[Senate Hearing 111-1138]
[From the U.S. Government Publishing Office]



                                                       S. Hrg. 111-1138
 
   SAFE PATIENT HANDLING AND LIFTING STANDARDS FOR A SAFER AMERICAN 

                               WORKFORCE

=======================================================================



                                HEARING

                               BEFORE THE

            SUBCOMMITTEE ON EMPLOYMENT AND WORKPLACE SAFETY

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,

                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                                   ON

   EXAMINING SAFE PATIENT HANDLING AND LIFTING STANDARDS FOR A SAFER 
AMERICAN WORKFORCE, INCLUDING S. 1788, TO DIRECT THE SECRETARY OF LABOR 
TO ISSUE AN OCCUPATIONAL SAFETY AND HEALTH STANDARD TO REDUCE INJURIES 
 TO PATIENTS, DIRECT-CARE REGISTERED NURSES, AND ALL OTHER HEALTH CARE 
 WORKERS BY ESTABLISHING A SAFE PATIENT HANDLING AND INJURY PREVENTION 
                                STANDARD

                               __________

                              MAY 11, 2010

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


      Available via the World Wide Web: http://www.gpo.gov/fdsys/




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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       TOM HARKIN, Iowa, Chairman

CHRISTOPHER J. DODD, Connecticut
BARBARA A. MIKULSKI, Maryland
JEFF BINGAMAN, New Mexico
PATTY MURRAY, Washington
JACK REED, Rhode Island
BERNARD SANDERS (I), Vermont
SHERROD BROWN, Ohio
ROBERT P. CASEY, JR., Pennsylvania
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
MICHAEL F. BENNET, Colorado

                                     MICHAEL B. ENZI, Wyoming
                                     JUDD GREGG, New Hampshire
                                     LAMAR ALEXANDER, Tennessee
                                     RICHARD BURR, North Carolina
                                     JOHNNY ISAKSON, Georgia
                                     JOHN McCAIN, Arizona
                                     ORRIN G. HATCH, Utah
                                     LISA MURKOWSKI, Alaska
                                     TOM COBURN, M.D., Oklahoma
                                     PAT ROBERTS, Kansas
                                       
                                       

                      Daniel Smith, Staff Director

                  Pamela Smith, Deputy Staff Director

     Frank Macchiarola, Republican Staff Director and Chief Counsel

            Subcommittee on Employment and Workplace Safety

                   PATTY MURRAY, Washington, Chairman

CHRISTOPHER J. DODD, Connecticut
BARBARA A. MIKULSKI, Maryland
SHERROD BROWN, Ohio
KAY R. HAGAN, North Carolina
JEFF MERKLEY, Oregon
AL FRANKEN, Minnesota
TOM HARKIN, Iowa (ex officio)

                                     JOHNNY ISAKSON, Georgia
                                     JUDD GREGG, New Hampshire
                                     RICHARD BURR, North Carolina
                                     JOHN McCAIN, Arizona
                                     ORRIN G. HATCH, Utah
                                     LISA MURKOWSKI, Alaska
                                     MICHAEL B. ENZI, Wyoming (ex 
                                     officio)

                      Scott Cheney, Staff Director

                 Edwin Egee, Republican Staff Director

                                  (ii)




                            C O N T E N T S

                               __________

                               STATEMENTS

                         TUESDAY, MAY 11, 2010

                                                                   Page
Murray, Hon. Patty, Chairman, Subcommittee on Employment and 
  Workplace Safety, Committee on Health, Education, Labor, and 
  Pensions, opening statement....................................     1
    Prepared statement...........................................     2
Franken, Hon. Al., a U.S. Senator from the State of Minnesota....     5
Collins, Captain James W., Ph.D., M.S.M.E., Associate Director 
  for Science, National Institute for Occupational Safety and 
  Health, Washington, DC.........................................     6
    Prepared statement...........................................     7
Hodgson, Michael, M.D., MPH, Chief Consultant, Veterans Health 
  Administration, Washington, DC.................................    11
    Prepared statement...........................................    13
Isakson, Hon, Johnny, a U.S. Senator from the State of Georgia, 
  prepared statement.............................................    14
Silverstein, Barbara, MSN, MPH, Ph.D., CPE, Research Director, 
  Washington State Department of Labor and Industries, Olympia, 
  WA.............................................................    24
    Prepared statement...........................................    25
Shogren, Elizabeth (Bettye), RN, MNA, Minnesota Nurses 
  Association, Staff Specialist, St. Paul, MN....................    28
    Prepared statement...........................................    30
Altaras, June M., RN, BSN, MN, Administrative Nursing Director, 
  Swedish Medical Center, Seattle, WA............................    32
    Prepared statement...........................................    35
Erickson, Douglas, FASHE, HFDP, CHFM, CHC, Deputy Executive 
  Director, American Society for Healthcare Engineering, Chicago, 
  IL.............................................................    45
    Prepared statement...........................................    47

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    David Michaels, Ph.D., MPH, Assistant Secretary of Labor for 
      the Occupational Safety and Health Administration (OSHA)...    54
    American Federation of State, County and Municipal Employees 
      (AFSCME)...................................................    55
    American Industrial Hygiene Association (AIHA)...............    56
    American Nurses Association (ANA)............................    57
    Response by Captain James W. Collins, Ph.D., M.S.M.E. to 
      questions of:
        Senator Hagan............................................    60
        Senator Isakson..........................................    62
    Response to questions of Senator Hagan by Michael Hodgson, 
      M.D., MPH..................................................    63

                                 (iii)



   SAFE PATIENT HANDLING AND LIFTING STANDARDS FOR A SAFER AMERICAN 
                               WORKFORCE

                              ----------                              


                         TUESDAY, MAY 11, 2010

                                       U.S. Senate,
           Subcommittee on Employment and Workplace Safety,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:32 p.m. in 
Room SD-430, Dirksen Senate Office Building, Hon. Patty Murray, 
chairman of the subcommittee, presiding.
    Present: Senators Murray, Franken, and Isakson.

                  Opening Statement of Senator Murray

    Senator Murray. Good afternoon. This subcommittee will come 
to order.
    I want to thank, first of all, Senator Isakson and his 
staff for being so collegial and courteous as we brought this 
hearing together, and really appreciate their work on the 
subcommittee.
    Senator Isakson will be joining us shortly; he's on his way 
over from the floor right now.
    I also want to thank all the witnesses who took the time to 
be here with us today. And I'm especially excited to have two 
witnesses from my home State of Washington. We'll hear from 
them shortly.
    But, let me just start by saying, our country has had too 
many reminders recently about the critical importance of worker 
safety. We were reminded when 29 workers lost their lives in a 
coal mine in West Virginia, and when seven passed away in a 
tragic oil refinery fire in my home State of Washington. These 
were really tragic events, but we need to remember that no 
threats to worker safety are acceptable, whether they result in 
injury, or worse. And, unfortunately, these threats are 
occurring all too often. I believe that workers ought to be 
able to feel confident that, while they're working hard and 
doing their jobs, their employers are doing everything possible 
to keep them safe. This should be true for miners, it should be 
true for refinery workers, and, the area we're going to be 
focusing on today, should be true for healthcare employees.
    As we all know, nurses are the backbone of our healthcare 
system, but too often they are overlooked in discussions of 
workplace safety, even though their jobs are consistently 
ranked as one of the most danger-prone in the country. In fact, 
on the list of workers facing workplace-related musculoskeletal 
disorders, nurses rank as the leading victim, sustaining these 
injuries at a rate nearly seven times the national average.
    Sadly, nearly half of the nurses on the job report chronic 
back pain, and more than 1 in 10 of them say they are planning 
to leave the field within the next year. This costs our 
hospitals and providers millions in worker compensation, 
overtime, replacement, and training costs, and it devastates 
workers and their families, moms and dads who can't pick up 
their children or grandchildren and cannot be physically active 
without constant pain. All of this is coming at a time when we 
need our nurses healthy and on the job more than ever.
    The need for registered nurses in the United States could 
reach as high as 500,000 over the next 15 years, which would be 
especially devastating at the very time we are trying to bring 
millions of new patients into the healthcare system.
    Today we are going to examine the impact of the injury 
rates our Nation's healthcare workers sustain due to lifting 
patients, and we're going to hear from witnesses about some 
solutions being developed to promote safer workplaces for our 
nurses.
    It used to be the case that we didn't have the research and 
equipment available to prevent lifting injuries, but now we 
know how to implement safe patient lifting policies. It's just 
a matter of making sure that it does happen.
    We know that, under ideal circumstances, a worker should 
only lift 50 pounds by his or herself, but there are few 50-
pound patients, and they are rarely positioned in such a way as 
to make safe lifting easy. In fact, over the course of their 
average day, nurses often need to lift more total pounds than 
many truck drivers and construction workers. It's clear that we 
need to be proactive and cost-effective to make sure nurses 
have the training and resources to handle patients in a way 
that's safe for them and for the patient.
    Our witnesses today will focus on safe patient handling, 
which has worked for the Veterans Administration, nine States, 
including my home State of Washington, and several hospital 
systems. There's no shortage of research or evidence about how 
this equipment works and how a program can be implemented, and 
there's no question it saves money, helps patients, and creates 
a safer work environment for patients.
    The question remains, What does a Federal solution need to 
look like? I am looking forward to hearing from our witnesses 
about this important issue.
    [The prepared statement of Senator Murray follows.]

                  Prepared Statement of Senator Murray

    This hearing of the subcommittee will come to order.
    Today's hearing examines the impact of injury rates among 
our Nation's healthcare workers due to lifting patients and the 
various solutions that States, the Veterans Health 
Administration and several hospital systems have developed to 
promote safer workplaces in their hospitals.
    I want to thank our witnesses for being here. I am 
especially excited to have two witnesses from my home State of 
Washington. I'd also like to thank Senator Isakson for working 
with me on a bipartisan basis to hold this hearing. As always, 
I appreciate your work on this subcommittee.
    We all know that nurses are the backbone of our healthcare 
system. And they will serve an even more vital part of our 
healthcare system under the reform law Congress recently 
passed. In fact, the Bureau of Labor Statistics projects that 
more than 581,500 new RN positions will be created through 
2018, an increase of 22 percent. Employment of RNs is expected 
to grow much faster than the average when compared to all other 
professions.
    Yet the Journal of the American Medical Association 
predicts a ``large and prolonged shortage of nurses.'' It is 
estimated that we will need to graduate 30,000 additional 
nurses annually to meet the Nation's healthcare needs, an 
expansion of 30 percent over the current number of annual nurse 
graduates. And to make matters worse, in a 2006 survey 55 
percent of nurses reported their intention to retire between 
2011 and 2020. The average age of the Registered Nurse is 
climbing. With the average age of RNs projected to be 44.5 
years by 2012, nurses in their 50s are expected to become the 
largest segment of the nursing workforce, accounting for almost 
one quarter of the RN population.
    So at a time when we need more nurses--many more nurses--we 
have both a systemic shortage and the potential for higher 
retirement rates on the near horizon. It seems to me that we 
should be doing everything we can to keep the nurses we have 
safe, healthy and on the job, as a bare minimum.
    But, and with no small irony, it is our nurses who too 
often selflessly break their own backs to deliver the best 
healthcare they can.
    Often overlooked in discussions of workplace safety are 
healthcare workers. When considering the idea of a ``dangerous 
industry,'' most Americans think of construction work, oil 
refineries, commercial fishing, and mining. However, 
statistically, healthcare work consistently falls among the 
most dangerous professions.
    Sadly, half of our nurses report they have chronic back 
pain, and back injuries to nurses are costly. They cost their 
employer in worker compensation, overtime, replacement and 
training costs. These costs then get passed on to the 
government in the form of additional training costs, lost 
productivity, and disability payments. But the biggest costs 
are borne by the workers and their families--moms and dads who 
can't pick up their kids and grandkids, or be physically active 
with them without constant pain.
    This is a lose-lose situation. Society loses someone who 
chose a job based on compassion and wanting to help and heal 
people. Those same people are forced to leave their important 
work because the up front cost of some lifting equipment seemed 
like a big investment that fiscal year.
    In the past, nurses were being hurt on the job when we 
didn't have the research and equipment available to prevent 
lifting injuries. But now we have the equipment and knowledge 
to implement safe patient lifting policies.
    NIOSH says that under the best circumstances, a worker 
should only lift 50 pounds. There are few 50-pound patients, 
and they surely aren't packaged into boxes with handles so you 
can bend at the knees. And there is a lot of bending and 
twisting involved in moving a patient. It's almost inevitable 
that manual lifting will overtime or suddenly hurt a healthcare 
worker. Why should our nurses have to lift more than truck 
drivers or construction workers?
    This committee has taken a serious look over time at the 
growing obesity epidemic, but one thing we haven't taken a look 
at yet is the effect of that epidemic on healthcare workers who 
must manually lift them. If you visit the Work Injured Nurses' 
Group's Web site, one of the top stories featured is about a 
nurse who was injured while lifting a single patient who 
weighed over 700 pounds with a colleague. While a great deal of 
injuries happen over time, as patients get heavier, the odds 
that a nurse will be hurt in a single lift has increased 
dramatically.
    Meanwhile, the shortage of registered nurses in the United 
States could reach as high as 500,000 by 2025 according to a 
reported released in March 2008 by Dr. Peter Buerhaus of 
Vanderbilt University School of Nursing, Dr. Douglas Staiger of 
Dartmouth University, and Dr. David Auerbach of the 
Congressional Budget Office. Moreover, the report found that 
the demand for registered nurses is expected to grow by 2 to 3 
percent each year. In September 2007, Dr. Christine T. Kovner 
and colleagues found that 13 percent of newly licensed 
registered nurses had changed principal jobs after 1 year and 
37 percent reported that they felt ready to change jobs,
    It is clear that we need proactive and cost-effective ways 
to stem the loss of nurses. That's why today's hearing will 
focus on something that has worked for the VA, nine States, 
including my home State of Washington, and several hospitals 
systems--safe patient handling.
    There's no shortage of research or evidence about how this 
equipment works and how to implement a program, and there's no 
question that this saves money and saves nurses backs. Now the 
question remains: what does a Federal solution need to look 
like?
    But before we hear from our witnesses, I'd like to 
recognize Senator Isakson for his opening statement.
    I am looking forward to hearing from our witnesses about 
this important issue:

     Capt. James W. Collins is the Associate Director 
for Science at NIOSH.
     Dr. Michael Hodgson is the Chief Consultant for 
the Occupational Health, Safety, and Prevention Healthcare 
Group in the Office of Public Health and Environmental Hazards 
at the Veterans Health Administration.
     Dr. Barbara Silverstein is the Research Director 
for Safety and Health Assessment and Research for Prevention at 
the Washington State Department of Labor and Industries.
     Elizabeth Shogren is a nurse from Minnesota.
     June Altaras is the Administrative Nursing 
Director at Swedish Medical Center in Seattle, WA.
     And Douglas Erickson is the Deputy Executive 
Director for the American Society for Healthcare Engineering.
    Senator Murray. We will hear Senator Isakson's opening 
statement when he arrives, but, at this point, I will turn to 
Senator Franken for his opening statement.

                      Statement of Senator Franken

    Senator Franken. Thank you, Madam Chair, for holding this 
hearing on such a crucial and urgent issue.
    We have a serious problem on our hands. We've got a nursing 
shortage, a nursing workforce that's growing older, and a 
general population growing heavier, with the obesity epidemic. 
This is a recipe for disaster, and we must take action now.
    Lifting and repositioning are the leading cause of back, 
neck, and shoulder injuries in the healthcare industry. Nurses' 
back injuries cost about $16 billion in worker compensation 
benefits each year, and another $10 billion in medical 
treatment and lost productivity.
    In 2007, nursing aides experienced musculoskeletal injuries 
at a rate of more than seven times the national average for all 
occupations, and a much higher rate than freight handlers and 
other jobs that require lots of heavy lifting.
    The problem is that right now there is a disconnect between 
this data and bedside practices. OSHA nursing home guidelines 
recommend that, ``Manual lifting of residents be minimized in 
all cases, and eliminated when feasible.'' And the National 
Institute of Occupational and Safety Health, NIOSH, sets the 
safe maximum lifting limit at 35 pounds. These recommendations 
are great, but they don't mean much if healthcare workers don't 
have the equipment they need to avoid unsafe lifting.
    Healthcare workers are the people we trust to care for our 
loved ones, to monitor our health, to provide us with the best 
treatment possible. That's what they're trained to do, that's 
what their expertise is, and that's why it is simply 
unacceptable that nurses and other healthcare workers are 
putting their own well-being on the line in order to care for 
their patients.
    Employers have a fundamental obligation to provide a safe 
work environment for all workers, and our healthcare workers 
are no exception. Not only are these injuries costly and 
inhumane, manually lifting patients isn't good for patients. 
When Minnesota passed historic safe patient handling 
legislation in 2009, it had the support of groups like the 
Minnesota Council on Disability. That's because mechanical 
lifts reduce the risk of patient injury, too. This equipment 
requires an up front investment, but research shows that it 
pays off in 2 to 3 years.
    The good news is that we know what to do to make things 
better. Because of the pioneering work in Minnesota, and 
stories like Bettye Shogren's, who will be testifying later, I 
am proud to have introduced Senate bill 1788, the Nurse and 
Health Care Worker Protection Act. Under my bill, OSHA would 
issue a standard on safe patient handling and injury 
prevention, including the use of lift equipment. All healthcare 
facilities would also be required to implement safe patient 
handling plans and train workers to use the necessary 
equipment.
    The most important take-home message from today's hearing 
is that we know how to make things better.
    I want to thank the witnesses for joining us today, and I 
encourage my colleagues to consider cosponsoring S. 1788, the 
Nurse and Health Care Worker Protection Act.
    Thank you.
    Senator Murray. Thank you very much, Senator.
    Senator Franken. Thank you, Madam Chairman.
    Senator Murray With that, we will turn it over to our first 
panel. Joining us today is Captain James Collins, the associate 
director for science at NIOSH, and Dr. Michael--say it for me.
    Dr. Hodgson. Hodgson.
    Senator Murray. Hodgson, very good, the director of 
occupational health programs at the VA.
    Welcome, to both of our witnesses. You have 5 minutes each, 
and your written testimony will be part of the full record.
    Captain Collins, we'll begin with you.

    STATEMENT OF CAPTAIN JAMES W. COLLINS, Ph.D., M.S.M.E., 
    ASSOCIATE DIRECTOR FOR SCIENCE, NATIONAL INSTITUTE FOR 
         OCCUPATIONAL SAFETY AND HEALTH, WASHINGTON, DC

