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• Manual lifting of residents be minimized in all cases and eliminated when feasible.
  
  
• 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.
    

• submit suggestions or concerns;
• discuss the workplace and work methods;
• participate in the design of work, equipment, procedures, and training;
• evaluate equipment;
• respond to employee surveys;
• participate in task groups with responsibility for ergonomics; and
• participate in developing the nursing home's ergonomics process.

• the level of assistance the resident requires;
  
• the size and weight of the resident;
  
• the ability and willingness of the resident to understand and cooperate; and
  
• any medical conditions that may influence the choice of methods for lifting or repositioning.

• The Resident Assessment Instrument published by the Centers for Medicare and Medicaid Services (CMS) provides a structured, standardized approach for assessing resident capabilities and needs that results in a care plan for each resident. Caregivers can use this information to help them determine the appropriate method for lifting or repositioning residents. Many nursing homes use this system to comply with CMS requirements for nursing homes. Employers can access this information from http://www.osha.gov/pls/oshaweb/owaredirect.html?p_url=http://www.cms.hhs.gov/medicaid/mds20/.
  
  
• Patient Care Ergonomics Resource Guide: Safe Patient Handling and Movement is published by the Patient Safety Center of Inquiry, Veterans Health Administration and the Department of Defense. This document provides flow charts (shown here in Figures 1-6) that address relevant resident assessment factors and recommends solutions for resident lifting and repositioning problems. This material is one example of an assessment tool that has been used successfully. Employers can access this information from http://www.osha.gov/pls/oshaweb/owaredirect.html?p_url=http://www.patientsafetycenter.com Nursing home operators may find another tool or develop an assessment tool that works better in their facilities.
  
  
• ·Appendix A of the Settlement Agreement between OSHA and Beverly Enterprises entitled Lift Program Policy and Guide recommends solutions for resident lifting and repositioning problems, based on the CMS classification system. (A rating of "4" indicates a totally dependent resident. A "3" rating indicates residents that need extensive assistance. A "2/1" rating indicates residents that need only limited assistance/general supervision. Residents rated "0" are independent.) Employers can access this information from http://www.osha.gov/index.html.

FIGURE 1. Transfer to and from: Bed to Chair, Chair to Toilet, Chair to Chair, or Car to Chair. Can patient bear weight? Fully Caregiver assistance not needed; stand by for safety as needed.   Partially   No Is the Patient cooperative? Yes Stand and pivot technique using a gait/transfer belt (1 careviger) -or- powered standing assist lift (1 caregiver) Is the Patient cooperative? No No     Use full body sling lift and 2 caregivers.   Yes     - For seated transfer aid, must have chair with arms that recess or are removable. - For full body sling lift, select a lift that was specifically designed to access a patient from the car (if the car is the starting or ending destination). - If partial weight bearing, transfer toward stronger side. - Toileting slings are available for toileting. - Bathing mesh slings are available for bathing. Does the Patient have upper extremity strength? No     Yes         Seated transfer aid; may use gait/transfer belt until the Patient is proficient in completing transfer independently.       FIGURE 2. Lateral Transfer to and from: Bed to Stretcher, Trolley     Caregiver assistance not needed; stand by for safety as needed.   Yes Partially Able Not At All Able If patient is <100 pounds: Use a lateral sliding aid and 2 caregivers.   Can Patient assist?   If patient is 100-200 pounds: Use a lateral sliding aid -or- a friction reducing device and 2 caregivers.     Partially Able Not At All Able If patient is >200 pounds: Use a lateral sling aid and 3 caregivers -or- a friction-reducing device or lateral transfer device and 2 caregivers -or- a mechanical lateral transfer device.

	FIGURE 3. Transfer to and from: Chair to Stretcher
	Is the Patient cooperative?	No	Use full-body sling lift and 2 or more caregivers.
	Yes
	Can the Patient bear weight?	Fully	Caregiver assistance not needed, stand by for safety as needed.
		Partially	If exam table/stretcher can be positioned to a low level, use a non-powered stand-assist aid. If not, use a full-body sling lift.
	No

FIGURE 4. Reposition in Bed: Side–to-Side, Up in Bed
			Caregiver assistance not needed; patient may/may not use positioning aid.
	Can Patient assist?	Fully			If patient is >200 pounds: Use a friction-reducing device and at least 3 caregivers.
		Partially
	No		Encourage patient to assist using a positioning aid or cues.
	Use full-body sling lift -or- friction-reducing device and 2 or more caregivers.				If patient is <200 pounds: Use a friction-reducing device and 2-3 caregivers.

This is not a one person task - DO NOT PULL FROM HEAD OF BED. When pulling a patient up in bed, the bed should be flat or Trendelenburg position to aid in gravity, with the side rail down. For patient with Stage III or IV pressure ulcers, care should be taken to avoid shearing force. The height of the bed should be appropriate for staff safety (at the elbows). If the patient can assist when repositioning “up in bed”, ask the patient to flex the knees and push on the count of three.

FIGURE 5. Reposition in Chair: Wheelchair and Dependency Chair
			Caregiver assistance not needed; stand by for safety as needed.
	Can Patient assist?	Fully
		Partially
	No		If Patient has upper extremity strength in both arms, have patient lift up while caregiver pushes knees to reposition. If Patient lacks sensation, cues may be needed to remind Patient to reposition.
	Does chair recline?	Yes
			Recline chair and use a friction-reducing device and 2 caregivers.
	No
	Is Patient cooperative?	Yes	Use full-body sling lift -or- non-powered stand-assist aid and 1 to 2 caregivers.
		No	Use full-body sling lift and 2 or more caregivers.

