[Senate Hearing 111-1138]
[From the U.S. Government Publishing Office]
S. Hrg. 111-1138
SAFE PATIENT HANDLING AND LIFTING STANDARDS FOR A SAFER AMERICAN
WORKFORCE
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HEARING
BEFORE THE
SUBCOMMITTEE ON EMPLOYMENT AND WORKPLACE SAFETY
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
ON
EXAMINING SAFE PATIENT HANDLING AND LIFTING STANDARDS FOR A SAFER
AMERICAN WORKFORCE, INCLUDING S. 1788, TO DIRECT THE SECRETARY OF LABOR
TO ISSUE AN OCCUPATIONAL SAFETY AND HEALTH STANDARD TO REDUCE INJURIES
TO PATIENTS, DIRECT-CARE REGISTERED NURSES, AND ALL OTHER HEALTH CARE
WORKERS BY ESTABLISHING A SAFE PATIENT HANDLING AND INJURY PREVENTION
STANDARD
__________
MAY 11, 2010
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
TOM HARKIN, Iowa, Chairman
CHRISTOPHER J. DODD, Connecticut
BARBARA A. MIKULSKI, Maryland
JEFF BINGAMAN, New Mexico
PATTY MURRAY, Washington
JACK REED, Rhode Island
BERNARD SANDERS (I), Vermont
SHERROD BROWN, Ohio
ROBERT P. CASEY, JR., Pennsylvania
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
MICHAEL F. BENNET, Colorado
MICHAEL B. ENZI, Wyoming
JUDD GREGG, New Hampshire
LAMAR ALEXANDER, Tennessee
RICHARD BURR, North Carolina
JOHNNY ISAKSON, Georgia
JOHN McCAIN, Arizona
ORRIN G. HATCH, Utah
LISA MURKOWSKI, Alaska
TOM COBURN, M.D., Oklahoma
PAT ROBERTS, Kansas
Daniel Smith, Staff Director
Pamela Smith, Deputy Staff Director
Frank Macchiarola, Republican Staff Director and Chief Counsel
Subcommittee on Employment and Workplace Safety
PATTY MURRAY, Washington, Chairman
CHRISTOPHER J. DODD, Connecticut
BARBARA A. MIKULSKI, Maryland
SHERROD BROWN, Ohio
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
TOM HARKIN, Iowa (ex officio)
JOHNNY ISAKSON, Georgia
JUDD GREGG, New Hampshire
RICHARD BURR, North Carolina
JOHN McCAIN, Arizona
ORRIN G. HATCH, Utah
LISA MURKOWSKI, Alaska
MICHAEL B. ENZI, Wyoming (ex
officio)
Scott Cheney, Staff Director
Edwin Egee, Republican Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
TUESDAY, MAY 11, 2010
Page
Murray, Hon. Patty, Chairman, Subcommittee on Employment and
Workplace Safety, Committee on Health, Education, Labor, and
Pensions, opening statement.................................... 1
Prepared statement........................................... 2
Franken, Hon. Al., a U.S. Senator from the State of Minnesota.... 5
Collins, Captain James W., Ph.D., M.S.M.E., Associate Director
for Science, National Institute for Occupational Safety and
Health, Washington, DC......................................... 6
Prepared statement........................................... 7
Hodgson, Michael, M.D., MPH, Chief Consultant, Veterans Health
Administration, Washington, DC................................. 11
Prepared statement........................................... 13
Isakson, Hon, Johnny, a U.S. Senator from the State of Georgia,
prepared statement............................................. 14
Silverstein, Barbara, MSN, MPH, Ph.D., CPE, Research Director,
Washington State Department of Labor and Industries, Olympia,
WA............................................................. 24
Prepared statement........................................... 25
Shogren, Elizabeth (Bettye), RN, MNA, Minnesota Nurses
Association, Staff Specialist, St. Paul, MN.................... 28
Prepared statement........................................... 30
Altaras, June M., RN, BSN, MN, Administrative Nursing Director,
Swedish Medical Center, Seattle, WA............................ 32
Prepared statement........................................... 35
Erickson, Douglas, FASHE, HFDP, CHFM, CHC, Deputy Executive
Director, American Society for Healthcare Engineering, Chicago,
IL............................................................. 45
Prepared statement........................................... 47
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
David Michaels, Ph.D., MPH, Assistant Secretary of Labor for
the Occupational Safety and Health Administration (OSHA)... 54
American Federation of State, County and Municipal Employees
(AFSCME)................................................... 55
American Industrial Hygiene Association (AIHA)............... 56
American Nurses Association (ANA)............................ 57
Response by Captain James W. Collins, Ph.D., M.S.M.E. to
questions of:
Senator Hagan............................................ 60
Senator Isakson.......................................... 62
Response to questions of Senator Hagan by Michael Hodgson,
M.D., MPH.................................................. 63
(iii)
SAFE PATIENT HANDLING AND LIFTING STANDARDS FOR A SAFER AMERICAN
WORKFORCE
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TUESDAY, MAY 11, 2010
U.S. Senate,
Subcommittee on Employment and Workplace Safety,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:32 p.m. in
Room SD-430, Dirksen Senate Office Building, Hon. Patty Murray,
chairman of the subcommittee, presiding.
Present: Senators Murray, Franken, and Isakson.
Opening Statement of Senator Murray
Senator Murray. Good afternoon. This subcommittee will come
to order.
I want to thank, first of all, Senator Isakson and his
staff for being so collegial and courteous as we brought this
hearing together, and really appreciate their work on the
subcommittee.
Senator Isakson will be joining us shortly; he's on his way
over from the floor right now.
I also want to thank all the witnesses who took the time to
be here with us today. And I'm especially excited to have two
witnesses from my home State of Washington. We'll hear from
them shortly.
But, let me just start by saying, our country has had too
many reminders recently about the critical importance of worker
safety. We were reminded when 29 workers lost their lives in a
coal mine in West Virginia, and when seven passed away in a
tragic oil refinery fire in my home State of Washington. These
were really tragic events, but we need to remember that no
threats to worker safety are acceptable, whether they result in
injury, or worse. And, unfortunately, these threats are
occurring all too often. I believe that workers ought to be
able to feel confident that, while they're working hard and
doing their jobs, their employers are doing everything possible
to keep them safe. This should be true for miners, it should be
true for refinery workers, and, the area we're going to be
focusing on today, should be true for healthcare employees.
As we all know, nurses are the backbone of our healthcare
system, but too often they are overlooked in discussions of
workplace safety, even though their jobs are consistently
ranked as one of the most danger-prone in the country. In fact,
on the list of workers facing workplace-related musculoskeletal
disorders, nurses rank as the leading victim, sustaining these
injuries at a rate nearly seven times the national average.
Sadly, nearly half of the nurses on the job report chronic
back pain, and more than 1 in 10 of them say they are planning
to leave the field within the next year. This costs our
hospitals and providers millions in worker compensation,
overtime, replacement, and training costs, and it devastates
workers and their families, moms and dads who can't pick up
their children or grandchildren and cannot be physically active
without constant pain. All of this is coming at a time when we
need our nurses healthy and on the job more than ever.
The need for registered nurses in the United States could
reach as high as 500,000 over the next 15 years, which would be
especially devastating at the very time we are trying to bring
millions of new patients into the healthcare system.
Today we are going to examine the impact of the injury
rates our Nation's healthcare workers sustain due to lifting
patients, and we're going to hear from witnesses about some
solutions being developed to promote safer workplaces for our
nurses.
It used to be the case that we didn't have the research and
equipment available to prevent lifting injuries, but now we
know how to implement safe patient lifting policies. It's just
a matter of making sure that it does happen.
We know that, under ideal circumstances, a worker should
only lift 50 pounds by his or herself, but there are few 50-
pound patients, and they are rarely positioned in such a way as
to make safe lifting easy. In fact, over the course of their
average day, nurses often need to lift more total pounds than
many truck drivers and construction workers. It's clear that we
need to be proactive and cost-effective to make sure nurses
have the training and resources to handle patients in a way
that's safe for them and for the patient.
Our witnesses today will focus on safe patient handling,
which has worked for the Veterans Administration, nine States,
including my home State of Washington, and several hospital
systems. There's no shortage of research or evidence about how
this equipment works and how a program can be implemented, and
there's no question it saves money, helps patients, and creates
a safer work environment for patients.
The question remains, What does a Federal solution need to
look like? I am looking forward to hearing from our witnesses
about this important issue.
[The prepared statement of Senator Murray follows.]
Prepared Statement of Senator Murray
This hearing of the subcommittee will come to order.
Today's hearing examines the impact of injury rates among
our Nation's healthcare workers due to lifting patients and the
various solutions that States, the Veterans Health
Administration and several hospital systems have developed to
promote safer workplaces in their hospitals.
I want to thank our witnesses for being here. I am
especially excited to have two witnesses from my home State of
Washington. I'd also like to thank Senator Isakson for working
with me on a bipartisan basis to hold this hearing. As always,
I appreciate your work on this subcommittee.
We all know that nurses are the backbone of our healthcare
system. And they will serve an even more vital part of our
healthcare system under the reform law Congress recently
passed. In fact, the Bureau of Labor Statistics projects that
more than 581,500 new RN positions will be created through
2018, an increase of 22 percent. Employment of RNs is expected
to grow much faster than the average when compared to all other
professions.
Yet the Journal of the American Medical Association
predicts a ``large and prolonged shortage of nurses.'' It is
estimated that we will need to graduate 30,000 additional
nurses annually to meet the Nation's healthcare needs, an
expansion of 30 percent over the current number of annual nurse
graduates. And to make matters worse, in a 2006 survey 55
percent of nurses reported their intention to retire between
2011 and 2020. The average age of the Registered Nurse is
climbing. With the average age of RNs projected to be 44.5
years by 2012, nurses in their 50s are expected to become the
largest segment of the nursing workforce, accounting for almost
one quarter of the RN population.
So at a time when we need more nurses--many more nurses--we
have both a systemic shortage and the potential for higher
retirement rates on the near horizon. It seems to me that we
should be doing everything we can to keep the nurses we have
safe, healthy and on the job, as a bare minimum.
But, and with no small irony, it is our nurses who too
often selflessly break their own backs to deliver the best
healthcare they can.
Often overlooked in discussions of workplace safety are
healthcare workers. When considering the idea of a ``dangerous
industry,'' most Americans think of construction work, oil
refineries, commercial fishing, and mining. However,
statistically, healthcare work consistently falls among the
most dangerous professions.
Sadly, half of our nurses report they have chronic back
pain, and back injuries to nurses are costly. They cost their
employer in worker compensation, overtime, replacement and
training costs. These costs then get passed on to the
government in the form of additional training costs, lost
productivity, and disability payments. But the biggest costs
are borne by the workers and their families--moms and dads who
can't pick up their kids and grandkids, or be physically active
with them without constant pain.
This is a lose-lose situation. Society loses someone who
chose a job based on compassion and wanting to help and heal
people. Those same people are forced to leave their important
work because the up front cost of some lifting equipment seemed
like a big investment that fiscal year.
In the past, nurses were being hurt on the job when we
didn't have the research and equipment available to prevent
lifting injuries. But now we have the equipment and knowledge
to implement safe patient lifting policies.
NIOSH says that under the best circumstances, a worker
should only lift 50 pounds. There are few 50-pound patients,
and they surely aren't packaged into boxes with handles so you
can bend at the knees. And there is a lot of bending and
twisting involved in moving a patient. It's almost inevitable
that manual lifting will overtime or suddenly hurt a healthcare
worker. Why should our nurses have to lift more than truck
drivers or construction workers?
This committee has taken a serious look over time at the
growing obesity epidemic, but one thing we haven't taken a look
at yet is the effect of that epidemic on healthcare workers who
must manually lift them. If you visit the Work Injured Nurses'
Group's Web site, one of the top stories featured is about a
nurse who was injured while lifting a single patient who
weighed over 700 pounds with a colleague. While a great deal of
injuries happen over time, as patients get heavier, the odds
that a nurse will be hurt in a single lift has increased
dramatically.
Meanwhile, the shortage of registered nurses in the United
States could reach as high as 500,000 by 2025 according to a
reported released in March 2008 by Dr. Peter Buerhaus of
Vanderbilt University School of Nursing, Dr. Douglas Staiger of
Dartmouth University, and Dr. David Auerbach of the
Congressional Budget Office. Moreover, the report found that
the demand for registered nurses is expected to grow by 2 to 3
percent each year. In September 2007, Dr. Christine T. Kovner
and colleagues found that 13 percent of newly licensed
registered nurses had changed principal jobs after 1 year and
37 percent reported that they felt ready to change jobs,
It is clear that we need proactive and cost-effective ways
to stem the loss of nurses. That's why today's hearing will
focus on something that has worked for the VA, nine States,
including my home State of Washington, and several hospitals
systems--safe patient handling.
There's no shortage of research or evidence about how this
equipment works and how to implement a program, and there's no
question that this saves money and saves nurses backs. Now the
question remains: what does a Federal solution need to look
like?
But before we hear from our witnesses, I'd like to
recognize Senator Isakson for his opening statement.
I am looking forward to hearing from our witnesses about
this important issue:
Capt. James W. Collins is the Associate Director
for Science at NIOSH.
Dr. Michael Hodgson is the Chief Consultant for
the Occupational Health, Safety, and Prevention Healthcare
Group in the Office of Public Health and Environmental Hazards
at the Veterans Health Administration.
Dr. Barbara Silverstein is the Research Director
for Safety and Health Assessment and Research for Prevention at
the Washington State Department of Labor and Industries.
Elizabeth Shogren is a nurse from Minnesota.
June Altaras is the Administrative Nursing
Director at Swedish Medical Center in Seattle, WA.
And Douglas Erickson is the Deputy Executive
Director for the American Society for Healthcare Engineering.
Senator Murray. We will hear Senator Isakson's opening
statement when he arrives, but, at this point, I will turn to
Senator Franken for his opening statement.
Statement of Senator Franken
Senator Franken. Thank you, Madam Chair, for holding this
hearing on such a crucial and urgent issue.
We have a serious problem on our hands. We've got a nursing
shortage, a nursing workforce that's growing older, and a
general population growing heavier, with the obesity epidemic.
This is a recipe for disaster, and we must take action now.
Lifting and repositioning are the leading cause of back,
neck, and shoulder injuries in the healthcare industry. Nurses'
back injuries cost about $16 billion in worker compensation
benefits each year, and another $10 billion in medical
treatment and lost productivity.
In 2007, nursing aides experienced musculoskeletal injuries
at a rate of more than seven times the national average for all
occupations, and a much higher rate than freight handlers and
other jobs that require lots of heavy lifting.
The problem is that right now there is a disconnect between
this data and bedside practices. OSHA nursing home guidelines
recommend that, ``Manual lifting of residents be minimized in
all cases, and eliminated when feasible.'' And the National
Institute of Occupational and Safety Health, NIOSH, sets the
safe maximum lifting limit at 35 pounds. These recommendations
are great, but they don't mean much if healthcare workers don't
have the equipment they need to avoid unsafe lifting.
Healthcare workers are the people we trust to care for our
loved ones, to monitor our health, to provide us with the best
treatment possible. That's what they're trained to do, that's
what their expertise is, and that's why it is simply
unacceptable that nurses and other healthcare workers are
putting their own well-being on the line in order to care for
their patients.
Employers have a fundamental obligation to provide a safe
work environment for all workers, and our healthcare workers
are no exception. Not only are these injuries costly and
inhumane, manually lifting patients isn't good for patients.
When Minnesota passed historic safe patient handling
legislation in 2009, it had the support of groups like the
Minnesota Council on Disability. That's because mechanical
lifts reduce the risk of patient injury, too. This equipment
requires an up front investment, but research shows that it
pays off in 2 to 3 years.
The good news is that we know what to do to make things
better. Because of the pioneering work in Minnesota, and
stories like Bettye Shogren's, who will be testifying later, I
am proud to have introduced Senate bill 1788, the Nurse and
Health Care Worker Protection Act. Under my bill, OSHA would
issue a standard on safe patient handling and injury
prevention, including the use of lift equipment. All healthcare
facilities would also be required to implement safe patient
handling plans and train workers to use the necessary
equipment.
The most important take-home message from today's hearing
is that we know how to make things better.
I want to thank the witnesses for joining us today, and I
encourage my colleagues to consider cosponsoring S. 1788, the
Nurse and Health Care Worker Protection Act.
Thank you.
Senator Murray. Thank you very much, Senator.
Senator Franken. Thank you, Madam Chairman.
Senator Murray With that, we will turn it over to our first
panel. Joining us today is Captain James Collins, the associate
director for science at NIOSH, and Dr. Michael--say it for me.
Dr. Hodgson. Hodgson.
Senator Murray. Hodgson, very good, the director of
occupational health programs at the VA.
Welcome, to both of our witnesses. You have 5 minutes each,
and your written testimony will be part of the full record.
Captain Collins, we'll begin with you.
STATEMENT OF CAPTAIN JAMES W. COLLINS, Ph.D., M.S.M.E.,
ASSOCIATE DIRECTOR FOR SCIENCE, NATIONAL INSTITUTE FOR
OCCUPATIONAL SAFETY AND HEALTH, WASHINGTON, DC
Mr. Collins. Madam Chair and members of the subcommittee, I
am pleased to appear before you today to provide testimony on
safe patient handling.
NIOSH has conducted extensive research on safe patient
handling over the past 20 years. Healthcare workers experience
a higher rate of musculoskeletal disorders than workers in
construction, mining, manufacturing, and wholesale and retail
trade. These injuries are due, in large part, to repeated
patient handling activities involving heavy manual lifting when
transferring and repositioning patients, often done in
extremely awkward postures. In the next few minutes, I would
like to describe the extent of the problem and some of the
solutions that have been shown to be effective in preventing
these injuries.
Direct and indirect costs associated with back injuries in
the healthcare industry, adjusted for inflation, are estimated
to be over $7 billion annually, in 2008 dollars. In 2000, over
10,900 registered nurses suffered lost-time work injuries due
to lifting patients, while nursing aides and orderlies suffered
the highest prevalence rates and report the most annual cases
of work-related back pain among female workers in the United
States. Of nurses who plan to leave the profession, 12 percent
cited back injuries as a contributing factor to their decision.
The risk of musculoskeletal disorders from patient handling
results from the high forces on a caregiver's spine when
lifting a patient. There is a risk of injury even if the
patient is of relatively low weight, such as when two
caregivers are lifting a 110-pound patient from a bed to a
chair. Between 1988 and 2008, the average prevalence of obesity
rose from 22 to over 35 percent, and the average prevalence of
extreme morbid obesity rose from 2.9 to 5.7 percent. The
average body weight of both patients and caregivers is
increasing, and is likely to play a major role in increasing
the risk of injury to healthcare workers.
Early discharge of patients from hospitals is another
concern. In 1980, the average length of hospital stay was 7.5
days, compared with only 4.8 days in 2005. When patients are
dismissed earlier from the hospital, home healthcare workers
are at increased risk because they're exposed to higher levels
of physical demands in a home-care environment, where the
availability of assistive patient handling technology is often
lacking.
To identify safer ways to lift and move nursing home
residents, NIOSH studied over 1,700 nursing personnel who were
trained to use mechanical lifting equipment to assist
residents. After the lifting equipment was installed, there was
a 61-percent reduction in workers' compensation injuries and a
66-percent reduction in lost-workday injuries attributed to
resident handling.
The initial investment of $158,000 for lifting equipment
and worker training was recovered in less than 3 years, due to
an annual savings of $55,000 in workers' compensation cost.
This is significant, given that cost is often cited as a
barrier to purchasing lifting equipment and establishing safe
patient lifting programs.
Another advantage of lifting equipment is the reduction in
the rate of assaults on caregivers during resident transfers,
down 72 percent in our study.
Another study examined the long-term effectiveness of a
safe lifting program. Manual lifting and transferring of
patients was replaced with modern battery-operated portable
hoists and other patient transfer assistive devices. The number
of injuries from patient transfers decreased by 62 percent;
lost workdays, by 86 percent; restricted workdays, by 64
percent; and workers' compensation costs were reduced by 84
percent.
Overall, the program produced many intangible benefits,
including improvements in patient comfort and safety during
transfers in patient care.
In closing, NIOSH has shown that manual handling of
patients is a serious risk to healthcare workers. Programs that
rely on the use of mechanical lifting devices, and worker
training in using these devices, offer practical solutions to
prevent healthcare worker injuries. These effective
alternatives to manual patient handling are safe, and can be
cost-effective to implement.
We appreciate the opportunity to present our work, and
thank you for your continued support. Additional information
and references to this work are presented in the written
testimony that we've provided. And I'd be pleased to answer
your questions.
[The prepared statement of Mr. Collins follows:]
Prepared Statement of Capt. James W. Collins, Ph.D., M.S.M.E.
Madam Chair and members of the subcommittee, my name is James
Collins and I am Associate Director for Science for the National
Institute for Occupational Safety and Health's (NIOSH) Division of
Safety Research, part of the Centers for Disease Control and Prevention
(CDC) within the Department of Health and Human Services (HHS). I am
pleased to appear before you today to provide testimony on Safe Patient
Handling. I am accompanied by Dr. Thomas Waters, Senior Research Safety
Engineer at NIOSH. Dr. Waters and I are also principal investigators
within NIOSH and we have conducted extensive research on safe patient
lifting.
Health care workers experience musculoskeletal disorders at a rate
exceeding that of workers in construction, mining, manufacturing, and
wholesale and retail trade.\1\ Musculoskeletal disorders (MSDs) are
disorders of the muscles, nerves, tendons, ligaments, joints, cartilage
and spinal discs. These injuries are due in large part to repeated
manual patient handling activities, often involving heavy manual
lifting when transferring and repositioning patients, working in
extremely awkward postures, and in pushing and pulling heavy objects.
The risk, which can exist even if the patient is of relatively low or
moderate weight, is magnified by the increasing weight of patients due
to the obesity epidemic in the United States, and the rapidly
increasing number of older people who require assistance with the
activities of daily living.\2\ \3\
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\1\ Bureau of Labor Statistics, U.S. Department of Labor, November
12, 2009, Case and Demographic Characteristics for Work-related
Injuries and Illnesses Involving Days Away From Work, Table 10--Number,
percent, and incidence rate of nonfatal occupational injuries and
illnesses involving days away from work by selected worker and case
characteristics and musculoskeletal disorders, All United States,
private industry, 2008. Accessible on the Web at: http://www.bls.gov/
lif/oshwc/osh/case/ostb2211.pdf.
