T215903 ESC102 Request for Proposal 1 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

Abstract
Personal support workers (PSWs) are health care workers that assist those in need with day-to-day activities. While PSWs work in a variety of settings, such as long-term care facilities and hospitals, this Request for Proposal (RFP) focuses primarily on those that provide in-home care to patients. One group that PSWs regularly provide service to is seniors. In many cases, these seniors need help transitioning from one position to another (i.e. bed to wheelchair). PSWs assist this movement by performing patient transfers. This RFP focuses on the risk of PSWs developing musculoskeletal disorders while performing these patient transfers. Musculoskeletal disorders (MSDs) are injuries to the muscles, ligaments and/or surrounding bone structures that do not develop from a singular event [1]. Factors that influence the development of MSDs include posture, mechanical load and psychosocial wellbeing [2][3]. As well, this community faces a heightened risk due to career-specific factors, such as funding and standardized training [4]. Health care professional, such as PSWs, report one of the highest rates for development of MSDs [5]. This RFP seeks solutions to help reduce the likelihood of PSWs developing MSDs. Potential solutions should seek to both minimalize the physical factors, while also being more accessible for PSWs with regard to the career-specific issues. Reference designs to current patient transfers aids are included to illustrate current industry standards, although the design team should not feel limited to any such design. Stakeholders related to this need will be outlined, identifying their particular design concerns. Finally, design requirements will be provided in order to create a design space for potential solutions. [1] Ontario Personal Support Worker Association. (2010) OPSWA. [Online]. HYPERLINK "http://opswa.com/Articles/What-is-a-PSW-.aspx" http://opswa.com/Articles/What-is-a-PSW-.aspx [2] T R Hales and B P Bernard, "Epidemiology of work-related musculoskeletal disorders," Orthopedic Clinics of North America, vol. 27, no. 4, pp. 670-709, 1996. [3] M. Hagberg and B. Silverstein et al., Work Related Musculoskeletal Disorders (WMSDs). London, UK: Taylor & Francis, 1995. [4] Isik Urla Zeytinoglu and Margaret A. Denton et al., "Self-Reported Msuculoskeletal Disorders Among Visiting and Office Home Care Workers," Women & Health, vol. 31, 2000. [5] Kirsten (OPSWA Communications Liaison) Ballantyne, [Interview]. January 2013. [6] Bureau of Labor Statistics, Table 12: Number and median days of nonfatal occupational injuries and illnesses with days away from work involving musculoskeletal disorders by selected occupations, 2001, March 2003.

T215903 ESC102 Request for Proposal 2 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

Table of Contents
Abstract .................................................................................................................................................... 1 1 Introduction ..................................................................................................................................... 3 2 Key Definitions ................................................................................................................................ 3
2.1 Community ................................................................................................................................................ 3 2.2 Quality of Life ........................................................................................................................................... 3 2.3 Need ............................................................................................................................................................. 3

3 Problem Specifics ........................................................................................................................... 4

3.1 Relation to Quality of Life .................................................................................................................... 4 3.2 Factors of Occurrence of MSDs........................................................................................................... 4 3.2.1 Posture .................................................................................................................................................................. 4 3.2.2 Mechanical Load ............................................................................................................................................... 4 3.2.3 Psychosocial Wellbeing................................................................................................................................... 4 3.3 Prevalence of MSDs amongst PSWs .................................................................................................. 5 3.3.1 Presence of MSD Factors ................................................................................................................................ 5 3.3.2 Training................................................................................................................................................................ 5 3.3.3 Access to Transfer Assist Devices ................................................................................................................ 5

4 Stakeholders .................................................................................................................................... 5
4.1 Personal Support Workers .................................................................................................................. 5 4.2 Senior Clients ........................................................................................................................................... 6 4.3 Canadian Government (Provincial and Federal)......................................................................... 7 4.4 Manufacturers.......................................................................................................................................... 7 4.5 Hospitals and Nursing Homes ............................................................................................................ 7

5 Reference Designs .......................................................................................................................... 7

5.1 Draw Sheets and Slider Sheets ........................................................................................................... 7 5.2 Transfer Belts ........................................................................................................................................... 8 5.3 Slide/Transfer Boards .......................................................................................................................... 8 5.4 Turning Discs ........................................................................................................................................... 9 5.5 Hoyer Lifts ................................................................................................................................................. 9

6 Design Requirements .................................................................................................................... 9

6.1 High-Level Objectives:........................................................................................................................ 10 6.2 Design Constraints: ............................................................................................................................. 10 6.2.1 Constraints Imposed By Codes and Standards ..................................................................................... 10 6.2.2 Additional Design Constraints ................................................................................................................... 10 6.3 Design Criteria ...................................................................................................................................... 10

Works Cited ........................................................................................................................................... 12

T215903 ESC102 Request for Proposal 3 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

1 Introduction
This Request for Proposal (RFP) focuses on the Personal Support Worker (PSW) community within the City of Toronto, and their need for a product to reduce the risk of developing musculoskeletal disorders. PSWs, alternatively recognized as home care workers [1], provide assistance to those that need help with day-to-day activities. PSWs provide care in a number of different settings, such as long-term care facilities, group homes, and hospitals [2]. In particular, this RFP will focus on PSWs that work inhome care for clients, working within the residence of the client themselves. The risk of developing a musculoskeletal disorder poses a serious quality of life issue to PSWs as it affects both their physical wellbeing and ability to work. This RFP will outline the mechanics behind the development of musculoskeletal disorders in PSWs, specifically in relation to patient transfers, and why this issue is especially prevalent in the PSW community. An examination of stakeholders will be completed, detailing their connections to this issues and particular interests with regards to a solution. An analysis of current products used for patient transfers will be included, discussing their advantages and shortcomings. Finally, this information will be synthesized to provide design requirements for a potential solution.