FIGURE 6. Transfer a Patient Up From The Floor
	Was Patient injured?	Yes	Was the injury minor?	No		Depends on type and severity of injury (follow Standard Operating Procedures).
	No1		Yes
				Is Patient independent?1			No	Full-body sling lift needed with 2 or more caregivers.
				Yes
				Caregiver assistance not needed; stand by for safety as needed.
	Comments: Use full-body sling that goes all the way down to the floor (most of the newer models are capable of this). 1Modifications made with concurrence of Dr. Audrey Nelson at Veterans Administration Hospital, Tampa, Florida.

Implementing Solutions for Resident Lifting and Repositioning The recommended solutions presented in the following pages are not intended to be an exhaustive list, nor does OSHA expect that all of them will be used in any given facility. The information represents a range of available options that a facility can consider using. Many of the solutions are simple, common sense modifications to equipment or procedures that do not require substantial time or resources to implement. Others may require more significant efforts. The integration of various solutions into the nursing home is a strategic decision that, if carefully planned and executed, will lead to long-term benefits. Administrators should also be cognizant of several factors that might restrict the application of certain measures, such as residents' rehabilitation plans, the need for restoration of functional abilities, other medical contraindications, emergency conditions, and residents' dignity and rights. The procurement of equipment and the selection of an equipment supplier are important considerations when implementing solutions. Employers should establish close working relationships with equipment suppliers. Such working relationships help with obtaining training for employees, modifying the equipment for special circumstances, and procuring parts and service when needed. Employers will want to pay particular attention to the effectiveness of the equipment, especially the injury and illness experience of other nursing homes that have used the equipment. The following questions are designed to aid in the selection of the equipment and supplier that best meets the needs of an individual nursing home. Availability of technical service - Is over-the-phone assistance, as well as onsite assistance, for repairs and service of the lift available? Availability of parts - Which parts will be in stock and available in a short time frame and how soon can they be shipped to your location? Storage requirements - Is the equipment too big for your facility? Can it be stored in close proximity to the area(s) where it is used? If needed, is a charging unit and back up battery included? What is the simplicity of the charging unit and space required for a battery charger if one is needed? If the lift has a self-contained charging unit, what is the amount of space necessary for charging and what electrical receptacles are required? What is the minimum charging time of a battery? How high is the base of the lift and will it fit under the bed and various other pieces of furniture? How wide is the base of the lift or is it adjustable to a wider and lockable position? How many people are required to operate the lift for lifting of a typical 200-pound person? Does the lift activation device (pendant) have remote capabilities? How many sizes and types of slings are available? What type of sling is available for optimum infection control? Is the device versatile? Can it be a sit-to-stand lift, as well as a lift device? Can it be a sit-to-stand lift and an ambulation-assist device? What is the speed and noise level of the device? Will the lift go to floor level? How high will it go? Based on many factors including the characteristics of the resident population and the layout of the facility, employers should determine the number and types of devices needed. Devices should be located so that they are easily accessible to workers. If resident lifting equipment is not accessible when it is needed, it is likely that other aspects of the ergonomics process will be ineffective. If the facility can initially purchase only a portion of the equipment needed, it should be located in the areas where the needs are greatest. Employers should also establish routine maintenance schedules to ensure that the equipment is in good working order. The following are examples of solutions for resident lifting and repositioning tasks. Transfer from Sitting to Standing Position Description: Powered sit-to-stand or standingassist devices. When to Use: Transferring residents who are partially dependent, have some weight-bearing capacity, are cooperative, can sit up on the edge of the bed with or without assistance, and are able to bend hips, knees, and ankles. Transfers from bed to chair (wheel chair, Geri or cardiac chair), or chair to bed, or for bathing and toileting. Can be used for repositioning where space or storage is limited. Points to Remember: Look for a device that has a variety of sling sizes, lift-height range, battery portability, hand-held control, emergency shut-off, and manual override. Ensure device is rated for the resident weight. Electric/battery powered lifts are preferred to crank or pump type devices to allow smoother movement for the resident, and less physical exertion by the caregiver. Resident Lifting Description: Portable lift device (sling type); can be a universal/hammock sling or a band/leg sling When to Use: Lifting residents who are totally dependent, are partial- or non-weight bearing, are very heavy, or have other physical limitations. Transfers from bed to chair (wheel chair, Geri or cardiac chair), chair or floor to bed, for bathing and toileting, or after a resident fall. Points to Remember: More than one caregiver may be needed. Look for a device with a variety of slings, lift-height range, battery portability, hand-held control, emergency shut-off, manual override, boom pressure sensitive switch, that can easily move around equipment, and has a support base that goes under beds. Having multiple slings allows one of them to remain in place while resident is in bed or chair for only a short period, reducing the number of times the caregiver lifts and positions resident. Portable compact lifts may be useful where space or storage is limited. Ensure device is rated for the resident weight. Electric/battery powered lifts are preferred to crank or pump type devices to allow a smoother movement for the resident, and less physical exertion by the caregiver. Enhances resident safety and comfort. Resident Lifting Description: Ceiling mounted lift device When to Use: Lifting residents who are totally dependent, are partial- or non-weight bearing, very heavy, or have other physical limitations. Transfers from bed to chair (wheel chair, Geri or cardiac chair), chair or floor to bed, for bathing and toileting, or after a resident falls. A horizontal frame system or litter attached to the ceiling-mounted device can be used when transferring residents who cannot be transferred safely between 2 horizontal surfaces, such as