Putting Policy and Research into Practice Dr Annalee

Putting Policy and Research into Practice Dr. Annalee Yassi, MD, MSc, FRCPC Canada Research Chair in Trans-disciplinary Health Promotion Research Founding Executive Director, Occupational Health and Safety Agency for Healthcare in BC Director, Institute of Health Promotion Research, U of British Columbia Professor, Department of Health Care & Epidemiology, U of British Columbia

OUTLINE 1. The Issues 2. Research: The Evidence 3. OHSAH: Research into Practice a. “No Manual Lifting” b. Prevention and Early Active Returnto-work Safely (PEARS) c. Community Alliance for Health Research 4. Conclusions

1. The issues: High injury rates & long duration of time loss post injury $ 1997 -2001: more than 40, 359 time-loss WCB claims to BC healthcare workers; $ More than 2 million days lost; $ Direct claims costs 1997 -2001: $220 million - WCB premiums for healthcare sector have been raised by 40% for 2001 ($25 million);

Healthcare sector in perspective Nearly 1 in 8 of all time-loss injuries in 2001 • The Healthcare sector is the No. 1 source of time loss claims and days lost in BC • More than Logging • More than Manufacturing • More than Construction 12% of all Days Lost in 2000

Trends in days lost

Number of claims by type of accident 2000 *Overexertion from patient handling is the greatest cause of injury.

2. Research: The Evidence • good OH&S practices, • functional joint OH&S committees, • return-to-work programs, • compliance with safety regulations, • senior management commitment to OH&S • and worker participation in decision making, lead to lower injury rates than organizations without these characteristics. • Habeck et al. Employer factors related to workers’ compensation claims and disability management. Rehabilitation Counseling Bulletin, 34: 210 -226, 1991. • Norman R, Wells R. Ergonomic interventions for reducing musculoskeletal disorders. In T. Sullivan (ed. ), Injury and the New World of Work. Columbia Press, 2000.

Research: The Evidence • The quality of workplace accommodation is crucial for return to work after soft tissue injuries; • “Usual activity” is better than intensive physio off-site or bed rest; • Extreme treatment is not necessary; • Physicians require the ability to explain the nature of injury and dispel worker fears. • Guzman et al. Perspectives of primary care physicians on return to work after an occupational soft tissue injury. In press Canadian Family Physician • Malmivaara et al. The treatment of low back pain – bed rest, exercises, or ordinary activity? New England Journal of Medicine 1995 • Skouen et al. Relative cost effectiveness of extensive and light multidisciplinary treatment programs vs treatment as usual for patients … SPINE Vol 27 Number 9, 2002

Research: The Evidence cont’d § Most research is based on single dimensional, medical models, even though work injuries arise from complex interactions; § Workplace culture characteristics contribute to both injury incidence and subsequent disability experience. § Evidence points to the need for more comprehensive programs – that include work place culture, and address both primary and secondary prevention. • Yassi et al. “Injury Prevention and Return to Work: Breaking Down the Two Solitudes”, In chapter T. Sullivan, J. W. Frank. (Eds) New Views on Preventing Work–Related Disability. Taylor & Francis Books Ltd. 2002.

3. OHSAH: Research into Practice

The OHSAH mandate is specific: C To identify and share best practices C To design pilot programs to implement these practices C To evaluate their effectiveness

Methods: A. Use evidence, (local and published internationally) to develop and disseminate best practice guidelines B. Create partnership initiatives with funding based on labour management cooperation and scientific validity C. Rigorous evaluation of effectiveness, and cost-benefit of workplace interventions

The Evidence… and its implications Both world literature and WCB data from BC substantiate high risk of MSI from patient handling – Thus unions and management prioritised the need to reduce these injuries but Mechanical devices cannot be used in all situations; and, without proper training, may be counterproductive* thus guidelines were needed. • *Daynard et al. Biomechanical analysis of cumulative spinal loads during patient handling activities: A substudy of a randomised controlled trial of measures to prevent lift and transfer injury to health care workers. Applied Ergonomics, 2001; 32: 199 -214.