\2\ State of Washington [2006]. An act relating to reducing
injuries among patients and health care workers. Accessible on Web at
http://www.leg.wa.gov/pub/billinfo/2005-06/Pdf/Bill_Reports/House/
1672.HBR.pdf.
\3\ Ogden, C., Carroll, M., and Curtin, L. (2006). prevalence of
overweight and obesity in the United States, 1999-2004. Journal of the
American Medical Association, 295, 1549-1555.
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NIOSH is proud of the work we have done researching MSDs in health
care settings, for developing and evaluating interventions to prevent
these problems among health care workers, and in working
collaboratively with other Federal agencies and Associations to reduce
risk for health care workers.
burden of injuries
Direct and indirect costs associated with back injuries in the
health care industry, adjusted for inflation, are estimated to be $7.4
billion annually in 2008 dollars.\4\ Additionally, nursing aides and
orderlies suffer the highest prevalence (18.8 percent) and report the
most annual cases (269,000) of work-related back pain among female
workers in the United States.\5\ In 2000, 10,983 registered nurses
(RNs) suffered lost-time work injuries due to lifting patients. It has
been reported that 12 percent of nurses who planned to leave the
profession cited back injuries as a contributing factor.\6\
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\4\ Waehrer G., Leigh J., and Miller T. Costs of Occupational
Injury and Illness Within the Health Services Sector, Intl. J. of
Health Services, Volt. 35(2) 342-359, 2005.
\5\ Guo, H.R., Tanka, S., Cameron, L.L., et al. (1995) Back pain
among workers in the United States: national estimates and workers at
high risk. Am J Ind Med, 28:591-602.
\6\ Stubbs, DA, Buckle, PW, Hudson, MP, Rivers, PM, and Baty D
(1986). Backing out: nurse wastage associated with back pain.
International Journal of Nursing Studies 23(4): 325-336.
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The age of the Registered Nursing population has been rising over
the past two decades. Between 2004 and 2008, the average age of all
licensed nurses rose from 46.8 to 47.0 years and that of employed
nurses rose from 45.4 to 45.5 years. This aging trend has raised
concerns that future retirements could substantially reduce the size of
the U.S. nursing workforce.\7\ Preserving the health of our nursing
staff and reducing back injuries in health care personnel is critical.
NIOSH has a comprehensive research program aimed at preventing work-
related MSDs with major efforts to reduce lifting injuries in health
care settings. NIOSH's research with diverse partners has already made
great strides in developing best practices and demonstrating the
effectiveness of these ``best practices'' in health care settings.
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\7\ U.S. Department of Health and Human Services (2010). Registered
Nurse Population: Findings from the 2008 National Sample Survey of
Registered Nurses. Available on the Internet: http://bhpr.hrsa.gov/
healthworkforce/rnsurvey/initialfindings2008.pdf.
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The risk of musculoskeletal disorders resulting from patient
handling results from the high internal forces created in the spine
when a person lifts a heavy object. Musculoskeletal disorders are a
high risk for patient handling because it can require lifting a patient
who is far away from the worker which puts heavy loads on the spine.
Repeated lifting of this type can result in scarring that causes more
damage. Studies have suggested that there can be risks of injury even
when two people are lifting a 110-lb patient from a bed to a chair.\8\
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\8\ Marras, W.S., Davis K.G., Kirking, B.C., Bertsche, P.K. (1999).
A comprehensive analysis of low-back disorder risk and spinal loading
during the transferring and repositioning of patients using different
techniques. Ergonomics. 42(7):904-926.
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NIOSH recommends that no caregiver should manually lift more than
35 lbs of a person's body weight for a vertical lifting task.\9\ NIOSH
further recommends that when the weight to be lifted exceeds this
limit, assistive devices should be used. These recommendations have
been adopted by the Veterans Health Administration (VHA) and
incorporated into its current patient handling recommendations and
patient handling algorithms. Moreover, other major interest groups,
such as the American Nurses Association (ANA), National Association of
Orthopaedic Nurses (NAON), and Association of PeriOperative Registered
Nurses (AORN) have all adopted similar patient handling guidelines that
recommend use of technology-based solutions for patient handling and
movement.\10\ \11\ \12\
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\9\ Waters T. (2007). When is it safe to manually lift a patient?
American Journal of Nursing. Volt. 107(8): 53-59.
\10\ AORN Workplace Safety Task force. (2007). Safe Patient
Handling & Movement in the PeriOperative Setting. Denver, CO:
Association of PeriOperative Registered Nurses (AORN).
\11\ de Castro, A.B. (2006). Handle With Care: The American Nurses
Association's Campaign to Address Work-Related Musculoskeletal
Disorders. Orthopeadic Nursing, 25, 6, 356-364. Reprinted from de
Castro, A.B. (2004). Handle With Care: The American Nurses
Association's Campaign to Address Work-Related Musculoskeletal
Disorders. Online Journal of Issues in Nursing. Volt. #9 No. 3.
Retrieved from http://www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/
Number3September30
/HandleWithCare.aspx.
\12\ NAON (2009) Safe Patient Handling. Special Issue. Orthopaedic
Nursing, 28(2S) 2-35.
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external factors
A major concern for health care workers is the obesity epidemic
that our country is facing. The average body weight of both patients
and caregivers is increasing over time and this increase in average
body weight is likely to play a major role in increasing risk of MSDs
for health care workers. Data from the National Health and Nutrition
Examination Survey show that between 1988 and 2008, the average
prevalence of obesity rose from 22.9 percent to 35.5 percent, and the
average prevalence of morbid (extreme) obesity rose from 2.9 percent to
5.7 percent. Rates of adult morbid obesity in 2008 ranged from 3.8
percent of Hispanic men to as high as 14.2 percent of non-Hispanic
black women.\13\ \14\
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\13\ Flegal, K., Carroll, M., Ogden, C., and Curtin, L. (2010).
Prevalence and trends in obesity among U.S. adults, 1999-2008. Journal
of the American Medical Association, 303, 235-241.
\14\ Flegal, K., Carroll, M., Ogden, C., and Johnson, C. (2002).
Prevalence and trends in obesity among U.S. adults, 1999-2000. Journal
of the American Medical Association, 288, 1723-1727.
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The majority of direct patient care workers are females who, on
average, have lower strength and lifting capacity than males. Most
female nurses work at a higher percentage of their maximum physical
capabilities than males when performing the same strength-demanding
tasks. While most health care workers do not have established maximum
weight lift limits, in manufacturing industries, where the majority of
workers are male, employers have developed maximum weight limits for
manual lifting and they have incorporated robots and other lifting
assistive devices.
A recently emerging issue that has resulted in increased risk for
MSDs for health care workers is that patients are often released from
the hospital following surgery and other treatments much earlier than
in the past. In 1980, for example, the average length of hospital stay
was 7.5 days compared with only 4.8 days in 2005.\15\ When patients are
dismissed from the hospital earlier in the recovery process, the
patient is often more dependent upon the caregiver for assistance in
being transferred or in moving. This has resulted in increased risk for
workers in the hospital setting due to the concentration of extreme
patient needs associated with patient transfers and movement while in
the acute care environment. It also increases the level of patient
transfer assistance needed in the home care environment at an earlier
stage of recovery than was previously required, placing home health
care workers at increased risk. The home health care worker is now
exposed to higher levels of physical demands in a care environment
where the availability of assistive patient handling technology is
often lacking.\16\ \17\
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\15\ National Center for Health Statistics (2007) 2005 National
Hospital Discharge Survey, Retrieved from http://www.cdc.gov/nchs/data/
ad/ad385.pdf on 2/2/2010.
\16\ Galinsky, T., Waters, T., and Malit, B. Overexertion Injuries
in Home Health Care Workers and Need for Ergonomics Home Health Care
Services Quarterly. 20(3):57-73. 2001.
\17\ NIOSH (2010) NIOSH Hazard Review Occupational Hazards in Home
Health Care. DHHS (NIOSH) Publications No. 2010-125. National Institute
for Occupational Safety and Health, Cincinnati, OH.
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prevention research
NIOSH carried out a comprehensive lab and field study to identify
safer ways to lift and move nursing home residents. The study design
included removing the excessive forces and extreme postures that can
occur when manually lifting residents. Historically, the caregiver has
used his or her own strength to provide manual assistance to the
resident. NIOSH also conducted a field study to determine if a ``best
practices'' intervention consisting of mechanical equipment to lift
physically dependent residents, training on the proper use of the
lifts, a safe lifting policy, and a medical management program would
reduce the rate and the associated costs of the resident handling
injuries for the nursing personnel in a real world setting. During the
6-year period, from January 1995 through December 2000, 1,728 nursing
personnel were studied before and after implementation of the
intervention. After the intervention, which was a safe lifting program
that includes mechanical lifting equipment, worker training on the use
of the lift, and a written resident lifting policy, there was a 61
percent (range 45-71 percent) reduction in workers' compensation
injuries involving resident handling, workers' compensation costs, and
lost work day injuries. The initial investment of $158,556 for lifting
equipment and worker training was recovered in less than 3 years on the
basis of post-intervention savings of $55,000 annually in workers'
compensation costs.\18\ This is significant given that cost is an often
cited barrier to purchasing lifting equipment and establishing safe
patient lifting programs. Another advantage of lifting equipment is the
reduction in the rate of assaults on caregivers during resident
transfers--down 72 percent on the basis of workers' compensation
claims.
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\18\ Collins, J.W., Wolf, L., Bell, J., and Evanoff, B., (2004). An
evaluation of a best practices'' musculoskeletal injury prevention
program in nursing homes Injury Prevention, 10, 206-211.
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Based on the successes achieved in the long-term care industry,
NIOSH has undertaken a new 6-year longitudinal research study to
evaluate the effectiveness of a ``best practices'' safe patient
handling program at two large acute-care hospitals in the United
States.
Another major study demonstrating success in reducing back injuries
to health care workers was funded by NIOSH through a cooperative
agreement. The study examined the long-term effectiveness of a safe
lifting program with the primary objective to reduce injuries to health
care workers resulting from manual lifting and transferring of
patients. These safe lifting programs, which used employee management
advisory teams, i.e., a participatory-team approach, were used in seven
nursing homes and one hospital. In this study, manual lifting and
transferring of patients was replaced with modern, battery operated,
portable hoists, and other patient-transfer assistive devices. The
number of injuries from patient transfers decreased by 62 percent, lost
work days decreased by 86 percent, restricted workdays decreased by 64
percent, and workers' compensation costs were reduced by 84 percent.
Overall, the program produced many intangible benefits including
improvements in patient comfort and safety during transfers and patient
care. The nursing personnel reported that their backs were less sore
and that they were less tired at the end of their shifts.\19\
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\19\ Garg, A. (1999). Long-term effectiveness of ``Zero-Lift
Programs'' in seven nursing homes and one hospital. U.S. Department of
Health and Human Services, National Institute for Occupational Safety
and Health, Contract Report No. U60/CCU512089-02.
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Despite the obvious advantages to using lifting equipment, schools
of nursing continue to teach, and nurses' licensure exams continue to
include, outdated and unsafe manual patient handling techniques.\20\
This is due in large part to outdated books and curricula both of which
promote unsafe patient handling practices. To address this, a team of
experts from NIOSH, the American Nurses Association, and the Veterans
Health Administration developed and evaluated an evidence-based
training program on safe patient handling for educators at schools of
nursing that relies on use of technology for moving and transferring
patients. The study found that when using the curriculum, nurse
educator and student knowledge improved significantly as did the
intention to use mechanical lifting devices in the near future.\21\
\22\ \23\
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\20\ National Council of State Boards of Nursing (2006). National
Council Licensure Examination (NCLEX) Web site. Accessible on Web at:
http://www.ncsbn.org/245.htm. Last accessed on November 25, 2006.
\21\ Nelson, et al. (2007): Evidence-Based Nursing School
Curriculum in Safe Patient Handling. International Journal of Nursing
Education Scholarship, Volt. 4, Iss. 1, Art. 26.
\22\ Menzel, N. (2007). Preventing Musculoskeletal Disorders in
Nurses: A Safe Patient Handling Curriculum Module for Nursing Schools.
Nurse Educator. 32 (3): 130-135.
\23\ NIOSH (2009), Safe Patient Handling Training Schools of
Nursing, Curricular Materials. DHHS (NIOSH) Publication No. 2009-127.
National Institute for Occupational Safety and Health, Cincinnati, OH.
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guidelines
Over the past decade, we have found that best practices are
specific to health care settings. What works in critical care may not
be appropriate for emergency room settings or operating rooms. Because
each health care setting has specific needs for specialized approaches,
NIOSH worked collaboratively with outside groups to develop safe
patient handling guidelines for caregivers in operating rooms and in
orthopaedic settings (AORN and NAON efforts).
Recently, the health care industry has recognized the risks
associated with performance of physically demanding patient handling
tasks, and to reduce costs and increase productivity, companies have
begun to implement ergonomic programs or practices aimed at preventing
these injuries. The core element of these programs is reliance on use
of state-of-the-art ergonomically designed equipment to assist the
worker in carrying out the prescribed task. As an added incentive to
adopt technology-based patient handling practices, OSHA recently
published an ergonomics guideline that provided an overview of the
risks of work-related MSDs in nursing homes. The guideline provided
information about the most effective approaches for mitigating or
reducing those risks, and discussed training needs.\24\ The most
important recommendation in the OSHA nursing home guideline was that
``manual lifting of residents be minimized in all cases and eliminated
when feasible.'' This is best accomplished by implementing a
technology-based safe patient handling program.
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\24\ OSHA (2009) Ergonomics for the Prevention of Musculoskeletal
Disorders: Guidelines for Nursing Homes. U.S. Department of Labor,
Occupational Safety and Health Administration. Document No. OSHA 3182-
3R.
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In 2009, NIOSH initiated a project aimed at improving safety while
lifting and moving bariatric patients. In health care settings, the
term ``bariatric'' is used to refer to patients whose weights exceed
the safety capacity of standard patient lifting equipment (300 lbs), or
who otherwise have limitations in health, mobility, or environmental
access due to their weight/size.\25\ Compared to the non-obese
population, obese individuals require more frequent and extensive
health care due to obesity-related health problems, and health care
personnel are encountering hospitalized and critical-care bariatric
patients on an increasingly frequent basis.\26\ \27\ \28\ In the
extreme, such patients can weigh over 1,200 pounds. The upcoming NIOSH
project will evaluate bariatric patient handling practices at multiple
hospitals, including intervention programs and health/safety outcomes,
in order to identify and promote evidence-based best practices.
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\25\ Bushard, S. (2002). Trauma in patients who are morbidly obese.
Association of PeriOperative Registered Nurses (AORN) Journal, 76, 585-
589.
\26\ Pieracci, F., Barie, P., and Pomp, A. (2006). Critical care of
the bariatric patient. Critical Care Medicine, 34, 1796-1804.
\27\ Reto, C. (2003). Psychological aspects of delivering nursing
care to the bariatric patient. Critical Care Nursing Quarterly, 26,
139-149.
\28\ Tizer, K. (2007). Extremely obese patients in the health care
setting: Patient and staff safety. Journal of Ambulatory Care
Management, 30, 134-141.
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We all have a vested interest in taking care of those who help take
care of us and our families when we need medical attention. It is
likely that the implementation of the research presented here will
significantly reduce injuries and illnesses for health care workers and
increase the quality of patient care. In turn, reducing MSDs among
nurses may help address the critical issues of nurse recruitment and
retention.
conclusion
In closing, NIOSH has shown that manual handling of patients is a
serious risk to health care workers and that we continue to work
diligently to protect the safety and health of those workers. We have
assessed the overall scope of the problem, characterized the risks from
moving patients, and identified increasing risks due to the aging
workforce and obesity epidemic in the United States. We have also
developed some practical solutions in terms of best practice programs
that rely on use of technology-based solutions. Our efforts have shown
that there are effective alternatives to manual patient handling that
are safe and cost-effective to implement. We appreciate the opportunity
to present our work to you and thank you for your continued support.
I would be pleased to answer your questions.
Senator Murray. Dr. Hodgson.
STATEMENT OF MICHAEL HODGSON, M.D., MPH, CHIEF CONSULTANT,
VETERANS HEALTH ADMINISTRATION, WASHINGTON, DC
Dr. Hodgson. Good afternoon, Chairman Murray and Ranking
Member Isakson, and thank you for the opportunity to discuss
safe patient handling and lifting standards for a safer
American workforce.
My testimony today will discuss our experience in the
Department of Veterans Affairs in evaluating and responding to
the concern.
Patient manual handling injuries generate staff shortages
for acute service delivery and affect workforce retention. In
the late 1990s, a nursing research group at the Tampa VA
undertook a review of nursing injuries; identified common and
specific mechanisms of injury related to patient handling and
movement; assembled an expert panel that redesigned patient
transfers; and identified the associated needed technology and
support.
A VA Health Services research and development grant
evaluated those recommended changes, and justified the new
program, now known as Safe Patient Handling. That program
supports both patient safety and employee injury prevention.
The VA Sunshine Healthcare Network VISN 8 in Florida evaluated
this program between 2001 and 2003 in a very rigorous way.
In parallel, external efforts by the VA program developers
included support for the development of OSHA's ``Ergonomics
Guidelines for Nursing Homes'' and leading the content and
writing of the ``2010 Guidelines for the Design and
Construction of Health Care Facilities'' that were recently
published by the American Society of Healthcare Engineers.
VISN 8 business-case calculations suggested an internal
rate of return on program investment of between 19 and 37
percent so that the VA funded a national program. Since 2008,
VA has disbursed approximately $143 million to VA healthcare
facilities for this initiative, with another $62 million
planned for fiscal year 2011.
The program itself consists of several major elements,
including the technology, such as ceiling lifts, sliding
devices, and the like; patient transfer algorithms that define
how nurses move patients as a function of patient dependency
and the goal of the transfer; unit peer leaders as local
program implementation support; and a whole series of
additional infrastructure elements.
Major implementation lessons over the last years include
the following:
First, the program fails without strong local
leadership and a robust unit peer leader program;
Second, immediate equipment availability is a
major driver for success so that ceiling lifts far outperform
portable equipment; and
Third, this is a fundamental change in patient
care processes so that it relies on the nursing community to
accept new technology and change longstanding practices.
Working with our Office of Nursing Services over the last
years has led VA to recognize that, even though implementation
must be a joint effort, the public face must include a very
prominent nursing presence.
Over the last year, new evidence from researchers in
Holland and from Stanford University suggests that the program
actually also supports dramatically improved quality of patient
care, as demonstrated by reduced rates of decubitus ulcers,
incontinence, and urinary tract infections.
In addition, a recent reanalysis from the Stanford
University program identified an internal rate of return
greater than 65 percent, a phenomenal addition from these
additional patient care quality measures.
VA's program encompasses a comprehensive evaluation
component, including status reports, audits and fiscal reviews,
and longitudinal evaluations of selected sites.
New technologies, that were not envisioned when the program
was designed in 2006, have emerged. So, for example, air-
assisted lateral transfer devices, powered wheelchairs and
stretchers, and car extractors were simply not available 5
years ago, when we designed the program. As the problem of
obesity increases for the veteran patient population, these
additional technologies have been developed for moving
patients, including overweight patients.
New equipment and extension of ceiling tracks into
bathrooms have been designed to reduce the frequency of
transfers, and we're currently modeling how and where the
additional newer program elements are likely to be beneficial
and cost-effective.
Chairman Murray, VA has found it can improve patient care
while reducing costs through efforts like the Safe Patient
Handling Program.
Thanks for the opportunity to describe this.
[The prepared statement of Dr. Hodgson follows:]
Prepared Statement of Michael Hodgson, M.D., MPH
Good afternoon, Chairman Murray and Ranking Member Isakson, and
thank you for the opportunity to discuss safe patient handling and
lifting standards for a safer American workforce. My testimony today
will discuss our experience in the Department of Veterans Affairs (VA)
in evaluating and responding to this concern.
Manual handling injuries, such as lifting patients, represent the
most frequent injuries to nursing personnel, an occupation with among
the highest injury rates in the United States. These injuries are the
primary reason for early retirement and disability retirement and,
thus, have major consequences affecting VA's ability to retain
qualified health care personnel.
Those injuries also increase workers' compensation costs and lead
to unplanned staff absences, causing problems for service delivery. In
response, a VA nursing research group in Tampa undertook a review of
nursing injuries in the late 1990s. They identified common and specific
mechanisms of injury related to patient handling and lifting. This
group then assembled an expert panel that included widely recognized VA
and non-VA researchers and practitioners that redesigned patient
transfers. This group identified the needed technology to support these
changes in process, i.e., appropriate patient transfers. They evaluated
those recommended changes in clinical practice with a VA Health
Services Research and Development grant and developed the new program
which we now know as ``Safe Patient Handling.'' That program supports
both patient safety and employee injury prevention. The VA Sunshine
Healthcare Network (Veterans Integrated Service Network, VISN 8) in
Florida deployed this program between 2001 and 2003 with a rigorous
evaluation component. Since that time, the VA Tampa Patient Safety
Center of Inquiry has continued to evolve the program with major
changes to the patient care handling process.
In parallel to these internal efforts, VA program developers
participated in the Occupational Safety and Health Administration's
(OSHA) Ergonomics Advisory Committee and supported the development of
OSHA's ergonomics guidelines for nursing homes. Recently the Facilities
Guidelines Institute (FGI) released the 2010 Guidelines for the Design
and Construction of Health Care Facilities [published by the American
Society of Healthcare Engineers (ASHE)], based on this work.
