When it comes to musculoskeletal disorders (MSDs), the long-term care industry experiences a unique set of workplace circumstances that create the perfect storm for increasing both the frequency of injuries and the cost to the industry. The following facts describe the makeup of the storm:

1. Many jobs within the long-term care industry expose the worker to both repetitive and forceful physical demands.
2. The long-term care industry experiences one of the highest work related injury
rates among all workplace sectors. (Table 1)
3. The long-term care industry experiences a high level of turnover on an annual
basis.
4. Many newly hired employees are not physically fit enough for the challenge of
unfamiliar and physically demanding tasks.

A recent report by the Bureau of Labor Statistics (BLS) shows that health-care workers have injury rates that equal or exceed rates in other industries that are traditionally considered hazardous (see Table 1). The total cost of such injuries is unknown, but in
2000, the U.S. Veterans’ Administration spent over $23 million USD for job-related
injuries related to patient care (VHA, 2001). The prevalence of low-back pain in nursing personnel has been reported at rates between 30% and 60% (Lagerstrom et al. 1998; Nelson et al, 2003; Videman et al, 2005), with this issue being identified as a major reason why nurses leave their profession (Nelson et al, 2003).

MSDs in health-care workers have been attributed in large part to patient transfer and lifting activities. For areas of the body that are most often affected by patient handling activities (i.e. shoulders, low back), the injury rates continue to indicate that health-care employees are in one of the highest risk work categories (see Table 1). Research studies focusing on biomechanics patient handling techniques have shown that these activities place high levels of compressive force on low-back structures, far exceeding the lifting limits recommended by the U.S. National Institute of Occupational Safety and Health (NIOSH).

Table 1: Bureau of Labor Statistics
Non-Fatal Occupational Injuries and Illness Involving Days Away from Work
(per 10,000 employees)
Occupation Sprains/Strains
& Tears Low Back
Injuries Shoulder
Injuries
Nursing Aides, Orderlies and
Attendants 280.8 185.2 35.9
Emergency Medical Technicians 217.8 121.7 22.3
Stock and Material Handlers 168.6 93.3 32.3
Truck Drivers, Heavy & Tractor
Trailer 168.7 78.3 33.2
Transportation Ticket Agents and
Travel Clerks 169.3 75.2 24.4

Given these facts, long-term care industry is faced with the task of developing strategies to address the components that drive risk and elevate cost. The purpose of this paper is to address these concerns and issues and offer one solution that is practical and financially feasible.

Post-Offer Screens (POS) and the Long-Term Care Industry

When developing a comprehensive ergonomics program, the goal is to implement elements that address the root cause of the problem. Further, these elements must address the problem at multiple points of exposure for the employees. In the case of long-term care industry, the high turnover rate presents the first challenge that must be addressed by an ergonomics program. By including a program element that focuses on musculoskeletal health and physical fitness at the point of hire, a company can address the issue of
injuries during the early days of employment.

A POS is one element of an ergonomics program. When deployed appropriately, POS matches the workers physical abilities with the predetermined physical demands of the job. The physical evaluation of potential employees is useful for injury prevention only if it can be related to the physical requirements of the job (Harbin et al. 2005). A secondary purpose is to direct higher risk persons to appropriate exercise programs to improve physical fitness.

A POS is typically administered after a conditional offer of employment has been made. The use of the POS is not a guarantee that a particular worker will never get injured on the job, rather the goal is to assure the worker has the physical abilities to safely perform
the essential job functions on the first day of employment. Another important feature of a
physical screening program is to assess all aspects of the conditional new hire. If the applicant has a pre-existing musculoskeletal injury that was not previously documented or sustained in a prior workers compensation claim, it may go undetected or unreported.
This undetected musculoskeletal problem has the potential to worsen into an injury when

they begin their work duties as a new employee. In this example, the undetected musculoskeletal problem now injury, becomes the responsibility of the new employer.

Given the level of exposure and costs associated with MSDs in the long-term care industry, implementation of POS program must show a level of effectiveness that demonstrates a tangible return on investment. In this paper a retrospective longitudinal study of a large soft drink manufacturing and distribution facility (NAICS 312111) that has implemented a POS program will be presented. The data we will compare three years of data prior to the implementation of the POS program and 6 years of subsequent data with the program in full effect.

Post-Offer Screen Testing Protocol

The process started with a functional job analyses (FJA) of each job to get an objective measure of the physical requirements of each task within the job. A functional job description was developed from this analysis and provided to the employer. From the FJA a task specific POS was developed.

The following outlines the components evaluated during the job analysis:

1. Review of the current job descriptions (if available)
2. Meeting with human resources, supervisors and employees about the job
duties, functions and discussing any concerns.
3. Determining the physical demands of the job with objective measurements
to determine the exact physical requirements needed to perform the job tasks

1. Reaching below / at / or above chest level
2. Pushing and pulling
3. Squatting, stooping and repeated bending
4. Kneeling / crouching or otherwise awkward positions
5. Ambulation agility and stamina, climbing
6. Sitting requirements
7. Standing and walking requirements
8. Repetitive hand or wrist activity
9. Finger and manual dexterity
10. Near and far vision acuity
11. Manual lifting loads at different zones (below knee level,
knee to waist, waist to chest, shoulder to overhead and carrying loads.)

