CoxHealth, Springfield, Mo, is a four-hospital system in southwestern Missouri with a total of approximately 1,000 beds. The system is rather large, with many hospital and clinic locations, and is also geographically diverse. Being spread out over quite a large area gives us some special challenges. For example, our size means that any change in equipment or supplies calls for extensive education: our four hospitals and 55 physician clinics have a total of 9,000 employees and a 502-member medical staff. The four radiology departments and two outpatient imaging centers are separated by as much as 80 km. When a change is suggested, therefore, we proceed carefully, as we did in converting our contrast bottles from glass to polymer, partly for ergonomic reasons.

Where ergonomics are concerned, nearly every radiology provider faces the same problems. Ergonomic hazards cause injuries in multiple ways. The injuries with which employers are probably most familiar are known as repetitive stress injuries, repetitive strain injuries, or cumulative trauma disorders. These are problems attributable to performing the same action over and over again, with stress building up on bones, muscles, joints, ligaments, and tendons over time. We face injuries related to repetitive motion in many areas of radiology, and this is a major problem in the field.


The main risk factors for repetitive stress injuries are repetitive motions, awkward postures, long periods of repetitive activity, lack of recovery time, forceful movements, vibration, uncomfortable environmental conditions, and stressful work organization. This can be used as a checklist for finding problems in radiology settings, particularly for CT services.

Our CT department is very large. Our busiest location performs approximately 70 scans per day; the smaller sites do proportionately less CT scanning, but still have high procedural volumes. In this busy environment, repetitive motions definitely occur. The technologists have to hang contrast bottles over and over, get patients on and off the table over and over, and do the same types of scanning over and over. Awkward postures may or may not be involved, depending on the situation. If the work environment is organized correctly, it will be possible for technologists to avoid many awkward postures. Hanging bottles overhead, however, is difficult to avoid. This is not an ergonomic action, and it does not represent ergonomic safety.

Ergonomic changes really involve making alterations in a job so that it fits the abilities and needs of the worker (rather than trying to fit the worker to the job). We know that the bottle of contrast medium must be hung up, so we do that every day, but we do not typically think of the strain that it puts on wrists, shoulders, or necks to handle that bottle.

Long periods of repetitive work are common among technologists, many of whom regularly work overtime. We face a technologist shortage, and CT is one of the areas in which our facility has the most serious shortages right now. The technologists’ long periods of repetitive activity are made worse by lack of recovery time. They are sometimes scheduled for twelve hour shifts (or working 8-hour shifts followed by call or overtime). During a shift, heavy work loads can interfere with recovery time between patients. At times, technologists may miss breaks or even lunch periods. This is a further intrusion into the recovery time employees need in order to avoid repetitive stress injuries.

Uncomfortable environmental conditions may also be a factor in ergonomic issues. Some facilities have problems regulating room temperature and stress on the body is increased when an employee must go from extreme heat to extreme cold, or must remain in a room that is too hot or cold.

The stress of work organization applies to nearly all health care environments. No matter how well organized the work itself becomes, especially in an area that deals with trauma, many high-needs patients and intensive care patients will come to the department. This inevitably creates a stressful work setting.


In investigating ergonomic problems in CT scanning, we focused on the subcategory of back injuries. Although we know that there are shoulder and hand injuries attributable to reaching overhead to hang contrast bottles, we have a hard time separating them from injuries due to using a mouse and keyboard when a Worker’s Compensation claim occurs. Of course, back injuries can also be attributed to moving patients, but over the course of a day, the handling of contrast (especially bending over to pick it up) is undoubtedly another stressor. People often complain that they have bent over, picked up something heavy, and hurt their backs. Many lose sight of the fact that most back injuries are actually repetitive stress injuries. Minor damage over a long period actually causes the back injury. Improper lifting is particularly implicated in causing this type of damage over many years. Bending over to pick up a newspaper may have been the action that precipitated the acute pain, but the underlying chronic injury accumulated over time.

