Catholic Mutual..."CARES"

Catholic Mutual..."CARES" BACK INJURY LOSS CONTROL FOR HEALTH CARE FACILITIES Occupational back injuries are a major loss exposure in the health care industry. Serious back injuries can result when employees handle heavy equipment or supplies or move patients. In nursing homes, lifting, transferring and transporting patients are the most frequent sources of employee injuries. The purpose of this safety information is to outline management programs and loss control procedures applicable to patient lifting exposures as a part of your overall Back Injury Loss Control and Claims Management Program. Patient Lifting Patients in a health care facility vary widely in their ability to care for themselves. The nursing personnel provide assistance to patients in the activities of daily living. Patients must often be moved to prevent skin disorders, muscular contractions, lung congestion, poor blood circulation, and other ailments caused by immobility. The care of each patient must be carefully designed by medical personnel. A patient assessment should be conducted upon admission and included in the patient care plan. A daily assessment should be made of each patient s ability to: ambulate sit up in bed turn from side to side move from a bed to a chair move from a bed to a wheelchair move to the toilet move to a shower or bathtub A sample patient assessment is presented in Exhibit 1. Back Injury Loss Control and Claims Management The nursing personnel are at a high risk of back injury while caring for patients. A Back Injury Loss Control and Claims Management Program is needed to control losses. This program should include: Workplace Exposure Evaluation and Control Safety Management Claims Management

The management of the facility must fully support the program. The administrator must make a commitment to provide the resources needed, including adequate staffing, properly maintained equipment and time for in-service training, incident investigation, and overall program administration. Workplace Exposure Evaluation and Control Job Hazard Analysis A Job Hazard Analysis of the patient lifting and mobilization tasks should be made. The analysis should consider the condition of the patients that are assisted. Separate recommended procedures are needed for patients of varying capabilities. The patient s physiological condition, mobility, weight, strength, endurance, balance, and ability to understand and follow directions significantly affects the difficulty of the task. The patient s psychological condition is also a factor to be considered. The movement of a cooperative, alert patient will obviously be easier than dealing with a combative or unstable patient. Frequency and Type of Transfer The frequency and type of patient transfers need to be considered. The number of patients in the facility and in each unit that need assistance should be considered. Mechanical Lifting Aids There are a variety of specialized devices available to aid in patient lifting. The analysis should address the availability, suitability, condition and maintenance of the mechanical patient transfer aids. If these devices are available and employees are trained in their use, the exposure to back injuries can be reduced. Written Procedures Written, recommended procedures for patient lifting should be developed from the results of the Job Hazard Analysis. These procedures can then be used for employee orientation and training. Once the recommended procedures are established and communicated, supervisors can evaluate activities and ensure that the procedures are followed. The procedures should include the type of equipment to be used for the specific task in relation to the assessment of the patient s condition. Different procedures and equipment may be needed to move patients of different levels of ability. A sample Gait Belt procedure is presented in Exhibit 2. A sample procedure for patient transfers is provided in Exhibit 3. These procedures are samples and need to be tailored to the specific transfer, patient, and equipment. Non-Nursing Staff Serious back injuries can also be suffered by maintenance, housekeeping, and dietary staff. Maintenance personnel will move heavy equipment, carry tools and be subject to falls from ladders. Housekeeping employees move beds and carry laundry, and kitchen personnel carry heavy pots and pans of food and are subject to falls on slippery floors. These tasks should be reviewed and these personnel included in the overall Back Injury Loss Control Program.

