bathroom safety for home care providers · high-fidelity home care simulation participants...

CRE-MSDClientHandlingCoPWebinar

Bathroomsafetyforhomecareproviders:AvoidingMSDswhenassis=ngfrailseniors

withbathingandtoile=ng

EmilyKingPostdoctoralFellow,UniversityofWaterloo

My background & interests • Bachelor’s: Mechanical Engineering – Biomechanics Option

• Masters focus: Falls – why do they happen more as we get older and how can they be prevented?

• PhD & Postdoctoral focus: Helping people to live well in their own homes for as long as possible, as independently as possible, without hurting their caregivers

• How? Research, education, product design

*Disclaimer: I’m not a clinician*

In this webinar, we will… • Quickly review how injuries happen • Highlight MSD risks in client handling • Assess how to make common bathroom activities

safer – Bathing – Toileting (including sit-to-stand transfers)

Safe caregiving requires

problem solving

Especially in home care, one size does not fit all

Two types of injury • Acute (sudden events)

– Care recipient falls/collapses • “his knees gave out”

– Poor coordination/co-operation between caregivers, or with the care recipient

• “client tried to sit too early”

Two types of injury • Acute (sudden events)

– Care recipient falls/collapses • “his knees gave out”

– Poor coordination/co-operation between caregivers, or with the care recipient

• “client tried to sit too early”

• Cumulative – Build-up of small bits of damage over time… but each

time is not enough to feel/hurt – Persistent back pain can tell you that this is becoming a

serious problem

Most caregiving injuries are back injuries

0

5

10

15

20

25

30

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45

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Back Shoulder Abdomen Arm Wrist Leg Multiple Body Parts

% L

ost-t

ime

Inju

ries

(US BLS 2010)

0

5

10

15

20

25

30

35

40

45

Overexertion Falls, slips and trips Transportation Violence Contact with objects

% o

f Inj

ury

Illne

ss

Event leading to injury or illness for home health care services workers

BLS, 2013

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% o

f Inj

ury

Illne

ss


BLS, 2013

https://trihomeandcommunity.com/falls/

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40

45


% o

f Inj

ury

Illne

ss


BLS, 2013

Most caregiving injuries are back injuries

0

5

10

15

20

25

30

35

40

45

50

Back Shoulder Abdomen Arm Wrist Leg Multiple Body Parts

% L

ost-t

ime

Inju

ries

(US BLS 2010)

Occupational hazards in home care • In client homes

– Dangerous home environments, client choices – Homes not set up as care environments – Poor access to equipment

• Interactions with clients & families • Inadequate organizational support • Demands of care work

– ‘awkward postures’, ‘physically-demanding work’, ‘heavy clients’, ‘cramped spaces’

13

Why Bathrooms? • Bathing and toileting are

among the most demanding home care activities1,2,3

• Injuries often happen in the bathroom2,4

1 Owen & Staehler (2003) Home Healthcare Nurse, 21: 180-186 2 Czuba et al (2012) Work, 42: 341-353

3 King et al (2016) J Appl Gerontol, ePub: 1-23

4 Stevens & Haas (2011) MMRW, 60: 729-733

Focus on Bathrooms

16

Practice Consultant: I think regardless of the diagnoses attached to it, its really is safe toileting, bathing, showering … If you were able to solve just those, that would improve the risk level. PSW: and that’s a primary reason PSWs are going into homes, personal care.

Challenges in the bathroom General challenges Activity-specific challenges 1. Coping with small spaces

2. Poor equipment-environment fit

3. Reliance on manual handling

4. The importance of normalcy

5. Unsteady and unpredictable clients

Toileting Assisting unsteady/unpredictable clients with: • transfers on and off the toilet • providing perineal care • raising and lowering the pants Bathing Transfers in and out of the bath/shower, particularly: • lifting the legs over the edge of the tub • assisting unsteady/unpredictable clients

17

General strategies for avoiding back injury

EVERY TIME, ask yourself: • Is this safe for me to do right now?

