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The elephant in the room: huge rates of nursing and healthcare worker injury--Part 2.

Continued from the last issue of the Oklahoma Nurse


Hospitals and nursing homes are well aware of the risks of back injury resulting from patient care. Virtually all of us have had numerous "back injury prevention" classes over our work life. Why then, are the injuries so high? Is it because we just don't listen? Or, is it because there is no safe way to manually lift and care for patients? Just look at the diagram above for a comparison between the NIOSH lifting standards and everyday patient care reality.

There are physiological reasons for this. William Marras, PhD, CPE, Honda Professor and Director of the Biodynamics Laboratory, Institute for Ergonomics at Ohio State University has made extensive studies on what happens to the human back under stress. (vi)

Basic anatomy lesson: the intervertebral disc is fibrous, dense tissue with a resilient gel filled center. The outer fibrous ring is called the annulus fibrosis, and the center the nucleus pulposus. It has no blood supply, and no nerve endings. It receives its fluid and nutrients by osmosis from the adjacent vertebrate bone through the end plate, which also attaches the disc to the vertebrae.

Pathophysiology, or, We all have our limits

When lifting tolerances are exceeded, the end plate of the intervertebral disc is damaged with tiny tears called microfractures. No pain is felt, since nerve endings are not present in the disc or the end plate. These microfractures then heal with protein agglutinens and scar tissue which is thicker and less permeable than the normal tissue. Over time, with many microfractures occurring, most of the end plate of the vertebra converts to scar tissue. The disc can no longer absorb fluid and nutrients. It becomes weakened, porous, soft and dry, which is the condition we know as degenerated disc. The softer tissue then bulges into the spinal column causing pain and muscle spasm, or the gel in the center of the disc can even herniate through the soft porous outer tissue, causing much greater pain. With severe degeneration, the disc can collapse, which narrows the space available for the nerve root. This narrowed space puts pressure on the nerves, causing pain and muscle spasm.



What are safe lifting pressures for the disc, or, Should you lift a "little 100 lb grandma"?

Downward pressure will cause damage to the disc end plate at pressures from 700 to 1100 lbs. Since many caregivers are physically small, the limits should be at the low end of this. However, most manual patient handling includes pushing and pulling elements. With pushing and pulling, damage occurs at about 1/3 the force. Nurses understand shearing: shearing damage to the disc occurs at lower forces than pressure.


This illustration shows only the downward pressure, and doesn't take into account the pulling (shearing) required to turn a patient on to his side. Nurses are the ONLY people who call 100 lbs light! Since there is no way to keep the weight bearing close to the body, no "good body mechanics" will compensate for the forces that damage your back.


THERE IS NO SAFE WAY TO MANUALLY MOVE A PATIENT!!! EVER. You WILL be injured every single time you manually move a patient. This includes not only transfers, but turning, linen changes, rolling a patient on to a sling, boosting the patient up in bed, and assisting the patient to stand.


WHAT IS THE SOLUTION to manual patient handling? Patients must be cared for. Every nurse knows it is not an option to simply refuse to care for their assigned patients.

Lifting Teams? These teams are very expensive, though they have been shown to reduce injuries. But, what about the lifting team? They will be injured as well, inevitably. Also, no lifting team can be everywhere at once, and patients may need repositioning at any time, not just on the lifting team schedule.

Patient Handling equipment is the only answer. There are multiple equipment solutions available on the market today. None does everything; but there is equipment available which will completely eliminate the manual lifting required for patient care.

We apologize to all makers of equipment which are not featured in this article. Care has been taken to present representative examples of equipment performing each task. Each facility should determine its own needs, and investigate each company and brand of equipment. We do not present the pros and cons of different types of equipment. A list of companies who manufacture and sell each type of equipment is provided, to give some place to start to those who might wish to begin. The list of companies is by no means exhaustive. No remuneration has been given by any company.

Tasks which exceed safe spinal loading, requiring Safe Patient Handling Equipment:

* Transfers: bed to bed, or gurney to bed

* Transfers: bed to chair, chair to shower

* Bed repositioning: Side to side turn, and pull away from the side rail

* Bed repositioning: Boosting to the head of the bed

* Bed repositioning: Linen changes and bathing

* Sling placement: Bending and lifting to roll a patient on to a sling

* Assisting patient to stand

* Assisting a patient up from the floor

Bed to bed transfer

This is a mattress that uses a blower to inflate a mattress, which then slides on a cushion of air. The brand name is Hover Matt. It removes most of the friction so the force needed for transfer is minimal.


Slide Boards reduce friction; not entirely but they help. Some facilities use a slick fabric tube or even garbage bags to reduce the friction in a bed to bed transfer.

Bed to wheelchair transfer

A ceiling lift can facilitate transfers, after placing the patient on a sling. This is an Arjo lift.


An Arjo bariatric lift accommodates heavy patients.


This Liko mobile lift will lift in sitting, standing or horizontal positions.



The Arjo 4-point spreader bar puts the patient in a comfortable semi-reclined position.

Bed Repositioning: Side to side turn

Advanced hospital beds have skin saving programs, and some abilities to reposition patients. This is the Hill-Rom Versa-Care bed. Some mattress overlays available will turn the patient by inflating the mattress on one side, then another.

Bed Repositioning: Boosting patients up in bed


The ErgoNurse, designed for bed repositioning, boosts a patient using the sheets. It will also lift for side to side turns, linen changes and bathing.


A Liko ceiling lift repositions a patient using a loop sling. Linen can be changed while the patient is suspended.

