Download - Guidelines for Nursing Homes: Ergonomics for the Prevention of Musculoskeletal Disorders

GuidelinesforNursingHomesOSHA 3182-3R 2009

Ergonomicsfor the Prevention of

Musculoskeletal Disorders

Guidelines for Nursing HomesErgonomics for the Preventionof Musculoskeletal Disorders

U.S. Department of LaborElaine L. Chao, Secretary

Occupational Safety and Health AdministrationJohn L. Henshaw, Assistant Secretary

OSHA 3182-3R 2009

Guidelines for Nursing Homes 1

2 Guidelines for Nursing Homes

Table of Contents

5 Executive Summary

7 SECTION I:

Introduction

9 SECTION II:

A Process for Protecting Workers

9 Provide Management Support

9 Involve Employees

10 Identify Problems

10 Implement Solutions

10 Address Reports of Injuries

11 Provide Training

11 Evaluate Ergonomics Efforts

12 SECTION III:

Identifying Problems and Implementing Solutions for Resident

Lifting and Repositioning

12 Identifying Problems for Resident Lifting and Repositioning

� Figure 1. Transfer to and from: Bed to Chair, Chair to Toilet,

Chair to Chair, or Car to Chair

� Figure 2. Lateral Transfer to and from: Bed to Stretcher, Trolley

� Figure 3. Transfer to and from: Chair to Stretcher

� Figure 4. Reposition in Bed: Side-to-Side, Up in Bed

� Figure 5. Reposition in Chair: Wheelchair and Dependency Chair

� Figure 6. Transfer a Patient Up From the Floor

17 Implementing Solutions for Resident Lifting and Repositioning

� Transfer from Sitting to Standing Position

� Resident Lifting

� Repositioning in Chair

� Ambulation

� Lateral Transfer; Repositioning

� Lateral Transfer in Sitting Position

� Transfer from Sitting to Standing Position

� Weighing

� Transfer from Sitting to Standing Position; Ambulation

� Repositioning

� Bathtub, Shower, and Toileting Activities


27 SECTION IV:

Identifying Problems and Implementing Solutions for

Activities Other than Resident Lifting and Repositioning

� Storage and Transfer of Food, Supplies, and Medications

� Mobile Medical Equipment

� Working with Liquids in Housekeeping

� Working with Liquids in Kitchens

� Hand Tools

� Linen Carts

� Handling Bags

� Reaching into Sink

� Loading or Unloading Laundry

� Cleaning Rooms (Wet Method)

� Cleaning Rooms (Electrical)

31 SECTION V:

Training

31 Nursing Assistants and Other Workers at Risk of Injury

31 Training for Charge Nurses and Supervisors

31 Training for Designated Program Managers

33 SECTION VI:

Additional Sources of Information

35 References

36 Appendix: A Nursing Home Case Study

Table of Contents


These guidelines providerecommendations for nursing homeemployers to help reduce the numberand severity of work-related muscu-loskeletal disorders (MSDs) in theirfacilities. MSDs include conditionssuch as low back pain, sciatica,rotator cuff injuries, epicondylitis,and carpal tunnel syndrome. Therecommendations in these guidelinesare based on a review of existingpractices and programs, State OSHAprograms, as well as availablescientific information, and reflectcomments received from representativesof trade and professional associations,labor organizations, the medicalcommunity, individual firms,and other interested parties. OSHAthanks the many organizationsand individuals involved for theirthoughtful comments, suggestions,and assistance.

More remains to be learned aboutthe relationship between workplaceactivities and the development ofMSDs. However, OSHA believesthat the experiences of many nursinghomes provide a basis for takingaction to better protect workers.As the understanding of these injuriesdevelops and information andtechnology improve, the recommenda-tions made in this document maybe modified.

Executive Summary

Although these guidelines aredesigned specifically for nursinghomes, OSHA hopes that employerswith similar work environments, suchas assisted living centers, homes forthe disabled, homes for the aged,and hospitals will also find thisinformation useful.

OSHA also recognizes that smallemployers, in particular, may nothave the need for as comprehensive aprogram as would result fromimplementation of every action andstrategy described in these guidelines.Additionally, OSHA realizes thatmany small employers may needassistance in implementing anappropriate ergonomics program.That is why we emphasize theavailability of the free OSHAconsultation service for smalleremployers. The consultation service isindependent of OSHA’s enforcementactivity and will be making specialefforts to provide help to the nursinghome industry.

These guidelines are advisory innature and informational in content.They are not a new standard orregulation and do not create any newOSHA duties. Under the OSH Act,the extent of an employer’s obligationto address ergonomic hazards isgoverned by the general duty clause,29 U.S.C. 654(a)(1).


An employer’s failure to implementthe guidelines is not a violation, orevidence of a violation, and may notbe used as evidence of a violation, ofthe general duty clause. Furthermore,the fact that OSHA has developedthis document is not evidence andmay not be used as evidence of anemployer’s obligations under thegeneral duty clause; the fact that ameasure is recommended in thisdocument but not adopted by anemployer is not evidence, and maynot be used as evidence, of aviolation of the general duty clause.In addition, the recommendationscontained herein should be adaptedto the needs and resources of eachindividual place of employment.Thus, implementation of the guide-lines may differ from site to sitedepending on the circumstancesat each particular site.

While specific measures maydiffer from site to site, OSHArecommends that:■ Manual lifting of residents beminimized in all cases andeliminated when feasible.

■ Employers implement an effectiveergonomics process that:■ provides management support;■ involves employees;■ identifies problems;■ implements solutions;■ addresses reports of injuries;■ provides training; and■ evaluates ergonomics efforts.These guidelines elaborate on

these recommendations, and includeadditional information employerscan use to identify problems andtrain employees. Of particular valueare examples of solutions employerscan use to help reduce MSDs in theirworkplace. Recommended solutionsfor resident lifting and repositioningare found in Section III, whilerecommended solutions for otherergonomic concerns are in SectionIV. The appendix includes a casestudy describing the process onenursing home used to reduce MSDs.

Executive Summary


Nursing homes that haveimplemented injury prevention effortsfocusing on resident lifting andrepositioning methods have achievedconsiderable success in reducingwork-related injuries and associatedworkers’ compensation costs. Pro-viding a safer and more comfortablework environment has also resulted inadditional benefits for some facilities,including reduced staff turnover andassociated training and administrativecosts, reduced absenteeism, increasedproductivity, improved employeemorale, and increased residentcomfort. These guidelines providerecommendations for employers tohelp them reduce the number andseverity of work-related musculoskele-tal disorders in their facilities usingmethods that have been found to besuccessful in the nursing homeenvironment.

Providing care to nursing homeresidents is physically demandingwork. Nursing home residents oftenrequire assistance to walk, bathe, orperform other normal daily activities.In some cases residents are totallydependent upon caregivers formobility. Manual lifting and othertasks involving the repositioning ofresidents are associated with anincreased risk of pain and injury tocaregivers, particularly to the back (2,3). These tasks can entail high physicaldemands due to the large amount

SECTION I

Introduction

of weight involved, awkward posturesthat may result from leaning over abed or working in a confined area,shifting of weight that may occur if aresident loses balance or strengthwhile moving, and many otherfactors. The risk factors that workersin nursing homes face include:■ Force - the amount of physical

effort required to perform a task(such as heavy lifting) or to main-tain control of equipment or tools;

■ Repetition - performing the samemotion or series of motions contin-ually or frequently; and

■ Awkward postures - assumingpositions that place stress on thebody, such as reaching aboveshoulder height, kneeling,squatting, leaning over a bed, ortwisting the torso while lifting (3).

Wyandot County Nursing Home in UpperSandusky, Ohio, has implemented a policyof performing all assisted residenttransfers with mechanical lifts, and haspurchased electrically adjustable beds.According to Wyandot, no back injuriesfrom resident lifting have occurred in overfive years. The nursing home also reportedthat workers’ compensation costs havedeclined from an average of almost$140,000 per year to less than $4,000 peryear, reduced absenteeism and overtimehave resulted in annual savings ofapproximately $55,000, and a reduction incosts associated with staff turnover hassaved an additional $125,000 (1). (seeReference List)


Excessive exposure to these riskfactors can result in a variety ofdisorders in affected workers (3, 5).These conditions are collectivelyreferred to as musculoskeletaldisorders, or MSDs. MSDs includeconditions such as low back pain,sciatica, rotator cuff injuries,epicondylitis, and carpal tunnelsyndrome (6). Early indications ofMSDs can include persistent pain,restriction of joint movement, or softtissue swelling (3, 7).