Safe Patient Handling Guidelines MSIP Program Implementation Guide qa consultation process, and an outline of workplace commitment, with terms and roles clearly defined; qeducation for the workforce, MSI risk identification; q. MSI risk assessments; q. MSI risk control; qtraining; qand evaluation of the control measures and the MSIP itself.

Safe Patient Handling Handbook 12, 000 copies to date

A rigorous evaluation of effectiveness and cost-benefit of a workplace intervention The effectiveness of implementing a ‘no lift’ policy, with training and installing mechanical lifts, was evaluated in the extended care unit of St. Joseph’s Hospital. The hospital had received WCB funding to install 65 ceiling lifts.

Methods to assess effectiveness and cost benefits: § A retrospective analysis was conducted for injuries that occurred 3 years pre- versus 1. 5 years post-installation; the time interval during which the installation occurred was not included; § Surveys assessing the prevalence of MSI symptoms and satisfaction were completed pre- and post-intervention; § Costs and benefits attributable to the Lifting System Project were identified and compared for a one-year period pre- and post-intervention.

Injury Rates (MSIs/100, 000 worked-hours) MSI rates 25 20 pre-intervention 15 post-intervention, pre. MSIP training post-intervention, during/post-MSIP training 10 5 0 repositioning patient lifts patient transfers • Ronald et al. Effectiveness of installing overhead ceiling lifts on reducing musculoskeletal injuries in an extended care hospital. AAOHN 2002, 50(3): 120 -127.

Payback from WCB perspective (non-discounted costs & benefits) • Spiegel et al. Cost-benefit of implementing a resident lifting system in an extended care hospital. AAOHN 2002, 50(3): 128 -134.

Cumulative present value costs and benefits from WCB perspective

Results § The incidence of lift and transfer claims decreased by 58% (from 24 to 1, p=. 01). § The costs per 100, 000 hours worked were reduced by 69% (from $65, 997 to $20, 731). § Savings come from both reduced MSI incidence and reduced duration of claims. § Staff preferred ceiling lifts to manual methods.

The Comox project summation: ã ã The Comox project was implemented with an initial one-lift pilot, with direct staff involvement in implementation decisions, evaluating its effectiveness, and the feasibility of a broader deployment. The involvement of the workers in implementing this intervention changed the culture of the workplace – likely playing a major role in decreasing time loss and costs.

St. Joseph’s staff testimonial “I don’t work in pain anymore… The lifts lift the patients – and lift our spirits!” - Joy Le Blanc’s testimony. “Thanks to overhead lifts, patient dignity has been reinstated…” Penny Hacking

Research and Policy into Practice

The evidence Dr. Barbara Silverstein, researcher with the Washington State Labor Department, speaking at the provincial healthcare leaders meeting in Vancouver on January 31, 2001. “zero-lift programs actually do prevent injuries AND are cost-effective. ”

The evidence Speaker Marie-Josée Robitaille, Director of Professional Services to Care Facilities with ASSTSAS, compared traditional floor lifts with ceiling lifts to emphasize cost effectiveness and efficiency. “. . . no employment accident related to patient transfers was recorded in the rooms where ceiling lifts were available. . ”

MEMORANDUM OF UNDERSTANDING Between Association of Unions And Health Employers Association of British Columbia

From the Mo. U q “…establish a financing framework to make funds available to purchase the necessary medical equipment; ” q “…clear industry guidelines for safe patients / residents handling; ” q “Encourage the full participation of the local Joint Occupational Health and Safety Committee in the development, implementation and on-going monitoring of this goal; ”

From the Mo. U q “Recommend to the Ministry of Health that q all new health care facilities be equipped with appropriate lifting equipment; ” and “Produce an annual report card on the progress to date, including specific recommendations for the coming year. ”* *Memorandum of Understanding re Manual Lifting. Health Employers Association of BC and the Association of Unions; March 18/19 2001

Capital Equipment Procurement 16 months later þ The Ministry of Health Services agreed to provide $15 million for the purchase of electrical beds and / or lifting equipment. þ The Workers’ Compensation Board (WCB) of BC has indicated their willingness to participate.