2 Key Definitions
2.1 Community
The American National Institute for Health defines a community to be a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings [3]. This community which this RFP focuses on is the Personal Support Worker (PSW) community. Under the general definition, this community is defined by its social ties (collective organizations such as the Ontario Personal Support Worker Association and the Community Care Access Centre), common perspectives related to a shared career, and joint action with regards to that career.

2.2 Quality of Life

For this RFP, the general definition quality of life is characterized within five dimensions: physical well-being, material well-being, social well-being, emotional well-being, and development and activity [4]. Additional attention is given to job security and its relation to income, as this can affect a persons quality of life [5]. For the scope of this RFP, quality of life for PSWs is defined by their physical, social, and material well-being, as it relates to the nature of their working environment (specifically by the longterm hazards and risks posed to their physical health).

2.3 Need
Need is defined by the Merriam-Webster dictionary as a physiological or psychological requirement for the well-being of an organism [6]. Relating this definition to the PSW community and the given definition for quality of life, we identify the need to decreasing the risk of musculoskeletal disorders relating to patient transfer. The specifics of this need and its relation to quality of life are discussed in Section 3.

T215903 ESC102 Request for Proposal 4 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

3 Problem Specifics
This RFP focuses on the occurrence of musculoskeletal disorders amongst PSWs as a result of patienthandling activities, specifically patient transfers. Musculoskeletal disorders (MSDs) refer to a range of disorders of the soft tissues and their surrounding structures not resulting from an acute or instantaneous event [3]. The need of the PSW community is to reduce the risk of MSDs occurring, in order to improve their quality of life

3.1 Relation to Quality of Life

The development of MSDs poses a serious quality of life problem for PSWs. As previously defined, this RFP focuses on quality of life as it relates to physical wellbeing, specifically any hazards or risks related to the work environment. Health care workers involved in direct patient care, such nurses or PSWs, are at a high-risk of developing MSDs [1], recording a higher-than-average rate of workdays missed due to MSDs [4]. Such injuries directly undermine the physical wellbeing of the PSW.

3.2 Factors of Occurrence of MSDs

A number of different factors can be responsible for the onset of an MSD. Three primary factors relating to patient transfers are posture, mechanical load [5] and psychosocial wellbeing [1].

3.2.1 Posture
Postures at the extreme end of ones range of motion often require muscle force to maintain the extended position. Alternatively, non-extreme postures may still result in abnormal gravity loading or musculoskeletal geometry, adding stress to the system separate of the mechanical load. Presence of these conditions in any combination increases the likelihood of an MSD occurring [5].

3.2.2 Mechanical Load

The mechanical load applied to the musculoskeletal Figure 1: Example of extreme posture with abnormal musculoskeletal geometry [27] system is the combination of tension, pressure, friction and irritation caused by exertion [5]. From an engineering perspective, this can be quantified as the compression, shear, and lateral forces applied on a given section of the musculoskeletal system. One study involving machine-assisted patient handling measured shear stresses of ~730N [6]. While this details only one case for mechanical loading, it can be assumed that loads would be similar or greater for patient handling with lesser degrees of mechanical aid. This creates a potential concern, as shear forces on ligaments exceeding 1000N present a great risk of injury [7].

3.2.3 Psychosocial Wellbeing

Psychosocial wellbeing, as it relates to MSDs, deals with the combination of a high workload, limited control and lack of social support at work amongst PSWs and its effect on job satisfaction [1]. Higher rates of lower back pain, a form of MSD, have been found in employees with low job satisfaction throughout a variety of industries [8]. The perception of psychosocial work factors amongst PSW is closely tied to the stress of patient care [1] and rates of occurrence for work-related MSD symptoms are higher in workers that report a greater psychological stress from work [9].

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3.3 Prevalence of MSDs amongst PSWs

While MSDs are by no means a problem unique to the PSW community, they do pose a significant problem within the community itself. As well as being susceptible to the factors mentioned above, PSWs are more likely to lack proper training or access to transfer assist devices (See Section 5) [14].

3.3.1 Presence of MSD Factors

In a comparison between PSWs and other municipal employees completed in Sweden (where PSWs are employed by the government) found a higher rate of occurrence for MSDs within the PSW community as compared to other jobs [9]. The same study also found that the presence of postures, loads and psychosocial factors relating to MSD development were higher in PSWs than in other workers, especially those relating to mechanical load and twisted postures [9]. Similar findings regarding occurrence rates are found in the US, where occupations related to nursing rank among the highest for days of work missed to MSDs [4].

3.3.2 Training
Education for PSWs within Ontario is comprised of a two-semester college program. No registration exam is required and likewise, no certification is provided upon completion of this program. Additionally, there is no individual regulating body for PSWs in the workforce [2]. These requirements are very relaxed when compared to those for a similar career, such as a Registered Practical Nurse (RPN). In Ontario, prospective RPNs must complete a postsecondary nursing course and pass a series of nursing exams [11]. The lack of well-defined requirements for training PSWs can result in an increased likelihood of developing an MSD. Untrained personnel performing patient-handling activities perform significantly worse than those who have received training, when evaluated by a teaching professional [12]. The Ontario Personal Support Worker Association has identified improper performance of these activities as a primary source of injury [14].