While some MSDs develop gradu-ally over time, others may resultfrom instantaneous events such as asingle heavy lift (3). Activities outsideof the workplace that involvesubstantial physical demands mayalso cause or contribute to MSDs (6).In addition, development of MSDsmay be related to genetic causes,gender, age, and other factors (5, 6).Finally, there is evidence that reportsof MSDs may be linked to certainpsychosocial factors such as jobdissatisfaction, monotonous work,and limited job control (5, 6). Theseguidelines address only physicalfactors in the workplace that arerelated to the development of MSDs.

After implementing a program designedto eliminate manual lifting of residents,Schoellkopf Health Center in NiagaraFalls, New York, reported a downwardtrend in the number and severity ofinjuries, with lost workdays droppingfrom 364 to 52, light duty daysdropping from 253 to 25, and workers’compensation losses falling from$84,533 to $6,983 annually (4).

At Citizens Memorial Health Care Facilityin Bolivar, Missouri, establishment of anergonomics component in the existingsafety and health program was reportedlyfollowed by a reduction in the number ofOSHA-recordable lifting-related injuries ofat least 45% during each of the next fouryears, when compared to the level ofinjuries prior to the ergonomics efforts.The number of lost workdays associatedwith lifting-related injuries was reportedto be at least 55% lower than levelsduring each of the previous four years.Citizens Memorial reported that thesereductions contributed to a direct savingsof approximately $150,000 in workers’compensation costs over a five yearperiod (8).

Introduction


The number and severity ofinjuries resulting from physicaldemands in nursing homes — andassociated costs — can be substan-tially reduced (2, 9). Providing analternative to manual resident liftingis the primary goal of the ergonomicsprocess in the nursing home settingand of these guidelines. OSHArecommends that manual lifting ofresidents be minimized in all casesand eliminated when feasible. OSHAfurther recommends that employersdevelop a process for systematicallyaddressing ergonomics issues in theirfacilities, and incorporate thisprocess into an overall program torecognize and prevent occupationalsafety and health hazards.

An effective process should betailored to the characteristics ofthe particular nursing home butOSHA generally recommends thefollowing steps:

Provide Management SupportStrong support by managementcreates the best opportunity forsuccess. OSHA recommends thatemployers develop clear goals, assignresponsibilities to designated staffmembers to achieve those goals,provide necessary resources, andensure that assigned responsibilitiesare fulfilled. Providing a safe andhealthful workplace requires a

SECTION II

A Process for ProtectingWorkers

sustained effort, allocation ofresources, and frequent follow-upthat can only be achieved throughthe active support of management.

Involve EmployeesEmployees are a vital source ofinformation about hazards in theirworkplace. Their involvement addsproblem-solving capabilities andhazard identification assistance,enhances worker motivation and jobsatisfaction, and leads to greateracceptance when changes are madein the workplace. Employees can:■ submit suggestions or concerns;■ discuss the workplace and

work methods;■ participate in the design of

work, equipment, procedures,and training;

■ evaluate equipment;■ respond to employee surveys;■ participate in task groups with

responsibility for ergonomics; and■ participate in developing the nurs-

ing home’s ergonomics process.


An Identify ProblemsNursing homes can more

successfully recognize problems byestablishing systematic methods foridentifying ergonomics concerns intheir workplace. Information aboutwhere problems or potentialproblems may occur in nursinghomes can be obtained from avariety of sources, including OSHA300 and 301 injury and illnessinformation, reports of workers’compensation claims, accident andnear-miss investigation reports,insurance company reports,employee interviews, employeesurveys, and reviews and observationsof workplace conditions. Onceinformation is obtained, it can beused to identify and evaluate elementsof jobs that are associatedwith problems. Sections III and IVcontain further information onmethods for identifying ergonomicsconcerns in the nursing homeenvironment.

Implement SolutionsWhen problems related toergonomics are identified, suitableoptions can then be selected andimplemented to eliminate hazards.Effective solutions usually involveworkplace modifications that

eliminate hazards and improve thework environment. These changesusually include the use of equipment,work practices, or both. Whenchoosing methods for lifting andrepositioning residents, individualfactors should be taken into account.Such factors include the resident’srehabilitation plan, the need to restorethe resident’s functional abilities,medical contraindications, emergencysituations, and resident dignity andrights. Examples of solutions can befound in Sections III and IV.

Address Reports of InjuriesEven in establishments witheffective safety and health programs,injuries and illnesses may occur.Work-related MSDs should bemanaged in the same manner andunder the same process as any otheroccupational injury or illness (10).Like many injuries and illnesses,employers and employees can benefitfrom early reporting of MSDs. Earlydiagnosis and intervention, includingalternative duty programs, areparticularly important in order tolimit the severity of injury, improvethe effectiveness of treatment,minimize the likelihood of disabilityor permanent damage, and reducethe amount of associated workers’compensation claims and costs.OSHA’s injury and illness recordingand reporting regulation (29 CFR1904) requires employers to keeprecords of work-related injuries andillnesses. These reports can help thenursing home identify problem areas



and evaluate ergonomic efforts.Employees may not be discriminatedagainst for reporting a work-relatedinjury or illness. [29 U.S.C. 660(c)]

ProvideTrainingTraining is necessary to ensure

that employees and managers canrecognize potential ergonomics issuesin the workplace, and understandmeasures that are available tominimize the risk of injury. Ergo-nomics training can be integratedinto general training on performancerequirements and job practices.Effective training covers the problemsfound in each employee’s job. Moreinformation on training can be foundin Section V.

Evaluate Ergonomics EffortsNursing homes should evaluatethe effectiveness of their ergonomicsefforts and follow-up on unresolvedproblems. Evaluation helps sustainthe effort to reduce injuries andillnesses, track whether or notergonomic solutions are working,identify new problems, and showareas where further improvement is

needed. Evaluation and follow-up arecentral to continuous improvementand long-term success. Once solutionsare introduced, OSHA recommendsthat employers ensure they areeffective. Various indicators (e.g.,OSHA 300 and 301 informationdata and workers’ compensationreports) can provide useful empiricaldata at this stage, as can other tech-niques such as employee interviews.For example, after introducing a newlift at a nursing home, the employershould follow-up by talking withemployees to ensure that the problemhas been adequately addressed. Inaddition, interviews provide amechanism for ensuring that thesolution is not only in place, but isbeing used properly. The same methodsthat are used to identify problems inmany cases can also be used forevaluation.



Identifying Problemsfor Resident Liftingand Repositioning

Assessing the potential for workto injure employees in nursing homesis complex because typical nursinghome operations involve the repeatedlifting and repositioning of theresidents. Resident lifting andrepositioning tasks can be variable,dynamic, and unpredictable innature. In addition, factors such asresident dignity, safety, and medicalcontraindications should be takeninto account. As a result, specifictechniques are used for assessingresident lifting and repositioningtasks that are not appropriate forassessing the potential for injuryassociated with other nursinghome activities.

An analysis of any resident liftingand repositioning task involves anassessment of the needs and abilitiesof the resident involved. Thisassessment allows staff members toaccount for resident characteristicswhile determining the safest methodsfor performing the task, within thecontext of a care plan that providesfor appropriate care and services forthe resident. Such assessmentstypically consider the resident’ssafety, dignity and other rights, aswell as the need to maintain orrestore a resident’s functional abilities.

SECTION III

A Identifying Problems and Implementing Solutionsfor Resident Lifting and Repositioning

The resident assessment shouldinclude examination of factorssuch as:■ the level of assistance the resident

requires;■ the size and weight of the resident;■ the ability and willingness of

the resident to understand andcooperate; and

■ any medical conditions that mayinfluence the choice of methodsfor lifting or repositioning.These factors are critically

important in determiningappropriate methods for lifting andrepositioning a resident. The sizeand weight of the resident will, insome situations, determine whichequipment is needed and how manycaregivers are required to provideassistance. The physical and mentalabilities of the resident also play animportant role in selectingappropriate solutions. For example,a resident who is able and willing topartially support their own weightmay be able to move from his or herbed to a chair using a standing assistdevice, while a mechanical sling liftmay be more appropriate for thoseresidents who are unable to supporttheir own weight. Other factorsrelated to a resident’s condition mayneed to be taken into account aswell. For instance, a resident whohas recently undergone hipreplacement surgery may requirespecialized equipment for assistancein order to avoid placing stress onthe affected area.

