A review of NEISS-Work data between 2015 and 2020 identified approximately 117,000 (95% CI: ±38,000) HCWs experienced nonfatal ED-treated injuries or exposures with an injury rate of 176 per 10,000 HCW FTEs (95% CI: ±57) (Table 1). Female HCWs accounted for 93% of ED-treated injuries, approximately injuries with a rate of 182 per 10,000 female HCW FTEs. Those aged 35 to 44 years experienced the highest rate of injury (212 per 10,000 HCW FTEs) but the largest proportion of injuries (26%) were among those aged 45 to 54 years. Younger HCWs, aged 17 to 24 years, accounted for 9% of the injuries and had an injury rate of 153 per 10,000 HCW FTEs; however, HCWs aged 55 to 64 years had an injury rate of 149 per 10,000 HCW FTEs but accounted for 17% of the injuries. Those aged 25 to 34 and 45 to 54 years had similar injury rates of 186 and 199, respectively, per HCW FTEs.

Overexertion and bodily reactions resulted in more than half (52%) of the HCWs’ nonfatal ED-treated injuries with a rate of 92 per 10,000 HCW FTEs (Table 1). Violence and other injuries by persons or animals accounted for 15% of the HCWs ED-treated injuries (Table 1). Falls, slips, and trips also accounted for 15% of the HCWs ED-treated injuries (Table 1).

Table 2 describes a more detailed analysis of injury event or exposure based on the OIICS¹⁶ two-digit event codes that found overexertion injuries involving an outside source (eg, lifting or moving a client) accounted for 42% of all HCW ED-treated injuries with a rate of 74 per 10,000 HCW FTEs. Falls on the same level accounted for 11% of HCW injuries with a rate of 20 per 10,000 HCW FTEs. Exposures to harmful substances accounted for 9% with a rate of 16 per 10,000 HCW FTEs. When examining the primary source of injury using OIICS¹⁶ two-digit codes, persons other than the injured worker (eg, clients) were the most frequent source (48%) with a rate of 84 per HCW FTEs. The second and third leading sources of injuries were floors, walkways, and other ground surfaces (13%), as well as animals (6%).

Overexertion and bodily reaction accounted for at least 31% of the total injury events or exposures for each age group (Fig. 1). Violence by other persons or animals was the second most common injury event among HCWs younger than 45 years. Those aged 17 to 24 years incurred a higher percentage of injuries related to violence, 27%, compared with 15% among those aged 25 to 44 years and 12% among those aged 45 to 64 years (Fig. 1). Among HCWs 65 years and older, falls, slips, and trips (46%) were the leading cause of injury and the second most common injury among those 45 to 64 years (17%). Falls, slips, and trips were the third most common injury among those aged 25 to 44 years (11%) (Fig. 1).

The most common HCW ED-treated injury diagnoses were sprains or strains (32%), contusions, abrasions, or crushes (10%), as well as lacerations or punctures (8%) (Table 3). The body parts that sustained the largest proportion of injuries included the trunk (back, chest, and abdomen) and neck (42%). Other body parts injured included upper extremities (32%), lower extremities (18%), and the head or face (6%) (Table 3).

Home care workers are the frontline workforce providing direct care for clients whose needs are greater than can be met through the health care system alone.²⁰ Home care workers are often asked to perform tasks that go beyond their formal role.²⁰ While these activities are critical in allowing clients to remain in their own homes, they may result in additional occupational hazards for the HCWs and potential negative impact on their job satisfaction if they are unable to meet client needs.^2,20,21 With an aging population and the continued increase in the demand for home care services, HCWs may face increasing and complex challenges,^5,20 such as caring for clients when lifting devices or other safety devices are needed but not available or wanted.^6,22 Home care workers may think that safety devices are time consuming or too difficult to operate. Clients may fear that assistive devices will be unsafe or uncomfortable.⁶ The tradeoff, however, when not using assistive devices, includes the HCW experiencing an overexertion injury, or the client being injured by being unintentionally dropped or jarred during an unassisted transfer.⁶

While the NEISS-Work surveillance system allows for the analysis of demographic and injury characteristics for HCWs who seek treatment at hospital EDs for nonfatal injuries, this system does not capture days away from work resulting from injury. The differences in case capture between NEISS-Work and the BLS Survey of Occupational Injuries and Illnesses (SOII) result in different estimates of injuries among workers. The BLS defines days away from work (DAFW) cases as those that result in one or more days away from work beyond the day of injury. The BLS SOII reported 40,080 nonfatal occupational injuries and illnesses involving DAFW among home health and personal care aides in 2020.²³ The injuries reported in SOII resulted in a median of 13 DAFW, slightly higher than the 12 median DAFW observed for all occupations.²³ The BLS DAFW is an indirect means to measure the severity of the injuries sustained by HCWs. Thus, these data suggest that HCWs experience somewhat more severe injuries than those experienced by other workers reported in SOII.