3.3.3 Access to Transfer Assist Devices

Within this RFP, transfer assist devices refer to any equipment, manually- or electrically-powered, which is used to reduce the mechanical load placed on a PSW during a patient transfer [13]. Use of any of these devices noticeably reduces the amount of stress felt by a PSW, signaling a reduction in mechanical load. [13] The issue here is PSWs often do not have access to such devices. Even when such devices are available, they tend to be older, less safe models. PSWs often lack the funding to purchase newer equipment [14].

4 Stakeholders
Due to the nature of the need being addressed, a number of different groups can be viewed as stakeholders. Each stakeholder group is analyzed to determine their concerns and interests regarding potential solutions.

4.1 Personal Support Workers

T215903 ESC102 Request for Proposal 6 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers Personal support workers, as the primary users of any solution, are the most important stakeholders in this project. According to a survey done by the Canadian Research Network for Care in the Community collaborated with PSNO and OCSA [14], 26% of PSWs in Ontario reported occupational health safety issues as a reason they would stop working as a PSW (See Figure 2). According to an interview with a currently employed PSW working with the Carefirst Seniors and Community Association, proper prevention of back strain can reduce discomfort felt after performing a patient transfer [19]. Helping PSWs prevent and reduce the occurrence of MSDs is the primary objective of this design. The training and education required for PSW qualification constitute a constraint on the design. The Ministry of Health and Long Term Care Personal Support Worker Training Standards (1997), issued by the OCSA (Ontario Community Support Association) in 2009 [15], outlines one possible qualification for a PSW certificate. The lack of thoroughly defined training standards for the operation of transfer aids increases the risk of injury. Additionally, the lack of both a unified regulatory body and reliable funding makes it difficult for some PSWs to acquire up-to-date equipment [2] [14]. As a result, the PSWs primary concerns regarding solutions are ease of operation, costs, and reduction of MSDs risk.

4.2 Senior Clients

According to a report written by OCSA in 2006 on the regulation of PSWs [16], the average age of residents in long-term care is 82.7 years old. At the same time, 57,000 PSWs out of 90,000 PSWs in Ontario [16] are working in long-term care sector. Seniors represent one of the largest groups PSW clients. As the clients are the ones being transfer by the PSWs, their stake in the design of a transfer aid must also be considered. Potential solutions must be designed with the safety of the seniors in mind.

Figure 2: Analysis of various factors that would persuade PSWs to quit their jobs [14]. Factors related to development of MSDs include Lack of Ongoing Training, Occupation Health Safety Issues, and Dissatisfaction w/ Work Conditions

Another concern of senior clients is the comfort level they experience during the transfer itself. This represents a design criterion, as different types of aids can have different perceived levels of comfort [13].

T215903 ESC102 Request for Proposal 7 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

4.3 Canadian Government (Provincial and Federal)

The Governments of Ontario and Canadas stakes relate primarily to regulations and codes. The federal governments main concern is that any solution must adhere to the appropriate codes and standards (See Section 6.2.1). As the level of government that deals with health care, the Ontario Government has primary concern is how a solution might affect training standards for PSWs. One of the current training standards is the 2009 revision of Ministry of Health and Long Term Care Personal Support Worker Training Standards originally issued in 1997. The solution, if implemented throughout the PSW community, may merit another revision of such standards. It may also be added to the existing Long-Term Care Homes Act under Nursing and Personal Support Services Sec. 36 Transferring and Positioning Techniques [17].

4.4 Manufacturers
As the creators and implementers of any proposed solution, the manufacturers have a unique set of concerns regarding said solutions. The manufacturers deal with the production of the solution, and as such must adhere to the applicable standards and codes (See Section 6.2.1). The criteria that directly affect the manufactures are the production cost, size and weight of the solution. Additionally, any material-related requirements will impact the manufacturers stake in the solution. While such considerations are of a lower priority than those of the PSWs and their clients, potential solutions should still consider these factors.

4.5 Hospitals and Nursing Homes

It is important to note that, while PSWs are the community on which this RFP focuses, they are not the only group that performs patient transfers in a health care setting. While workers at hospitals and nursing homes have more clearly defined job requirements [11], as well as access to better equipment through increased funding, any solution that can be used by PSWs can also be used by these groups. Their concerns regarding the solution are the same as those of the PSW. These groups are included as a stakeholder due to the relation between their community and that of the PSWs.

5 Reference Designs
There are currently a number of different devices used by PSWs to aid in patient transfer. This section outlines the most common devices available to PSWs: how they help to decrease the risk of MSDs, their advantages and disadvantages. One additional device, the Hoyer lift, will also be examined. The Hoyer lift is rarely used by PSWs, but is an industry standard in other medical establishments for patient transfers.

5.1 Draw Sheets and Slider Sheets

Draw sheets and slider sheets assist in the patient transfers by reducing the friction between the patient and a surface, such as a bed. This allows the patient to slide easily across the surface without needing to be lifted [18]. Draw and slider sheets are typically used to move patients across horizontal platforms, or to adjust their posture while in bed [19]. Draw and slider sheets are made of low-friction fabrics or gel-filled plastics. The primary difference between them is that draw sheets have one low-friction side, whereas slider sheets have two [18].

