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Guidance for Occupational Health Services in Medical Centers

2009; Lippincott Williams & Wilkins; Volume: 51; Issue: 11 Linguagem: Inglês

10.1097/jom.0b013e3181bb0d7c

1536-5948

Mark Russi, William G. Buchta, Melanie D. Swift, Lawrence D. Budnick, Michael J. Hodgson, David M. Berube, Geoffrey A. Kelafant,

Quality and Safety in Healthcare

Guidance for Occupational Health Services (OHS) in Medical Centers is dedicated to the memory of Dr. Geoff Kelafant, who was tragically killed in a diving accident in March 2004. Geoff was the original author of a set of guidelines for the practice of occupational health in medical centers and developed the idea to establish a public access internet site to assist practitioners of medical center occupational health (MCOH). For over 10 years, he developed and maintained the guidance document, added a broad range of additional information and links, and summarized information essential to the care of medical center-based working populations. Geoff did nearly all of this work without financial support and was steadfastly dedicated to improving the quality of medical practice in our field. In addition, he established an on-line discussion forum to address MCOH practice issues. Geoff oversaw the forum with his own unique and wonderful combination of biting wit, good judgment, and pithy commentary. Geoff was a dear friend and respected colleague. He was bright, funny, kind, and brutally honest. His gifts to those who practice MCOH have been inestimable; his absence leaves a void in our professional lives and for a great many of us, in our personal lives as well. Few have contributed as much to our small field. Geoff's enduring legacy is the profound impact he made on MCOH in the United States and Canada. His work supported the creation of a real community, a common purpose, and a set of standards among those of us who practice in the field. In many cultures and belief systems, we live on in this world because of our good deeds; Geoff will live longer than most. Purpose of This Guidance Document This document represents a collation of pertinent guidance, best practices, and professional opinions applicable to the practice of occupational medicine in the medical center setting. Its intent is to provide assistance in handling the broad range of issues encountered by hospital-based occupational medicine practitioners. The guidance document and its hyperlinks will be updated periodically to incorporate new information as it becomes available. Role of the MCOH Provider Medical Assessment of Employees Occupational health practice in a medical center setting requires the same skills as such practice elsewhere, including thoughtful administrative management; knowledge of and interactions with safety, industrial hygiene, and toxicology; and sound preventive and clinical medicine, including surveillance, assessment of history and physical findings, diagnosis, treatment, and disposition. Preplacement Medical Evaluation (PPME) The PPME usually represents the first clinical encounter for a prospective employee, setting the tone and defining expectations from OHS. The PPME, which must be done after the offer of a job, serves to document those existing medical issues that are likely to have an impact on the new employee's performance, health, and safety in the health care work setting. It is not designed to diagnose or treat previously undiscovered medical problems. The Americans with Disabilities Act of 1992 requires job descriptions that identify the "essential functions" of the job to be offered, with specific, precise descriptions and terminology with which employee capabilities must be compared. OHS should gather enough information to ensure that employees' medical and functional status enables them to perform the essential functions of the job. OHS should outline the specific constraints and restrictions that human resources (HR) can use to determine appropriate accommodation, where and if feasible and appropriate. Nevertheless, specific diagnoses or other clinical information should not be released. State laws differ, but occupational physicians must be aware of local licensing and skill requirements. In general, they must act as a resource for nurse-level and midlevel provider- based evaluations and should be involved in any communication with HR about restrictions or failure to meet medical or functional standards for the offered job. Refusal to clear someone for work must be based on the issues of "direct threats" and on inability to meet specific standards. For example, a known alcoholic in acute relapse may not be suitable for hire, if existing policy states as such, but a cocaine addict who has completed rehabilitation cannot be refused employment on that basis alone. Conditions identified during the course of the PPME, such as increased blood pressure, should be communicated to the individual with recommendations for follow-up, preferably in writing. New employees should also be fully informed of any recommended restrictions shared with HR. The PPME documentation should be housed in a record/database separate from the institution's medical record for patient care, primarily for access at a later date and to clarify the purpose of the data for evaluation rather than general health care. Of course, the data should be available to the providers of the health care institution if the new employee wishes to release the information to them according to the Health Information Portability and Accountability Act (HIPAA) of 1996 rules. Other evaluations, such as drug testing, commercial driver certification, baseline medical status before working with hazardous chemicals, immunization status, examinations for respirator clearance, or tuberculosis (TB) surveillance status may be required before starting work, but some may be delayed until specific job assignments have been clarified. Specific regulations apply to some functions, such as flight examinations or drug testing, requiring specific