    Mr. Collins. Madam Chair and members of the subcommittee, I 
am pleased to appear before you today to provide testimony on 
safe patient handling.
    NIOSH has conducted extensive research on safe patient 
handling over the past 20 years. Healthcare workers experience 
a higher rate of musculoskeletal disorders than workers in 
construction, mining, manufacturing, and wholesale and retail 
trade. These injuries are due, in large part, to repeated 
patient handling activities involving heavy manual lifting when 
transferring and repositioning patients, often done in 
extremely awkward postures. In the next few minutes, I would 
like to describe the extent of the problem and some of the 
solutions that have been shown to be effective in preventing 
these injuries.
    Direct and indirect costs associated with back injuries in 
the healthcare industry, adjusted for inflation, are estimated 
to be over $7 billion annually, in 2008 dollars. In 2000, over 
10,900 registered nurses suffered lost-time work injuries due 
to lifting patients, while nursing aides and orderlies suffered 
the highest prevalence rates and report the most annual cases 
of work-related back pain among female workers in the United 
States. Of nurses who plan to leave the profession, 12 percent 
cited back injuries as a contributing factor to their decision.
    The risk of musculoskeletal disorders from patient handling 
results from the high forces on a caregiver's spine when 
lifting a patient. There is a risk of injury even if the 
patient is of relatively low weight, such as when two 
caregivers are lifting a 110-pound patient from a bed to a 
chair. Between 1988 and 2008, the average prevalence of obesity 
rose from 22 to over 35 percent, and the average prevalence of 
extreme morbid obesity rose from 2.9 to 5.7 percent. The 
average body weight of both patients and caregivers is 
increasing, and is likely to play a major role in increasing 
the risk of injury to healthcare workers.
    Early discharge of patients from hospitals is another 
concern. In 1980, the average length of hospital stay was 7.5 
days, compared with only 4.8 days in 2005. When patients are 
dismissed earlier from the hospital, home healthcare workers 
are at increased risk because they're exposed to higher levels 
of physical demands in a home-care environment, where the 
availability of assistive patient handling technology is often 
lacking.
    To identify safer ways to lift and move nursing home 
residents, NIOSH studied over 1,700 nursing personnel who were 
trained to use mechanical lifting equipment to assist 
residents. After the lifting equipment was installed, there was 
a 61-percent reduction in workers' compensation injuries and a 
66-percent reduction in lost-workday injuries attributed to 
resident handling.
    The initial investment of $158,000 for lifting equipment 
and worker training was recovered in less than 3 years, due to 
an annual savings of $55,000 in workers' compensation cost. 
This is significant, given that cost is often cited as a 
barrier to purchasing lifting equipment and establishing safe 
patient lifting programs.
    Another advantage of lifting equipment is the reduction in 
the rate of assaults on caregivers during resident transfers, 
down 72 percent in our study.
    Another study examined the long-term effectiveness of a 
safe lifting program. Manual lifting and transferring of 
patients was replaced with modern battery-operated portable 
hoists and other patient transfer assistive devices. The number 
of injuries from patient transfers decreased by 62 percent; 
lost workdays, by 86 percent; restricted workdays, by 64 
percent; and workers' compensation costs were reduced by 84 
percent.
    Overall, the program produced many intangible benefits, 
including improvements in patient comfort and safety during 
transfers in patient care.
    In closing, NIOSH has shown that manual handling of 
patients is a serious risk to healthcare workers. Programs that 
rely on the use of mechanical lifting devices, and worker 
training in using these devices, offer practical solutions to 
prevent healthcare worker injuries. These effective 
alternatives to manual patient handling are safe, and can be 
cost-effective to implement.
    We appreciate the opportunity to present our work, and 
thank you for your continued support. Additional information 
and references to this work are presented in the written 
testimony that we've provided. And I'd be pleased to answer 
your questions.
    [The prepared statement of Mr. Collins follows:]
     Prepared Statement of Capt. James W. Collins, Ph.D., M.S.M.E.
    Madam Chair and members of the subcommittee, my name is James 
Collins and I am Associate Director for Science for the National 
Institute for Occupational Safety and Health's (NIOSH) Division of 
Safety Research, part of the Centers for Disease Control and Prevention 
(CDC) within the Department of Health and Human Services (HHS). I am 
pleased to appear before you today to provide testimony on Safe Patient 
Handling. I am accompanied by Dr. Thomas Waters, Senior Research Safety 
Engineer at NIOSH. Dr. Waters and I are also principal investigators 
within NIOSH and we have conducted extensive research on safe patient 
lifting.
    Health care workers experience musculoskeletal disorders at a rate 
exceeding that of workers in construction, mining, manufacturing, and 
wholesale and retail trade.\1\ Musculoskeletal disorders (MSDs) are 
disorders of the muscles, nerves, tendons, ligaments, joints, cartilage 
and spinal discs. These injuries are due in large part to repeated 
manual patient handling activities, often involving heavy manual 
lifting when transferring and repositioning patients, working in 
extremely awkward postures, and in pushing and pulling heavy objects. 
The risk, which can exist even if the patient is of relatively low or 
moderate weight, is magnified by the increasing weight of patients due 
to the obesity epidemic in the United States, and the rapidly 
increasing number of older people who require assistance with the 
activities of daily living.\2\ \3\
---------------------------------------------------------------------------
    \1\ Bureau of Labor Statistics, U.S. Department of Labor, November 
12, 2009, Case and Demographic Characteristics for Work-related 
Injuries and Illnesses Involving Days Away From Work, Table 10--Number, 
percent, and incidence rate of nonfatal occupational injuries and 
illnesses involving days away from work by selected worker and case 
characteristics and musculoskeletal disorders, All United States, 
private industry, 2008. Accessible on the Web at: http://www.bls.gov/
lif/oshwc/osh/case/ostb2211.pdf.
    \2\ State of Washington [2006]. An act relating to reducing 
injuries among patients and health care workers. Accessible on Web at 
http://www.leg.wa.gov/pub/billinfo/2005-06/Pdf/Bill_Reports/House/
1672.HBR.pdf.
    \3\ Ogden, C., Carroll, M., and Curtin, L. (2006). prevalence of 
overweight and obesity in the United States, 1999-2004. Journal of the 
American Medical Association, 295, 1549-1555.
---------------------------------------------------------------------------
    NIOSH is proud of the work we have done researching MSDs in health 
care settings, for developing and evaluating interventions to prevent 
these problems among health care workers, and in working 
collaboratively with other Federal agencies and Associations to reduce 
risk for health care workers.
                           burden of injuries
    Direct and indirect costs associated with back injuries in the 
health care industry, adjusted for inflation, are estimated to be $7.4 
billion annually in 2008 dollars.\4\ Additionally, nursing aides and 
orderlies suffer the highest prevalence (18.8 percent) and report the 
most annual cases (269,000) of work-related back pain among female 
workers in the United States.\5\ In 2000, 10,983 registered nurses 
(RNs) suffered lost-time work injuries due to lifting patients. It has 
been reported that 12 percent of nurses who planned to leave the 
profession cited back injuries as a contributing factor.\6\
---------------------------------------------------------------------------
    \4\ Waehrer G., Leigh J., and Miller T. Costs of Occupational 
Injury and Illness Within the Health Services Sector, Intl. J. of 
Health Services, Volt. 35(2) 342-359, 2005.
    \5\ Guo, H.R., Tanka, S., Cameron, L.L., et al. (1995) Back pain 
among workers in the United States: national estimates and workers at 
high risk. Am J Ind Med, 28:591-602.
    \6\ Stubbs, DA, Buckle, PW, Hudson, MP, Rivers, PM, and Baty D 
(1986). Backing out: nurse wastage associated with back pain. 
International Journal of Nursing Studies 23(4): 325-336.
---------------------------------------------------------------------------
    The age of the Registered Nursing population has been rising over 
the past two decades. Between 2004 and 2008, the average age of all 
licensed nurses rose from 46.8 to 47.0 years and that of employed 
nurses rose from 45.4 to 45.5 years. This aging trend has raised 
concerns that future retirements could substantially reduce the size of 
the U.S. nursing workforce.\7\ Preserving the health of our nursing 
staff and reducing back injuries in health care personnel is critical. 
NIOSH has a comprehensive research program aimed at preventing work-
related MSDs with major efforts to reduce lifting injuries in health 
care settings. NIOSH's research with diverse partners has already made 
great strides in developing best practices and demonstrating the 
effectiveness of these ``best practices'' in health care settings.
---------------------------------------------------------------------------
    \7\ U.S. Department of Health and Human Services (2010). Registered 
Nurse Population: Findings from the 2008 National Sample Survey of 
Registered Nurses. Available on the Internet: http://bhpr.hrsa.gov/
healthworkforce/rnsurvey/initialfindings2008.pdf.
---------------------------------------------------------------------------
    The risk of musculoskeletal disorders resulting from patient 
handling results from the high internal forces created in the spine 
when a person lifts a heavy object. Musculoskeletal disorders are a 
high risk for patient handling because it can require lifting a patient 
who is far away from the worker which puts heavy loads on the spine. 
Repeated lifting of this type can result in scarring that causes more 
damage. Studies have suggested that there can be risks of injury even 
when two people are lifting a 110-lb patient from a bed to a chair.\8\
---------------------------------------------------------------------------
    \8\ Marras, W.S., Davis K.G., Kirking, B.C., Bertsche, P.K. (1999). 
A comprehensive analysis of low-back disorder risk and spinal loading 
during the transferring and repositioning of patients using different 
techniques. Ergonomics. 42(7):904-926.
---------------------------------------------------------------------------
    NIOSH recommends that no caregiver should manually lift more than 
35 lbs of a person's body weight for a vertical lifting task.\9\ NIOSH 
further recommends that when the weight to be lifted exceeds this 
limit, assistive devices should be used. These recommendations have 
been adopted by the Veterans Health Administration (VHA) and 
incorporated into its current patient handling recommendations and 
patient handling algorithms. Moreover, other major interest groups, 
such as the American Nurses Association (ANA), National Association of 
Orthopaedic Nurses (NAON), and Association of PeriOperative Registered 
Nurses (AORN) have all adopted similar patient handling guidelines that 
recommend use of technology-based solutions for patient handling and 
movement.\10\ \11\ \12\
---------------------------------------------------------------------------
    \9\ Waters T. (2007). When is it safe to manually lift a patient? 
American Journal of Nursing. Volt. 107(8): 53-59.
    \10\ AORN Workplace Safety Task force. (2007). Safe Patient 
Handling & Movement in the PeriOperative Setting. Denver, CO: 
Association of PeriOperative Registered Nurses (AORN).
    \11\ de Castro, A.B. (2006). Handle With Care: The American Nurses 
Association's Campaign to Address Work-Related Musculoskeletal 
Disorders. Orthopeadic Nursing, 25, 6, 356-364. Reprinted from de 
Castro, A.B. (2004). Handle With Care: The American Nurses 
Association's Campaign to Address Work-Related Musculoskeletal 
Disorders. Online Journal of Issues in Nursing. Volt. #9 No. 3. 
Retrieved from http://www.nursingworld.org/MainMenuCategories/
ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/
Number3September30
/HandleWithCare.aspx.
    \12\ NAON (2009) Safe Patient Handling. Special Issue. Orthopaedic 
Nursing, 28(2S) 2-35.
---------------------------------------------------------------------------
                            external factors
    A major concern for health care workers is the obesity epidemic 
that our country is facing. The average body weight of both patients 
and caregivers is increasing over time and this increase in average 
body weight is likely to play a major role in increasing risk of MSDs 
for health care workers. Data from the National Health and Nutrition 
Examination Survey show that between 1988 and 2008, the average 
prevalence of obesity rose from 22.9 percent to 35.5 percent, and the 
average prevalence of morbid (extreme) obesity rose from 2.9 percent to 
5.7 percent. Rates of adult morbid obesity in 2008 ranged from 3.8 
percent of Hispanic men to as high as 14.2 percent of non-Hispanic 
black women.\13\ \14\
---------------------------------------------------------------------------
    \13\ Flegal, K., Carroll, M., Ogden, C., and Curtin, L. (2010). 
Prevalence and trends in obesity among U.S. adults, 1999-2008. Journal 
of the American Medical Association, 303, 235-241.
    \14\ Flegal, K., Carroll, M., Ogden, C., and Johnson, C. (2002). 
Prevalence and trends in obesity among U.S. adults, 1999-2000. Journal 
of the American Medical Association, 288, 1723-1727.
---------------------------------------------------------------------------
    The majority of direct patient care workers are females who, on 
average, have lower strength and lifting capacity than males. Most 
female nurses work at a higher percentage of their maximum physical 
capabilities than males when performing the same strength-demanding 
tasks. While most health care workers do not have established maximum 
weight lift limits, in manufacturing industries, where the majority of 
workers are male, employers have developed maximum weight limits for 
manual lifting and they have incorporated robots and other lifting 
assistive devices.
    A recently emerging issue that has resulted in increased risk for 
MSDs for health care workers is that patients are often released from 
the hospital following surgery and other treatments much earlier than 
in the past. In 1980, for example, the average length of hospital stay 
was 7.5 days compared with only 4.8 days in 2005.\15\ When patients are 
dismissed from the hospital earlier in the recovery process, the 
patient is often more dependent upon the caregiver for assistance in 
being transferred or in moving. This has resulted in increased risk for 
workers in the hospital setting due to the concentration of extreme 
patient needs associated with patient transfers and movement while in 
the acute care environment. It also increases the level of patient 
transfer assistance needed in the home care environment at an earlier 
stage of recovery than was previously required, placing home health 
care workers at increased risk. The home health care worker is now 
exposed to higher levels of physical demands in a care environment 
where the availability of assistive patient handling technology is 
often lacking.\16\ \17\
---------------------------------------------------------------------------
    \15\ National Center for Health Statistics (2007) 2005 National 
Hospital Discharge Survey, Retrieved from http://www.cdc.gov/nchs/data/
ad/ad385.pdf on 2/2/2010.
    \16\ Galinsky, T., Waters, T., and Malit, B. Overexertion Injuries 
in Home Health Care Workers and Need for Ergonomics Home Health Care 
Services Quarterly. 20(3):57-73. 2001.
    \17\ NIOSH (2010) NIOSH Hazard Review Occupational Hazards in Home 
Health Care. DHHS (NIOSH) Publications No. 2010-125. National Institute 
for Occupational Safety and Health, Cincinnati, OH.
---------------------------------------------------------------------------
                          prevention research
    NIOSH carried out a comprehensive lab and field study to identify 
safer ways to lift and move nursing home residents. The study design 
included removing the excessive forces and extreme postures that can 
occur when manually lifting residents. Historically, the caregiver has 
used his or her own strength to provide manual assistance to the 
resident. NIOSH also conducted a field study to determine if a ``best 
practices'' intervention consisting of mechanical equipment to lift 
physically dependent residents, training on the proper use of the 
lifts, a safe lifting policy, and a medical management program would 
reduce the rate and the associated costs of the resident handling 
injuries for the nursing personnel in a real world setting. During the 
6-year period, from January 1995 through December 2000, 1,728 nursing 
personnel were studied before and after implementation of the 
intervention. After the intervention, which was a safe lifting program 
that includes mechanical lifting equipment, worker training on the use 
of the lift, and a written resident lifting policy, there was a 61 
percent (range 45-71 percent) reduction in workers' compensation 
injuries involving resident handling, workers' compensation costs, and 
lost work day injuries. The initial investment of $158,556 for lifting 
equipment and worker training was recovered in less than 3 years on the 
basis of post-intervention savings of $55,000 annually in workers' 
compensation costs.\18\ This is significant given that cost is an often 
cited barrier to purchasing lifting equipment and establishing safe 
patient lifting programs. Another advantage of lifting equipment is the 
reduction in the rate of assaults on caregivers during resident 
transfers--down 72 percent on the basis of workers' compensation 
claims.
---------------------------------------------------------------------------
    \18\ Collins, J.W., Wolf, L., Bell, J., and Evanoff, B., (2004). An 
evaluation of a best practices'' musculoskeletal injury prevention 
program in nursing homes Injury Prevention, 10, 206-211.
---------------------------------------------------------------------------
    Based on the successes achieved in the long-term care industry, 
NIOSH has undertaken a new 6-year longitudinal research study to 
evaluate the effectiveness of a ``best practices'' safe patient 
handling program at two large acute-care hospitals in the United 
States.
    Another major study demonstrating success in reducing back injuries 
to health care workers was funded by NIOSH through a cooperative 
agreement. The study examined the long-term effectiveness of a safe 
lifting program with the primary objective to reduce injuries to health 
care workers resulting from manual lifting and transferring of 
patients. These safe lifting programs, which used employee management 
advisory teams, i.e., a participatory-team approach, were used in seven 
nursing homes and one hospital. In this study, manual lifting and 
transferring of patients was replaced with modern, battery operated, 
portable hoists, and other patient-transfer assistive devices. The 
number of injuries from patient transfers decreased by 62 percent, lost 
work days decreased by 86 percent, restricted workdays decreased by 64 
percent, and workers' compensation costs were reduced by 84 percent. 
Overall, the program produced many intangible benefits including 
improvements in patient comfort and safety during transfers and patient 
care. The nursing personnel reported that their backs were less sore 
and that they were less tired at the end of their shifts.\19\
---------------------------------------------------------------------------
    \19\ Garg, A. (1999). Long-term effectiveness of ``Zero-Lift 
Programs'' in seven nursing homes and one hospital. U.S. Department of 
Health and Human Services, National Institute for Occupational Safety 
and Health, Contract Report No. U60/CCU512089-02.
---------------------------------------------------------------------------
    Despite the obvious advantages to using lifting equipment, schools 
of nursing continue to teach, and nurses' licensure exams continue to 
include, outdated and unsafe manual patient handling techniques.\20\ 
This is due in large part to outdated books and curricula both of which 
promote unsafe patient handling practices. To address this, a team of 
experts from NIOSH, the American Nurses Association, and the Veterans 
Health Administration developed and evaluated an evidence-based 
training program on safe patient handling for educators at schools of 
nursing that relies on use of technology for moving and transferring 
patients. The study found that when using the curriculum, nurse 
educator and student knowledge improved significantly as did the 
intention to use mechanical lifting devices in the near future.\21\ 
\22\ \23\
---------------------------------------------------------------------------
    \20\ National Council of State Boards of Nursing (2006). National 
Council Licensure Examination (NCLEX) Web site. Accessible on Web at: 
http://www.ncsbn.org/245.htm. Last accessed on November 25, 2006.
    \21\ Nelson, et al. (2007): Evidence-Based Nursing School 
Curriculum in Safe Patient Handling. International Journal of Nursing 
Education Scholarship, Volt. 4, Iss. 1, Art. 26.
    \22\ Menzel, N. (2007). Preventing Musculoskeletal Disorders in 
Nurses: A Safe Patient Handling Curriculum Module for Nursing Schools. 
Nurse Educator. 32 (3): 130-135.
    \23\ NIOSH (2009), Safe Patient Handling Training Schools of 
Nursing, Curricular Materials. DHHS (NIOSH) Publication No. 2009-127. 
National Institute for Occupational Safety and Health, Cincinnati, OH.
---------------------------------------------------------------------------
                               guidelines
    Over the past decade, we have found that best practices are 
specific to health care settings. What works in critical care may not 
be appropriate for emergency room settings or operating rooms. Because 
each health care setting has specific needs for specialized approaches, 
NIOSH worked collaboratively with outside groups to develop safe 
patient handling guidelines for caregivers in operating rooms and in 
orthopaedic settings (AORN and NAON efforts).
    Recently, the health care industry has recognized the risks 
associated with performance of physically demanding patient handling 
tasks, and to reduce costs and increase productivity, companies have 
begun to implement ergonomic programs or practices aimed at preventing 
these injuries. The core element of these programs is reliance on use 
of state-of-the-art ergonomically designed equipment to assist the 
worker in carrying out the prescribed task. As an added incentive to 
adopt technology-based patient handling practices, OSHA recently 
published an ergonomics guideline that provided an overview of the 
risks of work-related MSDs in nursing homes. The guideline provided 
information about the most effective approaches for mitigating or 
reducing those risks, and discussed training needs.\24\ The most 
important recommendation in the OSHA nursing home guideline was that 
``manual lifting of residents be minimized in all cases and eliminated 
when feasible.'' This is best accomplished by implementing a 
technology-based safe patient handling program.
---------------------------------------------------------------------------
    \24\ OSHA (2009) Ergonomics for the Prevention of Musculoskeletal 
Disorders: Guidelines for Nursing Homes. U.S. Department of Labor, 
Occupational Safety and Health Administration. Document No. OSHA 3182-
3R.
---------------------------------------------------------------------------
    In 2009, NIOSH initiated a project aimed at improving safety while 
lifting and moving bariatric patients. In health care settings, the 
term ``bariatric'' is used to refer to patients whose weights exceed 
the safety capacity of standard patient lifting equipment (300 lbs), or 
who otherwise have limitations in health, mobility, or environmental 
access due to their weight/size.\25\ Compared to the non-obese 
population, obese individuals require more frequent and extensive 
health care due to obesity-related health problems, and health care 
personnel are encountering hospitalized and critical-care bariatric 
patients on an increasingly frequent basis.\26\ \27\ \28\ In the 
extreme, such patients can weigh over 1,200 pounds. The upcoming NIOSH 
project will evaluate bariatric patient handling practices at multiple 
hospitals, including intervention programs and health/safety outcomes, 
in order to identify and promote evidence-based best practices.
---------------------------------------------------------------------------
    \25\ Bushard, S. (2002). Trauma in patients who are morbidly obese. 
Association of PeriOperative Registered Nurses (AORN) Journal, 76, 585-
589.
    \26\ Pieracci, F., Barie, P., and Pomp, A. (2006). Critical care of 
the bariatric patient. Critical Care Medicine, 34, 1796-1804.
    \27\ Reto, C. (2003). Psychological aspects of delivering nursing 
care to the bariatric patient. Critical Care Nursing Quarterly, 26, 
139-149.
    \28\ Tizer, K. (2007). Extremely obese patients in the health care 
setting: Patient and staff safety. Journal of Ambulatory Care 
Management, 30, 134-141.
---------------------------------------------------------------------------
    We all have a vested interest in taking care of those who help take 
care of us and our families when we need medical attention. It is 
likely that the implementation of the research presented here will 
significantly reduce injuries and illnesses for health care workers and 
increase the quality of patient care. In turn, reducing MSDs among 
nurses may help address the critical issues of nurse recruitment and 
retention.
                               conclusion
    In closing, NIOSH has shown that manual handling of patients is a 
serious risk to health care workers and that we continue to work 
diligently to protect the safety and health of those workers. We have 
assessed the overall scope of the problem, characterized the risks from 
moving patients, and identified increasing risks due to the aging 
workforce and obesity epidemic in the United States. We have also 
developed some practical solutions in terms of best practice programs 
that rely on use of technology-based solutions. Our efforts have shown 
that there are effective alternatives to manual patient handling that 
are safe and cost-effective to implement. We appreciate the opportunity 
to present our work to you and thank you for your continued support.
    I would be pleased to answer your questions.

    Senator Murray. Dr. Hodgson.

  STATEMENT OF MICHAEL HODGSON, M.D., MPH, CHIEF CONSULTANT, 
         VETERANS HEALTH ADMINISTRATION, WASHINGTON, DC

    Dr. Hodgson. Good afternoon, Chairman Murray and Ranking 
Member Isakson, and thank you for the opportunity to discuss 
safe patient handling and lifting standards for a safer 
American workforce.
    My testimony today will discuss our experience in the 
Department of Veterans Affairs in evaluating and responding to 
the concern.
    Patient manual handling injuries generate staff shortages 
for acute service delivery and affect workforce retention. In 
the late 1990s, a nursing research group at the Tampa VA 
undertook a review of nursing injuries; identified common and 
specific mechanisms of injury related to patient handling and 
movement; assembled an expert panel that redesigned patient 
transfers; and identified the associated needed technology and 
support.
    A VA Health Services research and development grant 
evaluated those recommended changes, and justified the new 
program, now known as Safe Patient Handling. That program 
supports both patient safety and employee injury prevention. 
The VA Sunshine Healthcare Network VISN 8 in Florida evaluated 
this program between 2001 and 2003 in a very rigorous way.
    In parallel, external efforts by the VA program developers 
included support for the development of OSHA's ``Ergonomics 
Guidelines for Nursing Homes'' and leading the content and 
writing of the ``2010 Guidelines for the Design and 
Construction of Health Care Facilities'' that were recently 
published by the American Society of Healthcare Engineers.
    VISN 8 business-case calculations suggested an internal 
rate of return on program investment of between 19 and 37 
percent so that the VA funded a national program. Since 2008, 
VA has disbursed approximately $143 million to VA healthcare 
facilities for this initiative, with another $62 million 
planned for fiscal year 2011.
    The program itself consists of several major elements, 
including the technology, such as ceiling lifts, sliding 
devices, and the like; patient transfer algorithms that define 
how nurses move patients as a function of patient dependency 
and the goal of the transfer; unit peer leaders as local 
program implementation support; and a whole series of 
additional infrastructure elements.
    Major implementation lessons over the last years include 
the following:

     First, the program fails without strong local 
leadership and a robust unit peer leader program;
     Second, immediate equipment availability is a 
major driver for success so that ceiling lifts far outperform 
portable equipment; and
     Third, this is a fundamental change in patient 
care processes so that it relies on the nursing community to 
accept new technology and change longstanding practices.