The VISN 8 program reduced patient manual-handling caregiver
injuries and led to markedly increased employee and patient
satisfaction. Results that document the reductions in injury and the
increases in patient and provider satisfaction have been published in
the peer-reviewed literature. The initial business case calculations,
published in the peer-reviewed literature in 2005, suggested an
internal rate of return on program investment in the range of 19
percent. Subsequent internal work suggested an internal rate of return
of up to 37 percent. With such dramatic benefits, VA developed and
funded a national program, with a budget initiative that was proposed
in 2007 and that was to run through 2011. The first funds were
distributed in July 2008, and so far VA has disbursed approximately
$135 million to VA health care facilities for this initiative. VA has
budgeted another $62 million for fiscal year 2011, the final year
planned for implementation of the basic program. The program itself
consists of several major elements, including technology (ceiling
lifts, sliding devices, and the like), algorithms that define patient
transfers as a function of patient dependency and the goal of the
transfer, unit peer leaders as local program implementation support,
and infrastructure-like maintenance, equipment inventory, and
replacement. Standing up the program requires strong local leadership,
working through program implementation and planning issues, supporting
the local equipment selection, training peer leaders, and managing the
program. A broad range of training and education support materials have
been developed, from cognitive aids to support appropriate transfers
through books, CDs, and videotapes. A brief introductory video for
patient education, to guide expectations, is available on the Web sites
of some facilities.
Implementation lessons from several VISNs in 2004 and 2005 clearly
demonstrated that without a unit peer leader program and strong local
leadership, the program fails. Additional work suggests that just in
time equipment availability is a major driver; for example, ceiling
lifts far outperform portable equipment as they are always in the same
place. This is a fundamental change in patient care processes, and it
relies on the nursing community to accept new technology and change
long-standing processes. Many nursing schools have recently
incorporated this approach into their educational curricula. Working
with our Office of Nursing Services over the last year has led VA to
recognize that even though implementation must be a joint effort, the
public face must include a nursing presence, without which the program
simply fails.
New evidence from researchers in Holland and from Stanford
University suggests the program also supports improved quality of
patient care, which is demonstrated by reduced rates of decubitus
ulcers, incontinence, and urinary tract infections. In addition, the
Stanford analysis identified an internal rate of financial return
greater than 65 percent. Much of the cost savings is directly
attributable to nursing retention and the decreased cost of training.
The program encompasses a comprehensive evaluation component
including status reports, audits and fiscal reviews, and longitudinal
evaluations of selected sites. We are currently conducting a formal
evaluation of changes in injury rates as a function of program
implementation and activation status. This program highlights VA's work
on nursing workforce development and retention in parallel with the
efforts to support both employee working conditions and patient care.
Most importantly, it demonstrates the benefits of using rigorous,
evidence-based approaches to improve patient safety.
Finally, new technologies, not envisioned when the program was
designed in 2006, have emerged. For example, air-assisted lateral
transfer devices, powered wheelchairs and stretchers, and car
extractors were not available 5 years ago. As the problem of obesity
increases for the Veteran patient population, additional technologies
have been developed for moving patients, including overweight patients.
New equipment and extension of ceiling tracks into bathrooms have been
designed to reduce the frequency of transfers. We are currently
modeling how and where additional program elements are likely to be
beneficial.
VA continues to share information about the Safe Patient Program
throughout its national health care system. An annual conference in
Florida, co-sponsored by the National Institute of Occupational Safety
and Health, the University of Florida, and the Veterans Health
Administration, is one important way VA has increased awareness,
disseminated research, and conducted training.
Chairman Murray, every health care organization must address safe
patient handling and lifting standards. VA has found it can improve
patient care while reducing costs through efforts like the Safe Patient
Handling program. Thank you for the opportunity to appear, and I am
prepared to answer your questions at this time.
Senator Murray. Thank you both for your testimony.
Senator Isakson has joined us. I'll turn to him for opening
comments.
Senator Isakson. Out of respect for those testifying, I'd
ask unanimous consent that my opening statement be submitted
for the record.
Senator Murray. OK, thank you very much.
[The prepared statement of Senator Isakson follows:]
Prepared Statement of Senator Isakson
I thank Senator Murray for calling this hearing and welcome
our witnesses.
Every day, caregivers transfer, position, and mobilize
patients. Providing this assistance by the manual lifting of
patients can involve significant physical effort. This task is
further complicated with tubes and other devices hindering the
patient's movement.
Patients are moved or repositioned for a number of reasons,
including accomplishing patient care tasks, such as an
examination, preventing bedsores, or simply providing patients
with additional comfort and safety.
Manual patient handling, including lifting, transferring,
positioning, and sliding patients, can be difficult and even
dangerous for both caregivers and patients. There is evidence
that manual patient handling puts caregivers at considerable
risk for injuries.
For these reasons, more and more health care facilities are
installing assistive patient handling and movement technology.
This technology may not only make caregivers' work easier and
safer, but provide for better patient outcomes and improved
quality of life while receiving care. Additionally, this
technology may allow hospitals and nursing homes to mobilize
patients immediately following a procedure.
Legislation that would mandate lift policies and the use of
these assistive devices is currently before the HELP Committee.
The costs associated with this legislation are unnecessary and
come at a time when the industry is already crippled with costs
imposed by the new health care bill.
According to his own actuaries, the President's new health
care law bends Federal spending curve upward ``by a net total
of $251 billion'' over the next decade.
Many of the entities that will be forced to comply with the
crippling new mandates in the health reform bill are small
businesses that are struggling to keep their doors open.
The CMS Actuary has already told us the half trillion
dollars in Medicare cuts included in the new law may cause
providers to end their participation in the Medicare program,
and possibly jeopardize access to care for beneficiaries.
Further, the purchasing of medical devices will be more
expensive after Congress imposed a 2.3 percent excise tax on
device manufacturers. Passing a new mandate on lifting
assistive devices will only make these problems more severe.
While patient handling and movement technology certainly
holds much promise, I have been in Washington long enough to
know that not every good thing needs to be mandated
immediately. The health care industry is very active in this
area, going above and beyond current legal and regulatory
minimums to try to help both workers and patients.
In legislating in this area, Congress must consider the
high cost and all its ramifications, intended and unintended.
Senator Murray. We'll turn to questions, then.
Captain Collins, I'd like to start with you. Various NIOSH
publications make the point that simply training our workers to
lift differently is ineffective. We all know that lifting is
easier when you bend at the knees and hold the body weight
close, but obviously nurses, in having to lift patients, have
to reach over beds or equipment, and, we know, this often
results in nurses being more than 6 inches, at least, away from
their patient.
NIOSH standards say that the average person can lift 45 or
50 pounds, but how much do those figures change when the lift
requires bending over or holding your arms more than a foot
away from the center of your body mass?
Mr. Collins. Typically, about half, less than half--25 to
35 pounds is about the maximum acceptable lifting, with the
postures that nurses have to assume.
Senator Murray. So, our lifting standards don't reflect the
fact that nurses pick up things differently.
Mr. Collins. No.
Senator Murray. OK. Can you perhaps address for this
committee some of the other dangers that are inherent to
lifting human beings rather than some kind of inanimate object?
Mr. Collins. Well, the original lifting standards were
designed for inanimate objects, such as boxes. You can
understand that some nursing home patients can be combative,
resistant to being transferred, and they can also be injured if
they're mishandled or dropped during the course of lifting. And
they're not packaged very well for transfers, and they're
excessively heavy; well beyond the 51-pounds lifting limit.
Senator Murray. OK. Well, I suspect that most people don't
think of nurses or people in healthcare professions as having
to lift as much as construction workers. Can you tell us, What
is the comparison between how much a healthcare worker lifts in
a day, compared to other high-professions, like truck drivers
or construction workers?
Mr. Collins. It depends on the particular caregiver's job,
but I suspect it's very similar. In fact, when I first started
in this area of research, I was working with United Auto
Workers on a dissertation study with Johns Hopkins University.
They were a 95-percent male workforce, and they were restricted
from lifting over 35 pounds during the course of assembling
automobiles. And here, I had this concurrent study population
with female workers, nursing aides and orderlies, which the
workforce was 93 percent female, and there was an expectation
that they would lift 300-pound bodies as part of their daily
routine. We knew that we had a huge challenge ahead to discover
and evaluate effective methods to help them safely lift and
move patients.
Senator Murray. If we implemented a national lifting
standard, what kind of reduction in injury rates to nurses and
healthcare providers would we see?
Mr. Collins. In the two well-controlled studies that I've
been involved in, we've seen reductions of--where comprehensive
best-practices programs have been implemented in excess of 60
percent; and that's in the nursing home industry. I have a
current study where we're working with UPenn Medical Center and
Northwestern Memorial Hospital in an acute-care setting. These
are ongoing studies--the hospital study's still going, but
we're--preliminary results are over 50-percent injury
reductions there.
The National Research Council and the Institute of Medicine
have estimated that, when you reduce the biomechanical
exposures from manual lifting, that the assistive devices could
result in reductions somewhere between 55 and 65 percent.
Senator Murray. OK.
Dr. Hodgson, my father was in World War II and came home
injured, and was eventually diagnosed with Multiple Sclerosis.
And my family were caregivers, so I'm intimately aware of how
closely families and veterans take care of their loved ones. I
also worked in the Seattle VA, right after the Vietnam war, and
worked with soldiers who were both physically and mentally
injured, and I know how much families are involved in this.
And I wanted to ask you, Have you interviewed any veterans
who use the VA healthcare facilities--about their views on your
new safe patient handling policy?
Dr. Hodgson. Actually, it's a great question. And yes,
there are both formal evaluations of patient acceptance--even
in the early VISN 8 study, the patient acceptance was a major
criterion for evaluating the utility of the program. There's a
publication on that, that we can submit as part of the post-
hearing comments.
Dr. Hodgson. We do have a PVA service rep at every
hospital. The one from Tampa was actually lined up to come
tomorrow and testify on the panel, before the panel got moved.
He would be happy to fly up and talk.
Yes, we do know that patients like the technology. It makes
many of them feel much safer.
There are ways that it must be implemented. For example, in
our spinal cord injury units, the issue of dignity and thinking
through how patients are transferred is a real issue.
We have spent a fair amount of time thinking about that.
There is written peer-reviewed publicational record on that,
and there are lots of people who think about that. It's an
important issue.
Senator Murray. Thank you very much.
Senator Isakson.
Senator Isakson. Well, thank you Chairwoman Murray.
I do apologize to both of you, as well as the Chairman, for
being late. And that's why I didn't read my statement. It's
also why this next question may have already been either
explained in your testimony or come up.
On page 3 of Dr. Collins' transcript, it says,
``These recommendations''--referring to NIOSH's
recommendations on lifting--``have been adopted by the
Veterans Health Administration and incorporated into
its current patient handling recommendations and
patient handling algorithms.''
So, my question, Dr. Hodgson, is, What have you
implemented, by virtue of NIOSH's regulations, in terms of the
lifting of patients?
Dr. Hodgson. The VA program is designed a little
differently. NIOSH has been part and partner of our work over
the last 10 years, from the program design through the
conferences, but our program was designed in a different way,
not quantitatively to deal with specific lifting thresholds, in
terms of force requirements, but in terms of commonsense
approaches and likely issues. So, thinking through patient
dependency--fully, partially, or a minimally dependent
patient's weight and approximate, kind of, force requirements,
and designing the transfer to use technology to minimize the
amount of force required.
We don't actually have detailed force thresholds; we have,
from that HSR&D lab evaluation, the knowledge that, in general,
when you do something, following a set of algorithms with a
certain number of staff, you will not exceed weight limit
restrictions.
It wasn't designed the way the NIOSH program was laid out;
it was designed in an algorithmic, you know, operationally
efficient way.
Senator Isakson. In other words, you have parameters and
guidelines and recommendations as to the handling of the
movement of a patient and their weight, but you don't have a
specific approach that fits all movement. Is that what I heard
you say?
Dr. Hodgson. Each transfer requires a different set of
actions. If you're going to move a patient up in bed, or move a
patient from a bed to a wheelchair, or from a wheelchair onto a
commode, there are different acts that are required; you need
different technology, and you may need different numbers of
nurses. The force requirements to put someone in a sling, lying
on their back, are always going to be the same, but they are
going to be different from the force requirements and strength
requirements to take someone out of a sling once they're
sitting in a chair. Our program was designed to address, kind
of, the practicalities of movement, knowing the NIOSH lifting
equation and force requirements.
Senator Isakson. Well, I think the operative word of what
you just said is ``practicality.'' I speak from a recent
experience, where I was being lifted, back in March, and I was
in the hospital for a couple of days. And, in terms of getting
tests and being moved, having an IV, or whatever you might
have, there are lots of different circumstances under which
movement is important to the care of the patient, but
limitations of either the patient or the test, whatever it is--
an MRI or CAT scan or something like that--are very different.
So, your approach is very much to try and accomplishing the
minimizing of lifting, but being broad in the different ways in
which that's accomplished, I take it.
Dr. Hodgson. That's correct. That's the core of the unit
peer-leader program. You know, our approach is really to focus
on the nursing process and to provide local support--front-line
peer safety leaders, on some level--who will model appropriate
behavior, who will serve as resources to help people think
through how to do a lift that they haven't encountered, if we
happen not to have an algorithm, or if it's not in the nursing
care plan for that patient. So, having someone around who is
the designated expert--a nursing assistant, the licensed
practical nurse, an R.N.--but someone who's undergone a more
detailed, thoughtful training program, who is respected by
their peers, and then helps work through how that should work--
that's really the core of the nursing model, the nursing
process.
Senator Isakson. Well, the author of the legislation is on
our panel today--Senator Franken. And I certainly wait for him
to summarize the legislation. But, I would be very curious if
this is a one-size-fits-all approach to movement or whether
there's the type of flexibility that Dr. Hodgson has talked
about, because if it's a one-size-fits-all equipment-based,
installation-type situation, I would find that, having gone
through certain experiences, to be very difficult. But, I will
defer to the distinguished Senator from Minnesota to do that.
Thank you, Madam Chair.
Senator Murray. With that, we will turn to the
distinguished Senator from Minnesota, Senator Franken.
Senator Franken. Thank you, distinguished chairwoman, and
thank you for the lead-in, my distinguished colleague from
Georgia.
This is not a one-size-fits-all. You know, when I first
started running for the Senate, the SEIU--Service Employees
International Union--had a Walk-In-Our-Shoes Day. You could
choose to be one of anything that SEIU members do, and I chose
a nurse's assistant--in a nursing home--because my mom had
gotten such great care. I worked with a guy, Ulysses Bridges,
who had been a nurse's assistant for 25 years, or something,
and was awarded with people with severe MS, very disabled. He
had a sling. He had a sling to lift people. And I remember the
first patient that he lifted from bed to wheelchair, and he
said, ``These are lifesavers, these machines.'' And I remember
thinking, like, ``I don't know how he could have done this
without this thing.'' And he said, ``It just saves so many
backs''--basically, is what he was saying.
Dr. Hodgson, on our next panel we'll hear testimony
asserting that hospitals and other healthcare facilities don't
have the physical infrastructure to implement new standards for
patient handling. Can you describe how the VA was able to make
the necessary changes to their existing facilities?
Dr. Hodgson. I'm not an engineer, but there are three parts
to that answer:
In general, most of our hospitals are built in a
way that, in fact, the weight loads will work for ceiling
lifts;
Second, there are very formal structural
assessments that are sometimes needed to make sure--and
sometimes there is structural reinforcement required--to make
ceiling lifts safe; and
Third, where those can't be done, there are ways
of building a framework inside a room to effectively build a
steel cage--a frame, as it were--on which the ceiling-lift
track sits. It's not as aesthetically pleasing. It's not
consistent with, kind of, the philosophy of our, kind of,
making hospitals and what we call ``community living
centers''--nursing homes--look like home, but it works. It is
something that can be put up temporarily, as a portable thing,
in homes, in residences.
There are solutions for that in almost every place that
we've encountered.
Where it is not possible to do ceiling lifts, there is
portable equipment available to do that. It's generally more
expensive, but, you know, there are solutions.
Senator Franken. Thank you.
Captain Collins, NIOSH data show that the initial
investment in safe patient lifting equipment and training can
be recouped in less than 3 years. What specific savings are
included in that calculation? The workers' comp, savings in
overtime and placement, staff, etc.
Mr. Collins. That particular savings was ``direct cost
only'' for workers' compensation. That was the medical and
indemnity expenses associated with workers' comp only. That did
not include any indirect costs. The costs were recovered so
quickly, in that study--these were portable lifts that were
installed--or, were available for about every eight patient
rooms.
Senator Franken. And so, this doesn't include sick leave or
retraining.
Mr. Collins. None of that went into this calculation. This
was direct--the cost, on the expense side of the equation, was
for the purchasing of the lifting equipment, and the training
and the use of the equipment. And to counter that was the
reductions strictly in workers' compensation medical and
indemnity expenses.
Senator Franken. And just to assure my colleague, my
esteemed colleague from Georgia, this is not a one-size-fits-
all--I mean, each lifting exercise is different, right?
Mr. Collins. Right. There was multiple prescriptions for
how patients would be lifted, depending on their disability,
their weight, and their ability to bear weight. One of the
challenges in the study was how this was communicated from the
nurse management to the nursing aides and orderlies.
Senator Franken. I think part of the reason there are so
many injuries is that there are so many awkward, different ways
of having to lift so many patients--and there's almost an
infinite number of lifts that you have to do. And so, obviously
the commonsense solution to it is certainly not a one-size-
fits-all, is it?
Mr. Collins. No, sir.
Senator Franken. Well, thank you.
Thank you, Madam Chair.
Senator Murray. Thank you very much.
Captain Collins, I wanted to ask you--in your written
testimony, you talked about the fact that the average age of
the nurses has been rising, and that's a consideration in this.
And I wanted to know if you could describe for us, What's the
physiological difference between a 46-year-old person lifting
and a 26-year-old person lifting somebody?
Mr. Collins. Clearly, their lifting capacity would be
diminished. Their muscle strength would be diminished. And they
would have to call on a lot more of their ability to lift to--
as they age, to transfer patients.
Senator Murray. It would take additional staffing. Is that
part of the cost?
Mr. Collins. Additional staffing, certainly, and their
ability to lift is clearly diminished as they age.
Senator Murray. OK.
Dr. Hodgson, we've talked a little bit about this--
different kinds of equipment. I mean, most people think just
about the ceiling-mounted lift when they talk about it. What
are some of the other types of equipment, like in a very small
space, where you can't use a ceiling-mounted lift?
Dr. Hodgson. Well, actually, ceiling lifts are probably
easier to use in small spaces than if you have large patient
rooms. Sit-to-stand lift--I mean, there are portable lifts that
are either self-powered or that you push around, that have arms
that extend to let you, kind of, move patients from a bed out
into a chair. Sit-to-stand lifts help patients stand up. Things
like air-assisted lateral transfer devices are effectively, you
know, air mattresses that move patients laterally so that you
don't have to lean over and pull someone back. Powered
wheelchairs and powered stretchers--if you have a 600-pound
patient in a wheelchair, there is a lot of force requirement to
push that patient. Having a motor on that wheelchair or the
stretcher means you're not pushing 650 pounds down the hallway.
Car extractors are things that let you pull patients who are
sitting in a car out of the car and lift them into a wheelchair
or a gurney to cart them into a----
Senator Murray. I remember doing that with my dad many
times. Reaching into a car and trying to get him into a
wheelchair was extremely difficult.
Dr. Hodgson [continuing]. A huge problem and a very common
cause of injuries. You know, only about 60 percent of the
manual handling injuries are actually back injuries; the rest
are shoulder, neck, and forearm injuries. Some hit the knee.
But, those kinds of--leaning over and torquing your back and
pulling your shoulder--not uncommon.
Senator Murray. One of the challenges we're hearing about
is the training of the nurses with the use of all that kind of
equipment. If there were a national zero-lift requirement, do
you think nursing schools would be more likely to teach zero-
lift techniques--and simplify the burden of continuing
education? What do think the consequences would be?
Dr. Hodgson. Yes. And, in fact, that movement is well
underway. I think, 2 years ago, NIOSH and VHA had a joint
project with AORN and orthopaedic nurses to put this program
into the core curriculum in a series of nursing schools. Nurses
who were coming out of--that original project was, I think,
26----
Mr. Collins. Twenty-six.
Dr. Hodgson [continuing]. Nursing schools. That movement
has spread. Many nurses now come out expecting that as the
basic tool in a hospital.
We assumed, when VHA funded this program--back when the
discussions happened in 2007--that, within 10 years, we would
have a very hard time hiring nurses if we weren't, you know, up
on this, because nurses won't work without it. And with a
nursing shortage, there will be the opportunity to go where
people have that. We're already seeing that in cities where
there are disparities between hospitals. Nurses clearly walk
and make their choices.
Senator Murray. OK.
Senator Isakson.
Senator Isakson. I'm reading a bullet point, here in my
explanation in my manual, that says that the legislation
prohibits the manual lifting of patients, except where the
patient's care may be compromised. Is that the correct bottom
line?
Senator Franken. Yes.
Senator Isakson. There wouldn't be any manual lifting at
all; it would be equipment used to lift, except in the case
where somebody would be compromised--or, the patient's health
could be compromised.
Senator Franken. Yes.
Senator Isakson. Which means you would have to have this
stuff--whatever ``this assistance'' is, it would have to be
installed in the facility. Is that correct?
Senator Franken. Right.
Senator Isakson. OK. Captain Collins, as a--well, no, it's
just in your opinion--how long would it take to establish that
in the hospitals of the United States, in the nursing homes of
the United States? An installation.
Mr. Collins. Nationwide?
Senator Isakson. And it's a guess, I realize.
Mr. Collins. It would be a guess, sir. I don't know the
answer to that. I know that it has taken--and the current
acute-care hospital that I'm working now, it was a year-and-a-
half process to install 600 ceiling lifts in a 695-bed
hospital, and it was an incremental installation in that single
facility. And that was from the time that they began the
installation process. They estimate, to equip a room, when they
have the contracted installers, is about 4 hours per hospital
room.
Senator Isakson. The enforcement agency on this would end
up being OSHA, I believe. Is that not correct?
Mr. Collins. Yes, sir.
Senator Isakson. And the enforcement mechanism are no-
notice inspections, I believe.
Mr. Collins. Um.
Senator Isakson. That's what my notes say, but I could
stand to be corrected.
Mr. Collins. I am not sure about how the enforcement would
proceed.
Senator Isakson. The point I'm getting to is really this.
The VA has made an extraordinary effort to accomplish the
intent of NIOSH's recommendations, in terms of lifting,
correct, Dr. Hodgson?