certification by designated agencies such as the Federal Aviation Administration or testing and certification as a medical review officer under Department of Transportation Guidelines. Periodic Medical Evaluation The health care workplace represents a very hazardous environment (see Workplace Hazards). Engineering and administrative controls should precede the use of personal protective equipment (PPE), but medical surveillance for adverse health effects from hazardous exposures often represents good medical practice and is required by the federal and even some state laws for specific hazards. Surveillance is required for TB. The Occupational Safety and Health Administration (OSHA) enforces Centers for Disease Control and Prevention (CDC) guidelines on TB as regulation. OSHA and the National Institute for Occupational Safety and Health (NIOSH) recommend surveillance for employees exposed to hazardous drugs, despite a lack of robust scientific support for benefits or utility. For exposures to certain substances, eg, ethylene oxide, formaldehyde, lead, asbestos, cadmium, and ionizing radiation, federal OSHA standards require medical surveillance when action levels are surpassed. Most states have an impaired provider program for licensed individuals with mental, physical, or chemical dependence conditions that may impair their ability to practice safely. OHS is often part of the administrative process that initially reports such providers to the state licensing board(s) and subsequently monitors those providers to ensure compliance with the board recommendations. Clear understanding of the regulations, understanding of privacy issues, as defined in HIPAA and other regulations, and unambiguous communication capabilities, together with strict confidentiality in behavior and record keeping, are essential for successful practice. Episodic Medical Evaluation Job Transfers. Because different jobs have different physical requirements, the PPME is specific to the job. Therefore, OHS should have an agreement with HR to review employees who are transferring to jobs that have specific physical and/or mental requirements. This may only require a review of the employee's current medical status, particularly any temporary or permanent restrictions affecting work performance. If a face-to-face evaluation is normally required for the new job, the transferring employee should undergo that same evaluation. If a record review suggests a substantial mismatch of skills and requirements or simply a lack of information, OHS should contact the employee for clarification or a face-to-face evaluation. Illness/Injury Affecting Work Performance. Work-related injuries and illnesses are best evaluated and managed by an occupational health provider in OHS. Although health care workers (HCWs) may have the right to seek care elsewhere, the advantages of care from an in-house provider are straightforward. Convenience (access to physical therapy and other modalities), familiarity with the worksite, and communication ease with supervisors generally facilitate care and recovery. OHS must carefully maintain good relationships with all parties, understand and respect employee/supervisor relationships, and maintain a patient/employee focus in clinical management. For those employees seeking care elsewhere and who have restrictions or a prolonged duration of time away from work, the OHS provider should periodically contact the employee and request authorization to communicate with the treating provider. The treating provider should provide regular information to the supervisor or to HR on progress, as required by workers' compensation statutes. OHS often acts as the clearinghouse for communication between other providers and the employee's supervisor and/or HR. Nonoccupational injuries or illnesses should be treated similarly to work-related conditions if they affect work performance. Particularly in the case of contagious diseases, OHS providers should evaluate the employee before he or she returns to work, or establish criteria for returning to work that the employee's attending physician must attest to. Some facilities have a policy requiring OHS clearance after a certain minimum consecutive days off work. Home or sports injuries may also require evaluation to determine restrictions in the workplace. As a service to the employee and to minimize time away from work, many OHS units may offer limited acute care services, such as throat cultures, ear lavage, rash evaluation, etc. Such services serve several purposes. They help employees trust the OHS unit because they rely on providers. Travel time to and from physician offices is shortened, so that staff are available to work longer. Conditions with potential implications for coworkers and patients can be identified early. Medical evaluation/treatment should be provided for bloodborne pathogen and other infectious exposures, traumatic or ergonomic-related injuries, chemical exposures, and other work-related events. OHS should establish specific protocols and arrange 24/7 coverage. Job Fitness Evaluation. Immediate evaluation may be necessary when a worker on duty is exhibiting dangerous or unacceptable behavior: verbal or physical assault, lapses into unconsciousness, alcohol odor on breath, slurred/garbled speech, etc. Such evaluations should begin with a report from the supervisor of the specific behavior in question. The supervisor should escort the employee to OHS. The employee should not be released to work until OHS has conducted a thorough history, physical, and any necessary consultation/testing. If the worker is expected to return to work in some capacity, the cost of the evaluation should be borne as a business expense while records are kept confidential, and the provider only reports to the supervisor that the behavior was or was not related to a medical condition and when and under what conditions the employee may return to work. Consultative visits may be arranged with OHS on a scheduled basis if either a supervisor or worker recognizes