a bed to a stretcher or gurney while lying on their back, using other devices. Points to Remember: More than one caregiver may be needed. Some residents can use the device without assistance. May be quicker to use than portable device. Motors can be fixed or portable (lightweight). Device can be operated by hand-held control attached to unit or by infrared remote control. Ensure device is rated for the resident weight. Increases residents' safety and comfort during transfer. Ambulation Description: Ambulation assist device When to Use: For residents who are weight bearing and cooperative and who need extra security and assistance when ambulating. Points to Remember: Increases resident safety during ambulation and reduces risk of falls. The device supports residents as they walk and push it along during ambulation. Ensure height adjustment is correct for resident before ambulation. Ensure device is in good working order before use and rated for the resident weight to be lifted. Apply brakes before positioning resident in or releasing resident from device. Lateral Transfer; Repositioning Description: Devices to reduce friction force when transferring a resident such as a draw sheet or transfer cot with handles to be used in combination slippery sheets, low friction mattress covers, or slide boards; boards or mats with vinyl coverings and rollers; gurneys with transfer devices; and air-assist lateral sliding aid or flexible mattress inflated by portable air supply. When to Use: Transferring a partial- or non-weight bearing resident between 2 horizontal surfaces such as a bed to a stretcher or gurney while lying on their back or when repositioning resident in bed. Points to Remember: More than one caregiver is needed to perform this type of transfer or repositioning. Additional assistance may be needed depending upon resident status, e.g., for heavier or non-cooperative residents. Some devices may not be suitable for bariatric residents. When using a draw sheet combination use a good hand-hold by rolling up draw sheets or use other friction-reducing devices with handles such as slippery sheets. Narrower slippery sheets with webbing handles positioned on the long edge of the sheet may be easier to use than wider sheets. When using boards or mats with vinyl coverings and rollers use a gentle push and pull motion to move resident to new surface. Look for a combination of devices that will increase resident's comfort and minimize risk of skin trauma. Ensure transfer surfaces are at same level and at a height that allows caregivers to work at waist level to avoid extended reaches and bending of the back. Count down and synchronize the transfer motion between caregivers. Lateral Transfer; Repositioning Description: Convertible wheelchair, Geri or cardiac chair to bed; beds that convert to chairs. When to Use: For lateral transfer of residents who are partial- or non-weight bearing. Eliminates the need to perform lift transfer in and out of wheelchairs. Can also be used to assist residents who are partially weight bearing from a sit-to-stand position. Beds that convert to chairs can aid repositioning residents who are totally dependent, non-weight bearing, very heavy, or have other physical limitations. Points to Remember: More than one caregiver is needed to perform lateral transfer. Additional assistance for lateral transfer may be needed depending on residents status, e.g., for heavier or non-cooperative residents. Additional friction-reducing devices may be required to reposition resident. Heavy duty beds are available for bariatric residents. Device should have easy-to-use controls located within easy reach of the caregiver, sufficient foot clearance, and wide range of adjustment. Motorized heightadjustable devices are preferred to those adjusted by crank mechanism to minimize physical exertion. Always ensure device is in good working order before use. Ensure wheels on equipment are locked. Ensure transfer surfaces are at same level and at a height that allows caregivers to work at waist level to avoid extended reaches and bending of the back. Repositioning in Chair Description: Variable position Geri and Cardiac chairs When to Use: Repositioning partial- or non-weight-bearing residents who are cooperative. Points to Remember: More than one caregiver is needed and use of a friction-reducing device is needed if resident cannot assist to reposition self in chair. Ensure use of good body mechanics by caregivers. Wheels on chair add versatility. Ensure that chair is easy to adjust, move, and steer. Lock wheels on chair before repositioning. Remove trays, footrests, and seat belts where appropriate. Ensure device is rated for the resident weight. Lateral Transfer in Sitting Position Description: Transfer boards - wood or plastic (some with movable seat) When to Use: Transferring (sliding) residents who have good sitting balance and are cooperative from one level surface to another, e.g., bed to wheelchair, wheelchair to car seat or toilet. Can also be used by residents who require limited assistance but need additional safety and support. Points to Remember: Movable seats increase resident comfort and reduce incidence of tissue damage during transfer. More than one caregiver is needed to perform lateral transfer. Ensure clothing is present between the resident's skin and the transfer device. The seat may be cushioned with a small towel for comfort. May be uncomfortable for larger residents. Usually used in conjunction with gait belts for safety depending on resident status. Ensure boards have tapered ends, rounded edges, and appropriate weight capacity. Ensure wheels on bed or chair are locked and transfer surfaces are at same level. Remove lower bedrails from bed and remove arms and footrests from chairs as appropriate. Transfer from Sitting to Standing Position Description: Lift cushions and lift chairs When to Use: Transferring residents who are weight-bearing and cooperative but need assistance when standing and ambulating. Can be used for independent residents who need an extra boost to stand. Points to Remember: Lift cushions use a lever that activates a spring action to assist residents to rise up. Lift cushions may not be appropriate for heavier residents. Lift chairs are operated via a hand-held control that tilts forward slowly, raising the resident. Residents need to have physical and cognitive capacity to be able to operate lever or controls. Always ensure device is in good working order before use and is rated for the resident weight to be lifted. Can aid resident independence. Transfer from Sitting to Standing Position Description: Stand-assist devices can be fixed to bed or chair or be free-standing When to Use: Transferring residents who are weight-bearing and cooperative and can pull themselves up from sitting to standing position. Can be used for independent residents who need extra support to stand. Points to Remember: Check that device is stable before use and is rated for resident weight to be supported. Ensure frame is firmly attached to bed, or if it relies on mattress support that mattress is heavy enough to hold the