This article is written for cath lab staff and physicians. It is written for the government agencies and insurance carriers that look for ways to prevent injury and must pay the bills for those injuries that happen anyway. It is written for administrators and educators with the hope that the information we found will help them develop the tools and workplace standards for safety at work. Anyone can get hurt at work, but it should not hurt to do the work. That is the goal of ergonomics.
Are ergonomic injuries in the cath lab a real problem? After 5 years of researching this issue, I think we are getting some answers. An initial review of the available data revealed that cath lab staff ergonomic injury patterns were not well identified.1 I discovered this by trying to find statistics that separated cath lab staff injuries from all other injuries in the healthcare field. I sought information about whether there in fact are injuries in the cath lab, and where and how such injuries might be reported.
I began this research with the goal of developing a teaching tool to inform staff and administration of the ergonomic risks specific to the interventional field, and secondly, to help develop a modified standard for the tasks increasing the risk of repetitive stress injuries. However, the answers to these injury patterns were not easy to locate. Did I say ‘easy to locate’? I meant impossible to locate. If you read the statistics, cath lab professionals don’t have ergonomic injuries (see Table 1 as an example). Or, as was more likely, cath lab professionals were grouped together with everyone else and not pulled out to see what is happening specifically in our labs.1
My initial report, “Ergonomics in the Cath Lab (or how to save staff backs, necks, wrists…)” was published almost five years ago, in the May 2003 issue of Cath Lab Digest.2 I identified the seven ergonomic risk factors for repetitive or cumulative stress injuries (Table 2), and reviewed whether these factors were pertinent to cath lab tasks. This initial article was put together from a session called “Ergonomics” that I taught in 2002 through the HMP Communications/ Cath Lab Digest Regional Symposiums, and I drew on the work of Gary B. Orr, certified professional ergonomist (CPE), as well as from the field of physical therapy. These efforts helped spark industry interest in identifying tasks that lead to staff repetitive stress injuries like carpal tunnel syndrome.
In the 2003 report, I made the important point that “preventative maintenance for humans is just as important as preventative maintenance is for x-ray tubes.” For example, the cost of a single staff person with carpal tunnel surgery is around $24,000 for each wrist.4 That is just the medical cost, not the additional cost of replacing that person with another staff member, nor the loss of leave to the injured staff, nor the pain and suffering that the person and their family faces when faced with a debilitating, often permanent, injury.
Perhaps you also have seen co-workers with injuries like carpal tunnel syndrome, lumbar and cervical neck injuries, cataracts, breast cancer, and hip pain, and like me, wondered if the injury had a connection to our tasks. If there is even a possibility of that such injuries are caused by our work, it is important to identify what is hurting cath lab professionals, and what we can do to decrease the number of future injuries.
I knew there were nurses and technologists getting hurt at work. I saw them. I watched them go through physical therapy and surgery. Where and how were these injuries reported?
The U.S. Department of Labor, Occupational Safety and Health Administration (OSHA), U.S. Bureau of Labor Statistics, and National Center for Health Statistics have statistics available from the 1990’s which show:
1. The annual cost of work-related injuries to workers’ compensation was more than 20 billion dollars.
2. According to the Bureau of Labor Statistics, nearly two-thirds of ALL occupational illnesses were caused by repetitive-use injury to the wrist, elbow or shoulder, with carpal tunnel syndrome being the chief occupational hazard of the 1990’s.
3. 849,000 cases of carpal tunnel injury occurred in 1994.5 Federal agencies and professional societies knew we had a crisis in healthcare workers, with the decline in actual nurses and allied health professionals. With the reporting of this data, another problem arose: those workers already in the healthcare field seemed to be at risk of work-related repetitive stress injury. The Centers for Disease Prevention published a mandate titled ‘Healthy People 2010’ which has objectives aimed at reducing death and injuries that are work-related. It is an impressive document which can be reviewed and downloaded from the website www.healthypeople.gov.