From this information a job specific POS was developed and implemented with all new hires and with all employees returning to work (RTW) after an injury. The injury does not, necessarily, need to be work-related. All employees are required to perform and successfully complete a return to work POS before they are released back to their normal duties.

Outcomes

The following tables demonstrate the positive outcomes of the POS program. The data was collected over a nine-year period from January 2002 through December 2010. The data was taken directly from the OSHA 300 logs and the company’s workers compensation administrator provided the financial data. The data covers the 3 years (2002-2004) prior to beginning of the POS program and the subsequent 6 years (2005-
2010) when it was implemented. The POS program had a significant effect on reducing the number of musculoskeletal injuries, days away from work (lost time), restricted duty days and on direct workers compensation expenses.

Table 2 outlines the reduction in the number of musculoskeletal injuries after implementation of the POS program in 2005.

Table 2: Musculoskeletal Injuries pre and post POS program

YEAR LUMBAR OR SPINAL
INJURIES SHOULDER OR
EXTREMITY INJURIES TOTAL
2010 3 4 7
2009 2 2 4
2008 2 0 2
2007 5 3 8
2006 3 6 9
2005 5 4 9
2004 5 5 10
2003 7 4 11
2002 6 16 22

Table 3 outlines the reduction in days away from work and restricted duty days since the initiation of the POS program.

Table 3: Days away from work and restricted duty days

Time Period Days Away from Work
(Lost Time Days) On Job Transfer or
Restricted Duty Days
2002-2004 518 908
2005-2010 254 362
Reduction -264 -546

The direct workers compensation costs also dramatically decreased in the 6 years after initiating the POS program compared to the 3 years of data prior to the POS program. The soft drink manufacturing and distribution company used in this study is self-insured so the expenses are a direct cost to them.

Time Period Total direct expense paid over the time period
2002-2004 $360,409
2005-2010 $95,602
Cost of POS’s
2005-2010 $22,750
Cost Savings +$242,057

Based on the results of the study the return on investment (ROI) for the company over the
2005-2010-time period was significant. For every dollar spent on the POS program the
company saved over ten dollars in bottom line expenses. This does not include the indirect costs that are associated with a lost time claim further improving the ROI.

Financial Impact:

There have been several studies published that demonstrates the effectiveness of POS programs. Reimers et al. found a significant decrease in injuries and injury related expenses over a four-year period with the effective use of POS combined with work fitness programs.

In 1999, Nassau conducted 938 posts offer screens, of which 30 participants did not meet the physical requirements. When comparing the screen and non- screened groups Nassau identified that the average number of lost days in the screened employees (0.83 days) was considerably lower than the unscreened employees (3.83 days). The mean incurred medical costs per 100 FTEs was $311.15 for the screened employees compared to
$1432.57 for the unscreened employees. The mean frequency of injuries per 100 FTEs
was 0.58 in the screened employees as compared to 0.97 injuries in the unscreened employees.

In 2000, Gassoway and Flory conducted post-offer screens in 163 nursing assistants. A
year later they compared the turnover rate, injury costs and injury rates to the group of
144 nursing assistants hired in the previous year. They noted an $88,286.90 savings for
the reduction in the employee turnover rate and reduction in the injury rate for that year. The study estimated a six-dollar saving for every dollar spent on screening.

A compelling study on the effectiveness of POS was performed in 2003 by Littleton. Physical plant applicants at the University of Illinois were tested and the results indicated

that the number of lost workday cases decreased by 18% and the total injury costs decreased by 78%. Total cost savings were $18 per dollar spent on the program.

Harbin (2005) showed that physical capacity testing that compares lifting ability to specific job lifting requirements correlates to work injury incidence. The incidence of low back injuries in those workers with the physical capabilities to perform the required function of their job was 3%. However, among those workers who did not demonstrate the strength or physical abilities to perform their job, there was a 33 % incidence of low back injuries.

Conclusions:

The results of this study demonstrated dramatic declines in number of injuries, total costs and lost workdays in the six-year period following the POS program inception. The return on investment calculation demonstrated for every dollar spent on the program it saved eighteen in direct expenses. While a number of mitigating variables may have accounted for some of the profound effects noted, the results are consistent with existing literature.

The research shows that the incidence of injury will increase if someone does not have the physical ability to perform a job. This highlights the importance of having functional job descriptions that clearly delineates the physical demands of the job. This important information will prevent an employer from placing an individual on a job that they do not have the physical ability to perform. From the employee’s perspective, a POS program provides them with the assurance that they should be able to safely perform the job for which they were hired.

The LTC industry is plagued with high employee turnover and high musculoskeletal injury rates. The implementation of a POS program makes good financial and practical sense to reduce costs and improve worker retention and safety.

About the Author
Frank Gargano PT, DPT, OCS, MCTA, CWT
Dr. Gargano is a licensed Physical Therapist and is board certified in orthopedics. He
serves as the Vice President of Outpatient Services for HealthPRO® Rehabilitation. He is co- founder of the Workability Network, a national company that provides industrial rehabilitation products and services. He is a national lecturer and author on orthopedic, and manual therapy concepts.
He can be contacted at FGargano@therapypartnersohio.com or 440-498-9723.