    Working with our Office of Nursing Services over the last 
years has led VA to recognize that, even though implementation 
must be a joint effort, the public face must include a very 
prominent nursing presence.
    Over the last year, new evidence from researchers in 
Holland and from Stanford University suggests that the program 
actually also supports dramatically improved quality of patient 
care, as demonstrated by reduced rates of decubitus ulcers, 
incontinence, and urinary tract infections.
    In addition, a recent reanalysis from the Stanford 
University program identified an internal rate of return 
greater than 65 percent, a phenomenal addition from these 
additional patient care quality measures.
    VA's program encompasses a comprehensive evaluation 
component, including status reports, audits and fiscal reviews, 
and longitudinal evaluations of selected sites.
    New technologies, that were not envisioned when the program 
was designed in 2006, have emerged. So, for example, air-
assisted lateral transfer devices, powered wheelchairs and 
stretchers, and car extractors were simply not available 5 
years ago, when we designed the program. As the problem of 
obesity increases for the veteran patient population, these 
additional technologies have been developed for moving 
patients, including overweight patients.
    New equipment and extension of ceiling tracks into 
bathrooms have been designed to reduce the frequency of 
transfers, and we're currently modeling how and where the 
additional newer program elements are likely to be beneficial 
and cost-effective.
    Chairman Murray, VA has found it can improve patient care 
while reducing costs through efforts like the Safe Patient 
Handling Program.
    Thanks for the opportunity to describe this.
    [The prepared statement of Dr. Hodgson follows:]
            Prepared Statement of Michael Hodgson, M.D., MPH
    Good afternoon, Chairman Murray and Ranking Member Isakson, and 
thank you for the opportunity to discuss safe patient handling and 
lifting standards for a safer American workforce. My testimony today 
will discuss our experience in the Department of Veterans Affairs (VA) 
in evaluating and responding to this concern.
    Manual handling injuries, such as lifting patients, represent the 
most frequent injuries to nursing personnel, an occupation with among 
the highest injury rates in the United States. These injuries are the 
primary reason for early retirement and disability retirement and, 
thus, have major consequences affecting VA's ability to retain 
qualified health care personnel.
    Those injuries also increase workers' compensation costs and lead 
to unplanned staff absences, causing problems for service delivery. In 
response, a VA nursing research group in Tampa undertook a review of 
nursing injuries in the late 1990s. They identified common and specific 
mechanisms of injury related to patient handling and lifting. This 
group then assembled an expert panel that included widely recognized VA 
and non-VA researchers and practitioners that redesigned patient 
transfers. This group identified the needed technology to support these 
changes in process, i.e., appropriate patient transfers. They evaluated 
those recommended changes in clinical practice with a VA Health 
Services Research and Development grant and developed the new program 
which we now know as ``Safe Patient Handling.'' That program supports 
both patient safety and employee injury prevention. The VA Sunshine 
Healthcare Network (Veterans Integrated Service Network, VISN 8) in 
Florida deployed this program between 2001 and 2003 with a rigorous 
evaluation component. Since that time, the VA Tampa Patient Safety 
Center of Inquiry has continued to evolve the program with major 
changes to the patient care handling process.
    In parallel to these internal efforts, VA program developers 
participated in the Occupational Safety and Health Administration's 
(OSHA) Ergonomics Advisory Committee and supported the development of 
OSHA's ergonomics guidelines for nursing homes. Recently the Facilities 
Guidelines Institute (FGI) released the 2010 Guidelines for the Design 
and Construction of Health Care Facilities [published by the American 
Society of Healthcare Engineers (ASHE)], based on this work.
    The VISN 8 program reduced patient manual-handling caregiver 
injuries and led to markedly increased employee and patient 
satisfaction. Results that document the reductions in injury and the 
increases in patient and provider satisfaction have been published in 
the peer-reviewed literature. The initial business case calculations, 
published in the peer-reviewed literature in 2005, suggested an 
internal rate of return on program investment in the range of 19 
percent. Subsequent internal work suggested an internal rate of return 
of up to 37 percent. With such dramatic benefits, VA developed and 
funded a national program, with a budget initiative that was proposed 
in 2007 and that was to run through 2011. The first funds were 
distributed in July 2008, and so far VA has disbursed approximately 
$135 million to VA health care facilities for this initiative. VA has 
budgeted another $62 million for fiscal year 2011, the final year 
planned for implementation of the basic program. The program itself 
consists of several major elements, including technology (ceiling 
lifts, sliding devices, and the like), algorithms that define patient 
transfers as a function of patient dependency and the goal of the 
transfer, unit peer leaders as local program implementation support, 
and infrastructure-like maintenance, equipment inventory, and 
replacement. Standing up the program requires strong local leadership, 
working through program implementation and planning issues, supporting 
the local equipment selection, training peer leaders, and managing the 
program. A broad range of training and education support materials have 
been developed, from cognitive aids to support appropriate transfers 
through books, CDs, and videotapes. A brief introductory video for 
patient education, to guide expectations, is available on the Web sites 
of some facilities.
    Implementation lessons from several VISNs in 2004 and 2005 clearly 
demonstrated that without a unit peer leader program and strong local 
leadership, the program fails. Additional work suggests that just in 
time equipment availability is a major driver; for example, ceiling 
lifts far outperform portable equipment as they are always in the same 
place. This is a fundamental change in patient care processes, and it 
relies on the nursing community to accept new technology and change 
long-standing processes. Many nursing schools have recently 
incorporated this approach into their educational curricula. Working 
with our Office of Nursing Services over the last year has led VA to 
recognize that even though implementation must be a joint effort, the 
public face must include a nursing presence, without which the program 
simply fails.
    New evidence from researchers in Holland and from Stanford 
University suggests the program also supports improved quality of 
patient care, which is demonstrated by reduced rates of decubitus 
ulcers, incontinence, and urinary tract infections. In addition, the 
Stanford analysis identified an internal rate of financial return 
greater than 65 percent. Much of the cost savings is directly 
attributable to nursing retention and the decreased cost of training.
    The program encompasses a comprehensive evaluation component 
including status reports, audits and fiscal reviews, and longitudinal 
evaluations of selected sites. We are currently conducting a formal 
evaluation of changes in injury rates as a function of program 
implementation and activation status. This program highlights VA's work 
on nursing workforce development and retention in parallel with the 
efforts to support both employee working conditions and patient care. 
Most importantly, it demonstrates the benefits of using rigorous, 
evidence-based approaches to improve patient safety.
    Finally, new technologies, not envisioned when the program was 
designed in 2006, have emerged. For example, air-assisted lateral 
transfer devices, powered wheelchairs and stretchers, and car 
extractors were not available 5 years ago. As the problem of obesity 
increases for the Veteran patient population, additional technologies 
have been developed for moving patients, including overweight patients. 
New equipment and extension of ceiling tracks into bathrooms have been 
designed to reduce the frequency of transfers. We are currently 
modeling how and where additional program elements are likely to be 
beneficial.
    VA continues to share information about the Safe Patient Program 
throughout its national health care system. An annual conference in 
Florida, co-sponsored by the National Institute of Occupational Safety 
and Health, the University of Florida, and the Veterans Health 
Administration, is one important way VA has increased awareness, 
disseminated research, and conducted training.
    Chairman Murray, every health care organization must address safe 
patient handling and lifting standards. VA has found it can improve 
patient care while reducing costs through efforts like the Safe Patient 
Handling program. Thank you for the opportunity to appear, and I am 
prepared to answer your questions at this time.

    Senator Murray. Thank you both for your testimony.
    Senator Isakson has joined us. I'll turn to him for opening 
comments.
    Senator Isakson. Out of respect for those testifying, I'd 
ask unanimous consent that my opening statement be submitted 
for the record.
    Senator Murray. OK, thank you very much.
    [The prepared statement of Senator Isakson follows:]

                 Prepared Statement of Senator Isakson

    I thank Senator Murray for calling this hearing and welcome 
our witnesses.
    Every day, caregivers transfer, position, and mobilize 
patients. Providing this assistance by the manual lifting of 
patients can involve significant physical effort. This task is 
further complicated with tubes and other devices hindering the 
patient's movement.
    Patients are moved or repositioned for a number of reasons, 
including accomplishing patient care tasks, such as an 
examination, preventing bedsores, or simply providing patients 
with additional comfort and safety.
    Manual patient handling, including lifting, transferring, 
positioning, and sliding patients, can be difficult and even 
dangerous for both caregivers and patients. There is evidence 
that manual patient handling puts caregivers at considerable 
risk for injuries.
    For these reasons, more and more health care facilities are 
installing assistive patient handling and movement technology. 
This technology may not only make caregivers' work easier and 
safer, but provide for better patient outcomes and improved 
quality of life while receiving care. Additionally, this 
technology may allow hospitals and nursing homes to mobilize 
patients immediately following a procedure.
    Legislation that would mandate lift policies and the use of 
these assistive devices is currently before the HELP Committee. 
The costs associated with this legislation are unnecessary and 
come at a time when the industry is already crippled with costs 
imposed by the new health care bill.
    According to his own actuaries, the President's new health 
care law bends Federal spending curve upward ``by a net total 
of $251 billion'' over the next decade.
    Many of the entities that will be forced to comply with the 
crippling new mandates in the health reform bill are small 
businesses that are struggling to keep their doors open.
    The CMS Actuary has already told us the half trillion 
dollars in Medicare cuts included in the new law may cause 
providers to end their participation in the Medicare program, 
and possibly jeopardize access to care for beneficiaries. 
Further, the purchasing of medical devices will be more 
expensive after Congress imposed a 2.3 percent excise tax on 
device manufacturers. Passing a new mandate on lifting 
assistive devices will only make these problems more severe.
    While patient handling and movement technology certainly 
holds much promise, I have been in Washington long enough to 
know that not every good thing needs to be mandated 
immediately. The health care industry is very active in this 
area, going above and beyond current legal and regulatory 
minimums to try to help both workers and patients.
    In legislating in this area, Congress must consider the 
high cost and all its ramifications, intended and unintended.

    Senator Murray. We'll turn to questions, then.
    Captain Collins, I'd like to start with you. Various NIOSH 
publications make the point that simply training our workers to 
lift differently is ineffective. We all know that lifting is 
easier when you bend at the knees and hold the body weight 
close, but obviously nurses, in having to lift patients, have 
to reach over beds or equipment, and, we know, this often 
results in nurses being more than 6 inches, at least, away from 
their patient.
    NIOSH standards say that the average person can lift 45 or 
50 pounds, but how much do those figures change when the lift 
requires bending over or holding your arms more than a foot 
away from the center of your body mass?
    Mr. Collins. Typically, about half, less than half--25 to 
35 pounds is about the maximum acceptable lifting, with the 
postures that nurses have to assume.
    Senator Murray. So, our lifting standards don't reflect the 
fact that nurses pick up things differently.
    Mr. Collins. No.
    Senator Murray. OK. Can you perhaps address for this 
committee some of the other dangers that are inherent to 
lifting human beings rather than some kind of inanimate object?
    Mr. Collins. Well, the original lifting standards were 
designed for inanimate objects, such as boxes. You can 
understand that some nursing home patients can be combative, 
resistant to being transferred, and they can also be injured if 
they're mishandled or dropped during the course of lifting. And 
they're not packaged very well for transfers, and they're 
excessively heavy; well beyond the 51-pounds lifting limit.
    Senator Murray. OK. Well, I suspect that most people don't 
think of nurses or people in healthcare professions as having 
to lift as much as construction workers. Can you tell us, What 
is the comparison between how much a healthcare worker lifts in 
a day, compared to other high-professions, like truck drivers 
or construction workers?
    Mr. Collins. It depends on the particular caregiver's job, 
but I suspect it's very similar. In fact, when I first started 
in this area of research, I was working with United Auto 
Workers on a dissertation study with Johns Hopkins University. 
They were a 95-percent male workforce, and they were restricted 
from lifting over 35 pounds during the course of assembling 
automobiles. And here, I had this concurrent study population 
with female workers, nursing aides and orderlies, which the 
workforce was 93 percent female, and there was an expectation 
that they would lift 300-pound bodies as part of their daily 
routine. We knew that we had a huge challenge ahead to discover 
and evaluate effective methods to help them safely lift and 
move patients.
    Senator Murray. If we implemented a national lifting 
standard, what kind of reduction in injury rates to nurses and 
healthcare providers would we see?
    Mr. Collins. In the two well-controlled studies that I've 
been involved in, we've seen reductions of--where comprehensive 
best-practices programs have been implemented in excess of 60 
percent; and that's in the nursing home industry. I have a 
current study where we're working with UPenn Medical Center and 
Northwestern Memorial Hospital in an acute-care setting. These 
are ongoing studies--the hospital study's still going, but 
we're--preliminary results are over 50-percent injury 
reductions there.
    The National Research Council and the Institute of Medicine 
have estimated that, when you reduce the biomechanical 
exposures from manual lifting, that the assistive devices could 
result in reductions somewhere between 55 and 65 percent.
    Senator Murray. OK.
    Dr. Hodgson, my father was in World War II and came home 
injured, and was eventually diagnosed with Multiple Sclerosis. 
And my family were caregivers, so I'm intimately aware of how 
closely families and veterans take care of their loved ones. I 
also worked in the Seattle VA, right after the Vietnam war, and 
worked with soldiers who were both physically and mentally 
injured, and I know how much families are involved in this.
    And I wanted to ask you, Have you interviewed any veterans 
who use the VA healthcare facilities--about their views on your 
new safe patient handling policy?
    Dr. Hodgson. Actually, it's a great question. And yes, 
there are both formal evaluations of patient acceptance--even 
in the early VISN 8 study, the patient acceptance was a major 
criterion for evaluating the utility of the program. There's a 
publication on that, that we can submit as part of the post-
hearing comments.
    Dr. Hodgson. We do have a PVA service rep at every 
hospital. The one from Tampa was actually lined up to come 
tomorrow and testify on the panel, before the panel got moved. 
He would be happy to fly up and talk.
    Yes, we do know that patients like the technology. It makes 
many of them feel much safer.
    There are ways that it must be implemented. For example, in 
our spinal cord injury units, the issue of dignity and thinking 
through how patients are transferred is a real issue.
    We have spent a fair amount of time thinking about that. 
There is written peer-reviewed publicational record on that, 
and there are lots of people who think about that. It's an 
important issue.
    Senator Murray. Thank you very much.
    Senator Isakson.
    Senator Isakson. Well, thank you Chairwoman Murray.
    I do apologize to both of you, as well as the Chairman, for 
being late. And that's why I didn't read my statement. It's 
also why this next question may have already been either 
explained in your testimony or come up.
    On page 3 of Dr. Collins' transcript, it says,

          ``These recommendations''--referring to NIOSH's 
        recommendations on lifting--``have been adopted by the 
        Veterans Health Administration and incorporated into 
        its current patient handling recommendations and 
        patient handling algorithms.''

    So, my question, Dr. Hodgson, is, What have you 
implemented, by virtue of NIOSH's regulations, in terms of the 
lifting of patients?
    Dr. Hodgson. The VA program is designed a little 
differently. NIOSH has been part and partner of our work over 
the last 10 years, from the program design through the 
conferences, but our program was designed in a different way, 
not quantitatively to deal with specific lifting thresholds, in 
terms of force requirements, but in terms of commonsense 
approaches and likely issues. So, thinking through patient 
dependency--fully, partially, or a minimally dependent 
patient's weight and approximate, kind of, force requirements, 
and designing the transfer to use technology to minimize the 
amount of force required.
    We don't actually have detailed force thresholds; we have, 
from that HSR&D lab evaluation, the knowledge that, in general, 
when you do something, following a set of algorithms with a 
certain number of staff, you will not exceed weight limit 
restrictions.
    It wasn't designed the way the NIOSH program was laid out; 
it was designed in an algorithmic, you know, operationally 
efficient way.
    Senator Isakson. In other words, you have parameters and 
guidelines and recommendations as to the handling of the 
movement of a patient and their weight, but you don't have a 
specific approach that fits all movement. Is that what I heard 
you say?
    Dr. Hodgson. Each transfer requires a different set of 
actions. If you're going to move a patient up in bed, or move a 
patient from a bed to a wheelchair, or from a wheelchair onto a 
commode, there are different acts that are required; you need 
different technology, and you may need different numbers of 
nurses. The force requirements to put someone in a sling, lying 
on their back, are always going to be the same, but they are 
going to be different from the force requirements and strength 
requirements to take someone out of a sling once they're 
sitting in a chair. Our program was designed to address, kind 
of, the practicalities of movement, knowing the NIOSH lifting 
equation and force requirements.
    Senator Isakson. Well, I think the operative word of what 
you just said is ``practicality.'' I speak from a recent 
experience, where I was being lifted, back in March, and I was 
in the hospital for a couple of days. And, in terms of getting 
tests and being moved, having an IV, or whatever you might 
have, there are lots of different circumstances under which 
movement is important to the care of the patient, but 
limitations of either the patient or the test, whatever it is--
an MRI or CAT scan or something like that--are very different.
    So, your approach is very much to try and accomplishing the 
minimizing of lifting, but being broad in the different ways in 
which that's accomplished, I take it.
    Dr. Hodgson. That's correct. That's the core of the unit 
peer-leader program. You know, our approach is really to focus 
on the nursing process and to provide local support--front-line 
peer safety leaders, on some level--who will model appropriate 
behavior, who will serve as resources to help people think 
through how to do a lift that they haven't encountered, if we 
happen not to have an algorithm, or if it's not in the nursing 
care plan for that patient. So, having someone around who is 
the designated expert--a nursing assistant, the licensed 
practical nurse, an R.N.--but someone who's undergone a more 
detailed, thoughtful training program, who is respected by 
their peers, and then helps work through how that should work--
that's really the core of the nursing model, the nursing 
process.
    Senator Isakson. Well, the author of the legislation is on 
our panel today--Senator Franken. And I certainly wait for him 
to summarize the legislation. But, I would be very curious if 
this is a one-size-fits-all approach to movement or whether 
there's the type of flexibility that Dr. Hodgson has talked 
about, because if it's a one-size-fits-all equipment-based, 
installation-type situation, I would find that, having gone 
through certain experiences, to be very difficult. But, I will 
defer to the distinguished Senator from Minnesota to do that.
    Thank you, Madam Chair.
    Senator Murray. With that, we will turn to the 
distinguished Senator from Minnesota, Senator Franken.
    Senator Franken. Thank you, distinguished chairwoman, and 
thank you for the lead-in, my distinguished colleague from 
Georgia.
    This is not a one-size-fits-all. You know, when I first 
started running for the Senate, the SEIU--Service Employees 
International Union--had a Walk-In-Our-Shoes Day. You could 
choose to be one of anything that SEIU members do, and I chose 
a nurse's assistant--in a nursing home--because my mom had 
gotten such great care. I worked with a guy, Ulysses Bridges, 
who had been a nurse's assistant for 25 years, or something, 
and was awarded with people with severe MS, very disabled. He 
had a sling. He had a sling to lift people. And I remember the 
first patient that he lifted from bed to wheelchair, and he 
said, ``These are lifesavers, these machines.'' And I remember 
thinking, like, ``I don't know how he could have done this 
without this thing.'' And he said, ``It just saves so many 
backs''--basically, is what he was saying.
    Dr. Hodgson, on our next panel we'll hear testimony 
asserting that hospitals and other healthcare facilities don't 
have the physical infrastructure to implement new standards for 
patient handling. Can you describe how the VA was able to make 
the necessary changes to their existing facilities?
    Dr. Hodgson. I'm not an engineer, but there are three parts 
to that answer:

     In general, most of our hospitals are built in a 
way that, in fact, the weight loads will work for ceiling 
lifts;
     Second, there are very formal structural 
assessments that are sometimes needed to make sure--and 
sometimes there is structural reinforcement required--to make 
ceiling lifts safe; and
     Third, where those can't be done, there are ways 
of building a framework inside a room to effectively build a 
steel cage--a frame, as it were--on which the ceiling-lift 
track sits. It's not as aesthetically pleasing. It's not 
consistent with, kind of, the philosophy of our, kind of, 
making hospitals and what we call ``community living 
centers''--nursing homes--look like home, but it works. It is 
something that can be put up temporarily, as a portable thing, 
in homes, in residences.

    There are solutions for that in almost every place that 
we've encountered.
    Where it is not possible to do ceiling lifts, there is 
portable equipment available to do that. It's generally more 
expensive, but, you know, there are solutions.
    Senator Franken. Thank you.
    Captain Collins, NIOSH data show that the initial 
investment in safe patient lifting equipment and training can 
be recouped in less than 3 years. What specific savings are 
included in that calculation? The workers' comp, savings in 
overtime and placement, staff, etc.
    Mr. Collins. That particular savings was ``direct cost 
only'' for workers' compensation. That was the medical and 
indemnity expenses associated with workers' comp only. That did 
not include any indirect costs. The costs were recovered so 
quickly, in that study--these were portable lifts that were 
installed--or, were available for about every eight patient 
rooms.
    Senator Franken. And so, this doesn't include sick leave or 
retraining.
    Mr. Collins. None of that went into this calculation. This 
was direct--the cost, on the expense side of the equation, was 
for the purchasing of the lifting equipment, and the training 
and the use of the equipment. And to counter that was the 
reductions strictly in workers' compensation medical and 
indemnity expenses.
    Senator Franken. And just to assure my colleague, my 
esteemed colleague from Georgia, this is not a one-size-fits-
all--I mean, each lifting exercise is different, right?
    Mr. Collins. Right. There was multiple prescriptions for 
how patients would be lifted, depending on their disability, 
their weight, and their ability to bear weight. One of the 
challenges in the study was how this was communicated from the 
nurse management to the nursing aides and orderlies.
    Senator Franken. I think part of the reason there are so 
many injuries is that there are so many awkward, different ways 
of having to lift so many patients--and there's almost an 
infinite number of lifts that you have to do. And so, obviously 
the commonsense solution to it is certainly not a one-size-
fits-all, is it?
    Mr. Collins. No, sir.
    Senator Franken. Well, thank you.
    Thank you, Madam Chair.
    Senator Murray. Thank you very much.
    Captain Collins, I wanted to ask you--in your written 
testimony, you talked about the fact that the average age of 
the nurses has been rising, and that's a consideration in this. 
And I wanted to know if you could describe for us, What's the 
physiological difference between a 46-year-old person lifting 
and a 26-year-old person lifting somebody?
    Mr. Collins. Clearly, their lifting capacity would be 
diminished. Their muscle strength would be diminished. And they 
would have to call on a lot more of their ability to lift to--
as they age, to transfer patients.
    Senator Murray. It would take additional staffing. Is that 
part of the cost?
    Mr. Collins. Additional staffing, certainly, and their 
ability to lift is clearly diminished as they age.
    Senator Murray. OK.
    Dr. Hodgson, we've talked a little bit about this--
different kinds of equipment. I mean, most people think just 
about the ceiling-mounted lift when they talk about it. What 
are some of the other types of equipment, like in a very small 
space, where you can't use a ceiling-mounted lift?
    Dr. Hodgson. Well, actually, ceiling lifts are probably 
easier to use in small spaces than if you have large patient 
rooms. Sit-to-stand lift--I mean, there are portable lifts that 
are either self-powered or that you push around, that have arms 
that extend to let you, kind of, move patients from a bed out 
into a chair. Sit-to-stand lifts help patients stand up. Things 
like air-assisted lateral transfer devices are effectively, you 
know, air mattresses that move patients laterally so that you 
don't have to lean over and pull someone back. Powered 
wheelchairs and powered stretchers--if you have a 600-pound 
patient in a wheelchair, there is a lot of force requirement to 
push that patient. Having a motor on that wheelchair or the 
stretcher means you're not pushing 650 pounds down the hallway. 
Car extractors are things that let you pull patients who are 
sitting in a car out of the car and lift them into a wheelchair 
or a gurney to cart them into a----
    Senator Murray. I remember doing that with my dad many 
times. Reaching into a car and trying to get him into a 
wheelchair was extremely difficult.
    Dr. Hodgson [continuing]. A huge problem and a very common 
cause of injuries. You know, only about 60 percent of the 
manual handling injuries are actually back injuries; the rest 
are shoulder, neck, and forearm injuries. Some hit the knee. 
But, those kinds of--leaning over and torquing your back and 
pulling your shoulder--not uncommon.
    Senator Murray. One of the challenges we're hearing about 
is the training of the nurses with the use of all that kind of 
equipment. If there were a national zero-lift requirement, do 
you think nursing schools would be more likely to teach zero-
lift techniques--and simplify the burden of continuing 
education? What do think the consequences would be?
    Dr. Hodgson. Yes. And, in fact, that movement is well 
underway. I think, 2 years ago, NIOSH and VHA had a joint 
project with AORN and orthopaedic nurses to put this program 
into the core curriculum in a series of nursing schools. Nurses 
who were coming out of--that original project was, I think, 
26----
    Mr. Collins. Twenty-six.
    Dr. Hodgson [continuing]. Nursing schools. That movement 
has spread. Many nurses now come out expecting that as the 
basic tool in a hospital.
    We assumed, when VHA funded this program--back when the 
discussions happened in 2007--that, within 10 years, we would 
have a very hard time hiring nurses if we weren't, you know, up 
on this, because nurses won't work without it. And with a 
nursing shortage, there will be the opportunity to go where 
people have that. We're already seeing that in cities where 
there are disparities between hospitals. Nurses clearly walk 
and make their choices.
    Senator Murray. OK.
    Senator Isakson.
    Senator Isakson. I'm reading a bullet point, here in my 
explanation in my manual, that says that the legislation 
prohibits the manual lifting of patients, except where the 
patient's care may be compromised. Is that the correct bottom 
line?
    Senator Franken. Yes.
    Senator Isakson. There wouldn't be any manual lifting at 
all; it would be equipment used to lift, except in the case 
where somebody would be compromised--or, the patient's health 
could be compromised.
    Senator Franken. Yes.
    Senator Isakson. Which means you would have to have this 
stuff--whatever ``this assistance'' is, it would have to be 
installed in the facility. Is that correct?
    Senator Franken. Right.
    Senator Isakson. OK. Captain Collins, as a--well, no, it's 
just in your opinion--how long would it take to establish that 
in the hospitals of the United States, in the nursing homes of 
the United States? An installation.
    Mr. Collins. Nationwide?
    Senator Isakson. And it's a guess, I realize.
    Mr. Collins. It would be a guess, sir. I don't know the 
answer to that. I know that it has taken--and the current 
acute-care hospital that I'm working now, it was a year-and-a-
half process to install 600 ceiling lifts in a 695-bed 
hospital, and it was an incremental installation in that single 
facility. And that was from the time that they began the 
installation process. They estimate, to equip a room, when they 
have the contracted installers, is about 4 hours per hospital 
room.
    Senator Isakson. The enforcement agency on this would end 
up being OSHA, I believe. Is that not correct?
    Mr. Collins. Yes, sir.
    Senator Isakson. And the enforcement mechanism are no-
notice inspections, I believe.
    Mr. Collins. Um.
    Senator Isakson. That's what my notes say, but I could 
stand to be corrected.
    Mr. Collins. I am not sure about how the enforcement would 
proceed.
    Senator Isakson. The point I'm getting to is really this. 
The VA has made an extraordinary effort to accomplish the 
intent of NIOSH's recommendations, in terms of lifting, 
correct, Dr. Hodgson?
    But, this legislation would invalidate that--if it went 
into immediately, you'd have to go to manual equipment, versus 
what your term was. I've forgotten where my notes were--but, 
dealing with the situation according to the situation.
    What I'm trying to get at is, How long are we going to give 
health facilities the time to do this? What would be the 
interim position during that time, in terms of reducing the 
potential injury to workers, yet still providing for movement 
of those workers that might, in fact, in part, be manual?
    [No response.]
    Would anybody know, or have a guess?
    Senator Franken. I'm sorry, can you repeat the question?
    Dr. Hodgson. Is this a question about the legislation or--
--
    Senator Isakson. Yes, the question is, Between the time the 
legislation passed that mandated this, and the time the 
hospitals could actually install it, what's the transition 
mechanism that you're going to use, first of all? Because 
you're going to have patients coming and going in hospitals all 
the time.
    Senator Franken. Right. Well, we allow 2 years from the 
promulgation of a final regulation--for hospitals to enact. So, 
it would be 2\1/2\ years after enactment that providers would 
be expected to develop a plan. They wouldn't have to purchase 
the actual equipment until 2 years following the implementation 
of a final regulation. That's 4 years after the enactment.
    Senator Isakson. OK. So, you've got a 4-year--and you also 
have a grant program, is that right?--in HHS, to help hospitals 
in the acquisition? Correct?
    Senator Franken. Yes. This is Federal money.
    Senator Isakson. And my last question--and it's not--these 
aren't questions as much as they're kind of observations that 
portend themselves to be a question.
    In that one caveat, about the patient care being 
compromised, that clearly is going to be a--to a certain 
extent--a subjective judgment that's going to have to be made 
at a moment in time, but it looks like the enforceability, 
other than the no-notice inspection, is through litigation. Is 
that correct?
    [No response.]
    If somebody complained they had an injury because of the 
lifting, and the decision was made--
    Senator Franken. I think it would be done through OSHA.
    Senator Isakson. Through OSHA.
    Senator Franken. Yes.
    Senator Isakson. Thank you, Madam Chairman.
    Senator Franken. Yes. And OSHA--can I take it from here?
    Senator Murray. Senator Franken will take it----
    Senator Franken. OK, thank you.
    Under this legislation, OSHA would issue a standard on safe 
patient handling and injury prevention that requires the use of 
lift equipment to move patients, except in cases which would 
compromise patient care.
    Care facilities would implement safe patient handling and 
injury prevention plans.
    Workers would receive training on safe patient handling and 
injury prevention.
    Workers would be protected from employer retaliation if 
they refuse to accept assignments which do not meet safety 
standards.
    And Health and Human Services would administer a $200-
million grant program to cover costs of acquiring safe handling 
and equipment for eligible facilities.
    Let me ask, Captain Collins, What reduction in injury rates 
could we expect if a national lifting standard were 
implemented, as is called for in the bill?
    Mr. Collins. What we've seen in the best practices 
programs, where they have a comprehensive safe patient handling 
and movement program, injury reductions have been achieved in 
excess of 60 percent. And the Institute of Medicine and the 
National Research Council, who's examined the literature, has 
come to the conclusion, somewhere between 55- and 65-percent 
injury reduction when you eliminate--or significantly reduce--
the manual lifting and replace that with assistive devices.
    Senator Franken. Do you think that a standard would yield 
savings for healthcare facilities?
    Do you think that a standard would yield savings for 
healthcare facilities?
    Mr. Collins. Yes, sir. The findings that we have is that, 
when the programs are comprehensively implemented--somewhere 
between 3 and 5 years--the return on the investment is 
achieved. And after that, you're making money, so to speak.
    Senator Franken. There will be a return on investment, 
here, that's greater than the investment----
    Mr. Collins. Three to five years.
    Senator Franken. OK, thank you.
    Senator Murray. All right. Thank you very much, Senator 
Franken.
    With that, I'd like to thank both of our witnesses. We will 
leave the record open for additional questions for both of you.
    And, with that, I'd like to have our second panel come 
forward and get seated. And, while you're doing that, we will 
do introductions. So, if you can all move forward and sit at 
the desk, please.
    We're going to begin with: Dr. Barbara Silverstein, who is 
the research director for safety and health assessment and 
research for prevention at the Washington State Department of 
Labor and Industries; June Altaras, who is the administrative 
nursing director at Swedish Medical Center, in Seattle, WA; and 
Douglas Erickson, who is the chairman on Guidelines for Design 
and Construction of Healthcare Facilities at the Facilities 
Guidelines Institute.
    Senator Franken also has a witness today.
    And, Senator Franken, I'll let you introduce your witness.
    Senator Franken. Thank you, Madam Chair.
    I'm happy to introduce Bettye Shogren, a specialist in 
occupational health and safety from the Minnesota Nurses 
Association, and the Minnesotan who inspired S. 1788, the Nurse 
and Health Care Work Protection Act.
    Bettye's nursing career ended prematurely when her doctor 
put her under a 40-pound lifting restriction because of 
cumulative injuries from her job. Instead of purchasing the 
lifting equipment Bettye needed to safely care for her 
patients, her employer offered her an administrative position, 
a job that required no nursing education or skill.
    Unfortunately, Bettye is just one of many nurses who have 
lost their careers due to the lack of safe patient handling 
standards.
    Thank you, Bettye. Thank you for being here. I look forward 
to hearing your testimony.
    Senator Murray. All right.
    We'll begin with Ms. Silverstein.

