industry-standards-for-the-prevention-of-work-related

INDUSTRY STANDARDS FOR THE

PREVENTION OF WORK RELATED

MUSCULOSKELETAL DISORDERS IN

SONOGRAPHY

DEVELOPED THROUGH A 2016 CONSENSUS CONFERENCE

HOSTED BY THE SOCIETY OF DIAGNOSTIC MEDICAL

SONOGRAPHY

SUMMARY

The Industry Standards for the Prevention of Work Related Musculoskeletal Disorders (WRMSDs) in

Sonography is the work product of a 2016 Consensus Conference on Work Related Musculoskeletal

Disorders involving 26 sonography-related professional organizations, accreditation bodies, and

manufacturers. The organizations listed below, working collaboratively, and representing the

sonographic professional community, updated the 2003 standards for use by clinical, academic, and

manufacturing related sonographic industries. The objective of this project was to produce a detailed

resource that, when implemented, may assist in the reduction of WRMSDs among users of sonographic

equipment.

2016 CONSENSUS CONFERENCE SPEAKERS

The following content experts presented on occupational safety and health, the current research on

WRMSDs in sonography, and point-of-care and sonography at the Consensus Conference.

Occupational Safety and Health

Susan L. Murphey, BS, RDMS, RDCS, CECD

President, Essential WorkWellness

Current Research on WRMSDs

Kevin D. Evans, PhD, RT(R)(M)(BD), RDMS, RVS, FSDMS

Professor, The Ohio State University/College of Medicine

Laboratory for Investigatory Imaging, Director

Point-of-Care and Sonography

Dan Merton, BS, RDMS, FSDMS, FAIUM

Senior Project Manager, ECRI Institute

2016 CONSENSUS CONFERENCE ATTENDING ORGANIZATIONS

The following organizations were represented at the Consensus Conference. The organizations that have

formally endorsed the document are identified with the † symbol. Supporting organizations are

identified with the * symbol. (Note: Some organizations have internal policies that do not permit

endorsement of external documents. "Supporting organization" denotes a more limited level of review

and approval than endorsement and means the organization considers the clinical document to be of

educational value, although it may not agree with every recommendation or statement in the

document.)

 AHRA: The Association for Medical Imaging Management †

 Alliance for Physician Certification & Advancement *

 American College of Phlebology

 American College of Radiology

 American Institute of Ultrasound in Medicine *

 American Registry for Diagnostic Medical Sonography *

 American Registry of Radiologic Technologists †

 American Society of Echocardiography †

 Biodex Medical Systems, Inc.

 Cardiovascular Credentialing International *

 Carestream

 ECRI Institute *

 ESAOTE †

 Essential WorkWellness †

 GE Healthcare *

 Intersocietal Accreditation Commission

 Joint Review Committee on Education in Cardiovascular Technology

 Joint Review Committee on Education in Diagnostic Medical Sonography †

 Medical Positioning, Inc. †

 Mindray/Zonare

 Philips

 Society of Diagnostic Medical Sonography †

 Society of Radiologists in Ultrasound †

 Society for Vascular Ultrasound †

 Society of Nuclear Medicine and Molecular Imaging Technologist Section

 Sonography Canada *

 Sound Ergonomics †

OTHER SUPPORTING/ENDORSING ORGANIZATIONS

Other organizations that did not participate in the Consensus Conference, but have formally endorsed

the document are identified with the † symbol. Non-participating supporting organizations are identified

with the * symbol. (Note: Some organizations have internal policies that do not permit endorsement of

external documents. "Supporting organization" denotes a more limited level of review and approval

than endorsement and means the organization considers the clinical document to be of educational

value, although it may not agree with every recommendation or statement in the document.)

 Australasian Sonographers Association †

 Committee on Accreditation for Advanced Cardiovascular Sonography *

 Samsung †

ACKNOWLEDGEMENTS

The SDMS would like to acknowledge and thank Susan L. Murphey BS, RDMS, RDCS, CECD of Essential

WorkWellness for her work compiling the input of the 2016 Consensus Conference attendees into the

updated Industry Standards for the Prevention of Work Related Musculoskeletal Disorders (WRMSDs) in

Sonography.

BACKGROUND

Work Related Musculoskeletal Disorders (WRMSDs) are painful injuries affecting the muscles, nerves,

ligaments, and tendons of up to 90% of sonographers and other users of diagnostic medical sonography.

WRMSDs develop gradually over a period of time from repeated exposure to risk factors and are among

the most frequently reported cause of restricted or lost work time. WRMSDs can impose a substantial

personal toll on those affected since they may no longer be able to work or perform simple personal

tasks and activities of daily living.

The Industry Standards for the Prevention of Work Related Musculoskeletal Disorders in Sonography

were developed to expand, and make specific to sonography, abatement methods included in the

Occupational Safety and Health Act, which is supported by the Occupational Safety and Health

Administration (OSHA) and National Institute for Occupational Safety and Health (NIOSH).

