Health and Safety Executive

CORPORATE SCIENCE, ENGINEERING AND Project ANALYSIS DIRECTORATE Report Human Factors, Ergonomics and Psychology

RISK MANAGEMENT OF MUSCULOSKELETAL DISORDERS IN SONOGRAPHY WORK

Authors: Simon C Monnington1 Katie Dodd-Hughes Edmund Milnes Yasmeen Ahmad

Date: 23 March 2012

HSE Government Buildings, Ty Glas, Llanishen, Cardiff, CF14 5SH

EXECUTIVE SUMMARY

INTRODUCTION Healthcare professionals undertaking diagnostic imaging work using ultrasound equipment have a high prevalence of musculoskeletal disorders (MSD). There is a substantial amount of published information on MSD risk management specific to sonography. However, it is not clear how this information translates into practice in the UK. This report describes a project to examine MSD risk management performance across a range of sonography operations at UK NHS Trusts. This report is aimed at healthcare professionals involved with sonography work, their professional bodies and trusts that employ sonographers and operate services. It is also aimed at manufacturers of sonography equipment and training providers. This report will also be of use to regulators and other health and safety professionals involved with the health service.

MAIN FINDINGS Inspections of 14 NHS trusts in the UK were undertaken in 2007 to examine how effectively MSD risks were managed in sonography work. Overall, performance was found to be much less effective than it should be. This is cause for concern because of the high levels of MSD associated with sonography professionals and the large amount of industry specific guidance in existence. The main issues were:

 Risk assessments generally weren’t suitable and sufficient  Despite widespread awareness of the MSD risks to sonographers, action to tackle the problems tended to be superficial  Risk reduction and controls were generally not comprehensive enough to reach the ‘so far as is reasonably practicable’ standard  Workload was generally high in sonography. Work organisational / psychosocial factors were seldom sufficiently assessed and controlled, despite their apparent influence in reducing risk  In most cases training did not adequately address MSD risks, and how to conduct best practice scanning  Occupational Health provision, whilst generally good, tended not to be used proactively for sonographers  Health monitoring was rare, even for individuals with established MSD problems  Manufacturers and education providers have a key role in developing improved systems in sonography work. Both should take account of and facilitate fundamental changes to current scanning practice  Generally, the arrangements for sonography work could be improved which would improve efficiency as well as the health of sonographers.

To deliver a sustainable, efficient and safe sonography service the human factors issues in sonography need to be tackled in a thorough and fundamental way.

Improving standards Trusts should adopt the HSG60 seven stage approach for managing MSDs in sonography and across other specialist departments. The evidence strongly suggests that action is needed most in risk assessment and control. NHS trusts should provide the necessary resources to help all departments tackle their MSD risks effectively.

Efforts should be coordinated across all sonography modalities at a trust. Work organisation should be a central target. Increased sonographer control of their work should be considered as well as efforts to balance workload to enable rest breaks to be taken. Suitable changes to the physical environment like the introduction of slave

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monitors can be effective. The potential of introducing fundamental changes in sonography practice such as scanning with both hands and making effective use of voice activated systems should be a priority. There is a clear role for equipment manufacturers and education providers in developing / facilitating improvements to sonography systems of work supported by feedback of users.

Further detailed actions concerning sonography work are contained in this report.