But, this legislation would invalidate that--if it went
into immediately, you'd have to go to manual equipment, versus
what your term was. I've forgotten where my notes were--but,
dealing with the situation according to the situation.
What I'm trying to get at is, How long are we going to give
health facilities the time to do this? What would be the
interim position during that time, in terms of reducing the
potential injury to workers, yet still providing for movement
of those workers that might, in fact, in part, be manual?
[No response.]
Would anybody know, or have a guess?
Senator Franken. I'm sorry, can you repeat the question?
Dr. Hodgson. Is this a question about the legislation or--
--
Senator Isakson. Yes, the question is, Between the time the
legislation passed that mandated this, and the time the
hospitals could actually install it, what's the transition
mechanism that you're going to use, first of all? Because
you're going to have patients coming and going in hospitals all
the time.
Senator Franken. Right. Well, we allow 2 years from the
promulgation of a final regulation--for hospitals to enact. So,
it would be 2\1/2\ years after enactment that providers would
be expected to develop a plan. They wouldn't have to purchase
the actual equipment until 2 years following the implementation
of a final regulation. That's 4 years after the enactment.
Senator Isakson. OK. So, you've got a 4-year--and you also
have a grant program, is that right?--in HHS, to help hospitals
in the acquisition? Correct?
Senator Franken. Yes. This is Federal money.
Senator Isakson. And my last question--and it's not--these
aren't questions as much as they're kind of observations that
portend themselves to be a question.
In that one caveat, about the patient care being
compromised, that clearly is going to be a--to a certain
extent--a subjective judgment that's going to have to be made
at a moment in time, but it looks like the enforceability,
other than the no-notice inspection, is through litigation. Is
that correct?
[No response.]
If somebody complained they had an injury because of the
lifting, and the decision was made--
Senator Franken. I think it would be done through OSHA.
Senator Isakson. Through OSHA.
Senator Franken. Yes.
Senator Isakson. Thank you, Madam Chairman.
Senator Franken. Yes. And OSHA--can I take it from here?
Senator Murray. Senator Franken will take it----
Senator Franken. OK, thank you.
Under this legislation, OSHA would issue a standard on safe
patient handling and injury prevention that requires the use of
lift equipment to move patients, except in cases which would
compromise patient care.
Care facilities would implement safe patient handling and
injury prevention plans.
Workers would receive training on safe patient handling and
injury prevention.
Workers would be protected from employer retaliation if
they refuse to accept assignments which do not meet safety
standards.
And Health and Human Services would administer a $200-
million grant program to cover costs of acquiring safe handling
and equipment for eligible facilities.
Let me ask, Captain Collins, What reduction in injury rates
could we expect if a national lifting standard were
implemented, as is called for in the bill?
Mr. Collins. What we've seen in the best practices
programs, where they have a comprehensive safe patient handling
and movement program, injury reductions have been achieved in
excess of 60 percent. And the Institute of Medicine and the
National Research Council, who's examined the literature, has
come to the conclusion, somewhere between 55- and 65-percent
injury reduction when you eliminate--or significantly reduce--
the manual lifting and replace that with assistive devices.
Senator Franken. Do you think that a standard would yield
savings for healthcare facilities?
Do you think that a standard would yield savings for
healthcare facilities?
Mr. Collins. Yes, sir. The findings that we have is that,
when the programs are comprehensively implemented--somewhere
between 3 and 5 years--the return on the investment is
achieved. And after that, you're making money, so to speak.
Senator Franken. There will be a return on investment,
here, that's greater than the investment----
Mr. Collins. Three to five years.
Senator Franken. OK, thank you.
Senator Murray. All right. Thank you very much, Senator
Franken.
With that, I'd like to thank both of our witnesses. We will
leave the record open for additional questions for both of you.
And, with that, I'd like to have our second panel come
forward and get seated. And, while you're doing that, we will
do introductions. So, if you can all move forward and sit at
the desk, please.
We're going to begin with: Dr. Barbara Silverstein, who is
the research director for safety and health assessment and
research for prevention at the Washington State Department of
Labor and Industries; June Altaras, who is the administrative
nursing director at Swedish Medical Center, in Seattle, WA; and
Douglas Erickson, who is the chairman on Guidelines for Design
and Construction of Healthcare Facilities at the Facilities
Guidelines Institute.
Senator Franken also has a witness today.
And, Senator Franken, I'll let you introduce your witness.
Senator Franken. Thank you, Madam Chair.
I'm happy to introduce Bettye Shogren, a specialist in
occupational health and safety from the Minnesota Nurses
Association, and the Minnesotan who inspired S. 1788, the Nurse
and Health Care Work Protection Act.
Bettye's nursing career ended prematurely when her doctor
put her under a 40-pound lifting restriction because of
cumulative injuries from her job. Instead of purchasing the
lifting equipment Bettye needed to safely care for her
patients, her employer offered her an administrative position,
a job that required no nursing education or skill.
Unfortunately, Bettye is just one of many nurses who have
lost their careers due to the lack of safe patient handling
standards.
Thank you, Bettye. Thank you for being here. I look forward
to hearing your testimony.
Senator Murray. All right.
We'll begin with Ms. Silverstein.
STATEMENT OF BARBARA SILVERSTEIN, MSN, MPH, Ph.D., CPE,
RESEARCH DIRECTOR, WASHINGTON STATE DEPARTMENT OF LABOR AND
INDUSTRIES, OLYMPIA, WA
Dr. Silverstein. Thank you very much.
You have my written testimony, so I will make this brief.
Basically, Washington is one of nine States with safe
patient handling legislation. A legislation has been initiated
in another 10 States. Washington's law, which covers only
acute-care hospitals, has the following requirements:
A safe patient handling committee, with at least half of
the committee being direct-care staff.
A needs assessment for all patient care areas.
A minimum of one lifting or moving device per 10 acute-care
beds, or per unit.
The right to refuse unsafe handling.
And an annual program evaluation.
Additionally, the law provides incentives for
implementation of the safe patient handling legislation,
including a business and occupations tax credit through 2010.
And this is equivalent to about $1,000 per acute-care bed for
the hospitals in Washington State.
Placement in a reduced State-fund workers compensation
premium class for those hospitals that are part of the State
fund and have fully implemented safe patient handling programs.
And a department of health does the audit, rather than
OSHA, of implementing the safe patient handling legislation.
Since the law went into effect, injuries related to lifting
patients in Washington State have decreased about 35 percent.
The legislation is fully implemented at the end of this year,
but we've already decreased over 35 percent. And when we
compare that to nursing homes, that are not affected by the
legislation, their injury rates have been going up.
While there's reason to believe that improvement is the
result of safer work required by the legislation, definitive
proof of this would require a comparison with States without
legislation.
We began to compare Washington with the State of Idaho,
which does not have any legislation related to safe patient
handling. However, because they do not participate in the BLS
survey, we could not do a comparison of injury rates between
the two.
However, we were able to conduct a scientific study to
compare patient handling programs and activities in Washington
and Idaho hospitals of similar size and location--meaning rural
or urban--using surveys and site visits. And then, the results
of these studies have shown that Washington study hospitals
were much more informed about patient handling--safe patient
handling, but they had purchased more equipment, provided more
hands-on training for staff, and had involved staff in the
program development process--much more so than in Idaho.
One of the important components of successful
implementation of safe patient handling legislation in
Washington has also been the creation of an active tripartite
steering committee with a how-to Web site that has been used by
virtually all the hospitals in Washington State to assist in
implementation of the legislation. This steering committee has
been integral to the successful implementation, I would say.
We expect that these differences will result in measurable
improvements in injuries that are greater in Washington than
Idaho. While we don't have the definitive injury data yet, it's
reasonable to expand Washington's model to the country.
However, in my opinion, nursing homes should be included in any
national legislation. Nursing homes have been included in the
safe patient handling legislation in a number of other States,
but not yet in Washington.
Thank you for allowing me to provide this brief summary.
I'd be happy to answer any questions. And you have my written
testimony.
[The prepared statement of Dr. Silverstein follows:]
Prepared Statement of Barbara Silverstein, MSN, MPH, Ph.D., CPE
My name is Barbara Silverstein. I have been the Research Director
for the Washington State Department of Labor and Industries' Safety and
Health Assessment and Research for Prevention program (known as SHARP)
for almost 20 years. I received a Master of Science degree in nursing,
Master of Public Health in Epidemiology and Occupational Health, and
Ph.D. in epidemiologic science. We conduct safety and health research
in a variety of workplaces to identify potential hazards and evaluate
potential solutions. Health and safety of health care workers has been
one of our areas of study.
Research has shown that manual handling of patients increases risk
of injury for caregivers and patients. Injury statistics show manual
patient handling is dangerous to care givers and patients. Even with
``good'' lifting technique, it is not possible to manually lift
patients without exceeding the NIOSH action limit for manual handling.
Mechanical lifting devices are necessary but not sufficient.
Nursing homes and hospitals have amongst the highest numbers and
incidence rates of injuries in the United States. Back and shoulder
injuries related to manually handling patients comprise the largest
proportion of injuries. Patients are older, bigger, heavier, sicker and
rapidly changing status. Nursing staffs are also getting older, fewer,
working longer hours, suffering from career ending injuries and are not
easily replaced. Nursing schools have difficulty in recruiting faculty.
Nursing assistants can make more money working at fast food
restaurants. Nursing homes face management and staff turnover and
inadequate funding. Hospital and nursing home injury rates are high and
workers compensation claims for back injuries are costly. Safe patient
handling legislation and programs are aimed at reducing this burden for
workers, patients, families and society.
Washington is one of nine states that currently have safe patient
handling legislation to address this problem. Others include Illinois,
Ohio, Maryland, Minnesota, New Jersey, New York, Rhode Island and
Texas. Legislation has been initiated in another 10 States (California,
Florida, Kansas, Massachusetts, Michigan, Nevada, New York, Vermont,
Connecticut, Hawaii and Missouri). The legislation varies in terms of
coverage and requirements.
Safe Patient Handling (SPH) legislation has a positive impact on
staff knowledge and practice of safe patient handling as well as
reduction in patient handing injury rates. This has been demonstrated
in Washington State.
Washington State passed safe patient handling legislation for acute
care hospitals in 2006 with phase-in from 2007-10. Requirements and
incentives of the Washington State law requires that hospitals have:
A safe patient handling committee with at least half of
the committee comprised of direct care staff.
A needs assessment for all patient care areas.
Minimum of 1 handling device per 10 acute care beds/unit.
Right to refuse unsafe handling.
Annual evaluation.
Department of Health audit of SPH implementation and
practice.
Additionally, the law provided incentives for implementation,
including:
A tax credit equivalent to $1,000 per acute care bed for
SPH equipment purchases up to $10 million total.
Placement in a reduced workers compensation premium class
for those with fully implemented SPH programs.
Department of Health audit of SPH implementation.
This law is similar to the legislation proposed in H.R. 2381 Nurse
and Health Care Worker Protection Act of 2009 that also included all
direct care workers in health care facilities, and enforcement by OSHA.
To assist in the implementation of the Washington State law, a
steering committee was created in 2006 with initial representation from
the Washington State Hospital Association, Washington State Nurses
Association, SEIU1199NW, UFCW141 nurses, and SHARP. Since that time,
additional members from a number of large hospitals have been
participating in the steering committee. The steering committee Web
site (slide 8) is used by health care facilities to guide
implementation of safe patient handling programs and practices.
(www.washingtonsafepatient
handling.org)
The hospital financial tax credit incentive of $1,000 per acute
care bed for purchasing SPH equipment was used by most hospitals. Of 92
acute care hospitals, 28 used their maximum business and occupations
tax credit. As of March 2010, $7.6 million in tax credits were
accessed. Access to tax credits ends December 31, 2010.
In 2006, SHARP initiated a study to evaluate the potential impact
of this legislation on hospital nursing staff. In addition to
monitoring individual and overall injury incidence rates, we are
comparing SPH implementation and outcomes in four acute care hospitals
in Washington with four acute care hospitals in Idaho (which has no
legislation), matched for size (two large, two small) and geographic
location (east, west).
Incidence rates for patient handling related injuries increased in
2006, remained high in 2007 and dropped significantly from 2007 to
2008, and we have preliminary indications of a further decline in 2009.
However, injury rates are lagging indicators. Leading indicators
include changes in perceptions and practices. In order to capture
changes in these indicators, we focused on four hospitals in Washington
(with legislation) and four similar size and location (urban/rural) in
Idaho (without legislation).
2007 baseline data included staff surveys, staff and management
focus groups, observations and back injury workers compensation data.
We repeated data collection in 2009 and will collect the final round of
data in 2011. Direct care staff survey areas included demographics,
knowledge of SPH policies, procedures, committees, equipment and
training, as well as physical demands, health and quality of work life.
There were no significant differences in these areas between Washington
and Idaho at baseline. Slides 13-20 show a survey of some results at
baseline (2007 and follow-up 2009).
Findings to date are included in the accompanying figures and
include:
Decreasing workers compensation claims rates related to
patient handling injuries in Washington State acute care hospitals.
Compared to Idaho hospital staff survey data, Washington
survey data indicated greater staff knowledge about safe patient
handling including:
What ``safe patient handling'' means (safe for
patients/safe for staff) .
Less likelihood of injury on their team.
Satisfaction with patient handling equipment.
Availability of equipment to handle patients weighing
more than 500 pounds.
Greater likelihood to routinely use lifting and
transfer equipment.
Satisfaction with availability of patient handling
equipment.
Safety committee involvement in the purchase of SPH
equipment.
However, Washington nursing staffs were twice as likely to
report conflicting job demands as Idaho nursing staffs. This was not
necessarily related to the SPH program.
Focus groups (qualitative data) are used to ``put the meat on the
bones'' of surveys (quantitative data) by including clarification of
comments. Issues discussed in the staff and supervisor focus groups
included knowledge of SPH concepts, barriers and successes in
implementation.
At baseline, staff members were asked what SPH meant to them. Many
tended to focus on patient falls and using ``good body mechanics'' to
lift patients than on prevention of staff injuries using appropriate
equipment. There is no safe way to manually lift an adult patient by
one or more people.
In staff interviews in Washington State, there was much more
knowledge of the requirements of an effective SPH program, including
adequate staffing, safety committee involvement, hands-on training, and
management support. Safe patient handling can be very effective in
small as well as large hospitals as evidenced by comments from a staff
focus group that indicated management support and adequate equipment
were essential ingredients.
A lack of management knowledge about and support for a SPH program
in a large Idaho hospital was evidenced by relying on manual handling
with transporter support and a decision to not include ceiling lifts in
a new hospital when it is much less expensive to install them during
construction than in retrofitting. An example of a staff member using a
ceiling lift is provided on the last page of the figures attached to
this testimony. Using a ceiling lift is safer and more comfortable than
manual handling or using a floor lift for both the patient and the
staff.
Implementation of safe patient handling program cannot be
successful if done in isolation. Mechanisms must be in place for
continuous practice in use of equipment, easy availability of
equipment, on-going training opportunities for staff such as looking
for teachable moments with new or reluctant staff, a culture shift from
``back injuries are inevitable in nursing'' to, handling patients
safely for the patient and the care-giver. The VA has shown the
importance of facility champions and peer leaders in the implementation
and sustainability of SPH programs.
There is some indication among Washington nursing staff of
reduction in ``very, very'' physically demanding work by the first
follow-up (see accompanying slides). This is likely to result in
reduced injury and turnover of nursing staff in the future.
In summary, legislation and regulation can provide a ``floor'' for
what are minimally acceptable working conditions, but as a society, a
profession and an industry, we should expect more of ourselves and each
other. We need to take care of those who take care of us. Mason General
Hospital, a small critical access hospital in rural Washington,
provides an example of this through their ``environment of prevention''
which advertises their safe patient handling program to promote staff
recruitment and community good will. They have been quite successful in
their recruitment and retention of nursing staff. Perhaps this would
have happened eventually without legislation, but legislation provided
compelling and immediate incentives for implementation and
sustainability. Other examples can be found on the Washington State
Safe Patient Handling Steering Committee Web site (www.wash
ingtonsafepatienthandling.org).
The attached figures provide more detail and illustration.
Senator Murray. Thank you very much.
Ms. Shogren.
STATEMENT OF ELIZABETH (BETTYE) SHOGREN, RN, MNA, MINNESOTA
NURSES ASSOCIATION, STAFF SPECIALIST, ST. PAUL, MN
Ms. Shogren. Good afternoon, Chairman Murray and Senator
Isakson. Thank you for the opportunity to testify in support of
Senate bill 1788, the Nurse and Health Care Worker Protection
Act.
My name is really Elizabeth Shogren, but I think I might be
the only one who knows that, some days. I'm employed by the
Minnesota Nurses Association as a staff specialist in
occupational health and safety. I'm also a work-injured nurse.
I'm honored to speak on behalf of the thousands of nurses and
other healthcare workers who are work-injured, and the
thousands more who will be work-injured unless this legislation
is enacted.
In March 1982, as Senator Franken said, my bedside career
ended, not because I chose to end it, but because my injury
resulted in a 40-pound lifting restriction that my employer
would not accommodate.
I've been a nurse for less than 10 years. The last shift I
was able to work without pain, I was assigned to care for
several patients, one of whom weighed over 400 pounds. She
required repositioning every 2 hours and a boost up in bed
multiple times a shift. There weren't enough people to lend a
hand that night, so, with the help of one nursing assistant, we
cared for and moved her as prescribed and as needed. That was
the last shift I worked at the bedside.
When my physician determined I would have a permanent
lifting restriction, my employer offered me a job as an
admitting clerk, a job that required no education and no skill,
a job that was very similar to the one I had before I went to
nursing school.
I declined that position and began a litigation battle that
lasted 2 years and 9 months. My wage replacement benefits were
cut off. My medical care was threatened. My family's income was
cut in half. My husband took a second job to help us make ends
meet. And my three kids learned to do without things that they
took for granted up to that point.
I was fortunate to have the opportunity to fight, because
most people simply couldn't afford to do that.
I fought because what was happening to me wasn't right. It
wasn't right that my ability to be a bedside nurse was
determined, not by what I knew, but by how much I could lift. I
didn't have to lift weights to pass my licensing exam.
I fought because I was angry and because I needed to fight
more than I needed to win. But, ultimately, I did win, when the
Minnesota U.S. Supreme Court ruled that the job my employer
offered was not suitable work. And that remains the standard
for civil work and nurses in Minnesota, to this day.
By the time the court ruled, I was working for the
Minnesota Nurses Association, and we started getting calls, as
we published what happened, from nurses all around the country.
And they thought they were alone. And, back then, when nurses
got hurt, they disappeared; and they were at work 1 day, and
they were gone the next day, and you never saw them again.
With that--I'd like to say that's changed, but I feel
nurses and other healthcare workers who are injured are
frequently treated like disposable towels, and--they're used
and they're tossed aside when they are injured.
I talk to hundreds of nurses around the country every year
who have had the same kind of experiences. Many of them are
significantly worse than my situation.
I talk to other healthcare workers, too; and, sadly,
they're actually treated worse than registered nurses.
MNA has supported my efforts to improve the working
conditions that created these injuries, but for so long, all we
ever heard was, ``Nurses weren't lifting correctly. If you'd
just use good body mechanics, you wouldn't be hurt.''
In an average 8-hour shift, a nurse on a med-surg unit can
care for three to eight patients. Sometimes there's staff to
assist, sometimes there isn't. But, we still have to care for
them. We turn them, we lift them, we walk them, we even catch
them when they fall. We do whatever needs to be done, and we
work--we lift an average of 1.8 tons per shift. That's a lot of
weight: 1.8 tons per shift.
We're expected to work like this every shift for 30 or more
years in our career. And if you start adding up all the shifts,
it's a remarkable amount of weight that my body, and other
bodies, have to endure.
In 2004, we started hearing about the work of Audrey Nelson
and the work at the James A. Haley Tampa VA, in Tampa, FL. I
went to my first conference in 2004, along with a number of
other people. And to kind of quote a commercial, what I learned
was ``priceless.'' I learned what I always knew, but I had
evidence now that good body mechanics don't work to prevent
injuries related to patient handling.
The process that we had been instructed to do over and over
and over again to save our backs actually harms us more than it
ever helped us. They don't work, because lifting patients
exceeds the body's biomechanical limits.
I learned these types of injuries are largely preventable,
because there was equipment that was available; and using
equipment instead of our bodies prevents injuries.
I learned that many other industrialized countries had been
using equipment for 20 or more years, because they had laws
that required it.
And I also found out there was a quick return on
investment, because injuries to workers are reduced, therefore
workers' compensation claims are reduced, and patient injuries
are reduced, as well.
That's really important to me, the patient injury part,
because I'm still a nurse, and nurses care about stuff like
that.
There were 38 people from Minnesota at that conference in
2004, and we went back to Minnesota and said, ``What can we do
here to make it better?'' We worked extensively with one of the
major employers in Minnesota--Allina--as well as the Minnesota
Hospital Association, to help bring a new program, Safe Patient
Handling, to our State. We've seen significant success with
Allina, Mayo, Fairview, Bemidji, and a number of nursing homes.
And, although we commended those who were changing, we
needed the rest of the employers in the State to follow their
lead. Unfortunately, there was a great deal of reluctance to do
so, and we decided we needed a law.
So, in 2007, the Minnesota legislature passed the Minnesota
Safe Patient Handling Act, which requires the use of equipment
in all licensed healthcare facilities. It was amended in 2009
to include outpatient care facilities, as well.
I would like to read some testimony--but I'm going to run
out of time--from another nurse, Stacy Lundquist.
Senator Murray. All of your written testimony will become
part of the record.
Ms. Shogren. That's right.
Senator Murray. So, if you would just summarize.
Ms. Shogren. With that, we understand and believe that
employers don't intentionally want to hurt their employees.
But, rather, they continue to use a scientifically-based--
evidence-based theory that says it doesn't work, they rely on
industry practice, as we now know it. And we know it isn't
effective in preventing injury and protecting patients.
We aren't here to place blame; but, rather, to focus on
what we can do together to ensure safe working conditions in an
industry that faces an acute shortage of workers. Continued use
of manual patient handling is unsafe for healthcare workers and
for patients. It contributes to increased cost of care in an
environment when we're all questioning the rising cost of
healthcare.
