Safe Patient Handling: A Worthy Investment

1. Safe Patient Handling: A Worthy Investment Oregon OSHA

2. Injuries in Oregon Health Care • “Between 2001 and 2005, the Oregon Department of Consumer and Business Services received notification of 9,835 accepted disabling claims in the health care and residential care industries, an average of 1,967 claims per year. Although the numbers have remained steady from year to year, health care disabling claims are growing as a percentage of total disabling claims in Oregon.” “Accepted Disabling Claims in Health Care, Oregon, 2001-2005,” Oregon DCBS, IMD, July 2007

3. Dark Clouds on the Horizon for Health Care • A serious shortage of nurses is expected in the future as demographic pressures influence both supply and demand. The future demand for nurses is expected to increase dramatically as the baby boomers reach their 60s and beyond. • Looking forward, almost all surveyed nurses see the shortage in the future as a catalyst for increasing stress on nurses (98%), lowering patient care quality (93%) and causing nurses to leave the profession (93%). • the ratio of potential caregivers to the people most likely to need care, the elderly population, will decrease by 40% between 2010 and 2030. Demographic changes may limit access to health care unless the number of nurses and other caregivers grows in proportion to the rising elderly population. • Though AACN reported a 7.6% enrollment increase in entry-level baccalaureate programs in nursing in 2006 over the previous year, this increase is not sufficient to meet the projected demand for nurses. American Association of Colleges of Nursing

4. Some Unfortunate Math In the January/February 2007 issue of Health Affairs, Dr. David I. Auerbach and colleagues estimated that the U.S. shortage of registered nurses will increase to 340,000 by the year 2020. This is especially problematic for rural facilities who face greater obstacles in recruiting nurses. The ratio of potential caregivers to the people most likely to need care, the elderly population, will decrease by 40% between 2010 and 2030. Demographic changes may limit access to health care unless the number of nurses and other caregivers grows in proportion to the rising elderly population. American Association of Colleges of Nursing

5. How Serious Will It Get? What happens when demand exceeds supply? Department of Health and Human Services

6. Self-perpetuating Injuries have Resulted in Health Care

7. How Can Facilities Fight the Growing Shortage? • Preserve nurses currently employed. • Replacement is expensive and is detrimental to the team atmosphere and fluidity of operations. • Also, skilled health care workers, now more than ever, are not easily replaced. • An excellent way to keep nurses employed is to create a safe, manageable environment that minimizes physical and mental stress. Reducing injury risk will allow nurses to work longer and be more productive.

8. The Prevalence of Musculoskeletal Disorders in Oregon Health Care • MSDs accounted for half of all accepted disabling claims (ADCs) in Oregon health care between 2001 and 2005. • Patient handling MSDs made up 27.4% of total ADCs • Nurse aids comprised 32.6% of total ADCs, registered nurses 14.2% and other health aides 5.9% from 2001 through 2005 Musculoskeletal disorders are defined as injuries and disorders to muscles, nerve, tendons, ligaments, joints, cartilage, and spinal discs, such as sprains, strains, and tears, carpal tunnel syndrome, hermias, and pain caused by overexertion, repetitive motion, or bodily reactions due to bending, climbing, crawling, reaching or twisting “health care” includes SIC 80 (health services) and SIC 8361 (residential care) Oregon DCBS, IMD, July 2007

9. Injuries are a Cancer in the Workplace • From 2001 to 2005 nursing aides experienced a total of 3,205 injuries, registered nurses 1,397, and other health aides 583. • Many of those were patient handling MSDs. 167 of the injuries to health aids were patient handling MSDs, as were 2,371 for nursing aids and 881 for RNs. • The most frequent cause of injury was “bodily reaction and exertion” (63.2%) which includes bodily reactions, overexertion and repetitive motions. • Drastic reduction in patient handling MSDs is an essential step to combat the unfulfilled demand for nurses. Oregon DCBS, Information Management Division, July 2007.