INDUSTRY STANDARDS FOR THE PREVENTION OF WORK

RELATED MUSCULOSKELETAL DISORDERS IN SONOGRAPHY

Work Related Musculoskeletal Disorders (WRMSDs) affect many sonographers, sonologists, and other

users of medical ultrasound equipment. Preventing injury or managing the progression of symptoms can

be achieved by improving working posture and the ergonomics of the work environment. Maintaining a

neutral posture, where there is the least amount of stress on the musculoskeletal system, is one of the

fundamental principles of proper ergonomic design in the workplace. When risk factors cannot be

completely eliminated, it is important to limit the time spent in risk-producing postures in order to

reduce exposure.

Proper ergonomics must be an integral part of all aspects of the practice of sonography. The risks for

WRMSDs among sonographers include a broad range of contributing factors. Therefore, the employer,

manufacturer, sonographer/user, industry organizations, and educational programs all have the

responsibility to do their part to educate, train, exercise best practices, and provide equipment and

working conditions to prevent health and safety problems that cause WRMSDs.

I. MANUFACTURER’S RESPONSIBILITY/SCANNING WORKSTATION

With compelling evidence for WRMSDs in sonography, manufacturers must include ergonomics

as a primary consideration in the design of apparatus and equipment. Innovative design

addressing the ergonomics of workstation equipment for the sonographer/user can improve

postural positioning and image acquisition and ultimately, exposure to risks associated with

WRMSDs. The design of sophisticated and ergonomic workstation equipment (e.g. the

ultrasound system, exam table, chairs, and ancillary equipment) assists in improving comfort

and diagnostic accuracy, thus reducing sonographer/user fatigue and risk for injury.

A. ULTRASOUND SYSTEM

This section of the Industry Standards is specific to console based floor-standing models.

See Section B for recommendations for point-of-care (POC) and compact systems.

1. SYSTEM CONSOLE

a) System console should be fully adjustable for seated or standing use for

the anthropometrics of the 5

to 95

percentile of the user population.

b) System should be designed to be used in a seated position with

adequate clearance for legs and knees.

c) Easily accessible controls for achieving two-wheel and four-wheel

mobility, steering, and braked positions are recommended. For patient

and worker safety, system should have central locking brakes.

d) The base of the console should not interfere with the ability of

sonographer/user to position themselves close to the exam table while

maintaining direct access to the system.

e) It is recommended that systems be designed to support external devices

(e.g. external monitors, printers, recording devices, etc.) which do not

interfere with the adjustability of the system or the sonographer/user’s

ability to maintain a neutral posture.

f) Console footrest configurations that support the length of the foot and

encourage neutral position of the ankle are recommended.

g) Transporting equipment should not require more than 50 pounds of

push/pull force by a single sonographer/user. Otherwise, it is

recommended that additional personnel or motorized devices assist in

moving the equipment.

h) Primary transport handles should be adjustable in height and extend far

enough from the system to allow for leg clearance in a normal stride.

i) System height should be compatible with height differences for the user

population and ensure a full field of vision during transport.

j) Power cord length should be suitable for access to electrical outlets

without creating tripping or other safety hazards and with appropriate

storage for Ethernet and power cords during transport.

k) System should support the connection of multiple transducers to reduce

the frequency of manipulating transducer port connectors.

l) Systems that utilize a battery pack are recommended to have a battery

standby or scan time of at least 20 minutes.

2. CONTROL PANEL

a) Control panel should be height-adjustable, separate from the video

display monitor.

b) An appropriate degree of tilt is recommended to provide visibility of

control panel icons by seated or standing sonographer/user while

maintaining a neutral position of the wrist and forearm.

c) Control panel should include horizontal and rotational movement to

allow sonographer/user to work with a neutral position of the non-

scanning arm.

d) Touchscreens and/or keyboards should not restrict the ability to

maintain neutral posture, including limiting excessive reaching beyond

primary reach zone.

e) Software programming for the control panel should be aimed at

reducing keystrokes with the option of customizable controls based on

individual sonographer/user preferences.

f) Control panel should have an easily accessible, easy to use locking

mechanism for transporting and repositioning of the system.

g) Control panel layout should be user centered for both right and left-

handed sonographer/users.

h) Recommended control panel font size is equal or greater to ten

millimeters. QWERTY lettering should be of a contrasting color to the

key surface, with illumination, preferably adjustable in brightness. Key

surface should be greater or equal to six millimeters.

3. MONITORS

a) Monitors should be adjustable, separate from the control panel, with

the following features:

(1) Height adjustability appropriate for the anthropometrics of the

to 95

percentile of the user population and specific to the

demographic area of the users to minimize excess neck

flexion/extension

(2) Horizontal adjustability to maintain line of sight during scanning

without rotation of the neck

(3) Adjustable tilt

(4) Depth adjustability to achieve the OSHA recommended eye-

monitor distance of 20-40 inches, with font size appropriate for

viewing at corresponding distance

(5) Handle to facilitate single-handed adjustments of height, tilt,

and horizontal movement

(6) Locking mechanism with folding/collapsible feature for

transport to maintain clear line of sight

(7) High resolution with anti-glare properties that allows viewing

from seated or standing postures

b) Design of monitor arm should allow for single-handed adjustment in all

positions.

