular activities using the shoulder, arm, or hand can also be a significant personal risk factor that can contribute to further injury.

Recommendations

Thumb/Force

The use of an electronic pipette greatly reduces the force needed by the thumb to complete one cycle of pipetting. By using electronic pipettes, the use of a plunger to aspirate and deliver liquids as well as blow out the pipette tip is completely eliminated. Instead, a light touch of a button will complete these tasks. Unfortunately, they do not eliminate the necessity of the thumb to eject the tip, but with the reduction in force needed for other parts of the pipetting cycle, the cumulative stress on the thumb is greatly decreased.

Costs for electronic pipettes are only around twice as expensive as manual ones, so the cost difference is minor when compared to the cost of an injury. If it is not feasible to use an electronic pipette, using a manual pipette with low spring pressure and short length of travel to reduce thumb force needed is recommended (California Department of Health, 2001).

Hand and Wrist Movement/Repetitive Motion

It is important to use a pipette with a finger hook to reduce the time needed to grip the pipette. Finger hooks make it easy to rest the hand before, during, and after a pipette cycle (Erickson & Woodward, 2001). By relaxing the grip, possible injuries from inflammation of the tendons, such as carpal tunnel syndrome, can be decreased.

Keeping the wrist in a neutral posture is also important to reduce the prevalence of WMSDs. By taking the wrist out of neutral position, grip strength can be reduced by up to 42% (Kattel et al., 1996). This means that muscle use is not at full potential. Keeping the wrist neutral and choosing pipettes that do not require the wrist to be bent or tilted to aspirate or deliver liquids can substantially reduce the chance of injury.

In order to aid in muscle recovery and prevent ergonomic hazards, rotating pipetting tasks among several people or between laboratory tasks is suggested (Indiana University, 2014). Taking frequent breaks can also aid in preventing long periods of repetitive motion that occurs while pipetting.

Workstation/Awkward Postures

Laboratory workers have a higher prevalence of hand and shoulder ailments than other workers (Bjorksten et al., 1994) (Figure 15.40). One way to reduce these conditions is to decrease the time spent with the arm extended at shoulder height. Shorter pipettes decrease the height of the hand, keeping the arms in a more neutral posture close to the body, effectively reducing the tension on the shoulder that leads to fatigue and discomfort.

Figure 15.40  Hand and shoulder ailments among female laboratory workers and female state employees (Adapted from Bjorksten et al. (1994))

Proper workstation surface height is similarly important to reduce WMSDs. If standing, the workstation should be at a height that allows the worker to keep arms close to the body to keep neutral posture as much as possible. Antifatigue mats can also help with static postures while standing since pipetting can be repetitive in nature. If sitting, chair height should be adjusted to maintain proper neutral posture and reduce the need to bend the neck or hunch the shoulders or back. If possible, alternate sitting and standing (Indiana University, 2014).

If working in a hood or other workstation that requires awkward postures, limiting the time or spreading the work throughout the day can aid in muscle recovery to reduce the chance of stress on the body. Keeping work at the edge of the work surface can lower the instances of having to reach and extend the elbow and wrist.

To reduce contact stress injuries to muscles and tendons around the elbow, the workstation should have a padded or curved edge. This will maintain good blood flow to the forearm, wrist, and hand. Elevating the hands should be limited in order to minimize bending the elbow resulting in awkward postures.

CONCLUSION

Using a pipette has many ergonomic issues that can become problematic if not addressed. Fortunately, researchers have noticed this and have been able to give laboratory workers new knowledge and many suggestions to thwart the damage caused by the poor ergonomic tool use in the workplace. With ergonomic programs becoming more commonplace, tasks can be more expertly monitored to promote safe and rigorous ergonomic work practices and work habits that can be used to mitigate a lifetime of risk factors associated with WMSDs. Proper tool use can make a considerable difference in the reduction of injuries in the workplace.

MEDICAL RECORDS CASE STUDY

Case Study

A medical record contains, at a minimum, a 2-year medical history of the patient to include physical examination findings, treatment plans, operative records, consent forms, medication distribution, referral papers, admission and discharge records, and medical certificates. Care providers from different specialties within the hospital (dental, urgent care, and ophthalmology) request records, and then return them to the medical records department, who is responsible for their accuracy and completeness.

Medical records management requires a high level of detail. Inappropriate record keeping can result in medical claims, operative procedure complications, and alleged medical negligence. In addition, confidentiality laws and ethical principles protect the privacy of communication between patient and their doctor. These laws also protect the contents of the medical record that is maintained by a doctor and the hospital.

