• San Francisco General Hospital Department of Nursing had 459 workers compensation claims in FY 2001-2002, resulting in costs to the City of $1,423,399. Additionally, we estimate that San Francisco General Hospital spends approximately $306,000 to $460,000 annually to replace injured workers who provide direct patient care, resulting in total estimated costs to the City of $1.73 million to $1.88 million annually.
  
  
• The number of new work related injuries each year among nursing staff increased between FY 1997-1998 and FY 2000-2001, from 97 to 218, or 124.7 percent. In FY 1997-1998, 36 of the 97 nursing staff lost days from work and in FY 2000-2001, 41 of the 218 nursing staff lost days from work.
  
  
• The average number of lost workdays for work related injuries for registered nurses nationwide, as reported by the Federal Department of Labor, was 28.7 days. Therefore, the 37.92 average number of lost workdays for San Francisco General Hospital registered nurses was 9.22 days or over 32 percent more than the national average. Similarly, in FY 2000-2001, the average number of lost workdays for work related injuries for licensed vocational nurses and certified nursing assistants exceeded the national average by over 15.6 percent and by over 33 percent respectively.
  
  
• San Francisco General Hospital has implemented injury reduction programs that incorporate specific measures identified by the National Institute of Occupational Safety and Health to reduce back injuries among healthcare workers. The Hospital has purchased assist devices and other equipment to assist staff in patient mobility, and implemented a patient transfer team in 1997 to assist with patient lifting and train staff in lifting techniques.
  
  
• San Francisco General Hospital does not have an ongoing, structured back training program. The Hospital should implement annual mandatory back training classes, conducted by a physical therapist, for all clinical units.

Workers Compensation Claims among Nursing Staff

Increasing Number of Reported Work Place Injuries

San Francisco General Hospital is facing increased costs from work-related injuries among nursing staff. The number of new work-related injuries reported by nursing staff increased from FY 1997-1998 through FY 2000-2001. The number of new work-related injuries resulting in time lost from work decreased from FY 1997-1998 through FY 1999-2000 but increased again in FY 2000-2001, as noted in Table 16.1.

Table 16.1

Total Reported New Injuries for San Francisco General Hospital Department of Nursing, Number of Claims Resulting in Lost Workdays, and Total Number of Lost Workdays
FY 1997-1998 through FY 2000-2001

Source: Department of Public Health Occupational Safety and Health Section

The average number of lost workdays due to work related injuries for registered nurses, licensed vocational nurses, and certified nursing assistants often exceeded the national average. The average number of lost workdays varied from year to year, although in the most recent year reported (FY 2000-2001) the average number of lost workdays exceeded the national benchmark for all position classifications.

The average number of lost workdays for registered nurses in FY 2000-2001 were 37.92 days, compared to a national benchmark for registered nurses of 28.7 days, reported by the United States Department of Labor. The average number of lost workdays for licensed vocational nurses in FY 2000-2001 were 30.0 days, compared to a national benchmark of 11.7 days, and for certified nursing assistants were 124.50 days, compared to a national benchmark of 93.1 days.

Table 16.2

The Average Number of Lost Workdays for San Francisco General Hospital Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assistants, Compared to the Department of Labor Benchmark
FY 1997-1998 through FY 2000-2001

Source: San Francisco General Hospital and United States Department of Labor

Direct Expenditures for Workers Compensation Claims

Table 16.1 shows the number of new San Francisco General Hospital Department of Nursing workers compensation claims that were filed in each fiscal year, from FY 1997-1998 through FY 2000-2001. Because active workers compensation claims and resulting expenditures are carried over from prior years, the number of active claims and expenditures accumulate from year to year. Table 16.3 shows the number of active Department of Nursing workers compensation claims in FY 1998-1999 through FY 2001-2002 and the corresponding expenditures. Expenditures for active Department of Nursing workers compensation claims have ranged from $906,786 in FY 1998-1999 to $1,423,399 in FY 2001-2002.

Expenditures represent total direct expenditures for all active claims, including total temporary disability and permanent disability payments, medical costs, and vocational rehabilitation costs.