that work performance is impaired by a real or perceived medical condition. OHS can evaluate the worker, coordinate optimal control of the medical condition, and recommend restrictions/accommodations that will maximize success in the workplace. OHS must resist the temptation to attribute all performance deficits to a medical condition, thereby "medicalizing" poor motivation, relationship conflicts, or lack of skills. This caveat is true in any work environment, but the tendency to "medicalize" may be particularly tempting in a health care environment. Medical Direction The Unique Setting of OHS in Health Care Development and management of OHS in a health care setting is a daunting task and requires constant awareness of the distinction between the mission of the organization (health care delivery) and the unit (OHS delivery). Five principles are essential to establish a proper relationship with key members of the organization. Title: Although the OHS director in nonclinical industries is usually called the corporate medical director, that title may be impolitic in health care, particularly if the organization is physician led. Thus, the title of "Medical Director, OHS" clarifies the difference between mission leadership and line operations support. Reporting relationship: The OHS medical director should have ready access to the medical centers' senior management. OHS can provide case management to ensure proper care, appropriate restrictions, and timely return to duty after an illness or injury but often encounters resistance around job limitations and may require top management support. Role as a specialist: The OHS medical director must be able to assure colleagues in other disciplines that OHS is not in the business of "stealing" or diverting patients from other providers. Medical colleagues are often unaware of the specialty of occupational medicine and its contents. The OHS medical director must clarify the role of OHS for colleagues in family medicine, orthopedics, etc and be recognized as a specialist, expert in the management of disability, hazardous exposures, workers' compensation, and the interface of medical care with legislative requirements and regulations (Family Medical Leave Act [FMLA], Americans with Disabilities Act, HIPAA, OSHA standards, CDC guidelines, etc). Consultation services and support to colleagues struggling with such issues for outside care, including workers' compensation, are important in developing a role. Institutional visibility: The medical director of OHS must develop alliances with organizational units that may be foreign to other physicians in the medical center, including safety, HR, infection control, industrial hygiene, engineering, facilities management, environment services, purchasing, and the institution's insurance carrier. Assignment to key committees and attendance at meetings; establishment of policies, supported in the institutional framework; and participation in the various areas during rounds and problem solving are keys to maintain an effective presence. OHS staff: Success as a medical director of OHS hinges primarily on the relationship with occupational health nurses and other staff. Frequent meetings, philosophical alignment, and respect of each other's skills and opinions represent the foundation of a successful program. Nursing staff should be trusted to administer jointly developed policy and procedures, handle phone calls from employees, serve as internal case managers for disabled employees, and run programs, such as PPMEs, blood and body fluid exposure, TB surveillance, etc. Midlevel providers can manage much of the clinical volume. Staff may benefit from regular attendance at scientific meetings such as the annual American Occupational Health Conference (AOHC) of ACOEM, and they need accessibility for informal "curbside" consult or to transfer management of a difficult case. Disability Management Individual cases should be followed in OHS if they meet certain criteria—restrictions affecting work performance, prolonged time off work, or work-related injury/illness requiring ongoing treatment and/or restrictions. Case management requires differing levels of intensity depending on the severity/duration of the disability. At a minimum, a nurse case manager should monitor the medical records and work status reports from other providers with the option for direct communication with the employee or referral to the medical director/designee for evaluation. OHS must be careful to have authorization from the employee/patient to communicate with the supervisor and administration (see medical records and HIPAA). Population-based disability management is no different in health care than in any other industry and works most effectively when OHS, HR, and the insurer(s) share the same database(s). Return-to-work programs may be housed outside of OHS but require constant communication with OHS for clarification of restrictions and comparison of temporary work assignments. Ideally, alternate, "transitional" work should be available whether restrictions arise from an occupational or nonoccupational condition. OHS staff can serve as a resource to supervisors to coordinate the smooth and rapid return to work either in the original assignment or in another job within the organization. The success of this program depends on HR absence policies, disability benefits, and pay and reporting rules, ie, whether the supervisor retains the restricted employee on his/her payroll while on modified duty. As importantly, worker satisfaction and relationship with coworkers and supervisor represent more subtle but equally powerful forces. Again, OHS must be vigilant to avoid "medicalizing" relationship issues and to help to negotiate a return to some useful function within the organization. Health Benefits Administration Some input from OHS may be useful because employers construct health benefit plans for employees. In particular, occupational medicine providers may play a role in arranging employer-sponsored programs to address general