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



Compensation





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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

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


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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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Clearing the Air on Terms…

CompensabilityRecordable Reportable

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Learning Objectives

Understanding OSHA

Recordability



Compensation




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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



Compensation





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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


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Rigid Splints

Rigid Splints(that immobilize)

Elastic or Neoprene Wraps

(that don’t immobilize)VS


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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


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Sutures for Laceration Repair

Steri-Strips & Butterfly Bandages

Sutures, Staples & Glue

VS


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Physical Therapy with Modalities/Procedures

ChiropracticPhysical Therapy


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Section 3

Review

5 Minutes

Review

5 Minutes

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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




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




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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Section 4

Call to Action5 Minutes

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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


• 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

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=9638&p_table=STANDARDS



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What challenges do you anticipate implementing these actions into your daily practice?

Discussion

Questions?

1 optimizing early case management of occupational injuries december 17, 2013 dan r. azar md mph...

Documents

osha slide

recordable slide

aid list slide

recording slide

cancer slide

aid medical treatment

disaster management

job medical treatment