– How do I feel right now? – How is the care recipient right now? – Do we have enough time? – Is the environment safe?

• Space to move, no trip hazards, floor dry, etc.

• Make sure you plan ahead to have everything you need set up while the care recipient is still in a safe, stable place.

Try to avoid…

>16kg (35lb)

Flexion Lateral bending Twisting Too much weight

Body parts can be heavy – especially legs

Bodypart % Bodyweight 100 lb person

200 lb person

Head & neck 8% 8 lb 16 lb

Trunk 50% 50 lb 100 lb

1 Arm 5% 5 lb 10 lb

Whole leg 16% 16 lb 32 lb

Lower leg (below knee) 6% 6 lb 12 lb

Other body posture tips • Stable stance

– Keep your feet apart, one in front of the other – Keep your knees slightly bent

• Move in the same direction as the care

recipient https://youtu.be/k4nFZqqjqT0?t=163

The Safety Zone

Images courtesy of Saint Elizabeth Health Care

Safe techniques are easy to talk about…

…especially in empty classrooms…

…but harder in real life.

High-fidelity home care simulation Participants practicing community-based PSWs (n=8) Surrogate client • cognitively competent • frail, fear of falling • prone to hypotension 2 conditions steady, unsteady 2 care activities toileting, bathing

‘Assist the client you would in your usual practice’

28

Postural analysis: 3DMatch

29

Line up Undress Sit Go Clean Stand Dress

What’s hardest?

Toile=ngFlexion

<20° 20-45° 45-75°75-105° >105°LateralBending

<15° 15-30° >30°Twist

<15° 15-25° >25°

-me(seconds)

-20 -15 -10 -5 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150

raisetoiletlid(n=8)

walkingandposi>oning(n=16)

lowerclothing(n=15)

assisttosit(n=15)

arrangeclothing-seated(n=2)

waitforclienttoeliminate(n=16)

preparetoiletpaper(n=16)

posteriorperinealcare(n=15)

anteriorperinealcare(n=5)

assisttostand(n=15)

replaceclothing(n=15)

arrangeclothing-standing(n=16)

lowertoiletlid(n=8)

'Ac>vity'

'Neutral'

'Mild'

'Severe'

'>75'

'>105'

''

'Neutral'

'Mild'

'Severe'

''

'Neutral'

'Mild'

'Severe'

-50 0 50 100 150

raisetoiletlid(n=8)

walkingandposi8oning(n=16)

lowerclothing(n=15)

assisttosit(n=15)

arrangeclothing-seated(n=2)

waitforclienttoeliminate(n=16)

preparetoiletpaper(n=16)

posteriorperinealcare(n=15)

anteriorperinealcare(n=5)

assisttostand(n=15)

replaceclothing(n=15)

arrangeclothing-standing(n=16)

lowertoiletlid(n=8)

'Ac8vity'

'Neutral'

'Mild'

'Severe'

'>75'

'>105'

''

'Neutral'

'Mild'

'Severe'

''

'Neutral'

'Mild'

'Severe'

32

Hygienic care • Can cause

instability for the care recipient

• Sustained awkward postures required by the caregiver

Hygeniccare

Lateralbendovervanity–righthand

supportsarm,chestorrestson

back

Lateralbendovervanity–righthandonlowback

Shimmyclientforward,thenlateralbend

Clientstanding

Number of times observed 9 3 1 2

Duration (s) 17.6 (10.0) 9.0 (0.3) 25 8.9 (5.2)

Time in flexion >45° (s) 9.4 (5.3) 6.6 (0.3) 7 0

Time in lateral bend >15° (s) 6.8 (5.9) 6.7 (0.8) 10 3.3 (0.4)

Time in twisting >15° (s) 1.3 (1.8) 4.0 (2.6) 6.2 1.9 (1.8)Peak compression due to work posture at L4/L5 (kN) 1.9 (0.2) 1.9 (0.2) 1.8 1.6 (0.0)Average compression due to work posture at L4/L5 (kN)