A number of protocols have beendeveloped for systematically examiningresident needs and abilities and/or


n For seated transfer aid, must have chair with arms thatrecess or are removable.

n For full body sling lift, select a lift that was specificallydesigned to access a patient from the car (if the car isthe starting or ending destination).

n If partial weight bearing, transfer toward stronger side.n Toileting slings are available for toileting.n Bathing mesh slings are available for bathing.

Seated transfer aid; may use gait/transfer belt until thepatient is proficient in completing transfer independently.

Yes

Yes

No

Is the patientcooperative?

Can patientbear weight?

Fully

Partially

Stand and pivot technique using a gait/transfer belt(1 caregiver) -or- powered standing assist lift

(1 caregiver)

Use full body sling lift and2 caregivers.

Caregiver assistance not needed;stand by for safety as needed.


NoYes

No

No

Does thepatient have

upper extremitystrength?


If patient is <100 pounds:Use a lateral sliding aid and 2 caregivers.

If patient is 100-200 pounds:Use a lateral sliding aid -or- a friction reducing

device and 2 caregivers.

If patient is >200 pounds: Use a lateral sliding aidand 3 caregivers -or- a friction-reducing device or

lateral transfer device and 2 caregivers -or-a mechanical lateral transfer device.

Can patient assist?

Partially Able

Not At All Able

Source: The Patient Safety Center of Inquiry (Tampa, FL).Veterans Health Administration & Department of Defense.October 2001.

Source: The Patient Safety Center of Inquiry (Tampa, FL). VeteransHealth Administration & Department of Defense. October 2001.

Yes

n Surfaces should be even for lateral patient moves.n For patients with Stage III or IV pressure ulcers, care

must be taken to avoid shearing force.

FIGURE 1 Transfer to and from: Bed to Chair, Chair to Toilet, Chair to Chair, or Car to Chair

FIGURE 2 Lateral Transfer to and from: Bed to Stretcher, Trolley


Identifying Problems and Implementing Solutionsfor Resident Lifting and Repositioning

for recommending procedures andequipment to be used for performinglifting and repositioning tasks. Thefollowing are some examples:■ The Resident Assessment Instrument,

published by the Centers forMedicare and Medicaid Services(CMS), provides a structured,standardized approach for assessingresident capabilities and needsthat results in a care plan for eachresident. Caregivers can use thisinformation to help them determinethe appropriate method for liftingor repositioning residents. Manynursing homes use this system tocomply with CMS requirementsfor nursing homes. Employerscan access this information fromwww.cms.hhs.gov/medicaid/mds20/.

■ Patient Care Ergonomics ResourceGuide: Safe Patient Handling andMovement is published by thePatient Safety Center of Inquiry,Veterans Health Administration andthe Department of Defense. Thisdocument provides flow charts(shown here in Figures 1-6) thataddress relevant resident assessmentfactors and recommends solutionsfor resident lifting and repositioningproblems. This material is oneexample of an assessment tool thathas been used successfully. Employerscan access this information fromwww.patientsafetycenter.com.Nursing home operators mayfind another tool or develop anassessment tool that works better intheir facilities.

■ Appendix A of the SettlementAgreement between OSHA andBeverly Enterprises, entitled Lift

Program Policy and Guide,recommends solutions for residentlifting and repositioning problems,based on the CMS classificationsystem. (A rating of “4” indicatesa totally dependent resident; a “3”rating indicates residents that needextensive assistance; a “2/1”rating indicates residents that needonly limited assistance/generalsupervision. Residents rated “0”are independent.) Employers canaccess this information fromwww.osha.gov.The nursing home operator should

use an assessment tool which isappropriate for the conditions in anindividual nursing home. The specialneeds of bariatric (excessively heavy)residents may require additionalfocus. Assistive devices must becapable of handling the heavierweight involved, and modification ofwork practices may be necessary.A number of individuals in nursinghomes can contribute to residentassessment and the determination ofappropriate methods for assisting intransfer or repositioning. Interdisciplinaryteams such as staff nurses,certified nursing assistants, nursingsupervisors, physical therapists,physicians, and the resident or his/herrepresentative may all be involved. Ofcritical importance is the involvementof employees directly responsible forresident care and assistance, as theneeds and abilities of residents mayvary considerably over a short periodof time, and the employees responsiblefor providing assistance are in thebest position to be aware of andaccommodate such changes.



Use full-body sling lift and2 or more caregivers.


If exam table/stretcher can be positionedto a low level, use a non-powered

stand-assist aid. If not, use a full-body sling lift.



Can the patientbear weight?

Yes

No

Fully

No

Comments:High/low exam tables and stretchers would be ideal.

n This is not a one person task - DO NOT PULL FROM HEAD OF BED.n When pulling a patient up in bed, the bed should be flat or Trendelenburg

position to aid in gravity, with the side rail down.n For patient with Stage III or IV pressure ulcers, care should be taken to

avoid shearing force.n The height of the bed should be appropriate for staff safety (at the elbows).n If the patient can assist when repositioning “up in bed”, ask the patient to

flex the knees and push on the count of three.

If patient is <200 pounds:Use a friction-reducing device

and 2-3 caregivers.

If patient is >200 pounds:Use a friction-reducing device

and at least 3 caregivers.

Caregiver assistance notneeded; patient may/maynot use positioning aid.

Encourage patientto assist using a

positioning aid or cues.

PartiallyAble

Fully

No

Use full-body sling lift -or-friction-reducing device and 2 or

more caregivers.

Can Patientassist?

Source: The Patient Safety Center of Inquiry (Tampa, FL).Veterans Health Administration & Department of Defense.October 2001.

Source: The Patient Safety Center of Inquiry (Tampa, FL). VeteransHealth Administration & Department of Defense. October 2001.

FIGURE 4 Reposition in Bed: Side-to-Side, Up in Bed

FIGURE 3 Transfer to and from: Chair to Stretcher



Comments:n This is not a one person task: DO NOT PULL FROM BEHIND CHAIR.n Take full advantage of chair functions, e.g., chair that reclines, or use of

arm rest of chair to facilitate repositioning.n Make sure the chair wheels are locked.

No

No

Does chairrecline?

Fully

Partially

Yes

No

If patient has upper extremity strength inboth arms, have patient lift up while

caregiver pushes knees to reposition.

If patient lacks sensation, cues maybe needed to remind Patient to reposition.

Recline chair and use a friction-reducingdevice and 2 caregivers.

Use full-body sling lift -ornon-poweredstand-assist aid and 1 to 2 caregivers.



Is patientcooperative?

Can patientassist?

Yes

Comments:Use full-body sling that goes all the way down to thefloor (most of the newer models are capable of this).

1Modifications made with concurrence of Dr. AudreyNelson at Veterans Administration Hospital, Tampa,Florida.

Caregiver assistance notneeded; stand by for

safety as needed.

Is patientindependent?

Depends on type and severity of injury(follow Standard Operating Procedures).

Was patientinjured?

Was theinjury minor?

Full-body sling lift needed with2 or more caregivers.

Yes No

No

Yes

YesNo1

Source: The Patient Safety Center of Inquiry (Tampa, FL). Veterans Health Administration & Department of Defense. October 2001.

Source: The Patient Safety Center of Inquiry (Tampa, FL).Veterans Health Administration & Department of Defense. October 2001.

FIGURE 6 Transfer a Patient Up From the Floor

FIGURE 5 Repostition in Chair: Wheelchair and Dependency Chair



Implementing Solutionsfor Resident Liftingand Repositioning

The recommended solutionspresented in the following pages arenot intended to be an exhaustive list,nor does OSHA expect that all ofthem will be used in any givenfacility. The information represents arange of available options that afacility can consider using. Many ofthe solutions are simple, commonsense modifications to equipment orprocedures that do not requiresubstantial time or resources toimplement. Others may require moresignificant efforts. The integration ofvarious solutions into the nursinghome is a strategic decision that, ifcarefully planned and executed, willlead to long-term benefits. Equip-ment must meet applicable regula-tions regarding equipment design anduse, such as the restraint regulationsfrom the Centers for Medicare andMedicaid. In addition, administratorsshould follow any manufacturers’recommendations and review guide-lines, such as the FDA Hospital BedSafety Workgroup Guidelines, tohelp ensure patient safety. Manage-ment should also be cognizant ofseveral factors that might restrict theapplication of certain measures, suchas residents’ rehabilitation plans, theneed for restoration of functionalabilities, other medical contra-indications, emergency conditions,and residents’ dignity and rights.