Table 16.3

Department of Nursing Workers Compensation Claims and Expenditures from
FY 1998-1999 through FY 2001-2002

Source: San Francisco General Hospital

San Francisco General Hospital is unable to identify costs for replacing injured workers because the payroll system does not identify which salary expenditures are incurred for back filling positions. However, we estimate that salary costs for replacing injured workers were approximately $306,000 to $460,000 in FY 2001-2002, depending on whether replacement workers were paid straight time or overtime. Therefore, total estimated Department of Nursing expenditures in FY 2001-2002 for injured workers, including direct workers compensation expenditures for active claims and salary costs to replace injured workers, ranged from $1.73 million to $1.88 million.

San Francisco General Hospital’s Work Place Safety and Return to Work Programs

The Department of Public Health’s Analysis of Work Related Injury Data

The Department of Public Health’s Occupational Safety and Health Section has identified muscular-skeletal disorders as a prime cause of Department of Nursing work related injuries. Although the Department of Human Resources Workers

Compensation Division is responsible for managing workers compensation claims, the Department of Public Health’s Occupational Safety and Health Section receives and reviews all workers compensation claims. The Occupational Safety and Health Section works with Hospital departments to investigate work-related injuries and to develop prevention activities. The Occupational Safety and Health Section maintains a database of all work related injuries and generates quarterly reports, providing information on the frequency of occurrence and the cost of different categories of injuries. Occupational Safety and Health Section staff review the injury data to develop and implement injury prevention programs. Section staff identify specific locations within the Hospital with high incidents of injury, target interventions that will reduce injury-related costs, and meet with managers and staff to implement safety interventions.

San Francisco General Hospital Back Injury Prevention Practices

According to the Federal Center for Disease Control’s National Institute of Occupational Safety and Health (NIOSH), nursing personnel rank fifth among all job classifications for work-related back injuries in the United States. In a presentation to a NIOSH conference on ergonomics in January 1997, Dr. Barbara Owens of the University of Wisconsin reported that most studies of work place muscular-skeletal and back injuries in the healthcare industry result from the actual handling of patients, especially transferring patients with limited mobility. Dr. Owens conducted work place studies, combining assessing patients for mobility, training staff, and using assist devices in transferring patients. Dr. Owens reported that work place injuries were reduced by 40 percent and days lost from work were reduced by almost 95 percent. In the January, 1997 NIOSH conference, NIOSH identified specific measures to reduce muscular-skeletal and back injuries, including:

• Use of assist devices in lifting, transferring and moving patients;
• Sufficient number of assist devices in the clinical units;
• Assessment of the patient to determine mobility needs and appropriate assist devices;
• Patient transfer team to assist nursing staff with lifting, transferring and moving patients; and
• Educational programs to teach nursing staff preventive measures.

The Department of Nursing has implemented several programs designed to reduce muscular skeletal and back injuries among nursing staff, consistent with NIOSH recommendations.

Patient Assist Devices

San Francisco General Hospital Department of Nursing has introduced new patient assist devices to aid nursing staff in lifting and transferring patients. The Department of Public Health purchased 13 devices to assist with patient lifting at Laguna Honda Hospital as part of a pilot program in December 2001. Based on the results of this pilot program, San Francisco General Hospital purchased 14 lift devices. The San Francisco General Hospital Department of Nursing is developing training protocols for use of the lift devices and physical therapists are participating in training staff on lift device use. To follow-up on implementation of the lift devices, the Department proposes to survey nursing staff regarding use of the new lift.

The Department of Public Health Occupational Safety and Health Section identified increasing numbers of work-related injuries in the San Francisco General Hospital critical care units and conducted an ergonomic evaluation of the critical care units in March 2001. As a result of the evaluation, San Francisco General Hospital purchased new equipment for the critical care units, including three new ergonomic workstations, industrial casters to improve IV pole mobility, cardiac chairs with transfer devices, and a critical care unit bed maintenance contract to ensure adequate repair and mobility of beds. The critical care units had 18 incidents of work-related injuries in calendar year 2000, which was reduced to 13 incidents of work-related injuries in calendar year 2001. For the first nine months of calendar year 2002, the critical care units had ten work related injury. According to Department of Nursing staff, the Department will continue tracking critical care unit injuries over the next several months to evaluate the effectiveness of the interventions.

Patient Transfer Teams

In their presentation to the NIOSH conference, the Mayo Clinics System reported that they implemented the patient transfer team initiated by San Francisco General Hospital. San Francisco General Hospital created the patient transfer team five years ago under the Hospital’s Environmental Health and Safety program and transferred the patient transfer team to the Department of Nursing two years ago. The role of the team is to assist nursing staff in lifting, moving or transferring patients with limited mobility and in training staff at the bedside in patient mobility techniques.