In 2003, the Society of Diagnostic Medical Sonographers published “Industry Standards for Prevention of Work-Related Musculoskeletal Disorders in Sonography” (www.sdms.org). Both the document and the website are worth the time and effort to review and consider for your workplace. Of course there are inherent differences between cardiology, radiology and other medical imaging centers; however, with a good model from which to work, standards can be modified to fit each specialty.
As I said, I am not a scientist; I am a nurse in the interventional field. I reasoned that the best way for me to get the numbers was to go right to the source. I developed a simple survey that asked questions about staff injury patterns. The survey was distributed at scientific sessions like the American Association of Critical Care Nurses National Convention and the National Teaching Institute (NTI), in teaching classes through Cardiovascular Orientation Programs and the Society of Invasive Cardiovascular Professionals, at EuroPCR, and at the New Cardiovascular Horizons Scientific Sessions. The survey was also printed in Cath Lab Digest, and was available both in print and online (Figure 2). All responses were anonymous. Real people, in the lab, just like you and me.
The survey results were tabulated by the staff at RADI Medical Systems, Inc. (Wilmington, MA) (Table 3). RADI Medical has been the frontrunner in their support of this research. I have no financial interest in any medical company and am thankful to all the companies that are, like RADI, looking for ways to keep us safer at work.
Survey results regarding recovering access sites were surprising, particularly the mean holding pressure time of 19 minutes. We may have identified at least one task that could increase the risk of carpal tunnel injury to our health care workers. Three of the seven ergonomic risks are involved in holding manual pressure. These are the risks of position and pressure, force and duration, which may explain the trembling of those hands that held for 19 minutes. Have you ever been told to hold a groin as shown in Figure 3? Or mash out a hematoma? This position hurts both you and the patient. Yet position is not the only issue. Duration is another ergonomic risk factor. How long do we need to hold pressure, and how long do we need to hold occlusive pressure? Fortunately, excellent teaching sessions already exist on the topic of hemostasis, on both physiology and technique, for the recovery of access sites.6-8
Dr. David Allie, an endovascular surgeon, interventional cardiologist, scientist and educator to physicians and staff alike, has explored similar questions as to whether manual compression should still be the gold standard for achieving hemostasis, as Dr Seldinger stated in 1952.9 Is it the standard because of the safety to the patient and access site? I am also concerned that there is no mention of the hands that hold that manual pressure. Where is that safety standard? We are taught that we have to choose between safe practice for the patient and ergonomic safety for the staff recovering that patient, but these two sides do not need to be diametrically opposed. We just need to evaluate the task and look for ways to reduce the risk of injury. After collecting the survey data, I went back to asking questions and looking for answers. I contacted NIOSH, the National Institute of Occupational Safety and Health, a branch of the Centers for Disease Control, looking at tools available to collect objective data evaluating the actual stress and force delivered to the body as we do tasks at work. This agency actually has the scientists and tools to evaluate the tasks we do at work. The best part of such objective data collecting is that it is a free service provided by the U.S. Department of Health and Human Services. The way to get this agency to come to your institution is simply to write or call, and invite them to come. The tool they offer is called the Health Hazard Evaluation Program (www.cdc.gov/niosh). The next step is to identify an institution where these scientists can come and evaluate the tasks (interested facilities can contact me at firstname.lastname@example.org).
Hospitals in the U.S. and in the United Kingdom (which has identified holding pressure as high on the list of causes of repetitive stress injury) have also identified the number of times a person can do this task in a given day. In the U.K., the Occupational Health Department helped set those times. (I have asked the staff ‘across the pond’ to share their standards with us, as part of the work to find solutions. I will be returning as a speaker at EuroPCR 2008 and hope to see some of the written guidelines at that time.) We also have the strength of a multi-disciplinary committee, the Occupational Health Committee, chaired by Dr. James Goldstein at the Society for Cardiovascular Angiography and Interventions (SCAI). This committee, of which I am a member, is in the process of evaluating the impact of our injuries to our healthcare workers. Committee work is currently in progress, and it is exciting as well as troubling as the numbers and patterns of injuries are being revealed. We have healthcare workers, government agencies, industry professionals, medical societies and professional societies all working to identify the risks and injury patterns of our healthcare workers. Why? Well, it is a nice thing to do, but more than that, it is a mandated nice thing to do (by the U.S. Department of Health and Human Resources).
