1 Optimizing Early Case Management of Occupational Injuries December 17, 2013 Dan R. Azar MD MPH...
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Transcript of 1 Optimizing Early Case Management of Occupational Injuries December 17, 2013 Dan R. Azar MD MPH...
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Optimizing Early Case Management of Occupational Injuries
December 17, 2013
Dan R. Azar MD MPHRegional Managing PhysicianLockheed Martin CorporationSunnyvale CA
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Occupational Medicine Services
Surveillance and Recertification
• Performing focused occupational testing and examinations at the Wellness Center
• Coordinating these Medical Services at sites without a Wellness Center
Work-related Injury/Illness Care
• Treatment
• Leveraging Occupational Visits to address Personal Health issues
Medical Support for Other Business Operations
• Providing Medical Consultation to Business Area
• Hiring Process
• Fitness For Duty
• Clarifying Work Restrictions
• Assisting with Accommodation Process
• Supporting Crisis and Disaster Management
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Learning Objectives
Understanding Workers’
Compensation
Understanding OSHA Recordability
Effect of Treatment Decisions
Optimal Medical Management
Treating Occupational
Injuries / Illnesses
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What is Workers’ Compensation?
• State run “no fault” insurance system started in the early 1900s
• Intended to provide for medical care and wage replacement for employees in event of work-related injury/illness
• In return for immediate treatment, employees gave up the right to sue the employer in most cases
• No direct association with OSHA
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Learning Objectives
Understanding OSHA Recordability
Understanding Workers’
Compensation
Effect of Treatment Decisions
Optimal Medical Management
Treating Occupational
Injuries / Illnesses
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OSHA Recordable
Must post last years completed OSHA 300 Log in public area
for employees to view
Federal
States?
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Define OSHA Recordability
New Case
Work Related(results from an event occurring in the work
environment)
Treatment Provided General Recording Criteria
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General Recording Criteria
Death
Days away from work
Restricted work or transfer to another job
Medical treatment beyond first aid
Loss of consciousness
Significant injury or illness
Six (6) Areas Requiring Recording
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Significant injury or illness
Significant Injury
1. Fracture or “Cracked Bone” (no matter how small or well-tolerated)
2. Punctured eardrum
Significant Illness
1. Chronic irreversible disease2. Cancer
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Blood borne pathogen
percutaneous exposure
Removal due to Medical
Surveillance Results (e.g.
elevated blood lead)
Hearing loss (>25 dB & >10 dB from
baseline)
Tuberculosis acquired in
the workplace
Significant injury or illness
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Defining First Aid
Medical treatment beyond first aid
Diagnostic Procedures
are NOT Recordable
Observation or Counseling
is NOT Recordable
Treatment specifically included in OSHA’s
First Aid List is NOT
Recordable
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First Aid List
Non-prescription (OTC) medication taken in non-prescription dosage
Tetanus immunization
Cleaning, flushing or soaking wounds on the
surface of the skin
Wound Coverings
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First Aid List
Non-Rigid Support
Temporary Immobilization Device
(for transport)Eye Patch
Hot or Cold Therapy Drilling to Relieve
Nail Pressure or Blister Fluids
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Using Finger Guards
Removing Foreign Bodies from Eye
Massage
Drinking Fluids
Removing Foreign Objects (other than eye)
First Aid List
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Learning Objectives
Understanding OSHA
Recordability
Optimal Medical Management
Understanding Workers’
Compensation
Effect of Treatment Decisions
Treating Occupational
Injuries / Illnesses
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Optimal Approach to Treating an Occupational Injury / Illness
TreatmentDiagnosis
Causation
At first encounter these 3 issues
need to be addressed
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Treatment
Use same standard of care regardless of causation!!!
ACOEM Occupational Medicine Guidelineswww.mdguidelines.com
Agency for Healthcare Research & Quality http://www.ahrq.gov/clinic/http://www.guideline.gov/
Specialty Societies recommendations for treatmenthttp://www.aaos.org/Research/guidelines/guide.asp
Evidence Based Guidances
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Learning Objectives
Effect of Treatment Decisions
Understanding Workers’
Compensation
Understanding OSHA Recordability
Optimal Medical Management
Treating Occupational
Injuries / Illnesses
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Impact of Treatment Decisions on OSHA Recordability
Most Common Reasons a Claim Becomes OSHA Recordable
Work restrictions
(or a job transfer to another position)
Lost time beyond the day of injury (DOI)
Prescription medications/dosages
Physical Therapy with modalities/procedures
Rigid splints
(“stays” or limiting ROM)
Sutures for laceration repair
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Prescription Medications / Dosages
Prescription Medication
Over the Counter
VS
Acetaminophen alternating with an OTC NSAID to provide additional pain relief
This also educates EE on how to care for minor injuries with OTC meds
Don’t advise employees to take OTC meds in Prescription Dosages unless that is your intent
Ibuprofen: two 200 mg every 4-6 hours three or more 200 mg every 4-6 hours
Naproxen: one 220 mg every 8-12 hours two or more 220 mg every 8-12 hours
Impact of Treatment Decisions on OSHA Recordability
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Rigid Splints
Rigid Splints(that immobilize)
Elastic or Neoprene Wraps
(that don’t immobilize)VS
Impact of Treatment Decisions on OSHA Recordability
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Work Restrictions
But the clinician prescribes restriction of
“no lifting over 50 pounds
Current job only requires lifting 10 lbs. maximum per
lift
…and unnecessarily makes incident recordable
Impact of Treatment Decisions on OSHA Recordability
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Sutures for Laceration Repair
Steri-Strips & Butterfly Bandages
Sutures, Staples & Glue
VS
Impact of Treatment Decisions on OSHA Recordability
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Physical Therapy with Modalities/Procedures
ChiropracticPhysical Therapy
Impact of Treatment Decisions on OSHA Recordability
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New Case?S1: Installer comes into clinic for treatment due to increased LBP that occurred after
sitting in long meeting. Originally hurt back 2 years ago lifting at work. Was discharged from active care 6 months ago with “Future Medical” to address access to care for flare ups.