    STATEMENT OF BARBARA SILVERSTEIN, MSN, MPH, Ph.D., CPE, 
  RESEARCH DIRECTOR, WASHINGTON STATE DEPARTMENT OF LABOR AND 
                    INDUSTRIES, OLYMPIA, WA

    Dr. Silverstein. Thank you very much.
    You have my written testimony, so I will make this brief.
    Basically, Washington is one of nine States with safe 
patient handling legislation. A legislation has been initiated 
in another 10 States. Washington's law, which covers only 
acute-care hospitals, has the following requirements:
    A safe patient handling committee, with at least half of 
the committee being direct-care staff.
    A needs assessment for all patient care areas.
    A minimum of one lifting or moving device per 10 acute-care 
beds, or per unit.
    The right to refuse unsafe handling.
    And an annual program evaluation.
    Additionally, the law provides incentives for 
implementation of the safe patient handling legislation, 
including a business and occupations tax credit through 2010. 
And this is equivalent to about $1,000 per acute-care bed for 
the hospitals in Washington State.
    Placement in a reduced State-fund workers compensation 
premium class for those hospitals that are part of the State 
fund and have fully implemented safe patient handling programs.
    And a department of health does the audit, rather than 
OSHA, of implementing the safe patient handling legislation.
    Since the law went into effect, injuries related to lifting 
patients in Washington State have decreased about 35 percent. 
The legislation is fully implemented at the end of this year, 
but we've already decreased over 35 percent. And when we 
compare that to nursing homes, that are not affected by the 
legislation, their injury rates have been going up.
    While there's reason to believe that improvement is the 
result of safer work required by the legislation, definitive 
proof of this would require a comparison with States without 
legislation.
    We began to compare Washington with the State of Idaho, 
which does not have any legislation related to safe patient 
handling. However, because they do not participate in the BLS 
survey, we could not do a comparison of injury rates between 
the two.
    However, we were able to conduct a scientific study to 
compare patient handling programs and activities in Washington 
and Idaho hospitals of similar size and location--meaning rural 
or urban--using surveys and site visits. And then, the results 
of these studies have shown that Washington study hospitals 
were much more informed about patient handling--safe patient 
handling, but they had purchased more equipment, provided more 
hands-on training for staff, and had involved staff in the 
program development process--much more so than in Idaho.
    One of the important components of successful 
implementation of safe patient handling legislation in 
Washington has also been the creation of an active tripartite 
steering committee with a how-to Web site that has been used by 
virtually all the hospitals in Washington State to assist in 
implementation of the legislation. This steering committee has 
been integral to the successful implementation, I would say.
    We expect that these differences will result in measurable 
improvements in injuries that are greater in Washington than 
Idaho. While we don't have the definitive injury data yet, it's 
reasonable to expand Washington's model to the country. 
However, in my opinion, nursing homes should be included in any 
national legislation. Nursing homes have been included in the 
safe patient handling legislation in a number of other States, 
but not yet in Washington.
    Thank you for allowing me to provide this brief summary. 
I'd be happy to answer any questions. And you have my written 
testimony.
    [The prepared statement of Dr. Silverstein follows:]
    Prepared Statement of Barbara Silverstein, MSN, MPH, Ph.D., CPE
    My name is Barbara Silverstein. I have been the Research Director 
for the Washington State Department of Labor and Industries' Safety and 
Health Assessment and Research for Prevention program (known as SHARP) 
for almost 20 years. I received a Master of Science degree in nursing, 
Master of Public Health in Epidemiology and Occupational Health, and 
Ph.D. in epidemiologic science. We conduct safety and health research 
in a variety of workplaces to identify potential hazards and evaluate 
potential solutions. Health and safety of health care workers has been 
one of our areas of study.
    Research has shown that manual handling of patients increases risk 
of injury for caregivers and patients. Injury statistics show manual 
patient handling is dangerous to care givers and patients. Even with 
``good'' lifting technique, it is not possible to manually lift 
patients without exceeding the NIOSH action limit for manual handling. 
Mechanical lifting devices are necessary but not sufficient.
    Nursing homes and hospitals have amongst the highest numbers and 
incidence rates of injuries in the United States. Back and shoulder 
injuries related to manually handling patients comprise the largest 
proportion of injuries. Patients are older, bigger, heavier, sicker and 
rapidly changing status. Nursing staffs are also getting older, fewer, 
working longer hours, suffering from career ending injuries and are not 
easily replaced. Nursing schools have difficulty in recruiting faculty. 
Nursing assistants can make more money working at fast food 
restaurants. Nursing homes face management and staff turnover and 
inadequate funding. Hospital and nursing home injury rates are high and 
workers compensation claims for back injuries are costly. Safe patient 
handling legislation and programs are aimed at reducing this burden for 
workers, patients, families and society.
    Washington is one of nine states that currently have safe patient 
handling legislation to address this problem. Others include Illinois, 
Ohio, Maryland, Minnesota, New Jersey, New York, Rhode Island and 
Texas. Legislation has been initiated in another 10 States (California, 
Florida, Kansas, Massachusetts, Michigan, Nevada, New York, Vermont, 
Connecticut, Hawaii and Missouri). The legislation varies in terms of 
coverage and requirements.
    Safe Patient Handling (SPH) legislation has a positive impact on 
staff knowledge and practice of safe patient handling as well as 
reduction in patient handing injury rates. This has been demonstrated 
in Washington State.
    Washington State passed safe patient handling legislation for acute 
care hospitals in 2006 with phase-in from 2007-10. Requirements and 
incentives of the Washington State law requires that hospitals have:

     A safe patient handling committee with at least half of 
the committee comprised of direct care staff.
     A needs assessment for all patient care areas.
     Minimum of 1 handling device per 10 acute care beds/unit.
     Right to refuse unsafe handling.
     Annual evaluation.
     Department of Health audit of SPH implementation and 
practice.

    Additionally, the law provided incentives for implementation, 
including:

     A tax credit equivalent to $1,000 per acute care bed for 
SPH equipment purchases up to $10 million total.
     Placement in a reduced workers compensation premium class 
for those with fully implemented SPH programs.
     Department of Health audit of SPH implementation.

    This law is similar to the legislation proposed in H.R. 2381 Nurse 
and Health Care Worker Protection Act of 2009 that also included all 
direct care workers in health care facilities, and enforcement by OSHA.
    To assist in the implementation of the Washington State law, a 
steering committee was created in 2006 with initial representation from 
the Washington State Hospital Association, Washington State Nurses 
Association, SEIU1199NW, UFCW141 nurses, and SHARP. Since that time, 
additional members from a number of large hospitals have been 
participating in the steering committee. The steering committee Web 
site (slide 8) is used by health care facilities to guide 
implementation of safe patient handling programs and practices. 
(www.washingtonsafepatient
handling.org)
    The hospital financial tax credit incentive of $1,000 per acute 
care bed for purchasing SPH equipment was used by most hospitals. Of 92 
acute care hospitals, 28 used their maximum business and occupations 
tax credit. As of March 2010, $7.6 million in tax credits were 
accessed. Access to tax credits ends December 31, 2010.
    In 2006, SHARP initiated a study to evaluate the potential impact 
of this legislation on hospital nursing staff. In addition to 
monitoring individual and overall injury incidence rates, we are 
comparing SPH implementation and outcomes in four acute care hospitals 
in Washington with four acute care hospitals in Idaho (which has no 
legislation), matched for size (two large, two small) and geographic 
location (east, west).
    Incidence rates for patient handling related injuries increased in 
2006, remained high in 2007 and dropped significantly from 2007 to 
2008, and we have preliminary indications of a further decline in 2009.
    However, injury rates are lagging indicators. Leading indicators 
include changes in perceptions and practices. In order to capture 
changes in these indicators, we focused on four hospitals in Washington 
(with legislation) and four similar size and location (urban/rural) in 
Idaho (without legislation).
    2007 baseline data included staff surveys, staff and management 
focus groups, observations and back injury workers compensation data. 
We repeated data collection in 2009 and will collect the final round of 
data in 2011. Direct care staff survey areas included demographics, 
knowledge of SPH policies, procedures, committees, equipment and 
training, as well as physical demands, health and quality of work life. 
There were no significant differences in these areas between Washington 
and Idaho at baseline. Slides 13-20 show a survey of some results at 
baseline (2007 and follow-up 2009).
    Findings to date are included in the accompanying figures and 
include:

     Decreasing workers compensation claims rates related to 
patient handling injuries in Washington State acute care hospitals.
     Compared to Idaho hospital staff survey data, Washington 
survey data indicated greater staff knowledge about safe patient 
handling including:

          What ``safe patient handling'' means (safe for 
        patients/safe for staff) .
          Less likelihood of injury on their team.
          Satisfaction with patient handling equipment.
          Availability of equipment to handle patients weighing 
        more than 500 pounds.
          Greater likelihood to routinely use lifting and 
        transfer equipment.
          Satisfaction with availability of patient handling 
        equipment.
          Safety committee involvement in the purchase of SPH 
        equipment.

       However, Washington nursing staffs were twice as likely to 
report conflicting job demands as Idaho nursing staffs. This was not 
necessarily related to the SPH program.

    Focus groups (qualitative data) are used to ``put the meat on the 
bones'' of surveys (quantitative data) by including clarification of 
comments. Issues discussed in the staff and supervisor focus groups 
included knowledge of SPH concepts, barriers and successes in 
implementation.
    At baseline, staff members were asked what SPH meant to them. Many 
tended to focus on patient falls and using ``good body mechanics'' to 
lift patients than on prevention of staff injuries using appropriate 
equipment. There is no safe way to manually lift an adult patient by 
one or more people.
    In staff interviews in Washington State, there was much more 
knowledge of the requirements of an effective SPH program, including 
adequate staffing, safety committee involvement, hands-on training, and 
management support. Safe patient handling can be very effective in 
small as well as large hospitals as evidenced by comments from a staff 
focus group that indicated management support and adequate equipment 
were essential ingredients.
    A lack of management knowledge about and support for a SPH program 
in a large Idaho hospital was evidenced by relying on manual handling 
with transporter support and a decision to not include ceiling lifts in 
a new hospital when it is much less expensive to install them during 
construction than in retrofitting. An example of a staff member using a 
ceiling lift is provided on the last page of the figures attached to 
this testimony. Using a ceiling lift is safer and more comfortable than 
manual handling or using a floor lift for both the patient and the 
staff.
    Implementation of safe patient handling program cannot be 
successful if done in isolation. Mechanisms must be in place for 
continuous practice in use of equipment, easy availability of 
equipment, on-going training opportunities for staff such as looking 
for teachable moments with new or reluctant staff, a culture shift from 
``back injuries are inevitable in nursing'' to, handling patients 
safely for the patient and the care-giver. The VA has shown the 
importance of facility champions and peer leaders in the implementation 
and sustainability of SPH programs.
    There is some indication among Washington nursing staff of 
reduction in ``very, very'' physically demanding work by the first 
follow-up (see accompanying slides). This is likely to result in 
reduced injury and turnover of nursing staff in the future.
    In summary, legislation and regulation can provide a ``floor'' for 
what are minimally acceptable working conditions, but as a society, a 
profession and an industry, we should expect more of ourselves and each 
other. We need to take care of those who take care of us. Mason General 
Hospital, a small critical access hospital in rural Washington, 
provides an example of this through their ``environment of prevention'' 
which advertises their safe patient handling program to promote staff 
recruitment and community good will. They have been quite successful in 
their recruitment and retention of nursing staff. Perhaps this would 
have happened eventually without legislation, but legislation provided 
compelling and immediate incentives for implementation and 
sustainability. Other examples can be found on the Washington State 
Safe Patient Handling Steering Committee Web site (www.wash
ingtonsafepatienthandling.org).
    The attached figures provide more detail and illustration.

    Senator Murray. Thank you very much.
    Ms. Shogren.