Data from this study indicated the leading HCWs nonfatal ED-treated injury events included overexertion and bodily reaction; violence and other injuries by persons and animals; and falls, slips, and trips. Other studies have found similar results. A study of Washington state workers’ compensation claims for all in-home care services from 2012 to 2016 found that among all accepted workers’ compensation claims, leading injury events were work-related musculoskeletal disorders, 34.3%; falls on the same level, 16.7%; violence, 13.3%; and struck by or against object or equipment, 12.6%.² Another study that collected data through focus groups found that 44% of the participants reported injuries associated with transferring clients, including back and shoulder strains and 31% of the participants reported injuries involving falls that resulted in sprains, twists, and cuts.²⁴

The current study found that female HCWs accounted for 93% of the ED-treated injuries and had a larger rate of 206 per 10,00 HCW FTE compared with males who had a rate of 105 per 10,000 HCW FTE (Table 1). A study of direct care workers in the US provided key facts on HCWs, who are personal care aides and home health aides that support clients in private homes.²⁵ Of these HCWs, 85% were female.²⁵ While the current study did not report results by race or ethnicity, the earlier study of HCWs found that 37% were White, 27% were Black or African American, 9% were Asian or Pacific Islander, and 23% were Hispanic or Latino (any race),²⁵ indicating that minority populations represent greater proportions in the home care and residential care workforce than the total US workforce.²⁶ This same study found that more than half of HCWs had no formal education beyond high school and only approximately 63% were employed full-time, which may put them at risk for occupational health and safety inequities.²⁵ In 2021, per the BLS, home health and personal care aides had a median pay of $29,430 per year with an hourly rate of $14.15 per hour.⁵

Additional work and research are needed to prevent injuries among HCWs. Home care workers’ training should include information on how to effectively assess home hazards that may result in occupational injuries or exposures, and occupational health nurses can assist agencies in taking measures to address these hazards and improve the safety of the work environment for HCWs.¹⁰ Home care workers often mentioned resource constraints or lack of agency policy implementation as barriers to effective management of hazards, all too often resulting in HCWs perceiving a need to “make do” with a hazardous situation.²⁷ Future training for HCWs should include specific approaches to managing hazards that may be addressed within the client homes and how to effectively engage assistance from their agencies.¹⁰ This may include agencies development or reinforcement of polices to assist HCWs and their clients to improve hazardous conditions. Other suggested prevention strategies for reducing injuries among HCWs include working predictable hours; working with clients and established care plans with which they are familiar; having complete background information on clients; and having sufficient training that is appropriate for their work environment to address a client’s needs.¹³

A few agencies are working to train or improve the knowledge of these workers. One such training is the home health care interactive virtual simulation training system (HH-VSTS) that promotes accurate detection of health and safety hazards in client homes.^10,27,28 Part of the project was to assess what environmental health and safety hazards were encountered and how were the hazards distributed across specific rooms within client homes.¹⁰ The most common hazards identified throughout the home were trips, slips, and lifts.¹⁰ Other serious hazards encountered were exposure to biohazards, tobacco smoke, pests and rodents (bedbugs, mice), pets, inadequate ventilation and air quality, and the lack of proper equipment to assist clients.¹⁰

The evaluation of the efficacy of the HH-VSTS to assess the usability, usefulness, and desirability asked participants to identify hazards, why it is a hazard, and what to do.²⁸ Participants correctly identified hazards related to trips, slips, or lifts, what makes this a hazard, and what to do more often than the other two hazard types; electric, fire, burns; and environmental.²⁸ Participants indicated that the HH-VSTS was helpful for identifying all three categories of hazards and the “what to do” information was useful. In addition, the majority agreed that they would like this type of training at the workplace.²⁸

The NIOSH also provides resources for HCWs to care for themselves such as the Caring for Yourself While Caring for Others handbook, which includes a checklist of potentially hazardous work tasks, along with a collection of practical tips and tools for keeping a home safe for both the HCW and client.¹ The handbook also addresses communication strategies and workplace stress.¹ To assist with individual hazards among HCWs, the NIOSH created Fast Facts cards to provide brief explanations of potential hazards and preventative steps.¹ Topics include how to prevent violence on the job, musculoskeletal disorders, and exposure to unsafe conditions.¹

Another project, the Community of Practice and Safety Support (COMPASS) program was developed to prevent injuries and advance the health and well-being of HCWs.²⁹ “The purpose of the COMPASS pilot study was to develop and test the feasibility of the Total Worker Health^™ intervention for HCWs and estimate intervention effects on workers’ well-being, and health and safety behaviors.”²⁹ The COMPASS intervention provides a supportive work structure for HCWs, particularly for those who do not have safety and health resources typically provided by employers.²⁹ After a successful pilot study and randomized controlled trial, COMPASS was adapted for the Oregon Home Care Commission’s training system for statewide dissemination.²⁹ The preliminary training evaluation indicated that workers like the program, find the content useful, and intend to make changes after the training.²⁹

The growing demand for home care services is increasing the number of workers at risk for injury. Although HCWs are one of the fastest growing occupations, there are limited data that identify injury trends and describe injury events occurring among HCWs. Future analyses should prioritize nonfatal injury events such as overexertion; falls, slips, trips; exposure to environmental conditions and bodily fluids; and violence to gain a more thorough understanding of the events that are contributing to the largest number of injuries among HCWs. A better understanding of the occupational health and safety risks of HCWs and how those risks are managed will enable the development or improvement of programs to assist with training, education, and support of these workers.