Ergonomics Major Assignment: Patient Lifting

Occupational Hygiene & ErgonomicsErgonomics Analysis of Patient Lifting in Emergency RoomIkhwan Muhammad (1633893)

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Name: Ikhwan Muhammad Date: 12th September 2011

Ergonomics Analysis of Patient Lifting in Emergency Room

INTRODUCTION

This report analyzes the ergonomics aspect of patient lifting in Emergency Room. The author observes the practices in the Emergency Room of Cut Nyak Dhien Hospital Aceh, Indonesia. Cut Nyak Dhien Hospital is a government hospital in Meulaboh, a rural area in West Aceh, which suffered a massive destruction when Tsunami hit Aceh in 2004.

BACKGROUND AND LITERATURE REVIEW

Health and community services are known as a dangerous work sites for workers. The data collected by Safe Work Australia (2009) shows that in 2010-2011 there are 18030 claims for serious injury/illness in Australia. 14% of all serious workers compensation claims in three years period (2008-2011) are from this industry alone. Slightly more than half of this claims is associated with manual handling tasks, including lifting/handling tools/equipments. Among the health and community service workers, nurses have the higher tendencies of suffering work related injury and illness. The nurses are frequently faced to manual handling hazards; not only when they are directly doing nursing actions to patient but also in indirect patient care tasks (Retsas & Pinikahana 2008).Patient lifting/transferring is considered as one of as the hardest manual handling task to conduct compared to other (Garg, Owen & Carlson 1992; Retsas & Pinikahana 2008); this is reasonable because the body of a human is not something that can be easily gripped thus hard to lift without adopting awkward positions (Occupational Safety and Health Service 1993). Furthermore, numerous researches have proven the association between manual patient lifting and the incidences of back injury (Evanoff et al. 2003).Comment by Richard Fuller: Yes, well identifiedIn addition, Devereux (2004) also outline several psychosocial risk factors associated with back pain complaints which are also apparent in the nurses working condition (e.g. constant time pressure, pressure to work overtime, increasing demand of the job, sacrificing too much for the job, role conflict, threat of physical harm or injury)Comment by Richard Fuller: ExcellentThe combination of the physical and the psychosocial risk factors is complicated by the shared common culture of health care facilities. As emphasized by Reason (2000), it is common for healthcare institution to develop blame culture in reports of accident. Therefore, it is possible that the real number is far more than what is reported.Comment by Richard Fuller: This is an important pointUnfortunately, although the risk of manual handling in health and community services is apparent, many healthcare facilities in a developing country like Indonesia havent adopted ergonomic consideration and the incidences of back injury is still high (Fatoni, Handoyo & Swasti 2009). The consideration is even more crucial in a dynamic emergency situation.Moreover, the study on rural nurses in Australia reveals that they conduct more patient lifting and have lower psychological level compared to metropolitan nurses (Australian Safety and Compensation Council 2008). This condition put them to a greater risk of injury.Based on these reasons, it is essential to analyze the ergonomics of manual lifting practices in Emergency Room in Indonesias rural healthcare facilities and to provide recommendation for improvements.METHODOLOGY OF ERGONOMIC ANALYSIS

Figure 1. Ergonomic Framework (Grey et al 1987 in Rothmore 2012)

This report is based on the six components of Ergonomics Frameworks according to Grey et al (i.e. person, task, tools/workstation, environment, work organization, and company culture) (Grey et al 1987 in Rothmore 2012), therefore the report will observe:

1. The nurses personal characteristics: skills, health condition, stature/height, weight, age, limitation, experience and knowledge in manual lifting.

2. The manual patient lifting task: ergonomic assessment tools (REBA, checklist in National Code of Practice 2007), posture, repetitive/sustained forces exerted, speed of movement, duration, frequency, and condition of patient as the load of this task.

3. The tools/workstation used in the patient lifting: condition of bed, patient lifting assistance devices, manual handling aids.