  STATEMENT OF ELIZABETH (BETTYE) SHOGREN, RN, MNA, MINNESOTA 
       NURSES ASSOCIATION, STAFF SPECIALIST, ST. PAUL, MN

    Ms. Shogren. Good afternoon, Chairman Murray and Senator 
Isakson. Thank you for the opportunity to testify in support of 
Senate bill 1788, the Nurse and Health Care Worker Protection 
Act.
    My name is really Elizabeth Shogren, but I think I might be 
the only one who knows that, some days. I'm employed by the 
Minnesota Nurses Association as a staff specialist in 
occupational health and safety. I'm also a work-injured nurse. 
I'm honored to speak on behalf of the thousands of nurses and 
other healthcare workers who are work-injured, and the 
thousands more who will be work-injured unless this legislation 
is enacted.
    In March 1982, as Senator Franken said, my bedside career 
ended, not because I chose to end it, but because my injury 
resulted in a 40-pound lifting restriction that my employer 
would not accommodate.
    I've been a nurse for less than 10 years. The last shift I 
was able to work without pain, I was assigned to care for 
several patients, one of whom weighed over 400 pounds. She 
required repositioning every 2 hours and a boost up in bed 
multiple times a shift. There weren't enough people to lend a 
hand that night, so, with the help of one nursing assistant, we 
cared for and moved her as prescribed and as needed. That was 
the last shift I worked at the bedside.
    When my physician determined I would have a permanent 
lifting restriction, my employer offered me a job as an 
admitting clerk, a job that required no education and no skill, 
a job that was very similar to the one I had before I went to 
nursing school.
    I declined that position and began a litigation battle that 
lasted 2 years and 9 months. My wage replacement benefits were 
cut off. My medical care was threatened. My family's income was 
cut in half. My husband took a second job to help us make ends 
meet. And my three kids learned to do without things that they 
took for granted up to that point.
    I was fortunate to have the opportunity to fight, because 
most people simply couldn't afford to do that.
    I fought because what was happening to me wasn't right. It 
wasn't right that my ability to be a bedside nurse was 
determined, not by what I knew, but by how much I could lift. I 
didn't have to lift weights to pass my licensing exam.
    I fought because I was angry and because I needed to fight 
more than I needed to win. But, ultimately, I did win, when the 
Minnesota U.S. Supreme Court ruled that the job my employer 
offered was not suitable work. And that remains the standard 
for civil work and nurses in Minnesota, to this day.
    By the time the court ruled, I was working for the 
Minnesota Nurses Association, and we started getting calls, as 
we published what happened, from nurses all around the country. 
And they thought they were alone. And, back then, when nurses 
got hurt, they disappeared; and they were at work 1 day, and 
they were gone the next day, and you never saw them again.
    With that--I'd like to say that's changed, but I feel 
nurses and other healthcare workers who are injured are 
frequently treated like disposable towels, and--they're used 
and they're tossed aside when they are injured.
    I talk to hundreds of nurses around the country every year 
who have had the same kind of experiences. Many of them are 
significantly worse than my situation.
    I talk to other healthcare workers, too; and, sadly, 
they're actually treated worse than registered nurses.
    MNA has supported my efforts to improve the working 
conditions that created these injuries, but for so long, all we 
ever heard was, ``Nurses weren't lifting correctly. If you'd 
just use good body mechanics, you wouldn't be hurt.''
    In an average 8-hour shift, a nurse on a med-surg unit can 
care for three to eight patients. Sometimes there's staff to 
assist, sometimes there isn't. But, we still have to care for 
them. We turn them, we lift them, we walk them, we even catch 
them when they fall. We do whatever needs to be done, and we 
work--we lift an average of 1.8 tons per shift. That's a lot of 
weight: 1.8 tons per shift.
    We're expected to work like this every shift for 30 or more 
years in our career. And if you start adding up all the shifts, 
it's a remarkable amount of weight that my body, and other 
bodies, have to endure.
    In 2004, we started hearing about the work of Audrey Nelson 
and the work at the James A. Haley Tampa VA, in Tampa, FL. I 
went to my first conference in 2004, along with a number of 
other people. And to kind of quote a commercial, what I learned 
was ``priceless.'' I learned what I always knew, but I had 
evidence now that good body mechanics don't work to prevent 
injuries related to patient handling.
    The process that we had been instructed to do over and over 
and over again to save our backs actually harms us more than it 
ever helped us. They don't work, because lifting patients 
exceeds the body's biomechanical limits.
    I learned these types of injuries are largely preventable, 
because there was equipment that was available; and using 
equipment instead of our bodies prevents injuries.
    I learned that many other industrialized countries had been 
using equipment for 20 or more years, because they had laws 
that required it.
    And I also found out there was a quick return on 
investment, because injuries to workers are reduced, therefore 
workers' compensation claims are reduced, and patient injuries 
are reduced, as well.
    That's really important to me, the patient injury part, 
because I'm still a nurse, and nurses care about stuff like 
that.
    There were 38 people from Minnesota at that conference in 
2004, and we went back to Minnesota and said, ``What can we do 
here to make it better?'' We worked extensively with one of the 
major employers in Minnesota--Allina--as well as the Minnesota 
Hospital Association, to help bring a new program, Safe Patient 
Handling, to our State. We've seen significant success with 
Allina, Mayo, Fairview, Bemidji, and a number of nursing homes.
    And, although we commended those who were changing, we 
needed the rest of the employers in the State to follow their 
lead. Unfortunately, there was a great deal of reluctance to do 
so, and we decided we needed a law.
    So, in 2007, the Minnesota legislature passed the Minnesota 
Safe Patient Handling Act, which requires the use of equipment 
in all licensed healthcare facilities. It was amended in 2009 
to include outpatient care facilities, as well.
    I would like to read some testimony--but I'm going to run 
out of time--from another nurse, Stacy Lundquist.
    Senator Murray. All of your written testimony will become 
part of the record.
    Ms. Shogren. That's right.
    Senator Murray. So, if you would just summarize.
    Ms. Shogren. With that, we understand and believe that 
employers don't intentionally want to hurt their employees. 
But, rather, they continue to use a scientifically-based--
evidence-based theory that says it doesn't work, they rely on 
industry practice, as we now know it. And we know it isn't 
effective in preventing injury and protecting patients.
    We aren't here to place blame; but, rather, to focus on 
what we can do together to ensure safe working conditions in an 
industry that faces an acute shortage of workers. Continued use 
of manual patient handling is unsafe for healthcare workers and 
for patients. It contributes to increased cost of care in an 
environment when we're all questioning the rising cost of 
healthcare.
    The Nation needs what has been started in Minnesota and a 
number of other States. The patients across the country and 
their nurses and the other caregivers desperately need it.
    Thank you again for the opportunity to testify and to share 
my story. I am grateful for this hearing, and I've been waiting 
28 years for it to happen, so it's good to be here. And we're 
anxious to start working on a safe patient handling law for the 
Nation.
    It looks like I've got some time left, right?
    Senator Murray. No, well, you're actually 2\1/2\ minutes 
over, but----
    [Laughter.]
    Ms. Shogren. Oh, sorry.
    Senator Murray. We were listening.
    Ms. Shogren. I'm good at that. OK, thank you very much.
    [The prepared statement of Ms. Shogren follows:]
    Prepared Statement of Elizabeth (Bettye) Shogren, RN, MNA Staff 
                               Specialist
    Good morning. Chair Murray and Senator Isakson, thank you for the 
opportunity to testify in support of Senate bill 1788; the Nurse and 
Health Care Worker Protection Act.
    My name is Elizabeth Shogren. I am employed by the Minnesota Nurses 
Association as a Staff Specialist in Occupational Health and Safety. I 
am also a work injured registered nurse. I am honored to speak on 
behalf of the thousands of nurses and other healthcare workers who are 
work injured, and the thousands more who will be unless this 
legislation is enacted.
    In March 1982 my bedside nursing career ended. Not because I chose 
to end it, but because my injury resulted in a 40-pound lifting 
restriction that my employer would not accommodate. I had been a nurse 
less than 10 years. The last shift I was able to work without 
excruciating pain I was assigned to care for several patients, one of 
whom weighed over 400 pounds. She required repositioning every 2 hours 
and ``a boost up'' in bed multiple times per shift. There were not 
enough people to lend a hand that night so with the help of one nursing 
assistant, we cared for and moved her as prescribed and as needed. That 
was my last shift.
    When my physician determined I would have a permanent lifting 
restriction, my employer offered me a job as an admitting clerk. A job 
that required no nursing education or skill, a job that was very 
similar to one I worked before I became a nurse. I declined that 
position and began 2 years and 9 months of litigation. My wage 
replacement benefits were cut off, and my medical care was threatened. 
My family's income was cut in half. My husband took a second job to 
make ends meet and my three children learned to go without. I know I 
was fortunate to have the opportunity to fight as most people couldn't 
afford to.
    I fought because what happened to me wasn't right. It wasn't right 
that my ability to be a bedside nurse was being determined not by what 
I knew, but by how much I could lift. I didn't have to lift weights to 
pass my licensing exam. I fought because I was angry. I needed to 
fight, more than I needed to win, but ultimately I did.
    The MN Supreme Court ruled that the job my employer offered was not 
suitable work.
    By the time the court ruled, I was working for the MN Nurses 
Association. The news spread quickly of the court's decision and then 
the calls started coming, nurses from across the country. Nurses who 
thought they were alone. You see back then when nurses got hurt they 
disappeared. I would like to say that has changed but I feel Nurses and 
other healthcare workers who are injured are treated like disposable 
towels; used and tossed aside when they get hurt. Hurt caring for 
patients. I talk to hundreds of nurses every year who have the same 
kind of experiences. I talk to other healthcare workers, too. Sadly, 
they are often treated worse than registered nurses.
    The Minnesota Nurses Association has supported my efforts to 
improve the working conditions that create these injuries, but for so 
long all we heard was that nurses weren't lifting correctly. ``If you 
just used `good body mechanics' you wouldn't get hurt.''
    In an average 8-hour shift a nurse on a Medical/Surgical Unit can 
care for 3-8 patients. These patients come in all sizes; from tiny 
babies to patients who weigh 700 pounds or more all with varying 
degrees of need for assistance. Sometimes there is staff to assist with 
turns and repositioning and, other times there is not. When there is 
not, you still have to care for the patients. We turn them, we lift 
them, we walk them, and we even catch them when they fall; we do 
whatever needs to be done. We lift an average of 1.8 tons per 8 hour 
shift. That's right, you heard me right, we lift an average of 1.8 tons 
per 8 hour shift. We don't see that in other jobs; they use equipment. 
Yet nurses are expected to work like this every shift for 30 or more 
years relying on the hydraulics of their bodies.
    In the 2004 MN Workplace Safety Report, issued by the MN Dept. of 
Labor and Industry, workers with the most frequent OSHA recordable 
injuries were identified. It was a small wonder of the 14 occupations 
listed, Nursing Assistants were second; RNs seventh and LPNs twelfth. 
Essentially, the report said healthcare workers have higher rates of 
injury, and more severe injury than most other workers in this State. 
As an industry aggregate they are No. 1. In 2004 I also went to my 
first Safe Patient Handling Conference in Orlando. What I learned was 
priceless.
    Good body mechanics don't work to prevent injuries related to 
patient handling! The process nurses have been instructed to do and 
have practiced to ``save our backs'' for decades ACTUALLY harms us. 
They don't work because lifting patients exceed the body's 
biomechanical limits. I learned that these types of injuries were 
largely preventable because there was equipment available. Using 
equipment instead of our bodies prevents injury. I learned that many 
other industrialized countries had been using equipment for 20-plus 
years because they had laws that required it. I also found out that 
there is a quick return on investment because injuries to workers are 
reduced which in return decreased workers compensation costs. Patient 
injuries are reduced as well. This is especially important to me 
because I am still a nurse. I just take care of the people who take 
care of you. There were 38 people from MN at that Conference in 2004. 
We went home and we developed a plan to change what was happening in MN 
and we did!
    MNA has worked extensively with one of the employers, Allina, as 
well as the MN Hospital Association to bring a new program, Safe 
Patient Handling, to our State. We have seen significant success with 
Allina, Mayo, Fairview, Bemidji and some Nursing Homes. We commended 
those who are changing, but we needed the rest of the employers to 
follow their lead but they were reluctant to do so. That's when we 
realized we needed a law.
    In 2007 the MN legislature passed the MN Safe Patient Handling Act 
which requires the use of equipment in all licensed healthcare 
facilities. It was amended in 2009 to include all outpatient care 
settings.
    When we presented testimony one of our members, Stacy Lundquist 
testified. Stacey was severely injured at work while transporting a 
surgical patient and the patient's equipment--a combined weight of 
close to 1,000 pounds from one unit to the next. Stacey had begged her 
employer to invest in a $7,000 piece of equipment which could have 
pushed the bed for her, but they didn't see the need.
    I wish she was able to be here today, but her injuries prevent it. 
I would like to share with you some of her testimony. This is how her 
injury has impacted her life.

          ``I have had 4 surgeries over the last 3+ years; I suffer 
        from severe chronic pain which can only be controlled with 
        medication. I can walk only short distances with a cane and 
        must use a wheelchair when I leave my home. The pain is so 
        intense that some days I think it would be better to be a 
        paraplegic. I have lost my career. My injury fundamentally 
        changed every part of my life. I can't walk, I can't drive, I 
        can't shop, and I can't bike. I can't pitch a tent or camp or 
        hike in the woods. I can't sleep or rest without medication and 
        even then, I can't sleep very well. I couldn't pick up my first 
        grandchild. I believe all of that could have been prevented if 
        I had that piece of equipment. The pain I endure every day may 
        never end. The rest of my life will never be what it could have 
        been.''

    Safe Patient Handling is a program based on the scientific work of 
Dr. William Marras, and was initially implemented at the Veterans 
Administration Hospital in Tampa, FL. When the VA started using the new 
approach to lift, move, and transport patients two things happened: the 
frequency and severity of worker injury declined, and patient injuries 
related to falls and other injuries such as skin tears, dislocated 
shoulders, fractures, and pressure ulcers declined as well. That 
success has been replicated in numerous facilities across the country. 
This SPH program is public domain. It is free and walks an employer 
through the necessary steps to start and fully implement a SPH program.
    In MN we even asked for grant money to assist employers with start 
up costs associated with implementing this change. It isn't common to 
have a union ask for financial assistance for employers, but we 
believed it was in the best interest of patients, employers and workers 
and expedited the changes we needed.
    We understand and believe that employers do not intentionally want 
to hurt their employees. Rather they rely on an industry practice that 
we now know IS NOT effective in preventing injury and protecting 
patients. We are not here to place blame but rather to focus on what we 
can do together to ensure safe working conditions in an industry that 
faces an acute shortage of workers.
    Continued use of manual patient handling is unsafe for health care 
workers and patients. It contributes to increased cost of care in an 
environment where we are all questioning the rising cost of health 
care. The Nation needs what has been started in MN. The patients across 
the country, their nurses and other care givers desperately need it.
    Thank you again for the opportunity to testify and for me to share 
my story. 
I/we are grateful for this hearing and are anxious to start working on 
bringing Safe Pt. Handling to the Nation. I would be happy to take any 
questions at the appropriate time.

    Senator Murray. Thank you very much. I appreciate it.
    Ms. Altaras.

   STATEMENT OF JUNE M. ALTARAS, RN, BSN, MN, ADMINISTRATIVE 
     NURSING DIRECTOR, SWEDISH MEDICAL CENTER, SEATTLE, WA

    Ms. Altaras. Senator Murray and members of the 
subcommittee, thank you for this opportunity to share with you 
the learnings and results of Swedish Medical Center's Safe 
Patient Handling Program.
    My name is June Altaras, and I'm the nurse executive at 
Swedish Health Services, in Seattle, WA. Swedish is the 
largest, most comprehensive nonprofit healthcare provider in 
the great Northwest, employing 7,000 staff, 2,000 practicing 
physicians, and 1,000 volunteers.
    I was asked to testify today regarding our comprehensive 
Safe Patient Handling Program, called ``Safe Moves.''
    In March 2006, Washington State Governor Christine Gregoire 
signed new legislation requiring hospitals in the State to 
implement a safe patient handling program. This legislation 
caused this issue to be prioritized in our organization, and we 
moved systematically to develop a safe patient handling program 
that would benefit our patients, our staff, and reduce costs.
    The results of our work are overwhelming. We have developed 
a system that reduces workplace injuries, and days lost from 
those injuries, which has a direct result on our bottom line. 
Safe patient handling is not an initiative; it is a culture 
change, and, as such, it requires the engagement and support of 
front-line staff in designing the approach, establishing the 
workflow, and selecting the equipment. In addition, it requires 
the support of senior leadership, middle management, and unit 
experts. This is not a small undertaking; however, the results 
can be dramatic.
    I have been asked to address a few key aspects of our 
program. I will start with our lifting policy.
    Before adopting a formal lifting policy, we established a 
committee to evaluate the various lifting requirements 
throughout all units of the hospital. In addition, this 
committee researched what other hospitals were doing before 
developing recommendations for Swedish's lifting program and 
associated policies.
    In November 2007, we approved our employee safety standard, 
a policy intended to define Swedish Medical Center's commitment 
to partner with our employees to provide and support a safe 
workplace.
    In January 2008, we adopted our safe patient handling 
policy to promote and maintain a culture of safety by providing 
an environment of safe patient handling and movement for all 
inpatients and staff. These policies outline employee and 
manager responsibilities, required in depth educational 
trainings to ensure compliance, and clearly State that those 
found in violation of this policy may be subject to progressive 
corrective action.
    At a large health system like Swedish, there are different 
units, with vast differing lifting needs. As part of our year-
long assessment period, the Safe Patient Handling Committee 
conducted an in depth audit with each of our specialty units--
the ICUs, medical, surgical, and mother-baby units--to better 
understand the various lifting and repositioning needs and 
requirements, as well as the weights that were typical for 
their patient populations. We then engaged stakeholders from 
each of the units to play a role in selecting the actual 
lifting equipment, to ensure those actually using the equipment 
would find it useful.
    Swedish's initial investment in equipment was just over 
$1.1 million. Because this legislation was regulated by the 
State, Swedish was able to pay for a portion of the up front 
investment with a B&O tax credit. Additional investments 
include the labor costs associated with hiring a program 
director, as well as the 6,000-plus hours of employee training, 
totaling approximately $353,000, for a total first-year cost of 
$1.5 million. The yearly ongoing costs of retraining and 
staffing the program are approximately $300,000 per year.
    During the first 3 years of our program, 2007 through 2009, 
we have experienced a 60-percent reduction in work-injury 
incidents of our clinical staff, a 90-percent reduction in days 
lost from clinical work, and a total cost savings of $3 
million. This is a return of investment of approximately $1 
million in 3 years.
    The return on investment is undeniable and dramatic when a 
safe patient handling policy is implemented successfully.
    Swedish has relatively low nurse turnover rates. Turnover 
rates have dropped since safe patient handling policy has gone 
into effect. It would be disingenuous of me to attribute this 
trend to the safe patient handling program, given the current 
economic climate, but I do believe there is a probable 
correlation. And given that the cost to retrain a nurse is 
$60,000, this is very good news.
    In addition, our safe patient handling program and its 
resulting reduction in workplace injuries has been an important 
recruitment tool in attracting new talent to Swedish.
    While we don't have quantitative data about our program's 
effect on patient satisfaction, we have qualitative and 
anecdotal evidence. There have been many instances of bariatric 
patients walking rapidly after surgery because they are no 
longer fearful of falling, as the right equipment is in place 
to support them. Patients report feeling less guilty about 
staff potentially hurting themselves while assisting them with 
ambulating or repositioning, and also feeling less embarrassed 
when the right equipment is there and appropriately sized.
    We have also experienced decreased skin injuries, due, in 
part, to appropriate equipment to reposition our immobile 
patients.
    As you can tell from our results, safe patient handling at 
Swedish has been a resounding success. However, I believe it is 
important to note that there are several key factors that are 
critical to achieving success:

    Set a realistic timeline. This is a culture change. It 
cannot be implemented in a year, and results will take time. 
This is a long-term commitment that requires professionals to 
change years of work habits. The average age of a nurse is 
between 45 and 50 years old. Changing their work habits, for 
people who have been in the industry for so long, requires 
time.
    The investment is more than just equipment. Even though 
there are significant up front costs associated with purchasing 
various equipment and lifts, be prepared for, and factor in, a 
significant investment of human capital to establish a 
committee to conduct the appropriate research, assessment, and 
development of the program, an expert to direct the program, as 
well as up front training costs and ongoing annual retraining.
    Engage the front line. It is critical to engage those on 
the front lines of patient support across all hospital units in 
determining their equipment needs and eventual purchase, so 
that there is buy-in and support for these important decisions 
early on in the adoption process.

    In closing, implementing a safe patient handling program is 
a big undertaking that requires cultural change and 
organizational commitment to be successful. You will be asking 
seasoned professionals, many of whom have been on the job for 
over 20 years, to change the way they work, adjusting long-
formed habits and techniques. There must be clear commitment 
from organizational leadership, as well as stakeholders at all 
levels, to ensure success.
    Although implementing a culture of safe patient handling is 
not an easy task, Swedish believes it is the right thing to do. 
If approached methodically, you will not only see a generous 
return on your investment, but you will also have a healthier 
workforce.
    Thank you for this opportunity. I'll be happy to answer any 
questions.
    [The prepared statement of Ms. Altaras follows:]
           Prepared Statement of June M. Altaras, RN, BSN, MN
                           executive summary
    Swedish Medical Center is the largest, most comprehensive, 
nonprofit health provider in the Greater Seattle area. We have three 
hospital locations in Seattle, an emergency room and specialty center 
in Issaquah (East King County), Swedish Medical Center locations in 
Ballard, First Hill, Cherry Hill, Issaquah; Swedish Home Care; a 
network of 14 primary care clinics; multiple specialty clinics and 
affiliations with suburban physician groups.
    I was asked to testify today regarding our compressive safe patient 
handling program called Safe Moves. In March 2006, Washington State 
Governor Christine Gregoire signed new legislation requiring all 
hospitals in the State to implement a safe patient handling program. 
The requirement put forth in the legislation prioritized the issue 
throughout Swedish and we moved systematically to develop a safe 
patient handling program that would benefit our patients, our staff and 
would result in cost savings. We approached the adopting a safe patient 
handling policy with three key steps: research and assessment; 
investment in infrastructure and training; and measurement and 
accountability.
    The results of our work are overwhelming. We have developed a 
system that reduces workplace injuries and corresponding lost or 
restricted days of work, which has a direct result on our bottom line. 
In the last year alone, we attribute a total cost savings of $2,224,590 
for reducing days lost and restricted days due to workplace injuries. 
Patient safe handling is not simply an initiative or a program or a 
policy, it is a culture change and as such it requires the engagement 
and support of front line staff in designing the approach, establishing 
a workflow and selecting equipment. In addition, it requires the 
support of senior leadership, middle management and unit experts. This 
is not a small undertaking, it is a long-term commitment; however, the 
results can be dramatic.
    Implementing a safe patient handling program or policy or 
initiative is a big undertaking that requires cultural change and 
organizational commitment to be successful. You will be asking seasoned 
professionals--many of whom have been on the job for more than 20 
years--to change the way they work, adjusting long-formed habits and 
techniques. There must be clear commitment from organizational 
leadership as well as stakeholders at all levels to ensure deep 
commitment throughout the organization.
    Although implementing a culture of safe patient handling is not an 
easy task, if approached methodically and with a generous timeframe you 
will not only see a generous return on your investment, but also a 
healthier workforce.
                                 ______
                                 
    Senator Murray and members of the subcommittee, thank you for this 
opportunity to share with you the learnings and results of Swedish 
Medical Center's safe patient handling program. My name is June 
Altaras, and I am a nurse executive at Swedish Health Service in 
Seattle, WA.
    Swedish is the largest, most comprehensive, nonprofit health 
provider in the Greater Seattle area. We have three hospital locations 
in Seattle, an emergency room and specialty center in Issaquah (East 
King County), Swedish Medical Center locations in Ballard, First Hill, 
Cherry Hill, Issaquah; Swedish Home Care; a network of 12 primary care 
clinics; multiple specialty clinics and affiliations with suburban 
physician groups.
    I was asked to testify today regarding our compressive safe patient 
handling program called Safe Moves. In March 2006, Washington State 
Governor Christine Gregoire signed new legislation requiring all 
hospitals in the State to implement a safe patient handling program. 
The requirement put forth in the legislation prioritized the issue 
throughout the Swedish health system and we moved systematically to 
develop a safe patient handling program that would benefit our 
patients, our staff and would result in cost savings.
    The results of our work are overwhelming. We have developed a 
system that reduces workplace injuries and corresponding lost or 
restricted days of work, which has a direct result on our bottom line. 
Patient safe handling is not simply an initiative or a program or a 
policy, it is a culture change and as such it requires the engagement 
and support of front line staff in designing the approach, establishing 
a workflow and selecting equipment. In addition, it requires the 
support of senior leadership, middle management and unit experts. This 
is not a small undertaking, it is a long-term commitment; however, the 
results can be dramatic.
    I've outlined our approach to adopting a safe patient handling 
policy in three steps:

     Research and Assessment;
     Investment in Infrastructure and Training; and
     Measurement and Accountability.
                          program development
Step One: Research and Assessment
    In 2007 our organization created a committee of key stakeholders 
including the physical therapist who was hired to manage the program, 
front line nursing staff from each of our five hospital units (ICU, 
medical, surgical, mother/baby and pediatric), nursing leadership, 
safety team, and facilities. This committee researched and evaluated 
the patient safe handling programs at other hospitals to gain an 
understanding of the variety of ways this could be implemented at 
Swedish before developing their recommendations. In addition, the 
committee spent a year conducting in-depth assessments of each unit to 
better understand their lifting and repositioning needs and 
requirements as well as the weights that were typical for their patient 
populations.
    In November 2007 we approved our Employee Safety Standard, a policy 
intended to define Swedish Medical Center's commitment to partner with 
employees to provide and support a safe workplace.
    In the first year there was only one equipment purchase, which was 
to install ceiling lifts in each of the 42 ICU rooms. The data 
supporting the use of ceiling lifts for ICU patients was so compelling 
that there was no doubt that we should purchase the infrastructure and 
begin training and use immediately.
Step Two: Investment in Infrastructure and Training
    After the assessment the committee made its recommendations for 
each unit as well as for an overall policy. Investing in the 
infrastructure is only one part of the total cost, there is also a cost 
associated with initial ramp-up and training as well as on-going annual 
re-training. The committee recommended a scalable, multi-
disciplinary approach that could be customized for each hospital unit 
based on their specific needs and patient populations.
    In January 2008, Swedish adopted a Safe Patient Handling policy to 
promote and maintain a ``culture of safety'' by providing an 
environment of safe patient handling and movement for all inpatients 
and staff. These policies outline employee and manager 
responsibilities, including in-depth trainings to ensure compliance and 
clearly states that those found in violation of the policy may be 
subject to progressive corrective action, up to and including immediate 
termination of employment.
    It was critical to involve front line employees in the selection 
and purchase of the actual tools to ensure the employees who would be 
using the equipment were comfortable with the selection. At Swedish we 
have a range of lifting equipment from ceiling and floor lifts to 
Hovermatts to assist with lateral transfers.
Step Three: Measurement and Accountability
    Prior to 2007, our tracking of workplace injuries for allied health 
professionals was less robust and less consistent than it is today. 
Since 2007, we have been tracking injuries at each unit location and 
days and dollars lost as a result of those injuries. It took a few 
years to get our systems streamlined and to reduce some of the under-
reporting of injuries that went on previously.
    In addition, there are so many existing internal and third party 
measurements already that it can be difficult to implement a new 
measurement standard. For example The Occupational Safety and Health 
Act (OSHA) tracks workplace safety, but Swedish's OSHA numbers cannot 
be directly compared to the success of our safe handling program 
because of the different employee populations considered. Safe patient 
handling only impacts those employees with direct patient access, OSHA 
considers all work place injuries including administrative and support 
staff. Since 2007 we have been actively involved in measuring the 
direct impact of workplace injuries among employees that have direct 
patient access, so that we can accurately measure the success of our 
program year over year.
    We established a generous timeline to account for the steep 
learning curve that accompanies such cultural shifts. We knew that this 
was a long-term commitment that would take 2 to 3 years before we could 
measure real results in terms of the impact of patient safe handling 
policies.
                                results
    Although Swedish assembled a committee and installed ICU ceiling 
lifts in 2007, there were no programmatic adjustments until 2008. Since 
that time however, the results of the Safe Patient Handling efforts 
have been staggering.
    Swedish's initial investment of equipment was just over $1.1 
million. Because this legislation was regulated by the State, Swedish 
was able to pay for a portion of the up front investment with a $1 
million B&O tax. Additional up-front costs were labor costs including 
the hiring of one full-time employee to serve as the director of the 
program as well as approximately 6,000 hours of training (2 hours each 
for 3,000 employees) totaling $353,100 in up-front labor costs.
    In the last year alone, we attribute a total cost savings of 
$2,224,590 for reducing days lost and restricted days due to workplace 
injuries. When a nurse is injured and misses a day of work, there is a 
hard cost to replace that time that is at least 50 percent but often 
100 percent more expensive than the salary of the full-time employee. 
We used the conservative 50 percent rate to calculate our savings, so 
our savings is likely even greater.
    The return on investment is undeniable and dramatic when a safe 
patient handling policy is implemented successfully.
                            Recommendations
    Outlined below are our recommendations for how to implement a 
successful, results-driven safe patient handling program.
                        set a realistic timeline
    This is a major culture change, it cannot be implemented in a year 
and results will take time. This is a long-term commitment that 
requires professionals to change years of work habits. The average age 
of a nurse is between 45-50 years old, changing work habits of 
professionals who have been in the industry for so long requires real 
commitment.
               the investment is more than just equipment
    Even though there are significant up-front costs associated with 
purchasing various tools to ensure safe patient handling, there should 
also be a significant investment of human capitol to establish a 
committee to conduct the necessary research, hire someone to manage the 
program as well as up-front training costs and on-going, annual re-
training.
               investigate and learn from every incident
    When an injury is reported, we are very careful not to assume non-
compliance, nor is it assumed that every incidence of non-compliance 
should result in disciplinary action. We investigate every injury to 
determine if there is an opportunity for re-training, or if there are 
adjustments that need to be made in terms of our protocol. Of course 
there are times when non-compliance must result in disciplinary action, 
which is taken very seriously.
                         engage the front line
    It is critical to engage those on the front lines of patient 
support across all hospital units in determining their equipment needs 
and eventual purchase so that there is buy-in and support for these 
important decisions early in the adoption process.
                            Lessons Learned
            establish metrics that compare apples to apples
    The Occupational Safety and Health Act (OSHA) tracks workplace 
safety nationally, but Swedish's OSHA numbers cannot be measured 
against our Safe Moves numbers because of the different employee 
populations considered. Safe Moves only considers those employees with 
direct patient access, OSHA considers all work place injuries including 
administrative and support staff. Since 2007 we have been actively 
involved.
           ensure a multi-disciplinary/multi-vendor approach
    It is critical to involve as many parties as possible as early as 
possible in the process. Involving healthcare professionals with 
different responsibilities and patient populations will result in 
vastly different tools to ensure safe patient handling. For example, at 
Swedish, we created a specialized tool for one of our orthopedic 
surgeons based on his specific need with hip replacement patients.
          implement patient safety handling standards globally
    Patient safety handling should be part of all allied health 
training curriculum. All employees with direct patient access must be 
trained on patient safety handling compliance, from physicians, nurses 
and physical therapists to security guards, imaging specialists and 
respiratory therapists.
                plan for operational and equipment costs
    The up-front costs for equipment and operations are substantial, 
but with the right approach, organization commitment, and a reasonable 
timeframe to build toward results, costs can be turned into savings.
                                Summary
    Implementing a safe patient handling program or policy or 
initiative is a big undertaking that requires cultural change and 
organizational commitment to be successful. You will be asking seasoned 
professionals--many of whom have been on the job for more than 20 
years--to change the way they work, adjusting long-formed habits and 
techniques. There must be clear commitment from organizational 
leadership as well as stakeholders at all levels to ensure deep 
commitment throughout the organization.
    Although implementing a culture of safe patient handling is not an 
easy task, if approached methodically and with a generous timeframe you 
will not only see a generous return on your investment, but you will 
also have a healthier workforce.
                                 ______
                                 