frame. Can aid resident independence. Weighing Description: Scales with ramp to accommodate wheelchairs; portablepowered lift devices with built-in scales; beds with built-in scales. When to Use: To reduce the need for additional transfer of partialor non-weight-bearing or totally dependent residents to weighing device. Points to Remember: Some wheelchair scales can accommodate larger wheelchairs. Built-in bed scales may increase weight of the bed and prevent it from lowering to appropriate work heights. Transfer from Sitting to Standing Position; Ambulation Description: Gait belts/transfer belts with handles When to Use: Transferring residents who are partially dependent, have some weight-bearing capacity, and are cooperative. Transfers such as bed to chair, chair to chair, or chair to car; when repositioning residents in chairs; supporting residents during ambulation; and in some cases when guiding and controlling falls or assisting a resident after a fall. Points to Remember: More than one caregiver may be needed. Belts with padded handles are easier to grip and increase security and control. Always transfer to resident's strongest side. Use good body mechanics and a rocking and pulling motion rather than lifting when using a belt. Belts may not be suitable for ambulation of heavy residents or residents with recent abdominal or back surgery, abdominal aneurysm, etc. Should not be used for lifting residents. Ensure belt is securely fastened and cannot be easily undone by the resident during transfer. Ensure a layer of clothing is between residents' skin and the belt to avoid abrasion. Keep resident as close as possible to caregiver during transfer. Lower bedrails, remove arms and foot rests from chairs, and other items that may obstruct the transfer. For use after a fall always assess the resident for injury prior to movement. If resident can regain standing position with minimal assistance, use gait or transfer belts with handles to aid resident. Keep back straight, bend legs, and stay as close to resident as possible. If resident cannot stand with minimal assistance, use a powered portable or ceiling-mounted lift device to move resident. Repositioning Description: Electric powered height adjustable bed When to Use: For all activities involving resident care, transfer, repositioning in bed, etc., to reduce caregiver bending when interacting with resident. Points to Remember: Device should have easy-to-use controls located within easy reach of the caregiver to promote use of the electric adjustment, sufficient foot clearance, and wide range of adjustment. Adjustments are best completed within about 20 seconds to ensure staff use. Beds with a very wide range of adjustments may take longer but may also have other advantages to the caregivers and the residents. For residents that may be at risk of falling from bed some beds that lower closer to the floor may be needed. Heavy duty beds are available for bariatric residents. Beds raised and lowered with an electric motor are preferred over crank-adjust beds to allow a smoother movement for the resident and less physical exertion to the caregiver. Repositioning Description: Trapeze bar; hand blocks and push up bars attached to the bed frame When to Use: Reposition residents that have the ability to assist the caregiver during the activity, i.e., residents with upper body strength and use of extremities, who are cooperative and can follow instructions. Points to Remember: Residents use trapeze bar by grasping bar suspended from an overhead frame to raise themselves up and reposition themselves in a bed. Heavy duty trapeze frames are available for bariatric residents. If a caregiver is assisting ensure that bed wheels are locked, bedrails are lowered and bed is adjusted to caregiver's waist height. Blocks also enable residents to raise themselves up and reposition themselves in bed. Bars attached to the bed frame serve the same purpose. May not be suitable for heavier residents. Can aid resident independence. Repositioning Description: Pelvic lift devices (hip lifters) When to Use: To assist residents who also are cooperative and can sit up to a position on a special bed pan. Points to Remember: Convenience of device may reduce need for resident lifting during toileting. Device is positioned under the pelvis. The part of the device located under the pelvis gets inflated so the pelvis is raised and a special bedpan put underneath. The head of the bed is raised slightly during this procedure. Use correct body mechanics, lower bedrails and adjust bed to caregivers waist height to reduce bending. Bathtub, Shower, and Toileting Activities Description: Height adjustable bathtub and easy-entry bathtubs When to Use: Bathing residents who sit directly in the bathtub, or to assist ambulatory residents climb more easily into a low tub, or easy-access tub. Bathing residents in portable-powered or ceiling mounted lift device using appropriate bathing sling. Points to Remember: Reduces awkward postures for caregivers and those who clean the tub after use. The tub can be raised to eliminate bending and reaching for the caregiver. Use correct body mechanics, and adjust the tub to the caregiver's waist height when performing hygiene activities. Increases resident safety and comfort. Bathtub, Shower, and Toileting Activities Description: Height adjustable shower gurney or lift bath cart with waterproof top When to Use: For bathing non-weight bearing residents who are unable to sit up. Transfer resident to cart with lift or lateral transfer boards or other friction-reducing devices. Points to Remember: The cart can be raised to eliminate bending and reaching to the caregiver. Foot and head supports are available for resident comfort. May not be suitable for bariatric residents. Look for carts that are power-driven to reduce force required to move and position device. Bathtub, Shower, and Toileting Activities Description: Built-in or fixed bath lifts When to Use: Bathing residents who are partially weight bearing, have good sitting balance, can use upper extremities (have upper body strength), are cooperative, and can follow instructions. Useful in small bathrooms where space is limited. Points to Remember: Ensure that seat raises so resident's feet clear tub, easily rotates, and lowers resident into water. May not be suitable for heavy residents. Always ensure lifting device is in good working order before use and rated for the resident weight. Choose device with lift mechanism that does not require excessive effort by caregiver when raising and lowering device. Bathtub, Shower, and Toileting Activities Description: Shower and toileting chairs When to Use: Showering and toileting residents who are partially dependent, have some weight bearing capacity, can sit up unaided, and are able to bend hips, knees, and ankles. Points to Remember: Ensure that wheels move easily and smoothly; chair is high enough to fit over toilet; chair has removable arms, adjustable footrests, safety belts, and is heavy enough to be stable, and that the seat is comfortable, accommodates larger residents, and has a removable commode