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CONTENTS 1 INTRODUCTION .............................................................................................................. 1 1.1 Musculoskeletal disorders (MSD) in sonographers _____________________ 1 1.2 Key information on managing MSD risks in sonographers _______________ 2 1.3 Project aims and objectives ________________________________________ 2 2 PROJECT APPROACH.................................................................................................... 3 2.1 Checklist development ____________________________________________ 3 2.2 Project briefing___________________________________________________ 3 2.3 Project inspections _______________________________________________ 3 3 INSPECTION FINDINGS ................................................................................................. 4 3.1 Awareness of MSD risks ___________________________________________ 4 3.2 Occupational health provision ______________________________________ 4 3.3 MSD Monitoring __________________________________________________ 4 3.4 Scanning workload _______________________________________________ 5 3.5 MSD risk assessment _____________________________________________ 5 3.6 Risk reduction and control _________________________________________ 6 3.7 Worker involvement_______________________________________________ 7 3.8 Sonography workstation ___________________________________________ 8 3.9 Education and training ____________________________________________ 8 3.10 Patients with a high body mass index ________________________________ 9 3.11 Other DSE work __________________________________________________ 9 3.12 Professional and training issues ____________________________________ 9 3.13 Human performance _____________________________________________ 10 3.14 Sonography equipment manufacturers ______________________________ 10 3.15 Ergonomics and sonography education _____________________________ 12 4 CONCLUSIONS ............................................................................................................. 13 5 ACTIONS........................................................................................................................ 14 5.1 Risk management approach _______________________________________ 14 5.2 Risk reduction and control measures _______________________________ 15 5.3 Work organisational aspects ______________________________________ 17 5.4 Training and educational providers _________________________________ 17 5.5 Manufacturers __________________________________________________ 18 6 REFERENCES ............................................................................................................... 20 APPENDIX 1 .......................................................................................................................... 21 SUMMARY OF AN EVALUATION OF MUSCULOSKELETAL DISCOMFORT EXPERIENCED BY SONOGRAPHERS (DODD-HUGHES, 2008) ....................................... 21

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LIST OF FIGURES

Figure 1.1. Examples of sonography procedures and the range of awkward postures involved. Left, a vascular examination of the lower limbs giving rise to reaching, and twisting of the trunk as the sonographer applies the transducer with one hand and squeezes the muscle with the other. Right, an early pregnancy scan giving rise to extension and deviation of the wrist as the transducer is applied and finely moved to give an appropriate image on the screen. ______________________________________________________ 1 Figure 3.1. The range of scan times for various sonography modalities. ______ 5 Figure 3.2. The distribution of assessment methods used in sonography departments. ____________________________________________________ 6 Figure 3.3. Examples of poor standards of DSE set up in sonography consult rooms. _________________________________________________________ 9 Figure 5.1. A ceiling mounted slave monitor positioned to be viewed by a patient laying on the couch. The US machine can be seen positioned at the side of the couch. ________________________________________________ 15 Figure 5.2. The scanease limb / tranducer support system. _______________ 16 Figure 5.3. A simple cable support that reduces loading at the wrist associated with cable sag. _________________________________________ 16 Figure 5.4. Alternative design sonography system. ______________________ 18 Figure 5.5. A small portable ultrasound machine used for ward based examinations. ___________________________________________________ 19

LIST OF TABLES

Table 3.1. Examples of control measures to reduce MSD risk.Error! Bookmark not defined. Table 3.2. Worker involvement and MSD risk control RCI results. ___________ 7

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1 INTRODUCTION Diagnostic imaging using ultrasound equipment is an effective and useful tool for a range of clinicians in the National Health Service (NHS). Ultrasound uses high frequency sound waves to produce a real time image of the internal body. These images are used to check function, look for abnormalities and take measurements and stills for the most part non-invasively. Three main professions do ultrasound work: Radiographers work in obstetrics, gynaecology and general ultrasound; Cardiac Technicians undertake echocardiography (the heart); and Vascular Technicians investigate blood vessels using ultrasound. Midwives can undertake aspects of the obstetric work (e.g. dating scans etc). Ultrasound equipment is also deployed in musculoskeletal investigations. Medical practitioners can also use ultrasound machines. Sonography work involves an operator guiding a handheld transducer against the patient’s body while simultaneously monitoring a screen and using a keyboard to control / record the image.

1.1 Musculoskeletal disorders (MSD) in sonographers Several studies have identified aspects of sonography work that were associated with MSD. These included (fig 1.1): one-sided static working position; prolonged pinch gripping of the ultrasound transducer; abduction at the shoulder during transducer placement; and insufficient recovery time (Vanderpool et al, 1993; Magnavita et al, 1999; Schoenfeld et al, 1999; and Village and Trask, 2007). Most recently, Dodd-Hughes (2008) found evidence that work organization (psychosocial) factors (such as demand, control, support and role) as well as physical factors were associated with musculoskeletal problems in a sample of UK sonographers (see appendix 1 for a summary of this research). Musculoskeletal disorder prevalence rates in excess of 80% have been reported for sonographers in the literature (Smith et al. 1997; Magnavita et al, 1999 and Dodd-Hughes, 2008). Worryingly, Brown and Baker (2004) found that around 20% of sonographers reportedly left the profession due to persistent discomfort. The Society of Radiographers recently publicised a civil case where an ex-sonographer was awarded almost £230k for her career ending MSD.