4. TRANSDUCERS

a) Transducers and cables should be lightweight and balanced to minimize

torque on the wrist.

b) Transducer designs that facilitate a palmar grip and a neutral wrist

position are recommended.

c) Transducer housing should be slip resistant and sized to fit the 5

percentile of the hand size of the user population to reduce grip

force required to hold and manipulate the transducer.

d) It is recommended that cables be a suitable length for intended

applications and not interfere with access to equipment, system

interaction, or create safety hazards such as tripping or entanglement.

e) Low profile and easily accessible cable management systems are

recommended.

f) Transducer holders should be easily accessible with the ability to secure

a variety of probes, including endocavitary probes.

g) Transducer connector should be easily accessible, with minimal reach

and permit single-handed use with minimal force or pinch grip; if

applicable, customizable controls on transducers are recommended.

5. EXAMINATION TABLE

a) Tables should be height-adjustable to allow sonographers/users of

various stature to scan in a seated or standing position, maintaining an

arm abduction of less than 30 degrees. Electronic controls are

recommended.

b) Tables should be capable of being adjusted low enough for unassisted

access by patients, lateral transfers from wheelchairs, and/or in

accordance with applicable safe patient handling legislation.

c) Tables should be compatible for use with patient lifting devices.

d) Tables should have fully maneuverable wheels with wheel locks and

steering controls that are easily operated and accessed from scanning

position; a central wheel locking mechanism is recommended.

e) Tables should provide adequate clearance for the chair base and foot

ring, without restricting the ability of the sonographer/user to sit close

to the exam table. Clearance for knees and feet when seated at the

head or foot of the exam table is recommended.

f) For endovaginal scanning, tables should have easily accessible and

adjustable footboard and stirrups.

g) For cardiac imaging, tables should have an easily operated cardiac

access panel, drop away, or cut out section to allow unhindered access

to the apical region, without compromising the wrist/hand posture of

the sonographer/user.

h) For lower extremity venous reflux studies, tables must have the

capability to achieve reverse Trendelenburg to a minimum of 15

degrees and up to 25 degrees, with a footboard for patient safety.

i) A suitable patient chair or exam table is recommended for examinations

requiring the patient to be in a seated position, with access to the

region of interest, without compromising the posture of the

sonographer/user.

j) If side rails are present, they should not extend beyond the surface of

the table when retracted, limit access to the patient, or result in contact

stress to the sonographer/user in the lowered/stored position.

k) The following features may improve sonographer/user comfort and

assist in reducing scan time by improving patient positioning depending

on the procedure:

(1) Trendelenburg and reverse Trendelenburg to a minimum of 15

degrees; 25 degrees reverse Trendelenburg for lower extremity

venous reflux studies

(2) Fowler back (adjustable table back)

(3) Arm extension

(4) Patient safety straps

(5) Electronic controls that are accessible, easy to use, and do not

obstruct optimal patient positioning.

(6) Patient foot support (foot board)

6. SCANNING CHAIR

a) Chairs should be height-adjustable with sufficient range to allow for

neutral posture for the 5

to 95

percentile of the user population.

Height adjustment controls should be accessible from the seated

position. Height range should be suited to the type of exams being

performed and exam table specifications.

b) Chairs should have the following adjustable features, accessible from

the seated position:

(1) Adjustable lumbar support

(2) Adjustable seat depth for thigh support

(3) Adjustable footrest that does not interfere with the

sonographer/user’s ability to get close to the system and/or

exam table

(4) A seat that swivels to allow the sonographer/user to rotate

from the patient to the system while maintaining an aligned

posture.

c) Armrests are generally not recommended, as they result in increased

reach distance to the patient.

d) Chair casters should be suitable to the type of flooring. Reverse braking

casters may be preferred for cardiac scanning.

e) If performing lower extremity venous exams, an appropriate chair

should be provided with a height range that allows the

sonographer/user access to the lower leg in reverse Trendelenburg

while maintaining a neutral posture.

7. ACCESSORIES

a) Gel dispensers should minimize the grip force needed to dispense gel.

Consideration should be given to gel viscosity, size of opening, and

rigidity of container.

b) Support devices for supporting the scanning arm in abduction are

recommended, when applicable.

c) A wearable transducer cable support device is recommended to allow

the sonographer/user to reduce the grip by reducing the amount of

torque on the wrist/forearm.

d) Properly fitting, textured exam gloves should be available to reduce the

force required to grip the transducer.

e) Anti-fatigue mats are recommended for workstations requiring

prolonged standing.

f) External monitors should be available for exams where the image is

shared with other staff members or patients.

g) Wedge support cushions designed for endovaginal scanning should be

available for circumstances where exam table stirrups are not available.