1.6 (0.1) 1.6 (0.1) 1.4 1.4 (0.1)Cumulative compression due to work posture at L4/L5 (kNs) 28.5 (17.4) 14.4 (0.5) 34 12.7 (7.0)Average trunk extensor moment due to work posture (kNm)

64.3 (10.8) 59.4 (5.4) 37.7 43.4 (4.8)Cumulative trunk extensor moment due to work posture (kNms) 1186.9 (841.7) 534.8 (49.7) 941.4 398.8 (269.6)

34

=mesobserved

Recommendation: Bidet Seats

Lowering&replacingclothing

36

Reach

behindwalker,lower

garmentstonearknees

Reachoverwalker,lower

garmetstonearknees

Reachoverwalker,thenthroughtolower

garmentsbelowknees

Standbehind

client,stoploweringgarmentsatknees

Lower,trytoremovegarmentswithclientstandingatvanity

Numberoftimesobserved 7 3 3 1 1

Duration(s) 16.1(7.9) 17.5(7.4) 12.7(1.1) 13 69.2

Timeinflexion>45°(s) 1.1(0.9) 2.6(1.2) 2.1(1.2) 3 33.6Timeinlateralbend>15°(s) 3.2(2.5) 5.8(3.8) 4.4(3.7) 0 11.4

Timeintwisting>15°(s) 1.4(2.2) 1.3(2.0) 4.1(3.9) 8.6 3.4PeakcompressionduetoworkpostureatL4/L5(kN) 1.6(0.2) 1.8(0.2) 2.0(0.0)* 1.6 2AveragecompressionduetoworkpostureatL4/L5(kN) 1.2(0.1) 1.4(0.2) 1.5(0.0)* 1.3 1.5CumulativecompressionduetoworkpostureatL4/L5(kNs) 19.3(9.3) 23.3(7.9) 19.2(1.2) 16.5 101.2Averagetrunkextensormomentduetoworkposture(kNm) 19.9(5.4) 30.5(4.8)* 54.9(7.9)* 40.4 52.1Cumulativetrunkextensormomentduetoworkposture(kNms)

323.9(230.8)

524.8(209.9)

699.9(150.7) 525.2 3603.5

Waistbandsstartnearknees

Waistbandsstartnearfloor–bendto

raise

Waistbandsstartnearfloor–squatandminimalbendto

raise

Numberoftimesobserved 9 5 1

Duration(s) 19.8(7.3) 42.0(16.9)* 17.2

Timeinflexion>45°(s) 3.3(2.2) 10.5(4.1)* 0

Timeinlateralbend>15°(s) 7.0(5.4) 20.5(9.4)* 3.8

Timeintwisting>15°(s) 2.3(3.6) 9.3(7.7)* 0PeakcompressionduetoworkpostureatL4/L5(kN) 1.8(0.2) 1.8(0.1) 1.7

AveragecompressionduetoworkpostureatL4/L5(kN) 1.4(0.1) 1.4(0.1) 1.4

CumulativecompressionduetoworkpostureatL4/L5(kNs) 27.0(9.6) 58.8(25.1)* 24.3

Averagetrunkextensormomentduetoworkposture(kNm) 41.3(11.1) 46.2(12.0) 52.8

Cumulativetrunkextensormomentduetoworkposture(kNms) 782.6(315.8) 1925.2(1031.2)* 907.5

LowerclothingIfwaistbandsloweredbelowknees: é peak,averagecompression é averageextensormoment

ReplaceclothingIfwaistbandsstartnearfloor: é dura=on é =meflexed>45° é twisted/laterallybent>15° é cumula=vecompression,moment

=mesobserved

Lowering & replacing clothing • Lower only as far as

you need to • Plan your access

route to minimize bending

• Bend at the knees if you can

Sit&Stand

Bendovervanity Standbehind

client Bendoverwalker


Duration(s) 15.0(8.9) 11.4 11.4

Timeinflexion>45°(s) 0.9(1.9) 3.8 5.6

Timeinlateralbend>15°(s) 1.4(2.2) 0 0

Timeintwisting>15°(s) 0.3(0.8) 0 0PeakcompressionduetoworkpostureatL4/L5(kN) 1.5(0.3) 1.7 2