Figure 1.1. Examples of sonography procedures and the range of awkward postures involved. Left, a vascular examination of the lower limbs giving rise to reaching, and twisting of the trunk as the sonographer applies the transducer with one hand and squeezes the muscle with the other. Right, an early pregnancy scan giving rise to extension and deviation of the wrist as the transducer is applied and finely moved to give an appropriate image on the screen.

1.2 Key information on managing MSD risks in sonographers The Society of Diagnostic Medical Sonography (SDMS, 2003) developed consensus guidance on industry standards for the prevention of work related MSDs in sonographers. This process involved a number of key stakeholders including equipment manufacturers. The guidance described a range of useful ergonomics measures concerning:

 Equipment - ultrasound machine, table, chair, monitor etc  Work organisation - workload, scheduling and work area  Professional issues - adoption of best practice and training

The Society of Radiographers (2003 and 2007) in the UK produced useful documentation to help trusts, departments and individuals to tackle the risks of MSD that appear to be linked to sonography work. The Health and Safety Executive (HSE) has produced guidance material that is not specific but highly applicable to the management of MSD risks in sonography. For example, HSG 60 – upper limbs disorders and L26 - the display screen equipment (DSE) regulations (sonography is classed as DSE work).

The above indicates there is a useful amount of information available on the management of MSD risks associated with sonography. It was not clear how far this had been used in practice and HSE Sector, Specialists and Operational Inspectors have been aware of a number of trusts tackling problems related to MSD affecting their ultrasound imaging staff. Consequently, a project was undertaken to examine MSD risk management performance in sonography within the NHS.

1.3 Project aims and objectives This report describes a Specialist Inspector (Ergonomics and Human Factors) project examining the management of MSD risks associated with sonography work in the NHS.

The work delivered an inspection project examining MSD risks to sonography workers within the healthcare sector. Reference is made to stress issues where that could exacerbate MSD risks however risks of work related stress without an MSD link were outside the scope of the work. The focus was on establishing custom and practice with respect to management of MSD risks. The intention was to assess uptake and implementation of a range of risk reduction and control measures for sonography tasks.

This report is aimed at healthcare professionals involved with sonography work, their professional bodies and trusts that employ sonographers and operate services. It is also aimed at manufacturers of sonography equipment and training providers. This report will also be of use to regulators and other health and safety professionals involved with the health service.

2 PROJECT APPROACH 2.1 Checklist development Pilot visits were carried out to obtain relevant information on sonography tasks and issues that surround the sonographer within their workplace. This information was used in conjunction with current and available guidance to develop the checklists for use by the participating Specialist Inspectors (Human Factors and Ergonomics). Two checklists were developed, one aimed at the NHS Trust and the other for the individual departments. The Trust checklist contained items to prompt the inspector to consider aspects such as Trust awareness of MSD issues, occupational health provision and the approach used to monitoring and investigate cases. The department checklist considered the number, range and duration of scans undertaken; risk assessments; and controls measures implemented.

2.2 Project briefing A team briefing was undertaken to ensure that members of the inspection team were fully aware of the issues surrounding sonography, the aims of the visits and what needed to be delivered. A briefing pack was issued that contained relevant information: a literature review concerning MSD in sonography; the checklists; industry good practice guidance; and useful information from manufacturers and suppliers.

2.3 Project inspections An opportunistic sampling approach was used to select trusts for inspection. Local HSE inspectors were contacted and potential candidates for inspection were identified. Scenarios when an inspection was considered particularly useful included Trusts that had raised sonography work as an issue or perhaps introduced measures to reduce the risks that the local inspector had been made aware of. Not all inspections were selected in this way but the potential bias associated with selecting visits in this way needs to be acknowledged. Checks with professional bodies representing sonographers strongly suggested that the standards that were observed were a reasonable reflection of UK wide sonography practice. Each visit used the checklists as a basis for the inspection to promote consistency of approach. Checklists were completed for each trust and the departments visited. Each trust visited was presented with the specific findings and actions. The completed checklists were returned to the project leader for analysis.