The procurement of equipmentand the selection of an equipmentsupplier are important considerationswhen implementing solutions.

Employers should establish closeworking relationships with equipmentsuppliers. Such working relationshipshelp with obtaining training foremployees, modifying the equipmentfor special circumstances, andprocuring parts and service whenneeded. Employers will want to payparticular attention to the effectivenessof the equipment, especially theinjury and illness experience of othernursing homes that have used theequipment. The following questionsare designed to aid in the selection ofthe equipment and supplier that bestmeets the needs of an individualnursing home.■ Availability of technical service - Is

over-the-phone assistance, as wellas onsite assistance, for repairsand service of the lift available?

■ Availability of parts - Which partswill be in stock and available in ashort time frame and how soon canthey be shipped to your location?

■ Storage requirements - Is the equip-ment too big for your facility? Canit be stored in close proximity to thearea(s) where it is used?

■ If needed, is a charging unit andback up battery included? What isthe simplicity of the charging unitand space required for a batterycharger if one is needed?



■ If the lift has a self-containedcharging unit, what is the amountof space necessary for chargingand what electrical receptacles arerequired? What is the minimumcharging time of a battery?

■ How high is the base of the liftand will it fit under the bed andvarious other pieces of furniture?How wide is the base of the lift oris it adjustable to a wider andlockable position?

■ How many people are required tooperate the lift for lifting of atypical 200-pound person?

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

■ How many sizes and types ofslings are available? What type ofsling is available for optimuminfection control?

■ Is the device versatile? Can it be asit-to-stand lift, as well as a liftdevice? Can it be a sit-to-stand liftand an ambulation-assist device?

■ What is the speed and noise levelof the device? Will the lift go tofloor level? How high will it go?

Based on many factors, includingthe characteristics of the residentpopulation and the layout of thefacility, employers should determinethe number and types of devicesneeded. Devices should be located sothat they are easily accessible toworkers. If resident lifting equipmentis not accessible when it is needed, itis likely that other aspects of theergonomics process will be ineffective.If the facility can initially purchaseonly a portion of the equipmentneeded, it should be located in theareas where the needs are greatest.Employers should also establishroutine maintenance schedules toensure that the equipment is in goodworking order.The following are examples ofsolutions for resident lifting andrepositioning tasks.



Resident Lifting

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

When to Use:Lifting residents who aretotally dependent, arepartial- or non-weightbearing, are very heavy,or have other physicallimitations. Transfersfrom bed to chair (wheelchair, Geri or cardiacchair), chair or floor tobed, for bathing and toileting, or after a resident fall.

Points to Remember:More than one caregiver may be needed. Look for adevice with a variety of slings, lift-height range,battery portability, hand-held control, emergencyshut-off, manual override, boom pressure sensitiveswitch, that can easily move around equipment, andhas a support base that goes under beds. Havingmultiple slings allows one of them to remain in placewhile resident is in bed or chair for only a shortperiod, reducing the number of times the caregiverlifts and positions resident. Portable compact lifts maybe useful where space or storage is limited. Ensuredevice is rated for the resident weight. Electric/batterypowered lifts are preferred to crank or pump typedevices to allow a smoother movement for the resi-dent, and less physical exertion by the caregiver.Enhances resident safety and comfort.

Transfer from Sitting toStanding Position

Description:Powered sit-to-standor standing assistdevices.

When to Use:Transferringresidents who arepartially depen-dent, have someweight-bearingcapacity, arecooperative, can situp on the edge ofthe bed with orwithout 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 bathingand toileting. Can be used for repositioning wherespace or storage is limited.

Points to Remember:Look for a device that has a variety of sling sizes, lift-height range, battery portability, hand-held control,emergency shut-off, and manual override. Ensuredevice is rated for the resident weight. Electric/batterypowered lifts are preferred to crank or pump typedevices to allow smoother movement for the resident,and less physical exertion by the caregiver.



Ambulation

Description:Ambulation assist device.

When to Use:For residents who are weightbearing and cooperative andwho need extra security andassistance when ambulating.

Points to Remember:Increases resident safetyduring ambulation andreduces risk of falls. Thedevice supports residents asthey walk and push it alongduring ambulation. Ensure heightadjustment is correct for resident before ambulation.Ensure device is in good working order before useand rated for the resident weight to be lifted. Applybrakes before positioning resident in or releasing resi-dent from device.

Repositioning in Chair

Description:Variable positionGeri and Cardiacchairs.

When to Use:Repositioningpartial- or non-weight-bearingresidents who arecooperative.

Points toRemember:More than one caregiver is needed and use of a friction-reducing device is needed if resident cannot assist toreposition self in chair. Ensure use of good bodymechanics by caregivers. Wheels on chair add versatility.Ensure that chair is easy to adjust, move, and steer.Lock wheels on chair before repositioning. Removetrays, footrests, and seat belts where appropriate.Ensure device is rated for the resident weight.


Resident Lifting

Description:Ceiling mounted lift device.

When to Use:Lifting residents who are totally dependent, are partial- or non-weight bearing, veryheavy, 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 aresident falls. A horizontal frame system or litter attached to the ceiling-mounteddevice can be used when transferring residents who cannot be transferred safelybetween 2 horizontal surfaces, such as a bed to a stretcher or gurney while lying ontheir back, using other devices.

Points to Remember:More than one caregiver may be needed. Some residents can use the device withoutassistance. May be quicker to use than portable device. Motors can be fixed or portable(lightweight). Device can be operated by hand-held control attached to unit or byinfrared remote control. Ensure device is rated for the resident weight. Increases residents’safety and comfort during transfer.


Lateral Transfer; Repositioning

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

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

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, e.g., for heavier ornon-cooperative 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 otherfriction-reducing devices with handles such as slippery sheets. Narrower slippery sheets with webbing handlespositioned on the long edge of the sheet may be easier to use than wider sheets. When using boards or matswith 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. Ensuretransfer surfaces are at same level and at a height that allows caregivers to work at waist level to avoid extendedreaches and bending of the back. Count down and synchronize the transfer motion between caregivers.

Lateral Transfer; Repositioning

Description:Convertible wheelchair, Geri or cardiac chair to bed; beds thatconvert to chairs.

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

Points to Remember:More than one caregiver is needed to perform lateral transfer. Additional assistancefor lateral transfer may be needed depending on residents status, e.g., for heavier or non-cooperative residents.Additional friction-reducing devices may be required to reposition resident. Heavy duty beds are available forbariatric residents. Device should have easy-to-use controls located within easy reach of the caregiver, sufficientfoot clearance, and wide range of adjustment. Motorized height adjustable devices are preferred to thoseadjusted by crank mechanism to minimize physical exertion. Always ensure device is in good working orderbefore use. Ensure wheels on equipment are locked. Ensure transfer surfaces are at same level and at a heightthat allows caregivers to work at waist level to avoid extended reaches and bending of the back.


Lateral Transfer inSitting Position

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

When to Use:Transferring (sliding)residents who have goodsitting balance and arecooperative from onelevel surface to another,e.g., bed to wheelchair,wheelchair to car seat or toilet. Can also be used byresidents who require limited assistance but need addi-tional safety and support.

Points to Remember:Movable seats increase resident comfort and reduceincidence of tissue damage during transfer. More than onecaregiver is needed to perform lateral transfer. Ensureclothing is present between the resident’s skin and thetransfer device. The seat may be cushioned with a smalltowel for comfort. May be uncomfortable for largerresidents. Usually used in conjunction with gait belts forsafety depending on resident status. Ensure boards havetapered ends, rounded edges, and appropriate weightcapacity. Ensure wheels on bed or chair are locked andtransfer surfaces are at same level. Remove lower bedrailsfrom bed and remove arms and footrests from chairs asappropriate.


Description:Lift cushions and lift chairs.

When to Use:Transferring residents who areweight-bearing and cooperativebut need assistance when standingand ambulating. Can be used forindependent residents who needan extra boost to stand.