AveragecompressionduetoworkpostureatL4/L5(kN) 1.2(0.1) 1.4 1.7

CumulativecompressionduetoworkpostureatL4/L5(kNs) 18.0(10.6) 16.2 18.9

Averagetrunkextensormomentduetoworkposture(kNm) 24.3(19.0) 55.5 78.9

Cumulativetrunkextensormomentduetoworkposture(kNms) 334.6(250.3) 633.2 899.7

BendovervanityStandatfront

cornerofwalker,leantohelpclient

up

Standatfrontcornerofwalker,providelimitedassistance


Duration(s) 11.4(5.3) 22.4 8.2

Timeinflexion>45°(s) 0.3(0.8) 0 0

Timeinlateralbend>15°(s) 1.4(2.2) 13.4 0

Timeintwisting>15°(s) 1.2(4.4) 0 0PeakcompressionduetoworkpostureatL4/L5(kN) 1.4(0.2) 1.4 1.1AveragecompressionduetoworkpostureatL4/L5(kN) 1.3(0.1) 1.2 1.1CumulativecompressionduetoworkpostureatL4/L5(kNs) 14.6(7.4) 26 8.8Averagetrunkextensormomentduetoworkposture(kNm) 36.8(18.1) 13.7 2.6

Cumulativetrunkextensormomentduetoworkposture(kNms) 401.8(293.1) 306.6 21.3

Observedtechniques Taughttechnique

Smith(2011)HOP6

Stand-to-sit Sit-to-stand

Sit & Stand More space around the toilet would allow the preferred technique to be used… But it isn’t your house and that might require renovation.

Smith (2011) HOP6

Alternative tools for Sit to Stand

Armrests or a walker? “Because with the walker, like when she

bends over, she’s holding there and she’s down. So with the armrests, I have to use one arm when she’s wiping and

kinda block her, if she’s gonna fall.”

“I feel more secure that I am closer to the person than, you know. The

armrests comes out more, like here. And you have to be behind the armrests.”

Transfer Poles • Stable way to increase the base

of support and reduce the horizontal momentum needed to rise

Double or single poles: Near position is more helpful than far

• Install at approx 75% of thumb-tip reach

• This installation allows the pole to take

more of the load during Sit-to-Stand, reducing individual joint forces.

Vena et al, 2015

Independent or Assisted?

Demands of standing tub entry

• Slippery surface

• Step over high obstacle >35cm

Bathmat Textured Surface

Grab bar Improvised handholds

Grab bars help caregivers too

“The two gives her more support inside when you’re inside the tub”

Independent or Assisted?

-120-100-80 -60 -40 -20 0 20 40 60 80 100120140160180200220240260280300320340360380400

Prepare(n=14)

Mobility(n=14)

Removepyjamas(n=14)

Transferintobathtub(n=14)

Upperbody(n=14)

Perinealarea(n=13)

Lowerlimbs(n=13)

Upperbody(n=10)

Perinealarea(n=8)

Lowerlimbs(n=9)

Warmingtowel(n=13)

Upperbody(n=14)

Perinealarea(n=5)

Lowerlimbs(n=14)

Transferoutofbathtub(n=13)

Upperbody(n=6)

Lowerlimbs(n=6)

Wash

Rinse

Dry

LoJon

Jme(seconds)

Flexion<20° 20-45° 45-75°75-105° >105°

LateralBending<15° 15-30° >30°

Twist<15° 15-30° >30°

Bathing

50

Getting in & out Foot care

Seated bathtub entry/exit

Seated entry/exit

Transfer legs

Lifting the legs

Severely flexed posture to lift the foot from ground-level

Legs can be heavy - Swelling - Stiff joints (resistance) - How much can the care

recipient help? High obstacle to lift over

Can we make lifting the legs easier?

