Week 8 Flashcards
What is occupational medicine
Occupational medicine is the clinical component of occupational health..
It’s a discipline concerned with the effects of work on health and the influence of pre-existent health problems on the capacity to work
Occupational health
Promotion and maintenance of the highest degree of physical, mental and social well being of workers in all occupations by preventing departures from health, controlling risks and the adaptation of work to people and people to their jobs
Occupational disease
“Work related diseases” have multiple causes where factors in the work environment play a role, together with other risk factors in the development of such diseases
An “ occupational disease” is any disease contracted primarily as a result of an exposure to risk factors arising from work activity
Is work good for your health and well being? Waddell and Burton 2006
The study shows:
-theres is strong evidence that work is generally good for physical and mental health and well being
-worklessness is associated with poorer physical and mental health
-work can be therapeutic and can reverse the adverse health effects of unemployment
Consequences of unemployment
Unemployment can harm health
Long term sickness absence-less likely to return to work- unemployment
Unemployment leads to increased:
- physical health conditions
- mental health conditions
-smoking
-obesity
Sickness absence data- UK 2018
Estimated 141.4million working days lost because of sickness or injury
The average sickness absence rate is 2.0%
Groups with highest rate of SA:
-women, older workers, those with long term health conditions, people working PT and those working in organisations> 500 employees
Health of Britain’s working age population Dame Carol Black 2008
Prevention of illness and promotion of health and well being
Early interventions for those who develop health conditions
Improvement in health for those out of work i.e supporting those with potential to work
Who’s involved in OH
Occupational physician
General practitioners
Occupational health nurse
Occupational psychologist
Physiotherapists
Occupational hygienist
Ergonomists
Toxicologists
Epidemiologists
Engineers
Safety practitioners
The employee (patient)
The employer
Safety representatives
Lawyers
Multidisciplinary OH service required for the effective management of the health of working people and workplace
OHS types
Pre placement screening
Management referrals
Fitness for work
Health surveillance
Ill health retirement
Absence management
Immunisation
Travel advice
Mental health services
Muscoskeletal services
Wellbeing and health promotion
Benefits of OHS
Help prevent work related ill health
Advise on fitness for work, workplace safety and the prevention of occupational injuries and disease
Recommend appropriate adjustments in the workplace to help people stay in work
Improve attendance and performance of the workforce eg assisting in the management of sickness absence
Provide rehabilitation to help people RTW and give advice on alternative suitable work for people with health problems
Benefits of OH
Promote health in the workplace and healthy lifetsyles
Recommend and implement policies to maintain a safe and healthy workplace
Conduct research into work related health issues
Ensure compliance with H&S regulations including minimising and eliminating workplace hazards
Advise on medical health and I’ll health retirement
WHO global plan of action on workers health 2008-2017
Objectives:
-devising and implementing policy on workers health
-protecting and promoting health at the workplace
-improving the performance of and access to occupational health services
-providing and communicating evidence for action and practice
-incorporating workers health into other policies
Occupational health services OHS access
DWP report 2016:
-38% of those employees surveyed had access to OHS
-only 13% Uk workers can access an occ. physician
Provision of services across UK is sporadic influenced by size and nature industry:
->70% public sector workers have access
-only 10% of small enterprises provide access
Occupational health and safety law
Health and safety at work etc Act 1974:
HSWA 1974 places duties on:
-employers
-employees
-self employed
-manufacturers
-others eg sub-contractors
Regulations:
-control of substances hazardous to health regs
-control of noise at work regulations
-control of vibration at work regulations
-control of lead at work regulations
-control of asbestos at work regulations
-reporting of injuries, diseases and dangerous occurrences regulations RIDDOR
-health and safety (first aid) regulations
Regulation- generic framework
Hazard identification
Risk assessment
Prevention and control of exposure
Maintenance and effectiveness of control measures
Monitoring exposure
Health and medical surveillance
Information, instruction and training
Challenges of OHS changing nature of work and needs of workforce
Full time-> part time, flexible working
Physical-> sedentary work
Job for life-> portfolio careers
Retire at 65> work beyond 65
Long contract-> mobile workforce
Manufacturing-> service industries
Large firm-> SME
Employees-> sub contractors
Healthcare professionals must adapt
Hazard
Substance, agent or physical situation with potential for harm in terms of injury or Ill health, damage to property or a combination of these
Risk
Is the likelihood of the harm or undesired event occurring and the consequence of its occurrence. It is the probability that the substance or agent will cause adverse effect under the conditions of use and/or exposure and the possible extent of harm