B. POINT-OF-CARE/COMPACT ULTRASOUND SYSTEMS

A wide range of users such as paramedics, emergency physicians, pain management

physicians, anesthesiologists, and other specialists are increasingly utilizing compact,

handheld, and point-of-care (POC) ultrasound systems. Portability of these systems

depends on many factors. System weight, physical dimensions, and design should be

considered in determining the need for the use of a cart, backpack, suitcase, or other

means of transport.

The ergonomic challenges of such systems may overlap with other compact

technologies such as smartphones, tablets, and computer workstations on wheels. The

use of multiple technologies with similar risk factors has the potential to increase the

frequency and duration of exposure to risks, such as awkward postures of the neck and

trunk. Consequently, many of the recommendations for ultrasound systems and

computer workstations on wheels are applicable to compact, handheld, and point-of

care ultrasound systems. See Section II.E. for computer workstation on wheels

recommendations.

II. EMPLOYER RESPONSIBILITY

The key to prevention of WRMSDs is the mutual ownership of the problem, where both the

employer and employee accept a shared responsibility. As the owner of the work environment,

the employer has the greatest ability to influence task design and workstation equipment

through administrative and engineering (environmental) control measures. Furthermore, the

employer has the responsibility to provide ergonomic control measures at least to minimal

standards for compliance with the Occupational Safety and Health Act's "general duty" clause,

which states employers must provide a place of employment free from recognized hazards.

However, it is the culture, not the process that determines the ultimate success of a

safety/ergonomics program. A culture of safety is the shared commitment between

management and employees to ensure the safety of the work environment. In a positive

culture, safety is a core value of the organization, even at the expense of productivity or

efficiency.

A. RISK MANAGEMENT

Regular risk assessment, providing support for a culture of safety, and budgeting for

state-of-the-art equipment allows for the newest ideas and most up-to-date ergonomic

design in addressing sonographer/user fatigue and risk for injury.

1. Management must demonstrate a visible commitment to safety that positively

engages employees and provides follow through to employee concerns in a

timely manner. Opportunities and venues for open discussion about safety

concerns should be provided in a non-threatening, supportive manner. Effective

January 1, 2017, revised Federal OSHA requirements for reporting include

provisions that encourage workers to report work-related injuries or illnesses to

their employers and prohibit employers from retaliating against workers for

making those reports. Employers must:

a) Provide procedures for employees to promptly and accurately report

injuries/illness.

b) Inform employees of this procedure.

c) Inform employees of their right to report injuries/illnesses without

being discriminated against.

2. Employer should provide annual education and training to all

sonographers/users, new hires, supervisors, and managers on the risks and

prevention of musculoskeletal disorders related to sonography. Training format

and content should be specific to the level of risk and influence over control

measures.

3. Employer should perform risk assessments, at least annually, in consultation

with the sonographers/users to identify risks for musculoskeletal disorders

related to the practice of sonography. Assessment should include, but is not

limited to:

a) Scanning workstation equipment

b) Computer workstation equipment

c) Protocols

d) Scheduling (including breaks)

e) Room design layout

f) Workplace conditions (e.g., lighting, heat/AC, etc.)

g) Barriers to performance as identified by sonographer/user

h) Survey of sonographer/user symptoms (preferably anonymous)

i) A report of findings, determination of control measures, and a plan and

timeline for implementing control measures for the prevention and/or

reduction of identified hazards

4. Employer should conduct a needs assessment, with sonographer/user input,

prior to the purchase of new equipment and maintain a budget that

demonstrates ongoing planning toward adequate provision of ergonomic

equipment and ancillary devices as part of the risk assessment process.

5. Employer should provide a system to report and document symptoms or

concerns for WRMSDs and ensure sonographer/user knows how to use the

reporting system.

B. PROTOCOLS AND SCHEDULING

Employers should be aware that it has been demonstrated that there are risks for

WRMSDs associated with prolonged scanning time. Further research is needed to

determine appropriate limits. Employers should utilize currently available standards and

guidelines to establish protocols, scheduling, examination times, and volume of

examinations performed.

1. Employer should solicit sonographer/user input on establishing protocols to:

a) Support workload and scheduling with consideration of examination

type and length. The time allowed for each exam should take into

consideration the associated risk for injury.

b) Include time for non-scanning duties associated with each exam when

determining appropriate exam duration, including transport time for

portable exams.

c) Avoid back-to-back scheduling of difficult exams.

d) Encourage exam or task rotation as much as possible.

e) Eliminate outdated protocols especially those that increase exposure to

risk factors such as awkward postures and excessive force.

f) Limit standing protocols for lower extremity venous reflux studies. If

standing protocols are deemed necessary, they should be reserved for

isolated portions of the exam. Appropriate equipment, such as steps

and/or exam tables, should be provided to allow sonographer/user to

maintain neutral postural alignment while scanning regardless of

patient position.

g) Reserve bedside exams for critically ill patients. Scheduling of bedside

exams should include additional time allowance for transport of

equipment. Implement control measures to minimize long-range

manual transport of equipment. For example, consider allocation of

space for imaging suite on patient floors where patients require

monitoring and frequently undergo ultrasound examinations.

h) For the examination of difficult to image patients, such as those with

high BMI, limited mobility, and/or monitoring/intensive care

equipment, inform referring clinician and patients of the limitations of

the exam.

i) Limit non-emergent add-ons that would compromise time available for

examinations and/or muscle recovery time for sonographer/user.