Capital Equipment Procurement 16 months later, cont’d þ Access to WCB’s injury and claims data is in place, to enable better tracking and evaluation of injury rates. þ OHSAH has collected program material to aid health authorities in equipment purchase decisions. This material has been placed on OHSAH’s website. þ The MOHS has agreed to the carry over of unspent funds into the new fiscal year.

PEARS Prevention ü ü Early ü Active Preventing injuries through hazard assessment & workplace modifications Early intervention including encouraging early reporting of signs and symptoms Active involvement of the worker & other members of the PEAR team Return-to-work Safely üReturn to work of the injured worker…. The pear – a symbol of health & hope

Practical application: OHSAH’s 20 Principles of “RTW” 1. Preventing disability must be seen as an extension of preventing the injury. 2. The focus of post-injury intervention must be on workplace accommodation. 3. All alternate or modified work assignments must be meaningful. 4. The program should build on previous experience within the workplace. 5. There must be an evidence-based education component and communication plan delivered for each of the stakeholder groups. 6. There must be recognition of and respect for existing patient-doctor relationships. 7. The program must be entirely voluntary.

20 Principles of RTW cont’d 8. The program must be designed for rapid and easy implementation. 9. The program should be independent of WCB claims processing. 10. Income continuity as part of this program should begin upon the injured worker’s entrance into the program and continue as long as the worker is participating in the program. 11. Provisions should be made for in-house rehabilitation wherever possible, either on-site or organized away from the workplace. 12. Union representatives must be involved in all stages of the design and implementation of the project, including decisions regarding accommodation of the injured worker.

20 Principles of RTW cont’d 13. The types of injuries to be the focus of intervention should, initially, be acute musculoskeletal injuries. 14. The scope and parameters of the programs should be as broad as possible, within the confines of the resources available. 15. All injuries must be carefully tracked, and outcomes clearly identified. 16. OHSAH will provide technical assistance. 17. OHSAH will be actively involved in all stages of evaluation. 18. OHSAH will assist in procuring needed equipment. 19. OHSAH funding will be used primarily for hiring a qualified individual to lead and co-ordinate this integrated prevention and return-to-work program. 20. OHSAH funding will be provided on a “matching” contribution-in-kind basis.

§ § § § Promote a healthy, safe work environment Define roles and responsibilities Perform ergonomic risk assessments Implement risk control measures Identify, and meet, educational needs Develop and maintain data collection system Evaluate the program PROTOCOLS AT TIME OF INJURY: § Report to supervisor/person in charge § Report to PEARS Program Personnel (OHN or designate) § Document injury / complete form / pick up program package 24 -48 HOURS POST INJURY § Assessment by program OHN § Review of incident/injury § Assessment of treatment and accommodation needs

TIME LOSS? YES DON’T KNOW NO Own doctor Program Staff YES Assessment NO Program Staff 72 HOURS POST-INJURY PEARS PROGRAM / COMPLETE DOCUMENTATION RTW

Outcome measures 1. Injury rates: annual (pre vs. post-intervention with concurrent control group) 2. Time loss per injury (as above) 3. Total time loss: until 6 months post-injury (as above) 4. Re-injury rates within 6 months of injury (as above) 5. Pain and disability: baseline and 6 months post- injury (targeted group) 6. Satisfaction with program: survey at 6 months post injury (injured workers, union, managers, OHS staff, treating physicians/other practitioners) 7. Cost-benefit of the program

Community Alliance for Health Making Healthcare a Healthier to Work: Research (CAHR) Place A Partnership of Partnerships Project #1 Project #2 Project #3 Project #4 Project #5 Project #6 Project #7 Project #8 Project #9 Creating a BC healthcare cohort Caring for the caregivers of alternate level care patients Reducing injuries in intermediate care workers Effectiveness and cost benefit of ceiling lifts to reduce musculoskeletal injury Improving the health of homecare workers Chemical substitution: employee health & organisational impacts Repositioning of patients in bed: multi-site trial of George Pearson repositioning drawsheet Health Evidence Application Linkage Network (HEALNet) Towards building an effective and efficient regional occupational health program for the healthcare sector in Winnipeg

Objective: • To identify and compare how organisational and care factors related to ALC affect nurse health and well-being, injury rates, nurse retention and recruitment. * The care given to the patients in an acute-care hospital bed, who no longer require acute medical care but whose discharge is delayed usually by the unavailability of post-hospital care.