Occupational hazards classification
Physical
Chemical
Biological
Psycho-social/ organisational: eg working hours, demands workload, control, bullying, conflicting roles, poor relationships, support, communication etc
Ergonomic (mechanical)
Safety
Two main elements of occupational disease
-exposure effect relationship between a specific working environment/activity and a specific disease
-diseases occur among group of persons (at work) at a frequency above average morbidity of the rest of population
Importance occupational history whether a disease is caused by work or in public
Industrial injuries disablement benefit scheme IIDB and prescribed disease
Administered by DWP (social security act 1988)
IIAC makes recommendations to Secretary of State
Non-contributory no fault benefit for disablement for accident at work or one of 70 prescribed diseases known to be a risk from certain jobs
Diseases prescribed:
-risk at least doubled (epidemiology evidence)
-jobs listed against particular disease
Occupational disease- biological agents examples
Anthrax- handling animals susceptible to infection
Extrinsic allergic alveolitis- exposure to moulds, fungal spores, MWF mist, handling bagasse, caring for or handling birds
Hepatitis B or C virus- contact with human blood
Q fever- contact with animals and their remains (abattoir workers)
Occupational disease- physical hazards examples
Leukaemia- ionising radiation
Cataract - radiation
Occupational deafness
Hand arm vibration syndrome HAVS
Carpal tunnel syndrome CTS
Decompression sickness, barotrauma (compressed air, gases)
Dependent on dose, exposure duration
Musculoskeletal disorders
WRULD and LBP
Tendonitis or tenosynovitis (hand and arm)- repetitive movements,forceful exertions of wrist, eg meat cutters, assembly workers
Cramp of hand and forearm (chronic)- repetitive work movement
Prepatellar bursitis- due to prolonged stay in kneeling position
CTS- extended periods of repetitive forceful work, work involving vibration, extreme postures of the wrist
Occ. disease cancer
Caused by following agents in workplace examples:
-asbestos, bis-chloromethyl ether BCME, chromium VI compounds, coal tars, coal tar pitch, beta-naphthylamine, vinyl chloride, benzene, ionising radiations, mineral oil, nickel compounds, wood dust, beryllium and its compounds, cadmium and its compounds
Occ. diseases- respiratory
Pneumoconioses- fibrogenic mineral dust, mining, quarrying, sand blasting, grinding of granite
Chronic obstructive pulmonary diseases: coal dust, wood dust, paper dust etc
Upper airway disorders- sensitising agents or irritants
Asthma- sensitising agents (epoxy resins, enzymes, flour dust) or irritants
Occ. diseases skin
Allergic contact dermatoses and contact urticaria causes recognised allergy- provoking agents arising from work activities
Irritant contact dermatoses caused recognised irritant agents arising from work activities
Occupational history
An occupational history is a chronological list of all patients employment, expanded as necessary to detail any evidence of occupational exposure to potentially hazardous agents and resulting effects on health
Most effective instrument:
-to determine if there is evidence that work is a likely cause of ill health (diagnosis of disease)
-diagnosis will lead to better management or appropriate referral
-for assisting return to work after injury or disease if it helps to identify shortfalls in health or fitness against required standards
Occupational history- gaining info
Systematic questioning of current and previous work and associated history
Procedures:
-oral questioning about current job
-oral questioning about previous jobs
-proforma about previous jobs
-proforma in own time and oral questioning- probably gives best chance of full and accurate account and is economic with OH practitioner time
Diagnosis of diseases
Need to first establish the type of disease/disorder and whether the sign, symptoms, clinical features fit with what is known about the health effect
Example: baker reports respiratory symptoms
Occupational exposure assessment
There must be indication of sufficient occupational exposure
Exposure information on hazards
-type eg chemical substance, noise, radiation
-level and duration of exposure
-when exposed (specific job tasks)
-potential health effects
Exposure information
Evidence of occupational exposure may be obtained from:
-occupational history
-results of exposure survey at work: personal environmental or biological monitoring data samples
-exposure records: workplace risk assessments
Medical tests
Reported signs and symptoms may be supported in some cases by suitable tests eg spirometry, audiometry, vision testing, patch testing
Examples:
-extent of hearing loss and type
-allergic reactions to substances used at work
-decrement in lung function
Temporality
When in relation to exposure do/did the symptoms start
-exposure must be prior to start to symptoms
Reversibility
Do the symptoms improve when no longer exposure
Peak flow variation between workdays and weekends
Exposure response
Exposure (level must be sufficient to cause the disease)
Are the symptoms especially worse when undertaking high exposure tasks or when areas with high exposures
Strength of association
Do other workers suffer similar symptoms associated with the same exposures
Differential diagnosis
Non-occupational conditions that have similar clinical features as the occupational disease:
-non occupational exposure
-environmental
-social (smoking, alcohol)