Currently, the Department of Nursing has two certified nursing assistants assigned to the patient transfer team, who perform other patient care functions when not required to assist with lifting. The Department of Nursing schedules one certified nursing assistant for one eight hour day shift and one eight hour evening shift with a two-hour overlap from 3:30 p.m. to 5:30 p.m. to assist nursing staff in the clinical units with lifting and transferring patients. Based on recommendations from staff nurses, the Hospital proposes scheduling a two-person team for eight hours, reducing the number of hours per day that the transfer team is available. According to the Mayo Clinic Systems’ evaluation of the patient transfer team, the patient transfer team incurred no injuries in 11,000 patient transfers. However, the Mayo Clinic Systems’ evaluation also showed that nursing staff did not consistently use transfer techniques taught by the patient transfer team when the transfer team was not present.

The Department of Nursing should conduct periodic surveys of nursing personnel to assess the effectiveness of the bedside training, including the extent to which nursing staff use patient mobility techniques in the absence of the team.

Staff Training and Education

San Francisco General Hospital does not have a formal back training program. The Hospital conducts periodic education programs to reduce the number of muscular-skeletal and back injuries but the programs do not reach all nursing staff. In 2002, the Department of Nursing has conducted "back fairs" to train nursing staff in lifting procedures and in working with assist devices. According to the Department of Nursing, approximately 200 nursing staff out of more than 1,000 possible nursing staff attended the back fairs, which were voluntary and conducted on work time.

The Hospital’s orientation program for new employees includes back training provided by physical therapists, but the Department of Nursing does not currently conduct annual updates. Physical therapy staff conduct training classes for specific Hospital departments when requested by the department and have provided in-service training on the new lift devices. The Department of Nursing is also drafting language, incorporating the use of assist devices into the patient care plan and into the assessment of patients when they are admitted or transferred to a new clinical unit.

The Department of Nursing should schedule annual mandatory back training updates for nursing staff, and impose sanctions for nursing staff who fail to attend the annual mandatory back training updates. Currently, the Department of Nursing places nursing staff on unpaid leave if the staff member fails to complete other mandatory annual nursing updates within 30 days.

San Francisco General Hospital would incur costs for conducting annual mandatory back training classes for education staff and physical therapists to organize and conduct the classes and for nursing staff time to attend classes. We estimate that annual mandatory back training could cost approximately $72,000 for nursing instructor and physical therapist time to conduct the classes and for nursing staff to attend the classes. We believe that these increased costs would be offset by reductions in direct workers compensation payments and salary costs to back fill positions of injured workers.

The Department of Nursing Return to Work Program

The goal of the Department of Nursing is to return injured nursing staff to work as quickly as possible. Once the injured worker is released by the physician to return to work, the Department accommodates the worker by placing her or him in a work assignment consistent with her or his abilities. In October, 2001, centralized responsibility for temporary transitional work assignments for nursing personnel was assumed by the Department of Nursing, although the Occupational Safety and Health Section continues to monitor temporary transitional work assignments. According to the Department, by centralizing responsibility for temporary transitional work assignments, the Department is better aware of the number of staff working temporary transitional assignments and the specific assignment.

Under temporary transitional work assignments, the worker is assigned to restricted duty for up to 90 days. By policy, temporary transitional work assignments for more than 90 days require approval by the Director of Occupational Safety and Health and are extended only if the worker shows reasonable medical improvements. If the worker’s injuries result in permanent work restrictions and the worker is unable to return to full duty, the temporary transitional work assignment is terminated.

Under California statute, there is no legal limitation the duration of a workers compensation claim. Only the worker’s personal physician can determine when the worker’s injury is "permanent and stationary". Once the worker’s injury is determined "permanent and stationary", the worker is eligible for retraining. According to the Department of Nursing, one to two nursing staff are assigned to temporary transitional work assignments on average, although at the time of the interview, ten nursing staff were assigned to temporary transitional work assignments. These temporary work assignments generally do not extend for more than 30 days.