Lifting the legs

Can we reduce the weight of the lift?

• Lift one leg at a time • Ways for the care

recipient to help?


Lifting the legs Can we reduce the height of the lift?

• Less destabilizing • Good for stiff joints

Can we reduce the weight of the lift?

• Lift one leg at a time • Ways for the care

recipient to help?


Lifting the legs Can we reduce the height of the lift?

• Less destabilizing • Good for stiff joints

Can we reduce the bending needed? • Sit to lift? • Leg lifter? Can we reduce the weight

of the lift? • Lift one leg at a time • Ways for the care

recipient to help?

Transfer Legs

59

Simulation with direct measurement

60

Participants practicing community-based PSWs (n=8) Surrogate client • cognitively competent • frail, fear of falling Each tool/technique tried 3 times Interviews to solicit feedback • preferences • applicability to practice Measure • Postures of the trunk and shoulders • Muscle activity in the back and shoulders

Forwardbending

AlthoughLegLihertakeslonger

0

20

40

60

80

100

120

max mean

Trun

kfle

xion

angle(d

egrees)

Stoop

LegLi4er

Stool

05

10152025303540

20-45° 45-60° >60°Du

ra%o

nob

served

(s)

Trunkforwardflexionangle

Stoop

LegLi4er

Stool

0

20

40

60

80

100

120

max mean max mean

Shou

ldereleva,o

nan

gle(degrees)

Le3Shoulder RightShouder

Stoop_to_Li4

Leg_Li4er

Sit_to_Li4

0

20

40

60

80

100

120

max mean

Trun

kfle

xion

angle(d

egrees)

Stoop

LegLi4er

Stool

61

*p<.05

êbyLegLiherêbySittoLih

0

20

40

60

80

100

120

max mean max mean

Shou

ldereleva,o

nan

gle

(degrees)


Stoop

LegLi4er

Stool

0

5

10

15

20

25

60-90° >90° 60-90° >90°Du

ra%o

nob

served

(s)

Le1Shoulder RightShoulderEleva%onangle

Stoop

LegLi3er

Stool

0

20

40

60

80

100

120

max mean max mean

Shou

ldereleva,o

nan

gle(degrees)


Stoop

LegLi4er

Stool

62

*p<.05

Armeleva=on

êbyLegLiherébySittoLih

MuscleAc=vity

êbyLegLiherébySittoLih

0

20

40

60

80

100

120

max mean max mean

Shou

ldereleva,o

nan

gle

(degrees)


Stoop

LegLi4er

Stool

Qualitative feedback Leg_lifter reduces bending and effort:

– 8/8 PSWs prefered it

Sit_to_lift reduces bending, but is not worth the hassle – 4/8 refused or strongly disliked – 4/8 PSWs had a positive comment

64

Ah, the leg lifter. It’s the best. It is. It’s… effortless, you know? … We need some of those. (PSW-3)

I like the stool. … Because you get to sit there instead of bending. (PSW-1)

It'd be too much hassle … because you're going to be going up and down … (PSW-1)

•Better for back •Easier on the shoulder

Budget options: a towel, or other loop of fabric?

•Much easier for back •Harder on shoulders & arms •Sitting is work for the legs

Seated entry/exit

Shifting on the bench

Seated entry/exit


Can be an awkward posture • Bench positioning? • How much help do you need to give? Hand positions


Seated entry/exit Can be an awkward posture • Bench positioning? • How much help do you need to give? Hand positions Can we reduce the force

needed? • How much can the care

recipient do themselves? • Friction-reducing bench • Budget options

Results: Move Body

69

Slide-Rotate Bench Garbage bag Standard bench

Non-neutral ébySlide-RotatebenchtrunkposturesébyGarbagebag

70

0

5

10

15

20

25

30

35

40

20-45° 45-60° >60° >20°LateralBend

>20°AxialTwist

Dura%o

nob

served

(s)

ForwardFlexion

Standard_Bench

Slide_Rotate_Bench

Garbage_Bag

0

20

40

60

80

100

120

max mean max mean max mean

Trun

kan

gle(degrees)