-hobbies, pets
-medical history
-family history/genetic
Need to also consider other employment
Additional information for diagnosis occupational disease
Minimum intensity level of exposure required to cause disease
Minimum duration of exposure
Maximum latency periods- length of time between from cessation of exposure beyond which it unlikely that the disease can be attributed to work
Minimum induction period-shortest period form beginning of exposure to beginning of disease below which the exposure would have been unlikely to caused the disease
Bradford hills ‘hill’s criteria for causation’
Temporality
Reversibility
Exposure- response
Strength of association
Specificity
Consistency
Analogy
Biological gradient
Biological plausibility
Principles than be useful in establishing epidemiological evidence of evidence a causal relationship between presumed cause and an observed effect
The larger the association between exposure and disease the more likely it is to be causal
What is RIDDOR
Reporting of injuries, diseases and dangerous occurrences regulations 2013
RIDDOR requires employers and other people in control of work premises to report and keep records of
RIDDOR- record and report:
-work related accidents which cause death;
-work related accidents which cause certain serious injuries (reportable injuries)
-diagnosed cases of certain industrial diseases
-certain dangerous occurrences i.e incidents with potential to cause harm
Occupational diseases- reportable
CTS- work involves regular use of percussive or vibrations tools
Severe cramp of hand/forearm- prolonged periods repetitive movements
Occupational dermatitis- regular exposure to known skin sensitisers or irritants
HAVS- regular use of percussive or vibrating tools or holding of materials which are subject to percussive processes
Occupational asthma- significant or regular exposure to a known respiratory sensitisers
Tendonitis or tenosynovitis of hand forearm- where the persons work is physically demanding and involves frequent, repetitive movements
Any cancer attributed to an occupational exposure to a known human carcinogen or mutagen
Any disease attributed to an occupational exposure to a biological agent
Waddell and Burton 2006
Benefit of being in work:
-improves general and mental health
-reduces psychological distress and minor psychiatric morbidity
-minimises the harmful physical, mental and social effects of long term sickness absence
-reduces the risk of long term incapacity
-improves quality of life and wellbeing
Fitness for work- Aim
Is to ensure the individual is fit to perform the tasks required for their job effectively and without risk to their own or others health and safety
Fitness for work why assessment may be needed
Patients condition may limit or prevent them form performing job effectively
The patients conditions may be made worse by the job and the work environment
Patients condition makes certain jobs and work environment unsafe to them personally
Patients condition may make it unsafe both for themselves and others
Patients condition may pose a risk to the community
Assess fitness for work when
Post offer (pre placement)
RTW after sickness absence
Job change- role or work demands
Periodic review relating to specific
RTW after injury or illness
Possible retirement on grounds of ill health
Referral for fitness to work who
Self referral
Management referral
-sickness absence (short and long term)
Human Resources
Management referrals
Standard referral form
Seen and signed by worker
Consultation with OH professional
30-60 mins assessment
History, examination (investigations)
Report explained to individual
Option to see report before its sent
Dual responsibility of OH professionals
Assessing fitness for work Whose responsibility
A GP is rarely involved with determining fitness to start work
Normally the employers responsibility (with advice from their OH advisor)
Return to work
A GP is often involved in assessing fitness to return to work RTW
Fundamental questions:
-does the patient want to RTW
-does patient need to be symptom free before RTW
- is some work feasible
Moving from ‘sick note’ to ‘fit note’
Many people with health conditions can work as they recover from their condition
Work can aid recovery and benefit the employer by reducing sickness absence
Need to focus on what individual can do rather than incapacity
Introduced in 2010 doctor to advise if an employee may be fit to work with some support
Tick Boxes for doctors to use to suggest common ways to help a return to work
Note:
-certification for statutory sick pay (and other benefits)
-advisory (to the patient), not an instruction
GPs and OH
The patients occupation is not always recorded
The patient is not asked about their work
GPs don’t feel trained to use to fit note and rarely advise someone might be fit
GPs often don’t understand occupational health
Aim of the OH assessment
Effects of health on work
Effects of work on health
Workplace adjustments/adaptations etc required for employee to work safely
Communicate outcome and recommendations
Equality Act 2010
Matching individual to the job
A functional assessment of the individuals capacities will be of most use when as much is known about the job as about the individual assessed
Medical assessment
Patient details
Reason for referral
Sickness absence record
Current job- job tasks/ environment/hours/shifts/night worker
Occupational history
Presenting complaint, diagnosis may or may not be available
History of presenting complaint- medication
Past medical, social and family history