T215903 ESC102 Request for Proposal 8 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers
A) B) C)

D)

E)

Figure 3: Examples of various transfer aids. A) Draw Sheets. B) Slider Sheets. C) Transfer Belts. D) Slide/Transfer Board. E) Turning Disks. All Photos credited to [18].

The advantage of these sheets is that they are intuitive to use and easy to manufacture, while still being effective in transferring patients. Using sheets also reduces the force required to move patients [18]. The disadvantages of the sheets are that cannot be used to transfer patients over any gaps. Draw sheets and slider sheets are less compatible with certain transfers, such as bed-to-wheelchair transfers [18]. Furthermore, two caregivers are required to perform a safe sheet transfer [20].

5.2 Transfer Belts

The transfer belt helps transfer patients by allowing the patient to perform assisted walking. This involves placing the belt around the patients waist and having the PSW hold it as the patient moves through the transfer [21]. Transfer belts can also be used to guide patients along transfer boards. Transfer belts come in a variety of sizes and shapes, and can be fastened with a buckle, clasp or Velcro. The handles may be positioned vertically, horizontally, diagonally, or in any combination of the three [21]. Padded versions are available, but while they are more comfortable for some patients, they may decrease the caregivers feeling of control if not secured properly [18]. Transfer belts provide the PSW a secure grip in transferring the patient, while also allowing them to work with a more comfortable posture. The downside of transfer belts deals with leveling the belt. If belt would be too wide or narrow it could cause problems for a patient. Transfer belts do not reduce the patients weight in any way, and are therefore not recommended for lifting patients. In fact, the use of transfer belts may cause additional stress to certain parts of the musculoskeletal system [21]. Finally, use of the handgrips limits a PSWs ability to respond to an emergency by limiting the use of their hands [18].

5.3 Slide/Transfer Boards

A transfer board is an instrument used to bridge between two horizontal surfaces such as from a bed to a stretcher. Smaller slide boards also exist, and are designed for seated lateral transfers. They are often tapered at each end and can be used to bridge a gap such as when transferring between a bed and a wheelchair [18]. Transfer boards use rollers, fabric or vinyl coverings to reduce friction across their surface, similar to draw and slider sheets, and are often used in combination with the sheets. These boards

T215903 ESC102 Request for Proposal 9 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers are suitable only for those patients who can power themselves by sliding or rolling along the board with guidance from a knowledgeable caregiver [18]. The advantage of transfer boards is that they dont require any lifting on the part of the PSW; moreover some patients may be able to transfer themselves. When a PSW needs to assist with such a transfer, it takes much less force than a manual lift [18]. The problem with transfer boards is that surfaces must be at an equal height for an easy transfer. Usage also requires the patients assistance in most cases, making the transfer board impractical. In addition, use of the boards may still require the PSW to work with awkward postures, increasing the risk of developing an MSD [18].

5.4 Turning Discs

Turning disks are used to rotate the patient during a transfer, often used in conjunction with other transfer devices [18]. Turning disks consist of two circular discs that rotate against each other. The inner surfaces are made of low-friction material, while the outer surfaces are typically high-friction. Different models of turning disk exist for pivoting seated patients or standing patients [18]. One of the advantages of the disk is that the patients feet do not need to be turned or adjusted after the transfer. Turning disks also require minimal force to rotate or pivot patients [18]. However, most disks used in transfer are bulky, which can make them difficult to transport between clients homes. In some cases, the disk can be difficult to control, moving too easily with light patients, while heavy patients require excessive force to transfer [18].

5.5 Hoyer Lifts

The Hoyer lift, a common brand of sling lift, is a complex tool that used for lifting and transferring the patient with a minimum of physical effort. The Hoyer lift uses a cradle with an attached sling to maintain the comfortable and safe position of the patient while using a moving boom and rolling base to minimize efforts of the caregiver. There are various types of Hoyer lift, such as powered lifters or hydraulic lifters. The sling is a modular component, with different slings available for different patients [22]. Hoyer lifts have been commonly found in medical institutions, including hospitals and nursing homes, for several decades [13]. PSWs rarely have access to a Hoyer lift due to its high cost and need for careful assembly and maintenance [23] [24]. Use of a Hoyer lift has been shown to reduce musculoskeletal stress noticeably when compared to other transfer devices and unaided transfers [13]. The modular nature of the sling component allows for customization to the needs of the patient [22]. The primary disadvantage of the Hoyer lift is its cost. As the most expensive transfer device, PSWs can rarely afford one. It is also comparably hard to manufacture, opposing the simple designs of the other transfer devices. Hoyer lifts are also not intuitive to use, requiring a precise understanding of how to operate them safely [22] [24].

6 Design Requirements
This section outlines the design objectives, constraints and criteria to which any proposed solution for this RFP should adhere. These requirements will help create a design space.

T215903 ESC102 Request for Proposal 10 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

6.1 High-Level Objectives:

1. Design a solution that reduces the risk of PSWs developing musculoskeletal disorders (MSDs) while performing patient transfers. 2. Design a solution that is {affordable, intuitive} for PSWs 3. Design a solution that is {safe, comfortable} for the patient being transferred.

6.2 Design Constraints:

The following constraints are strict design requirements imposed in order to assure the solutions adequately address the needs of the PSW community. Each constraint is listed in brief to maintain clarity. Any additional information regarding the constraints will be provided in footnotes.

