Chapter 21 Preventing Back Injuries

Patient Transfer and Mobility

PERIOPERATIVE BACK INJURIES—PERSPECTIVES AND CHALLENGES

Nurses have traditionally been willing to sacrifice their own bodies for the sake of their patients. When a patient begins to slip, nurses are more inclined to seek to catch them rather than safely guide their fall. The urgency of setup and turnovers in the operating room (OR) may prompt a perioperative nurse to ignore assistive devices or not take the time to call for extra help. For many it is an expectation that they will have a back injury as an outcome of their career. Nurses will compromise their own well-being for the benefit of others. Although the intent of these actions is noble, the outcomes often leave nurses in physical states in which they can no longer care for anyone but themselves.

Back Injuries Statistics

Nurses are typically within the top ten categories of professions to suffer from work-related spine injuries. When combined with associated caregivers such as nursing aides, attendants, and orderlies, they make up the largest single number (de Castro, 2004). Nelson et al (2009) state, “Patient transfer tasks are high risk and occur in every clinical setting.” Some studies indicate that annually 40,000 nurses report back-related injuries, and that 12% of nurses who leave the profession each year do so because of back injuries (O’Malley et al, 2006; American Nurses Association, 2009). Another 52% complain of back pain (Nelson and Baptiste, 2004). The nursing shortage could potentially be eliminated if qualified nurses were able to live out their careers rather than have their careers cut short by spine injuries. It stands to reason that if back injuries account for the highest percentages of nurses leaving the profession and are the largest factor contributing to the nursing shortage (O’Malley et al, 2006), then preventive programs should be at least as important as additional nursing programs. It is estimated that back injuries in the health care industry account for approximately $20 billion annually (Bell et al, 2008). In addition, there are indirect costs of “overtime, decreased morale, use of replacement workers, continual hiring and training cycles, and increased worker compensation and employee healthcare costs” (Spry, 2009).

Bariatrics

Another factor that has changed the nature of patient handling is the rise in obesity. The bariatric population of North America is growing and shows no signs of plateauing anytime soon (Hurd, 2009). In the United States alone, the bariatric population has soared to 38 million in the past decade. Muir et al (2007) define the obese patient as anyone over 350 lb or someone with a body mass index of greater than 49. They further estimate that about one quarter of the bariatric population is classified as severely obese. These patients arrive with increased morbidity and mobility issues. They are making up an increasing percentage of the surgical population, not just for bariatric-specific procedures, but often for the comorbidities that are associated with excessive weight. Michelle McCleery, RN, PHD, manager of safety programs for Hill-Rom, has said, “I’ve never talked with one hospital that did not see a relationship between the increase in the severely obese patient population and staff injuries” (Safety in mobility, 2004). No longer are perioperative staff safe to just count to three and then “heave-ho.” To prevent spinal injury, it will take a team effort, using all available resources accompanied by a change in culture, emphasizing safety over expediency. If we do not initiate some of the back injury prevention measures from a nursing model, it will be done for us by a legislated mandate, as has already occurred in a number of states.

The Gender Factor

Further contributing to the high numbers of back injuries in the nursing profession is the well-known fact that it is a predominantly female profession. In a classic article published in the Lancet in 1965, the authors used scientific measures to indicate the physiologic differences between males and females in their oxygen consumption, lifting power, and degree of sustaining capabilities when lifting an object over a period of time. The evidence was clear that females in the nursing profession are at a distinct physical disadvantage while doing tasks that would not be tolerated in male-dominated professions (Tsolaki et al, 1965). Some studies have specifically focused weight-tolerance measurements on what is safe for females. The small percentage of men in the nursing profession might find it frustrating if they were to be considered the brawn of the unit. We may all agree that simply recruiting men into the profession will not likely solve the musculoskeletal injuries in the nursing profession and especially in the operating room. We will need to look to other more viable and sustainable solutions that work for both genders.

The Aging Workforce

As society and legislated expectations gradually raise the anticipated age of retirement, aging nurses will seek to remain employed longer into the years that traditionally have been considered the retirement years. Minimizing the risks of personal injury in the workplace may provide a safe place to live out those years, as well as serve as an enticement for novice nurses to seek employment in a distinctly safer environment. The discerning nurse may begin choosing a place of employment based not merely on money and geography, but rather on the safe work culture of the prospective employer.

BARRIERS AND HAZARDS

A multitude of factors may negatively influence back injuries. The aging workforce, staffing shortages, nurse’s self-sacrificing ethic, obesity of both patient and staff, increasing acuity of the patient population accompanied by decreased patient mobility, and institutional cultural expectations are all factors that influence the prevalence of back injuries.

