From the Beginning to the End: Interventions to Prevent Back Injury in Nursing Home Workers

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From the Beginning to the End: Interventions to

Prevent Back Injury in Nursing Home Workers

James W. Collins, PhD, MSME

Associate Director for Science

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health Division of Safety Research

The findings and conclusions in this presentation are those of the author and do not necessarily

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Leading Sources of Workers’ Compensation in Health Care

• Overexertion, primarily due to

patient lifting and repositioning

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0 200000 400000 600000 800000 1000000 1200000 1400000 1600000 1800000 2000000 A ssa ults Au to Bod_{ily R} eac tion C au gh t I_n E_xp os ur_e Slip /F all N ee dle stic_k O the r O vere xe_rt ion R ep et itiv_e St ruc k B y

Incident Type

(4)

Translating

Research to Practice

Research and innovation

development is becoming less

about invention and discovery and more about what we do with our knowledge of the problem and the potential solutions to the problem.

(5)

P ro o f o f C o n c e p t C o n c e p t P ro p o s a l R esear ch P ilot ing Partners Research _Practice

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Research Process to

Change Industry Practice

•

Review of the Scientific Literature

•

Analysis of the Injury Data

•

Peer & Stakeholder Review and input from “Key Opinion” Leaders

(7)

Research Methods to

Change Industry Practice

•

Intervention Trials

–Develop Business Case

–Assess Program Sustainability

•

Develop “Best Practices”

(8)

Elements of a “Best

Practices” Program

“Best Practices” Management Support Safety Culture Medical Management Stakeholder Input Lab and Field Testing Engineering Controls Written Polices

(9)

Even when lifting a

patient with two people, the weight of any adult far exceeds the acceptable limits for

(10)

(11)

Highest Risk Occupations for Back Pain in Females in the U.S.

Occupation Cases Prevalence

Nursing Aides & Orderlies 269,000 18.8

Licensed Practical Nurses 99,000 16.3

Maids 84,000 14.9

Janitors and Cleaners 102,000 13.3

Health Aides, except Nursing

39,000 11.1

(12)

“The adult human form is an

awkward burden to lift or carry. Weighing up to 200 pounds or

more, it has no handles, it is not rigid, and it is susceptible to

severe damage if mishandled or dropped.

(13)

When lying in a bed, a patient

is placed inconveniently for

lifting, and the weight and

placing of such a load would

be tolerated by few industrial

(14)

Stakeholder and

Peer Review Team

• Industry Expertise (Stakeholders) – Trade Associations

– Unions

– Equipment Manufacturers – End-Users/Adopters

• International Experts (Peer Reviewers) Scientific study design expertise

(15)

Study Partners

and Stakeholders

• BJC Health Care

• BJC Occupational Health Nurse Council

• Washington Univ. – School of Medicine

• West Va. Univ.– College of Engineering

• Lifting Equipment Manufacturers

• NIOSH – DSR

• Schools of Nursing/NCLEX

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LAB STUDY • Efficacy • Exposure Assessment • Biomechanical Stress • Patient Comfort and Security • Ease of Use • Time to Conduct Transfer FIELD STUDY • Effectiveness • Injury rates • Workers’ Compensation costs

• Lost workday rates

• Restricted workday rates

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Lab Study Findings

• Lifting devices significantly

reduce low-back compressive forces and remove 2/3 of the lifting exposures

• Lifting devices reduce the risk of sudden movement injury

(19)

(20)

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Length of Follow up

1 year is

not enough

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Injury Rate Due to Resident Lifting/Transferring 17.7 18.8 10.8 9 8.4 6.4 4.2 4.2 1.6 0 2 4 6 8 10 12 14 16 18 20 1995 1996 1997 1998 1999 2000 2001 2002 2003

Resident Lift Injury Rate

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Workers’ Compensation Costs Due to Resident lifting/Transferring

$0 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 1995 1996 1997 1998 1999 2000 2001 2002 2003 $183,012 $161,337 $111,837 $61,020 $31,716 $249,706 $20,820 $68,623 $14,228 Intervention

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Design Research to

Consider Transiti

ons

•

Higher rates when workers are in transition, huge injury rates for:

– New employees

•Especially the first 3 to 6 months on the job

– Transferring into a new job

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Pre- and Post-Intervention

Injury Rates by Age Group

0 5 10 15 20 16-24 25-34 35-44 45-54 55+ Pre-Int Post-Int

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Pre- and Post Patient Handling Injury Rate by Length of Employment 0 2 4 6 8 10 12 14 16 18

< 1 year 1-5yr 5-10yr >10yrs.