bucket for toileting. Ensure that brakes lock and hold effectively and that weight capacity is sufficient. Bathtub, Shower, and Toileting Activities Description: Bath boards and transfer benches When to Use: Bathing residents who are partially weight bearing, have good sitting balance, can use upper extremities (have upper body strength), are cooperative, and can follow instructions. Independent residents can also use these devices. Points to Remember: To reduce friction and possible skin tears, use clothing or material between the resident's skin and the board. Can be used with a gait or transfer belt and/or grab bars to aid transfer. Back support and vinyl padded seats add to bathing comfort. Look for devices that allow for water drainage and have height-adjustable legs. May not be suitable for heavy residents. If wheelchair is used ensure wheels are locked, the transfer surfaces are at the same level, and device is securely in place and rated for weight to be transferred. Remove arms and foot rests from chairs as appropriate and ensure that floor is dry. Bathtub, Shower, and Toileting Activities Description: Toilet seat risers When to Use: For toileting partially weight-bearing residents who can sit up unaided, use upper extremities (have upper body strength), are able to bend hips, knees, and ankles, and are cooperative. Independent residents can also use these devices. Points to Remember: Risers decrease the distance and amount of effort required to lower and raise residents. Grab bars and height-adjustable legs add safety and versatility to the device. Ensure device is stable and can accommodate resident's weight and size. Bathtub, Shower, and Toileting Activities Description: Grab bars and stand assists; can be fixed or mobile. Long-handled or extended shower heads, or brushes can be used for personal hygiene. When to Use: Bars and assists help when toileting, bathing, and/ or showering residents who need extra support and security. Residents must be partially weight bearing, able to use upper extremities (have upper body strength), and be cooperative. Long-handled devices reduce the amount of bending, reaching, and twisting required by the caregiver when washing feet, legs, and trunk of residents. Independent residents who have difficulty reaching lower extremities can also use these devices. Points to Remember: Movable grab bars on toilets minimize workplace congestion. Ensure bars are securely fastened to wall before use. Section IV. Identifying Problems and Implementing Solutions for Activities Other than Resident Lifting and Repositioning Some reports indicate a significant number of work-related MSDs in nursing homes occur in activities other than resident lifting. (2, 3) Examples of some of the activities that the nursing home operator may want to review are: bending to make a bed or feed a resident; lifting food trays above shoulder level or below knee level; collecting waste; pushing heavy carts; bending to remove items from a deep cart; lifting and carrying when receiving and stocking supplies; bending and manually cranking an adjustable bed; and removing laundry from washing machines and dryers. These tasks may not present problems in all circumstances. Employers should consider the duration, frequency, and magnitude of employee exposure to forceful exertions, repetitive activities and awkward postures when determining if problems exist in these and other areas. In the vast majority of cases, job assessments can be accomplished by observing employees performing the task, by discussing with employees the activities and conditions that they associate with difficulties, and checking injury records. Observation provides general information about the workstation layout, tools, equipment, and general environmental conditions in the workplace. Discussing tasks with employees helps to ensure that a complete picture of the process is obtained. Employees who perform a given task are also often the best sources for identifying the cause of a problem, and developing the most practical and effective solutions. Once information is obtained and problems identified, suitable improvements can be implemented. Finally, there are a number of resources available to help determine if specific activities have the potential for causing injuries. For example, support is available from OSHA's consultation program, insurance companies, and state workers' compensation programs. The following are examples of possible solutions for activities other than resident lifting and repositioning. Storage and Transfer of Food, Supplies and Medications Description: Use of carts When to Use: When moving food trays, cleaning supplies, equipment, maintenance tools, and dispensing medications. Points to Remember: Speeds process for accessing and storing items. Placement of items on the cart should keep the most frequently used and heavy items within easy reach between hip and shoulder height. Carts should have full-bearing wheels of a material designed for the floor surface in your facility. Cart handles that are vertical, with some horizontal adjustability will allow all employees to push at elbow height and shoulder width. Carts should have wheel locks. Handles that can swing out of the way may be useful for saving space or reducing reach. Heavy carts should have brakes. Balance loads and keep loads under cart weight restrictions. Ensure stack height does not block vision. Low profile medication carts with easy-open side drawers are recommended to accommodate hand height of shorter nurses. Mobile Medical Equipment Description: Work methods and tools to transport equipment When to Use: When transporting assistive devices and other equipment Points to Remember: Oxygen tanks: Use small cylinders with handles to reduce weight and allow for easier gripping. Secure oxygen tanks to transport device. Medication pumps: Use stands on wheels. Transporting equipment: Push equipment, rather than pull, when possible. Keep arms close to the body and push with whole body and not just arms. Remove unnecessary objects to minimize weight. Avoid obstacles that could cause abrupt stops. Place equipment on a rolling device if possible. Take defective equipment out of service. Perform routine maintenance on all equipment. Ensure that when moving and transporting residents, additional equipment such as oxygen tanks and IV/medication poles are attached to wheelchairs or gurneys or moved by another caregiver to avoid awkwardly pushing with one hand and holding freestanding equipment with the other hand. Working with Liquids in Houskeeping Description: Filling and emptying liquids from containers When to Use: In housekeeping areas when filling and emptying buckets with floor drain arrangements. Points To Remember: Reduces risk of spills, slips, speeds process, and reduces waste. The faucet and floor drain is used in housekeeping. Ensure that casters don't get stuck in floor grate. Use hose to fill bucket. Use buckets with casters to move mop bucket around. Ensure casters are maintained and roll easily. Working with Liquids in Kitchens Description: Filling and emptying liquids from