R1: Not a new case; recorded in log 2 years ago.
S2: What if increase in LBP occurred after lifting chair at end of meeting?R2: Depends on whether aggravation is significant and directly connected to new
incident.
ExerciseOSHA Recordability Scenarios
Recordable Based on DiagnosisS1: Slipped & fell- landed on back. Felt disoriented but got right back up and came to
clinic as instructed by mgr. Reports feeling fine. R1: No loss of consciousness (LOC), therefore non-recordable.
S2: Same Hx but didn’t get right back up; EE can’t remember how long she lay there or exactly what happened right before she fell; co-worker states she was not responsive to voice or touch for 5 minutes; a little tired but otherwise feels fine.
R2: Probable LOC; therefore, OSHA recordable.
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Exercise
Dispense Ibuprofen 200 2 tab QID or acetaminophen 650 q6 alternating with IBU
Scenario One approach => OSHA Recordable
Another approach => Non-recordable
Design engineer diagnosed with new onset lateral epicondylitis 3 days ago that occurred on business travel associated with lifting heavy carry-on bag into overhead bin.
• No additional travel planned in near term
• Employee has been back from trip 2 days and has intermittent pain primarily with ADL’s (dressing, pulling up covers in bed)
• No difficulty performing usual work but it hurts occasionally while at work
• Took dose of expired IB600 first day but none past 2 days
“To avoid aggravating injury” you prescribe work restrictions for upper extremities that if followed verbatim would preclude handling large blue prints and working on computer.
Discuss with employee whether s/he feels able to safely continue working. Explore if s/he can self-accommodate or easily coordinate assignment with co-workers and supervisor
Respect and empower those employees able to safely self-accommodate without formal restrictions
Refill Ibuprofen 600mg TID with meals
Dispense Ibuprofen 200mg 2 tabs QID and/or acetaminophen 325/500mg 2 tabs QID
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Exercise
Dispense Ibuprofen 200 2 tab QID or acetaminophen 650 q6 alternating with IBU
Scenario One approach => OSHA Recordable
Another approach => Non-recordable
Employee presents with new onset low back pain associated with fall on manufacturing floor yesterday. Felt well enough to perform full duty today but not pain-free (3-4/10). During the visit EE indicates taking Naproxen 500mg PRN for migraines. When asked, she states didn’t take Naproxen 500mg for LBP “because it wasn’t that bad.” Woke up 2 times last night (as usual- to urinate) and noted LBP with turning over in bed and today while getting out of car, but not really at work.
You advise EE to use Naproxen 500 for LBP.
Note use for migraines and offer EE OTC Naproxen 220mg to be used for LBP.
Prescribe muscle relaxant for QHS and day use PRN.
Do not dispense medication that is unlikely to expedite recovery- and may actually diminish functional capacity. Offer topical counter irritant and reusable hot/cold pack instead.
Prescribe PTx.Review self-care and proper body mechanics in clinic with employee.
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Exercise
Dispense Ibuprofen 200 2 tab QID or acetaminophen 650 q6 alternating with IBU
Scenario One approach => OSHA Recordable
Another approach => Non-recordable
Software engineer came in 2 days after hurting neck climbing under desk to plug in cable. Worked yesterday with moderate discomfort relieved by stretching intermittently and 2 separate doses of Naproxen 220mg.
EE expresses fear and frustration but acknowledges that he feels partly better today as compared to yesterday. No radiating arm symptoms or sensory changes.
You take him off the balance of today and recommended he reattempt full duty tomorrow.
Employee was coping with discomfort at work. Continue this strategy unless medically contraindicated, unreasonably painful or occupationally unsafe, since:
• had developed coping strategy that worked
• was not requested by employee • and is likely to hurt just as much at
home as at work reinforces illness behavior
• After thorough exam, reassure EE
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Review & Discussion
What makes a injury OSHA recordable? Death
Days away from work
Restricted work or transfer to another job
Any medical treatment not found on this first aid list (slides 22-24)
Loss of consciousness
Significant injury or illness
• Non-prescription medication dose (OTC) in non-prescription dosages
• Tetanus immunization• Cleaning, flushing or soaking wounds on
the surface of the skin• Wound coverings• Eye patch• Hot or cold therapy
• Temporary immobilization device • Drilling to relieve nail pressure or blister fluids• Non-rigid support• Using finger guards• Massage• Drinking fluids• Removing foreign bodies from eye• Removing foreign objects (other than eye)
• Diagnostic procedures (e.g. X-rays, blood work) are not OSHA recordable treatment• Counseling and/or Observation are not OSHA recordable treatment
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Call to Action
1. With each encounter consider whether First Aid treatment is a medically appropriate option
2. Educate and reassure injured workers about pathology, treatment plan, self-care and prognosis.
3. Use early rechecks and an “open door” policy to safely provide conservative care and avoid unnecessary restrictions
4. If appropriate clinical decisions generate an OSHA recordable case clearly document your reasoning focusing on severity, safety and/or treatment guidance. Consult your supervising MD/DO or a peer if you are undecided about how aggressively to treat.
5. If treatment is recordable, prescribe whatever else is appropriate to expedite recovery.
6. Best Online Resource:http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=9638&p_table=STANDARDS
Includes: • Criteria for OSHA recordability• List of First Aid Treatments• FAQ’s
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What challenges do you anticipate implementing these actions into your daily practice?
Discussion
Questions?