Law and Management in Occupational Health and Safety Patients in the Perioperative environment are often required to be repositioned on the operating table and most of these patients have had a regional or general anaesthetic, making it impossible for them (the patient) to assist staff in that repositioning. The added risk in any repositioning is loss or damage to the patients’ airway, and maintaining the patients’ musculoskeletal alignment, so as to not cause any damage to nerves, muscles, limbs, spine and or neck etc.
The repositioning should be assessed to determine if it can be done manually or by some assistive devices. During the surgery it may be necessary to lift the patients’ legs, arms or head to prepare the area for sterile field draping, which may result in nursing or theatre support staff at risk of musculoskeletal injuries, and in situations where bariatric patients (over 100kgs) the manual handling staff may need limb holding devices.
Prior to surgery, the anaesthetic nurse, anaesthetist, surgeon, theatre support technician or orderly should plan and collaborate regarding positioning, support and moving devices as well as the technique which will be utilised in the moving and repositioning of the patient – during and after the procedure when the patient will be transferred on to another bed for the post-operative recovery period. When transferring a patient from patient bed to operating table, it is important to have enough staff to assist with the transfer and to use the correctly placed support devices as well as using good body mechanics (ergonomic techniques).
When patients are obese it may be necessary to use soft gel straps to support the patients legs so that they do not move off the operating table and cause debilitating and painful nerve damage. This project is to develop a Safety Management Plan to implement a safe practical way to identify, assess and control risks in the Perioperative environment (Operating Theatre) specifically relating to the lateral transfer and or movement of patients requiring surgery at this hospital facility. Perioperative Manual Handling Safety Management Plan Perioperative Manual Handling
Safety Management Plan Using the 5 step process in the Queensland Government risk assessment plan the following matrix is how the Perioperative unit could benefit from experienced, safety motivated and interested staff could act as agents for change and safety in a more deliberate and focussed way to reduce the hazard of musculoskeletal injuries to staff especially in the task of laterally transferring patients from the operating table to the postoperative bed. These patients are usually unconscious and unable to assist or communicate their needs and concerns at this time.
Perioperative Safety Management – Risk Identification and Controls| Step 1| Look at the Hazard * Musculoskeletal disorders in nursing staff and orderlies when undertaking a lateral or horizontal transfer of unconscious patient from operating table to post-operative bed| How to look for HazardsKnowledge and Understanding Manual Handling Policies * Manual Tasks Involving the Handling of People Code of Practice 2001 * Workplace Health and Safety Act 1995 * Workplace Health and Safety Regulation 2008 * Manual Handling Training – especially regarding unconscious patients| What to look for * Practices that are causing discomfort either for the member of staff or patient * Practices that are likely to cause nerve or musculoskeletal injuries – shoulder, fingers, wrist, forearm, back, neck, sciatic nerve, knees, ankles| Step 2| Decide who might be harmed and how * Nursing Staff * Orderlies * Anaesthetists * Surgeons/Assistants * Recovery Staff | Assess the riskHow might someone be harmed * Injury to patient when moving the unconscious patient from operating bed to recovery bed with a supported airway * Lateral or sideways movement requiring pushing, pulling and lifting of limbs by team members * The staff member who controls move not always in ‘sync’ with rest of team – uncoordinated transfer * Existing musculoskeletal disorders experienced by staff and patients| What is this harm? * Airway becoming dislodged * Back, Neck, arm, shoulder injury to staff using Manual Handling techniques and devices * Uncoordinated transfer * Sideways twisting for person holding feet during transferHow likely is this harm? According to the consequences/ likelihood matrix below * Injury to patient – likely/major consequences * Unplanned airway removal – likely/major to catastrophic *
Musculoskeletal injury – likely/moderate to major * Exacerbating and worsening musculoskeletal disorders– likely/major to catastrophic (permanent loss of employment) * Team unpreparedness – likely/minor – major| Step 3| Decide the control measures| Regulations ? * Workplace Health and Safety Act 1995 * Workplace Health and Safety Regulation 2008Codes of Practice? * Manual Tasks Involving the Handling of People Code of Practice 2001What are existing controls? * Mater Operating Theatres Manual Handling Policies and Clinical Practices Manual * Manual Handling Training – Generic – needs to be targeted especially movement and care regarding unconscious patientsAre controls as high as possible? Current Manual Handling training stands at a compulsory slide sheet in-service lasting approximately 5 minutes every six months * In-service is generic and not specifically targeted to moving unconscious patients who are not able to follow instructions or cooperate with staff requests in this lateral move post operatively * Training needs to be comprehensive and developed with ergonomic and physical therapist input so that staff movement and body positioning minimises potential and foreseeable damage to limbs, nerves, shoulders and lower backs * Equipment needs be demonstrated in a non-clinical simulation before using on any patients to maximise the potential for team confidence and competence in the use of equipment – minimising harm in actual situations| Do controls protect everyone? * Controls at present minimise the importance of Manual handling techniques * Manual handling needs to have a higher profile in the unit so that it is possible to protect patients, staff and visiting surgeons and anaesthetists * Controls in place are in policy manuals, and highlighted at orientation (can be months after starting employment). * New staff are on the job immediately and therefore don’t have ‘training’ at the best and highest level of competency and developmentWhat additional controls are required? Higher profile on training by manual handling experts * Regular manual handling workshops and training groups in simulated situations = staff practice on other staff. * In-service and practical demonstrations to highlight the importance of correct posture for staff, correct lateral moving techniques and equipment for staff * Correct and helpful exercises that staff can do ‘on the run’ so that the manual handling tasks are done after staff are ‘warmed up’ * Weekly highlights on noticeboard on an important point regarding safe lifting, moving and back care for staff = many hospitals and aged care centres have excellent back injury prevention programs and are readily available at websites and search engine destinations. Step 4| Put Control measures in placeOH&S representative to Train and utilise staff who are Interested and experienced in Manual Handling of people| Developing a plan for improving controlsTrain the Trainer programs for interested personnel – not necessarily Registered Nurses (Enrolled Nurses with experience and interest)Train staff in the Incident Reporting Program and to build Staff confidence in using the software – when a hazard is reported or an injury – Staff need to be confident that it will be followed up and that negative consequences of hazard identification and reporting are not safe practices in the workplace | Improving controls * Making the Incident reporting program more user friendly and encourage staff to use the program and give timely feedback on statistics * Encourage staff to report all injuries and near misses so that the unit builds a culture of ‘safety is every ones business and responsibility’ * Make safety a priority and that means staff safety as well as patient safety – reward safety issues and hazard reporting * Encourage staff to come up with solutions to risks and hazard identification – involve everyone| Step 5| Review the Controls * 3 monthly reviews of competencies and updating of training for any new staff * Staff surveys to indicate self- satisfaction of training and competencies| Are the controls working? * Feedback from Staff self-satisfaction surveys * Anecdotal feedback from workshops and training sessions * Improvement or decline – what would staff change or improve? | Are there any new Problems? * New staff training before actually moving a patient * Generic manual handling policies * Minimum lateral transfer equipment – slide sheet and patslide? Hovermat beds possible? * People not lifting feet when patslide positioned – heel damage or pain if patslide strikes patients heel or ankle? * Apathy, lack of interest and poor technique? | PURPOSE AND SCOPE of Safety Management Plan Mercy Health and Aged Care Central Queensland Limited (MHAACCQ, 2010) is committed to the provision of a place of work that is safe and without risk to the health, safety and welfare of its employees, or any other person of our workplace We believe that * All injuries can be prevented * Working safely is a condition of employment * Employee involvement is essential * Management are ultimately accountable for safety
Munn (2011) suggests that tasks performed in the perioperative environment may present a high risk to staff for musculoskeletal injuries relating to patient handling include * Transferring patients on and off operating tables ( in this case Lateral pushing and pulling of up to 180 kgs) * Repositioning patients on operating table ( this unit has weight limits on operating table – 300 kgs) * Lifting and holding patients extremities – orthopaedic, cosmetic and general surgery * Standing for prolonged periods of time – scrub nurse has limited movement whilst scrubbed * Holding retractors for long periods of time – self retaining retractors not always suitable * Lifting and carrying equipment and supplies Pushing, pulling and moving equipment on wheels – endoscopic and microscopes Manual Handling is a major cause of injury in health care facilities. Manual handling regulations require a hazard identification, risk assessment and control approach. Obligations and the Workplace Health and Safety Act 1995 The Workplace Health and Safety Act 1995 imposes obligations on people at workplaces to ensure workplace health and safety. This is done when persons are free from the risk of death, injury or illness created by workplaces, relevant workplace areas, work activities or plant and substances for use at a workplace. Ensuring workplace health and safety involves identifying and managing exposure to the risks at your workplace. RESPONSIBILITIES Part 3, Division 