containers When to Use: In dietary when pouring soups or other liquid foods that are heavy. Points To Remember: Reduces risk of spills and burns, speeds process, and reduces waste. Use an elevated faucet or hose to fill large pots. Avoid lifting heavy pots filled with liquids. Use ladle to empty liquids, soups, etc. from pots. Small sauce pans can also be used to dip liquids from pots. If the worker stands for more than 2 hours per day, shock-absorbing floors or insoles will minimize back and leg strain. With hot liquids, ensure a splash guard is included. Hand Tools Description: Select and use properly designed tools When to Use: When selecting frequently used tools for the kitchen, housekeeping, laundry and maintenance areas. Points To Remember: Enhances tool safety, speeds process, and reduces waste. Handles should fit the grip size of the user. Use bent-handled tools to avoid bending wrists. Use appropriate tool weight. Select tools that have minimal vibration or vibration damping devices. Implement a regular maintenance program for tools to keep blades sharp and edges and handles intact. Always wear the appropriate personal protective equipment. Linen Carts Description:Spring loaded carts that automatically bring linen within easy reach When to Use: Moving or storing linen. Points to Remember: Speeds process for handling linen, and reduces wear on linen due to excessive pulling. Select a spring tension that is appropriate for the weight of the load. Carts should have wheel locks and height-appropriate handles that can swing out of the way. Heavy carts should have brakes. Handling Bags Description: Equipment and practices for handling bags When to Use: When handling laundry, trash and other bags. Points to Remember: Reduces risk of items being dropped, and speeds process for removing and disposing of items. Receptacles that hold bags of laundry or trash should have side openings that keep the bags within easy reach and allow employees to slide the bag off the cart without lifting. Provide handles to decrease the strain of handling. Chutes and dumpsters should be positioned to minimize lifting. It is best to lower the dumpster or chute rather than lift materials to higher levels. Provide automatic opening or hardware to keep doors open to minimize twisting and awkward handling. Reaching into Sink Description: Tools used to modify a deep sink for cleaning small objects When to Use: Cleaning small objects in a deep sink. Points to Remember: Place an object such as a plastic basin in the bottom of the sink to raise the work surface. An alternative is to use a smaller porous container to hold small objects for soaking, transfer to an adjacent countertop for aggressive cleaning, and then transfer back to the sink for final rinsing. Store inserts and containers in a convenient location to encourage consistent use. This technique is not suitable in kitchens/food preparation. Loading or Unloading Laundry Description: Front-loading washers and dryers When to Use: When loading or unloading laundry from washers, dryers and other laundry equipment. Points to Remember: Speeds process for retrieving and placing items, and minimizes wear-and-tear on linen. Washers with tumbling cycles separate clothes, making removal easier. For deep tubs, a rake with long or extendable handle can be used to pull linen closer to the door opening. Raise machines so that opening is between hip and elbow height of employees. If using top loading washers, work practices that reduce risk include handling small loads of laundry, handling only a few items at a time, and bracing your body against the front of the machine when lifting. If items are knotted in the machine, brace with one hand while using the other to gently pull the items free. Ensure that items go into a cart rather than picking up baskets of soiled linen or wet laundry. Cleaning Rooms (Wet Method) Description: Work methods and tools to clean resident rooms with water and chemical products When to Use: When cleaning with water and chemical products; and using spray bottles. Points to Remember: Cleaning Implement use: Alternate leading hand; avoid tight static grip and use padded non-slip handles. Spray bottles: Use trigger handles long enough for the index and middle fingers. Avoid using the ring and little fingers. For all cleaning: Use chemical cleaners and abrasive sponges to minimize scrubbing force. Use kneepads when kneeling. Avoid bending and twisting. Use extension handles, step stools, or ladders for overhead needs. Use carts to transport supplies or carry only small quantities and weights of supplies. Ventilation of rooms may be necessary when chemicals are used. Avoid lifting heavy buckets, e.g., lifting a large, full bucket from a sink. Use a hose or similar device to fill buckets with water. Use wheels on buckets that roll easily and have functional brakes. Ensure that casters are maintained. Use rubber-soled shoes in wet areas to prevent slipping. Cleaning wheelchairs: Cleaning workstation should be at appropriate height. Cleaning Rooms (Electrical) Description: Work methods and tools to vacuum and buff floors When to Use: Vacuuming and buffing floors. Points to Remember: Both vacuum cleaners and buffers should have lightweight construction,adjustable handles, triggers (buffer) long enough to accommodate at least the index and middle fingers, and easy to reach controls. Technique is important for both devices, including use of appropriate grips, avoiding tight grips and for vacuuming, by alternating grip. The use of telescoping and extension handles, hoses and tools can reduce reaching for low areas, high areas and far away areas. Maintain and service the equipment and change vacuum bags when 1/2 to 3/4 full. Vacuums and other powered devices are preferred over manual equipment for moderate-to-long duration use. Heavy canisters or other large, heavy equipment should have brakes. Section V. Training Training is critical for employers and employees to safely use the solutions identified in these guidelines. Of course, training should be provided in a manner and language that all employees can understand. The following describes areas of training for nursing home employees, their supervisors, and program managers who are responsible for planning and managing the nursing home's ergonomics efforts. OSHA recommends refresher training be provided as needed to reinforce initial training and to address new developments in the workplace. Nursing Assistants and Other Workers at Risk of Injury Employees should be trained before they lift or reposition residents, or perform other work that may involve risk of injury. Ergonomics training can be included with other safety and health training, or incorporated into general instructions provided to employees. Training is usually most effective when it includes case studies or demonstrations based on the nursing home's polices, and allows enough time to answer any questions that may arise. Training should ensure that these workers understand: policies and procedures that should be followed to avoid injury, including proper work practices and use of