The Nation needs what has been started in Minnesota and a
number of other States. The patients across the country and
their nurses and the other caregivers desperately need it.
Thank you again for the opportunity to testify and to share
my story. I am grateful for this hearing, and I've been waiting
28 years for it to happen, so it's good to be here. And we're
anxious to start working on a safe patient handling law for the
Nation.
It looks like I've got some time left, right?
Senator Murray. No, well, you're actually 2\1/2\ minutes
over, but----
[Laughter.]
Ms. Shogren. Oh, sorry.
Senator Murray. We were listening.
Ms. Shogren. I'm good at that. OK, thank you very much.
[The prepared statement of Ms. Shogren follows:]
Prepared Statement of Elizabeth (Bettye) Shogren, RN, MNA Staff
Specialist
Good morning. Chair Murray and Senator Isakson, thank you for the
opportunity to testify in support of Senate bill 1788; the Nurse and
Health Care Worker Protection Act.
My name is Elizabeth Shogren. I am employed by the Minnesota Nurses
Association as a Staff Specialist in Occupational Health and Safety. I
am also a work injured registered nurse. I am honored to speak on
behalf of the thousands of nurses and other healthcare workers who are
work injured, and the thousands more who will be unless this
legislation is enacted.
In March 1982 my bedside nursing career ended. Not because I chose
to end it, but because my injury resulted in a 40-pound lifting
restriction that my employer would not accommodate. I had been a nurse
less than 10 years. The last shift I was able to work without
excruciating pain I was assigned to care for several patients, one of
whom weighed over 400 pounds. She required repositioning every 2 hours
and ``a boost up'' in bed multiple times per shift. There were not
enough people to lend a hand that night so with the help of one nursing
assistant, we cared for and moved her as prescribed and as needed. That
was my last shift.
When my physician determined I would have a permanent lifting
restriction, my employer offered me a job as an admitting clerk. A job
that required no nursing education or skill, a job that was very
similar to one I worked before I became a nurse. I declined that
position and began 2 years and 9 months of litigation. My wage
replacement benefits were cut off, and my medical care was threatened.
My family's income was cut in half. My husband took a second job to
make ends meet and my three children learned to go without. I know I
was fortunate to have the opportunity to fight as most people couldn't
afford to.
I fought because what happened to me wasn't right. It wasn't right
that my ability to be a bedside nurse was being determined not by what
I knew, but by how much I could lift. I didn't have to lift weights to
pass my licensing exam. I fought because I was angry. I needed to
fight, more than I needed to win, but ultimately I did.
The MN Supreme Court ruled that the job my employer offered was not
suitable work.
By the time the court ruled, I was working for the MN Nurses
Association. The news spread quickly of the court's decision and then
the calls started coming, nurses from across the country. Nurses who
thought they were alone. You see back then when nurses got hurt they
disappeared. I would like to say that has changed but I feel Nurses and
other healthcare workers who are injured are treated like disposable
towels; used and tossed aside when they get hurt. Hurt caring for
patients. I talk to hundreds of nurses every year who have the same
kind of experiences. I talk to other healthcare workers, too. Sadly,
they are often treated worse than registered nurses.
The Minnesota Nurses Association has supported my efforts to
improve the working conditions that create these injuries, but for so
long all we heard was that nurses weren't lifting correctly. ``If you
just used `good body mechanics' you wouldn't get hurt.''
In an average 8-hour shift a nurse on a Medical/Surgical Unit can
care for 3-8 patients. These patients come in all sizes; from tiny
babies to patients who weigh 700 pounds or more all with varying
degrees of need for assistance. Sometimes there is staff to assist with
turns and repositioning and, other times there is not. When there is
not, you still have to care for the patients. We turn them, we lift
them, we walk them, and we even catch them when they fall; we do
whatever needs to be done. We lift an average of 1.8 tons per 8 hour
shift. That's right, you heard me right, we lift an average of 1.8 tons
per 8 hour shift. We don't see that in other jobs; they use equipment.
Yet nurses are expected to work like this every shift for 30 or more
years relying on the hydraulics of their bodies.
In the 2004 MN Workplace Safety Report, issued by the MN Dept. of
Labor and Industry, workers with the most frequent OSHA recordable
injuries were identified. It was a small wonder of the 14 occupations
listed, Nursing Assistants were second; RNs seventh and LPNs twelfth.
Essentially, the report said healthcare workers have higher rates of
injury, and more severe injury than most other workers in this State.
As an industry aggregate they are No. 1. In 2004 I also went to my
first Safe Patient Handling Conference in Orlando. What I learned was
priceless.
Good body mechanics don't work to prevent injuries related to
patient handling! The process nurses have been instructed to do and
have practiced to ``save our backs'' for decades ACTUALLY harms us.
They don't work because lifting patients exceed the body's
biomechanical limits. I learned that these types of injuries were
largely preventable because there was equipment available. Using
equipment instead of our bodies prevents injury. I learned that many
other industrialized countries had been using equipment for 20-plus
years because they had laws that required it. I also found out that
there is a quick return on investment because injuries to workers are
reduced which in return decreased workers compensation costs. Patient
injuries are reduced as well. This is especially important to me
because I am still a nurse. I just take care of the people who take
care of you. There were 38 people from MN at that Conference in 2004.
We went home and we developed a plan to change what was happening in MN
and we did!
MNA has worked extensively with one of the employers, Allina, as
well as the MN Hospital Association to bring a new program, Safe
Patient Handling, to our State. We have seen significant success with
Allina, Mayo, Fairview, Bemidji and some Nursing Homes. We commended
those who are changing, but we needed the rest of the employers to
follow their lead but they were reluctant to do so. That's when we
realized we needed a law.
In 2007 the MN legislature passed the MN Safe Patient Handling Act
which requires the use of equipment in all licensed healthcare
facilities. It was amended in 2009 to include all outpatient care
settings.
When we presented testimony one of our members, Stacy Lundquist
testified. Stacey was severely injured at work while transporting a
surgical patient and the patient's equipment--a combined weight of
close to 1,000 pounds from one unit to the next. Stacey had begged her
employer to invest in a $7,000 piece of equipment which could have
pushed the bed for her, but they didn't see the need.
I wish she was able to be here today, but her injuries prevent it.
I would like to share with you some of her testimony. This is how her
injury has impacted her life.
``I have had 4 surgeries over the last 3+ years; I suffer
from severe chronic pain which can only be controlled with
medication. I can walk only short distances with a cane and
must use a wheelchair when I leave my home. The pain is so
intense that some days I think it would be better to be a
paraplegic. I have lost my career. My injury fundamentally
changed every part of my life. I can't walk, I can't drive, I
can't shop, and I can't bike. I can't pitch a tent or camp or
hike in the woods. I can't sleep or rest without medication and
even then, I can't sleep very well. I couldn't pick up my first
grandchild. I believe all of that could have been prevented if
I had that piece of equipment. The pain I endure every day may
never end. The rest of my life will never be what it could have
been.''
Safe Patient Handling is a program based on the scientific work of
Dr. William Marras, and was initially implemented at the Veterans
Administration Hospital in Tampa, FL. When the VA started using the new
approach to lift, move, and transport patients two things happened: the
frequency and severity of worker injury declined, and patient injuries
related to falls and other injuries such as skin tears, dislocated
shoulders, fractures, and pressure ulcers declined as well. That
success has been replicated in numerous facilities across the country.
This SPH program is public domain. It is free and walks an employer
through the necessary steps to start and fully implement a SPH program.
In MN we even asked for grant money to assist employers with start
up costs associated with implementing this change. It isn't common to
have a union ask for financial assistance for employers, but we
believed it was in the best interest of patients, employers and workers
and expedited the changes we needed.
We understand and believe that employers do not intentionally want
to hurt their employees. Rather they rely on an industry practice that
we now know IS NOT effective in preventing injury and protecting
patients. We are not here to place blame but rather to focus on what we
can do together to ensure safe working conditions in an industry that
faces an acute shortage of workers.
Continued use of manual patient handling is unsafe for health care
workers and patients. It contributes to increased cost of care in an
environment where we are all questioning the rising cost of health
care. The Nation needs what has been started in MN. The patients across
the country, their nurses and other care givers desperately need it.
Thank you again for the opportunity to testify and for me to share
my story.
I/we are grateful for this hearing and are anxious to start working on
bringing Safe Pt. Handling to the Nation. I would be happy to take any
questions at the appropriate time.
Senator Murray. Thank you very much. I appreciate it.
Ms. Altaras.
STATEMENT OF JUNE M. ALTARAS, RN, BSN, MN, ADMINISTRATIVE
NURSING DIRECTOR, SWEDISH MEDICAL CENTER, SEATTLE, WA
Ms. Altaras. Senator Murray and members of the
subcommittee, thank you for this opportunity to share with you
the learnings and results of Swedish Medical Center's Safe
Patient Handling Program.
My name is June Altaras, and I'm the nurse executive at
Swedish Health Services, in Seattle, WA. Swedish is the
largest, most comprehensive nonprofit healthcare provider in
the great Northwest, employing 7,000 staff, 2,000 practicing
physicians, and 1,000 volunteers.
I was asked to testify today regarding our comprehensive
Safe Patient Handling Program, called ``Safe Moves.''
In March 2006, Washington State Governor Christine Gregoire
signed new legislation requiring hospitals in the State to
implement a safe patient handling program. This legislation
caused this issue to be prioritized in our organization, and we
moved systematically to develop a safe patient handling program
that would benefit our patients, our staff, and reduce costs.
The results of our work are overwhelming. We have developed
a system that reduces workplace injuries, and days lost from
those injuries, which has a direct result on our bottom line.
Safe patient handling is not an initiative; it is a culture
change, and, as such, it requires the engagement and support of
front-line staff in designing the approach, establishing the
workflow, and selecting the equipment. In addition, it requires
the support of senior leadership, middle management, and unit
experts. This is not a small undertaking; however, the results
can be dramatic.
I have been asked to address a few key aspects of our
program. I will start with our lifting policy.
Before adopting a formal lifting policy, we established a
committee to evaluate the various lifting requirements
throughout all units of the hospital. In addition, this
committee researched what other hospitals were doing before
developing recommendations for Swedish's lifting program and
associated policies.
In November 2007, we approved our employee safety standard,
a policy intended to define Swedish Medical Center's commitment
to partner with our employees to provide and support a safe
workplace.
In January 2008, we adopted our safe patient handling
policy to promote and maintain a culture of safety by providing
an environment of safe patient handling and movement for all
inpatients and staff. These policies outline employee and
manager responsibilities, required in depth educational
trainings to ensure compliance, and clearly State that those
found in violation of this policy may be subject to progressive
corrective action.
At a large health system like Swedish, there are different
units, with vast differing lifting needs. As part of our year-
long assessment period, the Safe Patient Handling Committee
conducted an in depth audit with each of our specialty units--
the ICUs, medical, surgical, and mother-baby units--to better
understand the various lifting and repositioning needs and
requirements, as well as the weights that were typical for
their patient populations. We then engaged stakeholders from
each of the units to play a role in selecting the actual
lifting equipment, to ensure those actually using the equipment
would find it useful.
Swedish's initial investment in equipment was just over
$1.1 million. Because this legislation was regulated by the
State, Swedish was able to pay for a portion of the up front
investment with a B&O tax credit. Additional investments
include the labor costs associated with hiring a program
director, as well as the 6,000-plus hours of employee training,
totaling approximately $353,000, for a total first-year cost of
$1.5 million. The yearly ongoing costs of retraining and
staffing the program are approximately $300,000 per year.
During the first 3 years of our program, 2007 through 2009,
we have experienced a 60-percent reduction in work-injury
incidents of our clinical staff, a 90-percent reduction in days
lost from clinical work, and a total cost savings of $3
million. This is a return of investment of approximately $1
million in 3 years.
The return on investment is undeniable and dramatic when a
safe patient handling policy is implemented successfully.
Swedish has relatively low nurse turnover rates. Turnover
rates have dropped since safe patient handling policy has gone
into effect. It would be disingenuous of me to attribute this
trend to the safe patient handling program, given the current
economic climate, but I do believe there is a probable
correlation. And given that the cost to retrain a nurse is
$60,000, this is very good news.
In addition, our safe patient handling program and its
resulting reduction in workplace injuries has been an important
recruitment tool in attracting new talent to Swedish.
While we don't have quantitative data about our program's
effect on patient satisfaction, we have qualitative and
anecdotal evidence. There have been many instances of bariatric
patients walking rapidly after surgery because they are no
longer fearful of falling, as the right equipment is in place
to support them. Patients report feeling less guilty about
staff potentially hurting themselves while assisting them with
ambulating or repositioning, and also feeling less embarrassed
when the right equipment is there and appropriately sized.
We have also experienced decreased skin injuries, due, in
part, to appropriate equipment to reposition our immobile
patients.
As you can tell from our results, safe patient handling at
Swedish has been a resounding success. However, I believe it is
important to note that there are several key factors that are
critical to achieving success:
Set a realistic timeline. This is a culture change. It
cannot be implemented in a year, and results will take time.
This is a long-term commitment that requires professionals to
change years of work habits. The average age of a nurse is
between 45 and 50 years old. Changing their work habits, for
people who have been in the industry for so long, requires
time.
The investment is more than just equipment. Even though
there are significant up front costs associated with purchasing
various equipment and lifts, be prepared for, and factor in, a
significant investment of human capital to establish a
committee to conduct the appropriate research, assessment, and
development of the program, an expert to direct the program, as
well as up front training costs and ongoing annual retraining.
Engage the front line. It is critical to engage those on
the front lines of patient support across all hospital units in
determining their equipment needs and eventual purchase, so
that there is buy-in and support for these important decisions
early on in the adoption process.
In closing, implementing a safe patient handling program is
a big undertaking that requires cultural change and
organizational commitment to be successful. You will be asking
seasoned professionals, many of whom have been on the job for
over 20 years, to change the way they work, adjusting long-
formed habits and techniques. There must be clear commitment
from organizational leadership, as well as stakeholders at all
levels, to ensure success.
Although implementing a culture of safe patient handling is
not an easy task, Swedish believes it is the right thing to do.
If approached methodically, you will not only see a generous
return on your investment, but you will also have a healthier
workforce.
Thank you for this opportunity. I'll be happy to answer any
questions.
[The prepared statement of Ms. Altaras follows:]
Prepared Statement of June M. Altaras, RN, BSN, MN
executive summary
Swedish Medical Center is the largest, most comprehensive,
nonprofit health provider in the Greater Seattle area. We have three
hospital locations in Seattle, an emergency room and specialty center
in Issaquah (East King County), Swedish Medical Center locations in
Ballard, First Hill, Cherry Hill, Issaquah; Swedish Home Care; a
network of 14 primary care clinics; multiple specialty clinics and
affiliations with suburban physician groups.
I was asked to testify today regarding our compressive safe patient
handling program called Safe Moves. In March 2006, Washington State
Governor Christine Gregoire signed new legislation requiring all
hospitals in the State to implement a safe patient handling program.
The requirement put forth in the legislation prioritized the issue
throughout Swedish and we moved systematically to develop a safe
patient handling program that would benefit our patients, our staff and
would result in cost savings. We approached the adopting a safe patient
handling policy with three key steps: research and assessment;
investment in infrastructure and training; and measurement and
accountability.
The results of our work are overwhelming. We have developed a
system that reduces workplace injuries and corresponding lost or
restricted days of work, which has a direct result on our bottom line.
In the last year alone, we attribute a total cost savings of $2,224,590
for reducing days lost and restricted days due to workplace injuries.
Patient safe handling is not simply an initiative or a program or a
policy, it is a culture change and as such it requires the engagement
and support of front line staff in designing the approach, establishing
a workflow and selecting equipment. In addition, it requires the
support of senior leadership, middle management and unit experts. This
is not a small undertaking, it is a long-term commitment; however, the
results can be dramatic.
Implementing a safe patient handling program or policy or
initiative is a big undertaking that requires cultural change and
organizational commitment to be successful. You will be asking seasoned
professionals--many of whom have been on the job for more than 20
years--to change the way they work, adjusting long-formed habits and
techniques. There must be clear commitment from organizational
leadership as well as stakeholders at all levels to ensure deep
commitment throughout the organization.
Although implementing a culture of safe patient handling is not an
easy task, if approached methodically and with a generous timeframe you
will not only see a generous return on your investment, but also a
healthier workforce.
______
Senator Murray and members of the subcommittee, thank you for this
opportunity to share with you the learnings and results of Swedish
Medical Center's safe patient handling program. My name is June
Altaras, and I am a nurse executive at Swedish Health Service in
Seattle, WA.
Swedish is the largest, most comprehensive, nonprofit health
provider in the Greater Seattle area. We have three hospital locations
in Seattle, an emergency room and specialty center in Issaquah (East
King County), Swedish Medical Center locations in Ballard, First Hill,
Cherry Hill, Issaquah; Swedish Home Care; a network of 12 primary care
clinics; multiple specialty clinics and affiliations with suburban
physician groups.
I was asked to testify today regarding our compressive safe patient
handling program called Safe Moves. In March 2006, Washington State
Governor Christine Gregoire signed new legislation requiring all
hospitals in the State to implement a safe patient handling program.
The requirement put forth in the legislation prioritized the issue
throughout the Swedish health system and we moved systematically to
develop a safe patient handling program that would benefit our
patients, our staff and would result in cost savings.
The results of our work are overwhelming. We have developed a
system that reduces workplace injuries and corresponding lost or
restricted days of work, which has a direct result on our bottom line.
Patient safe handling is not simply an initiative or a program or a
policy, it is a culture change and as such it requires the engagement
and support of front line staff in designing the approach, establishing
a workflow and selecting equipment. In addition, it requires the
support of senior leadership, middle management and unit experts. This
is not a small undertaking, it is a long-term commitment; however, the
results can be dramatic.
I've outlined our approach to adopting a safe patient handling
policy in three steps:
Research and Assessment;
Investment in Infrastructure and Training; and
Measurement and Accountability.
program development
Step One: Research and Assessment
In 2007 our organization created a committee of key stakeholders
including the physical therapist who was hired to manage the program,
front line nursing staff from each of our five hospital units (ICU,
medical, surgical, mother/baby and pediatric), nursing leadership,
safety team, and facilities. This committee researched and evaluated
the patient safe handling programs at other hospitals to gain an
understanding of the variety of ways this could be implemented at
Swedish before developing their recommendations. In addition, the
committee spent a year conducting in-depth assessments of each unit to
better understand their lifting and repositioning needs and
requirements as well as the weights that were typical for their patient
populations.
In November 2007 we approved our Employee Safety Standard, a policy
intended to define Swedish Medical Center's commitment to partner with
employees to provide and support a safe workplace.
In the first year there was only one equipment purchase, which was
to install ceiling lifts in each of the 42 ICU rooms. The data
supporting the use of ceiling lifts for ICU patients was so compelling
that there was no doubt that we should purchase the infrastructure and
begin training and use immediately.
Step Two: Investment in Infrastructure and Training
After the assessment the committee made its recommendations for
each unit as well as for an overall policy. Investing in the
infrastructure is only one part of the total cost, there is also a cost
associated with initial ramp-up and training as well as on-going annual
re-training. The committee recommended a scalable, multi-
disciplinary approach that could be customized for each hospital unit
based on their specific needs and patient populations.
In January 2008, Swedish adopted a Safe Patient Handling policy to
promote and maintain a ``culture of safety'' by providing an
environment of safe patient handling and movement for all inpatients
and staff. These policies outline employee and manager
responsibilities, including in-depth trainings to ensure compliance and
clearly states that those found in violation of the policy may be
subject to progressive corrective action, up to and including immediate
termination of employment.
It was critical to involve front line employees in the selection
and purchase of the actual tools to ensure the employees who would be
using the equipment were comfortable with the selection. At Swedish we
have a range of lifting equipment from ceiling and floor lifts to
Hovermatts to assist with lateral transfers.
Step Three: Measurement and Accountability
Prior to 2007, our tracking of workplace injuries for allied health
professionals was less robust and less consistent than it is today.
Since 2007, we have been tracking injuries at each unit location and
days and dollars lost as a result of those injuries. It took a few
years to get our systems streamlined and to reduce some of the under-
reporting of injuries that went on previously.
In addition, there are so many existing internal and third party
measurements already that it can be difficult to implement a new
measurement standard. For example The Occupational Safety and Health
Act (OSHA) tracks workplace safety, but Swedish's OSHA numbers cannot
be directly compared to the success of our safe handling program
because of the different employee populations considered. Safe patient
handling only impacts those employees with direct patient access, OSHA
considers all work place injuries including administrative and support
staff. Since 2007 we have been actively involved in measuring the
direct impact of workplace injuries among employees that have direct
patient access, so that we can accurately measure the success of our
program year over year.
We established a generous timeline to account for the steep
learning curve that accompanies such cultural shifts. We knew that this
was a long-term commitment that would take 2 to 3 years before we could
measure real results in terms of the impact of patient safe handling
policies.
results
Although Swedish assembled a committee and installed ICU ceiling
lifts in 2007, there were no programmatic adjustments until 2008. Since
that time however, the results of the Safe Patient Handling efforts
have been staggering.
Swedish's initial investment of equipment was just over $1.1
million. Because this legislation was regulated by the State, Swedish
was able to pay for a portion of the up front investment with a $1
million B&O tax. Additional up-front costs were labor costs including
the hiring of one full-time employee to serve as the director of the
program as well as approximately 6,000 hours of training (2 hours each
for 3,000 employees) totaling $353,100 in up-front labor costs.
In the last year alone, we attribute a total cost savings of
$2,224,590 for reducing days lost and restricted days due to workplace
injuries. When a nurse is injured and misses a day of work, there is a
hard cost to replace that time that is at least 50 percent but often
100 percent more expensive than the salary of the full-time employee.
We used the conservative 50 percent rate to calculate our savings, so
our savings is likely even greater.
The return on investment is undeniable and dramatic when a safe
patient handling policy is implemented successfully.