  Appendix A.--Breakdown of Cost Savings Resulting From Reducing Days 
                        Away and Restricted Days

                 Total cost savings for reducing days lost and restricted days per year $2,224,590
----------------------------------------------------------------------------------------------------------------
                                                                                               Cost Savings (due
                                                                                                  to reducing
                                   Days Away Avoided     Working Hours    Average RN wage at      backfill /
                                                             Saved              Swedish        replacement rate*
                                                                                                of $62.02/hour)
----------------------------------------------------------------------------------------------------------------
Lost Days.......................  973 days..........  11,676 hours......  $41.35............  $724,203 ($62.02 x
                                                                                               11,676)
Restricted Days**...............  2016 days.........  24,192 hours......  $41.35............  $1,500,387 ($62.02
                                                                                               x 24,192)
                                 -------------------------------------------------------------------------------
  Total Savings.................  ..................  ..................  ..................  2,224,590
----------------------------------------------------------------------------------------------------------------
*Using a conservative 50% higher rate of $62.02/hr although rate actually ranges 50-100 percent higher.
**All restricted hours are backfilled with temporary labor because you never know the patient situation which
  may cause an Allied Health Professional to risk their physical well-being to help a patient.


        Appendix B.--Total Up Front/Initial Investment of Funds


------------------------------------------------------------------------

------------------------------------------------------------------------
Total up front Investment for Labor Costs:
  1 FTE for Director of Program...........  $105,000+
  Approximately 6,000 hours of training @   $248,100 (3,000 employees)
   $41.35.
                                           -----------------------------
    Total up front Labor Investment.......  $353,100
Total up front Dollar Investment for
 Equipment:
  Initial Investment of funds.............  $1,100,000.00
  HoverMatts CH Surgery...................  $6,152.00
  CH Neuro ICU-Golvo/slings...............  $11,165
  CH CICU-Viking/slings/Hovermatt.........  $15,018.40
  CH Abm. Infusion-Golvo/Slings...........  $7,212.40
                                           -----------------------------
  Total Equipment Investment..............  $1,128,382.80

Total Up Front/Initial Dollar Investment of Funds: $1,481,482.80
                Appendix C.--Total Ongoing Program Costs


------------------------------------------------------------------------

------------------------------------------------------------------------
1 FTE for Director of Program.............  $105,000+
Approximately 3,000 hours of training @     $124,000 (3,000 employees.
 $41.35.                                     Repeat training is 1 hour
                                             versus 2 hours)
                                           -----------------------------
  Total Ongoing Labor Investment..........  $299,000


                   Appendix D.--Nurse Turnover Rates


------------------------------------------------------------------------
                                              Nurse Turnover Rates  (In
                   Year                               percent)
------------------------------------------------------------------------
2006......................................  8.76
2007......................................  8.15
2008......................................  9.38
2009......................................  6.94
------------------------------------------------------------------------

    Appendix E.--Swedish Medical Center's Safe Patient Handling and 
                   Employee Safety Standard Policies.













    Senator Murray. Thank you very much.
    Mr. Erickson.

 STATEMENT OF DOUGLAS ERICKSON, FASHE, HFDP, CHFM, CHC, DEPUTY 
      EXECUTIVE DIRECTOR, AMERICAN SOCIETY FOR HEALTHCARE 
                    ENGINEERING, CHICAGO, IL

    Mr. Erickson. Good afternoon, Madam Chair and Senator 
Isakson.
    I'm Douglas Erickson, chairman of the Guidelines for Design 
and Construction of Healthcare Facilities. I'm a healthcare 
engineer. I'm a fellow within the American Society for 
Healthcare Engineering, and have more than 35 years of 
experience in the healthcare field, specializing in the 
development of codes and standards supporting the healthcare 
physical environment. I appreciate the opportunity to present 
before the subcommittee this afternoon.
    First, there are Federal programs and standards already in 
place to systematically implement a no-lift policy, so 
additional regulation is unnecessary.
    Second thing is that there are technical difficulties in 
installing patient lifting devices in our healthcare 
facilities, and it is extremely difficult and complex, in many 
instances.
    And, third, the patient disruption in an occupied 
environment is significant when modifications are made to 
install equipment needing structural support.
    A major concern of mine, as an expert in writing and 
implementing codes and standards in the healthcare physical 
environment, is that we are trying to rush such a monumental 
modification into our Nation's existing healthcare system. This 
action will absolutely create havoc, panic to comply, a 
tremendous waste of our healthcare resources. In my 
professional judgment and that of other professionals in my 
field, it will take decades to bring about the necessary 
physical modifications to provide mechanical lifting equipment 
sufficient to implement a no-lift policy throughout the entire 
system.
    The fact is, most existing healthcare facilities in the 
United States are not designed and constructed to accommodate 
the installation of fixed lifting equipment, or, in many cases, 
to accommodate the use of even portable equipment.
    While we are making great advances in modernizing our 
hospitals, nursing facilities, clinics, and other patient care 
sites, the fact remains: We are still providing care in 
buildings that date back to the early 20th century.
    Some points to consider:

    Healthcare facilities have been including permanently 
installed ceiling- and wall-mounted lifting devices in new 
construction and major renovation, but in existing 
construction, it is minimal, because of the time and cost to 
gain access to the structural components of the ceiling or 
walls.
    Structural capacity of our floors, ceilings, and walls may 
be inadequate to support lifting devices.
    Most healthcare facilities have semiprivate rooms that do 
not provide a good environment for fixed lifts, due to the 
limited size and configuration of those rooms.
    Installing lifting devices will require, in many instances, 
the need to reposition lighting fixtures, ventilation systems, 
sprinkler heads, ceiling-mounted radiology equipment, OR 
lights, electrical conduits, plumbing pipes, and has the 
potential of even needing to use asbestos abatement if asbestos 
is still contained and encapsulated within the ceiling cavity.
    Installing lifting devices will also result in the loss of 
bed capacity and the disruption due to noise, vibration, 
infection control, and other risks to patients, when making 
facility modifications.

    Our healthcare facilities need a systematic approach to 
instituting safe patient handling practices that include all 
interested parties. The healthcare industry already has a time-
tested, formulated process and quality document known as the 
Guidelines for Designing Construction of Healthcare Facilities. 
The 2010 edition is the latest in a 63-year history of this 
document to aid in the design and construction of healthcare 
facilities. Approximately 42 State departments of health 
already adopt some iteration of the guidelines.
    Over the past 4 years, the authors of the guidelines have 
undertaken a national consensus effort to develop quality 
standards for assessing safe patient handling risk and 
implementing a program to install mechanical lifting devices in 
new construction and major facility modifications.
    The 116-person all-volunteer committee consists of nurses, 
surgeons, occupational health experts, infection prevention, 
and we have worked with safe patient handling experts, nursing 
union representatives, State and Federal authorities, and also 
health professionals, to develop the standard on patient 
handling and movement.
    The effort has two distinct, yet interdependent, phases. 
First, a patient-handling needs assessment to identify 
appropriate handling and movement of patients. And the second 
one would be to define the space requirements, the structural 
and the other technical aspects to accommodate the 
incorporation of such patient equipment, and also--within that 
environment.
    In conclusion, safe patient handling is critical to the 
fabric and future of the healthcare system. However, this needs 
to be accomplished in a highly systematic fashion, or the fix 
could be worse than the problem.
    The Facility Guidelines Institute stands ready to work with 
lawmakers on innovative ways to build on efforts already 
happening at the Federal, State, and public levels, and to 
share information that will help healthcare organizations make 
smart choices on implementing a safe patient handling program.
    Madam Chair, it has been an honor to be here this 
afternoon, and I would like to thank the subcommittee for 
inviting me to present on this very important topic.
    [The prepared statement of Mr. Erickson follows:]
   Prepared Statement of Douglas S. Erickson, FASHE, HFDP, CHFM, CHC
    Good afternoon, Madame Chairperson and committee members. I 
appreciate the opportunity to present before the Senate Employment and 
Workplace Safety Subcommittee. The subject being addressed by the 
subcommittee is of great importance to the overall success of our 
health care system.
    As a health care engineer, I've been involved in the patient care 
environment for nearly 35 years and involved in the patient safe 
movement issue for the past 10 years. From my experience, I do not 
believe a Federal Government approach to safe-patient handling is the 
best approach.
    I come before the committee not to argue against the merits of a 
safe-patient handling bill, as having some form of legislation to 
protect the health care worker from injury and to support safe movement 
of patients in health care facilities is extremely important and worthy 
of the current attention. My concern as a citizen and as an expert in 
writing and implementing codes and standards in the health care 
physical environment is that we are not allowing enough time to 
properly alter the health care built environment to accommodate 
mechanical lifting equipment. Trying to rush such a monumental 
modification to our Nation's health care system will create havoc, 
panic, and a tremendous waste of health care resources. My experience 
of more than 30 years--writing standards, compromising on proposed 
language, advocating for and against the adoption of codes and 
standards, and having to implement and live with those codes once 
issued--indicates it will take time to bring about the necessary 
physical modifications to provide mechanical lifting equipment 
sufficient to implement a no-lift policy throughout the entire system.
    The safe-patient handling and lift standards as presented will not 
allow enough time to alter the built environment and install mechanical 
lifting devices before the no-lift policy is mandated. This will create 
havoc in the health care industry as organizations will panic and do 
something--anything--to avoid impending OSHA fines, ultimately wasting 
a tremendous amount of health care resources.
    Yes, we can mandate that OSHA shall establish a Federal Safe-
Patient Handling Standard in a year and, yes, we can mandate that all 
health care facilities shall develop and implement a safe-patient 
handling plan not later than 6 months after such a standard is 
published. However, the truth is that complying with these mandates 
cannot be physically accomplished within those timeframes.
    To modify our Nation's health care facilities and provide 
mechanical lifting equipment to fully support a no-lift policy 
throughout the entire health care system will take a decade or more to 
achieve.
    The fact is that most existing health care facilities in the United 
States are not designed and constructed to accommodate the installation 
of fixed lifting equipment or, in many cases, to accommodate the use of 
portable lifting devices. While we are making great advances in 
modernizing our hospitals, nursing facilities, clinics, and other 
patient care sites, the fact remains that the U.S. health care system 
is still providing care in buildings that date back to the early 20th 
century. Many health care facilities were designed and built under the 
Hill-Burton program and have inflexible physical environments. Some 
points to consider:

     Very few hospitals have been retrofitting patient rooms 
with permanently installed ceiling- or wall-mounted patient lifting 
devices. At issue is the tremendous cost to gain access to the 
structural components of the ceiling or wall. A typical retrofit for a 
ceiling-mounted lift would mean removing a portion of the existing 
plaster or acoustical ceiling, cubicle track, light fixtures, sprinkler 
piping, and potentially the heating and cooling ductwork. Often, the 
space above the acoustical ceiling is limited in height and would not 
permit installation of the structural supports needed for the ceiling-
mounted grid of a mechanical lift system. For a wall-mounted lift, the 
wall must be strengthened with additional structural elements and 
structural plates, which must be fit in among the other equipment 
located on the headwall, including electrical devices such as the nurse 
call, emergency/normal power receptacles, medical gas connections, and 
patient-related equipment for monitoring, suction, and bed control. 
Other physical features needing modification to accommodate 
installation of lifts are the toilet room doorframe and the wall above 
the doorframe to permit passage of the track and hoist cabling.
     Most ceiling- and wall-mounted lifts are installed during 
new construction or major renovation projects.
     Most ceiling-mounted lifts are installed in private rooms 
as the semi-private room is not an appropriate environment due to the 
size and configuration of the room, which means the patient on the far 
side of the room would have to be hoisted over the other patient to 
reach the toilet room.
     The use of portable lifts in semi-private patient rooms is 
limited based on the size of the room. With its typical footprint of 
30 x 40, maneuvering a patient lift into position in an older room 
of 160 sq. ft. is almost impossible due to the equipment, both patient-
related and family-related, that fills it. Also, the bed size has 
increased dramatically over the past 20 years, limiting the clear floor 
space in the patient room.

    Other architectural and business-related issues to consider when 
installing mechanical lifting equipment in existing buildings include 
these:

     Structural capacity of floor slabs, ceilings and walls 
capable of supporting the lift loads.
     Positioning of light fixtures, A/C diffusers, fire 
sprinkler heads.
     Items above ceiling (e.g. other ceiling-mounted equipment 
such as radiology equipment and OR lights, HVAC equipment, electrical 
conduits, plumbing equipment).
     Amount of interstitial space (dictates the amount of 
lateral bracing required and type of attachment method--rod or 
pendant--needed to achieve a stable system).
     Unique architectural considerations: Multi-level ceiling 
heights, vaulted ceilings, soffits, non-structural or radius walls.
     Header and door walls (structural vs. non-structural 
walls--use of structural walls creates more challenges in room-to-room 
tracking).
     Fire code requirements.
     Ceiling height compared to maximum lifting range required 
by lifting practices.
     Wall-mounted barriers: TVs, light fixtures, cabinets, and 
door swing radius must be considered in determining track dimensions.
     Motor maintenance: Enough space must be allowed between 
rail-end and wall for removal of the lift motor.
     Recessed track (for straight, traverse, or curved track, 
ensure dropped ceiling grid is butted against track).
     Conveniently accessible space for motor and hanger bar 
storage when not in use.
     Location/design of privacy curtains.
     Approval of plans by State architectural review boards, 
which can take as long as 6-18 months.
     Loss of bed capacity when making modifications to 
accommodate installation of fixed lifting equipment.
     Infection control risk to patients from generation of 
aspergillus or other harmful spores and bacteria in the patient 
environment.
     Asbestos abatement if asbestos is still encapsulated in 
the cavity above the patient environment.
     Training of facility and maintenance staff on the new 
equipment.

    The solution for creating a safe-patient handling program has been 
clearly defined in the VA manual on developing a no-lift policy.
    In this manual, the Veterans Administration's first statement is 
that, for a no-lift policy to be successful, the health care facility 
MUST have required infrastructure in place before it is implemented. 
This infrastructure includes:

     An adequate number and variety of patient handling aids 
and mechanical lifting equipment on each high-risk patient care unit.
     Sufficient numbers of staff trained and competent in the 
use of these aids and equipment.
     Staff trained and skilled in applying safe patient 
handling and movement algorithms.
     Administrators and supervisors who support the 
comprehensive approach.

    The U.S. health care system needs a systematic approach to 
instituting mandatory safe-patient handling that includes all 
interested parties.
    Over the past 4 years, the authors of the Guidelines for Design and 
Construction of Health Care Facilities have undertaken a national 
consensus effort to develop quality standards for assessing safe-
patient handling risk and implementing a program to install mechanical 
lifting devices in new health care construction and major 
modifications. The 116-person, all-volunteer multidisciplinary 
committee worked with industry safe-patient handling experts, nursing 
union representatives, State and Federal authorities, and health care 
professionals to develop the concept of a patient handling and movement 
assessment (PHAMA) along with an industry best practice to provide 
guidance for implementing the program. A compilation of the safe-
patient handling provisions in the 2010 Guidelines for Design and 
Construction of Health Care Facilities and Patient Handling and 
Movement Assessments: A White Paper have been provided for further 
review (see Attachment 2).
    National guidelines for effectively evaluating safe-patient 
handling needs, patient movement equipment, and space design 
considerations were released in January 2010.
    This national team of experts crafted safe-patient handling 
language for public review and comment. After a 2-year review process, 
all the public comments were addressed and the following core 
paragraphs emerged. Another 10 pages of requirements and appendix 
material within the Guidelines support these two paragraphs (see 
Attachment 1).

        1.2-5 Patient Handling and Movement Assessment

         A patient handling and movement assessment (PHAMA) is 
        conducted to direct/assist the design team in incorporating 
        appropriate patient handling and movement equipment into the 
        health care environment. The purpose of this equipment is to 
        increase or maintain patient mobility, independent functioning, 
        and strength as well as to provide a safe environment for staff 
        and patients during performance of high-risk patient handling 
        tasks.

         The PHAMA has two distinct yet interdependent phases. The 
        first phase includes a patient handling needs assessment to 
        identify appropriate patient handling and patient movement 
        equipment for each service area in which patient handling and 
        movement occurs. The second phase includes definition of space 
        requirements and structural and other design considerations to 
        accommodate incorporation of such patient handling and movement 
        equipment.

    Simultaneous to the crafting of standards language, the white paper 
on patient handling and movement (PHAM) was being developed to support 
these new requirements. In addition to the workplace safety issues of 
safe-patient handling, this white paper sensitizes us to many 
additional advantages that PHAM equipment may offer, including:

     Better patient outcomes and improved quality of life for 
both patients and caregivers.
     Economic benefits from avoiding adverse events related to 
manual patient handling.
     Improved patient outcomes stemming from the potential for 
hospitals and nursing homes to mobilize patients using assistive 
devices immediately following a procedure or admission and diagnosis.

    The authors concluded that these benefits and possibilities deserve 
to receive more emphasis--in addition to (rather than instead of) 
workplace safety.
    The health care industry already has a time-tested, formalized 
process and quality document for designing and constructing health care 
facilities.
    The 2010 edition is the latest in the 63-year history of this 
Guidelines document to aid in the design and construction of health 
care facilities.
    The original General Standards appeared in the Federal Register on 
February 14, 1947, as part of the implementing regulations for the 
Hill-Burton program. The standards were revised from time to time as 
needed. In 1974 the document was retitled Minimum Requirements of 
Construction and Equipment for Hospital and Medical Facilities to 
emphasize that the requirements were generally minimum, rather than 
ideal standards. The 1974 edition was the first for which public input 
and comment were requested.
    In 1984 the Department of Health and Human Services (DHHS) removed 
from regulation the requirements relating to minimum standards of 
construction, renovation, and equipment of hospitals and medical 
facilities, as cited in the Minimum Requirements, DHEW Publication No. 
(HRA) 81-14500. Since the Federal grant and loan programs had expired, 
there was no need for the Federal Government to retain the guidelines 
in regulation format. To reflect its non-regulatory status, the title 
was changed to Guidelines for Construction and Equipment of Hospital 
and Medical Facilities. Since that time, the document has been 
continuously updated every 4 to 5 years, using a public revision 
process.
    The 2010 Guidelines was written by a 116-person, multidisciplinary 
Health Guidelines Revision Committee (HGRC) with representation from 
nurses, surgeons, anesthesiologists, neonatologists, infection 
preventionists, administrators, architects, facility managers, 
consulting engineers, safety and security professionals, risk managers, 
and more than 25 State, Federal, and private enforcing authorities.
    The 2010 edition had more than 25 focus groups reviewing specific 
sections of the 2006 document or working on the development of new 
sections. Two specialty subcommittees were formed to take on major 
projects on acoustic design and patient handling and movement. 
Expertise on these specialty subcommittees was bolstered by the 
contributions of outside technical and subject experts. The HGRC 
reached a consensus at its final meeting and unanimously endorsed the 
revised guidelines to be sent out for letter ballot, which was then 
unanimously approved.
    A public process, with a 63-year history, is already in place with 
a set of consensus standards for assessing and implementing safe-
patient handling. The Guidelines is adopted by the Joint Commission, 
HUD, PHS/IHS, HRSA, and State departments of health and licensure. So 
the process works without the need for a set of Federal Government 
safe-patient handling standards.
                               conclusion
    Safe-patient handling is critical to the fabric and future of the 
health care system. I agree that the health care system needs to 
implement policies and install adequate equipment to protect workers 
and patients when manual handling is required. However, this needs to 
be accomplished in a highly systematic fashion or the fix could be 
worse than the purpose for implementing the program.
    The FGI and its health guidelines revision committee members stand 
ready to work with lawmakers on innovative ways to build on efforts 
already occurring at the Federal, State and public levels and to share 
information that help health care organizations make smart choices on 
implementing a safe-patient handling program.
    Madame Chairperson, it has been an honor to be here this afternoon, 
and I would like to thank the Health, Education, Labor, and Pensions 
Committee for inviting me to present on this very important topic, and 
of course I am available for any questions from the committee.