Some specialty fabrics will allow boosting with minimal effort, then resist sliding again.

Linen changes and bathing of bedridden patients


Ceiling lifts can use repositioning slings to move the patient around for linen changes and bathing.

Placing the patient on a sling:


The ErgoNurse uses a sheet to suspend the patient, allowing sling placement without bending and lifting.

Assisting a patient up from the floor


The HoverJack, from HoverTech, inflates to lift a patient from the floor.

Companies offering Safe Patient Handling equipment:

ArjoHuntleigh/Diligent Services

aXtraHand, LLC

Barton Medical Corporation

Dane Technologies, Inc.



ERGOtug, Division of NuStar, Inc.

EZ Way

Guldmann Inc.

Hill-Rom, Inc.

Horcher Lifting Systems, Inc.

HoverTech International

Jamar Health Products, Inc.

Joerns Healthcare, Inc.


Medcare Products

Molift, Inc.

Optima Products, Inc.

Prism Medical


Rehab Seating Systems

Rifton Equipment



SureHands Lift & Care Systems

Technimotion Medical, a Division of Ergo-Asyst Technology

Vancare, Inc.

Help is on the horizon. Nationally, the Nurse and Health Care Worker Protection Act of 2009 has been introduced in both houses of Congress. In brief, these bills (identical at the present time) require OSHA to establish a safe patient handling standard, require health care facilities to establish safe patient handling programs, and allow health care workers to refuse to perform any lifting task which exceeds the standards or for which they have not been trained. The House bill is HR 2381, and the Senate bill is S 1788. It is certain that the wealthy and powerful hospital lobby will oppose the bill. However, we nurses have numbers on our side. Since there are about 2.5 million nurses, and about 1 million nursing aides, if we were all to contact our legislators, we could ensure the passage of these bills.


For the House of Representatives: Go to: House. gov, and put in your zip code. The website will tell you who your representative is, and contact information for them.

Note! The volume of emails is now so great that less attention is paid to them. They will get it, but it might take a while. It is better to send a hard copy of your letter.


Safe Patient Handling equipment is very cost effective. When associated factors such as lost work days, modified duty, worker retraining, employee turnover, and even bedsores are factored in, the hospital recoups its investment in less than two years!

Those who have instituted Safe Patient Handling programs have learned that not only is equipment needed, but training, education and surprisingly, enforcement. Though it may seem a paradox, many times caregivers resist change. They've been doing it one way for their entire working careers as caregivers, and feel that it takes too much time, or is inconvenient. Yet, they continue to incur injuries at high rates. However, when a no-lift policy is implemented (and if necessary, enforced), the staff will adopt the safe patient handling equipment especially as they realize their back pain and injuries diminish. Oregon SAIF, the State Worker Comp Company, instituted pilot Safe Patient Handling programs, and has seen injury rates and costs plummet. (ix) Harris Methodist Ft. Worth, in Ft. Worth Texas, also instituted a pilot program, and went to zero injuries. (x) Their pilot unit has had no injuries in 2 V years. We know that these injuries are entirely preventable. Let's work together and solve this problem.

NIOSH. (National Institute of Occupational Safety and Health) a division of the Centers for Disease control, sets standards for safe lifting practices.

The Standards The Reality

When a worker's hands are 10 inches from the ankles, 113 of the worker's body weight may be lifted, if a rest period follows. This is about 51 pounds for the average worker



When the worker's hands are farther from the ankles, the weight must be reduced. When the hands are 16 inches Tram the ankles, the weight must be reduced by 40%.This would be about 30 lbs.

When a worker's hands are 25 inches from the ankles, the weight must be reduced by 60%.This would average 20 lbs. NO Weight should be lifted beyond that point


The Reality

When a nurse turns a patient from side-to-side the reach is 33 to 35 inches. The nurse must lift 35% of the patient's body weight an average of 52.5 lbs. This is FAR beyond safe lifting limits!



To transfer a patient, the nurses kneel on the bed, reach completely across, and pull. This requires even worse body mechanics.

Pulling a patient up in bed requires that the patient be lifted nearly off the mattress. Though the reach is not fan half of a normal patient's body weight (75 lbs.) is excessive lifting.


(i) "Safe Patient Handling: A Report", by Peter Hart & Associates, March 2006

(ii) Tuohy-Main, Kate, "Why manual handling should be eliminated for resident and carer safety," Geriaction 1997, 15(10)

(iii) Eldlich, Richard F., Kathryne L. Winters, Mary Anne Hudson, L.D. Britt, William B. Long, "Prevention of disabling back injuries in nurses by the use of mechanical patient lift systems," Journal of Long-Term Effects of Medical Implants, 2004, 14(6)

(iv) Bureau of Labor Statistics, Department of Labor, Nonfatal Occupational Injuries and Illnesses Requiring Days Away from Work, 2007, Nov. 2008

(v) Bureau of Labor Statistics, 2008, op cit

(vi) Marras, W. "A Comprehensive Analysis of low-back disorder risk and spinal loading in patient handling," Ergonomics, 1999, 42(7) 904-906

(vii) Bloswick, Donald, Professor of Ergonomics at the University of Utah, "Manual Material Handling"

(viii) Marras, 2009 op cit

(ix) Oregon SAIF, report, 571.aspx

(x) Dougherty, M, "Handle With Care," Strategies for Nurse Managers, April 2008
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Publication:Oklahoma Nurse
Article Type:Report
Geographic Code:1U7OK
Date:Dec 1, 2010
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