6.2.1 Constraints Imposed By Codes and Standards

Solution MUST follow the product standards listed in CSA-Z10535-03 [25]. Solution MUST EITHER1: a. Be capable of undergoing one or more sterilization procedures listed in CSA Z314.8-08 [26]. b. Be safely disposable after use. Solution MUST NOT need to be dismantled and reassembled each time it is to be used2. Forces applied to musculoskeletal system MUST NOT exceed 1000N when lifting a patient of average weight [6]. Solution MUST allow the PSW to respond quickly to an emergency without endangering the patient. A lack of instruction in proper use of solution MUST NOT drastically endangers the PSW or patient.

6.2.2 Additional Design Constraints

6.3 Design Criteria

The following criteria are measurements provided to assess the performance of the solution in addressing the needs of the PSW community. Each criterion is listed in brief to maintain clarity. Any additional information regarding the criteria will be provided in footnotes.

Criteria
Force Applied to PSW Affordability

Reason for Criteria

This provides a metric assessing a solution ability to address the need Improves viability of solution for PSWs, given insufficient

Metric(s)
Force applied: Newtons Cost: $CDN

Target Metric(s)
Less is better. Given constraint <1000N (see above) Cheaper is better

1 2

The choice of constraint depends on if the solution is intended to be reusable or not. As PSWs that provide in-home care are sometimes required to work in multiple locations within a short period of time, this constraint allows the PSW to make use of the solution in different locations without undue strife.

T215903 ESC102 Request for Proposal 11 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers funding [14] Allows PSWs to use device in multiple locations, as required by their job Reduces risk of injury due to improper use [14] Analyzes the patients stake in a solution Determines the average amount of time before a solution must be replaced.

Portability

Dimensions: Meters Weight: Kilograms Required instruction time4: Hours Holistic measurement5 Avg. product lifespan: years

{Smaller3, lighter} is better

Intuitive Use Comfort of Patient Longevity of Product6

Less time is better More comfortable is better Longer is better

Note: The solution must still be large enough to properly assist in patient transfer. Meeting the size criterion is secondary to the high-level objectives of safely transferring the patient. 4 This refers to the amount of time required, on average, for a PSW to be properly instructed in the safe use of the solution. 5 Note: Patient comfort should be ideally measured by surveying test patients, and rating their perceived comfort levels while being transferred for example, the survey shown on page 302 of the following study [13]. 6 Note: This criterion does not apply to any solutions that are designed to be disposable.

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Appendix A Transcript of Interview: Kirsten Ballantyne

Note: Transcript redacted for anonymity of RFP Team To: Kirsten Ballantyne: 2013-01-29 Hello Ms. Ballantyne, I'm a first year student at the University of Toronto's Faculty of Applied Science and Engineering. I'm currently studying Engineering Science, and one of my projects this term looks at identifying a community within the City of Toronto, and designing a Request for Proposal around one of that community's needs. My team has chosen personal support workers as the community we would like to focus on. Is there anyone at the OPSWA, either you or someone else, that I could talk to to better understand the needs of personal support workers? Thank you for your time From: Kirsten Ballantyne: 2013-01-29 Good day, You certainly can ask questions. Please ask away. Many, I'm sure, questions you have could also be answered from out website. Www.opswa.com Looking forward to your questions, Kirsten, OPSWA communications liaison To: 2013-01-30 Hello again, Thank you for your time. I looked through the articles on available on the OPSWA website, and they definitely did help to answer some of my question. To that end, I have two questions I like to ask you. First off, are there any aspects of a personal support worker's job where the current protocols (available technology and common practices) could be improved? One of the goals of this project is improving quality of life within the chosen community, so if you can think of any facets of being a personal support worker that could be improved in such a respect would be appreciated. Secondly, referring specifically to the article about transfers and assistive devices, how present is the risk of back injury when it comes to performing transfers? Additionally, how well do the current practices and assistive devices prevent back injuries from occuring? Thanks again for your time.

T215903 ESC102 Request for Proposal 13 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers From: 2013-01-30 Good evening, The protocols and technologies in place can certainly be improved. Many company's are coming up to date and using computerized documentation programs and also telephone callin systems for signing in and out of clients homes (home care) and or for messaging systems. All institutions/facilities/residences would very much benefit from up to date technology if they have not yet implemented it. Equipment PSWs use is a rough subject. New facilities usually carry all brand new equipment. But private run facilities and or home care may not have up to date(older) or safe equipment. Or they may not have enough equipment. Due to funding or personal finances. The PSW role was a grey area in the health care field. Now it is becoming much more black and white but PSWs desperately need a governing body so all standards and practices are universal. That is the goal. It protects, most importantly, the patients/clients and as well as the PSWs. As for back injuries, many injuries of all kinds happen because of unsafe equipment or improper use. Education is a must! Learning how to safety assist transfers and how to safety use the transferring devices is so important. Body mechanics! Even a brand new piece of equipment can result in injury if a PSW does not use proper body mechanics. Knowing the equipment they are using is also important. PSWs are not to use any new equipment or use any old equipment unless they properly know how to. A supervisor or trainer is to sign off that the PSW can use it safety and correctly. From that point on the PSW is able to provide care with those devices themselves, unless... it is a lift or other device that requires 2 PSWs to use safely. Its called a "2 person transfer". I hope I managed to answer your questions? Regards, Kirsten To: 2013-01-31 Good morning, Thank you once again. Using the information given in your answers, my group has been able to begin framing our RFP. If it isn't too much trouble I do have one follow-up question. Most importantly, is there an average price range for the equipment that PSWs use? And if so, what is it? If it's different for different types of equipment, I'd be interested in knowing all the various ranges. Thanks again for your time,