10. Patient Handling Injury Claims 1997 - 2006 in Oregon Oregon DCBS, Information Management Division, July 2007.

11. Holistic Estimates of the Costs of Workplace Injuries • The most expensive medical conditions per 1000 full time employees for all companies based on medical, drug, absenteeism and presenteeism costs: • Back/neck pain $530,000/1000 FTEs* • Depression $425,000 • Fatigue $410,000 • Other chronic pain $385,000 • Sleeping problem $350,000 • High cholesterol $280,000 • Arthritis $275,000 • Hypertension $265,000 • Obesity $225,000 • Anxiety $220,000 *Full Time Equivalents Loeppke et al. 2007

12. MSDs are Extremely Costly! Although insurance covers some costs up front, they are recouped by insurers in changing rates over time. Meanwhile… Indirect costs associated with injuries are generally MORE expensive than the injuries themselves and are never covered.

13. What Does Insurance Cover in Oregon? Direct Costs Only Medical coverage includes: • Medical treatment of injuries • Drug costs Indemnity coverage includes: • Time loss costs • Temporary and permanent disability payments • Fatality costs/awards • Vocational assistance costs • Settlement costs • Claim expense costs Oregon State Workers’ Compensation Division, SAIF Corporation

14. The Covered Costs of Patient Handling MSDs in Oregon • The average patient handling injury costs $11,055 in medical and indemnity costs over the lifetime of the claim. • Injuries to health aids cost on average $10,049 • Nursing aid injuries cost $9,062 • Registered nurse injuries cost $16,090 • All other health care employees cost $11,950 Oregon DCBS, Information Management Division, July 2007.

15. Total Injury Occurrence and Direct Costs by Occupation

16. Patient Handling MSD Claim Cost Components Why do these figures matter? Implicit within “indemnity” costs, which comprised 55% of total claims cost in the time period, are time loss and disability costs. Insurance compensations go to the employee, not the facility. They do not pay for the costs associated with absenteeism, presenteeism and other indirect costs incurred in the workplace during and following an injury. Oregon DCBS, Information Management Division, 2007

17. Total Injury Cost Estimates • Presenteeism represents the costs incurred by injured workers who return to work before completely recovering and are therefore less productive than in a healthy state. • Presenteeism can result in more long-term health issues. • Employees arriving at work despite injury may only operate at a fraction of their normal capacity while still requiring the same wages. • Although significant, presenteeism is only one of many indirect and uncovered costs associated with an injury. Covered Costs Uncovered Costs Loeppke et al. 2007

18. Another Look at Indirect Costs The Stanford Department of Civil Engineering determined that the indirect costs of injuries are generally inversely related to the severity of the injury. Note the initially high, then decreasing ratio of indirect to direct costs as total costs increase. Consider a very expensive and crippling injury versus a mild injury. For cost calculations based on these general dynamics see OR-OSHA’s Safe Patient Handling Pays program on the web at https://www4.cbs.state.or.us/exs/osha/safety/ $afety Pays, OSHA, 1998

19. MSD Indirect Cost Estimates • Referring back to the Oregon data, the average patient handling MSD in health care as a whole between 1997 and 2006 costs $11,055in medical and indemnity costs alone. • By Federal OSHA’s “Safety Pays” model, this direct cost correlates with an indirect cost of $12,500 yielding an estimated total cost of $23,555. • Indirect costs vary considerably depending on many situation-specific conditions. Despite their unpredictability, its important to remember that they do exist and inhibit facilities from operating as efficiently as otherwise possible. $afety Pays, OSHA, 1998

20. Some Possible Indirect Costs

21. Training & Hiring Costs Following Injuries are Pricey! • Orientation Costs • Advertising/Interviewing • Use of traveling nurses • Overtime • Temporary replacement • Lost productivity • Terminal payouts = $92,442 in 2000 dollars, and $145,000 for specialty nurses OUCH! Robert Wood Johnson Foundation, 2006

22. And the Good News…These Injuries are Preventable! …And it’s profitable to do so! 95% percent of business executives report that workplace safety has a positive impact on a company's financial performance. Liberty Mutual

23. Prevent an Injury, Save a Dollar, Earn a Dollar • Suppose a facility experiences only 1 ergonomically-related disabling MSDs per year. • Each incurs $12,500 in indirect, uncovered costs. • Eliminating one claim = $12,500 dollars saved at the end of that year. • Reductions in yearly turnover from 5 to 4 employees results in $92,442 saved. • Total savings in the first year of implementation are $104,942 through indirect and rehiring/ retraining costs avoided by eliminating just one injury.