ForwardFlexion LateralBend AxialTwist


*p<.05

0

5

10

15

20

25

30

35

40

20-45° 45-60° >60° >20°LateralBend

>20°AxialTwist

Dura%o

nob

served

(s)

ForwardFlexion

Standard_Bench

Slide_Rotate_Bench

Garbage_Bag

0

20

40

60

80

100

120


Trun

kan

gle(degrees)



0

20

40

60

80

100

120

max mean max meanShou

lderEleva-o

nan

gle(degrees)


Standardbench

Slide/rotatebench

Garbagebag

0

5

10

15

20

25

30

35

60-90° >90° 60-90° >90°

Dura-o

nob

served

(s)

Le4Shoulder RightShoulderEleva-onangle

Standardbench

Slide/rotatebench

Garbagebag

0

5

10

15

20

25

30

35

40

20-45° 45-60° >60° >20°LateralBend

>20°AxialTwist

Dura%o

nob

served

(s)

ForwardFlexion

Standard_Bench

Slide_Rotate_Bench

Garbage_Bag

0

20

40

60

80

100

120


Trun

kan

gle(degrees)



0

20

40

60

80

100

120

max mean max meanShou

lderEleva-o

nan

gle(degrees)


Standardbench

Slide/rotatebench

Garbagebag

0

5

10

15

20

25

30

35

60-90° >90° 60-90° >90°

Dura-o

nob

served

(s)

Le4Shoulder RightShoulderEleva-onangle

Standardbench

Slide/rotatebench

Garbagebag

0

5

10

15

20

25

30

35

40

20-45° 45-60° >60° >20°LateralBend

>20°AxialTwist

Dura%o

nob

served

(s)

ForwardFlexion

Standard_Bench

Slide_Rotate_Bench

Garbage_Bag

0

20

40

60

80

100

120


Trun

kan

gle(degrees)



Armeleva=onébySlide-Rotatebench ébyGarbagebag

710

5

10

15

20

25

30

35

40

20-45° 45-60° >60° >20°LateralBend

>20°AxialTwist

Dura%o

nob

served

(s)

ForwardFlexion

Standard_Bench

Slide_Rotate_Bench

Garbage_Bag

0

20

40

60

80

100

120


Trun

kan

gle(degrees)



*p<.05

Muscleac=vityêbySlide-Rotatebench

72

0

5

10

15

20

25

30

35

40

20-45° 45-60° >60° >20°LateralBend

>20°AxialTwist

Dura%o

nob

served

(s)

ForwardFlexion

Standard_Bench

Slide_Rotate_Bench

Garbage_Bag

0

20

40

60

80

100

120


Trun

kan

gle(degrees)



*p<.05

73

Qualitative Feedback Slide_Rotate_Bench makes the transfer easier

– 8/8 PSWs preferred over standard

BUT - release buttons are hard to access, - seat should lock nearer a 45-degree angle, and - may be too expensive for many clients

Garbage_Bag percieved as a good option if Slide_Rotate_Bench is unavailable

– 2/8 PSWs preferred over Slide_Rotate_Bench

BUT - care necessary to prevent client slipping off bench - may complicate cleaning

It’s easier to push her. And to come back, right? To get into the tub and get out of the tub. (PSW-7)

Well, for now, most clients they don’t really have it [the slide_rotate_bench]. I think the garbage bag is really a good idea. … Because they probably couldn’t afford a chair like that. (PSW-5)

Sliding/rotating bath bench • Awkward catch locations • Substantial reductions in force required to slide • Easier on the back

Cheaper (but less effective) ways to reduce push/pull forces • Garbage bag is better than nothing on a dry bench • Wet bench is easier than a dry bench, about the same as the garbage bag.

Washing the feet/lower legs

Ways to get nearer the feet

“But of course not a lot of their bathrooms are really clean…”

Stay safe!

[email protected] [email protected]

bathroom safety for home care providers · high-fidelity home care simulation participants...

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