From: 2013-01-31

T215903 ESC102 Request for Proposal 14 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

Good morning, I personally do not know the price ranges for the equipment used. I'm assuming since there are so many transfer devices, from hand held to mechanical, that the price range is very wide. Certain medical and home care medical shops do specialize in supplying some of these. If you google it I am sure you will find some information. I'm glad I could help, Kirsten Ballantyne OPSWA Communications Liaison

Appendix B Summary of Interview: Winnie Zhang

What do your services cover? Cleaning, Feeding, Reminding clients for taking medicine, helping client before and after shower..etc Are lifting and moving the major action while you are working? Yes, lot of the seniors are disabled to some extent, most of them require walker or cane and some of them are completely disable, so while feeding, moving them to shower, a lot of lifting, holding are required. The other primary source of lifting and moving is cleaning. How often do you feel discomfort in your muscle? It is hard to say, it sort of builds up over time. However, I do use some sort of thermotherapy such as heat bag to help relaxing my muscle. What kind of negative impacts on your spare time brought by musculoskeletal discomfort? It brings physical discomfort such as muscle ache at a certain posture and feeling of tiredness. It often ruins the mood during rest too. Remaining details are omitted due to its insignificance in the discussion

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Appendix C Select Hoyer Lift Manuals, Guides, and Specifications

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T215903 ESC102 Request for Proposal 19 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

Appendix D Selected Standards from CSA-Z10535-03

5 Mobile hoists - Specific requirements and test methods This clause specifies requirements and test methods for mobile hoists which are additional to those specified in 4. 5.1 Requirements for static strength After the static test as defined in 5.2, the hoist shall function as defined by the manufacturer. There shall be no deformation or wear that may affect its function. 5.2 Test methods for static strength The hoist and lifting devices shall be loaded statically according to the procedures and order described below. The hoist shall be placed on an inclined surface and secured against tipping but not against deformation. The lifting boom/actuator shall be set in the most adverse position. The hoist shall then be loaded with 1,25 times maximum load for 5 min in the following directions: a) 10 forwards; b) 10 backwards; c) 5 sideways in the most adverse direction (both left and right sides where applicable). The test is then performed with the surface horizontal and with 1,5 times maximum load (3.24) for 20 min. 5.3 Requirements for static stability During the static stability test according to 5.4, both unloaded and loaded with the maximum load (3.24), the hoist shall not lose its equilibrium (balance) at the following angles: a) forward and backward directions 10 with the chassis in the intended travelling position; b) forward and backward directions 7 with the chassis in the most adverse condition; c) any other direction, 5. 5.4 Test methods for static stability a) The tests shall be carried out in the forward and backward travelling directions and with the chassis in the travelling position as indicated by the manufacturer and with the load placed in the most adverse position. b) The tests shall be carried out in the forward and backward directions and in the most adverse direction. If there is more than one intended direction of travel (forwards) they shall all be regarded as forwards. c) The tests shall be carried out with the hoist in its most adverse position regarding the position of the wheels, CSP, base and brakes. Unloaded Position the unloaded hoist on the test surface with the wheels towards the stop(s). Incline the test plane gradually until the hoist loses its equilibrium (balance). Record the angle of inclination. Repeat the test in the backward and sideways directions. Loaded Attach the maximum load to the hoist's CSP in such a way that the load is able to move freely. Repeat the procedure as for the unloaded hoist. For hoists with rigid patient supports the centre of gravity of the load shall be placed in relation to the back rest according to figure 2, but not more than 350 mm from the front edge of the seat.

5.5 Requirements for immobilizing device (brakes)

T215903 ESC102 Request for Proposal 20 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers An immobilizing device shall be provided for mobile hoists. When tested in accordance with 5.6 a maximum movement of 10 mm in any direction is allowed. 5.6 Test methods for immobilizing device (brakes) To ensure that the requirement described in 5.5 above is fulfilled, a hoist shall be positioned on a 1 slope with the immobilizing device(s) activated. The maximum load shall be applied to the hoist in the most adverse position. 5.7 Requirements for moving forces The maximum forces required for moving the hoist shall be as follows when tested with the maximum load on the hoist: a) starting/turning: 160 N b) driving (pushing/pulling): 85 N 5.8 Test methods for moving forces The test shall be carried out on a flat, smooth and horizontal steel plate. The hoist shall be loaded with the maximum load (3.24) with the lifting arm set to obtain the maximum reach. The castors shall be set at 180 to the direction of pulling/pushing. Using a dynamometer, a starting force is gradually applied to the push handle until the hoist begins to move. Repeat five (5) times. The highest force noted during these tests shall be recorded as the starting force. The starting force shall be applied and recorded as follows: a) in the forward direction b) in the backward direction c) in the direction that begins to turn the hoist. 5.9 Instructions for use This clause specifies information required for mobile hoists additional to that specified in 4.11. The manufacturer shall provide the following information as a minimum: - daily check list - functional dimensions, including: a) the height of the base, in accordance with figure 4; b) the maximum/minimum external/internal width, in accordance with figures 5 and 6; c) the under-base clearance, in accordance with figure 4; d) the maximum and minimum hoisting reach (see figure 7 for example); e) the hoisting range in relation to the hoisting reach, in accordance with figure 7; f) the turning radius; g) the total mass of the hoist excluding body support unit; h) the number of parts and the identification of those parts into which the hoist can be disassembled; i) the mass of the heaviest part of the hoist.