A general procedure for handling a medical record begins with the medical records department receiving a “pull” request generated from the appointment desk. Care providers are primarily responsible for documenting the patients' health history under their care; such records have a direct relationship with the management of the patients' care. Twice a day, the technicians query the database to obtain a list of records that are needed for the next day's appointment calendar. Technicians spend up to 2 h a day pulling medical records for either appointments or audit purposes and another 2 h filing them back into the system after they are verified and complete. Three of the seven shelves are within easy reach. Some technicians use step stools for the highest shelve (Figure 15.41).

Figure 15.41  Medical record storage

Each department (or specialty) retrieves the records before the shift begins and returns them at the end of the day; these records are not necessarily complete. Returned records are verified for completeness by the records department; pending laboratory or X-ray results and other documentation (patient sheets), not directly noted by the caregiver in the record, must be retrieved from a computer system, printed and manually filed into the record. This process is time consuming and accounts for a majority of the technicians' time. It results in batch sorting records on the technician's work surface. For example, sorting categories include completed, incoming, needs laboratory work. The limited size of the workstation surface requires batches and individual records be handled unnecessarily. In other words, the technicians move piles of records to make room for more urgent work.

Once the record is complete, it is filed back into/onto the shelves. Other responsibilities include assembling a new record and archiving. The department “pulls” approximately 5000 appointment records a month. In addition, a minimum of 200 records are “pulled” for audits and another 50 for other purposes (e.g., needs to be copied, patient relocating). Each record is handled a minimum of four times and an average of six times: 5250 records × 4 moves = 21,000 moves/month; 5250 records × 6 moves = 31,500 moves/month.

Ergonomics Hazards Handling Records Within the Storage System

Managing medical records in the current storage system requires repetitive, awkward postures while pulling or filing records that are above shoulder height and below elbow height. Sixty percent of the records are outside of the comfortable reach envelope for standing. Technicians also pull records while kneeling or standing on a step stool.

An automated storage system, regardless of the increase in storage space, will reduce reaching in awkward postures and provide a standing work surface. Having a work surface in front of the file shelves reduces records handling because the patient sheets can be filed in-place instead of bringing the record to the desk.

The recommendations were to install an automated record storage equipment shown in Figure 15.42.

Figure 15.42  Automated record storage system

The Interim recommendations included the following:

· Use rolling tool stools when accessing lowest shelves.

· Use rolling tables when managing records within the isle.

· Continue with archiving to decrease the volume of records and, when feasible, consolidate records to the center three shelves.

· Implement stretch and flex into the work day to oxygenate fatigued muscles and increase circulation.

HOSPITAL CASE STUDY

Ergonomic Risk Assessment for a Hospital

Introduction

This report summarizes the ergonomic risk assessment conducted at a hospital. Two areas were observed in order to determine solutions to reduce ergonomic stressors: the labor and delivery patient rooms and the patient transport by ambulance gurney. This assessment is based upon interviews with nurses, corpsmen, emergency medical technicians (EMTs), local fire department response personnel, and base safety personnel. In addition, the hospital ergonomic team identified the priority areas and suggested improvements.

The operations reviewed present opportunities to reduce the risk of WMSDs and improve safety, health, and productivity. MSDs are injuries and illnesses that affect muscles, nerves, tendons, ligaments, joints, spinal discs, skin, subcutaneous tissues, blood vessels, and bones. WMSDs are

· Musculoskeletal disorders to which the work environment and the performance of work contribute significantly or

· Musculoskeletal disorders that are aggravated or prolonged by work conditions.

LABOR AND DELIVERY WARD

Description of the Operation

Patients arrive at the emergency room entrance via ambulance or personal vehicle. Typically, for patients arriving via personal vehicle, one or two nurses help the patient out of the personal vehicle and into a wheelchair, then out of the wheelchair and onto an Obstetrics/Gynaecology stretcher for transport to the labor and delivery room.

For the labor and delivery procedure, the OB/GYN stretcher leg support collapses downward. As the leg support folds down, the nurse must pull on the seating area to slide the patient closer to the edge of the stretcher for care. In addition, leg supports (stirrups) are difficult to adjust and in the labor and delivery room, the limited space makes it difficult to care for the patient from all sides (see  Figure 15.43 ).