Recommendations
Outlined below are our recommendations for how to implement a
successful, results-driven safe patient handling program.
set a realistic timeline
This is a major culture change, it cannot be implemented in a year
and results will take time. This is a long-term commitment that
requires professionals to change years of work habits. The average age
of a nurse is between 45-50 years old, changing work habits of
professionals who have been in the industry for so long requires real
commitment.
the investment is more than just equipment
Even though there are significant up-front costs associated with
purchasing various tools to ensure safe patient handling, there should
also be a significant investment of human capitol to establish a
committee to conduct the necessary research, hire someone to manage the
program as well as up-front training costs and on-going, annual re-
training.
investigate and learn from every incident
When an injury is reported, we are very careful not to assume non-
compliance, nor is it assumed that every incidence of non-compliance
should result in disciplinary action. We investigate every injury to
determine if there is an opportunity for re-training, or if there are
adjustments that need to be made in terms of our protocol. Of course
there are times when non-compliance must result in disciplinary action,
which is taken very seriously.
engage the front line
It is critical to engage those on the front lines of patient
support across all hospital units in determining their equipment needs
and eventual purchase so that there is buy-in and support for these
important decisions early in the adoption process.
Lessons Learned
establish metrics that compare apples to apples
The Occupational Safety and Health Act (OSHA) tracks workplace
safety nationally, but Swedish's OSHA numbers cannot be measured
against our Safe Moves numbers because of the different employee
populations considered. Safe Moves only considers those employees with
direct patient access, OSHA considers all work place injuries including
administrative and support staff. Since 2007 we have been actively
involved.
ensure a multi-disciplinary/multi-vendor approach
It is critical to involve as many parties as possible as early as
possible in the process. Involving healthcare professionals with
different responsibilities and patient populations will result in
vastly different tools to ensure safe patient handling. For example, at
Swedish, we created a specialized tool for one of our orthopedic
surgeons based on his specific need with hip replacement patients.
implement patient safety handling standards globally
Patient safety handling should be part of all allied health
training curriculum. All employees with direct patient access must be
trained on patient safety handling compliance, from physicians, nurses
and physical therapists to security guards, imaging specialists and
respiratory therapists.
plan for operational and equipment costs
The up-front costs for equipment and operations are substantial,
but with the right approach, organization commitment, and a reasonable
timeframe to build toward results, costs can be turned into savings.
Summary
Implementing a safe patient handling program or policy or
initiative is a big undertaking that requires cultural change and
organizational commitment to be successful. You will be asking seasoned
professionals--many of whom have been on the job for more than 20
years--to change the way they work, adjusting long-formed habits and
techniques. There must be clear commitment from organizational
leadership as well as stakeholders at all levels to ensure deep
commitment throughout the organization.
Although implementing a culture of safe patient handling is not an
easy task, if approached methodically and with a generous timeframe you
will not only see a generous return on your investment, but you will
also have a healthier workforce.
______
Appendix A.--Breakdown of Cost Savings Resulting From Reducing Days
Away and Restricted Days
Total cost savings for reducing days lost and restricted days per year $2,224,590
----------------------------------------------------------------------------------------------------------------
Cost Savings (due
to reducing
Days Away Avoided Working Hours Average RN wage at backfill /
Saved Swedish replacement rate*
of $62.02/hour)
----------------------------------------------------------------------------------------------------------------
Lost Days....................... 973 days.......... 11,676 hours...... $41.35............ $724,203 ($62.02 x
11,676)
Restricted Days**............... 2016 days......... 24,192 hours...... $41.35............ $1,500,387 ($62.02
x 24,192)
-------------------------------------------------------------------------------
Total Savings................. .................. .................. .................. 2,224,590
----------------------------------------------------------------------------------------------------------------
*Using a conservative 50% higher rate of $62.02/hr although rate actually ranges 50-100 percent higher.
**All restricted hours are backfilled with temporary labor because you never know the patient situation which
may cause an Allied Health Professional to risk their physical well-being to help a patient.
Appendix B.--Total Up Front/Initial Investment of Funds
------------------------------------------------------------------------
------------------------------------------------------------------------
Total up front Investment for Labor Costs:
1 FTE for Director of Program........... $105,000+
Approximately 6,000 hours of training @ $248,100 (3,000 employees)
$41.35.
-----------------------------
Total up front Labor Investment....... $353,100
Total up front Dollar Investment for
Equipment:
Initial Investment of funds............. $1,100,000.00
HoverMatts CH Surgery................... $6,152.00
CH Neuro ICU-Golvo/slings............... $11,165
CH CICU-Viking/slings/Hovermatt......... $15,018.40
CH Abm. Infusion-Golvo/Slings........... $7,212.40
-----------------------------
Total Equipment Investment.............. $1,128,382.80
Total Up Front/Initial Dollar Investment of Funds: $1,481,482.80
Appendix C.--Total Ongoing Program Costs
------------------------------------------------------------------------
------------------------------------------------------------------------
1 FTE for Director of Program............. $105,000+
Approximately 3,000 hours of training @ $124,000 (3,000 employees.
$41.35. Repeat training is 1 hour
versus 2 hours)
-----------------------------
Total Ongoing Labor Investment.......... $299,000
Appendix D.--Nurse Turnover Rates
------------------------------------------------------------------------
Nurse Turnover Rates (In
Year percent)
------------------------------------------------------------------------
2006...................................... 8.76
2007...................................... 8.15
2008...................................... 9.38
2009...................................... 6.94
------------------------------------------------------------------------
Appendix E.--Swedish Medical Center's Safe Patient Handling and
Employee Safety Standard Policies.
Senator Murray. Thank you very much.
Mr. Erickson.
STATEMENT OF DOUGLAS ERICKSON, FASHE, HFDP, CHFM, CHC, DEPUTY
EXECUTIVE DIRECTOR, AMERICAN SOCIETY FOR HEALTHCARE
ENGINEERING, CHICAGO, IL
Mr. Erickson. Good afternoon, Madam Chair and Senator
Isakson.
I'm Douglas Erickson, chairman of the Guidelines for Design
and Construction of Healthcare Facilities. I'm a healthcare
engineer. I'm a fellow within the American Society for
Healthcare Engineering, and have more than 35 years of
experience in the healthcare field, specializing in the
development of codes and standards supporting the healthcare
physical environment. I appreciate the opportunity to present
before the subcommittee this afternoon.
First, there are Federal programs and standards already in
place to systematically implement a no-lift policy, so
additional regulation is unnecessary.
Second thing is that there are technical difficulties in
installing patient lifting devices in our healthcare
facilities, and it is extremely difficult and complex, in many
instances.
And, third, the patient disruption in an occupied
environment is significant when modifications are made to
install equipment needing structural support.
A major concern of mine, as an expert in writing and
implementing codes and standards in the healthcare physical
environment, is that we are trying to rush such a monumental
modification into our Nation's existing healthcare system. This
action will absolutely create havoc, panic to comply, a
tremendous waste of our healthcare resources. In my
professional judgment and that of other professionals in my
field, it will take decades to bring about the necessary
physical modifications to provide mechanical lifting equipment
sufficient to implement a no-lift policy throughout the entire
system.
The fact is, most existing healthcare facilities in the
United States are not designed and constructed to accommodate
the installation of fixed lifting equipment, or, in many cases,
to accommodate the use of even portable equipment.
While we are making great advances in modernizing our
hospitals, nursing facilities, clinics, and other patient care
sites, the fact remains: We are still providing care in
buildings that date back to the early 20th century.
Some points to consider:
Healthcare facilities have been including permanently
installed ceiling- and wall-mounted lifting devices in new
construction and major renovation, but in existing
construction, it is minimal, because of the time and cost to
gain access to the structural components of the ceiling or
walls.
Structural capacity of our floors, ceilings, and walls may
be inadequate to support lifting devices.
Most healthcare facilities have semiprivate rooms that do
not provide a good environment for fixed lifts, due to the
limited size and configuration of those rooms.
Installing lifting devices will require, in many instances,
the need to reposition lighting fixtures, ventilation systems,
sprinkler heads, ceiling-mounted radiology equipment, OR
lights, electrical conduits, plumbing pipes, and has the
potential of even needing to use asbestos abatement if asbestos
is still contained and encapsulated within the ceiling cavity.
Installing lifting devices will also result in the loss of
bed capacity and the disruption due to noise, vibration,
infection control, and other risks to patients, when making
facility modifications.
Our healthcare facilities need a systematic approach to
instituting safe patient handling practices that include all
interested parties. The healthcare industry already has a time-
tested, formulated process and quality document known as the
Guidelines for Designing Construction of Healthcare Facilities.
The 2010 edition is the latest in a 63-year history of this
document to aid in the design and construction of healthcare
facilities. Approximately 42 State departments of health
already adopt some iteration of the guidelines.
Over the past 4 years, the authors of the guidelines have
undertaken a national consensus effort to develop quality
standards for assessing safe patient handling risk and
implementing a program to install mechanical lifting devices in
new construction and major facility modifications.
The 116-person all-volunteer committee consists of nurses,
surgeons, occupational health experts, infection prevention,
and we have worked with safe patient handling experts, nursing
union representatives, State and Federal authorities, and also
health professionals, to develop the standard on patient
handling and movement.
The effort has two distinct, yet interdependent, phases.
First, a patient-handling needs assessment to identify
appropriate handling and movement of patients. And the second
one would be to define the space requirements, the structural
and the other technical aspects to accommodate the
incorporation of such patient equipment, and also--within that
environment.
In conclusion, safe patient handling is critical to the
fabric and future of the healthcare system. However, this needs
to be accomplished in a highly systematic fashion, or the fix
could be worse than the problem.
The Facility Guidelines Institute stands ready to work with
lawmakers on innovative ways to build on efforts already
happening at the Federal, State, and public levels, and to
share information that will help healthcare organizations make
smart choices on implementing a safe patient handling program.
Madam Chair, it has been an honor to be here this
afternoon, and I would like to thank the subcommittee for
inviting me to present on this very important topic.
[The prepared statement of Mr. Erickson follows:]
Prepared Statement of Douglas S. Erickson, FASHE, HFDP, CHFM, CHC
Good afternoon, Madame Chairperson and committee members. I
appreciate the opportunity to present before the Senate Employment and
Workplace Safety Subcommittee. The subject being addressed by the
subcommittee is of great importance to the overall success of our
health care system.
As a health care engineer, I've been involved in the patient care
environment for nearly 35 years and involved in the patient safe
movement issue for the past 10 years. From my experience, I do not
believe a Federal Government approach to safe-patient handling is the
best approach.
I come before the committee not to argue against the merits of a
safe-patient handling bill, as having some form of legislation to
protect the health care worker from injury and to support safe movement
of patients in health care facilities is extremely important and worthy
of the current attention. My concern as a citizen and as an expert in
writing and implementing codes and standards in the health care
physical environment is that we are not allowing enough time to
properly alter the health care built environment to accommodate
mechanical lifting equipment. Trying to rush such a monumental
modification to our Nation's health care system will create havoc,
panic, and a tremendous waste of health care resources. My experience
of more than 30 years--writing standards, compromising on proposed
language, advocating for and against the adoption of codes and
standards, and having to implement and live with those codes once
issued--indicates it will take time to bring about the necessary
physical modifications to provide mechanical lifting equipment
sufficient to implement a no-lift policy throughout the entire system.
The safe-patient handling and lift standards as presented will not
allow enough time to alter the built environment and install mechanical
lifting devices before the no-lift policy is mandated. This will create
havoc in the health care industry as organizations will panic and do
something--anything--to avoid impending OSHA fines, ultimately wasting
a tremendous amount of health care resources.
Yes, we can mandate that OSHA shall establish a Federal Safe-
Patient Handling Standard in a year and, yes, we can mandate that all
health care facilities shall develop and implement a safe-patient
handling plan not later than 6 months after such a standard is
published. However, the truth is that complying with these mandates
cannot be physically accomplished within those timeframes.
To modify our Nation's health care facilities and provide
mechanical lifting equipment to fully support a no-lift policy
throughout the entire health care system will take a decade or more to
achieve.
The fact is that most existing health care facilities in the United
States are not designed and constructed to accommodate the installation
of fixed lifting equipment or, in many cases, to accommodate the use of
portable lifting devices. While we are making great advances in
modernizing our hospitals, nursing facilities, clinics, and other
patient care sites, the fact remains that the U.S. health care system
is still providing care in buildings that date back to the early 20th
century. Many health care facilities were designed and built under the
Hill-Burton program and have inflexible physical environments. Some
points to consider:
Very few hospitals have been retrofitting patient rooms
with permanently installed ceiling- or wall-mounted patient lifting
devices. At issue is the tremendous cost to gain access to the
structural components of the ceiling or wall. A typical retrofit for a
ceiling-mounted lift would mean removing a portion of the existing
plaster or acoustical ceiling, cubicle track, light fixtures, sprinkler
piping, and potentially the heating and cooling ductwork. Often, the
space above the acoustical ceiling is limited in height and would not
permit installation of the structural supports needed for the ceiling-
mounted grid of a mechanical lift system. For a wall-mounted lift, the
wall must be strengthened with additional structural elements and
structural plates, which must be fit in among the other equipment
located on the headwall, including electrical devices such as the nurse
call, emergency/normal power receptacles, medical gas connections, and
patient-related equipment for monitoring, suction, and bed control.
Other physical features needing modification to accommodate
installation of lifts are the toilet room doorframe and the wall above
the doorframe to permit passage of the track and hoist cabling.
Most ceiling- and wall-mounted lifts are installed during
new construction or major renovation projects.
Most ceiling-mounted lifts are installed in private rooms
as the semi-private room is not an appropriate environment due to the
size and configuration of the room, which means the patient on the far
side of the room would have to be hoisted over the other patient to
reach the toilet room.
The use of portable lifts in semi-private patient rooms is
limited based on the size of the room. With its typical footprint of
30 x 40, maneuvering a patient lift into position in an older room
of 160 sq. ft. is almost impossible due to the equipment, both patient-
related and family-related, that fills it. Also, the bed size has
increased dramatically over the past 20 years, limiting the clear floor
space in the patient room.
Other architectural and business-related issues to consider when
installing mechanical lifting equipment in existing buildings include
these:
Structural capacity of floor slabs, ceilings and walls
capable of supporting the lift loads.
Positioning of light fixtures, A/C diffusers, fire
sprinkler heads.
Items above ceiling (e.g. other ceiling-mounted equipment
such as radiology equipment and OR lights, HVAC equipment, electrical
conduits, plumbing equipment).
Amount of interstitial space (dictates the amount of
lateral bracing required and type of attachment method--rod or
pendant--needed to achieve a stable system).
Unique architectural considerations: Multi-level ceiling
heights, vaulted ceilings, soffits, non-structural or radius walls.
Header and door walls (structural vs. non-structural
walls--use of structural walls creates more challenges in room-to-room
tracking).
Fire code requirements.
Ceiling height compared to maximum lifting range required
by lifting practices.
Wall-mounted barriers: TVs, light fixtures, cabinets, and
door swing radius must be considered in determining track dimensions.
Motor maintenance: Enough space must be allowed between
rail-end and wall for removal of the lift motor.
Recessed track (for straight, traverse, or curved track,
ensure dropped ceiling grid is butted against track).
Conveniently accessible space for motor and hanger bar
storage when not in use.
Location/design of privacy curtains.
Approval of plans by State architectural review boards,
which can take as long as 6-18 months.
Loss of bed capacity when making modifications to
accommodate installation of fixed lifting equipment.
Infection control risk to patients from generation of
aspergillus or other harmful spores and bacteria in the patient
environment.
Asbestos abatement if asbestos is still encapsulated in
the cavity above the patient environment.
Training of facility and maintenance staff on the new
equipment.
The solution for creating a safe-patient handling program has been
clearly defined in the VA manual on developing a no-lift policy.
In this manual, the Veterans Administration's first statement is
that, for a no-lift policy to be successful, the health care facility
MUST have required infrastructure in place before it is implemented.
This infrastructure includes:
An adequate number and variety of patient handling aids
and mechanical lifting equipment on each high-risk patient care unit.
Sufficient numbers of staff trained and competent in the
use of these aids and equipment.
Staff trained and skilled in applying safe patient
handling and movement algorithms.
Administrators and supervisors who support the
comprehensive approach.
The U.S. health care system needs a systematic approach to
instituting mandatory safe-patient handling that includes all
interested parties.
Over the past 4 years, the authors of the Guidelines for Design and
Construction of Health Care Facilities have undertaken a national
consensus effort to develop quality standards for assessing safe-
patient handling risk and implementing a program to install mechanical
lifting devices in new health care construction and major
modifications. The 116-person, all-volunteer multidisciplinary
committee worked with industry safe-patient handling experts, nursing
union representatives, State and Federal authorities, and health care
professionals to develop the concept of a patient handling and movement
assessment (PHAMA) along with an industry best practice to provide
guidance for implementing the program. A compilation of the safe-
patient handling provisions in the 2010 Guidelines for Design and
Construction of Health Care Facilities and Patient Handling and
Movement Assessments: A White Paper have been provided for further
review (see Attachment 2).
National guidelines for effectively evaluating safe-patient
handling needs, patient movement equipment, and space design
considerations were released in January 2010.
This national team of experts crafted safe-patient handling
language for public review and comment. After a 2-year review process,
all the public comments were addressed and the following core
paragraphs emerged. Another 10 pages of requirements and appendix
material within the Guidelines support these two paragraphs (see
Attachment 1).
1.2-5 Patient Handling and Movement Assessment
A patient handling and movement assessment (PHAMA) is
conducted to direct/assist the design team in incorporating
appropriate patient handling and movement equipment into the
health care environment. The purpose of this equipment is to
increase or maintain patient mobility, independent functioning,
and strength as well as to provide a safe environment for staff
and patients during performance of high-risk patient handling
tasks.
The PHAMA has two distinct yet interdependent phases. The
first phase includes a patient handling needs assessment to
identify appropriate patient handling and patient movement
equipment for each service area in which patient handling and
movement occurs. The second phase includes definition of space
requirements and structural and other design considerations to
accommodate incorporation of such patient handling and movement
equipment.
Simultaneous to the crafting of standards language, the white paper
on patient handling and movement (PHAM) was being developed to support
these new requirements. In addition to the workplace safety issues of
safe-patient handling, this white paper sensitizes us to many
additional advantages that PHAM equipment may offer, including:
Better patient outcomes and improved quality of life for
both patients and caregivers.
Economic benefits from avoiding adverse events related to
manual patient handling.
Improved patient outcomes stemming from the potential for
hospitals and nursing homes to mobilize patients using assistive
devices immediately following a procedure or admission and diagnosis.
The authors concluded that these benefits and possibilities deserve
to receive more emphasis--in addition to (rather than instead of)
workplace safety.
The health care industry already has a time-tested, formalized
process and quality document for designing and constructing health care
facilities.
The 2010 edition is the latest in the 63-year history of this
Guidelines document to aid in the design and construction of health
care facilities.
The original General Standards appeared in the Federal Register on
February 14, 1947, as part of the implementing regulations for the
Hill-Burton program. The standards were revised from time to time as
needed. In 1974 the document was retitled Minimum Requirements of
Construction and Equipment for Hospital and Medical Facilities to
emphasize that the requirements were generally minimum, rather than
ideal standards. The 1974 edition was the first for which public input
and comment were requested.
In 1984 the Department of Health and Human Services (DHHS) removed
from regulation the requirements relating to minimum standards of
construction, renovation, and equipment of hospitals and medical
facilities, as cited in the Minimum Requirements, DHEW Publication No.
(HRA) 81-14500. Since the Federal grant and loan programs had expired,
there was no need for the Federal Government to retain the guidelines
in regulation format. To reflect its non-regulatory status, the title
was changed to Guidelines for Construction and Equipment of Hospital
and Medical Facilities. Since that time, the document has been
continuously updated every 4 to 5 years, using a public revision
process.
The 2010 Guidelines was written by a 116-person, multidisciplinary
Health Guidelines Revision Committee (HGRC) with representation from
nurses, surgeons, anesthesiologists, neonatologists, infection
preventionists, administrators, architects, facility managers,
consulting engineers, safety and security professionals, risk managers,
and more than 25 State, Federal, and private enforcing authorities.
The 2010 edition had more than 25 focus groups reviewing specific
sections of the 2006 document or working on the development of new
sections. Two specialty subcommittees were formed to take on major
projects on acoustic design and patient handling and movement.
Expertise on these specialty subcommittees was bolstered by the
contributions of outside technical and subject experts. The HGRC
reached a consensus at its final meeting and unanimously endorsed the
revised guidelines to be sent out for letter ballot, which was then
unanimously approved.
A public process, with a 63-year history, is already in place with
a set of consensus standards for assessing and implementing safe-
patient handling. The Guidelines is adopted by the Joint Commission,
HUD, PHS/IHS, HRSA, and State departments of health and licensure. So
the process works without the need for a set of Federal Government
safe-patient handling standards.
conclusion
Safe-patient handling is critical to the fabric and future of the
health care system. I agree that the health care system needs to
implement policies and install adequate equipment to protect workers
and patients when manual handling is required. However, this needs to
be accomplished in a highly systematic fashion or the fix could be
worse than the purpose for implementing the program.
The FGI and its health guidelines revision committee members stand
ready to work with lawmakers on innovative ways to build on efforts
already occurring at the Federal, State and public levels and to share
information that help health care organizations make smart choices on
implementing a safe-patient handling program.
Madame Chairperson, it has been an honor to be here this afternoon,
and I would like to thank the Health, Education, Labor, and Pensions
Committee for inviting me to present on this very important topic, and
of course I am available for any questions from the committee.
Senator Murray. Thank you very much.
I want to thank all of our witnesses today for excellent
testimony. This is extremely helpful to this committee.
We have hit a couple of time constraints. Senator Isakson
has to leave; he has a previous engagement. We have four votes
that are going to start, here shortly, which are going to take
over an hour. And all of us have questions.
So, what I'm going to do is allow Senator Isakson to ask
his questions. I will have one or two, and turn it over to
Senator Franken. Hopefully, we can finish those before the
votes begin.
And the rest of the questions will be submitted to all of
you to return in writing.
So, with that, let me turn it over to Senator Isakson.
Senator Isakson. Well, thank you, Madam Chairman. Actually,
I'm not going to ask a question. But, two things:
One, first, thanks, to each of you, for your testimony.
Second, I really commend pages 5, 6, and 7 of Ms. Altaras's
testimony, which were, I think, really excellent--both in terms
of recommendations as well as lessons learned, which goes back
to some of those initial questions I asked. It was very helpful
to me. I commend you on that.