Points to Remember:Lift cushions use a lever thatactivates a spring action toassist residents to rise up. Liftcushions may not be appropriate for heavier residents.Lift chairs are operated via a hand-held control thattilts forward slowly, raising the resident. Residentsneed to have physical and cognitive capacity to beable to operate lever or controls. Always ensure deviceis in good working order before use and is rated forthe resident weight to be lifted. Can aid resident inde-pendence.


Description:Stand-assist devices can be fixed to bed or chair or befree-standing. There is a variety of such devices onthe market.

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

Points to Remember:Check that device is stable before use and is rated forresident weight to be supported. Ensure frame is firmlyattached to bed, or if it relies on mattress support thatmattress is heavy enough to hold the frame. Can aidresident independence.

Weighing

Description:Scales with ramp to accommodatewheelchairs; portable-powered liftdevices with built-in scales; bedswith built-in scales.

When to Use:To reduce the need for additionaltransfer of partialor non-weight-bearing or totally dependentresidents to weighing device.

Points to Remember:Some wheelchair scales can accommo-date larger wheelchairs. Built-in bed scalesmay increase weight of the bed and prevent it fromlowering to appropriate work heights.


Transfer from Sitting to Standing Position;Ambulation

Description:Gait belts/transfer belts with handles.

When to Use:Transferring residents who are partially dependent, have some weight-bearingcapacity, and are cooperative. Transfers such as bed to chair, chair to chair, orchair to car; when repositioning residents in chairs; supporting residents duringambulation; and in some cases when guiding and controlling falls or assisting aresident after a fall.

Points to Remember:• More than one caregiver may be needed. Belts with padded handles are easierto grip and increase security and control. Always transfer to resident’s strongestside. Use good body mechanics and a rocking and pulling motion rather than liftingwhen using a belt. Belts may not be suitable for ambulation of heavy residents or residentswith recent abdominal or back surgery, abdominal aneurysm, etc. Should not be used forlifting residents. Ensure belt is securely fastened and cannot be easily undone by the resident duringtransfer. Ensure a layer of clothing is between residents’ skin and the belt to avoid abrasion. Keepresident as close as possible to caregiver during transfer. Lower bedrails, remove arms and foot restsfrom 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 standingposition 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 tomove resident.

Repositioning

Description:Electric poweredheight adjustable bed.

When to Use:For all activitiesinvolving residentcare, transfer, reposi-tioning in bed, etc., toreduce caregiver bendingwhen interacting with resident.

Points to Remember:Device should have easy-to-use controls located withineasy reach of the caregiver to promote use of the electricadjustment, sufficient foot clearance, and wide range ofadjustment. Adjustments must be completed in 20seconds or less to ensure staff use. For residents that maybe at risk of falling from bed some beds that lower closerto the floor may be needed. Heavy duty beds are availablefor bariatric residents. Beds raised and lowered with anelectric motor are preferred over crank-adjust beds toallow a smoother movement for the resident and lessphysical exertion to the caregiver.

Repositioning

Description:Trapeze bar; hand blocks andpush up bars attached to thebed frame.

When to Use:Reposition residents that havethe ability to assist the caregiverduring the activity, i.e., residentswith upper body strength anduse of extremities, who arecooperative and can followinstructions.

Points to Remember:Residents use trapeze bar by grasping bar suspended froman overhead frame to raise themselves up and repositionthemselves in a bed. Heavy duty trapeze frames areavailable 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 alsoenable residents to raise themselves up and repositionthemselves in bed. Bars attached to the bed frame servethe same purpose. May not be suitable for heavierresidents. Can aid resident independence.


Repositioning

Description:Pelvic lift devices (hip lifters).

When to Use:To assist residents whoare cooperative and cansit up to a position on aspecial bed pan.

Points to Remember:Convenience of devicemay reduce need for residentlifting during toileting. Device is positionedunder the pelvis. The part of the device located underthe pelvis gets inflated so the pelvis is raised and aspecial bedpan put underneath. The head of the bed israised slightly during this procedure. Use correct bodymechanics, lower bedrails, and adjust bed to caregiverswaist height to reduce bending.

Bathtub, Shower,andToileting Activities

Description:Height adjustablebathtub and easy-entry bathtubs.

When to Use:Bathing residentswho sit directly inthe bathtub, or toassist ambulatoryresidents climbmore easily into alow tub, or easy-access tub. Bathing resi-dents in portable-powered or ceilingmounted lift device using appropriate bathing sling.

Points to Remember:Reduces awkward postures for caregivers and thosewho clean the tub after use. The tub can be raised toeliminate bending and reaching for the caregiver. Usecorrect body mechanics, and adjust the tub to thecaregiver’s waist height when performing hygieneactivities. Increases resident safety and comfort.


Description:Shower and toileting chairs.

When to Use:Showering and toiletingresidents who are partiallydependent, have someweight bearing capacity,can sit up unaided, and areable to bend hips, knees,and ankles.

Points to Remember:Ensure that wheels move easily andsmoothly; chair is high enough to fit over toilet; chairhas removable arms, adjustable footrests, safety belts,and is heavy enough to be stable; and that the seat iscomfortable, accommodates larger residents, and has aremovable commode bucket for toileting. Ensure thatbrakes lock and hold effectively and that weightcapacity is sufficient.


Description:Toilet seat risers.

When to Use:For toileting partiallyweight-bearing residentswho can sit up unaided,use upper extremities(have upper bodystrength), are able tobend hips, knees, andankles, and are coop-erative. Independentresidents can also use these devices.

Points to Remember:Risers decrease the distance and amount of effortrequired to lower and raise residents. Grab bars andheight-adjustable legs add safety and versatility to thedevice. Ensure device is stable and can accommodateresident’s weight and size.



Description:Bath boards and transfer benches.

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

Points to Remember:To reduce friction and possible skin tears, use clothing or material between theresident’s skin and the board. Can be used with a gait or transfer belt and/orgrab bars to aid transfer. Back support and vinyl padded seats add to bathingcomfort. 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 deviceis securely in place and rated for weight to be transferred. Remove arms andfoot rests from chairs as appropriate and ensure that floor is dry.


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

Long-handled or extended shower heads, or brushes can be used forpersonal hygiene.

When to Use:Bars and assists help when toileting, bathing, and/ or showering residentswho need extra support and security. Residents must be partially weightbearing, able to use upper extremities (have upper body strength), and becooperative.

Long-handled devices reduce the amount of bending, reaching, andtwisting required by the caregiver when washing feet, legs, and trunk ofresidents. Independent residents who have difficulty reaching lowerextremities can also use these devices.

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



Description:Height adjustableshower gurney or liftbath cart withwaterproof top.

When to Use:For bathing non-weight bearingresidents who areunable to sit up.Transfer resident tocart with lift or lateraltransfer boards or otherfriction-reducing devices.

Points to Remember:The cart can be raised to eliminate bending andreaching to the caregiver. Foot and head supportsare available for resident comfort. May not besuitable for bariatric residents. Look for carts thatare power-driven to reduce force required to moveand position device.


Description:Built-in or fixedbath lifts.

When to Use:Bathing residentswho are partiallyweight bearing,have good sittingbalance, can useupper extremities(have upper bodystrength), are cooperative, and canfollow instructions. Useful in small bathrooms wherespace is limited.

Points to Remember:Ensure that seat raises so resident’s feet clear tub, easilyrotates, and lowers resident into water. May not besuitable for heavy residents. Always ensure lifting de-vice is in good working order before use and rated forthe resident weight. Choose device with lift mechanismthat does not require excessive effort by caregiverwhen raising and lowering device.


Some reports indicate a significantnumber of work-related MSDs innursing homes occur in activitiesother than resident lifting. (2, 3)Examples of some of the activitiesthat the nursing home operator maywant to review are:■ bending to make a bed or feed a

resident;■ lifting food trays above shoulder

level or below knee level;■ collecting waste;■ pushing heavy carts;■ bending to remove items from a

deep cart;■ lifting and carrying when receiving

and stocking supplies;■ bending and manually cranking

an adjustable bed; and■ removing laundry from washingmachines and dryers.These tasks may not presentproblems in all circumstances.Employers should consider theduration, frequency, and magnitudeof employee exposure to forcefulexertions, repetitive activities, andawkward postures when determiningif problems exist in these and otherareas. In the vast majority of cases,job assessments can be accomplishedby observing employees performing

SECTION IV

A Identifying Problems and Implementing Solutions forActivities Other than Resident Lifting and Repositioning

the task, by discussing with employeesthe activities and conditions thatthey associate with difficulties, andchecking injury records. Observationprovides general information aboutthe workstation layout, tools,equipment, and general environmentalconditions in the workplace.Discussing tasks with employeeshelps to ensure that a completepicture of the process is obtained.Employees who perform a given taskare also often the best sources foridentifying the cause of a problem,and developing the most practicaland effective solutions. Onceinformation is obtained and problemsidentified, suitable improvements canbe implemented. Finally, there are anumber of resources available to helpdetermine if specific activities havethe potential for causing injuries. Forexample, support is available fromOSHA’s consultation program,insurance companies, and stateworkers’ compensation programs.The following are examples ofpossible solutions for activities otherthan resident lifting and repositioning.