24. Safe Patient Handling Programs are Proven to Reduce… • Associated costs by 35-65% (MSDs are generally more expensive than other injury types). • Lifting related claims by 30-95% • Lost workday injury rates by up to 66% • Restricted workdays up to 38% • Workers’s compensation costs by 30-75% • The number of workers suffering from repeat injuries *According to NIOSH, mechanical lift equipment is the only effective way to prevent overexertion injuries that occur due to patient handling. Enos, 2007

25. If All Patient Handling Injuries were Eliminated… • Total injuries to health care employees could be reduced by about two-thirds! • Oregon health care facilities would save $4,435,126 yearly in claims alone. Oregon IMD 2007

26. What is required for a Successful Safe Patient Handling Program? Program Plan Multidisciplinary SPH program Identified program champion and facilitator Hazard Identification & Control Evaluation of system to ensure compatibility between equipment, patients and facility design Implementation of SPH equipment Identification of Best Work Practices Development of Administrative Controls (policy/procedure) Education & Training Equipment competency training for expert or super users, employees, support staff and patients & their families Safety Culture Facility-wide internalizatin of the importance of safety Employees actively involved in development, implementation and evaluation of the SPH program No manual lifting policies Enos, 2007

27. Components of Project Success Follow the link to see a “No lift” policy draft: http://www.visn8.med.va.gov/patientsafetycenter/safePtHandling/default.asp

28. Safe Patient Handling Expenses • Safety Culture Development -ergonomic consultations -published safety policy -internal enforcement • Equipment -lift equipment -installation -associated supplies -maintenance due to depreciation -possible loss or theft • Training -backfill for those being trained -trainer expenses -training materials Investment requirements are facility specific. Professional consultation may be necessary to ensure that the right equipment and training is purchased, otherwise the program will not enjoy the full potential benefits. For an idea of how to cater to the needs of a specific facility see: http://www.visn8.med.va.gov/patientsafetycenter/safePtHandling/default.asp for “Assessment Form and Algorithms” to decide what your unique patient, employee, structural, and budget conditions require.

29. Equipment Types • Lateral Transfer: Supine • Repositioning: Bed and Chair • Lift and Transfers: Seated • Sit to Stand position • Ambulation • Lifting Patients from the floor • Bathtub, Shower and Toilet transfers • Weighing • Moving beds & wheelchairs Department of Veterans Affairs, Enos 2007

30. SPH Savings • Lower MSD incidence rate => fewer workers’ compensation claims => lower insurance premiums => higher profits • Longer employee retention => lower hiring and retraining costs => higher profits • More productive employees => lower staffing costs => higher profits

31. Two Empirical Accounts • JW Collins L Wolf, J Bell and B Evanoff, “An Evaluation of a ‘Best Practices’ Musculoskeletal Injury Prevention Program in Nursing Homes,” 2004 • Kris Siddharthan, Audrey Nelson, Hope Tiesman, FangFei Chen, “Cost Effectiveness of a Multifaceted Program for Safe Patient Handling,” 2005

32. JW Collins “An evaluation of a ‘best practices’ musculoskeletal injury prevention program in nursing homes” Investment • Invested $143,556 in equipment and $27,600 in training ($498 an $77 per employee respectively) • Trained 288 employees for 1 ¼ hours each on equipment use • Recorded data 3 years before and 3 years after program implementation Results • MSD claims were reduced by 57% from 129 to 56 • Direct injury costs dropped from $441,670 to $277,061 yielding a savings of $164,609 during the post-implemenation period and an annualized saving of $54,870. • The 10 year net present value of the project at the time of implementation was $594,605. • Accounting for estimated capital maintenance, anticipated retraining, and training backfill, the adjusted recovery time on investment was 3 ¾ years