equipment; how to recognize MSDs and their early indications; the advantages of addressing early indications of MSDs before serious injury has developed; and the nursing home's procedures for reporting work-related injuries and illnesses as required by OSHA's injury and illness recording and reporting regulation (29 CFR 1904). Training for Charge Nurses and Supervisors Charge nurses and supervisors should reinforce the safety program of the facility, oversee reporting guidelines and help assure the implementation of resident and task specific ergonomics recommendations, e.g., using a mechanical lift. Because charge nurses and supervisors are likely to receive reports of injuries, and are usually responsible for implementing the nursing home's work practices, they may need more detailed training than nursing assistants on: methods for ensuring use of proper work practices; how to respond to injury reports; and how to help other workers implement solutions. Training for Designated Program Managers Staff members who are responsible for planning and managing ergonomics efforts need training so they can identify ergonomics concerns and select appropriate solutions. These staff members should receive information and training that will allow them to: identify potential problems related to physical activities in the workplace through observation, use of checklists, injury data analysis, or other analytical tools; address problems by selecting proper equipment and work practices; help other workers implement solutions; and evaluate the effectiveness of ergonomics efforts. References (1) Documents submitted to OSHA by Wyandot County Nursing Home. (Ex. 3-12) (2) Garg, A. 1999. Long-Term Effectiveness of "Zero-Lift Program" in Seven Nursing Homes and One Hospital. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institution for Occupational Safety and Health (NIOSH), Cincinnati, OH. August. Contract No. U60/CCU512089-02. (Ex. 3-3) (3) Fragala, G., PhD, PE, CSP. 1996. Ergonomics: How to Contain On-the-Job Injuries in Health Care. Joint Commission on Accreditation of Healthcare Organizations. (4) Occupational Safety and Health Administration, Region II. Summer, 2002. New York OSHA E-Newsletter, Vol. 1, Issue 2. (5) National Institute for Occupational Safety and Health (NIOSH). 1997. Musculoskeletal Disorders and Workplace Factors - A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back. (Ex. 3-4) (6) National Research Council and Institute of Medicine. 2001. Musculoskeletal Disorders and the Workplace - Low Back and Upper Extremities. National Academy of Sciences. Washington, DC: National Academy Press. (Ex. 3-6) (7) Taylor and Francis. 1988. Cumulative Trauma Disorders: A Manual for MSDs of the Upper Limb. Putz-Anderson, V., ed. (8) Documents submitted to OSHA by Citizens Memorial. (Ex. 3-25) (9) U.S. General Accounting Office. 1997. Worker Protection - Private Sector Ergonomics Programs Yield Positive Results. August. GAO/HEHS-97-163. (Ex. 3-92) (10) American Health Care Association, American Association of Homes and Services for the Aging, National Center for Assisted Living. 2002. Comments submitted to OSHA. (Ex. 4-15) Appendix - A Nursing Home Case Study Introduction Wyandot County Nursing Home used a process that reflects many of the recommendations in these guidelines to address safety and health concerns and phase-in its current program that entails no manual lifting of residents. First and foremost, Wyandot's administrator provided strong commitment and support in addressing the home's problems. He also involved Wyandot's workers in every phase of the effort. He talked to his employees, learned about stressful parts of their jobs, and then found solutions. He and his employees identified existing and potential sources of injury at the home and worked to implement solutions. He trained employees each time the nursing home introduced new equipment. He continually checked new equipment, and he continues to evaluate the overall effectiveness of his safety and health efforts. This case study was developed from information provided by Wyandot County Nursing Home. OSHA visited the nursing home to discuss the ergonomics program with the nursing home administrator, observe ergonomics corrective actions, and talk to employees, residents, and family members about their experiences. Wyandot is located in Upper Sandusky, Ohio. It is a 100-bed, county-run facility that has served Wyandot County in its present building for the past 28 years. It is divided into two sections to serve residents with different levels of need. The A-Wing, with 32 rooms, serves residents who are mostly ambulatory and require only a minimum of help with daily living. In the B-and C-Wings, with 32 double rooms and four private ones, residents receive care that ranges from extensive to total. Wyandot has 90 employees, 45 of whom are nursing assistants. This makes for a nursing staff ratio of 2.4 hours for each resident per day. Identifying Problems Before Wyandot implemented its ergonomics program, the home was experiencing problems that were a growing concern to both the county and Wyandot's administrator. According to Wyandot, workers' compensation costs averaged almost $140,000 from 1995-1997. The turnover rate among nursing assistants averaged over 55 percent during that same time period. This meant that of the 45 nursing assistants working at Wyandot, on average 25 new ones had to be hired each year. Wyandot's administrator began to look for more effective ways to address injuries among workers and the high turnover rate. A back injury suffered by a worker that cost Wyandot $240,000 in workers' compensation expenses provided significant motivation to find a strategy that would work. As Wyandot's administrator investigated that injury, he also examined other sources of potential injury within the home. In doing so, he learned that resident transfer and repositioning tasks presented high risks for injuries. He called on the Ohio Bureau of Workers' Compensation (OBWC), for help because he thought Wyandot was following best practices and people were still being injured. An OBWC ergonomist visited the home and told him that he had unrealistic expectations about his nursing staff's ability to manually lift and reposition residents. Involving Employees Wyandot's administrator thought that he could better use his existing staff. After hearing about a "no lift" policy and seeing an impressive demonstration of mechanical lifts at an industry conference, he began to consider setting up a program at Wyandot. He became convinced that such a program would keep employees safer and help slow the turnover rate while ensuring safety and high quality care for residents. He decided that the best approach was to involve employees at every level in reducing injuries and slowing the turnover rate. More than 30 workers volunteered to examine the tasks of moving and repositioning residents. Wyandot employees concluded that better body mechanics -- the traditional method of lifting and transferring residents at most nursing homes -- was not the answer. In fact, he and his staff determined that