Storage and Transfer of Food,Supplies, and Medications

Description:Use of carts.

When to Use:When moving food trays,cleaning supplies,equipment, maintenancetools, and dispensingmedications.

Points to Remember:Speeds process for accessing and storingitems. Placement of items on the cart should keep themost frequently used and heavy items within easyreach between hip and shoulder height. Carts shouldhave full-bearing wheels of a material designed for thefloor surface in your facility. Cart handles that arevertical, with some horizontal adjustability, will allowall employees to push at elbow height and shoulderwidth. Carts should have wheel locks. Handles thatcan swing out of the way may be useful for savingspace or reducing reach. Heavy carts should havebrakes. Balance loads and keep loads under cartweight restrictions. Ensure stack height does notblock vision. Low profile medication carts with easy-open side drawers are recommended to accommodatehand height of shorter nurses.

Mobile MedicalEquipment

Description:Work methods and tools totransport equipment.

When to Use:When transporting assistivedevices and other equipment.

Points to Remember:• Oxygen tanks: Use smallcylinders with handles toreduce weight and allow for easier gripping. Secureoxygen tanks to transport device.

• Medication pumps: Use stands on wheels.• Transporting equipment: Push equipment, rather thanpull, when possible. Keep arms close to the body andpush with whole body and not just arms. Removeunnecessary objects to minimize weight. Avoid obstaclesthat could cause abrupt stops. Place equipment on arolling device if possible. Take defective equipment out ofservice. 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 gurneysor moved by another caregiver to avoid awkwardlypushing with one hand and holding freestandingequipment with the other hand.

Working with Liquids inHousekeeping

Description:Filling andemptying liquidsfrom containers.

When to Use:In housekeepingareas when fillingand emptyingbuckets withfloor drainarrangements.

Points to Remember:Reduces risk of spills, slips, speeds process, andreduces waste. The faucet and floor drain is used inhousekeeping. Ensure that casters don’t get stuck infloor grate. Use hose to fill bucket. Use buckets withcasters to move mop bucket around. Ensure castersare maintained and roll easily.

Working with Liquids inHousekeeping

Description:Filling and emptying liquidsfrom containers.

When to Use:In dietary when pouringsoups or other liquid foodsthat are heavy.

Points to Remember:Reduces risk of spills andburns, speeds process, andreduces waste.Use an elevated faucet or hose to fill large pots. Avoidlifting heavy pots filled with liquids. Use ladle to emptyliquids, soups, etc., from pots. Small sauce pans can alsobe used to dip liquids from pots. If the worker standsfor more than 2 hours per day, shock-absorbing floorsor insoles will minimize back and leg strain. With hotliquids, ensure a splash guard is included.


HandTools

Description:Select and use properlydesigned tools.

When to Use:When selecting frequentlyused tools for the kitchen,housekeeping, laundry andmaintenance areas.

Points to Remember:Enhances tool safety,speeds process, and reduceswaste. Handlesshould fit the grip size of the user. Use bent-handledtools to avoid bending wrists. Use appropriate toolweight. Select tools that have minimal vibration orvibration damping devices. Implement a regularmaintenance program for tools to keep blades sharpand edges and handles intact. Always wear theappropriate personal protective equipment.

Linen Carts

Description:Spring loaded carts that automaticallybring linen within easy reach.

When to Use:Moving or storing linen.

Points to Remember:Speeds process forhandling linen, andreduces wear on linendue to excessive pulling.Select a spring tension thatis appropriate for theweight of the load. Cartsshould have wheel locks and height-appropriatehandles that can swing out of the way.Heavy carts should have brakes.

Handling Bags

Description:Equipment and practices forhandling bags.

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

Points to Remember:Reduces risk of items beingdropped, and speeds process forremoving and disposing of items.Receptacles that hold bags oflaundry or trash should have side openingsthat keep the bags within easy reach and allow employ-ees to slide the bag off the cart without lifting. Providehandles to decrease the strain of handling. Chutes anddumpsters should be positioned to minimize lifting. Itis best to lower the dumpster or chute rather than liftmaterials to higher levels. Provide automatic openingor hardware to keep doors open to minimize twistingand awkward handling.

Reaching into Sink

Description:Tools used tomodify a deep sinkfor cleaning smallobjects.

When to Use:Cleaning smallobjects in a deepsink.

Points to Remember:Place an object such as a plasticbasin in the bottom of the sink to raise the worksurface. An alternative is to use a smaller porouscontainer to hold small objects for soaking, transfer toan adjacent countertop for aggressive cleaning, andthen transfer back to the sink for final rinsing.Store inserts and containers in a convenient location toencourage consistent use. This technique is not suitablein kitchens/food preparation.


Loading or UnloadingLaundry

Description:Front-loading washersand dryers.

When to Use:When loading or unloadinglaundry from washers,dryers and other laundryequipment.

Points to Remember:Speeds process for retrievingand placing items, and minimizeswear-and-tear on linen. Washerswith tumbling cycles separate clothes, making removaleasier. For deep tubs, a rake with long or extendablehandle can be used to pull linen closer to the dooropening. Raise machines so that opening is between hipand elbow height of employees. If using top loadingwashers, work practices that reduce risk includehandling small loads of laundry, handling only a fewitems at a time, and bracing your body against thefront of the machine when lifting. If items are knottedin the machine, brace with one hand while using theother to gently pull the items free. Ensure that items gointo a cart rather than picking up baskets of soiledlinen or wet laundry.

Cleaning Rooms(Wet Method)

Description:Work methods and tools toclean resident rooms withwater and chemical products.

When to Use:When cleaning with waterand chemical products andusing spray bottles.

Points to Remember:• Cleaning implement: usealternate leading hand, avoid tight static gripand use padded non-slip handles.• Spray bottles: Use trigger handles long enough for theindex and middle fingers. Avoid using the ring andlittle fingers.• For all cleaning: Use chemical cleaners and abrasivesponges to minimize scrubbing force. Use kneepadswhen kneeling. Avoid bending and twisting. Useextension handles, step stools, or ladders for overheadneeds. Use carts to transport supplies or carry onlysmall quantities and weights of supplies. Ventilation ofrooms may be necessary when chemicals are used.• Avoid lifting heavy buckets, e.g., lifting a large, fullbucket from a sink. Use a hose or similar device to fillbuckets with water. Use wheels on buckets that rolleasily and have functional brakes. Ensure that castersare maintained. Use rubber-soled shoes in wet areas toprevent slipping.• Cleaning wheelchairs: Cleaning workstation shouldbe at appropriate height.

Cleaning Rooms(Electrical)

Description:Work methods and tools to vacuum andbuff floors.

When to Use:Vacuuming and buffing floors.

Points to Remember:• Both vacuum cleaners and buffersshould have lightweight construction,adjustable handles, triggers (buffer)long enough to accommodate at leastthe index and middle fingers, and easy to reach controls.Technique is important for both devices, including use ofappropriate grips, avoiding tight grips, and for vacuuming,by alternating grip. The use of telescoping and extensionhandles, hoses, and tools can reduce reaching for low areas,high areas, and far away areas. Maintain and service theequipment and change vacuum bags when 1/2 to 3/4 full.• Vacuums and other powered devices are preferred overmanual equipment for moderate-to-long duration use.Heavy canisters or other large, heavy equipment shouldhave brakes.


Training is critical for employersand employees to safely use thesuggestions identified in these guide-lines. Of course, training should beprovided in a manner and languagethat all employees can understand.The following describes areas oftraining for nursing home employees,their supervisors, and programmanagers who are responsible forplanning and managing the nursinghome’s ergonomics efforts. OSHArecommends refresher training beprovided as needed to reinforceinitial training and to address newdevelopments in the workplace.