    Senator Murray. Thank you very much.
    I want to thank all of our witnesses today for excellent 
testimony. This is extremely helpful to this committee.
    We have hit a couple of time constraints. Senator Isakson 
has to leave; he has a previous engagement. We have four votes 
that are going to start, here shortly, which are going to take 
over an hour. And all of us have questions.
    So, what I'm going to do is allow Senator Isakson to ask 
his questions. I will have one or two, and turn it over to 
Senator Franken. Hopefully, we can finish those before the 
votes begin.
    And the rest of the questions will be submitted to all of 
you to return in writing.
    So, with that, let me turn it over to Senator Isakson.
    Senator Isakson. Well, thank you, Madam Chairman. Actually, 
I'm not going to ask a question. But, two things:
    One, first, thanks, to each of you, for your testimony.
    Second, I really commend pages 5, 6, and 7 of Ms. Altaras's 
testimony, which were, I think, really excellent--both in terms 
of recommendations as well as lessons learned, which goes back 
to some of those initial questions I asked. It was very helpful 
to me. I commend you on that.
    And I thank all our panelists for their effort today.
    Thank you.
    Senator Murray. Thank you very much.
    Ms. Altaras, let me start with you. You have over 100 years 
of service. Congratulations. I think it's 110, now, Swedish has 
been operating. You have a mix of old and new buildings that 
you dealt with as you implemented this policy. Can you tell us 
what impact the age and condition of your buildings had on your 
efforts?
    Ms. Altaras. We've taken a multiequipment approach. We have 
not installed ceiling lifts in 100 percent of our rooms. We 
make a decision on whether ceiling lifts are appropriate, based 
on the assessment of each individual nursing unit, of what 
patient populations are in that unit and what the work is in 
that unit. Ceiling lifts are not necessarily appropriate for 
all areas.
    In the surgical suites, we use HoverMatts, because it would 
be very difficult to install ceiling lifts in surgical OR 
rooms. And we use HoverMatts in that setting.
    There are many settings where the patients can reposition 
themselves in bed, and, really, the goal is to get them from 
sit-to-stand, so we use portable movement machines to go from a 
sit-to-stand position. So, the ceiling lifts aren't necessarily 
required. You can use HoverMatts in those situations also. So, 
we've used a variety of approaches.
    Some of our older buildings, we have found that there are 
the--if you decide it's appropriate to use ceiling lifts in 
older construction, you can use the portable framework, where 
you can install the motor and the tracking to use that lift. 
But, I think that you need to do very in depth assessment to 
make sure ceiling lifts is actually the appropriate solution 
with that patient population and nursing unit.
    Senator Murray. OK, thank you very much.
    And, Ms. Silverstein, I wanted to ask you about the 
recruitment and retention of experienced nurses and, in your 
experience, how this policy has helped with that.
    Dr. Silverstein. In doing the interviews in both Idaho and 
Washington, where there has been available equipment, nursing 
staff may have, at first, been reluctant, but, once they became 
used to using the equipment, were absolutely delighted with it 
and felt that their careers could last a lot longer.
    The turnover--we don't have evidence that the turnover has 
dramatically decreased across the board, but it has, we know, 
in certain hospitals, where they've really implemented safe 
patient handling.
    Senator Murray. OK.
    Senator Franken.
    Senator Franken. Thank you, Madam Chair.
    Ms. Silverstein and Ms. Altaras, could you please respond 
to Mr. Erickson's assertion that it would take decades to 
implement this bill?
    Minnesota facilities, Ms. Shogren, were able to make 
changes much more quickly. And I assume Washington has, too.
    I want to point out that my legislation really gives 4 
years to enact this--so, can you respond to Mr. Erickson, 
either of you, or any of you? Ms. Shogren, too.
    Dr. Silverstein. Three years. In Washington.
    Senator Franken. You did it--in the entire State.
    Dr. Silverstein. Yes.
    Senator Franken. In 3 years.
    Dr. Silverstein. Yes.
    Senator Franken. OK.
    And, Ms. Altaras.
    Ms. Altaras. It took our organization 3 years, and we have 
three hospitals. We have over 1,000 patient beds, in addition 
to all of our--we have 60-plus operating rooms. And we were 
able to install in--it's actually under 3 years.
    Senator Franken. And, Ms. Shogren, what was the experience 
in Minnesota?
    Ms. Shogren. The law won't be fully implemented until the 
end of the year, but the law provides about 2\1/2\ years to 
fully implement the program; and there is a provision for 
hardship, for an additional year. It can be extended if the 
employer is experiencing hardship.
    Senator Franken. One of the reasons I love nurses is that 
they're patient advocates. And from the patient's perspective, 
the disability community in Minnesota, Ms. Shogren, when this 
law was passed--I understood they were for it, right? They were 
advocating for it.
    Ms. Shogren. Well, we talked with just about anyone who 
would talk with us as we were getting ready to work on the 
bill, and we found that, within the disability community, we 
had some kindred spirits there, from a different perspective.
    They were very concerned, especially in the outpatient-care 
settings, which is why we did the amendment, that even though 
the facilities had ramps at the doorways and buttons that you 
could push to open the doors for you, that once they got beyond 
the waiting room, they were not equipped to care for them, and 
they couldn't get on the exam table. So, for instance, the MS 
Society lobbyist testified that only about 20 percent of women 
with MS can get a Pap smear every year, because they simply 
can't get on the table. And that was a very fundamental issue 
around access to healthcare that we felt was very compelling.
    We also know that when we lift patients manually, we're 
generally hurting them; that's why they're combative. And I 
didn't go into nursing to hurt people, and the fact that I can 
use equipment to help move someone, versus, brute force to try 
and do it, seemed to me a much more compassionate and humane 
way to deal with the issues of people in need of assistance.
    Senator Franken. Let me ask you about the Minnesota 
Hospital Association. Did the Minnesota Hospital Association 
oppose the safe patient handling bill that was enacted in 
Minnesota?
    Ms. Shogren. No. They testified they felt it was the right 
thing to do.
    Senator Franken. Well, I'm proud that Minnesota hospitals 
understand that worker safety is part and parcel of good 
patient care. And if we can succeed in Minnesota, in 
Washington--if this can be implemented within 3 years in 
Washington, I don't know why it would take decades in other 
States.
    So, thank you all for your testimony today.
    And thank you, Madam Chairwoman.
    Senator Murray. Well, thank you, again, to all of you.
    We're going to leave the committee record open for the next 
7 days for all committee members to be able to add their 
statements and to ask questions of all of our witnesses.
    And I personally want to thank all of you for taking time 
out of your lives to come and help us understand the 
implications of this.
    Senator Franken, thank you for your tremendous 
participation on this, as well.
    With that, this hearing is adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

Prepared Statement of David Michaels, PhD, MPH, Assistant Secretary of 
   Labor for the Occupational Safety and Health Administration (OSHA)
    Chair Murray, Ranking Member Isakson and members of the 
subcommittee, patient handling is an important issue that affects 
health care workers in the United States. Health care workers 
experience large numbers of work-related musculoskeletal disorders 
(MSDs) as a result of manually lifting, moving, assisting, and 
repositioning patients. An OSHA analysis of the latest Bureau of Labor 
Statistics data available showed more than 36,000 workers were injured 
lifting, repositioning and transferring patients in 2008. These are 
just the injuries that resulted in days away from work, the total is 
much higher and many injuries may not be reported. Almost all of the 
injured workers were nurses and nursing aides, and most were women. 
Disabling back injuries or the fear of being injured have contributed 
to the large number of nurses leaving the profession, thus increasing 
the nursing shortage. An estimated 12 percent to 18 percent of nursing 
personnel leave the profession annually due to chronic back pain, and 
another 12 percent consider a job transfer to reduce their risk of back 
injury.\1\
---------------------------------------------------------------------------
    \1\ Hal Wardell, ``Reduction of Injuries Associated with Patient 
Handling'' AAOHN Journal, October 2007, Volt. 55, No. 10, 407-412.
---------------------------------------------------------------------------
    Due to the seriousness of this problem, OSHA supports the efforts 
of the subcommittee to address this significant occupational safety and 
health issue. OSHA agrees with the statement provided by the National 
Institute for Occupational Safety and Health (NIOSH) regarding research 
on patient handling risk, and supports NIOSH's efforts to learn more 
about this problem and its solutions. But while more research is always 
welcome, there are well established and proven interventions that have 
been successful in preventing these injuries in health care 
establishments across the country.
    We acknowledge the advancements the U.S. Department of Veterans 
Affairs has made in this area, pulling in the experience of the VA 
Sunshine Healthcare Network (Veterans Integrated Service Network, VISN 
8) to implement safe patient handling procedures in VA clinics 
nationwide. Between 2001 and 2003, VISN 8 deployed a program that 
reduced patient manual-handling caregiver injuries and led to markedly 
increased employee and patient satisfaction. Based on these results, VA 
developed and funded a national program through a budget initiative in 
fiscal year 2007.
    Additionally, OSHA has a long history with this issue. In 2000, 
OSHA issued a comprehensive ergonomics standard that included health 
care workers. This standard was repealed by Congress and the President 
in 2001. In 2003, OSHA published ergonomic best practice guidelines for 
nursing homes. These guidelines recommend that manual lifting and 
transferring of patients should be minimized in all cases and 
eliminated when feasible. The guidelines also recommend that employers 
implement an effective ergonomics process that provides management 
support, involves employees, identifies problems, implements solutions, 
addresses reports of injuries, provides training, and evaluates 
ergonomics efforts.
    Many States have also recognized the seriousness of this problem, 
and eleven have successfully enacted safe patient handling laws. 
Several others are considering similar legislation. A study is 
currently underway in the State of Washington to evaluate the 
effectiveness of their legislation, and results may be available later 
this year. Health care employers covered by State laws, as well as 
employers who have voluntarily implemented safe patient handling 
programs, have successfully reduced injury rates to nurses and other 
health care providers. OSHA supports the subcommittee's efforts to 
provide the same protection to all health care workers.
    OSHA implemented a National Emphasis Program in September 2002 that 
focused on ergonomic hazards in nursing home facilities. We continue to 
investigate patient and resident handling incidents and have conducted 
4,109 ergonomics inspections in nursing homes. To address enforcement 
of ergonomic hazards, OSHA uses Section 5(a)(1) of the Occupational 
Safety and Health Act, commonly referred to as the General Duty Clause. 
Enforcement under the General Duty Clause poses many difficulties, as 
very stringent legal tests must be met to successfully support 
citations. Despite the size of the problem and OSHA's efforts to deal 
with it, the Agency has only been able to issue 12 General Duty Clause 
ergonomic citations to health care facilities in the last 8 years. The 
General Duty Clause does not provide an efficient means for dealing 
with these workplace hazards. However, OSHA has put numerous health 
care facilities on notice by issuing ergonomic hazard alert letters. 
These letters inform employers of potential ergonomic risk factors 
observed at their facility and provide recommendations on how to reduce 
the risk of these hazards.
    Thank you for the opportunity to comment on the issue of safe 
patient handling. OSHA applauds the subcommittee's efforts to shed 
light on this problem that affects too many of our Nation's healthcare 
workers.
                                 ______
                                 
                                              May 10, 2010.
Hon. Patty Murray,
Chair, Subcommittee on Employment and Workplace Safety,
Committee on Health, Education, Labor, and Pensions,
U.S. Senate,
Washington, DC 20510.
    Dear Madam Chairwoman: On behalf of the 1.6 million members of the 
American Federation of State, County and Municipal Employees (AFSCME), 
I request that the attached statement from AFSCME be included in the 
record for the May 11, 2010 hearing on Safe Patient Handling and 
Lifting Standards for a Safer American Workforce before the 
Subcommittee on Employment and Workplace Safety, of the Senate Health, 
Education, Labor, and Pensions Committee.
    We thank you for holding this important hearing.
            Sincerely,
                                       Charles M. Loveless,
                                           Director of Legislation.
                                 ______
                                 
  Prepared Statement of the American Federation of State, County and 
                      Municipal Employees (AFSCME)
    We submit this statement on behalf of the 1.6 million members of 
the American Federation of State, County and Municipal Employees 
(AFSCME) for the official record of the Hearing on Safe Patient 
Handling and Lifting Standards for a Safer American Workforce of the 
Employment and Workplace Safety Subcommittee of the Health, Education, 
Labor, and Pensions Committee.
    Approximately 360,000 AFSCME members work in our Nation's health 
care system to provide quality care for patients in hospitals, clinics, 
long-term care facilities, public health and other practice settings. 
These nurses, nursing aides, orderlies, attendants and other health 
care workers who lift or move patients as part of their jobs are at 
great risk of developing preventable musculoskeletal injuries and 
disorders. According to the U.S. Department of Labor, Bureau of Labor 
Statistics, nursing personnel are consistently listed as one of the top 
10 occupations for work-
related musculoskeletal disorders (for example, back pain, herniated 
discs, pulled or torn ligaments). In 2007, nursing staff ranked first 
in the incidence rate of such injuries--with a case rate of 252 cases 
per 10,000 workers, a rate seven times the national musculoskeletal 
average for all occupations. The nursing occupation also typically 
ranks in the top 10 in yearly incidence rate of sprain and strain 
injuries.
    In most industries the injury rates for musculoskeletal disorders 
have declined in recent years but for nurses in the healthcare industry 
the rates have not declined. Patient handling and movement tasks are 
physically demanding, often performed in less than ideal conditions and 
often are unpredictable in nature, placing healthcare workers at risk. 
Healthcare workers are at even higher risk for back and other injuries 
when they work in facilities with low staffing, lack lifting equipment 
in good repair and have a high proportion of dependent patients. In 
addition, the shortage of nurses, longer work hours, aging workforce 
and increased obesity rates of patients all contribute to risk of 
injury. There are adverse consequences to the worker and patient as a 
result of improper and unsafe handling. It is time for Congress to act 
to change industry patient handling practices that put workers at risk.
    For many years, employers have focused on outdated and ineffective 
techniques for patient handling based on ``proper'' body mechanics. 
There is strong evidence that these commonly used approaches are not 
effective in reducing worker injuries. There is a need for a specific 
national safety and health standard for this group of workers because 
patient handling is very different from lifting and moving other 
objects of the same weight. For example, weight can shift, and patients 
can resist movement and may even be combative. Accordingly, AFSCME 
urges the subcommittee to pass the Nurse and Health Care Worker 
Protection Act of 2009 (S. 1788) which would move healthcare employers 
away from ineffective approaches to evidence-based safe patient 
handling practices.
    The legislation would prompt a real paradigm shift based upon over 
three decades of research to support interventions that are effective 
in reducing musculoskeletal pain and injuries in healthcare workers who 
lift and handle patients. Under the legislation the U.S. Department of 
Labor's Occupational Safety and Health Administration (OSHA) would 
issue a standard on safe patient handling and injury prevention that 
requires the use of lift equipment to move patients except in cases 
which would compromise patient care. It would also require healthcare 
facilities to implement safe patient handling and injury prevention 
plans. Healthcare workers would receive training on safe patient 
handling and injury prevention. In addition, healthcare workers would 
be protected from employer retaliation if they refused to accept 
assignments which do not meet safety standards.
    For the foregoing reasons, AFSCME urges the subcommittee to pass 
the Nurse and Health Care Worker Protection Act of 2009.
   Prepared Statement of the American Industrial Hygiene Association 
                                 (AIHA)
                safe handling of patients and residents
    It is the position of the American Industrial Hygiene Association 
(AIHA) that:

    1. The proper implementation of legislation can help to reduce the 
presence of the risk factors associated with musculoskeletal disorders, 
including work-related musculoskeletal disorders (WMSD), arising from 
the manual handling of patients and residents. Some of the critical 
components of legislation to address this exposure:

     AIHA believes that management systems are the best/
recommended approach to hazard identification, risk assessment, and 
risk mitigation. As such, AIHA recommends that hospitals, nursing 
homes, and other health care facilities have a written safe patient 
handling policy or related policy incorporating all the necessary 
elements of a management system, such as elements in the AIHA/ANSI Z10-
2005, Occupational Health and Safety Management Systems.
     The need for occupational providers of these services to 
have a patient handling committee or sub-committee. The committee 
should have representation from, but not be limited to, administration, 
education, unit management, nurses, nurses aides, maintenance, 
housekeeping, techs, and transport.
     The policy needs to address patient handling hazard 
assessment, task type and frequency, patient dependency levels, 
environmental restrictions, enhanced use of mechanical devices, 
incorporating space and construction design for mechanical lifting 
devices into job design and architectural plans, details for assuring 
proper equipment maintenance, storage and availability, training 
programs, responsibility and accountability systems for both management 
and associates.
     The policy needs to address how to evaluate the 
effectiveness of the program. Activity, outcomes and compliance 
measures should be in place to evaluate success.
     The policy should address methods of sustainability and 
enhancement of the program as new technology and/or additional 
resources becomes available.
     While there is significant ergonomic risk associated with 
handling residents in home health care, there is currently a lack of 
knowledge regarding how to properly control this exposure. Research 
should be funded and other efforts undertaken to fill this knowledge 
gap.

    2. There is a significant need to improve safe patient and resident 
handling with the resultant positive outcomes to include:

     The reduction of musculoskeletal disorder development and 
their resulting costs.
     Improved caregiver efficiencies and productivity. Reduces 
non-value added task for caregivers thereby freeing them up to spend 
more time on patient care.
     Reduction in the physical demand required to provide this 
care.
     With the ever increasing concern due to nursing shortages, 
improving caregiver safety will help reduce the loss of human assets as 
well as reduce turnover, recruitment and training costs. Improvement in 
the desirability of providing this care, thereby increasing the 
population willing to enter and remain in the health care profession.
     With the use of lifting devices and progressive mobility 
models for patients, caregivers can reduce the number and severity of 
pressure ulcers and wounds, decrease the number of patient falls, and 
enhance lung function and circulation, thereby improving the clinical 
outcomes for patients and residents and provide a greater quality of 
care. This will lead to a reduction in length of stays and related 
healthcare costs.

    3. There is a significant body of scientific evidence (as a start, 
see the references that follow) demonstrating that effective ergonomics 
programs applied to patient and resident handling will result in the 
positive outcomes mentioned above.
    4. The funding of research into improving home health care 
ergonomics, including the increase of the availability and quality of 
resident handling equipment, should help lead to:

     Reduction in home health care worker WMSD.
     Reduction in the need to have family members sent to 
nursing homes or hospitals to receive care.
     Reduction in the overall healthcare cost during the period 
when care can be provided at home.
     Maintaining a stronger family unit during the period when 
care can be provided at home.
                               References
    Waters, Thomas R. ``4th Annual Safe Patient Handling & Movement 
Conference Speech: State of the Science in Ergonomics,'' Online Journal 
of Issues in Nursing. Volume 10, No. 2, 2007. Available: 
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/KeynotesofNote/Speech.aspx.
    Nelson, Audrey L., et al. ``Effectiveness of an Evidence-Based 
Curriculum Module in Nursing School Targeting Safe Patient Handling and 
Movement,'' International Journal of Nursing, Volume 4, Issue 1, 2007.
    Nelson, Audrey L., et al. ``Link Between Safe Patient Handling and 
Patient Outcomes in Long-Term Care,'' Rehabilitation Nursing, Volume 
33, No. 1, January/February 2008.
    Waters, Thomas R. ``When is it Safe to Manually Lift a Patient?'' 
American Journal of Nursing (AJN), Volume 107, No. 8, August 2007.
    Menzel, Nancy N. ``Preventing Musculoskeletal Disorders in Nurses: 
A Safe Patient Handling Curriculum Module for Nursing Schools,'' Nurse 
Educator, Volume 32, No. 3, May/June 2007.
    Waters, Thomas R. ``Patient Handling Tasks with High Risk for 
Musculoskeletal Disorders in Critical Care,'' Critical Care Nursing 
Clinics of North America, Volume 19, 2007.
                                 ______
                                 
                                              May 10, 2010.
Hon. Patty Murray, Chairwoman,
Subcommittee on Employment and Workplace Safety,
Committee on Health, Education, Labor, and Pensions,
143 Hart Senate Office Building,
Washington, DC 20510.
    Dear Chairwoman Murray: On behalf of the American Nurses 
Association (ANA), we request the opportunity to submit testimony for 
the hearing record regarding the Subcommittee on Employment and 
Workplace Safety's hearing on Safe Patient Handling & Lifting Standards 
for a Safer American Workforce. ANA is the only full-service 
professional association representing the interests of the Nation's 3.1 
million registered nurses (RNs) through its constituent member nurses 
associations, its organizational affiliates, and its workforce advocacy 
affiliate, the Center for American Nurses.
    For more than a decade, the American Nurses Association has been 
leading the fight on behalf of registered nurses, health care workers 
and patients to eliminate manual patient handling. The Nation--now 
facing a serious nursing shortage--can no longer afford to lose the 
nurses who leave the profession annually due to musculoskeletal 
injuries and pain.
    ANA greatly appreciates your consideration of this request. Thank 
you again, and please feel free to contact me at (301) 628-5098 or at 
the e-mail address: [email protected] if you have additional 
questions.
            Sincerely,
                                    Rose Gonzalez, MPS, RN,
                                      Director, Government Affairs.
                                 ______
                                 