Safety Management Program The workplace controls and procedures must be supported by effective management controls. The administrator must commit the necessary resources for an effective program, including: proper employee selection, including medical histories, reference checks, application and medical examinations effective documented employee orientation and training programs, including the recommended transfer procedures body mechanics incident investigation and reporting adequate staffing and supervision so that nursing personnel can obtain assistance if necessary effective supervisory training and enforcement of required patient lifting procedures documented current assessments of each patient s physical condition and limitations written safe lifting procedures based on the patient s assessment, available equipment, and the strength necessary for patient lifting accident investigations to determine the causes of the injury and to develop effective corrective action to control future injuries. Exhibit 4 illustrates areas to be thoroughly investigated in investigating patient transfer accidents. accident analysis to discover recurring factors that indicate the need for further investigation and review of existing procedures and equipment proper management selection of mechanical patient lifting equipment and gait/walking belts planned, programmed and audited inspection and maintenance program for all mechanical equipment Claims Management An effective Claims Management Program is needed to control the costs of back injuries which do occur. Claims management procedures include: prompt reporting and investigation of claims prompt identification of potential serious claims medical cost control design and use of light duty talks to encourage rehabilitation coordination among employer, insurer, and employee to promote recovery and prompt return to work

Patient Lifting Aids Many mechanical lifting aids are available to aid health care personnel. Careful research of the products currently available for specific applications is needed. These aids are designed and manufactured for specific applications, depending on the patient s capabilities and where the patient is being moved to and from. Employee and supervisory training in the proper use of each brand or style of device is essential. Specific procedures for use of these devices must be developed and enforced. Employees must be trained initially and provided periodic refresher training. New training will be needed whenever a new brand or style of lifting aid is acquired. The operating and maintenance procedures recommended by the manufacturer should be carefully reviewed. Generally two employees are required when mechanical lifting aids are being used. Gait belts are used on patients who require assistance with walking. Back injuries can result when a staff member tries to catch a patient who begins to fall. If the patient is wearing a gait belt and begins to collapse, the employee can ease the falling patient to the floor. Proper instruction in the use of gait belts based on patient assessments and the manufacturer s recommendations is essential. Management Control Once the Back Injury Loss Control and Claims Management Program is established, management must monitor the program. A sample self-evaluation checklist for the patient lifting portion of the program is presented in Exhibit 5. Summary Inadequately controlled patient transfers can result in serious, disabling employee and patient injuries. The reduction of patient lifting incidents requires a coordinated, planned approach with management, supervisory, and employee involvement. The elements of the Back Injury Loss Control and Claims Management program can be adopted to reduce back injury losses throughout the facility.

EXHIBIT 1 SAMPLE PATIENT ASSESSMENT OUTLINE Height/Weight Is the patient of average or above average height or weight? Physiological Condition How is the patient s posture and circulation? Should the patient be gradually elevated in bed prior to transfer to avoid sudden drop in blood pressure? Diagnosis Related Factors Does the patient diagnosis indicate any specific conditions, i.e., osteoporosis, brittle bones, cancer? Mobility Are joint motions restricted? Is a prosthetic device available to aid in ambulating? Strength/Endurance Will fatigue prevent the patient from completing a transfer? Balance/Stability Does the patient have a tendency to fall or lean to one side or have muscle spasms? Is the patient taking any medication which will cause him/her to be atoxic or dizzy? Footwear Does the patient have proper footwear to prevent sliding? Understanding Is the patient aware enough to see, hear and follow simple commands? Does the patient need a hearing aid or glasses? If so, are they on? Motivation Is the patient eager and willing to ambulate? Uncooperative? Is pain a factor? Has the patient sustained a previous fall? Communication Have you discussed what you are planning with the patient? Is the patient aware of his/her role in the transfer? By taking a moment to assess your patient, you can prevent a patient s fall and/or an employee back injury. NOTE: This is a sample outline for developing a patient assessment. Each facility should develop a patient assessment protocol and assign accountability for patient assessment procedures.