4. The surrounding environment (Emergency Room): lighting, noise, thermal condition (heat and humidity), flooring, housekeeping, placement of the furniture and tools.

5. The work organization in the Emergency Department: time constraints, availability of resources and guidance, staffing levels, shift and rest-break arrangement, provision of education and training, manual lifting assessment system, division of responsibilities, distribution of workload, team-lifting procedure, documentation of injury, work practice inspection schedule, injury report system, and availability of safety committee.

6. The culture in the Emergency department: safety culture, ergonomic awareness, team work, and goals/objectives.

FINDINGS AND DISCUSSIONS

1. The nurses personal characteristicsFrom the data registration, the majority of the nurses are male (sixteen nurses), only seven of them are female. The age of the nurse range from twenty three to thirty one years old.

Figure 2. The Gender of the Nurses

Figure 3. The Age of the Nurses

The nurses told that they did not receive any training/induction program prior to their placement. However, they consider themselves familiar with the task as it is taught in diploma of nursing. Three nurses are new workers and two nurses have more than five years of experience of working in Emergency Room. None of the nurses report injury associated with patient lifting.

2. The manual patient lifting task

The observations reveal that the nurses adopt awkward postures while conducting the task, this include bending, twisting, and reaching which all pose risk to injury (Australian Safety and Compensation Council 2007). The load of the task varies and is unpredictable. No lifting assessment system. No certain procedures in conducting the task; in most cases two nurses and two patients family do the lifting.

Figure 4. Patient Lifting

The duration of the task is between 1-2 minutes, while the frequency varies up to eight tasks per shift. In a mass accident (e.g. traffic accident, food poisoning) the nurses conduct repetitive manual patient lifting procedures without adequate rest break/recovery time. Comment by Richard Fuller: Important statistics

The result of REBA (Hignett & McAtamney 2000) (see appendix 1) shows that the score is 8-10 and the task is considered as high risk. The result of the checklist in National Code of Practices (Australian Safety and Compensation Council 2007)(see appendix 2) indicates problems in nature of the load handled, the design of the workplace, the equipment used, and the work organization.

3. The tools/workstation used in the patient lifting

There are two tools used in the procedures of manual patient lifting in this Emergency Room; transport beds and patient beds. No patient lifting assistance devices are provided. The patient beds are in a fixed position without wheels and adjusting control. Only the back rest can be adjusted.

Figure 5. Patient Bed

The transport beds are equipped with adjusting control, wheels, and brakes which are in a good condition.

Figure 6. Transport Bed

4. The surrounding environment (Emergency Room)

Figure 7. Emergency Room

The room is equipped with numbers of lighting which suffice the visual requirement of the task. The room temperature is not measured but considered sufficient by the staff. There are four air conditioning facilities, although not all of them are working well but the nurses dont have problem because the room is well ventilated. The floor is not slippery and is cleaned daily. One of the notable problems here is the short distance between the beds, which is insufficient for transferring the patient from/to transport beds.

Figure 8. Space Between Bed

5. Work organization

There are three shifts each day; the morning and the afternoon shift last for six hours, while the night shift last for twelve hour. In each shift, there are four nurses, one transporter, and one administration staff in charge. The four nurses are in charge of the six patient beds in the emergency room. There are schedule rotations between the nurses, up to four shifts per week. There is no division of task between nurses, no training or induction program, and no accident/injury registration. Another problem is that the number of nurse is not adequate for team lifting. In a situation where the patient beds are full (six beds), the nurses ask the patients family to help them lifting the patient. Comment by Richard Fuller: Important for many reasons including re-assessment risk post intervention and particularly for development of a just and fair culture where reporting hazards, risks and injury problems is encouraged

6. Company culture

The interviews reveal that there is no ergonomic awareness among the staff and no clear safety objectives stated in the protocols or working procedures. The tools and equipments used in the facilities are not designed with ergonomics consideration.