33. Kris Siddharthan, “Cost Effectiveness of a Multifaceted Program for Safe Patient Handling” Investment • Invested $774,000 in equipment and $392,423 in training ($1,441 and $121 per employee respectively) • Trained 537 employees for 6 hours each on equipment use • Recorded data for ¾ years before and ¾ years after program implementation Results • MSD claims were reduced by 30% from 129 to 91 • Direct injury costs dropped from $344,793 to $126,420 yielding a savings of $218,373 during the post-intervention period and an annualized savings of $291,164 • The 10 year net present value of the project at the time of implementation was $847,501. • Accounting for estimated capital maintenance, anticipated retraining, and training backfill, the adjusted recovery time on investment was 4.6 years

34. Investment Recovery Time Periods In Siddharthan et al. investment recovery occurred in 4.3 years In Collins et al. recovery occurred in slightly less than 3 years Siddharthan et al., 2005, Collins et al., 2004

35. Discussion of Cost Recovery • Studies assumed facilities were self-insured so savings were realized immediately • The Siddharthan cost curve is positively sloped to reflect 4% annual capital and retraining costs subject to turnover rates. Collins did not estimate these factors so costs over time were not calculated. • Most Oregon facilities are insured so recovery based solely on dropping premium rates may take longer. • Neither study accounted for savings through indirect costs avoided. Had these been considered, the recovery time period would have been much shorter.

36. Monitoring Investment Recovery • Follow the progress of your safe patient handling program by tracking incident rates over time and comparing to previous rates will give you an idea of the program’s efficacy. • Incident Rates are calculated as follows: IR = (Number of incidents per year) x (200,000 hours of work) (Number of hours worked by target population) Ex: 3 MSDs x 200,000 hours = 3 100 employees x (50 weeks x 40 hours) • Incident rates control for employee population change and employee hours worked so figures can be compared between facilities and over time. Lynda Enos, “Cost Justification of Ergonomics Programs,” Central Oregon Occupational Safety & Health Conference 2005

37. Another Measurement Technique • Records of changes in injury Severity Rates can provide information about whether or not the program is reducing the severity of injuries that do still occur. • Severity rates are calculated as follows: SR = (Number of lost or resting workdays) x (200,000 hours of work) Number of hours worked by the target population Ex: If the MSDs kept employees home for 20, 30 and 50 days, SR = (20 + 30 + 50) x 200,000 = 100 100 employees x (50 weeks x 40 hours) Enos 2005

38. And Then?… • Compare yearly claims list from before and after program implementation. • If facility has correctly used the lift equipment, significant decreases in the number and severity of patient-handling injuries should be evident. • Remember savings extend beyond the reductions in claims costs! Tracking changes to yearly turnover, rehiring and retraining will reveal additional savings.

39. References • “Economic evaluation in occupational health – its goals, challenges, and opportunities” The Scandinavian Journal of Work, Environment and Health • American Association of Colleges of Nursing, Fact Sheet, March 2007. http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm • Chuck Easterly, Claims Manager, SAIF Corporation, June 2007 • Lynda Enos RN, MS, COHN-S, CPE, Oregon Nurse’s Association, 2007 • “Accepted Disabling Claims in Health Care,” Oregon DCBS, Information Management Division, July 2007 • Loeppke, Ronald, Michael Taitel, Dennis Richling, et al., “Health and productivity as a Business Strategy,” Journal of Occupational and Environmental Medicine, Volume 49, Number 7, July 2007, 712-721 • JW Collins L Wolf, J Bell and B Evanoff, “An Evaluation of a ‘Best Practices’ Musculoskeletal Injury Prevention Program in Nursing Homes,” IP Online, 2004 • Kris Siddharthan, Audrey Nelson, Hope Tiesman, FangFei Chen, “Cost Effectiveness of a Multifaceted Program for Safe Patient Handling,” 2005 • “Safe Patient Handling and Movement,” Department of Veteran’s Affairs, 8/7/2007, http://www.visn8.med.va.gov/patientsafetycenter/safePtHandling/default.asp • Oregon Information Management Division, Bulletin 220 data regarding patient handling accepted disabling claims. • “Wisdom at Work: The Importance of the Older and Experience Nurse in the Workplace”, Robert Wood Johnson Foundation, 2006.