EXHIBIT 2 SAMPLE GAIT BELT PROCEDURE Policy The policy of this agency concerning the gait belt is: a gait belt will be worn and used by all staff members having direct resident care responsibilities. Purpose To promote patient and staff safety. Procedure 1. The belt will be signed out at the beginning of each shift and signed back in when returned at the end of the shift. 2. The belt will be worn by all residents requiring 1 or 2 person assist. 3. The belt should be used on any independent resident who becomes unsteady. 4. The staff member will wear the belt snugly around his or her waist when not in use for a resident. 5. The belt will be placed snugly around the resident s waist and used in these situations: a. transferring a resident from the bed to the chair, etc. b. ambulating a resident in their room or in the hallway c. when a 3 person lift is necessary d. subsequent to a resident s fall, a gait belt must be applied before the resident can be lifted from the floor e. any resident who needs moderate to maximal assistance to perform a pivot transfer (not a carry transfer); during this transfer, two nursing personnel must assist with the use of a gait belt, even if one person is only present as a stand-by 6. Exceptions to any of the above will be at the approval of and under the direction of the floor supervisor.

Important Rules to Remember: 1. The belt must be worn on the outside of the staff member s clothing. 2. The loops of the belt should be positioned either in the back or on one side prior to use. 3. Check for instructions related to a specific resident. In some cases, the belt loops may be positioned in front. 4. The staff member will hold on to the loop with one hand when in use. If two staff members are involved, then both will hold on to the loops. 5. In the case where a resident appears upset, allow the patient time to calm down. Never attempt to move an uncooperative or resistive resident. NOTE: This is a sample procedure that needs to be tailored to the individual facility.

EXHIBIT 3 Sample Patient Transfer Procedures Preparation A. Before you attempt to transfer a patient, be sure to evaluate the situation. The most important factor involved is SAFETY, both your safety and that of your patient. A poorly executed transfer, even with the smallest patient, can cause unnecessary problems and permanent injury to both of you. Never take a transfer lightly, giving it your FULL attention from beginning to end. It takes only a quick second to lose control of the transfer situation. B. Always take the time to explain to your patient what you are planning to do and exactly how you expect the patient to help. A patient who is knowledgeable and calm about the transfer will make all the difference in the ease in which you are able to move him efficiently and safely. BE A GOOD LISTENER. Give your patient an opportunity to express any fears. Discuss these fears with the patient and offer reassurance before beginning the transfer. C. If you have any doubt that you will be able to complete a transfer by yourself - DON T DO IT. Get help. D. Always maintain good body mechanics. E. Always lock the wheelchair, geri-chair or stretcher before beginning any transfers. F. If, during a transfer, you feel that you are losing control of the transfer and you cannot return the patient to the original position, DO NOT attempt to hold the patient up until help arrives, especially if help is not immediately available within the room. Gently lower the patient to the floor with the use of good body mechanics. While lowering the patient, make sure the patient s legs are not in an awkward position. Once the patient is properly positioned on the floor, make him/her comfortable with a pillow and get help. G. Following a transfer, ALWAYS praise your patient. Pride in accomplishment, however minimal, is valuable to a patient. If you believe the patient is capable of more involvement, gently state that you expect more of him/her the next time. NOTE: This is a sample patient transfer procedure. Detailed procedures for specific types of transfers should be developed and employees properly trained and supervised.

General Points to Remember 1. Never pull a patient by his or her extremity to effect a transfer or ambulation. 2. Check the amount of weight bearing a hip fracture patient is allowed to bear prior to attempting a transfer. If there is any doubt regarding the amount of weight bearing allowed, transfer them with NO weight bearing. 3. Always leave your patient COMFORTABLE. If he is complaining of discomfort or pain, adjust his position until he is completely comfortable. 4. Remember that most patients who have fallen have the fear of falling as their main obstacle. DON T RUSH THROUGH TRANSFERS. 5. Take the time to know the conditions of your patients. Know how to handle them and know what to expect. 6. DON T COMPARE PATIENT PERFORMANCE. Two patients with identical diagnoses will not necessarily reach the same level of functioning. Quite often there is more than one diagnosis involved, and the combination results in altered performance in all areas of daily living. 7. DO NOT ambulate or exercise any patient currently undergoing Physical Therapy without consent of the Physical Therapy Department. NOTE: This is a sample patient transfer procedure. Detailed procedures for specific types of transfers should be developed and employees properly trained and supervised.