RECOMMENDATIONS FOR IMPROVEMENT

Elimination of manual handling task itself should be prioritized in the apparent presence of manual handling hazard (Australian Safety and Compensation Council 2007). However, it is impossible to eliminate the hazard and the risk posed in patient lifting task, therefore the best option would be changing the way patient lifting is performed to minimize the risks. Based on the ergonomic analysis, the improvements can be achieved by altering the nature of the load handled, the design of the workplace, the equipment used, and the work organization.

A. Alter the design of the workplaceProvide sufficient space between patients beds

The space around the patient bed should accommodate the use of patient lifting assistance device and the procedure of team lifting. Comment by Richard Fuller: excellentComment by Richard Fuller: yes

B. Alter the nature of the load handled

Introduce patient lifting assistance devices and provide training for lift usage

The use of patient lifting assistance device will significantly reduce the burden of patient lifting task. Its effectiveness in reducing the incidences of musculoskeletal injuries has been outlined in numerous studies (Collins et al. 2004; Evanoff et al. 2003; Li, Wolf & Evanoff 2004). Among the devices, pat slides (sliding board) and slings are the frequently used devices by nurses (Retsas & Pinikahana 2008). However, the high cost of the devices would make it hard for the hospital management to adopt this option. There are also reasons that prevent nurses from using the devices although it is available for use; most of these relate with the impracticality of the devices in a real time situation (Retsas & Pinikahana 2008). Therefore, the nurses should be involved in the discussion if the hospital management decides to provide the devices to ensure that it will suffice their need in the task. Comment by Richard Fuller: Relatively low costComment by Richard Fuller: Also hover mats and overhead lifting devices which are high costComment by Richard Fuller: Important point

C. Alter the equipment used

Use ergonomically designed patient bed

The hospital management needs to provide adjustable patient bed to prevent the nurses from adopting awkward position while conducting the task. The height of the beds should be able to adjust so that the patient can be positioned between the nurses waist level and the nurses can adopt upright and forward facing posture (Occupational Safety and Health Service 1993). The control to adjust should be well-positioned in the appropriate reach distance of the nurses.Comment by Richard Fuller: This may be an important risk control for avoiding awkward postures

D. Alter the work organization

Provision of injury prevention and rehabilitation program

The hospital management should clearly establish injury prevention and rehabilitation program. A team should be designated to conduct periodical review and monitor the progress of the program.Comment by Richard Fuller: important

Patient lifting education, training and induction programComment by Richard Fuller: ? manual handling or manual task performance may be better

The hospital management need to provide training on patient lifting prior to the nurses placement, which cover general health and safety policies and procedures, body structure and function, reporting procedures, control of manual handling activities, patient assessment, injury management policy, patient handling, safe use of equipment, and team lifting (Occupational Safety and Health Service 1993). However, defining what is proper in patient lifting procedures is problematic. Therefore, provision of training alone without implementation of other control options (e.g. provision of manual lifting assistance device) is not sufficient (Nelson, Fragala & Menzel 2003). Comment by Richard Fuller: yes, training has a place and should also include risk assessment and risk management principles and practice, and biomechanics

Assessment of patients handling requirement

Every patient that requires assistance should be assessed prior to the lifting. According to Occupational Safety and Health Service (1993) the assessment should include the degree of patient mobility, the type of lift/transfer likely to be needed, any lift/transfer that must not be used, the number of staff required to lift/transfer the patient/resident, equipment/mechanical assistance needed, the patients ability to understand and co-operate with instructions, the likelihood that the patient will become aggressive, the likelihood that the patient will become contracted, the likelihood that the patient will make uncontrolled movement, and special needs.

Division of workload

There should be a clear division of workload. High frequency and duration of patient lifting increase the risk of injury (Occupational Safety and Health Service 1993); therefore the burden of the task need to be spread evenly among the nurses.