One of the largest barriers to eliminating back injuries in the perioperative setting is the nursing ethic of putting the patient’s well-being ahead of one’s own. There are numerous other barriers to safe back care within the perioperative setting. Most equipment and safe patient handling programs that are available in the hospital setting are designed for a medical/surgical floor and adapt very poorly to the OR. Lift teams are outlined in the literature but focus exclusively on non-OR environments. Many of the patient transfer devices are not designed to fit into the OR context. For example, the spread legs of a typical lift device will not go under a solid-based OR bed, yet to be stable, especially for bariatric patients, this would be required. Ceiling lifts are very difficult to retrofit into existing ORs because of the existence of booms, ceiling lights, and ventilation systems. Murphy (2009) states, “You wouldn’t be able to use overhead lifts in the OR.”

Defining the Limits

“No one can define a weight where it is safe to lift” (Safety in mobility, 2004). The National Institute for Occupational Safety and Health (NIOSH) had estimated that the average worker should limit his or her lifting to 51 lb (de Castro, 2004). Since then, further studies have lowered that number to 35 lb (Nelson et al, 2009; Waters et al, 2009). Measures that have sought to quantify how much weight an individual should be able to safely lift fail to factor in the fact that patients do not come with handles, do not have their weight evenly distributed, and can be either predictably or unexpectedly combative. Added to this is the fact that patients are often in positions that require flexion and awkward posture of the caregiver, combining for a less-than-ideal position or location for lifting, even if the patient is an appropriate weight. Waters et al (2009) indicate that a female should not lift more than 11.1 lb in a one-handed lift. In the OR this may exclude lifting limbs for preparation or even some pieces of equipment that exceed this weight. Table 21-1 shows the typical weights of various body parts.

TABLE 21-1 Lifting and Holding Legs, Arms, and Head for Prepping

Unique Operating Room Challenges

The challenges of the OR are unique to the OR. Positioning a patient into a prone position on a spine table, tower table, or Wilson frame would be impractical with lift equipment. Repositioning an intubated patient requires the gentle measures of the human touch. Adding an equipment component to this action should be as an adjunct to fine-tuning the personal element rather than the other way around.

Ergonomic Stressors

The AORN Position Statement on Ergonomically Healthy Workplace Practices (2006) identifies ergonomic stressors that are likely to contribute to back injuries during patient handling tasks. These include the following:

Figure 21-1 Ergonomic tool for retraction.

(From Nelson A et al: Development of the AORN guidance statement: safe patient handling and movement in the perioperative setting. In Peterson C, editor: AORN guidance statement: safe patient handling and movement in the perioperative setting, Denver, 2007, Association of periOperative Registered Nurses.)

Figure 21-2 Ergonomic tool for prolonged standing.

Other ergonomic stressors are listed in Box 21-1.

BOX 21-1 Clinical Points

Operating Room Ergonomic Stressors

• Overexertion

• Forceful tasks

• Walking long distances in larger operating rooms

• Flooring not ergonomically designed

• Working in low light conditions

• Repetitive motions

• Lateral transfers of patients

• Static standing positions

• Moving heavy equipment

• Trip hazards

• Holding or carrying instruments

• Awkward posture

• Working in crowded environments

• Retrieving or storing items stored too high or too low

• Fast-paced work expectations

• Holding or moving patient extremities

• Pushing or pulling motions

• Wearing lead aprons

• Standing on tubes or cords

• Positioning patients

• Reaching for supplies above one’s head

• Bending to retrieve items from low shelves or off the floor

• Manual handling of bariatric patients

• Wearing orthopedic helmets

• Wet flooring

• Fatigue

• Prolonged work hours

• Manual cranking of equipment

• Pushing wheeled equipment in the presence of tubes and cords

Expectations of Efficiency

Another barrier to eliminating back injuries is the inherent expectation of speed in the OR. When it is difficult to get the whole team to stop for a surgical time-out, who will have the patience required to wait for the OR team to appropriately position a patient for surgery with elaborate lift equipment? The culture of the OR may need to be confronted until safety outweighs expediency.

Ergonomic Hazards

Many additional hazards await the OR team member. Night shifts are noted to produce higher rates of injuries, because the lack of resources may lead one to take more risks. Working long shifts of greater than 12 hours or working over 40 hours per week is also “associated with a 50% to 170% age-adjusted rate of musculoskeletal disorders of the neck, shoulders and back” (Mathias and Patterson, 2005). In addition, mandatory overtime, increased work pace, and increased physical and psychologic demands are further hazards for back injury (Safe patient handling, 2006).