Conclusions

San Francisco General Hospital Department of Nursing had $1,423,399 in FY 2001-2002 in direct expenditures for nursing staff’s work-related injuries. These expenditures do not include Hospital costs for overtime and per diem staff to back fill vacant nursing positions. We estimate that San Francisco General Hospital spends approximately $306,000 to $460,0000 annually to back fill direct patient care positions to replace injured workers. Estimated total Department of Nursing expenditures for work place injuries are $1.73 million to $1.88 million annually.

Hospital data shows that the number of new injuries, resulting in lost workdays is increasing. In FY 2000-2001, the average number of lost workdays for San Francisco General Hospital certified nursing assistants, licensed vocational nurses, and registered nurses exceeded the national average.

The Department of Public Health has identified muscular-skeletal and back injuries as a major cause of work-related injuries for nursing staff. According to the National Institute of Occupational Safety and Health, a comprehensive back training program to reduce muscular-skeletal and back injuries includes sufficient availability of lift assist devices in clinical units, thorough assessment of each patient’s mobility needs, a patient transfer team to assist nursing staff with lifting, and educational programs to teach nursing staff preventive measures. San Francisco General Hospital has implemented injury reduction programs that incorporate these specific measures. The Hospital has introduced new patient assist devices and is drafting language to incorporate devices into the patient care plan. The Hospital also employs two specially trained certified nursing assistants for the patient transfer team. Each certified nursing assistant is assigned to an eight-hour shift with a two-hour overlap. The Department of Nursing is considering scheduling a two-person patient transfer team for eight hours, reducing the number of hours that at least one person is available for the transfer team.

The Hospital does not conduct annual mandatory back training classes for nursing staff. Approximately 200 nursing staff out of approximately 1,000 nursing staff, attended the back fairs in 2002. Although the back fairs were conducted on work time and nursing managers were instructed to encourage attendance, attendance was limited. We recommend that the Hospital implement annual mandatory back training classes, conducted by a physical therapist, for all clinical units. To enforce the annual back training, the Department of Nursing should impose the same sanctions that are imposed for failure to complete other mandatory annual training.

Recommendations

The Department of Nursing should:

Costs and Benefits

San Francisco General Hospital would incur estimated costs of approximately $72,000 for conducting annual mandatory back training classes for education staff and physical therapists to organize and conduct the classes and for nursing staff time to attend classes. However, such costs would be more than offset by reductions in direct workers compensation payments and salary costs to back fill positions of injured workers.

1. Nursing classifications include registered nurses, licensed vocational nurses, certified nursing assistants, mental health rehabilitation workers, psychiatric technicians, nursing managers and supervisors, nursing instructors, operating room technicians and registered nurses, public health nurses, clinical nurse specialists, anesthetists, and central processing and distribution technicians.
2. "Report on the American Workforce, 1999", United States Department of Labor.
3. We based our estimate on: (a) the number of new injuries reported in FY 2001-2002, (b) the total number of lost work days for each direct patient care position (nursing assistants, mental health rehabilitation workers, psychiatric technicians, surgical procedures technicians, and registered nurses), and (c) the hourly pay rate at salary step three for each classification.
4. Presentation to the National Institute of Occupational Safety and Health Conference, January 9, 1997, Chicago, Illinois, by Bernice Owen, University of Wisconsin School of Nursing.
5. Dr. Owens reported that the number of injuries were reduced from 20 injuries, resulting in 64 lost work days, in the pre-intervention period to 12 injuries, resulting in 3 lost work days in the post-intervention period.
6. Presentation to the National Institute of Occupational Safety and Health Conference, January 9, 1997, Chicago, Illinois, by Eric Meittunen, Environmental and Occupational Safety Coordinator, Mayo Clinic Systems.
7. According to the presentation by Eric Meittunen of the Mayo Clinic Systems, in the absence of the patient transfer team, 20 percent of nursing staff used correct patient transfer techniques "all of the time", 58 percent used correct transfer techniques "most of the time", and 15 percent used correct transfer techniques "about half of the time".
8. The Hospital currently conducts the annual training program for nursing staff electronically and does not provide a live presentation.
9. Cost estimates are based on (a) 224 one hour classes for five nursing staff, (b) two hours of physical therapist and nursing instructor preparation and class time for each one hour class, and (c) one hour pay for each direct patient care position (nursing assistant, mental health rehabilitation worker, surgical technician, public health team leader, licensed vocational nurse, registered nurse, psychiatric technician, operating room nurse, central processing and distribution technician, and senior central processing and distribution technician) to attend the class.