2, Section 28 – Obligations of persons conducting business or undertaking (1) A person (the relevant person) who conducts a business or undertaking has an obligation to ensure the workplace health and safety of the person, each of the person’s workers and any other persons is not affected by the conduct of the relevant person’s business or undertaking. (2) The obligation is discharged if the person, each of the person’s workers and any other persons are not exposed to risks to their health and safety arising out of the conduct of the relevant person’s business or undertaking. (3) The obligation applies— (a) whether or not the relevant person conducts the business or undertaking as an employer, self-employed person or otherwise; and (b) whether or not the business or undertaking is conducted for gain or reward…” Work Health and Safety Act 1995 (Qld) Part 3, Div 1, Section 26 (3) If a code of practice states a way of managing exposure to a risk, a person discharges the person’s workplace health and safety obligation for exposure to the risk only by— (a) adopting and following a stated way that manages exposure to the risk; or (b) doing all of the following— (i) adopting and following another way that gives the same level of protection against the risk; (ii) taking reasonable precautions; (iii) exercising proper diligence. ” People handling activities and injury The most frequently injured body parts from people handling activities undertaken without assistance are the back, shoulders and wrist.
People handling activities can contribute to a number of Work-Related Musculoskeletal Disorders (WRMDs) including: a) Low Back Disorders (injuries to muscles, ligaments, inter-vertebral discs and other structures in the back). b) Tendon Disorders (injuries affecting the tendons in the wrist, and elbows particularly). c) Nerve Disorders (injuries affecting the wrist, neck and shoulder). d) Upper limb muscle strains (injuries affecting the rotator cuff* and forearm particularly). “WRMDs occur in two ways: gradual wear and tear (cumulative trauma) caused by frequent periods of muscular effort involving the same body parts, and sudden damage caused by nexpected movements, intense or strenuous activity, for example, when people being handled move suddenly or when the worker is handling a load beyond their capacity. Gradual wear and tear is the most common way WRMDs occur. Even when an injury seems to be caused by overload, the triggering event might just be the final trauma to tissues already damaged by previous exposures to people handling and other manual activities. It is recommended that when a healthcare worker needs to lift more than 15. 3 kilos of patient weight, lifting aids should be used. The lateral transfer of a patient from one surface to another, such as from operating table to patients bed, poses a risk to staff for developing musculoskeletal disorders.
Some general guiding principles pertaining to the transfer of a patient to an operating table are: * The number of staff involved in a transfer is needed to be sufficient based on the patients weight, and to ensure that ALL extremities are supported and the patients alignment and airway are maintained * The lateral transfer device needs to support the whole length of the patients body * The are where the patient is being transferred to needs to be slightly lower * When a patient is being transferred from supine (on back) to prone (on front) the support equipment (such as pillows or spine table need to be utilised in the transfer * Mechanical devices such as Hover Mat air assisted mattress transfer devices have been devised to assist in the safe transfer of Perioperative patients” Manual Tasks Involving the Handling of People Code of Practice 2001, Qld. “ Section 27A – Managing exposure to risks (1) To properly manage exposure to risks, a person must— (a) identify hazards; and (b) assess risks that may result because of the hazards; and (c) decide on appropriate control measures to prevent, or minimise the level of, the risks; and (d) implement control measures; and e) monitor and review the effectiveness of the measures. (2) To properly manage exposure to risks, a person should consider the appropriateness of control measures in the following order— (a) eliminating the hazard or preventing the risk; (b) if eliminating the hazard or preventing the risk is not possible, minimising the risk by measures that must be considered in the following order— (i) substituting the hazard giving rise to the risk with a hazard giving rise to a lesser risk; (ii) isolating the hazard giving rise to the risk from anyone who may be at risk; (iii) minimising the risk by engineering means; (iv) applying administrative measures; (v) using personal protective equipment. 9 Without limiting section 28, discharging an obligation under the section includes, having regard to the circumstances of any particular case, doing all of the following— (a) providing and maintaining a safe and healthy work environment; (b) providing and maintaining safe plant; (c) ensuring the safe use, handling, storage and transport of substances; (d) ensuring safe systems of work; (e) providing information, instruction, training and supervision to ensure health and safety. ” Workplace Health and Safety Act 1995, Qld Manual Tasks Involving the Handling of People Code of Practice 2001 The People Handling Code of Practice states ways to prevent or minimise exposure to risk due to the handling of people that can cause or aggravate work related musculoskeletal disorders.
