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

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1 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 represent the views of NIOSH."

2 Leading Sources of Workers Compensation in Health Care Overexertion, primarily due to patient lifting and repositioning Slips, Trips, and Falls

3 Incident Type Cost of Workers Compensation Claims Bodily Reaction Overexertion Auto Assaults Exposure Slip/Fall Caught In Needlestick Struck By Repetitive Other

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 Research Practice Concept Proposal Research Proof of Concept Piloting Partners Scientists Stewards of Translation

6 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 Multidisciplinary Lab/Field Research

7 Research Methods to Change Industry Practice Intervention Trials Develop Business Case Assess Program Sustainability Develop Best Practices Disseminate research findings

8 Elements of a Best Practices Program Engineering Controls Management Support Safety Culture Written Polices Best Practices Medical Management Lab and Field Testing Stakeholder Input

9 Even when lifting a patient with two people, the weight of any adult far exceeds the acceptable limits for manual lifting.

10 Safe Patient Lifting Study

11 Highest Risk Occupations for Back Pain in Females in the U.S. Occupation Cases Prevalence Nursing Aides & Orderlies 269, Licensed Practical Nurses 99, Maids 84, Janitors and Cleaners 102, Health Aides, except 39, Nursing Registered Nurses 174,

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 workers. Lancet,1965

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 Subject Matter 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 Legislators

16 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 Return to work issues

17

18 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

21 Length of Follow up 1 year is not enough

22 Injury Rate Due to Resident Lifting/Transferring Intervention Resident Lift Injury Rate

23 Workers Compensation Costs Due to Resident lifting/transferring $300,000 $250,000 $200,000 $183,012 Intervention $161,337 $249,706 $150,000 $100,000 $50,000 $111,837 $61,020 $31,716 $20,820 $68,623 $14,228 $

24 Design Research to Consider Transitions 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 Returning to work after an injury

25 Pre- and Post-Intervention Injury Rates by Age Group Pre-Int Post-Int

26 Pre- and Post Patient Handling Injury Rate by Length of Employment Pre- Post < 1 year 1-5yr 5-10yr >10yrs.

27 Pre- and Post Patient Handling Injury Rates by Gender Male Female Pre Post

28 Injury Rate Pre- and Post for each Nursing Home Pre- Post 5 0 A B C D E F

29 Poisson Regression Results Worker Compensation Data Rate Ratio =.34 (.24,.47), p-value =.0001 OSHA 200 logs Rate Ratio =.42 (.30,.58), p-value = st Reports of Employee Injury Rate Ratio =.62 (.47,.82), p-value =.006

30 Field Study Results Pre- vs. Post-Intervention 47 Worker Comp Claims per Year vs % 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% $152,075 Worker Comp Costs vs. $74,352

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.

32 Elements of a Best Practices Program Engineering Controls Management Support Safety Culture Written Polices Best Practices Medical Management Lab and Field Testing Stakeholder Input

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, , 71% adoption) Television Cell Phones Personal Computers

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 innovation?

38 Diffusion Occurs Within a Social System Not all members of a social system are created equal. 1. Stakeholders 2. Opinion Leaders (2%)

39 Rate of Adoption Explained by 5 Attributes 1. Relative Advantage 2. Compatibility 3. Complexity 4. Trialability 5. Observability

40 Relative Advantage The degree to which an innovation is better than the idea it replaces Economic profitability (cost-benefit) Productivity Injury reduction

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 NCLEX Test Questions

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

49 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 Federal Bill Submitted

50 ANA Safe Patient Handling and Mobility Standard Standards to establish basis for policies, laws, regulations to protect workers, patients 26 Member Work Group

51 Rates of Sprains and Strains Involving Days Away from Work in Hospitals and Nursing Homes, Health Care Patients as Source, Rate per 10,000 full-time workers Nursing homes: Spearman's rho = -0.98, p < Hospitals: 1993 Spearman's rho = , p < Hospitals Nursing home and residential care facilities

52 Future Research Acute care hospitals Home health care Bariatric Patients Evaluation of Legislation Refine Nursing Curriculum Show Link to Patient Outcomes Slips, Trips, and Falls

53 Key Point Successful Translation of Occupational Safety and Health Research can take up to 20 years to implement to change industry practice

54 Thank you! James W. Collins 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.

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