Nursing Assistants and OtherWorkers at Risk of Injury

Employees should be trainedbefore they lift or reposition residents,or perform other work that mayinvolve risk of injury. Ergonomicstraining can be included with othersafety and health training, orincorporated into general instructionsprovided to employees. Training isusually most effective when itincludes case studies or demonstrationsbased on the nursing home’s polices,and allows enough time to answerany questions that may arise.Training should ensure that theseworkers understand:

SECTION V

Training

■ policies and procedures thatshould be followed to avoidinjury, including proper workpractices and use of equipment;

■ how to recognize MSDs and theirearly indications;

■ the advantages of addressing earlyindications of MSDs beforeserious injury has developed; and

■ the nursing home’s procedures forreporting work-related injuriesand illnesses as required byOSHA’s injury and illnessrecording and reporting regulation(29 CFR 1904).

Training for Charge Nursesand Supervisors

Charge nurses and supervisorsshould reinforce the safety programof the facility, oversee reportingguidelines, and help ensure theimplementation of resident and taskspecific ergonomics recommendations,e.g., using a mechanical lift. Becausecharge nurses and supervisors arelikely to receive reports of injuries,


and are usually responsible forimplementing the nursing home’swork practices, they may need moredetailed training than nursingassistants 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 DesignatedProgram Managers

Staff members who are responsiblefor planning and managing ergonomicsefforts need training so they canidentify ergonomics concerns andselect appropriate solutions. Thesestaff members should receive

information and training that willallow them to:■ identify potential problems related

to physical activities in the workplacethrough observation, use ofchecklists, injury data analysis,or other analytical tools;

■ address problems by selectingproper equipment and workpractices;

■ help other workers implementsolutions; and

■ evaluate the effectiveness ofergonomics efforts.

Training


The following sources may beuseful to those seeking furtherinformation about ergonomics andthe prevention of work-related MSDsin nursing homes.

A Back Injury PreventionGuide for Health Care Providers,Cal/OSHA Consultation Programs,(800) 963-9424, www.dir.ca.gov/dosh/dosh_publications/backinj.pdfThis guide discusses the scope of theback injury problem in health care,how to analyze the workplace, howto identify and implement improve-ments, and how to evaluate results.It includes checklists that can assistin analyzing the work environment.

Patient Care ErgonomicsResource Guide: Safe PatientHandling and Movement, PatientSafety Center of Inquiry, VeteransHealth Administration andDepartment of Defense, (813) 558-3902, www.patientsafetycenter.comThis document describes a comprehen-sive program developed to preventMSDs related to resident liftingand repositioning. It includesassessment criteria and flowchartsfor selecting equipment and techniquesfor safe lifting and repositioningbased on resident characteristics.

Resident Assessment Instrument,U.S. Department of Health andHuman Services - Centers for Medi-careand Medicaid Services (CMS),www.cms.hhs.gov/medicaid/mds20/

SECTION VI


This document is used by manynursing homes to evaluate residentneeds and capabilities.

Elements of Ergonomics Programs,U.S. Department of Health andHuman Services - NationalInstitute for Occupational Safetyand Health, (800) 356-4674,www.cdc.gov/niosh/ephome2.htmlThe basic elements of a workplaceprogram aimed at preventing work-related musculoskeletal disorders aredescribed in this document. Itincludes a “toolbox,” which is acollection of techniques, methods,reference materials, and sources forother information that can help inprogram development.

In addition, OSHAC’s TrainingInstitute in Arlington Heights,Illinois, offers courses on varioussafety and health topics, includingergonomics. Courses are also offeredthrough Training Institute EducationCenters located throughout thecountry. For a schedule of courses,contact the OSHA Training Institute,2020 South Arlington Heights Road,Arlington Heights, Illinois, 60005,(847) 297-4810, or visit OSHA’straining resources webpage atwww.osha.gov. Choose “Training”from the blue column on the right,under Compliance Assistance.

There are many states andterritories that operate their ownoccupational safety and healthprograms under a plan approved byOSHA (23 cover both private sector,state and local government employees,and three only cover public employees).See the map on www.osha.govfor information on how to contact astate plan directly for informationabout specific state nursing homeinitiatives and compliance assistance,or state standards that may apply tonursing homes.

A free consultation service isavailable to provide occupationalsafety and health assistance tobusinesses. OSHA Consultation isfunded primarily by federal OSHAbut delivered by the 50 stategovernments, the District of Columbia,Guam, Puerto Rico, and the VirginIslands. The states offer the expertiseof highly qualified occupationalsafety and health professionals toemployers who request help toestablish and maintain a safe andhealthful workplace. Developed forsmall and medium-sized employers in

hazardous industries or withhazardous operations, the service isprovided at no cost to the employerand is confidential. Information onOSHA consultation can be found atwww.osha.gov. Choose “Consultation”from the blue column at the rightunder Compliance Assistance, orrequest the booklet ConsultationServices for the Employer (OSHA3047) from OSHA’s PublicationsOffice at (202) 693-1888.

More information on ergonomicsand other safety and health issues isavailable on OSHA’s website atwww.osha.gov. See the index at thetop of the home page. For anyadditional information regardingGuidelines for Nursing Homes,please contact the OSHA’sDirectorate of Standards andGuidance at 202-693-1950.



(1) Documents submitted to OSHA by Wyandot County Nursing Home. (Ex. 3-12)

(2) Garg, A. 1999. Long-Term Effectiveness of “Zero-Lift Program” in Seven NursingHomes and One Hospital. U.S. Department of Health and Human Services, Centers forDisease Control and Prevention, National Institute for Occupational Safety and Health(NIOSH), Cincinnati, OH. August. Contract No. U60/CCU512089-02. (Ex. 3-3)

(3) Fragala, G., PhD, PE, CSP. 1996. Ergonomics: How to Contain On-the-Job Injuries inHealth Care. Joint Commission on Accreditation of Healthcare Organizations.

(4) Occupational Safety and Health Administration, Region II. Summer, 2002. New YorkOSHA E-Newsletter, Vol. 1, Issue 2.

(5) National Institute for Occupational Safety and Health (NIOSH). 1997. Musculoskele-tal Disorders and Workplace Factors - A Critical Review of Epidemiologic Evidence forWork-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back.(Ex. 3-4)

(6) National Research Council and Institute of Medicine. 2001. Musculoskeletal Disor-ders and the Workplace - Low Back and Upper Extremities. National Academy ofSciences. Washington, DC: National Academy Press. (Ex. 3-6)

(7) Taylor and Francis. 1988. Cumulative Trauma Disorders: A Manual for MSDs of theUpper Limb. Putz-Anderson, V., ed.

(8) Documents submitted to OSHA by Citizens Memorial. (Ex. 3-25)

(9) U.S. General Accounting Office. 1997. Worker Protection - Private Sector Ergonom-ics Programs Yield Positive Results. August. GAO/HEHS-97-163. (Ex. 3-92)

(10) American Health Care Association, American Association of Homes and Servicesfor the Aging, National Center for Assisted Living. 2002. Comments submitted toOSHA. (Ex. 4-15)

References



IntroductionWyandot County Nursing Home

used a process that reflects many ofthe recommendations in theseguidelines to address safety andhealth concerns and phase-in itscurrent program that entails nomanual lifting of residents. First andforemost, Wyandot’s administratorprovided strong commitment andsupport in addressing the home’sproblems. He also involvedWyandot’s workers in every phaseof the effort. He talked to hisemployees, learned about stressfulparts of their jobs, and then foundsolutions. He and his employeesidentified existing and potentialsources of injury at the home andworked to implement solutions.He trained employees each timethe nursing home introduced newequipment. He continually checkednew equipment, and he continues toevaluate the overall effectiveness ofhis safety and health efforts.Wyandot is located in UpperSandusky, Ohio. It is a 100-bed,county-run facility that has servedWyandot County in its presentbuilding for the past 28 years. It isdivided into two sections to serveresidents with different levels ofneed. The A- wing, with 32 rooms,serves residents who are mostlyambulatory and require only aminimum of help with daily living.

Appendix - A Nursing Home Case Study

In the B- and C- wings, with 32double rooms and four private ones,residents receive care that rangesfrom extensive to total. Wyandothas 90 employees, 45 of whom arenursing assistants. This makes for anursing staff ratio of 2.4 hours foreach resident per day.