Musculoskeletal injuries increase in proportion to the frequency of actions such as forceful pushing and pulling, twisting, and assuming awkward positions for lifting or transferring (Nelson et al, 2009). The activity most likely to lead to back injury while lifting is the action of twisting while lifting a load (Lavender et al, 2007). The study also concluded that when proper body mechanics were employed, the injury rates were not affected significantly until a twisting motion was included in the activity (Lavender et al, 2007). Wardell (2007) stated that “Nurses spend between 20% and 30% of their work time bending forward or with their bodies twisted.” Figure 21-3 illustrates a common hazard of twisting. A draped microscope is often pushed all the way into a corner, leaving little choice for the nurse but to drag this cumbersome item from a sideways twisted position. Lifting or moving patients in beds does not lend itself to the classic lifting posture of keeping the weight close to your body and using your legs as the lifters. Often the smaller muscles of the arms and hands do much of the lifting because of the compromised positions in which nurses find themselves. Murphy (2009) reflected on the fact that an increasing number of caregivers now fall into the bariatric category. Thus, when the traditional body mechanics concept of keeping the weight close to your core is followed, the lifted weight may still be a long distance from the spinal cord, significantly increasing the mechanical stressors.

Figure 21-3 Twisting hazard. Moving heavy equipment from awkward positions is a critical hazard encountered in the operating room. In this staged photo the microscope is additionally difficult to move because of its position in the corner and the presence of a sterile drape.

A joint project of the Association of PeriOperative Registered Nurses (AORN), NIOSH, the Patient Safety Center of Inquiry at the James A. Haley Veterans Administration Medical Center (VMAC), and the American Nurses Association (ANA) determined seven “high-risk” activities within the OR that were most likely to lead to musculoskeletal injuries (Nelson et al, 2007). In this case the term “high-risk” referred to those activities “that push the limits of human capabilities—e.g., heavy loads, sustained awkward positions, bending and twisting, reaching, fatigue or stress, force, or standing for long periods of time. It is the combination of frequency, duration and stress of these tasks that predispose nurses to MSDs” (musculoskeletal disorders) (Nelson et al, 2007). More specifically, seven identified high-risk tasks are as follows (Nelson et al, 2007):

Any OR nurse looking at this list would agree that each task has strong potential for back injuries. The AORN Guidance Statement: Safe Patient Handling and Movement in the Perioperative Setting (Peterson, 2007) created a list of the degrees of stress involved with various movements in relation to equipment in the OR (Table 21-2). Mathias and Patterson (2005) identifies prolonged standing for the perioperative nurse as the number one hazard for back strain. Prolonged standing was placed ahead of patient movement and positioning, no matter what the age of the care provider.

TABLE 21-2 Recommendations for Pushing, Pulling, and Moving Equipment on Wheels

ALGORITHMS

To deal with each of the seven high-risk tasks, the AORN task force developed algorithms, also referred to as “Ergonomic Tools” to provide guidance in the patient handling decision-making process. Many safe patient handling programs have instituted similar lift algorithms. Algorithms are visual maps that guide the caregiver very clearly through a decision-making pathway when considering patient handling. In a publication designed as a bariatric patient–handling toolkit, Baptiste (2007) developed algorithms specifically for the bariatric population.

Patient assessment is essential when considering how to approach mobilizing or transferring a patient. Assessment should include cognitive status, weight, ability to assist, potential for unexpected movements, and presence of tubes, drains and intravenous (IV) lines. In the OR some of these variables are commonly present. Even transferring the patient just from the OR bed to the stretcher will often involve most of them and often in multiples. Depending on such an assessment of the patient’s ability to assist, the algorithm may direct whether additional care or equipment is needed (Figure 21-4). A patient’s weight or level of consciousness may also lead to another level of equipment use or higher number of patient caregivers. It may seem embarrassing at first to ask for assistance to lift a leg into a stirrup. Nurses have always bravely done these tasks on their own. As the weight of legs has increased with the bariatric evolution, nurses’ conditioning may have led them to continue to single-handedly lift increasingly heavy legs because that is what has always been done. It may take a shift in perspective to be willing to ask for additional help. At times it may be beneficial to use a lift device when positioning a very large leg. At other times, four people may coordinate their efforts to lift both legs simultaneously to accomplish the task in the manner recommended by the AORN (2009) Recommended Practices for Positioning the Patient in the Perioperative Practice Setting. Sufficient help and movement aids need to be employed to safely transfer the patient or even position a heavy limb. Manual lifting should never be attempted if it involves lifting most or all of the patient’s weight. Transfer aids should be employed along with sufficient personnel to ensure safety of the patient and the care providers.