2. To reduce the incidence of WRMSDs, it is recommended that employers

implement a staffing schedule that:

a) Maintains adequate staffing levels for patient load

b) Allows for mandatory meal breaks and rest breaks from scanning,

particularly for procedures comprised of similar postural and muscular

force attributes

c) Avoids shifts greater than eight hours to limit the duration of exposure

to risk

C. EXAMINATION AREA

1. Dedicated examination area should be at least 150 square feet to provide

adequate space for equipment maneuverability around all sides of the exam

table, patient privacy, and inclusion of a sink for hand hygiene compliance.

2. Cable length for Ethernet or similar Digital Imaging and Communications in

Medicine (DICOM) should be suitable to access wall outlets with cable

management to prevent safety hazards such as tripping. Cable length should

allow positioning of the system for access to any region of interest being

scanned without compromising posture of sonographer/user.

3. Power and Ethernet/DICOM outlets should be spaced closely enough to

eliminate tripping hazards from outstretched cables. Outlet placement is

recommended to be approximately 43 inches from floor to reduce

bending/reaching below knee level to access.

4. Examination area doorway should allow easy access for wheelchairs, beds, and

ultrasound equipment.

5. Flooring should allow for movement of equipment with no more than 50 lbs of

push/pull force and in compliance with infection control practices according to

The Joint Commission or other agency standards.

6. Individual controls for heating and ventilation of the examination area is

recommended to ensure the functionality of the equipment and comfort of

sonographer/user and patient.

7. Lighting of the examination room should be adjustable with dimmer controls

that are easily accessible from the scanning area. Any windows should be

shaded to eliminate light.

8. Frequently used supplies (e.g. linens, gel, gloves) should be stored in the

examination area and easily accessible without reaching above shoulder height

or below knee height.

D. COMPUTER WORKSTATION

The following standards are recommended for stationary computer workstations

frequently used for imaging related activities. As with any shared workstation,

equipment should be adjustable enough to accommodate a wide range of workers.

1. Chairs should be height adjustable so that each sonographer/user can sit with

feet flat on the floor or a foot rest, with a height range appropriate for the desk

height.

2. Chairs should have lumbar support and a seat pan depth and width sufficient to

support the width and length of sonographer/user’s thighs. Lumbar support and

seat pan depth should be adjustable if used by multiple sonographers/users.

3. Armrests should be adjustable and/or removable and should not restrict the

sonographer/user’s ability to get close to the workstation.

4. If desk height is not adjustable, a keyboard tray option should be provided.

5. Desk layout should provide a separate surface for hard copy documents and

sufficient space underneath for legs while sitting, and should not restrict the

ability to get close to workstation.

6. Desk depth should be sufficient to accommodate the keyboard and monitor

while maintaining an eye-monitor distance of 20-40 inches.

7. Monitor should possess height/tilt adjustability to accommodate a neutral neck

posture.

8. Keyboard and mouse should encourage neutral postures of the wrist, hand, and

shoulders. Trackball mouse (or similar) designs are recommended to minimize

movement of the upper extremity during mouse related activities.

E. COMPUTER WORKSTATION ON WHEELS

The following standards are recommended for computer workstations on wheels that

are utilized for imaging related activities.

1. Cart should be height adjustable, to accommodate both seated and standing

use, if applicable. It should be lightweight for ease of movement and

adjustability, with a stable base and casters suitable to the type of flooring and

with easily accessible braking capabilities. Multiple handle options are

recommended for transport.

2. Monitor should be easily adjustable, independent from the remainder of the

system, with anti-glare properties, and viewable from multiple angles. The

range of monitor height adjustability should accommodate the 5

to 95

percentile of the user population. Wall mounted monitors should be on a height

adjustable rail or monitor arm.

3. Keyboard/keyboard tray/mouse should be easily height adjustable, separate

from the remainder of the system, with mousing surfaces on the same level as

the keyboard. Height range should accommodate the 5

to 95

percentile of

user population. The keyboard and mouse should encourage a neutral position

of the wrists, hands, and forearms. Appropriate infection control properties

should be maintained according to Joint Commission on Accreditation of

Healthcare Organizations (JCAHO) or similar agency requirements.

4. Adequate cable management, for ease of movement and safety, should be

provided.

5. CPU storage should be suitable for cart stability. Lightweight, minimal footprint

CPU technology is recommended.