It applies to any workplace activity requiring the use of force by a person to hold, support, transfer (lift, lower, carry, push, pull, slide), or restrain another person at a workplace. This code outlines practical ways in which a person to whom this code applies can meet the requirements of the Workplace Health and Safety Act 1995. Guidance on the broad area of manual tasks in all its forms, including the moving of equipment used for handling people, is provided in the Manual Tasks Code of Practice. What is “people handling”? “People handling” refers to any workplace activity where a person is physically moved, supported or restrained at a workplace.
Specifically, people handling refers to workplace activities requiring the use of force exerted by a worker* to hold, support, transfer* (lift, lower, carry, push, pull, slide), or restrain* a person* at a workplace. * Exacerbating and worsening musculoskeletal disorders– likely/major to catastrophic (permanent loss of employment) * Team unpreparedness – likely/minor – major * http://www. noweco. com/risk/risk04e. gif All people handling activities are a potential source of injury and therefore, a hazard. If you undertake people handling at your workplace, you should use a process to manage the risks associated with this hazard People handling is often only one part of a theatre nurses job.
If other parts of the nurses job also involve manual handling of other loads, it is necessary to assess the whole job and manage the risks associated with undertaking those activities which add to the accumulative stress on the worker’s body. 1. People handling activities is a collective term for a group of related people handling tasks. 2. People handling tasks are the specific ‘pieces’ of work undertaken at the workplace, which involve the physical movement of a person. 3. People handling actions are the individual elements of the task and refer to movements which are undertaken. ” Manual Tasks Involving the Handling of People Code of Practice 2001, Qld.
Common work-related actions within people handling tasks which contribute to WRMDs include: * frequent and repetitive lifting with a bent and/or twisted back regardless of weight * static working positions with the back bent, for example, holding a limb during a surgical procedure or providing stability while a person stands “ Manual Tasks Involving the Handling of People Code of Practice 2001, Qld. Risk factors To gain a greater understanding of the relationship between people handling activities and injury, it is useful to consider the ‘risk factors’ which influence the level of risk associated with undertaking people handling tasks. These risk factors can be grouped into two distinct categories: * direct risk factors – which directly stress/injure the worker’s body * contributing risk factors and modifying risk factors – which affect how the task or action is done. There are three direct risk factors: * forceful exertion * working postures (awkward, static) * repetition and duration. The risk management process
Under the Workplace Health and Safety Act 1995 (the Act), exposure to health and safety risks that arise from workplace hazards (such as people handling) must be managed. The Act places this responsibility for workplace health and safety upon certain people (such as relevant persons and persons in control of workplaces) Risk management is an ongoing process. It should be undertaken: * now, if it has not been undertaken before * when changes occur at, or are planned for, the workplace * when there are indications for potential injury * after an incident (or ‘near miss’) occurs * at regularly scheduled times appropriate to the workplace.
The steps below illustrate the application of the risk management process to managing exposure to the risks associated with people handling. Identification The first step in the process of managing exposure to people handling risks is identification. This step involves identifying people handling tasks, actions within each task, direct risk factors, and, contributing and modifying risk factors The first part of identification is to make a list of those tasks undertaken at the workplace that involve handling people. 1. Consult with workers and observe the tasks. 2. Make a list of all the people handling tasks. 3. Make a list of the actions within each of these tasks 4. For each action, determine which of the direct risk factors are present. 5.
For each action, identify the contributing and modifying factors Assessment Assessment involves determining the level of risk associated with each of the people handling actions identified. The desired outcome of the assessment step is a prioritised list of people handling actions requiring control. Further, when more than one people handling task is assessed, then the overall risk estimate for the task can be used to develop a prioritised list of tasks requiring control. Consult with workers throughout this process to assist with determining the level of risk associated with each of the people handling actions and the priority of each task. 1. Consult with the workers. 2.