EXHIBIT 4 Employee Back Injury Accident Investigation Supplement Describe the day-to-day job of the employee. To what extent is this injury the result of cumulative overexertion or a single incident? What circumstances brought about the necessity of patient handling? Is the patient classified as ambulatory, semi-ambulatory or non-ambulatory? Is this classification correct? Height and weight of patient height and weight of employees? Was helper available was helper used? Patient lifting aids available used? Describe any physical factors lighting, traction, necessity of awkward or hazardous work posture, etc.? Patient personal factors involved combative, unconscious, sudden movement or collapse, etc. Was unsafe act on the part of employee necessitated by patient care emergency? If so, describe. In retrospect, how would you have told the employee to do the task? Would this have prevented the injury?

1. Facility Capacity EXHIBIT 5 Health Care Facility Patient Transfer Self-Evaluation Tool Facility Name & Location Number of skilled nursing beds Number of intermediate care beds Number of residential care beds Total beds Percentage occupancy % Nursing Staff Total employees Number of nursing assistants Number of vacant nursing assistant positions Percentage of vacant nursing assistant positions %

2. Patient Assessment Patient Assessment (physical limitations, combative); patient s need for staff assistance in transfers Nurses do not assess patient needs. Nurses assess patient needs and verbally tell other staff (no written communications). Nurses assess patient needs. Verbal communication to other staff during report. Written documentation is in the chart rolodex patient card, color coding on patient door, or other method. 3. Nursing Procedures on Patient Transfers Nursing Procedures (patient transfer bed to chair, use of hydraulic lift, bathtub, other) There are no written nursing procedures. Written procedures are established on some types of transfers. No review of procedures. Written procedures on all types of patient transfers; no review of procedures. 4. Pre-Employment Screening Pre-Employment Screen There is no preemployment screening. Reference checks of previous employers are made. The job description outlines lifting requirements for the job. It is reviewed prior to offer of employment. 5. Light Duty Job Description Light Duty Job Description for Nursing Assistants There is no written job description for light duty. There is no light duty work. There is no written job description for light duty. Some light duty jobs are assigned informally. There is a written job description designating duties for all nursing assistants on light duty. Duties are not tailored to the limitations of each employee. In addition to group 2 steps, staff in nursing unit regularly reviews patient needs and appropriate staff precautions. Written procedures on transfers are reviewed and revised annually as needed. Pre-employment physicals are required for those involved with lifting duties. Specific light duty tasks are tailored to the limitations of each employee. Employee and supervisor sign a statement of specific duties.

6. Equipment A. Patient Lifting Equipment B. Gait Belt Gait belts are not used. C. Bathtubs There are no bathtub patient transfer devices. 7. Training Training in Body Mechanics and Patient Transfers There is no Equipment is equipment to assist available but not in patient transfers. used. Equipment is used sometimes, but not on all appropriate patients. Gait belts used occasionally. Step 1 and limited staff training on gait belts. Bathtub transfer equipment is used sometimes. Bathtub transfer equipment is used for most appropriate patients and well is maintained. There is no Step 1, and annual employee training in refresher training for body mechanics. nursing staff. Training is provided during new employee orientation only. 8. Claims Control There is no established claims control program. Sporadic follow-up with claims personnel. Frequent contact between the facility and claims handling personnel. Adequate equipment is available and well maintained. Staff is familiar with the use of the equipment. All appropriate patients are transferred with the proper equipment. Gait belts used on appropriate patients. Staff is trained and comfortable in the use of gait belts. Bathtub transfer equipment is in use for all appropriate patients and is well maintained. Staff is trained in their use. Steps 1, 2, and reminder training for employees with back injury to return to work. Established program with frequent contact between the handling and claim personnel. Aggressive use of loss mitigation techniques. Comments/Recommendations Completed by Date