3 INSPECTION FINDINGS Thirty-two departments undertaking sonography work were inspected from 14 NHS Trusts across the UK. All trusts conducted obstetric and general radiology sonography. Seven (50%) trusts operated an echo cardiology service and 12 (85%) operated a stand alone vascular service. The trusts were located UK wide (4 in Wales, 2 in Scotland and 8 in England). The sample was not selected at random but it was considered to reasonably reflect sonography practices in the UK.

3.1 Awareness of MSD risks Awareness of sonographers being a group of workers with a particular MSD issue was exceptionally high in the departments and trusts visited. In 94% of departments visited managers were aware of individuals having experienced or currently experiencing MSD problems attributed to their work. In at least 4 trusts visited awareness of the MSD issue in sonography at the trust level was stimulated by employee litigation claims. As a result, Inspectors did not need to persuade managers and staff that MSDs were a real concern requiring attention.

An overwhelming majority of departments (96%) were aware of some form of guidance on the topic. The most commonly cited guidance was from the Society of Radiographers (SoR) and HSE’s guidance on the Display Screen Equipment Regulations (L26). The SoR has done an effective job of raising levels of awareness but this may well have been limited to sonography modalities operated and run by Radiographers. Echo and vascular teams were less aware of the SoR guidance. In addition, guidance and information on MSD provided by their respective professional bodies appeared to be much less comprehensive than that supplied by the SoR. It is important to note that there is a great deal of commonality between sonography modalities in terms of the range and depth of MSD risks present in their professions. Hence, all modalities can make effective use of the range of existing guidance and should do so. It should be recognised that the industry has raised the issues of MSD in sonography to a large extent prior to this project.

A small opportunistic sample of sonographers in each department was asked about the musculoskeletal problems they had experienced. In common with the extensive literature supporting a high prevalence of MSD in sonography staff the interviews identified that nearly 90% had experienced some type of musculoskeletal discomfort during their career. Around half of the interviewees reported the discomfort they experienced as ‘severe’. Almost 30% of those experiencing problems had also taken time off work as a result. There was strong agreement between the findings of the sonographer interviews and department manager awareness of MSD problems in their unit.

3.2 Occupational health provision All of the trusts reportedly had systems in place for prompt access to occupational health support. However, it was unclear why, given that so many sonographers experienced musculoskeletal ill- health, occupational health support was not being utilised more often than it was? In some cases time pressure and workload may have been enough to deter sonographers seeking assistance. There were signs that some staff considered pain and discomfort to be ‘part of the job’. Most Trusts investigated MSD incident reports with support from the BackCare Advisor and / or Occupational Health (OH). Triggering the involvement of these professionals appeared to take a mostly reactive route. It was also found that 85% of trusts’ investigation process included identifying remedial actions. This suggested that most trusts recognised that part of the investigation process was to identify and implement interventions that will reduce the risk of injury occurring again.

3.3 MSD Monitoring Effective and informative health monitoring for MSD was not widely observed at the trusts / departments visited. In fact, MSD monitoring was identified in just 35% of the Trusts visited and these were usually passive and reactive in nature.

3.4 Scanning workload Sonographers can be expected to undertake up to 35 scans per day. Most departments seemed to operate in the range of 12 to 20 scans per sonographer per day. The number of scans did vary with department function and the mix of full and part time staff. The quickest scans can take as little as 5 minutes to complete but some abnormality, abdominal, echo and vascular scans can take between 25 – 50 mins to complete. Most general ultrasound departments tended to work on a 15 to 20 minute slot for scans when booking appointments. It seemed challenging for a general or obstetric department to work effectively using a standard expected slot time given the wide range of scan times reported (figure 3.1). Sonographers often commented that their work load encroached on their planned breaks. Some suggested that their workload was such that they were left with insufficient time for a proper lunch break. Extensions to the working day were frequently mentioned and at some departments it appeared to be common practice for extra patients to be added to the, already full, work list. There were suggestions that sonographers have been instructed to increase the