And I thank all our panelists for their effort today.
Thank you.
Senator Murray. Thank you very much.
Ms. Altaras, let me start with you. You have over 100 years
of service. Congratulations. I think it's 110, now, Swedish has
been operating. You have a mix of old and new buildings that
you dealt with as you implemented this policy. Can you tell us
what impact the age and condition of your buildings had on your
efforts?
Ms. Altaras. We've taken a multiequipment approach. We have
not installed ceiling lifts in 100 percent of our rooms. We
make a decision on whether ceiling lifts are appropriate, based
on the assessment of each individual nursing unit, of what
patient populations are in that unit and what the work is in
that unit. Ceiling lifts are not necessarily appropriate for
all areas.
In the surgical suites, we use HoverMatts, because it would
be very difficult to install ceiling lifts in surgical OR
rooms. And we use HoverMatts in that setting.
There are many settings where the patients can reposition
themselves in bed, and, really, the goal is to get them from
sit-to-stand, so we use portable movement machines to go from a
sit-to-stand position. So, the ceiling lifts aren't necessarily
required. You can use HoverMatts in those situations also. So,
we've used a variety of approaches.
Some of our older buildings, we have found that there are
the--if you decide it's appropriate to use ceiling lifts in
older construction, you can use the portable framework, where
you can install the motor and the tracking to use that lift.
But, I think that you need to do very in depth assessment to
make sure ceiling lifts is actually the appropriate solution
with that patient population and nursing unit.
Senator Murray. OK, thank you very much.
And, Ms. Silverstein, I wanted to ask you about the
recruitment and retention of experienced nurses and, in your
experience, how this policy has helped with that.
Dr. Silverstein. In doing the interviews in both Idaho and
Washington, where there has been available equipment, nursing
staff may have, at first, been reluctant, but, once they became
used to using the equipment, were absolutely delighted with it
and felt that their careers could last a lot longer.
The turnover--we don't have evidence that the turnover has
dramatically decreased across the board, but it has, we know,
in certain hospitals, where they've really implemented safe
patient handling.
Senator Murray. OK.
Senator Franken.
Senator Franken. Thank you, Madam Chair.
Ms. Silverstein and Ms. Altaras, could you please respond
to Mr. Erickson's assertion that it would take decades to
implement this bill?
Minnesota facilities, Ms. Shogren, were able to make
changes much more quickly. And I assume Washington has, too.
I want to point out that my legislation really gives 4
years to enact this--so, can you respond to Mr. Erickson,
either of you, or any of you? Ms. Shogren, too.
Dr. Silverstein. Three years. In Washington.
Senator Franken. You did it--in the entire State.
Dr. Silverstein. Yes.
Senator Franken. In 3 years.
Dr. Silverstein. Yes.
Senator Franken. OK.
And, Ms. Altaras.
Ms. Altaras. It took our organization 3 years, and we have
three hospitals. We have over 1,000 patient beds, in addition
to all of our--we have 60-plus operating rooms. And we were
able to install in--it's actually under 3 years.
Senator Franken. And, Ms. Shogren, what was the experience
in Minnesota?
Ms. Shogren. The law won't be fully implemented until the
end of the year, but the law provides about 2\1/2\ years to
fully implement the program; and there is a provision for
hardship, for an additional year. It can be extended if the
employer is experiencing hardship.
Senator Franken. One of the reasons I love nurses is that
they're patient advocates. And from the patient's perspective,
the disability community in Minnesota, Ms. Shogren, when this
law was passed--I understood they were for it, right? They were
advocating for it.
Ms. Shogren. Well, we talked with just about anyone who
would talk with us as we were getting ready to work on the
bill, and we found that, within the disability community, we
had some kindred spirits there, from a different perspective.
They were very concerned, especially in the outpatient-care
settings, which is why we did the amendment, that even though
the facilities had ramps at the doorways and buttons that you
could push to open the doors for you, that once they got beyond
the waiting room, they were not equipped to care for them, and
they couldn't get on the exam table. So, for instance, the MS
Society lobbyist testified that only about 20 percent of women
with MS can get a Pap smear every year, because they simply
can't get on the table. And that was a very fundamental issue
around access to healthcare that we felt was very compelling.
We also know that when we lift patients manually, we're
generally hurting them; that's why they're combative. And I
didn't go into nursing to hurt people, and the fact that I can
use equipment to help move someone, versus, brute force to try
and do it, seemed to me a much more compassionate and humane
way to deal with the issues of people in need of assistance.
Senator Franken. Let me ask you about the Minnesota
Hospital Association. Did the Minnesota Hospital Association
oppose the safe patient handling bill that was enacted in
Minnesota?
Ms. Shogren. No. They testified they felt it was the right
thing to do.
Senator Franken. Well, I'm proud that Minnesota hospitals
understand that worker safety is part and parcel of good
patient care. And if we can succeed in Minnesota, in
Washington--if this can be implemented within 3 years in
Washington, I don't know why it would take decades in other
States.
So, thank you all for your testimony today.
And thank you, Madam Chairwoman.
Senator Murray. Well, thank you, again, to all of you.
We're going to leave the committee record open for the next
7 days for all committee members to be able to add their
statements and to ask questions of all of our witnesses.
And I personally want to thank all of you for taking time
out of your lives to come and help us understand the
implications of this.
Senator Franken, thank you for your tremendous
participation on this, as well.
With that, this hearing is adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of David Michaels, PhD, MPH, Assistant Secretary of
Labor for the Occupational Safety and Health Administration (OSHA)
Chair Murray, Ranking Member Isakson and members of the
subcommittee, patient handling is an important issue that affects
health care workers in the United States. Health care workers
experience large numbers of work-related musculoskeletal disorders
(MSDs) as a result of manually lifting, moving, assisting, and
repositioning patients. An OSHA analysis of the latest Bureau of Labor
Statistics data available showed more than 36,000 workers were injured
lifting, repositioning and transferring patients in 2008. These are
just the injuries that resulted in days away from work, the total is
much higher and many injuries may not be reported. Almost all of the
injured workers were nurses and nursing aides, and most were women.
Disabling back injuries or the fear of being injured have contributed
to the large number of nurses leaving the profession, thus increasing
the nursing shortage. An estimated 12 percent to 18 percent of nursing
personnel leave the profession annually due to chronic back pain, and
another 12 percent consider a job transfer to reduce their risk of back
injury.\1\
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\1\ Hal Wardell, ``Reduction of Injuries Associated with Patient
Handling'' AAOHN Journal, October 2007, Volt. 55, No. 10, 407-412.
---------------------------------------------------------------------------
Due to the seriousness of this problem, OSHA supports the efforts
of the subcommittee to address this significant occupational safety and
health issue. OSHA agrees with the statement provided by the National
Institute for Occupational Safety and Health (NIOSH) regarding research
on patient handling risk, and supports NIOSH's efforts to learn more
about this problem and its solutions. But while more research is always
welcome, there are well established and proven interventions that have
been successful in preventing these injuries in health care
establishments across the country.
We acknowledge the advancements the U.S. Department of Veterans
Affairs has made in this area, pulling in the experience of the VA
Sunshine Healthcare Network (Veterans Integrated Service Network, VISN
8) to implement safe patient handling procedures in VA clinics
nationwide. Between 2001 and 2003, VISN 8 deployed a program that
reduced patient manual-handling caregiver injuries and led to markedly
increased employee and patient satisfaction. Based on these results, VA
developed and funded a national program through a budget initiative in
fiscal year 2007.
Additionally, OSHA has a long history with this issue. In 2000,
OSHA issued a comprehensive ergonomics standard that included health
care workers. This standard was repealed by Congress and the President
in 2001. In 2003, OSHA published ergonomic best practice guidelines for
nursing homes. These guidelines recommend that manual lifting and
transferring of patients should be minimized in all cases and
eliminated when feasible. The guidelines also recommend that employers
implement an effective ergonomics process that provides management
support, involves employees, identifies problems, implements solutions,
addresses reports of injuries, provides training, and evaluates
ergonomics efforts.
Many States have also recognized the seriousness of this problem,
and eleven have successfully enacted safe patient handling laws.
Several others are considering similar legislation. A study is
currently underway in the State of Washington to evaluate the
effectiveness of their legislation, and results may be available later
this year. Health care employers covered by State laws, as well as
employers who have voluntarily implemented safe patient handling
programs, have successfully reduced injury rates to nurses and other
health care providers. OSHA supports the subcommittee's efforts to
provide the same protection to all health care workers.
OSHA implemented a National Emphasis Program in September 2002 that
focused on ergonomic hazards in nursing home facilities. We continue to
investigate patient and resident handling incidents and have conducted
4,109 ergonomics inspections in nursing homes. To address enforcement
of ergonomic hazards, OSHA uses Section 5(a)(1) of the Occupational
Safety and Health Act, commonly referred to as the General Duty Clause.
Enforcement under the General Duty Clause poses many difficulties, as
very stringent legal tests must be met to successfully support
citations. Despite the size of the problem and OSHA's efforts to deal
with it, the Agency has only been able to issue 12 General Duty Clause
ergonomic citations to health care facilities in the last 8 years. The
General Duty Clause does not provide an efficient means for dealing
with these workplace hazards. However, OSHA has put numerous health
care facilities on notice by issuing ergonomic hazard alert letters.
These letters inform employers of potential ergonomic risk factors
observed at their facility and provide recommendations on how to reduce
the risk of these hazards.
Thank you for the opportunity to comment on the issue of safe
patient handling. OSHA applauds the subcommittee's efforts to shed
light on this problem that affects too many of our Nation's healthcare
workers.
______
May 10, 2010.
Hon. Patty Murray,
Chair, Subcommittee on Employment and Workplace Safety,
Committee on Health, Education, Labor, and Pensions,
U.S. Senate,
Washington, DC 20510.
Dear Madam Chairwoman: On behalf of the 1.6 million members of the
American Federation of State, County and Municipal Employees (AFSCME),
I request that the attached statement from AFSCME be included in the
record for the May 11, 2010 hearing on Safe Patient Handling and
Lifting Standards for a Safer American Workforce before the
Subcommittee on Employment and Workplace Safety, of the Senate Health,
Education, Labor, and Pensions Committee.
We thank you for holding this important hearing.
Sincerely,
Charles M. Loveless,
Director of Legislation.
______
Prepared Statement of the American Federation of State, County and
Municipal Employees (AFSCME)
We submit this statement on behalf of the 1.6 million members of
the American Federation of State, County and Municipal Employees
(AFSCME) for the official record of the Hearing on Safe Patient
Handling and Lifting Standards for a Safer American Workforce of the
Employment and Workplace Safety Subcommittee of the Health, Education,
Labor, and Pensions Committee.
Approximately 360,000 AFSCME members work in our Nation's health
care system to provide quality care for patients in hospitals, clinics,
long-term care facilities, public health and other practice settings.
These nurses, nursing aides, orderlies, attendants and other health
care workers who lift or move patients as part of their jobs are at
great risk of developing preventable musculoskeletal injuries and
disorders. According to the U.S. Department of Labor, Bureau of Labor
Statistics, nursing personnel are consistently listed as one of the top
10 occupations for work-
related musculoskeletal disorders (for example, back pain, herniated
discs, pulled or torn ligaments). In 2007, nursing staff ranked first
in the incidence rate of such injuries--with a case rate of 252 cases
per 10,000 workers, a rate seven times the national musculoskeletal
average for all occupations. The nursing occupation also typically
ranks in the top 10 in yearly incidence rate of sprain and strain
injuries.
In most industries the injury rates for musculoskeletal disorders
have declined in recent years but for nurses in the healthcare industry
the rates have not declined. Patient handling and movement tasks are
physically demanding, often performed in less than ideal conditions and
often are unpredictable in nature, placing healthcare workers at risk.
Healthcare workers are at even higher risk for back and other injuries
when they work in facilities with low staffing, lack lifting equipment
in good repair and have a high proportion of dependent patients. In
addition, the shortage of nurses, longer work hours, aging workforce
and increased obesity rates of patients all contribute to risk of
injury. There are adverse consequences to the worker and patient as a
result of improper and unsafe handling. It is time for Congress to act
to change industry patient handling practices that put workers at risk.
For many years, employers have focused on outdated and ineffective
techniques for patient handling based on ``proper'' body mechanics.
There is strong evidence that these commonly used approaches are not
effective in reducing worker injuries. There is a need for a specific
national safety and health standard for this group of workers because
patient handling is very different from lifting and moving other
objects of the same weight. For example, weight can shift, and patients
can resist movement and may even be combative. Accordingly, AFSCME
urges the subcommittee to pass the Nurse and Health Care Worker
Protection Act of 2009 (S. 1788) which would move healthcare employers
away from ineffective approaches to evidence-based safe patient
handling practices.
The legislation would prompt a real paradigm shift based upon over
three decades of research to support interventions that are effective
in reducing musculoskeletal pain and injuries in healthcare workers who
lift and handle patients. Under the legislation the U.S. Department of
Labor's Occupational Safety and Health Administration (OSHA) would
issue a standard on safe patient handling and injury prevention that
requires the use of lift equipment to move patients except in cases
which would compromise patient care. It would also require healthcare
facilities to implement safe patient handling and injury prevention
plans. Healthcare workers would receive training on safe patient
handling and injury prevention. In addition, healthcare workers would
be protected from employer retaliation if they refused to accept
assignments which do not meet safety standards.
For the foregoing reasons, AFSCME urges the subcommittee to pass
the Nurse and Health Care Worker Protection Act of 2009.
Prepared Statement of the American Industrial Hygiene Association
(AIHA)
safe handling of patients and residents
It is the position of the American Industrial Hygiene Association
(AIHA) that:
1. The proper implementation of legislation can help to reduce the
presence of the risk factors associated with musculoskeletal disorders,
including work-related musculoskeletal disorders (WMSD), arising from
the manual handling of patients and residents. Some of the critical
components of legislation to address this exposure:
AIHA believes that management systems are the best/
recommended approach to hazard identification, risk assessment, and
risk mitigation. As such, AIHA recommends that hospitals, nursing
homes, and other health care facilities have a written safe patient
handling policy or related policy incorporating all the necessary
elements of a management system, such as elements in the AIHA/ANSI Z10-
2005, Occupational Health and Safety Management Systems.
The need for occupational providers of these services to
have a patient handling committee or sub-committee. The committee
should have representation from, but not be limited to, administration,
education, unit management, nurses, nurses aides, maintenance,
housekeeping, techs, and transport.
The policy needs to address patient handling hazard
assessment, task type and frequency, patient dependency levels,
environmental restrictions, enhanced use of mechanical devices,
incorporating space and construction design for mechanical lifting
devices into job design and architectural plans, details for assuring
proper equipment maintenance, storage and availability, training
programs, responsibility and accountability systems for both management
and associates.
The policy needs to address how to evaluate the
effectiveness of the program. Activity, outcomes and compliance
measures should be in place to evaluate success.
The policy should address methods of sustainability and
enhancement of the program as new technology and/or additional
resources becomes available.
While there is significant ergonomic risk associated with
handling residents in home health care, there is currently a lack of
knowledge regarding how to properly control this exposure. Research
should be funded and other efforts undertaken to fill this knowledge
gap.
2. There is a significant need to improve safe patient and resident
handling with the resultant positive outcomes to include:
The reduction of musculoskeletal disorder development and
their resulting costs.
Improved caregiver efficiencies and productivity. Reduces
non-value added task for caregivers thereby freeing them up to spend
more time on patient care.
Reduction in the physical demand required to provide this
care.
With the ever increasing concern due to nursing shortages,
improving caregiver safety will help reduce the loss of human assets as
well as reduce turnover, recruitment and training costs. Improvement in
the desirability of providing this care, thereby increasing the
population willing to enter and remain in the health care profession.
With the use of lifting devices and progressive mobility
models for patients, caregivers can reduce the number and severity of
pressure ulcers and wounds, decrease the number of patient falls, and
enhance lung function and circulation, thereby improving the clinical
outcomes for patients and residents and provide a greater quality of
care. This will lead to a reduction in length of stays and related
healthcare costs.
3. There is a significant body of scientific evidence (as a start,
see the references that follow) demonstrating that effective ergonomics
programs applied to patient and resident handling will result in the
positive outcomes mentioned above.
4. The funding of research into improving home health care
ergonomics, including the increase of the availability and quality of
resident handling equipment, should help lead to:
Reduction in home health care worker WMSD.
Reduction in the need to have family members sent to
nursing homes or hospitals to receive care.
Reduction in the overall healthcare cost during the period
when care can be provided at home.
Maintaining a stronger family unit during the period when
care can be provided at home.
References
Waters, Thomas R. ``4th Annual Safe Patient Handling & Movement
Conference Speech: State of the Science in Ergonomics,'' Online Journal
of Issues in Nursing. Volume 10, No. 2, 2007. Available:
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/KeynotesofNote/Speech.aspx.
Nelson, Audrey L., et al. ``Effectiveness of an Evidence-Based
Curriculum Module in Nursing School Targeting Safe Patient Handling and
Movement,'' International Journal of Nursing, Volume 4, Issue 1, 2007.
Nelson, Audrey L., et al. ``Link Between Safe Patient Handling and
Patient Outcomes in Long-Term Care,'' Rehabilitation Nursing, Volume
33, No. 1, January/February 2008.
Waters, Thomas R. ``When is it Safe to Manually Lift a Patient?''
American Journal of Nursing (AJN), Volume 107, No. 8, August 2007.
Menzel, Nancy N. ``Preventing Musculoskeletal Disorders in Nurses:
A Safe Patient Handling Curriculum Module for Nursing Schools,'' Nurse
Educator, Volume 32, No. 3, May/June 2007.
Waters, Thomas R. ``Patient Handling Tasks with High Risk for
Musculoskeletal Disorders in Critical Care,'' Critical Care Nursing
Clinics of North America, Volume 19, 2007.
______
May 10, 2010.
Hon. Patty Murray, Chairwoman,
Subcommittee on Employment and Workplace Safety,
Committee on Health, Education, Labor, and Pensions,
143 Hart Senate Office Building,
Washington, DC 20510.
Dear Chairwoman Murray: On behalf of the American Nurses
Association (ANA), we request the opportunity to submit testimony for
the hearing record regarding the Subcommittee on Employment and
Workplace Safety's hearing on Safe Patient Handling & Lifting Standards
for a Safer American Workforce. ANA is the only full-service
professional association representing the interests of the Nation's 3.1
million registered nurses (RNs) through its constituent member nurses
associations, its organizational affiliates, and its workforce advocacy
affiliate, the Center for American Nurses.
For more than a decade, the American Nurses Association has been
leading the fight on behalf of registered nurses, health care workers
and patients to eliminate manual patient handling. The Nation--now
facing a serious nursing shortage--can no longer afford to lose the
nurses who leave the profession annually due to musculoskeletal
injuries and pain.
ANA greatly appreciates your consideration of this request. Thank
you again, and please feel free to contact me at (301) 628-5098 or at
the e-mail address: [email protected] if you have additional
questions.
Sincerely,
Rose Gonzalez, MPS, RN,
Director, Government Affairs.
______
Prepared Statement of the American Nurses Association (ANA)
The American Nurses Association (ANA), the largest nursing
organization in the country, is pleased to submit our statement for the
record to the Subcommittee on Employment and Workplace Safety's hearing
on the Safe Patient Handling & Lifting Standards for a Safer American
Workforce.
Founded in 1896, ANA is the only full-service professional
association representing the interests of the Nation's 3.1 million
registered nurses (RNs) through its constituent member nurses
associations, its organizational affiliates, and its workforce advocacy
affiliate, the Center for American Nurses. The ANA advances the nursing
profession by fostering high standards of nursing practice, promoting
the rights of nurses in the workplace, projecting a positive and
realistic view of nursing, and by lobbying the Congress and regulatory
agencies on health care issues affecting nurses and the public.
The ANA prides itself on our long history as patient advocates.
Patient advocacy has always been at the core of nursing and ANA takes
that responsibility very seriously. We believe that it is possible to
care for our patients without jeopardizing our own safety and health--
and that of our patients. For almost two decades, the American Nurses
Association (ANA) has been leading the fight on behalf of registered
nurses, health care workers and patients to eliminate manual patient
handling. This issue is at the heart of our members day-to-day lives.
Moreover, it affects the lives of dedicated support staff including
nurses' aides, patient care assistants and health care technicians who
work alongside the registered nurse to provide competent, compassionate
care to patients. A Safe Patient Handling program decreases injury to
nurses, other health care workers and patients, while reducing work-
related health care costs and improving the safety of patient care
delivery.
The Nation--now facing a serious nursing shortage--can no longer
afford to lose the nurses who leave the profession annually due to
musculoskeletal injuries and pain. The extent of musculoskeletal
disorders among the U.S. nursing workforce is particularly distressing.
It is estimated that greater than 52 percent of the nursing workforce
suffers from chronic back pain. Injuries and pain secondary to patient
handling tasks exacerbate the shortage and are of particular concern
with the aging of the nursing workforce. Although the Occupational
Safety and Health Act (OSHA, 1970) requires employers to maintain
records of serious workplace injuries and illnesses (29 U.S.C. section
657c(2)), these statistics may not capture episodic and remitting
musculoskeletal injuries. Because this type of injury is largely a
result of cumulative physical insult over time, they often go
underreported, so the reported data is likely just the tip of the
iceberg.
In spite of the statistics and OSHA recommendations, ``no lift''
policy initiatives in other nations such as the United Kingdom and
Australia have been slow to be accepted in the United States. In 2003,
the ANA Handle with Care program was developed to support safer
practices with regards to patient handling. Approaches to addressing
this issue include recommended changes in nursing school curriculum as
well as legislation.
ANA's policy is supported by a 2003 Institute of Medicine report
entitled Keeping Patients Safe: Transforming the Environment for Nurses
which describes the nurses work environment as a potential threat to
their safety as well as that of patients. As a result, legislation in a
number of States focusing on nurses working conditions has been
advanced. An example is requiring the creation of safe patient handling
programs with ``no manual lift'' policies.
Although progress to address patient handling has been made as
evidenced by changes in nursing schools' curriculums and continued
activity within the State legislatures, initiatives are too few and too
limited in scope, and injuries continue to occur. Legislation is needed
at the Federal level. ANA strongly supports, and is actively working to
enact The Nurse and Health Care Worker Protection Act of 2009 (H.R.