Current Status of ALC in South Fraser Health Region (SFHR) ØSFHR had the greatest shortage of extended care beds of any region in the province due to the rapidly growing elderly population (ALC Task Force Report, 1998). ØThe ALC population in the region’s four acute-care hospitals accounted for about 25% of inpatient days! ØALC patients are assigned and cared for in different wards with different characteristics (e. g. , Dedicated ALC units, Geriatric Assessment Units (GAU), Mixture of ALC and others, etc. )

Injuries and ALC : Why the concern? Ø The care of ALC patents often requires intensive lifting and transferring and / or suffer from dementia high injury risk. Ø By definition ALC patients are not in facilities optimally designed for their care (with respect to staff mix, equipment, training of staff, etc. ). Ø The injury risk may depend on the characteristics of units where they are housed – and specifically on how the existence of ALC patients was taken into consideration on these units.

Project Cohort and Variables Cohort Ø 2, 854 patient handling staff, employed on June 10, 2001 in any of the 4 hospitals in SFHR Ø Followed up from June 10 to December 10, 2001 with respect to injuries ( from databases) Ø Surveyed wrt job conditions on the units on which they worked Sept 10, 2001, as well as their perceptions and self-reported health.

INJURY RISK FOR CAREGIVERS OF ALC PATIENTS • Of the 2, 854 patient handling staff, 533 (18. 7%) sustained an injury in the previous year • 1, 654 cohort members (58% of all patient care staff – RNs, LPNs, CEs and Rehab staff) work on a ward with ALC patients • Injury rates ranged from 8% on dedicated ALC wards to 20. 3% on “high-mix” wards and 20. 7% GAUs

INJURY RISK FOR CAREGIVERS OF ALC PATIENTS cont’d • Risk of patient handling injury was 3. 5 -4 x higher for “high-mix” and GAU compared to non-ALC; and 7. 5 x higher for violence-related injuries • Age, senority and hospital were not significantly associated with risk of injury but occupation (being an LPN or Care Aide, OR=1. 58 wrt RN), ALC care model, and history of previous injury (OR = 3. 23) were.

SATISFACTION & BURN-OUT • For those who did not enjoy ALC, this effected satisfaction with profession, hospital and unit, as well as burn-out • Satisfaction was high on GAU and dedicated ALC and lower on mixed wards • Factor analysis with the Nurse Work Index resulted in factors labeled “perceived support for nursing professionalism”, “support of management”, “satisfactory resource allocation”, and “working relationships”. Other than perceived “working relationships, ” all factors varied significantly by ALC model • Characteristics of management style and work environment were powerful determents of satisfaction, burn-out and self-rated health, but were dwarfed by variable such as occupation and ALC model with respect to predicting injuries.

POLICY IMPLICATIONS • Dedicated ALC wards are a better way of caring for ALC patients with respect to reducing risk of injuries to staff • Greater attention needs to be paid to preventing injuries on GAUs, especially violence related injuries • Training, work assignments and other factors to prevent injuries to LPNs and Care Aides should be reviewed • Staff should be informed upon recruitment whether they will be working with ALC patients or on wards with a high ALC patient load; an effort should be made to not place staff to work with ALC patients who don’t enjoy this • Increased worker participation and management attention to health and safety could improve perceived management supportiveness and satisfaction with the hospital and could decrease burn-out

CONCLUSIONS: ü ü Joint union-management governance Strong partnership with the research community ü Addressing workplace health and safety ü Reducing injuries ü Reducing time loss and injury costs

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