Figure 15.43  Nurse assumes awkward posture while exerting force to pull the patient

Ergonomic Issue Description

The major ergonomic risk factors for the labor and delivery task are excessive lifting from transferring patients, and awkward postures and excessive force caused by operating the stretcher.

Excessive Lifting

As long ago as 1965, a study of the physical loads on nurses noted that an adult human being is awkward to lift or carry because it is not a rigid load and it has no handles. The study further noted that a patient lying in a bed is particularly hard to lift just by virtue of physical position relative to the lifter. Added to the physical burden is the mental stress of knowing that a human being can be severely damaged if dropped or handled incorrectly. The study observed that loads on nurses may be worse than those on industrial workers.

Half a century later, the situation of nurses remains unchanged. Manually lifting and transferring patients is a high-risk activity, both for the healthcare worker and for the patient. Of all occupations, nursing has one of the highest incidences of work-related back problems.

Recommendations

· Ensure that yearly back injury prevention training covers proper body mechanics, lifting techniques, stretching, and information on the use of patient transfer/handling equipment. Refer to  Appendix A .

· Where feasible, use a mechanical assist patient transfer aids such as a portable lift to transfer patients from a personal vehicle to the stretcher or wheelchair. Use raise-to-stand units to help patients stand and walk. Refer to  Appendix B .

· Where feasible, use manual assist patient transfer/handling aids such as gate belts to assist with patient movement and lateral transfer. Refer to  Appendix B .

· Where feasible, transfer the patient directly onto the OB/GYN stretcher.

· Since OB patients are typically 30–60 lb heavier than other patients, the hazard abatement program will provide bariatric wheelchairs; these larger wheelchairs allow more room for patient transfer and comfort.

Awkward Posture

The patient rooms do not allow the nurse to easily care for the patient from all sides. The space restriction forces the nurses to bend forward or twist at the trunk while providing care. Depending on the type of care being administrated, the nurse may have to assume this posture for a few seconds to a few minutes. The muscles must apply considerably more contraction force to hold awkward postures, particularly if the position is maintained for more than a couple of seconds.

Excessive Force

The height of the hands affects the amount of force needed to push or pull an object. When the hands are slightly above waist height, a worker gets the most from the muscles. As the hands are moved lower or higher, the working posture becomes more awkward, and the muscles must exert more force. Nurses in the labor and delivery ward exert force while in an awkward posture to position the patient for treatment. The nurse's hands are well below waist height when pulling on the leg support to position the patient. Performing forceful exertions can irritate tendons, joints, and discs, leading to inflammation, fluid buildup, and constriction of blood vessels and nerves in the area.

RECOMMENDATION

Replace the dated OB/GYN stretcher. The facility is evaluating three OB/GYN stretchers with smaller dimensions to increase space in the patient room and reduce reaching. Features of the new model include lightweight construction; side rails; 8-in. locking casters; and easy glide controls that are operated from a standing, not stooped, posture to provide quick and easy patient positioning with reduced force. This stretcher also has integrated foot supports that increase patient comfort and provide ease of operation by the nurse.

PATIENT TRANSPORT

Injury Data

Documented shoulder and arm strain from attempting to arrest a falling gurney with patient when the equipment failed to lock into position.

Description of the Operation

Ambulance personnel are faced with an ever-changing, uncontrolled work environment in which patients are commonly moved from homes with narrow passageways to the ambulance for transportation to hospitals. Once at the hospital, the ambulance crew transports the patient from the ambulance to the emergency room, then transfers the patient to a short-term care ward stretcher for treatment.

Loading the Gurney

At the pickup site, with the patient on the gurney, the ambulance technicians position the gurney at the rear of the ambulance. One technician folds up the gurney's legs, disengages the wheel locks, and pushes the gurney into the ambulance (Photo 2). The second technician stands at the side of the gurney to help with guiding and to reassure the patient. During this process, the technician at the end of the gurney bears the weight of both the gurney and the patient while pushing the gurney into the ambulance. The process is complicated because the patient's feet interfere with the gurney's base controls and handhold at the foot end, as shown in  Figure 15.44 .

Figure 15.44  Patient transport

Unloading the Gurney

The gurney is removed from the ambulance with one technician outside the ambulance at the foot of the gurney and the other technician inside the ambulance. The technician at the foot pulls the gurney out until the base drops and supports the gurney weight. Again, the patient's feet can obstruct the handhold and require the technician to bend, as shown in Photos 2 and 3. The gurney lacks standard safety equipment to arrest a fall from the ambulance in the event the base does not engage or technician footing is compromised.