there was no safe way to lift a resident other than with mechanical lifts. To determine what equipment would work best, Wyandot tried out various pieces of equipment, evaluated each lift, and then decided what would be most appropriate for Wyandot's needs. Implementing Solutions With recommendations from employees, Wyandot's administrator bought several portable mechanical lifts for the B- and C-wings. These involved portable sit-to-stand lifts, walk/ambulating lifts, and total lifts. Nurses and assistants could move each of these from room to room as they worked with individual residents. However, many of the staff remained unconvinced of the value of using equipment. In fact, initially only the workers who had actually evaluated the lifts were using them. According to Wyandot's administrator, it was very difficult getting workers to overcome their insistence on doing things the old way. Because many workers said it took too long to use the mechanical lifts, one of the co-charge nurses decided to do a time study. She wanted to test how long it took to lift a resident manually compared to using a mechanical lift. The mechanical lift took about 5 minutes. Meanwhile, to perform the manual lift, a nursing assistant first had to find someone to help. This took 15 minutes. Thus, the time study showed that using the equipment actually saved time. One worker, who admitted that she did not initially use the sit-to-stand lift because it was a "hassle," reconsidered her opinion after an outbreak of the flu reduced the number of staff members available for assistance. In her words, "I was forced to use the lift. Awesome. It was just great. I was so sorry my fellow employees had to suffer with the flu bug to get me to use this contraption." Wyandot's administrator also wanted to replace the old hand-crank beds at Wyandot with electric beds. To do this, he also needed to find beds that would be used in the "low-bed" system in place for many residents. There were not many options available, so he took his ideas and engineering background to a bed company and inquired about having beds designed to fit Wyandot's needs. The bed manufacturer designed the new beds to lift from the floor to a height of about 30 inches in 20 seconds. In addition, these fast beds were designed so that residents would be less likely to slide to the foot of the bed as they were raised to a sitting position. As a result, residents would not need to be repositioned. Also, the beds could be used with a gait-belt for ambulatory residents to assist them from a sitting to a standing position. About three years after Wyandot began its ergonomics effort, the nursing home received a grant from the OBWC Division of Safety and Hygiene through an ergonomic emphasis program to deal with cumulative trauma disorders. The grant enabled Wyandot's administrator to purchase 58 fast electric beds, a turning point for staff acceptance. When the first ceiling lifts were installed seven months later, employees were ready to use them. One nursing assistant, who has been with Wyandot for 19 years, explained why she liked the new beds so much. "We can quickly bring the bed up to our work height with a push of a button and we can reposition a resident . . . with ease without stooping or struggling." The final phase of Wyandot's program began with the introduction of the ceiling lifts. Wyandot's administrator evaluated several ceiling lift systems. Wyandot chose a system with a motorized lift and a ceiling mounted track. Tracks were retrofitted into the rooms at a cost of about $12,000 for two double rooms and one bathroom. The first double room had a track that extended into the bathroom. However, newer systems used a transfer between the room and bathroom, which simplified the system and reduced costs. Providing Training As Wyandot purchased and installed new equipment, workers received training on how to use it, and guidelines for equipment use were put into place. An LPN in-service director did the training. New employees learn how to use the devices and know where to go for further instruction or help. Eventually, most of the nursing assistants adapted to the mechanical lifts and refused to use any other lifting techniques. Providing Management Support Wyandot's administrator took a personal interest in ergonomic issues. To address high injury and turnover rates at Wyandot, he remained committed to identifying and solving problems. For example, on one occasion the staff said that the lifts were not easy to roll on the floors in the B- and C-Wings. To solve the problem, he experimented with different wheels that would roll more easily and turn in tight places with less effort. Finally, he worked with a manufacturer to find and buy better casters to suit the home's flooring. Evaluating Efforts To start with, Wyandot's administrator spent $150,000 to buy equipment. He later set aside another $130,000 to continue his efforts, for a total of $280,000. Wyandot has saved $55,000 annually in payroll costs, according to Wyandot's administrator, because of reduced overtime and absenteeism. The home estimates savings of more than $125,000 in turnover costs. Meanwhile, workers' compensation costs also have fallen drastically. For example, Wyandot reports that, after the program was implemented workers' compensation costs declined from an average of $140,000 per year to began to average less than $4,000 per year. From the time workers began to use the sit-to-stand lifts, which were among the first to be introduced at Wyandot, the incidence of back injuries stopped. Once the fast beds were introduced only six new hires were needed in the following year. Worker satisfaction has increased greatly. One nursing assistant, who has spent most of her career working in nursing homes, confessed to being sore and unhappy at Wyandot before the lifts were introduced. After the innovations at the nursing home, she reported that she is no longer hurting. She concluded that "I think my career is right here in the Wyandot County Nursing Home till my time is due to retire comfortable. And you know if my time comes to be in a nursing home I do hope I get one like ours." Mechanical lifts have also helped return a sense of dignity to Wyandot's residents. As one nursing assistant put it, through the use of the mechanical lifts, the residents are able to wear normal clothing again, which "improves their self-esteem and keeps them warmer." The wife of one totally dependent resident who has been at Wyandot for eight years reports that because of her husband's size, he cannot help the nurses and nursing assistants in moving him from place to place. Before the overhead electric lifts and electric beds were installed in his room, it took three and sometimes four nursing assistants to move him from the bed to his cart or to the toilet. He had numerous bruises from falling and dreaded being moved. With the lifts in place, the resident's wife reports that the staff "can easily move him about to his chair and to the toilet. He cannot sit without help but the sling gives him comfortable support and makes it possible to have some dignity."