T215903 ESC102 Request for Proposal 21 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

Appendix E Selected Standards from CSA-Z314.8-08

5 Evaluation and purchase of reusable medical devices
5.1 General 5.1.1 The facility shall have procedures for the evaluation and purchase of reusable medical devices. These procedures shall include clearly defined responsibilities, be consistent with the requirements in Clause 5, and be maintained as specified in Clauses 4.5 and 4.6. 5.1.2 When purchasing a reusable medical device, the health care facility shall confirm that it is properly licensed in Canada and meets applicable Canadian standards. Devices not manufactured for medical use shall not be used on patients. Note: See the CAN/CSA-C22.2 No. 60601 series of Standards and Health Canadas listing of active medical device licences (www.mdall.ca). 5.1.3 Purchasing decisions for reusable medical devices shall involve representatives from the departments in the health care facility that will use, reprocess, and maintain the devices. The following departments should be involved as appropriate to the complexity, risk class, and intended use of the device: (a) sterile processing; (b) purchasing; (c) operating room or other unit/department that will use the device; (d) risk management; (e) infection prevention and control; (f) occupational health and safety; (g) patient services; and (h) support services. Note: Input from risk management personnel is particularly important when purchasing devices that could endanger occupational health and safety during reprocessing, or are difficult to clean effectively (e.g., sharps and devices with narrow lumens). 5.1.4 Single-use devices or components shall be considered when purchasing sharps or devices with sharp components that cannot be cleaned safely. Note: Sharps can cause occupational injuries, and reprocessing increases the risk of such injuries occurring. Among the devices that cannot be cleaned safely are needles, lancets, blades, and glass. 5.1.5 For devices with narrow lumens or other characteristics that make them difficult to clean effectively, single-use devices or components should be considered. This decision shall be made in consultation with the facility personnel or department responsible for infection prevention and control and for risk management. Notes: (1) Patients can be placed at risk by reusable devices that cannot be cleaned effectively or that cannot be adequately checked for cleanliness during reprocessing. (2) Such devices include catheters, devices with fine cannulae or lumens, and devices with drains.

T215903 ESC102 Request for Proposal 22 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers 5.2 Manufacturers instructions 5.2.1 Prior to purchasing a new medical device, health care facility personnel shall review the manufacturers instructions to ascertain that the recommended decontamination procedures (a) are device specific, legible, and understandable; (b) clearly indicate which parts need to be disassembled, and provide clear disassembly instructions (including illustrations where necessary); (c) can be achieved, given the resources of the facility; (d) are in accordance with the intended use of the device; (e) state whether or not the device is immersible; (f) specify the necessary materials (i.e., detergents, enzymatic solutions, etc.) and equipment for proper cleaning and maintenance of the device; and (g) specify if there is a limit to the number of times the device can be reprocessed, or if reprocessing will contribute to degradation of the medical device. Note: See CAN/CSA-ISO 17664 for additional information on the information that manufacturers should supply. Written confirmation that the reprocessing instructions have been validated shall be obtained from the device manufacturer. 5.2.2 If the instructions are unclear, incomplete, or inadequate, the manufacturer shall be contacted for clarification or additional information. If clear, validated instructions are unavailable for a device, it shall not be purchased unless the health care facilitys risk management, biomedical engineering, and infection prevention and control personnel provide written confirmation that the device can be reprocessed and reused based on internally-developed procedures. Note: Facilities that are not able to obtain the relevant instructions can report problems to the following: (a) Health Canada at (i) 1-800-267-9675; (ii) mdpr@hc-sc.gc.ca; or (iii) www.hc-sc.gc.ca/dhp-mps/compli-conform/prob-report-rapport/mavprfmdrioevraim_tc-tm_e.html (b) Medical Devices Canada (MEDEC) at 1-866-58-MEDEC. 5.2.3 All manufacturer information shall be received and maintained in printed form (e.g., in binders, manuals, or monographs) or in electronic format, or both, so as to facilitate device maintenance, as well as staff training and education. 5.3 Initial processing All newly purchased, non-sterile devices shall be inspected and decontaminated before further processing or use. Critical devices shall be sterilized. Depending on their intended use, semi-critical and non-critical devices shall be cleaned and disinfected as appropriate. Notes: (1) Many newly purchased devices are received non-sterile from the manufacturer and require cleaning prior to disinfection and sterilization. Anti-corrosive and anti-rusting agents such as oils, greases, or waxes are sometimes applied to the device by the manufacturer in order to protect it during shipping. Such agents will interfere with sterilization if not removed. Manual washing is in some cases necessary to remove these agents; consult the manufacturers instructions for initial cleaning. Questions on procedures should be referred to the manufacturer. (2) Guidance on reprocessing of heat-sensitive devices requiring sterilization or high-level disinfection should be soughtfrom the manufacturer.