home and workplace safety, healthy dietary choices, age-specific cancer screening recommendations, smoking cessation, and other preventative health efforts. OHS staff often serve as a resource to employees reminding them when they might benefit from an available service. Employee Assistance Program (EAP) EAP in the health care setting is particularly valuable for de-escalation of relationship issues in the workplace. HCWs and supervisors tend to view all problems in the context of medical diagnoses and may require clarification of such issues outside the medical arena. EAP does not establish an on-going relationship with the worker as a patient and generally does not bill on a fee-for-services basis. Such services may be obtained through an outside vendor, but there are some particular advantages to keep EAP services in house. The medical director may want to serve as a liaison to the EAP for oversight/advice about policies and particular cases as well as to gather data as to any trends in employee dissatisfaction or types of problems. When particular problems arise in a work area, an EAP counselor can serve in an organizational development role to guide the workers in that unit to a reasonable reconciliation before individual members develop performance deficits or symptoms of distress that will affect productivity or tax the health care system. Confidentiality and maintenance of trust do require a great deal of attention with in-house units, both in selection of a physical location and in maintenance of confidentiality. Medical Records To satisfy HIPAA, OHS must decide whether it is part of the practice of the health care organization or part of the administration. This then defines how records are stored (firewall), who has access to which elements (role-based access), and whether a signed release is needed (HIPAA-compliant release). Although individual circumstances may vary, it is usually preferable to place OHS as part of the practice. This allows free communication between the medical director/OHS staff and the other providers in the organization. OHS must have specific authorization from the employee/patient to release any medical information to the supervisor/administration. Generally, OHS will not need to share medical information with the employer, even with a release. Communication regarding work status should be devoid of protected health information. Medical records and documentation should be housed in a record/database separate from the institution's medical record for patient care. It should include preplacement, medical surveillance, infectious disease, and workers compensation records. They should not be accessible to professionals without the involvement in direct care of the employee. Still, the data should be available to health care providers if the employee wishes to release the information to them. Health Care Safety and Occupational Health The Joint Commission on Accreditation of Health Care Facilities requires facilities that have a safety program. Such programs require skills in safety, industrial hygiene, engineering, environmental management, housekeeping, workers' compensation, and clinical disciplines. Such programs generally consist of written policies, require some form of internal inspection and quality assurance, and rely on defined approaches to the solving of recognized problems. Establishment of top management commitment to safety, health, and environmental management represents a core value for an organization without which little progress will occur. Joint Commission on Accreditation of Health Care Facilities requires some form of record keeping. Although OSHA logs (1910.1904) often represent the formal output, many facilities and employers have developed complex systems to bring the various disciplines together in a single community of practice. This is generally collected in a committee called, in health care, an "environment of care" committee, a safety committee, or other organizational unit with regular meetings, minutes, a strategic plan, and formal reporting relationships to hospital leadership. Safety staff often take the lead, but OHS clinician collaboration in several core functions is essential for the successful administration of these programs. The hazards section of this guideline identifies hazards for which the hospital (internal or consulting) safety staff should develop programs. Many of these require medical surveillance programs, medical evaluation for fitness and capacity, and medical support for failures. Safety investigations of adverse incidents to employees require the establishment of incident review boards. Such investigations identify what should have occurred, what actually occurred, and why the two diverged in an attempt to prevent the next occurrence. Such groups generally function better when they are composed of individuals with a wide variety of skills (safety, engineering, and clinical) and diverse viewpoints (management, professional, and employee representatives). Many facilities establish a fixed set of criteria by which incidents for review are selected (all lost-time cases or all diseases or all cases costing more than a set sum of money or events by quarterly frequency of occurrence). Scheduled evaluations of the environment of care (safety rounds) can identify newly occurring hazards, inurement to hazards, and worsening work practices. Walkthroughs with safety, employee health, and employee representatives remain an important tool for safety management. Annual written reports of money spent, costs saved, and services delivered remind the management of the value of programs. www.jointcommission.org/ www.va.gov/ncps/ www.osha.gov/SLTC/accidentinvestigation/index.html Biological Hazards Modes of Transmission HCWs may be exposed to a variety of biological hazards. As discussed below, effective immunization and infection control programs, as well as appropriate postexposure evaluation and medical management policies must be established. Common bloodborne pathogens include