Increase number of nurses in charge per shift

In an emergency case where patient need assistance of more than one person, the task should be done in team. It is emphasized that the number of workers is in proportion to the weight of the load and the difficulty of the lift and that those lifting have been trained to team lift (Australian Safety and Compensation Council 2007). Therefore the number of nurses in charge per shift should be increased to accommodate team lifting and to prevent any untrained person (e.g. patients family, administration staff) take part.

Safety policy in compliances with legislation, standard, and national code of practice

In an Australian setting, the policy and the implementation of ergonomic program should be in accordance with Work Health and Safety Act 2010, National Code of Practice for the Prevention of Musculoskeletal Disorders from Performing Manual Tasks at Work (Australian Safety and Compensation Council 2007) and AS/NZS ISO 31000:2009 Risk managementPrinciples and guidelines (Standards Australia 2004).Comment by Richard Fuller: good

REFERENCES

Australian Safety and Compensation Council 2007, National Code of Practice for the Prevention of Musculoskeletal Disorders from Performing Manual Tasks at Work, Commonwealth of Australia, Canberra.

2008, Occupational Health and Safety risk factors for rural and metropolitan nurses: comparative results from a national nurses survey, Commonwealth of Australia, Canberra.

Collins, J, Wolf, L, Bell, J & Evanoff, B 2004, 'An evaluation of a best practices musculoskeletal injury prevention program in nursing homes', Injury Prevention, vol. 10, no. 4, pp. 206-211.

Devereux, J 2004, The role of work stress and psychological factors in the development of musculoskeletal disorders: The stress and MSD study, HSE Books.

Evanoff, B, Wolf, L, Aton, E, Canos, J & Collins, J 2003, 'Reduction in injury rates in nursing personnel through introduction of mechanical lifts in the workplace', American journal of industrial medicine, vol. 44, no. 5, pp. 451-457.

Fatoni, H, Handoyo, H & Swasti, KG 2009, 'Hubungan Sikap dan Posisi Kerja dengan Low Back Pain pada Perawat di RSUD Purbalingga', Jurnal Keperawatan Soedirman (JKS), vol. 4, no. 3, pp. 131-139.

Garg, A, Owen, B & Carlson, B 1992, 'An ergonomic evaluation of nursing assistants' job in a nursing home', Ergonomics, vol. 35, no. 9, pp. 979-995.

Hignett, S & McAtamney, L 2000, 'Rapid entire body assessment (REBA)', Applied ergonomics, vol. 31, no. 2, pp. 201-205.

Li, J, Wolf, L & Evanoff, B 2004, 'Use of mechanical patient lifts decreased musculoskeletal symptoms and injuries among health care workers', Injury Prevention, vol. 10, no. 4, pp. 212-216.

Nelson, A, Fragala, G & Menzel, N 2003, 'Myths and Facts About Back Injuries in Nursing: The incidence rate of back injuries among nurses is more than double that among construction workers, perhaps because misperceptions persist about causes and solutions. The first in a two-part series', AJN The American Journal of Nursing, vol. 103, no. 2, pp. 32-40.

Occupational Safety and Health Service 1993, Back in Care: Preventing musculoskeletal injuries in staff in hospitals and residential care facilities, Occupational Safety and Health Service, Wellington, .

Reason, J 2000, 'Human error: models and management', BMJ, vol. 320, no. 7237, pp. 768-770.

Retsas, A & Pinikahana, J 2008, 'Manual handling activities and injuries among nurses: an Australian hospital study', Journal of advanced nursing, vol. 31, no. 4, pp. 875-883.

Rothmore, P 2012, 'Module 2: physical ergonomics', lecture notes in the topic Ergonomics: Occupational Hygiene and Ergonomics.

Safe Work Australia 2009, Work related injuries 2005-06: health and community service industry, Safe Work Australia, .

Standards Australia 2004, AS/NZS ISO 31000:2009 Risk managementPrinciples and guidelines, Standards Australia, Sydney, .

Appendix 1. Rapid Entire Body Assessment (REBA) sheetIkhwan Muhammad - 1633893Page 2