Determine the level of risk associated with each action 3. Prioritise actions for control. In order to prioritise the people handling actions, the risk associated with performing each action should be assessed. It is up to the assessor how this assessment is done. The assessor can choose any method of risk assessment as long as a prioritised list of actions is achieved. A way of assessing risk is to consider the likelihood and consequences of an incident occurring at the workplace. Likelihood – of an incident occurring at the workplace * To estimate the likelihood of an incident occurring at the workplace, the following aspects can be considered: * how often the action is undertaken the number of workers performing the same or a similar action * the duration of time that the action is performed * distractions * the effectiveness of existing control measures * capacity and characteristics of the workers * environment * availability and use of equipment * condition of equipment * injury data/history6. Consequences – of an incident occurring at the workplace To estimate consequences, the severity of a potential injury or illness that could result from performing a people handling action can be considered. Reference can also be made to injury records and statistics, and information on injuries from people handling in related industries for an indication of the potential severity of injury.
Use this likelihood and consequence estimate to rank and then, list the people handling actions requiring control. The decision is then made that for some actions, for example, those for which it is very unlikely that an incident would occur and for which the consequences are minor, may not require control. A summary of the assessment process Consult with workers: * Estimate the likelihood of an incident occurring at the workplace. * Estimate the consequences of an incident occurring at the workplace * List the people handling actions in the order of they require control. Questions to ask: * What do the workers think? * What is the likelihood and potential severity of injury associated with each action? * What should be fixed? What should be fixed first? Control Risk control strategies involve: * making decisions about the best measure(s) to control exposure to the contributing and modifying risks identified * implementing the chosen controls. Consultation with workers is an important part of this process. Design controls involve the arrangement, or alteration of: * physical aspects of the work area such as equipment or furniture/fittings, or * the work procedure. * Design controls are preferred because they – * can eliminate or at least minimise exposure to risk factors * have the advantage of being relatively permanent (compared with administrative controls). For these reasons, implement design controls wherever possible. Administrative controls are achieved primarily by modifying existing personnel arrangements. Administrative controls do not remove the root cause of potential problems. These controls can only reduce exposure to the risk of injury. They might also be forgotten or not followed under stressful or other conditions as they are behaviour based, for example coping with staff reduction It includes consideration of factors such as – * the work postures required to carry out the action, how often it is repeated and for how long. Provide mechanical aids – where appropriate given the sterile environment in the perioperative unit – Hovermats are elpful in reducing the load of manual handling – but these are prohibitively expensive and require as many people to move patient safely as any other method Task-specific training Training in work methods for specific tasks or actions helps workers to carry out these tasks/actions in a safe and effective way. * Controls should not create other risks – the solutions should not result in a transfer of risk, for example, incorrect use of a handling aid, such as a transfer sheet can create forceful exertions on the workers forearm Although all the manual handling issues in the Perioperative are beyond this papers’ parameters, at least this area of patient care should be lifted to a much higher profile from a management, safety and a professional longevity perspective.
Low back pain has been described as one of the main occupational problems among healthcare workers and nurses frequently have the highest incidence (Karahan, Kav, Abbasoglu & Dogan,2008) What is needed is a consistent, determined and educated effort on the part of the unit manager, nurse educator and occupational health and safety team to implement a program that will drive the manual handling of people to the forefront of safety practices in the unit – where bariatric patients (more than 100kgs) are becoming the norm rather than the exception, across all age groups and gender. Hospital and other care facilities have not generally been designed with the movement of bariatric patients in mind. – ( Safework Australia, 2009). It is assumed largely by practicing nurses in the perioperative unit that new staff that join the team have some background in manual handling.
Many students report that they have little to no manual handling training, other than hands on with another marginally more experienced nurse directing their work task, this is not a satisfactory or safe method of training – either for the nurse or the patient. Much more emphasis must be directed at the pre-employment and career development process in the safe development and competent use of manual handling techniques of vulnerable, often otherwise well patients who have mostly elective surgery for non- life threatening procedures. As the patient advocate, it is the nurses responsibility to ensure a safe passage through the perioperative journey.