human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV); uncommon pathogens include syphilis, viral diseases, and malaria. Pathogens transmitted through the airborne route include TB, measles, varicella, and under certain conditions smallpox, hemorrhagic fevers, severe acute respiratory syndrome (SARS), and possibly influenza. Droplet-transmitted pathogens include meningococcus, pertussis, Haemophilus influenzae, Mycoplasma pneumoniae, group A Streptococcus, mumps, rubella, adenoviruses, parvovirus, and influenza. Infections spread by skin exposure include Herpes simplex (HSV), papilloma virus, and fungi. Enteric pathogens include hepatitis A virus (HAV), Salmonella, Shigella, and Norovirus. Research institutions may present special challenges, such as those associated with handling animals in research and biological agents that require special facilities. Infection Control Practices www.cdc.gov/ncidod/dhqp/about.html www.cdc.gov/ncidod/dhqp/index.html www.cdc.gov/ncidod/dhqp/healthDis.html www.cdc.gov/ncidod/dhqp/worker.html www.cdc.gov/ncidod/dhqp/gl_hcpersonnel.html www.cdc.gov/ncidod/dhqp/wrkr_occHealth.html www.shea-on-line.org/ http://www.apic.org//AM/Template.cfm?Section=Home1 www.cdc.gov/ncidod/dhqp/gl_environinfection.html www.cdc.gov/ncidod/dhqp/gl_isolation.html www.cdc.gov/ncidod/dhqp/gl_handhygiene.html Appropriate training and policies to minimize patient-to-employee and employee-to-patient transmission of communicable disease are essential. Effective surveillance activities should also be in place to prevent transmission of communicable disease and to diminish absenteeism. Policies and procedures should include the following. Thorough preplacement evaluation, including documentation of immunizations, TB surveillance testing, and orientation to communicable disease work restrictions. Periodic reevaluation to encourage preventive activity and use of PPE. Initial and periodic mandatory training in the use of PPE and universal precautions. Periodic review of employee lists to assure adequate numbers and training of employees for respirator use. Immunization review and updated programs. Ongoing TB testing requirements to include employees, volunteers, students, and medical staff. Care of personnel for work-related exposures and illnesses. Monitoring exposures to infectious disease. Maintenance of employee health records. Providing educational sessions and literature encouraging work and personal hygiene. Establishing work restriction programs to prevent transmission of communicable disease. Suggested Immunizations for Health Care Facility Employees A number of immunizations may be indicated or considered in HCWs depending on the risk of exposure or the infection risk to patients. These vaccinations include the following. Diseases for which immunization is strongly recommended—HBV, measles, mumps, rubella, influenza, varicella, pertussis. Diseases for which immunization/prophylaxis may be indicated—HAV, meningococcal disease. No increased risk among HCWs but should be current—diphtheria, tetanus. Special circumstances, including research and animal laboratories—rabies, Q fever, polio, vaccinia, others as appropriate for circumstances. ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4618.pdf www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm www.cdc.gov/vaccines/vpd-vac/varicella/vac-faqs-clinic-hcp.htm Needlestick Injuries Needlestick injuries remain a significant cause of HCW injuries. Sharps with engineered safety features should be regularly reviewed, trialed, and implemented where feasible. Needles should not be recapped or broken before disposal. Puncture resistant containers should not be filled to capacity. Needlestick injuries require determination of worker and source (wherever possible) serological status regarding HBV, HCV, and HIV. Appropriate consents to HIV test the worker and source are necessary, and regulations vary by state. Under special circumstances, some states allow for source patient testing without the permission of the source patient. Recommendations and practices regarding bloodborne exposures change frequently and policies should regularly be reviewed and updated. Generally, serological follow-up of the HCW exposed to HIV, HBV, or HCV should be carried out at baseline, 6 weeks, 3 months, and 6 months following exposure. Current guidance with respect to prophylaxis or early treatment of specific infections should be followed (see specific bloodborne pathogens below). In all cases of confirmed HBV, HCV, or HIV exposure, which include mucous membrane exposure as well as the more common sharps exposure, a counseling session with a knowledgeable health care provider should be offered to the exposed employee. Information should be obtained to determine whether the employee is a member of a high-risk group. The employee should be advised to report any illness that occurs within the initial 6-month period after exposure, particularly skin rashes, fever, malaise, joint pain, muscle aches, enlargement of lymph nodes, and any acute infections. Instructions on the use of condoms or abstinence to prevent sexual transmission of HIV during the 6 months after exposure should be given. Women of childbearing age should be checked for pregnancy if they elect to take prophylactic medication. Benefit and risk information regarding medications should also be discussed. Information should be provided regarding availability of follow-up counseling and community resources. Standard first aid should be provided for all needlestick injuries, cut and bite wounds, including washing the injury site and applying antiseptic. If the exposure is to mucous membranes (ie, the eyes), copious irrigation should be performed immediately. Preplacement testing for bloodborne diseases, especially HCV, is a controversial issue. Workers' compensation precedent in some states assumes that a HCW who has contracted a bloodborne disease must have acquired it as a result of an occupational exposure unless there is compelling evidence to the contrary. Preplacement te