6. Accessories specific to the work environment, such as sharps disposal

containers, hand sanitizer, bar code readers, and chart holders are

recommended. Placement of accessories should not hinder neutral posture or

interfere with adjustability of the system.

7. System should have battery capacity of at least 20 minutes with a battery status

gauge.

8. Information security and infection control features applicable with local

requirements should be maintained.

III. SONOGRAPHER/USER RESPONSIBILITY – CONTROL MEASURES

It is the responsibility of sonographers, sonologists, students and other users of medical

ultrasound to follow current best practices to reduce the risk of developing WRMSDs. Each

employee is responsible for their own personal health and wellness including the knowledge and

application of work practices for self-management, hazard identification, and implementation of

control measures. Steps should be taken to minimize those factors known to cause WRMSDs and

movements that require departure from a neutral posture. The following represents a collection

of maneuvers and control measures that, when used in concert, reduce risk and improve

comfort of those performing ultrasound examinations. Users performing POC ultrasound

examinations should be aware of WRMSDs and follow applicable standards.

A. NEUTRAL POSTURE

Neutral posture is a seated or standing posture balanced around the sonographer/user’s

center of gravity. This posture reduces strain on the musculoskeletal system. When

leaning, bending, or reaching out of this balanced posture, postural imbalances occur,

along with increased muscle strain and uneven loads on the bones and joints. Prolonged

exposure to imbalances causes muscles to become overstretched, tendons to fray, and

skeletal structures to deviate from their normal alignment.

1. Sonographer/user should minimize risk by avoiding non-neutral and static

postures, such as:

a) Sustained reach

b) Bending and twisting of the trunk

c) Excess neck flexion, extension, and/or rotation

d) Excess reach and abduction of the scanning and non-scanning arm

e) Working with the arm behind midline

f) Excess grip force and transducer pressure

g) Prolonged awkward or static posture

h) Uneven seated or standing weight distribution

2. Sonographer/user should take the time to ergonomically optimize all equipment

to suit individual postural requirements and have accessories on hand before

beginning to scan.

3. Sonographer/user should utilize measures to reduce risk factors for WRMSDs

such as instructing the patient to move closer, adjusting the ultrasound system,

exam table, and chair, avoiding shifts greater than eight hours, and using other

ancillary devices.

4. Sonographer/user should employ muscle recovery time throughout the day.

a) Relax the muscles of the hands, wrists, shoulders, and neck

b) Take frequent mini breaks throughout the workday, including

microbreaks throughout the exam

c) Take meal breaks separate from work-related tasks or similar motions

d) Re-focus eyes occasionally onto distant objects

e) Vary procedures, tasks, and activities as much as reasonably possible

B. Safe Patient Handling

It is well documented that the single most important factor for reducing the risk of back

injury among healthcare workers is to eliminate the manual lifting of patients. Several

states have enacted safe patient handling legislation and a number of facilities have

adopted best practices, replacing manual lifting with lifting devices and lift teams. While

the focus of most of this legislation has been the reduction of risk factors related to

patient transfer and repositioning among nursing personnel, orderlies and attendants,

diagnostic imaging staff face a variety of patient handling tasks such as transferring

patients from a stretcher or wheelchair to an exam table, and then back again.

Sonographers are also frequently required to manually reposition patients to obtain

optimal imaging. Repeated exposure to the strain and exertion inherent in these

activities contributes to the cumulative trauma and associated risk for developing

WRMSDs.

1. Sonographer/user should utilize correct body mechanics when moving,

wheelchairs, beds, stretchers, and ultrasound equipment. Correct body

mechanics guidelines are available from employers or regulatory bodies.

2. Manual transfer or repositioning of patients should not be undertaken by

sonographer/user. Seek assistance and training from employer for safe patient

handling devices as needed. Always utilize appropriate patient

assist/lift/positioning devices.

C. The Sonographer/User’s Role in Safety

Safety requires a team approach for success. While the oversight and support of safety

and ergonomics must be employer driven, each individual should have a collective and

personal commitment to safe work practices. Ultimately, the level of engagement,

participation, and ownership of personal risk management is determined at the decision

making level. Each individual has a risk perception and risk tolerance that drives

behavior. It is up to each individual sonographer to be informed and pro-active in

managing personal risk.

1. Sonographer/user should document and report to their employer any

ergonomic concerns or persistent pain or injury and seek competent medical

advice.

2. Sonographer/user should maintain a level of physical fitness appropriate for the

demands of the work tasks required.

3. Sonographer/user should collaborate with employers on staffing solutions that

allow sufficient recovery from physically demanding tasks and time away from

the work environment such as:

a) Adequate staffing levels

b) Frequency of call rotation

c) Task rotation

d) Scheduling of examinations

e) Limiting shifts to no more than eight hours

4. Sonographer/user should be aware of the duration of exposure to risk factors

and take steps, when possible, to minimize prolonged exposure such as utilizing

machine driven protocols and accepting limitations of imaging capabilities with

difficult to image patients (e.g., those with high BMI, limited mobility, and/or

monitoring/intensive care equipment).