The data we have collected thus far supports the hypothesis that musculoskeletal repetitive stress injury patterns do exist in the cath lab. The survey results support the efforts and development of a multi-disciplinary approach to further study these serious health risks to our practitioners. When this data was compiled, it revealed that those who reported injuries did consider them work-related (86%). The survey showed that only 54% of those hurt and who sought medical treatment felt it worked. That is just over half. One out of two cath lab professionals who are hurt still suffer after treatment.
The numbers also showed 75% of those responding held manual pressure to recover their patients’ access sites. I surmise that Dr. Seldinger &’gold standard’; is still in practice. The mean holding time of 19 minutes is a long time to hold force against a pressure. Or, to put it in ergonomic risk terms, duration, force, and position. Holding pressure for 19 minutes, in the same position, with the hands in an unnatural position, will increase the risk of carpal tunnel strain and injury.
The survey results are not only another piece in the puzzle, but a call to action. We need to develop a standard to reduce workplace injuries for our invasive laboratories. These standards must address the roles of the health professional, their employers, educators, their work environment, as well as the manufacturers of the equipment used in invasive cardiology and medical imaging suites. All who care for our patients are involved, and the creation of standards will ultimately benefit not only us, but our patients.
Acknowledgments: The author wishes to send her heartfelt thanks and acknowledgments to Tommy Maloney, Chuck Williams and Rebecca Kapur for their editorial help. It is wonderful to have people who help others make their points clear and easier to read.
1. Wiatrowski W. Occupations with the Most Injuries and Illnesses with Days Away from Work, 2002. U.S. Department of Labor, Bureau of Labor Statistics. Compensation and Working Conditions. Available online at http://www.bls.gov/ opub/cwc/sh20040525ch01.htm. Accessed December 18, 2007.
2. Holton, M. Ergonomics in the Cath Lab (or how to save staff backs, necks, wrists…) Cath Lab Digest 2003;11(5):1-14. Accessed December 13, 2007. Available online at: http://cathlabdigest.com/article/1637
3. Lecture Orr G. An Overview of Ergonomics. Orr Consulting. ergotonic@ aol.com
4. As calculated in 2005 by Magnolia Outpatient Rehabilitation Facility, 2205 5th Street North, Columbus, MS 39705. Tel. (662) 243-1097.
5. Balance Systems, Inc. Advanced Research in Rehabilitation Technology. National & International Statistics for Carpal Tunnel Syndrome and Other Associated Repetitive Strain Injuries of the Upper Extremity. Available at: http://www.repetitive-strain.com/national.html. Accessed December 17, 2007.
6. Powell D. Understanding Hemostasis. CME offering 2004-2006: www.naccme. com. No longer available.
7. Guiry M. Removal of the Femoral Arterial Sheath, The Medicines Company.
8. Achieving Successful Hemostasis: Prevent RSI Through Mechanical Compression. A North American Center for Continuing Medical Education (NACCME) CME/ CEU Educational Program. Accessed December 13, 2007. Available at: http:// www.naccme.com/webcasts/170_index.cfm
9. Allie D, Herbert CJ, Walker CM. Vascular Access Site Hemostasis: “An Endovascular Surgeon’s Perspective” Manual Compression May Not Be Benign Part 1. Cath Lab Digest Sept 2004:12(9):1,6–14. Accessed December 13, 2007. Available online at: http://
10. Society of Cardiovascular Angiography & Interventions. Press Room: 11/22/2004. “Survey Finds Interventional Cardiologists Suffer High Rate of Orthopedic Injuries.” Accessed December 13, 2007. Available at: http://www.scai. org/pr.aspx?PAGE_ID=3727
11. Holton M. Erogonomics Revisited: Carpal Tunnel Syndrome. Cath Lab Digest 2005 Mar;13(3):48–53.