T215903 ESC102 Request for Proposal 23 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers

Appendix F -- References
[1] I. U. Zeytinoglu and M. A. Denton et al., "Self-Reported Musculoskeletal Disorders Among Visiting and Office Home Care Workers," Women & Health, vol. 31, 2000. [2] Ontario Personal Support Worker Association, "What is a PSW?," 2010. [Online]. Available: http://opswa.com/Articles/What-is-a-PSW-.aspx. [Accessed 30 January 2013]. [3] K. M. MacQueen and E. McLellan et al., "What Is Community? An Evidence-Based Definition for Participatory Public Health," American Journal of Public Health, vol. 91, no. 12, pp. 1929-1938, 2001. [4] D. Felce and J. Perry, "Quality of life: Its definition and measurement," Research in Developmental Disabilities, vol. 16, no. 1, pp. 51-74, 1995. [5] B. Zhao, Perceptions of Quality of Life and Use of Human, 2004. [6] Merriam-Webster, "Need - Definition," 2013. [Online]. Available: http://www.merriamwebster.com/dictionary/need?show=0&t=1360945280. [Accessed 20 January 2013]. [7] T. R. Hales and B. P. Bernard, "Epidemiology of work-related musculoskeletal disorders," Orthopedic Clinics of North America, vol. 27, no. 4, pp. 679-709, 1996. [8] Bureau of Labor Statistics, Table 12: Number and median days of nonfatal occupational injuries and illnesses with days away from work involving musculoskeletal disorders by selected occupations, 2001, U.S. Department of Labor, 2003. [9] M. Hagberg and B. Silverstien et al., Work Related Musculoskeletal Disorders (WMSDs), London: Taylor & Francis, 1995, pp. 5,6,146-155. [10] W. S. Marras and G. G. Knapik et al., "Lumbar spine forces during manoeuvring of ceiling-based and floor-based patient transfer devices," Ergonomics, vol. 52, no. 3, pp. 398-397, March 2009. [11] S. M. McGill, "The Biomechanics of Low Back Injury: Implications on Current Practice in Industry and the Clinic," Journal of Biomechanics, vol. 30, no. 5, pp. 465-475, 1997. [12] S. J. Bigos and M. C. Battie et al., "A Prospective Study of Work Perceptions and Psychosocial Factors Affecting the Report of Back Injury," Spine, vol. 16, no. 1, 1991. [13] J. A. Johansson, "Psychosocial work factors, physical work load and associated musculoskeletal symptoms among home care workers," Scandinavian Journal of Psychology, vol. 36, pp. 113-129, 1995. [14] K. Ballantyne, Interviewee, Communications Liaison, Ontario Personal Support Worker Association. [Interview]. 29-31 January 2013. [15] College of Nurses of Ontario, "Become a Nurse in Ontario - How to Apply," 01 January 2013. [Online]. Available: http://www.cno.org/en/become-a-nurse/new-applicants1/ontario/. [Accessed 06 February 2013]. [16] T. Yonetsuji and Y. Takebe et al., "A Measurement and Evaluation Method of a Support System to Teach How to Improve Transferring Patients," in Proceedings of the 2011 IEEE International

T215903 ESC102 Request for Proposal 24 Reducing the Risk of Musculoskeletal Disorders in Personal Support Workers Conference on Robotics and Biomimetics, Phuket, Thailand, 2011. [17] A. Garg and B. Owen et al., "A biomechanical and ergonomic evaluation of patient transferring tasks: bed to wheelchair and wheelchair to bed," Ergonomics, vol. 34, no. 3, pp. 289-312, 1991. [18] J. Lum and J. Sladek et al., "Ontario Personal Support Workers in Home and Community Care: CRNCC/PSNO Survey Results," Toronto, 2010. [19] W. Zhang, Interviewee, Carefirst Seniors & Community Services Association. [Interview]. 10 February 2013. [20] Ontario Community Support Association, "PSW Standards," 2009. [Online]. Available: http://www.ocsa.on.ca/userfiles/PSW_Training_Standards.pdf. [Accessed 10 February 2013]. [21] A. Laupacis and K. Born, "Ontario's Plan for Personal Support Workers," 10 May 2012. [Online]. Available: http://healthydebate.ca/2012/05/topic/community-long-term-care/personal-supportworkers. [Accessed 10 February 2013]. [22] Government of Ontario, "Ontario Regulation 79/10," 2010. [23] Workers' Compensation Board of British Columbia, Transfer Assist Devices for Safer Handling of Patients: A Guide for Selection and Safe Use, 2006 ed. ed., British Columbia, 2006. [24] B. R. Hegner and J. F. Needham, Assisting in Long-Term Care, 4 ed., Clifton Park, New York: Delmar Thomson Learning, 2002, p. 245. [25] S. Thompaon, "Manual handling 2 - repositioning a surpine patient using a slide sheet," 12 January 2009. [Online]. Available: http://www.nursingtimes.net/nursing-practice/student-nurses/manualhandling-2-repositioning-a-supine-patient-using-a-slide-sheet/1963080.article. [26] C. Lawrie, "Leading the way: Ontario campaigns against influenza," The Safe Angle, vol. 4, no. 1, January 2002. [27] C. M. Magistro and R. W. Bohannon, How To Use a Patient Lifter: A Positioning and Transfer Guide, Sunrise Medical. [28] "Preferred Health Choice," [Online]. Available: http://www.phconline.com/Hoyer_Lift_Supply_s/44.htm. [29] Sunrise Medical, Hoyer Hydraulic Patient Lifters: User Instruction Manual & Warranty. [30] Canadian Standards Association, Hoists for the transfer of disabled persons - Requirements and test methods, 2003. [31] Canadian Standards Association, Decontamination of reusable medical devices, 2009. [32] Canadian Centre for Occupational Health and Safety, 2005.