Identifying ProblemsBefore Wyandot implemented its

ergonomics program, the home wasexperiencing problems that were agrowing concern to both the countyand Wyandot’s administrator.According to Wyandot, workers’compensation costs averaged almost$140,000 per year from 1995-1997.The turnover rate among nursingassistants averaged over 55 percent

This case study was developed frominformation provided by WyandotCounty Nursing Home. OSHA visitedthe nursing home to discuss theergonomics program with the nursinghome administrator, observeergonomics corrective actions, and talkto employees, residents, and familymembers about their experiences.


during that same time period.This meant that of the 45 nursingassistants working at Wyandot,on average 25 new ones had to behired each year.

Wyandot’s administrator began tolook for more effective ways toaddress injuries among workers andthe high turnover rate. A back injurysuffered by a worker that costWyandot $240,000 in workers’compensation expenses providedsignificant motivation to find a strategythat would work. As Wyandot’sadministrator investigated that injury,he also examined other sources ofpotential injury within the home. Indoing so, he learned that residenttransfer and repositioning taskspresented high risks for injuries.

He called on the Ohio Bureau ofWorkers’ Compensation (OBWC)for help because he thoughtWyandot was following bestpractices and people were still beinginjured. An OBWC ergonomistvisited the home and told him thathe had unrealistic expectations abouthis nursing staff’s ability to manuallylift and reposition residents.

Involving EmployeesWyandot’s administrator thought

that he could better use his existingstaff. After hearing about a “no lift”policy and seeing an impressivedemonstration of mechanical lifts atan industry conference, he began toconsider setting up a program atWyandot. He became convinced thatsuch a program would keep employeessafer and help slow the turnover ratewhile ensuring safety and highquality care for residents.

He decided that the bestapproach was to involve employeesat every level in reducing injuriesand slowing the turnover rate.More than 30 workers volunteeredto examine the tasks of movingand repositioning residents.

Wyandot employees concludedthat better body mechanics — thetraditional method of lifting andtransferring residents at most nursinghomes — was not the answer. In fact,he and his staff determined that therewas no safe way to lift a residentother than with mechanical lifts. Todetermine what equipment wouldwork best, Wyandot tried outvarious pieces of equipment, evaluatedeach lift, and then decided whatwould be most appropriate forWyandot’s needs.

Implementing SolutionsWith recommendations from

employees, Wyandot’s administratorbought several portable mechanicallifts for the B- and C-wings. Theseinvolved portable sit-to-stand lifts,walk/ambulating lifts, and total lifts.Nurses and assistants could moveeach of these from room to room asthey worked with individual residents.However, many of the staff remainedunconvinced of the value of usingequipment. In fact, initially only theworkers who had actually evaluatedthe lifts were using them.

Appendix


According to Wyandot’sadministrator, it was very difficultgetting workers to overcome theirinsistence on doing things the oldway. Because many workers said ittook too long to use the mechanicallifts, one of the co-charge nursesdecided to do a time study. Shewanted to test how long it took tolift a resident manually compared tousing a mechanical lift. The mechanicallift took about 5 minutes. Meanwhile,to perform the manual lift, a nursingassistant first had to find someone tohelp. This took 15 minutes. Thus,the time study showed that using theequipment actually saved time.

One worker, who admitted thatshe did not initially use the sit-tostandlift because it was a “hassle,”reconsidered her opinion after anoutbreak of the flu reduced thenumber of staff members availablefor assistance. In her words, “I wasforced to use the lift. Awesome. Itwas just great. I was so sorry myfellow employees had to suffer withthe flu bug to get me to use thiscontraption.”

Wyandot’s administrator alsowanted to replace the old hand-crankbeds at Wyandot with electric beds.To do this, he also needed to findbeds that would be used in the“low-bed” system in place for many

residents. There were not manyoptions available, so he took hisideas and engineering background toa bed company and inquired abouthaving beds designed to fit Wyandot’sneeds. The bed manufacturerdesigned the new beds to lift fromthe floor to a height of about 30inches in 20 seconds. In addition,these fast beds were designed so thatresidents would be less likely to slideto the foot of the bed as they wereraised to a sitting position. As aresult, residents would not need to berepositioned. Also, the beds could beused with a gait-belt for ambulatoryresidents to assist them from a sittingto a standing position.

About three years after Wyandotbegan its ergonomics effort, thenursing home received a grant fromthe OBWC Division of Safety andHygiene through an ergonomicemphasis program to deal withcumulative trauma disorders. Thegrant enabled Wyandot’s administratorto purchase 58 fast electric beds, aturning point for staff acceptance.When the first ceiling lifts wereinstalled seven months later,employees were ready to use them.

One nursing assistant, who hasbeen with Wyandot for 19 years,explained why she liked the newbeds so much. “We can quickly bringthe bed up to our work height with apush of a button and we canreposition a resident . . . with easewithout stooping or struggling.”

Appendix


The final phase of Wyandot’sprogram began with the introductionof the ceiling lifts. Wyandot’sadministrator evaluated severalceiling lift systems. Wyandot chose asystem with a motorized lift and aceiling mounted track. Tracks wereretrofitted into the rooms at a cost ofabout $12,000 for two double roomsand one bathroom. The first doubleroom had a track that extended intothe bathroom. However, newersystems used a transfer between theroom and bathroom, which simplifiedthe system and reduced costs.

Providing TrainingAs Wyandot purchased and

installed new equipment, workersreceived training on how to use it,and guidelines for equipmentuse were put into place. An LPNin-service director did the training.New employees learned how to usethe devices and knew where to gofor further instruction or help.Eventually, most of the nursingassistants adapted to the mechanicallifts and refused to use any otherlifting techniques.

Providing Management SupportWyandot’s administrator took a

personal interest in ergonomic issues.To address high injury and turnoverrates at Wyandot, he remainedcommitted to identifying and solvingproblems. For example, on oneoccasion the staff said that the liftswere not easy to roll on the floors inthe B- and C- wings. To solve theproblem, he experimented withdifferent wheels that would roll moreeasily and turn in tight places withless effort. Finally, he worked with amanufacturer to find and buy bettercasters to suit the home’s flooring.

Evaluating EffortsTo start with, Wyandot’s

administrator spent $150,000 to buyequipment. He later set aside another$130,000 to continue his efforts,for a total of $280,000. Wyandothas saved $55,000 annually inpayroll costs, according to

Appendix


Wyandot’s administrator, because ofreduced overtime and absenteeism.The home estimates savings of morethan $125,000 in turnover costs.Meanwhile, workers’ compensationcosts also have fallen drastically.For example, Wyandot reports that,after the program was implementedworkers’ compensation costs declinedfrom an average of $140,000per year to less than $4,000 per year.

From the time workers began touse the sit-to-stand lifts, which wereamong the first to be introduced atWyandot, the incidence of backinjuries stopped. Once the fast bedswere introduced only six new hireswere needed in the following year.

Worker satisfaction has increasedgreatly. One nursing assistant, whohas spent most of her career workingin nursing homes, confessed tobeing sore and unhappy at Wyandotbefore the lifts were introduced.After the innovations at the nursinghome, she reported that she is nolonger hurting. She concluded that“I think my career is right here inthe Wyandot County Nursing Hometill my time is due to retire comfortable.And you know if my timecomes to be in a nursing home I dohope I get one like ours.”

Mechanical lifts have also helpedreturn a sense of dignity toWyandot’s residents. As one nursingassistant put it, through the use ofthe mechanical lifts, the residents areable to wear normal clothing again,which “improves their self-esteemand keeps them warmer.”

The wife of one totally dependentresident who has been at Wyandotfor eight years reports that becauseof her husband’s size, he cannot helpthe nurses and nursing assistants inmoving him from place to place.Before the overhead electric lifts andelectric beds were installed in hisroom, it took three and sometimesfour nursing assistants to move himfrom the bed to his cart or to thetoilet. He had numerous bruises fromfalling and dreaded being moved.With the lifts in place, the resident’swife reports that the staff “can easilymove him about to his chair and tothe toilet. He cannot sit without helpbut the sling gives him comfortablesupport and makes it possible tohave some dignity.”

Appendix

Download - Guidelines for Nursing Homes: Ergonomics for the Prevention of Musculoskeletal Disorders

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