      Prepared Statement of the American Nurses Association (ANA)
    The American Nurses Association (ANA), the largest nursing 
organization in the country, is pleased to submit our statement for the 
record to the Subcommittee on Employment and Workplace Safety's hearing 
on the Safe Patient Handling & Lifting Standards for a Safer American 
Workforce.
    Founded in 1896, ANA is the only full-service professional 
association representing the interests of the Nation's 3.1 million 
registered nurses (RNs) through its constituent member nurses 
associations, its organizational affiliates, and its workforce advocacy 
affiliate, the Center for American Nurses. The ANA advances the nursing 
profession by fostering high standards of nursing practice, promoting 
the rights of nurses in the workplace, projecting a positive and 
realistic view of nursing, and by lobbying the Congress and regulatory 
agencies on health care issues affecting nurses and the public.
    The ANA prides itself on our long history as patient advocates. 
Patient advocacy has always been at the core of nursing and ANA takes 
that responsibility very seriously. We believe that it is possible to 
care for our patients without jeopardizing our own safety and health--
and that of our patients. For almost two decades, the American Nurses 
Association (ANA) has been leading the fight on behalf of registered 
nurses, health care workers and patients to eliminate manual patient 
handling. This issue is at the heart of our members day-to-day lives. 
Moreover, it affects the lives of dedicated support staff including 
nurses' aides, patient care assistants and health care technicians who 
work alongside the registered nurse to provide competent, compassionate 
care to patients. A Safe Patient Handling program decreases injury to 
nurses, other health care workers and patients, while reducing work-
related health care costs and improving the safety of patient care 
delivery.
    The Nation--now facing a serious nursing shortage--can no longer 
afford to lose the nurses who leave the profession annually due to 
musculoskeletal injuries and pain. The extent of musculoskeletal 
disorders among the U.S. nursing workforce is particularly distressing. 
It is estimated that greater than 52 percent of the nursing workforce 
suffers from chronic back pain. Injuries and pain secondary to patient 
handling tasks exacerbate the shortage and are of particular concern 
with the aging of the nursing workforce. Although the Occupational 
Safety and Health Act (OSHA, 1970) requires employers to maintain 
records of serious workplace injuries and illnesses (29 U.S.C. section 
657c(2)), these statistics may not capture episodic and remitting 
musculoskeletal injuries. Because this type of injury is largely a 
result of cumulative physical insult over time, they often go 
underreported, so the reported data is likely just the tip of the 
iceberg.
    In spite of the statistics and OSHA recommendations, ``no lift'' 
policy initiatives in other nations such as the United Kingdom and 
Australia have been slow to be accepted in the United States. In 2003, 
the ANA Handle with Care program was developed to support safer 
practices with regards to patient handling. Approaches to addressing 
this issue include recommended changes in nursing school curriculum as 
well as legislation.
    ANA's policy is supported by a 2003 Institute of Medicine report 
entitled Keeping Patients Safe: Transforming the Environment for Nurses 
which describes the nurses work environment as a potential threat to 
their safety as well as that of patients. As a result, legislation in a 
number of States focusing on nurses working conditions has been 
advanced. An example is requiring the creation of safe patient handling 
programs with ``no manual lift'' policies.
    Although progress to address patient handling has been made as 
evidenced by changes in nursing schools' curriculums and continued 
activity within the State legislatures, initiatives are too few and too 
limited in scope, and injuries continue to occur. Legislation is needed 
at the Federal level. ANA strongly supports, and is actively working to 
enact The Nurse and Health Care Worker Protection Act of 2009 (H.R. 
2381/S. 1788). This legislation would help improve patient safety and 
protect registered nurses and other health care workers from 
debilitating injuries that could force them from their professions. ANA 
strongly urges Congress to enact The Nurse and Health Care Worker Act 
of 2009 (H.R. 2381/S. 1788).
    Safe Patient Handling Programs Are Important . . . For Registered 
Nurses, Health Care Workers . . . and Patients!
    A Safe Patient Handling (SPH) program decreases injury to nurses, 
other health care workers and patients, while reducing work-related 
health care costs and improving the safety of patient care delivery. 
The performance of tasks such as lifting, repositioning and 
transferring patients exposes nurses and other health care personnel to 
increased risk for work-related musculoskeletal disorders. With the 
development of assistive equipment and devices, such as lifting 
equipment and lateral transfer and friction reducing devices, the risk 
of musculoskeletal injury can be eliminated or significantly reduced.
    According to the Bureau of Labor Statistics, nursing aides, 
orderlies, and attendants reported the highest incidence rate of 
musculoskeletal disorders (MSD) requiring days away from work in 2006 
(BLS, 2007). This group was ranked second in overall musculoskeletal 
disorders requiring days away from work, with Registered Nurses ranked 
fifth.\1\
---------------------------------------------------------------------------
    \1\ Bureau of Labor Statistics (BLS). (2007). Nonfatal occupational 
illness and injuries causing days away from work, 2006. U.S. Department 
of Labor NEWS. USDL 07-1741. http://www.bls.gov/iif/oshwc/osh/case/
osnr0029.pdf.
---------------------------------------------------------------------------
    Healthcare workers are over represented for upper extremity MSD 
among worker's compensation claims. Injured nurses contribute to about 
one-fourth of all claims and one-third of total compensation costs. 
More than one-third of back injuries among nurses have been associated 
with the handling of patients and the frequency with which nurses are 
required to move them.
    The extent of musculoskeletal disorders among the U.S. nursing 
workforce is particularly distressing when considered in the context of 
the current nursing shortage. The Nation--now facing a serious nursing 
shortage--can no longer afford to lose the nurses who leave the 
profession annually due to musculoskeletal injuries and pain. Injuries 
secondary to patient handling and movement tasks compound factors 
driving the nursing shortage.
    An ANA Health and Safety Survey revealed that 88 percent of nurses 
reported that health and safety concerns influence their decision to 
remain in nursing and the kind of nursing work they choose to perform. 
More than 70 percent said the acute and chronic effects of stress and 
overwork were among their top three health concerns, with more than 
two-thirds reporting they work some type of mandatory overtime every 
month. In addition, nurses cited a disabling back injury (60 percent), 
followed by contracting HIV or hepatitis from a needlestick injury (45 
percent) as also being among their top three health and safety 
concerns. The survey further revealed that fewer than 20 percent of 
respondents felt safe in their current work environment.\2\
---------------------------------------------------------------------------
    \2\ ANA Health & Safety Survey, Sept. 7, 2001. See 
www.nursingworld.org/surveys/hssurvey.htm for details.
---------------------------------------------------------------------------
    Safe patient movement and handling benefits patients as well. The 
potential for patient injury (such as falls and skin tears) as a 
consequence of a manual handling mishap is reduced by using assistive 
equipment and devices. Equipment and devices provide a more secure 
process for lifting, transferring or repositioning patients.
     Studies have shown that the use of mechanical lifting 
equipment increases a resident's comfort and feelings of security when 
compared to manual methods.\3\
---------------------------------------------------------------------------
    \3\ Zhuang Z, et al. (2000). Psychophysical assessment of assistive 
devices for transferring patients/residents. Applied Ergonomics. 31(1), 
35-44.
---------------------------------------------------------------------------
     Patient handing technology encourages the safe movement 
and repositioning of patients, which is required to avoid pressure 
ulcers (bed sores). Years of research point to the effectiveness of 
patient turning and repositioning as the primary means to avoid 
pressure ulcers.\4\
---------------------------------------------------------------------------
    \4\ Thomas, David. (2001). Prevention and treatment of pressure 
ulcers: What works? What doesn't? Cleveland Clinic Journal of Medicine. 
(68) 8. August. http://www.ccjm.org/pdffiles/Thomas801.pdf.
---------------------------------------------------------------------------
     The National Institute for Occupational Safety and Health 
(NIOSH) reports that manual lifting is associated with undesirable 
outcomes for patients, including: Decreased quality of care . . . 
Diminished resident safety and comfort . . . Decreased resident 
satisfaction . . . Higher risks of falls, or of being dropped, friction 
burns, and dislocated shoulders . . . Skin tears and bruises.\5\
---------------------------------------------------------------------------
    \5\ National Institute for Occupational Safety and Health (NIOSH). 
(2006). Safe Lifting and Movement of Nursing Home Residents. DHHS 
(NIOSH) Publication No. 2006-117. http://www.cdc.gov/niosh/docs/2006-
117/pdfs/2006-117.pdf.

    Most importantly, patients are afforded a safer means to progress 
through their care, have less anxiety, are more comfortable and 
maintain their dignity and privacy. Assistive patient-handling 
equipment can be selected to match a patient's ability to assist in his 
or her own movement, thereby promoting patient autonomy and 
rehabilitation.
           safe patient handling programs pay for themselves
    ANA strongly believes that enactment of the Nurses and Health Care 
Worker Protection Act of 2009 (H.R. 2381/S. 1788) will not only save 
the health and careers of registered nurses and other health care 
workers, but that it will also inevitably reduce costs for health care 
facilities. In essence, a business case can be made for implementing a 
safe patient handling program.

     Initial investment in both lifting equipment and employee 
training can be recovered in 2 to 3 years through reductions in 
workers' compensation costs.\6\
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    \6\ Collins et al., 2004; Tiesman et al., 2003; Nelson et al., 
2003; Garg, 1999.
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     Research has shown that resident lifting programs reduce 
workers' compensation injury rates by 61 percent, lost workday injury 
rates by 66 percent, restricted workdays by 38 percent, and the number 
of workers suffering from repeated injuries.\7\
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    \7\ Collins J.W., et al. 2004. An evaluation of a ``best 
practices'' musculoskeletal injury prevention program in nursing homes. 
Injury prevention. Injury Prevention (10) 206-211.
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     SPHM programs are cost-effective due to reductions in 
workers' compensation claims, costs associated with absenteeism, and 
turnover.\8\
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    \8\ Bureau of Labor Statistics (BLS). (2007). Nonfatal occupational 
illness and injuries causing days away from work, 2006. U.S. Department 
of Labor NEWS. USDL 07-1741. http://www.bls.gov/iif/oshwc/osh/case/
osnr0029.pdf.
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     It was estimated the Veterans Health Administration (VHA) 
spent approximately $22 million a year on health care worker injuries 
associated with patient movement. After initiating safe patient lifting 
programs in 23 units as part of an observation study, it was 
demonstrated that the VHA was able to recoup all of the direct and 
indirect costs associated with the safe lifting program in 4.3 years. 
The savings occur through significant reductions in workers 
compensation payments and avoidance of costs associated with caregiver 
absenteeism.\9\
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    \9\ Siddarthan, K., Nelson, A., Tiesman, H., & Chen, F. (2007). 
Cost effectiveness of a multifaceted program for safe patient handling. 
Advances in Patient Safety, 3(1):347-358.
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     The Centers for Disease Control and Prevention (CDC) 
recently released the results of a 6-year field study of a safe patient 
lifting program. This study showed that the investment in equipment and 
training was recouped in less than 3 years in lower worker compensation 
claims.\10\
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    \10\ NIOSH (2007). The NIOSH Traumatic Injury and Prevention 
Program Evidence Package. March, 2007. http://www.cdc.gov/niosh/nas/
traumainj/pdfs/TIchapter5NAS03-07.pdf.

    While the evidence shows that manual patient handling is a high-
hazard task, with high incidence rates of musculoskeletal disorders for 
nurses and other personnel, employers remain reluctant to institute 
safe patient handling programs regardless of the data that demonstrates 
a strong return on investment for registered nurses, health care 
workers and patients.
 the nurse and health care worker protection act of 2009 (h.r. 2381/s. 
                                 1788)
    The American Nurses Association strongly supports the Nurse and 
Health Care Worker Protection Act of 2009 (H.R. 2381/S. 1788). This 
bill would require OSHA to develop and implement a standard that will 
eliminate manual lifting of patients by direct-care registered nurses 
and other health care workers. The legislation will also require health 
care facilities to develop a plan to comply with the standard (with 
input from RNs), provides protection for RNs through refusal of 
assignment and whistle blower provisions, and requires the Secretary to 
perform audits.
    The Nurse and Health Care Worker Protection Act of 2009 will 
address some of the issues previously noted by decreasing injuries 
sustained by registered nurses, health care workers, and patients. It 
will also improve the safety of patient care delivery while reducing 
work-related health care costs.
                               conclusion
    We applaud the subcommittee's foresight in acknowledging the issue 
of manual lifting, transferring and repositioning patients as a 
continued hazard for nurses, health care workers and patients. As we 
expand access to health care services, ANA believes that the enactment 
of H.R. 2381/S. 1788 will reduce the number of injuries incurred by 
registered nurses, health care workers and patients. H.R. 2381/S. 1788 
will also serve to decrease patient anxiety and improve the overall 
quality of care. Again, the ANA is pleased to submit our statement for 
the record and will work with Congress to secure enactment of The Nurse 
and Health Care Worker Act of 2009 (H.R. 2381/S. 1788). Thank you.
       Response by Captain Collins to Questions of Senator Hagan 
                          and Senator Isakson
                             senator hagan
    Question 1. In your testimony, you indicated that ``direct and 
indirect costs associated with back injuries in the health care 
industry, adjusted for inflation, are estimated to be $7.4 billion 
annually in 2008 dollars.'' My question to you is: can you elaborate 
more on what the cost trajectory has been over the years and what the 
future may hold, for costs associated with back injuries in the health 
care industry?
    Answer 1. We expect future costs associated with back injuries in 
health care to increase due to demographic trends, economic factors, 
and management strategies that continue to change. These are described 
in the bullets below. Note that costs mentioned below refer to workers' 
compensation costs only, that are a portion of the true occupational 
safety and health costs to workers, employers, and society overall.
    There is evidence that occupational back injuries result in 
additional health care costs, over and above the medical costs covered 
through worker's compensation. For example, Lipscomb et al. (2009) \1\ 
examined private health insurance payments for back diagnoses among a 
15-year cohort of 18,768 carpenters who worked in the State of 
Washington during 1989-2003. They found that private health insurance 
payment rates for workers with one work-related injury were 40 percent 
higher than those with no history of work injury, while payment rates 
for those with four or more work-related injuries were almost three 
times the payment rate for those with no prior work injury. After the 
first work-related back injury claim, medical costs for back disorders 
covered by private health insurance increased 19 percent in the first 
year, and 30 percent for each year thereafter. Increasing private 
payments and deductibles were observed in contrast with a decline in 
reported work-related injuries. The authors concluded that their 
findings suggest cost-shifting from workers' compensation to the union-
provided health insurance and to the worker.
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    \1\ Lipscomb HJ, Dement JM, Silverstein B, Cameron W, Glazner JE. 
2009. Who is paying the bills? Health care costs for musculoskeletal 
back disorders, Washington State union carpenters, 1989-2003. JOEM 
51(10):1185-1192.
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    In addition, there is evidence that workers suffering from back 
injuries are more likely to suffer from additional health conditions. 
For example, Nimgade et al. (2010) \2\ analyzed health claims during 
December 1998 to March 2004 in a community-based health maintenance 
organization in Massachusetts that serves more than 200,000 clients. 
They reviewed healthcare expenditures in a random sample of 655 
patients with new onset low back pain in 1999. A total of 6.5 percent 
of these patients had their low back pain services covered by worker's 
compensation, and 18 percent had received worker's compensation health 
coverage at some point during 1999 to 2004. No significant difference 
existed between the population and the study sample with respect to 
age, gender, worker's compensation status, or distribution of low back 
pain diagnostic criteria. The authors concluded that the traditional 
estimates of low back pain, that are based primarily on low back pain 
services, underestimate the true cost of the condition that would 
include physical or mental co-morbidities.
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    \2\ Nimgade A, McNeely E, Milton D, Celona J. 2010. Increased 
expenditures for other health conditions after an incident of low back 
pain. Spine 35(7): 769-777.
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    Aging patients and workers: \3\
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    \3\ Restrepo T, Shuford H, De A. 2007. An Emerging Issue for 
Workers Compensation--Aging Baby Boomers and a Growing Long-Term Care 
Industry. National Council on Compensation Insurance Research Brief: 
https://www.ncci.com/documents/research-baby-boomer-fall07.pdf.

     The share of low back injuries for direct care workers in 
long-term care settings (including nursing homes, residential care, and 
home healthcare) is almost twice that for workers in all other 
industries (23 percent vs. 12 percent). The proportion of strains due 
to lifting in long-term care settings is approximately twice that for 
workers in all other industries, (41 percent for long-term care 
settings and 25 percent for all other).
      Total workers' compensation losses per worker are higher 
than average and employment is growing faster than average in the long-
term care settings. Strains due to lifting were the top cause of all 
workers' compensation injuries.
      Incidence rates with days away from work are above 
average in all long-term care settings.
      The rapidly aging population will likely cause the number 
of long-term care settings to grow faster than average.

    Obese patients and workers: \4\
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    \4\ NCCI. Winter 2009. Gauging Current Conditions: The Economic 
Outlook and Its Impact on Workers Compensation. National Council on 
Compensation Insurance Research Newsletter: https://www.ncci.com/
documents/GaugingtheEconomy-Winter2009.pdf.

      The number of workers' compensation claims and total 
medical payments are higher for claims by obese claimants.
      Obesity increases the risk for other injuries and 
illnesses.
      In the United States, the prevalence of obesity measured 
by body mass index (BMI) over 30 has increased by more than two since 
1990, and continues to increase.

    Employment trends in healthcare: \5\
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    \5\ Bureau of Labor Statistics, U.S. Department of Labor, Career 
Guide to Industries, 2010-11 Edition, Healthcare, on the Internet at 
http://www.bls.gov/oco/cg/cgs035.htm (visited June 17, 2010).

      Wage and salary employment in the healthcare industry is 
projected to increase 22 percent through 2018, compared to 11 percent 
for all industries combined.
      Employment growth is expected to account for about 22 
percent of all wage and salary jobs added to the economy over the 2008-
18 period.
      Projected rates of employment growth for the various 
segments of the industry range from 10 percent in hospitals, the 
largest and slowest growing industry segment, to 46 percent in the much 
smaller home healthcare services.

    Employment in healthcare will continue to grow due to many 
contributing factors: \5\

      The proportion of the population in older age groups will 
grow faster than the total population between 2008 and 2018.
      Older persons have a higher incidence of injury and 
illness and often take longer to heal from maladies--as a result, 
demand for healthcare services will increase, especially in employment 
settings specializing in geriatric care.
      Employment in home healthcare and nursing and residential 
care settings should increase rapidly as life expectancies rise, and 
families are less able to care for their elder family members and rely 
more on long-term care facilities.

    Severely ill patients will live longer: \5\

      Advances in medical technology will continue to improve 
the survival rate of severely ill and injured patients, who will then 
need extensive therapy and care.
      New technologies will continue to enable earlier 
diagnoses of many diseases which often increase the ability to treat 
conditions that were previously not treatable.

    Employment changes across worksites: \5\

      Because of cost pressures, healthcare facilities may 
reduce their staff to reduce labor costs, distributing the same amount 
of work over fewer healthcare workers.
      Where patient care demands and regulations allow, 
healthcare facilities will substitute lower paid providers and will 
cross-train their workforces.
      Traditional inpatient hospital positions are no longer 
the only option for many future healthcare workers; persons seeking a 
career in the field must be willing to work in various employment 
settings.
      Hospitals will be the slowest growing segment within the 
healthcare industry because of efforts to control hospital costs, 
shorten lengths of hospital stays, and increase the use of outpatient 
clinics and other alternative care sites.

    Question 2. In your testimony, you make reference to the aging 
nursing population and that, ``this aging trend has raised concerns 
that future retirements could substantially reduce the size of the U.S. 
nurse workforce.'' I am fully aware of the alarming nursing shortage we 
have across the Nation and in North Carolina. North Carolina's nursing 
shortage ranks 19th highest in the Nation. My State nurse shortage is 
already over 8,000 and only projected to get worse. My question to you 
is: what impact would safe patient handling and lifting standards have 
on the current nursing workforce and the new generation of nurses?
    Answer 2. Safe patient handling and lifting standards would reduce 
injuries in current and future nurses and potentially keep them from 
leaving the field due to back injuries. Our data has shown that 
mechanical assisted lifting, when used within a safe lifting program, 
reduces the number of injuries in nurses. It has been estimated that 
approximately 12 percent of nurses who planned to leave the profession 
cited back injuries as a contributing factor for leaving the 
profession. This statistic does not include the nurses who have 
sustained permanently disabling work-related injuries and are unable to 
return to work.
                            senator isakson
    Question 1. Legislation before this committee, S. 1788, would 
``require the use of engineering controls to perform lifting, 
transferring, and repositioning of patients and the elimination of 
manual lifting of patients by direct-care registered nurses and all 
other health care workers, through the use of mechanical devices to the 
greatest degree feasible except where the use of safe patient handling 
practices can be demonstrated to compromise patient care.'' The 
standard would apply to all health care facilities including, but not 
limited to, out-patient centers, rehabilitation facilities, skilled 
nursing facilities, nursing homes, and home health care. How would such 
a rigid standard be flexible enough to account for the myriad of 
patient treatments at a wide range of facilities?
    Answer 1. The proposed standard appears to be flexible enough to 
accommodate a variety of healthcare needs. There are several different 
types of mechanical lifts available to assist patients with mobility 
restrictions. The type of equipment prescribed for a particular patient 
depends on the healthcare setting, the nature of the transfer task, the 
patient's ability to bear weight, the patient's weight, the 
cooperativeness of the patient, the patient's upper body strength, the 
patient's overall ability to assist with the transfer, and the needs of 
the patient. The fundamental principle of any safe patient handling and 
movement program, regardless of the type of facility, is the use of 
mechanical lifting equipment to eliminate the manual lifting of 
patients by healthcare workers.

    Question 2. Would a health care facility in minimal compliance with 
Minnesota's standard need to make additional alterations to meet the 
new standard imagined by S. 1788?
    Answer 2. No, if the pending Federal legislation were enacted, 
facilities in Minnesota that are meeting the minimal requirements of 
the existing Minnesota State law should already be in compliance with 
the standards proposed by S. 1788.

    Question 3. How many years do you think it would take every health 
care facility in Minnesota to reach the new standard imagined by S. 
1788?
    Answer 3. If the pending Federal legislation were enacted, 
facilities in Minnesota that are meeting the minimal requirements of 
the existing Minnesota State law should already be in compliance with 
the standards proposed by S. 1788.

    Question 4. How much do you think health care facilities in 
Minnesota would have to spend to implement every aspect of S. 1788?
    Answer 4. Healthcare facilities in Minnesota that are in compliance 
with the Minnesota State law should not have to spend any additional 
money to be in compliance with the Federal law. Further, research has 
shown that the initial capital investment in lifting equipment and 
worker training is recovered based on savings in workers' compensation 
expenses in 3 to 5 years.

    Question 5. Similarly, would a health care facility in minimal 
compliance with Washington State's standard need to make additional 
alterations to meet the new standard imagined by S. 1788?
    How many years do you think it would take every health care 
facility in Washington to reach the new standard imagined by S. 1788? 
How much do you think health care facilities in Washington would have 
to spend to implement every aspect of S. 1788?
    Answer 5. The law in Washington State applies only to hospitals. 
Thus, other healthcare facilities would need alterations to meet the 
standard proposed in S. 1788. NIOSH is not in a position to assess how 
long it would take every healthcare facility in Washington to reach the 
standard proposed by S. 1788 or how much healthcare facilities would 
have to spend to comply with such a standard.

    Question 6. Does any State in the union proscribe manual lifts of 
patients? Does any State require the use of engineering controls to 
perform lifting, transferring, and repositioning of all patients?
    Answer 6. No State proscribes manual lifting; however, Illinois, 
Maryland, Minnesota, New Jersey, Rhode Island, Texas and Washington 
have enacted laws (citations provided below) to restrict/ reduce manual 
lifting of patients by requiring engineering controls with exceptions 
to certain circumstances.

    Illinois: 210 ILL. COMP. STAT. ANN. 85/6.25.
    Maryland: MD. CODE ANN., Health 19-377.
    Minnesota: MINN. STAT. ANN. 182.6553.
    New Jersey: NJ. STAT. ANN. 26:2H-14.8-14.14.
    Rhode Island: R.I. GEN. LAWS 23-17-59.
    Texas: TEX. CODE ANN. HEALTH & SAFETY 256.002.
    Washington: WASH. REV. CODE ANN. 70.41.390 AND 72.23.390.
  Response to Questions of Senator Hagan by Michael Hodgson, M.D., MPH
    Question 1. In your testimony, you discussed how the VA system has 
implemented safe patient handling and lifting policies. I welcome the 
idea that these policies promote a culture of safety and provide an 
environment for safe patient handling for patients and staff, in 
addition to lowering costs. My question to you is: What have you 
experienced working with the lifting equipment and the need for 
maintenance and replacement? At what frequency does lifting equipment 
need to be replaced?
    Answer 1. Clearly, effective maintenance programs and plans are an 
essential element if the safe patient handling initiative is to be 
successful. These maintenance programs require input both from patient 
care staff (nursing and infection control), and engineering staff 
(biomedical engineering or other engineering departments). These 
programs should include planning for slings, electrical and electronic 
equipment maintenance, and repairs. Backup plans when equipment is not 
functional or in repair are also important.
    There are no formal data on replacement frequency, as of yet. Our 
assumptions have been that the program likely needs to be refreshed at 
least every 10 years because technology ages. In general, this type of 
equipment has two major components to consider. The rail system, 
following normal standards, is designed for infinite life or at least a 
20-year minimum. Only failures to maintain the system connections, or 
overload of the system connections, will generally result in an earlier 
life termination. The second is the lift unit. It too, if properly 
maintained, would last mechanically for at least 10 years. Overload, 
battery death, or preventive maintenance failures would shorten the 
life. The major wear points are the lift belt/strap/cable/chain and the 
batteries/hand controls/power supply wipers/brushes. VA assumes the 
need for new batteries every 3 years, at a maximum, and new belts every 
year for a normally used unit, with 7-10 lifts per day. Preventive 
maintenance always follows the manufacturer's recommendations, or will 
be more frequent as needed.
    On the other hand, new technology is developed every year, and some 
of that is very useful in preventing injuries. For example, VA's 
program, designed in 2006, was based on publications from 2006 and 
earlier. As a result, since that time VA's national program has 
evolved. Additional benefits have been recognized, including reductions 
in skin problems (ulcers) and other improved patient care outcomes.

    Question 2. Furthermore, would health facilities benefit from 
budgeting for maintenance and replacement expenses versus budgeting for 
unpredictable expenses due to injuries?
    Answer 2. Yes. This benefit has been used to justify the 
implementation of safe patient handling programs.

    [Whereupon, at 3:54 p.m., the hearing was adjourned.]

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