Pre-Post

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Pre- and Post Patient Handling

Injury Rates by Gender

0 2 4 6 8 10 12 14 16 Male Female Pre Post

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Injury Rate Pre- and Post

for each Nursing Home

0 5 10 15 20 25 A B C D E F Pre-Post

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Poisson Regression Results

• Worker Compensation Data

– Rate Ratio = .34 (.24, .47),

– p-value = .0001

• OSHA 200 logs

– Rate Ratio = .42 (.30, .58),

– p-value = .0001

• 1st _{Reports of Employee Injury}

– Rate Ratio = .62 (.47, .82),

(30)

Field Study Results

Pre- vs. Post-Intervention

• 47 Worker Comp Claims per Year vs. 16 66%

• 14.0 Injuries/100 Nursing Staff vs. 5.6/100 60%

• LWD Rates 5.8/100 vs. 2.0/100 66%

• RWD Rates 9.3/100 vs. 5.7/100 39%

(31)

An evidence-base of science

indicates that a comprehensive

safe patient handling program

can be a highly effective

solution, not simply relying on

teaching safe body mechanics.

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Elements of a “Best

Practices” Program

“Best Practices” Management Support Safety Culture Medical Management Stakeholder Input Lab and Field Testing Engineering Controls Written Polices

(33)

Sustainability

•

What happens when the research

ends?

•

Is the intervention self sustaining?

•

Are the findings strong enough to

change industry practice or serve as the basis of a national campaign?

(34)

Adoption of Innovations

Getting a new idea

adopted, even when it

has obvious advantages

is difficult

(35)

Diffusion of Innovations

• Internet – Fastest (13 years,

1989-2002, 71% adoption)

• Television

• Cell Phones

(36)

Adoption

•

Many technologists believe:

– innovations will sell themselves – benefits are obvious

•

Instant success usually takes 15 to 20 years

– Fact, most innovations diffuse at a disappointingly slow rate

(37)

Common Problem

What can we do to

speed up the rate of

Diffusion of an

(38)

Diffusion Occurs Within a

Social System

Not all members of a social

system are created equal.

1. Stakeholders

(39)

Rate of Adoption

Explained by 5 Attributes

1.

Relative Advantage

2.

Compatibility

3.

Complexity

4.

Trialability

5.

Observability

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Relative Advantage

The degree to which an innovation

is better than the idea it replaces

•

Economic profitability (cost-benefit)

•

Productivity

(41)

Compatibility Assessment

•

Peer and stakeholder review

•

Determine end user needs

•

Discuss perceptions of the problem and previous attempts to address

•

End user may want to participate in innovation design

(42)

Complexity

Simpler is better. The

complexity of an

innovation is inversely

related to the rate of

adoption.

(43)

Trialability

Lab Study testing patient lifts

Field Study – Patient lifts from 3 different manufacturers were trialed for 30 days

by nursing staff

Created Buy-in, ownership of the program, staff more likely to use

(44)

Business Case

Does the intervention

pay for itself?

(45)

Business Case

• Business Case

for Safe Patient Lifting Programs • Mailed to 17,000 Nursing Homes • Portuguese & Japanese • 2 year payback

(46)

New Student

Nursing Curriculum

•

NIOSH, ANA, and the Veteran’s Administration

•

Evidence-Base of Science

•

Nursing School Faculty

•

26 Schools of Nursing/Clinical Labs

(47)

Practical Guide for Health Care Professionals/Nursing Curriculum

(48)

National Conference

•

VA, NIOSH, ANA Co-sponsor

•

Started 10 years ago 75 attendees

•

Has grown to over 1,200 attendees

–Health Care practitioners –Not Scientists

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Legislation

• Testimony before Congress

• 10 State laws

– California – 10/11 – New Jersey – 01/08 – Minnesota – 05/07 – Maryland 03/07

– Texas State Law -- 01/06

– Washington State Law – 03/06 – Hawaii – 04/06

– Rhode Island – 07/06 – Ohio – 03/05

– New York – 04/05

(50)

ANA Safe Patient Handling

and Mobility Standard

•

Standards to establish basis for

policies, laws, regulations to protect workers, patients

(51)

Nursing homes: Spearman's rho = -0.98, p < 0.0001

Hospitals: Spearman's rho = -0.99, p < 0.0001

Rates of Sprains and Strains Involving Days Away from Work in Hospitals and Nursing Homes, Health Care Patients as Source,

1992-2005 110.8 110.3 98.4 _95.3 _92.9 100.0 86.5 _80.3 76.2 _69.0 75.7 63.1 _59.4 53.5 397.8 358.7 319.9 330.0 301.1 273.8 232.1 214.3 225.2 172.6 201.6 140.0 121.7 121.2 0 50 100 150 200 250 300 350 400 450 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 R at e p er 10, 000 f u ll -t im e w o rker s

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Future Research

•

Acute care hospitals

•

Home health care

•

Bariatric Patients

•

Evaluation of Legislation

•

Refine Nursing Curriculum

•

Show Link to Patient Outcomes

(53)

Key Point

Successful Translation of

Occupational Safety and

Health Research can take up

to 20 years to implement to

change industry practice

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Thank you!

James W. Collins

E-mail:

jcollins1@cdc.gov

“The findings and conclusions in this presentation have not been formally disseminated by the National Institute for Occupational Safety and Health and

should not be construed to represent any agency determination or policy.”