2381/S. 1788). This legislation would help improve patient safety and
protect registered nurses and other health care workers from
debilitating injuries that could force them from their professions. ANA
strongly urges Congress to enact The Nurse and Health Care Worker Act
of 2009 (H.R. 2381/S. 1788).
Safe Patient Handling Programs Are Important . . . For Registered
Nurses, Health Care Workers . . . and Patients!
A Safe Patient Handling (SPH) program decreases injury to nurses,
other health care workers and patients, while reducing work-related
health care costs and improving the safety of patient care delivery.
The performance of tasks such as lifting, repositioning and
transferring patients exposes nurses and other health care personnel to
increased risk for work-related musculoskeletal disorders. With the
development of assistive equipment and devices, such as lifting
equipment and lateral transfer and friction reducing devices, the risk
of musculoskeletal injury can be eliminated or significantly reduced.
According to the Bureau of Labor Statistics, nursing aides,
orderlies, and attendants reported the highest incidence rate of
musculoskeletal disorders (MSD) requiring days away from work in 2006
(BLS, 2007). This group was ranked second in overall musculoskeletal
disorders requiring days away from work, with Registered Nurses ranked
fifth.\1\
---------------------------------------------------------------------------
\1\ Bureau of Labor Statistics (BLS). (2007). Nonfatal occupational
illness and injuries causing days away from work, 2006. U.S. Department
of Labor NEWS. USDL 07-1741. http://www.bls.gov/iif/oshwc/osh/case/
osnr0029.pdf.
---------------------------------------------------------------------------
Healthcare workers are over represented for upper extremity MSD
among worker's compensation claims. Injured nurses contribute to about
one-fourth of all claims and one-third of total compensation costs.
More than one-third of back injuries among nurses have been associated
with the handling of patients and the frequency with which nurses are
required to move them.
The extent of musculoskeletal disorders among the U.S. nursing
workforce is particularly distressing when considered in the context of
the current nursing shortage. The Nation--now facing a serious nursing
shortage--can no longer afford to lose the nurses who leave the
profession annually due to musculoskeletal injuries and pain. Injuries
secondary to patient handling and movement tasks compound factors
driving the nursing shortage.
An ANA Health and Safety Survey revealed that 88 percent of nurses
reported that health and safety concerns influence their decision to
remain in nursing and the kind of nursing work they choose to perform.
More than 70 percent said the acute and chronic effects of stress and
overwork were among their top three health concerns, with more than
two-thirds reporting they work some type of mandatory overtime every
month. In addition, nurses cited a disabling back injury (60 percent),
followed by contracting HIV or hepatitis from a needlestick injury (45
percent) as also being among their top three health and safety
concerns. The survey further revealed that fewer than 20 percent of
respondents felt safe in their current work environment.\2\
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\2\ ANA Health & Safety Survey, Sept. 7, 2001. See
www.nursingworld.org/surveys/hssurvey.htm for details.
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Safe patient movement and handling benefits patients as well. The
potential for patient injury (such as falls and skin tears) as a
consequence of a manual handling mishap is reduced by using assistive
equipment and devices. Equipment and devices provide a more secure
process for lifting, transferring or repositioning patients.
Studies have shown that the use of mechanical lifting
equipment increases a resident's comfort and feelings of security when
compared to manual methods.\3\
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\3\ Zhuang Z, et al. (2000). Psychophysical assessment of assistive
devices for transferring patients/residents. Applied Ergonomics. 31(1),
35-44.
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Patient handing technology encourages the safe movement
and repositioning of patients, which is required to avoid pressure
ulcers (bed sores). Years of research point to the effectiveness of
patient turning and repositioning as the primary means to avoid
pressure ulcers.\4\
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\4\ Thomas, David. (2001). Prevention and treatment of pressure
ulcers: What works? What doesn't? Cleveland Clinic Journal of Medicine.
(68) 8. August. http://www.ccjm.org/pdffiles/Thomas801.pdf.
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The National Institute for Occupational Safety and Health
(NIOSH) reports that manual lifting is associated with undesirable
outcomes for patients, including: Decreased quality of care . . .
Diminished resident safety and comfort . . . Decreased resident
satisfaction . . . Higher risks of falls, or of being dropped, friction
burns, and dislocated shoulders . . . Skin tears and bruises.\5\
---------------------------------------------------------------------------
\5\ National Institute for Occupational Safety and Health (NIOSH).
(2006). Safe Lifting and Movement of Nursing Home Residents. DHHS
(NIOSH) Publication No. 2006-117. http://www.cdc.gov/niosh/docs/2006-
117/pdfs/2006-117.pdf.
Most importantly, patients are afforded a safer means to progress
through their care, have less anxiety, are more comfortable and
maintain their dignity and privacy. Assistive patient-handling
equipment can be selected to match a patient's ability to assist in his
or her own movement, thereby promoting patient autonomy and
rehabilitation.
safe patient handling programs pay for themselves
ANA strongly believes that enactment of the Nurses and Health Care
Worker Protection Act of 2009 (H.R. 2381/S. 1788) will not only save
the health and careers of registered nurses and other health care
workers, but that it will also inevitably reduce costs for health care
facilities. In essence, a business case can be made for implementing a
safe patient handling program.
Initial investment in both lifting equipment and employee
training can be recovered in 2 to 3 years through reductions in
workers' compensation costs.\6\
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\6\ Collins et al., 2004; Tiesman et al., 2003; Nelson et al.,
2003; Garg, 1999.
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Research has shown that resident lifting programs reduce
workers' compensation injury rates by 61 percent, lost workday injury
rates by 66 percent, restricted workdays by 38 percent, and the number
of workers suffering from repeated injuries.\7\
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\7\ Collins J.W., et al. 2004. An evaluation of a ``best
practices'' musculoskeletal injury prevention program in nursing homes.
Injury prevention. Injury Prevention (10) 206-211.
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SPHM programs are cost-effective due to reductions in
workers' compensation claims, costs associated with absenteeism, and
turnover.\8\
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\8\ Bureau of Labor Statistics (BLS). (2007). Nonfatal occupational
illness and injuries causing days away from work, 2006. U.S. Department
of Labor NEWS. USDL 07-1741. http://www.bls.gov/iif/oshwc/osh/case/
osnr0029.pdf.
---------------------------------------------------------------------------
It was estimated the Veterans Health Administration (VHA)
spent approximately $22 million a year on health care worker injuries
associated with patient movement. After initiating safe patient lifting
programs in 23 units as part of an observation study, it was
demonstrated that the VHA was able to recoup all of the direct and
indirect costs associated with the safe lifting program in 4.3 years.
The savings occur through significant reductions in workers
compensation payments and avoidance of costs associated with caregiver
absenteeism.\9\
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\9\ Siddarthan, K., Nelson, A., Tiesman, H., & Chen, F. (2007).
Cost effectiveness of a multifaceted program for safe patient handling.
Advances in Patient Safety, 3(1):347-358.
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The Centers for Disease Control and Prevention (CDC)
recently released the results of a 6-year field study of a safe patient
lifting program. This study showed that the investment in equipment and
training was recouped in less than 3 years in lower worker compensation
claims.\10\
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\10\ NIOSH (2007). The NIOSH Traumatic Injury and Prevention
Program Evidence Package. March, 2007. http://www.cdc.gov/niosh/nas/
traumainj/pdfs/TIchapter5NAS03-07.pdf.
While the evidence shows that manual patient handling is a high-
hazard task, with high incidence rates of musculoskeletal disorders for
nurses and other personnel, employers remain reluctant to institute
safe patient handling programs regardless of the data that demonstrates
a strong return on investment for registered nurses, health care
workers and patients.
the nurse and health care worker protection act of 2009 (h.r. 2381/s.
1788)
The American Nurses Association strongly supports the Nurse and
Health Care Worker Protection Act of 2009 (H.R. 2381/S. 1788). This
bill would require OSHA to develop and implement a standard that will
eliminate manual lifting of patients by direct-care registered nurses
and other health care workers. The legislation will also require health
care facilities to develop a plan to comply with the standard (with
input from RNs), provides protection for RNs through refusal of
assignment and whistle blower provisions, and requires the Secretary to
perform audits.
The Nurse and Health Care Worker Protection Act of 2009 will
address some of the issues previously noted by decreasing injuries
sustained by registered nurses, health care workers, and patients. It
will also improve the safety of patient care delivery while reducing
work-related health care costs.
conclusion
We applaud the subcommittee's foresight in acknowledging the issue
of manual lifting, transferring and repositioning patients as a
continued hazard for nurses, health care workers and patients. As we
expand access to health care services, ANA believes that the enactment
of H.R. 2381/S. 1788 will reduce the number of injuries incurred by
registered nurses, health care workers and patients. H.R. 2381/S. 1788
will also serve to decrease patient anxiety and improve the overall
quality of care. Again, the ANA is pleased to submit our statement for
the record and will work with Congress to secure enactment of The Nurse
and Health Care Worker Act of 2009 (H.R. 2381/S. 1788). Thank you.
Response by Captain Collins to Questions of Senator Hagan
and Senator Isakson
senator hagan
Question 1. In your testimony, you indicated that ``direct and
indirect costs associated with back injuries in the health care
industry, adjusted for inflation, are estimated to be $7.4 billion
annually in 2008 dollars.'' My question to you is: can you elaborate
more on what the cost trajectory has been over the years and what the
future may hold, for costs associated with back injuries in the health
care industry?
Answer 1. We expect future costs associated with back injuries in
health care to increase due to demographic trends, economic factors,
and management strategies that continue to change. These are described
in the bullets below. Note that costs mentioned below refer to workers'
compensation costs only, that are a portion of the true occupational
safety and health costs to workers, employers, and society overall.
There is evidence that occupational back injuries result in
additional health care costs, over and above the medical costs covered
through worker's compensation. For example, Lipscomb et al. (2009) \1\
examined private health insurance payments for back diagnoses among a
15-year cohort of 18,768 carpenters who worked in the State of
Washington during 1989-2003. They found that private health insurance
payment rates for workers with one work-related injury were 40 percent
higher than those with no history of work injury, while payment rates
for those with four or more work-related injuries were almost three
times the payment rate for those with no prior work injury. After the
first work-related back injury claim, medical costs for back disorders
covered by private health insurance increased 19 percent in the first
year, and 30 percent for each year thereafter. Increasing private
payments and deductibles were observed in contrast with a decline in
reported work-related injuries. The authors concluded that their
findings suggest cost-shifting from workers' compensation to the union-
provided health insurance and to the worker.
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\1\ Lipscomb HJ, Dement JM, Silverstein B, Cameron W, Glazner JE.
2009. Who is paying the bills? Health care costs for musculoskeletal
back disorders, Washington State union carpenters, 1989-2003. JOEM
51(10):1185-1192.
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In addition, there is evidence that workers suffering from back
injuries are more likely to suffer from additional health conditions.
For example, Nimgade et al. (2010) \2\ analyzed health claims during
December 1998 to March 2004 in a community-based health maintenance
organization in Massachusetts that serves more than 200,000 clients.
They reviewed healthcare expenditures in a random sample of 655
patients with new onset low back pain in 1999. A total of 6.5 percent
of these patients had their low back pain services covered by worker's
compensation, and 18 percent had received worker's compensation health
coverage at some point during 1999 to 2004. No significant difference
existed between the population and the study sample with respect to
age, gender, worker's compensation status, or distribution of low back
pain diagnostic criteria. The authors concluded that the traditional
estimates of low back pain, that are based primarily on low back pain
services, underestimate the true cost of the condition that would
include physical or mental co-morbidities.
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\2\ Nimgade A, McNeely E, Milton D, Celona J. 2010. Increased
expenditures for other health conditions after an incident of low back
pain. Spine 35(7): 769-777.
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Aging patients and workers: \3\
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\3\ Restrepo T, Shuford H, De A. 2007. An Emerging Issue for
Workers Compensation--Aging Baby Boomers and a Growing Long-Term Care
Industry. National Council on Compensation Insurance Research Brief:
https://www.ncci.com/documents/research-baby-boomer-fall07.pdf.
The share of low back injuries for direct care workers in
long-term care settings (including nursing homes, residential care, and
home healthcare) is almost twice that for workers in all other
industries (23 percent vs. 12 percent). The proportion of strains due
to lifting in long-term care settings is approximately twice that for
workers in all other industries, (41 percent for long-term care
settings and 25 percent for all other).
Total workers' compensation losses per worker are higher
than average and employment is growing faster than average in the long-
term care settings. Strains due to lifting were the top cause of all
workers' compensation injuries.
Incidence rates with days away from work are above
average in all long-term care settings.
The rapidly aging population will likely cause the number
of long-term care settings to grow faster than average.
Obese patients and workers: \4\
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\4\ NCCI. Winter 2009. Gauging Current Conditions: The Economic
Outlook and Its Impact on Workers Compensation. National Council on
Compensation Insurance Research Newsletter: https://www.ncci.com/
documents/GaugingtheEconomy-Winter2009.pdf.
The number of workers' compensation claims and total
medical payments are higher for claims by obese claimants.
Obesity increases the risk for other injuries and
illnesses.
In the United States, the prevalence of obesity measured
by body mass index (BMI) over 30 has increased by more than two since
1990, and continues to increase.
Employment trends in healthcare: \5\
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\5\ Bureau of Labor Statistics, U.S. Department of Labor, Career
Guide to Industries, 2010-11 Edition, Healthcare, on the Internet at
http://www.bls.gov/oco/cg/cgs035.htm (visited June 17, 2010).
Wage and salary employment in the healthcare industry is
projected to increase 22 percent through 2018, compared to 11 percent
for all industries combined.
Employment growth is expected to account for about 22
percent of all wage and salary jobs added to the economy over the 2008-
18 period.
Projected rates of employment growth for the various
segments of the industry range from 10 percent in hospitals, the
largest and slowest growing industry segment, to 46 percent in the much
smaller home healthcare services.
Employment in healthcare will continue to grow due to many
contributing factors: \5\
The proportion of the population in older age groups will
grow faster than the total population between 2008 and 2018.
Older persons have a higher incidence of injury and
illness and often take longer to heal from maladies--as a result,
demand for healthcare services will increase, especially in employment
settings specializing in geriatric care.
Employment in home healthcare and nursing and residential
care settings should increase rapidly as life expectancies rise, and
families are less able to care for their elder family members and rely
more on long-term care facilities.
Severely ill patients will live longer: \5\
Advances in medical technology will continue to improve
the survival rate of severely ill and injured patients, who will then
need extensive therapy and care.
New technologies will continue to enable earlier
diagnoses of many diseases which often increase the ability to treat
conditions that were previously not treatable.
Employment changes across worksites: \5\
Because of cost pressures, healthcare facilities may
reduce their staff to reduce labor costs, distributing the same amount
of work over fewer healthcare workers.
Where patient care demands and regulations allow,
healthcare facilities will substitute lower paid providers and will
cross-train their workforces.
Traditional inpatient hospital positions are no longer
the only option for many future healthcare workers; persons seeking a
career in the field must be willing to work in various employment
settings.
Hospitals will be the slowest growing segment within the
healthcare industry because of efforts to control hospital costs,
shorten lengths of hospital stays, and increase the use of outpatient
clinics and other alternative care sites.
Question 2. In your testimony, you make reference to the aging
nursing population and that, ``this aging trend has raised concerns
that future retirements could substantially reduce the size of the U.S.
nurse workforce.'' I am fully aware of the alarming nursing shortage we
have across the Nation and in North Carolina. North Carolina's nursing
shortage ranks 19th highest in the Nation. My State nurse shortage is
already over 8,000 and only projected to get worse. My question to you
is: what impact would safe patient handling and lifting standards have
on the current nursing workforce and the new generation of nurses?
Answer 2. Safe patient handling and lifting standards would reduce
injuries in current and future nurses and potentially keep them from
leaving the field due to back injuries. Our data has shown that
mechanical assisted lifting, when used within a safe lifting program,
reduces the number of injuries in nurses. It has been estimated that
approximately 12 percent of nurses who planned to leave the profession
cited back injuries as a contributing factor for leaving the
profession. This statistic does not include the nurses who have
sustained permanently disabling work-related injuries and are unable to
return to work.
senator isakson
Question 1. Legislation before this committee, S. 1788, would
``require the use of engineering controls to perform lifting,
transferring, and repositioning of patients and the elimination of
manual lifting of patients by direct-care registered nurses and all
other health care workers, through the use of mechanical devices to the
greatest degree feasible except where the use of safe patient handling
practices can be demonstrated to compromise patient care.'' The
standard would apply to all health care facilities including, but not
limited to, out-patient centers, rehabilitation facilities, skilled
nursing facilities, nursing homes, and home health care. How would such
a rigid standard be flexible enough to account for the myriad of
patient treatments at a wide range of facilities?
Answer 1. The proposed standard appears to be flexible enough to
accommodate a variety of healthcare needs. There are several different
types of mechanical lifts available to assist patients with mobility
restrictions. The type of equipment prescribed for a particular patient
depends on the healthcare setting, the nature of the transfer task, the
patient's ability to bear weight, the patient's weight, the
cooperativeness of the patient, the patient's upper body strength, the
patient's overall ability to assist with the transfer, and the needs of
the patient. The fundamental principle of any safe patient handling and
movement program, regardless of the type of facility, is the use of
mechanical lifting equipment to eliminate the manual lifting of
patients by healthcare workers.
Question 2. Would a health care facility in minimal compliance with
Minnesota's standard need to make additional alterations to meet the
new standard imagined by S. 1788?
Answer 2. No, if the pending Federal legislation were enacted,
facilities in Minnesota that are meeting the minimal requirements of
the existing Minnesota State law should already be in compliance with
the standards proposed by S. 1788.
Question 3. How many years do you think it would take every health
care facility in Minnesota to reach the new standard imagined by S.
1788?
Answer 3. If the pending Federal legislation were enacted,
facilities in Minnesota that are meeting the minimal requirements of
the existing Minnesota State law should already be in compliance with
the standards proposed by S. 1788.
Question 4. How much do you think health care facilities in
Minnesota would have to spend to implement every aspect of S. 1788?
Answer 4. Healthcare facilities in Minnesota that are in compliance
with the Minnesota State law should not have to spend any additional
money to be in compliance with the Federal law. Further, research has
shown that the initial capital investment in lifting equipment and
worker training is recovered based on savings in workers' compensation
expenses in 3 to 5 years.
Question 5. Similarly, would a health care facility in minimal
compliance with Washington State's standard need to make additional
alterations to meet the new standard imagined by S. 1788?
How many years do you think it would take every health care
facility in Washington to reach the new standard imagined by S. 1788?
How much do you think health care facilities in Washington would have
to spend to implement every aspect of S. 1788?
Answer 5. The law in Washington State applies only to hospitals.
Thus, other healthcare facilities would need alterations to meet the
standard proposed in S. 1788. NIOSH is not in a position to assess how
long it would take every healthcare facility in Washington to reach the
standard proposed by S. 1788 or how much healthcare facilities would
have to spend to comply with such a standard.
Question 6. Does any State in the union proscribe manual lifts of
patients? Does any State require the use of engineering controls to
perform lifting, transferring, and repositioning of all patients?
Answer 6. No State proscribes manual lifting; however, Illinois,
Maryland, Minnesota, New Jersey, Rhode Island, Texas and Washington
have enacted laws (citations provided below) to restrict/ reduce manual
lifting of patients by requiring engineering controls with exceptions
to certain circumstances.
Illinois: 210 ILL. COMP. STAT. ANN. 85/6.25.
Maryland: MD. CODE ANN., Health 19-377.
Minnesota: MINN. STAT. ANN. 182.6553.
New Jersey: NJ. STAT. ANN. 26:2H-14.8-14.14.
Rhode Island: R.I. GEN. LAWS 23-17-59.
Texas: TEX. CODE ANN. HEALTH & SAFETY 256.002.
Washington: WASH. REV. CODE ANN. 70.41.390 AND 72.23.390.
Response to Questions of Senator Hagan by Michael Hodgson, M.D., MPH
Question 1. In your testimony, you discussed how the VA system has
implemented safe patient handling and lifting policies. I welcome the
idea that these policies promote a culture of safety and provide an
environment for safe patient handling for patients and staff, in
addition to lowering costs. My question to you is: What have you
experienced working with the lifting equipment and the need for
maintenance and replacement? At what frequency does lifting equipment
need to be replaced?
Answer 1. Clearly, effective maintenance programs and plans are an
essential element if the safe patient handling initiative is to be
successful. These maintenance programs require input both from patient
care staff (nursing and infection control), and engineering staff
(biomedical engineering or other engineering departments). These
programs should include planning for slings, electrical and electronic
equipment maintenance, and repairs. Backup plans when equipment is not
functional or in repair are also important.
There are no formal data on replacement frequency, as of yet. Our
assumptions have been that the program likely needs to be refreshed at
least every 10 years because technology ages. In general, this type of
equipment has two major components to consider. The rail system,
following normal standards, is designed for infinite life or at least a
20-year minimum. Only failures to maintain the system connections, or
overload of the system connections, will generally result in an earlier
life termination. The second is the lift unit. It too, if properly
maintained, would last mechanically for at least 10 years. Overload,
battery death, or preventive maintenance failures would shorten the
life. The major wear points are the lift belt/strap/cable/chain and the
batteries/hand controls/power supply wipers/brushes. VA assumes the
need for new batteries every 3 years, at a maximum, and new belts every
year for a normally used unit, with 7-10 lifts per day. Preventive
maintenance always follows the manufacturer's recommendations, or will
be more frequent as needed.
On the other hand, new technology is developed every year, and some
of that is very useful in preventing injuries. For example, VA's
program, designed in 2006, was based on publications from 2006 and
earlier. As a result, since that time VA's national program has
evolved. Additional benefits have been recognized, including reductions
in skin problems (ulcers) and other improved patient care outcomes.
Question 2. Furthermore, would health facilities benefit from
budgeting for maintenance and replacement expenses versus budgeting for
unpredictable expenses due to injuries?
Answer 2. Yes. This benefit has been used to justify the
implementation of safe patient handling programs.
[Whereupon, at 3:54 p.m., the hearing was adjourned.]