In the health care environment, workers are constantly lifting, pulling, and pushing. If they work in the field for several years, that stress adds up for them. The potential for a small contrast bottle to cause a back injury may not always be apparent, but it should be remembered that contrast must often be handled in case quantities. The weight of a case can be significant, and many people must handle it; depending on the hospital’s delivery methods, it may be lifted and moved by employees from the manufacturer, distributor, purchasing department, pharmacy, radiology department, and (when the bottles are empty) environmental services. The weight of that case is not just a radiology issue, although radiology personnel will handle the individual bottles several times in the course of shelving, retrieving, opening, hanging, and discarding them.

In our case, the weight of the case is relatively minor because we are using 100-mL vials packed 10 to a box. Each time the box is handled, though, a small stress is repeated.

After use, when the empty bottles are discarded, they are handled less frequently, but the weight involved can be significant when a full trash receptacle is lifted. If glass bottles are piled in puncture-proof containers for disposal, the containers can become quite heavy. In some facilities, radiology personnel are required to transport the full containers to a central location for disposal; even in hospitals where environmental-services staff can be called to pick up the container in the department, the weight of glass is still a problem. Polymer contrast bottles weigh 50% less than glass bottles when they are full and 80% less than glass when they are empty (for the 100-mL size). That dramatic decrease in weight represents a huge reduction in the risk of repetitive stress.

In reviewing our employee health expenses in the radiology department for the past four quarters with the risk manager, we did not find a great deal of expense related to repetitive stress injuries. We did not evaluate incident reports, focusing instead on actual paid Worker’s Compensation claims for back injuries among radiology staff. The paid claims amounted to roughly $100,000 for the most recent four quarters. Most of the claims were tied to specific falls or other accidents at work.

As with cuts due to glass contrast bottles, it appears that repetitive stress injuries to the back are significantly underreported in radiology. For example, a CT technologist at our facility has undergone cervical laminectomy and fixation within the past 6 months, and another was off work due to a back injury for at least a week, but both cases were considered unrelated to work. It is clear, however, that many such injuries result from long-term, job-related abuse of the spine, whether the final episode requiring treatment takes place at work or elsewhere.


CoxHealth has a very aggressive injury-reduction program. It focuses attention on factors that can make a significant difference in injury rates: education, monitoring awareness, staffing, and equipment. Our educational effort to reduce injuries begins at a new employee’s initial orientation, which includes material on back safety and some general ergonomic orientation. Employees are aware, from the beginning, that it is their responsibility to help us understand where they need assistance in addressing the ergonomics of the workplace. Monitoring awareness includes tracking injury-related expenses, which we now perform quarterly. The department heads receive reports listing the department’s Worker’s Compensation expenses for the quarter and comparing the actual expenses with the costs that were projected for the period, based on average levels of injury. Because CoxHealth is self-insured, this information is monitored closely.

Adequate staffing is also important in decreasing injuries, since an employee working too quickly and/or without help is more likely to be hurt. Using the proper equipment to address stressors is the fourth major step in reducing the risk of job-related injury. By making the equipment better for employees, we can increase the ergonomic soundness of their jobs. The decision to adopt polymer contrast packaging is a good example of this kind of intervention to reduce injury risk. The 50% (full) to 80% (empty) reduction in the weight of contrast bottles is a significant improvement because the bottles are handled so many times, both in cases and individually. For this reason, the effects of conversion to polymer contrast bottles are multidepartmental, following the path that the bottles take from their arrival at the facility to their disposal in the outgoing trash. The use of polymer containers for contrast media reduces the cost of injuries not just for the radiology department, but also for the organization as a whole. The prevention of injury may be difficult to quantify because employees are subjected to many stressors in addition to the handling of contrast bottles. Qualitatively, however, there is no doubt that the polymer packaging is appreciated. Our CT technologists immediately commented on how pleased they were with the lighter weight and greater ease of handling of the new contrast bottles.

Shawn Snider, RT(R),(M), MSA, is administrative director, Radiology, CoxHealth, Springfield, Mo. This article has been adapted from Ergonomics, which he presented at the Polymer Bottle Safety Focus Group on September 10, 2004, in Las Vegas.