IV. EDUCATION AND TRAINING

Ongoing education and training is an essential part of an effective safety and ergonomics

program. According to the National Institute for Occupational Health and Safety (NIOSH), the

appropriate level of training is determined by the position the staff member holds in relation to

exposure and abatement of hazards. Recognizing different training needs is critical to

developing and maintaining a successful ergonomics program. Workers with direct exposure to

hazards should have more comprehensive training that includes blended learning formats of

visual, auditory, and kinesthetic learning styles.

Potential education/training resources:

• Journals, textbooks

• Online resources such as webinars and videos

• Employer and/or academic sponsored in-services

• Seminars, lectures, workshops, or conferences offered by professional

organizations or manufacturers

A. ACADEMIC SETTING

It is recommended that all program managers, students, and educators, including

clinical site instructors, be able to recognize the general risks for WRMSDs, including

signs and symptoms, and be able to participate in developing strategies to prevent or

remediate hazards. Program Directors should be aware that it has been demonstrated

that there are risks for WRMSDs associated with prolonged scanning time. They should

utilize reasonable guidelines when establishing the duration and frequency of scanning

in labs.

Students going into clinical practice and their clinical instructors should have additional

job specific training and formal instruction to be able to:

• Recognize risks for WRMSDs

• Identify signs and symptoms for WRMSDs

 Have a depth of knowledge sufficient enough to participate in

developing strategies to prevent or remediate hazards

 Have the fundamental ability to remediate risk factors for WRMSDs

within self-control

• Know the process for reporting injuries or concerns for WRMSDs

 Have a basic understanding of the Worker’s Compensation claim

process

Training should include documented competency in all areas for new students and at

least annually thereafter. Persons expected to play a key role in problem-solving

ergonomic hazards should have added instruction or seek the guidance of an

ergonomics specialist. Additional training and continuing medical education (CME) may

be required by accrediting agencies.

B. CLINICAL SETTING

It is recommended that all physicians, support staff, managers, supervisors, and

sonographers/users be able to recognize the general risks for WRMSDs, including signs

and symptoms, and be able to participate in developing strategies to prevent or

remediate hazards.

In addition, sonographers/users should have job specific training and formal instruction

to be able to:

• Recognize job-specific risks for WRMSDs

• Identify signs and symptoms for WRMSDs

 Have a depth of knowledge sufficient enough to participate in

developing strategies to prevent or remediate hazards

 Have the fundamental ability to remediate risk factors for WRMSD

within self control

• Know the process for reporting injuries or concerns for WRMSDs

• Have a basic understanding of the Worker’s Compensation claim

process

Training should include documented competency in all areas for new hire employees

and at least annually thereafter. Persons expected to play a key role in problem-solving

ergonomic hazards should have added instruction or seek the guidance of an

ergonomics specialist.

REFERENCES

1. Kroemer K, Grandjean E. Fitting the Task to the Human. 5th ed. Philadelphia: Taylor & Francis, Inc.;

1997.

2. Eastman Kodak Company. Ergonomic Design for People at Work. 2nd ed. (Rodgers S, ed.). New York,

NY: Van Nostrand Reinhold International; 1989.

3. Salvendy G. Handbook of Human Factors and Ergonomics. New York: John Wiley & Sons, Inc.; 1997.

4. Hedge A. Cuergo: Computer workstation ergonomics guidelines. Cornell University Ergonomics Web.

Available at: http://ergo.human.cornell.edu/ergoguide.html. Accessed August 25, 2016.

5. Computer Workstations eTool. United States Department of Labor Occupational Safety and Health

Administration 2015. Available at:

https://www.osha.gov/SLTC/etools/computerworkstations/components_monitors.html. Accessed

August 25, 2016.

6. Farrell A. Connected Care - Wirelessly Enabled; Industry Snapshot of Point of Care Wireless Devices.

HIMSS Management Engineering Performance Improvement Task Force; 2007. Available at:

https://hctg.files.wordpress.com/2009/02/wtr2009newsletter.pdf. Accessed January 4, 2009.

7. Washington K. Workstations on Wheels: A Solution to Improve Care Delivery, Operational Efficiency,

and the Organizations Bottom Line. Executive Healthcare Management Available at:

https://hctg.files.wordpress.com/2009/02/wtr2009newsletter.pdf. Accessed December 29, 2008.

8. Gale K, Gale A. Nursing Adoption of IT: A Look from the Inside Out. KLAS Enterprises, LLC; 2007.

Available at: https://hctg.files.wordpress.com/2009/02/wtr2009newsletter.pdf. Accessed January 4,

2009.

9. NIOSH Publication No. 97-117 Elements of Ergonomics Programs. Centers for Disease Control and

Prevention; 1997. Available at: https://www.cdc.gov/niosh/docs/97-117/pdfs/97-117.pdf. Accessed

January 2009.

