Optimizing
Early Case Management
of Occupational Injuries
December 17, 2013
Dan R. Azar MD MPH
Regional Managing Physician
Lockheed Martin Corporation
Sunnyvale 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
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
• Leveraging Occupational Visits to
address Personal Health issues
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Learning Objectives
Understanding
Workers’
Compensation
Understanding
OSHA Recordability
Treating
Occupational
Injuries / Illnesses
Effect of Treatment
Decisions
Optimal Medical
Management
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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
Workers’
Compensation
Understanding
OSHA Recordability
Treating
Occupational
Injuries / Illnesses
Effect of Treatment
Decisions
Optimal Medical
Management
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OSHA Recordable
Federal
Must post last years completed
OSHA 300 Log in public area
for employees to view
7
Define OSHA Recordability
Work Related
(results from an event
occurring in the work
environment)
New Case
Treatment Provided
General Recording Criteria
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General Recording Criteria
Six (6) Areas Requiring Recording
Death
Days away from work
Restricted work or transfer to another job
Loss of consciousness
Significant injury or illness
Medical treatment beyond first aid
9
Significant injury or illness
Significant Illness
Significant Injury
1.
2.
Fracture or “Cracked Bone” (no
matter how small or well-tolerated)
Punctured eardrum
1.
2.
Chronic irreversible disease
Cancer
10
Significant injury or illness
Blood borne
pathogen
percutaneous
exposure
Hearing loss (>25
dB & >10 dB
from baseline)
Removal due
to Medical
Surveillance
Results (e.g.
elevated blood
lead)
Tuberculosis
acquired in
the workplace
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Medical treatment beyond first aid
Defining 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
Temporary
Immobilization Device
Eye Patch
(for transport)
Hot or Cold
Therapy
Non-Rigid
Support
Drilling to Relieve
Nail Pressure or
Blister Fluids
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First Aid List
Drinking Fluids
Using Finger
Guards
Removing Foreign
Bodies from Eye
Massage
Removing Foreign Objects
(other than eye)
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Clearing the Air on Terms…
Recordable
Compensability
Reportable
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Learning Objectives
Understanding
Workers’
Compensation
Understanding
OSHA
Recordability
Treating
Occupational
Injuries / Illnesses
Effect of Treatment
Decisions
Optimal Medical
Management
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Optimal Approach to Treating an Occupational
Injury / Illness
At first encounter
these 3 issues
need to be
addressed
Diagnosis
Treatment
Causation
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Treatment
Use same standard of care regardless of causation!!!
Evidence Based Guidances
ACOEM Occupational Medicine Guidelines
www.mdguidelines.com
Agency for Healthcare Research & Quality
http://www.ahrq.gov/clinic/
http://www.guideline.gov/
Specialty Societies recommendations for treatment
http://www.aaos.org/Research/guidelines/guide.asp
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Learning Objectives
Understanding
Workers’
Compensation
Understanding
OSHA Recordability
Treating
Occupational
Injuries / Illnesses
Effect of Treatment
Decisions
Optimal Medical
Management
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Impact of Treatment Decisions on OSHA Recordability
Prescription
medications/dosages
Rigid splints
(“stays” or limiting ROM)
Physical Therapy with
modalities/procedures
Most Common Reasons a Claim
Becomes OSHA Recordable
Lost time beyond the day
of injury (DOI)
Sutures for laceration
repair
Work restrictions
(or a job transfer to
another position)
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Impact of Treatment Decisions on OSHA Recordability
Prescription Medications / Dosages
Don’t advise employees to take OTC meds in
Prescription Dosages unless that is your intent
Over the
Counter
Ibuprofen:
Naproxen:
VS
Prescription
Medication
two 200 mg every 4-6 hours
three or more 200 mg every 4-6
hours
one 220 mg every 8-12 hours
two or more 220 mg every 8-12
hours
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
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Impact of Treatment Decisions on OSHA Recordability
Rigid Splints
Rigid Splints
(that immobilize)
VS
Elastic or Neoprene
Wraps
(that don’t immobilize)
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Impact of Treatment Decisions on OSHA Recordability
Work Restrictions
Current job only requires
lifting 10 lbs. maximum per
lift
But the clinician
prescribes restriction of
“no lifting over 50 pounds
…and unnecessarily makes incident recordable
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Impact of Treatment Decisions on OSHA Recordability
Sutures for Laceration Repair
Sutures, Staples &
Glue
VS
Steri-Strips &
Butterfly Bandages
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Impact of Treatment Decisions on OSHA Recordability
Physical Therapy with
Modalities/Procedures
Physical Therapy
Chiropractic
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Section 3
Review
5 Minutes
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Exercise
OSHA Recordability Scenarios
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.
Recordable Based on Diagnosis
S1: 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
Scenario
One approach =>
OSHA 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
Discuss with employee
whether s/he feels able to
safely continue working.
“To avoid aggravating injury”
Explore if s/he can selfyou prescribe work restrictions accommodate or easily
for upper extremities that if
coordinate
assignment
with650
Dispense Ibuprofen 200
2 tab QID or
acetaminophen
followed verbatim
would
q6 alternating with IBUco-workers and supervisor
preclude handling large blue
prints and working on
Respect and empower those
computer.
employees able to safely
self-accommodate without
formal restrictions
Refill Ibuprofen 600mg TID
with meals
Another approach =>
Non-recordable
Dispense Ibuprofen 200mg
2 tabs QID
and/or acetaminophen
325/500mg 2 tabs QID
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Exercise
Scenario
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.
One approach =>
OSHA Recordable
Another approach =>
Non-recordable
You advise EE to use
Naproxen 500 for LBP.
Note use for migraines and
offer EE OTC Naproxen
220mg to be used for LBP.
Dispense Ibuprofen 200 2 tab QID or acetaminophen 650
q6 alternating with IBU
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
Scenario
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.
One approach =>
OSHA Recordable
Another approach =>
Non-recordable
Employee was coping with
discomfort at work. Continue this
strategy unless medically
contraindicated, unreasonably
Dispense Ibuprofen 200 2 tab QID or acetaminophen 650
painful or occupationally unsafe,
q6 alternating with IBU
since:
You take him off the balance of
• had developed coping strategy that
today and recommended he
worked
reattempt full duty tomorrow.
• 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 Action
5 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
Loss of consciousness
Significant injury or illness
Any medical treatment not found on this first aid list (slides 22-24)
• 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.
2.
3.
4.
5.
6.
With each encounter consider whether First Aid treatment is a medically
appropriate option
Educate and reassure injured workers about pathology, treatment plan, self-care
and prognosis.
Use early rechecks and an “open door” policy to safely provide conservative care
and avoid unnecessary restrictions
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.
If treatment is recordable, prescribe whatever else is appropriate to expedite
recovery.
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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Discussion
What challenges do you anticipate implementing
these actions into your daily practice?
Questions?
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