Functioning and leisure activities
Physical examination as required
Additional assessment
Questionnaires
Spirometry, audiometry, vision, workplace assessment
Fitness to drive- role of doctors
Advise the individual on the impact of their medical condition for safe driving
Advise individual on their legal requirements to notify the DVLA of any relevant conditions
Notify the DVLA when fitness to drive requires notification but individual cannot or will not notify the DVLA themselves
The driver is legally responsible for informing the DVLA
The equality act 2010
Unlawful for employer to discriminate against workers including job applicants on grounds of medical disability it requires that all reasonable steps be taken to accommodate their health problems
Equality act- disability
Definition of disability: physical or mental impairment and the impairment has a substantial and long term adverse effect on their ability to carry out normal day to day activities
Fitness for work report
Fit
Unfit (physically, mentally incapable of performing task)
Fit with restrictions/adjustments
Cannot make assessment with further information
RTW- employer may ask GP or specialist a range of questions
When is the likely date of RTW
Will there be any residual disability upon RTW
Will it be permanent or temporary
Will the employee be able to render regular service
If the answer to 2 is yes what duties would you recommend that your patient does not do and for how long
Will your patient require continued treatment or medication upon RTW
Advice to employer by OHP
Written recommendations to manager/HR
Discuss content of report with employee
Offer to show report to employee before it is sent (written consent)
Copy to employee
Copy to GP
Arrange follow up assessment
RTW components
Management commitment
Employee involvement
Education
Team approach (long term absence)
-HR, management, OH, clinicians, OT
Monitor/identify on going risks
Effective use of rehabilitation and health facilities
Workplace modifications
Encourage patient to keep in touch with work
Reduced hours: half days/phased return
Change pattern of work/shifts
Change tasks or work content
Adapt the workplace: alter layout
Reduce pace of work: frequent or longer breaks
Adapt equipment
Provide training
Provide for mobility and transport
Redeployment- temporary or permanent
Access to work
Workplace risk assessment 5 steps HSE
Identify hazards
Decide who might be harmed and how
Evaluate the risks and decide on precautions
Record your findings and implement them
Review your assessment and update if necessary
Hazard identification
Job title alone may be insufficient need to understand job tasks, work environment and work organisation
Example job titles in a foundry :
-“ forge worker”
-‘stamper’
-‘laddle person’
-foundry operative
-die caster
Hazard identifying hazards- methods and info sources
Observation of work practices and the work environment
Supplier data sheets
Records on site
Published literature
Hazard information
Type of hazards (classification)
Where present
Hazard characteristics
Who is exposed and number exposed
Exposure circumstances- how and when
Measures used to minimise risks to health
Hazard classification
Physical
Chemical
Biological
Psychosocial
Ergonomic
Mechanical
Safety
Who might be harmed
Machine operators
Supervisors
Maintenance staff
Other workers in area
Cleaners-waste disposal
Visitors
toxicological information
Hazard routes of exposure
Concentration of substance
Potential health effects- acute and chronic
Potential effects of combined exposures
Areas of body exposed (dermal)
Target organs
Measurement of exposure levels
Environmental (ambient):
-personal: inhalation (breathing zone), dermal,noise, vibration, radiation
-fixed point sampling (static): thermal, light
Biological:
-blood, urine, exhaled breath
Compare measured personal exposure levels with occupational exposure limits OELs
OELs are set by the HSE for different hazards types and used by employer to demonstrate compliance. OEL are either based on a threshold or non-threshold concept
Evaluate measures used in the workplace to minimise risks
What control measure are used to minimise the risk
How effective are the control measures
Hierarchy of control:
-elimination
-substitution
-engineering controls
-administrative controls
-PPE
Review health surveillance HS data for employees
What is HS: putting in place systematic, regular and appropriate procedure to detect early signs of work related ill health among employees exposed to certain health risks; and acting upon the results
Purpose of HS:
-early identification of effects of exposure to hazards at work
-assess effectiveness of control measures in the workplace
-identify individuals who may be more susceptible
-make decisions on fitness for work
Criteria for conducting HS in workplace
Identifiable disease or effect related to exposure
Reasonable likelihood that disease will occur under conditions of exposure
Valid technique for detecting indication of disease or effect
Record findings
Who is at risk
Risk of what
-acute and chronic health effects
Likelihood of work related Ill health
Action plan to minimise risk further
Review risk assessment- when
Any changes which effect the level of risk to employees examples changes in the following:
-substances/tool used
-methods of work
-production methods
-finding from HS
Managing risks in the workplace
Substitute hazards for less toxic
Change methods of work
Improve control measures or their effectiveness
Increase the level of health surveillance
Additional training for those exposed