10. Whittemore D, Moll J. COWs and WOWs, Oh My! Health Management Technology Available at:

http://www.healthmgttech.com/features/2008_july/0708_cows.aspx. Accessed December 29, 2008.

11. OSHA Act of 1970. United States Department of Labor Occupational Safety and Health

Administration 2016. Available at:

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=OSHACT&p_id=3359. Accessed

October 14, 2016.

12. Recommendations for Continuous Quality Improvement in Echocardiography. Supplement to

Journal of American Society of Echocardiography 1995;8(5):Part 2.

13. Ergonomics - Solutions to Control Hazards. United States Department of Labor Occupational Safety

and Health Administration 2016. Available at:

https://www.osha.gov/SLTC/ergonomics/controlhazards.html. Accessed August 27, 2016.

14. American Nurses Association; Safe Patient Handling and Mobility. Available at:

http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda-

Reports/State-SafePatientHandling. Accessed October 18, 2016.

15. OSHA Fact Sheet; Final Rule to Improve Tracking of Workplace Injuries and Illnesses. Available at:

https://www.osha.gov/Publications/OSHA3862.pdf. Accessed October 18, 2016.

16. Evans K, Roll S, Baker J. Work-Related Musculoskeletal Disorders (WRMSD) Among Registered

Diagnostic Medical Sonographers and Vascular Technologists: A Representative Sample. Journal of

Diagnostic Medical Sonography 2009;25(6):287-299.

17. American Nurses Association; Handle with Care Fact Sheet. 2016. Available at:

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/Factsheets-and-

Toolkits/FactSheet.html. Accessed January 24, 2017.

GLOSSARY

Administrative Control Measures: Changes in work practices that reduce the frequency and/or duration

of exposure to risk factor for WRMSDs. Although not as effective as Engineering Controls, Administrative

Controls such as staffing levels, task rotation, regulated breaks, and maintaining equipment can

successfully reduce risk for injury.

Anthropometrics: Comparative data of human body dimensions for various populations. Often the 5

percentile of a user population is referenced in the design process in order to accommodate the

largest cross section of users.

Compact Ultrasound Systems: See Point-of-Care Ultrasound Systems

Control measures: Ergonomic solutions implemented as a way to address risks for WRMSDs.

Interventions include Administrative (work practice) controls and Engineering (environmental) controls,

as well as Personal Protective Equipment. See Administrative Control Measures and Engineering Control

Measures.

Control panel: The user interface of an ultrasound system for imaging controls and data input. May or

may not include a separate keyboard.

Demographic area: The quantifiable characteristics of a given human population or population segment,

such as when used to identify consumer markets.

Engineering Control Measures: Also called environmental controls, these are the most effective control

measures since they result in physical change to the workplace, which eliminates/reduces the hazard of

the job/task. Engineering controls such as protocol changes and providing appropriate equipment can

eliminate risk factors altogether in some circumstances.

Force: Pressure applied uniformly over a surface, measured as force per unit of area. Examples include

push/pull force, grip force, and applied compression force.

Keyboard: The user interface on an ultrasound system for input of patient data and other information.

The keyboard may or may not be incorporated into the Control Panel.

Mini breaks: A small duration break lasting a minute or two taken frequently during a task to relax

muscular tension. In scanning, these muscles include, but are not limited to, the neck, shoulder, wrist,

and fingers.

Monitor: The image display portion of an ultrasound system or computer. The monitor may or may not

also have touchscreen functionality for imaging control or data input.

Neutral Posture: The posture which, whether sitting or standing, minimizes the stress on the body by

keeping joints aligned. Neutral posture places the least stress on the musculoskeletal system, providing

maximum endurance, control, strength and comfort by maintaining a balanced, resting posture around

a joint. The opposite of neutral posture is awkward posture.

Point-of-Care Ultrasound Systems: A smaller, portable, compact ultrasound system used to image a

patient at the site of primary care. Systems may be hand-held, configured with or without a cart as an

accessory, and are often used by non-sonographers such as paramedics, emergency physicians, pain

management physicians, anesthesiologists, and other specialists.

Primary Reach Zone: The area in front of and to the side of the body that can be reached while keeping

the elbows at the sides of the body. It is recommended that 80% of work be kept within the primary

reach zone. Reaching frequently or for prolonged periods outside the primary reach zone increases

muscular effort and fatigue and the associated risks for WRMSDs.

Sonographer: A medical professional who uses an ultrasound system to obtain images of structures

inside the human body for medical diagnosis by a physician.

Steering: Relates to mobility and functionality of wheels or casters. A directional caster is sometimes

known as a “steering” caster.

System Console: All the components of an ultrasound unit base, not including the control panel,

monitor, or transducers, with accessories such as ECG leads and image/data acquisition devices.

Touchscreen: A system interface that allows input via touch, such as on the control panel or monitor of

an ultrasound system.

User: A professional who utilizes ultrasound equipment to answer clinical questions in a medical setting.