Gurney Operation

The gurney is raised and lowered with one technician at each end, as shown in  Figure 15.44 . To lower the gurney, the technician at the foot of the gurney disengages a lock located beneath the patient's feet. The feet of a tall patient make it difficult for the technician to grasp the mechanism. Locks at the head and the foot of the gurney must be disengaged at the same time. Once the locks are disengaged, the crew bears the weight of both the gurney and the patient while lowering the gurney. If one end disengages without the other, the gurney can fall. To raise the gurney, the technicians disengage the locks and lift the gurney until they hear an audible indication.

Ergonomic Issue Description

The major ergonomic risk factor for the ambulance technicians is excessive lifting and force due to manual handling of the gurney.

The gurneys used at this facility have limited height positions. Their short wheelbase and small diameter wheels make them unstable on some terrain, thus creating a risk to both the technician and the patient if a gurney falls. The gurneys are not tension controlled; therefore, the technician bears the weight of the patient and gurney during lifting and lowering. The handles on the foot end of the gurney are under the cot, forcing the technician into awkward postures. The gurneys have a no catch system to arrest a gurney falling from the back of the ambulance.

Excessive Lifting

When technicians bend over to perform a lift, such as when raising and lowering the gurney, the muscles in the back must exert a lot of force to raise and lower the weight of the upper body. This causes the back muscles to fatigue more rapidly and puts pressure on the discs in the lower back. When technicians have to maintain awkward postures for more than a few seconds, their back muscles and discs experience the application of a large amount of static force. The problem becomes worse when either greater weight or greater distance is required.

If the weight of the load were to suddenly shift while being lifted, the resulting awkward posture, combined with the weight and distance of the load from the lower spine, could tear tendons, ligaments, and muscles.

Recommendations

· Ensure that yearly back injury prevention training covers proper body mechanics, lifting techniques, stretching, and information on the use of patient transfer/handling equipment.

· The staff are evaluating two stretchers with the following features: a catch mounted at the rear of the ambulance to arrest a fall; a minimum of five height positions; weight-sensitive tension control or lift assist; a single hand lever to set cot height and lock release; lightweight construction; 6-in.-diameter wheels with locks; foot-end lifting system; and four-point patient restraining harness.

KEY POINTS

Working in health care is a very stressful job, both from a psychological and physical perspective.

Use of the correct patient handling devices and techniques can help to reduce the potential for injuries associated with patient handling.

The use of medical devices also poses a risk to the user from an ergonomic perspective. Proper use of these devices and the proper selection of the device in the first place can help to reduce the potential for injury.

REVIEW QUESTIONS

1. What factors make lifting a patient so potentially hazardous to healthcare professionals?

2. How will the current trend of Americans becoming heavier impact the potential for a WMSD?

3. Surgeons use devices such as retractors and scalpels on a daily basis. What types of injuries might they develop?

4. Seating is important for healthcare professionals. What factors would be important in the design of these sorts of chairs?

5. The posture a healthcare professional has to attain to move a patient can be quite awkward. Besides the devices listed in this chapter, what other types of equipment might be important?

6. Seating is important for healthcare professionals. What factors would be important in the design of these sorts of chairs?

7. The posture a healthcare professional has to attain to move a patient can be quite awkward. Besides the devices listed in this chapter, what other types of equipment might be important?

REFERENCES

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1. Kattel, B., Fredericks, T., Fernandez, J., and Lee, D. (1996). The Effect of Upper-Extremity Posture on Maximum Grip Strength. International Journal of Industrial Ergonomics, 18, 423–429.

2. Lichty, M., Janowitz, I., & Rempel, D. (2011). Ergonomic Evaluation of Ten Single-Channel Pipettes. Work, 39(2), 177–185.

3. Mayo Clinic. (2012). Diseases and Conditions: De Quervain's Tenosynovitis. Retrieved from Mayoclinic.org: http://www.mayoclinic.org/diseases-conditions/de-quervains-tenosynovitis/basics/definition/con-20027238.

4. McGowan, B. (2011). Ergonomics and Aging Population. Retrieved from http://www.humantech.com/blog/ergonomics-and-the-aging-population/

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6. Workplace Health Promotion. (n.d.). Retrieved 2015, from CDC: http://www.cdc.gov/workplacehealthpromotion/implementation/topics/disorders.html.

ADDITIONAL SOURCE

1. Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders, U.S. Department of Labor, Elaine L. Chao, Secretary.