“First Aid Only!” Dan Rafael Azar MD MPH QME Medical Director Alliance Occupational Medicine Santa Clara & Milpitas www.allianceoccmed.com

“Always Start With a Joke”

Recording Criteria (Section 14300.4) Basic requirement: Each employer required by this article (>10 EE’s) to keep records of fatalities, injuries, and illnesses must record each fatality, injury and illness that: (1) Is work-related (Section 14300.5) and (2) Is a new case (Section 14300.6) and (3) Meets one or more of the general recording criteria of Section 14300.7 OR the application to specific cases of Section 14300.8 through Section 14300.12.

Work-related? An event or exposure in the work environment either caused or contributed to the resulting condition or significantly aggravated a pre-existing injury or illness

Determination of New Cases Section 14300.6 (a) Basic requirement. You must consider an injury or illness to be a "new case" if: (1) The employee has not previously experienced a recorded injury or illness of the same type that affects the same part of the body, or (2) The employee previously experienced a recorded injury or illness of the same type that affected the same part of the body but had recovered completely (all signs and symptoms had disappeared) from the previous injury or illness and an event or exposure in the work environment caused the signs or symptoms to reappear.

General Recording Criteria §14300.7 A work-related injury or illness must be recorded if it results in one or more of the following: (A) Death: Section 14300.7(b)(2) (B) Days away from work: Section 14300.7(b)(3) (C) Restricted work or transfer to another job: Section 14300.7(b)(4) (D) Medical treatment beyond first aid : Section 14300.7(b)(5) (E) Loss of consciousness : Section 14300.7(b)(6) (F) A significant injury or illness diagnosed by a physician or other licensed health care professional : Section 14300.7(b)(7)

What is the Definition of Non-Recordable Medical Treatment? §14300.7 1. Visits to a physician or other licensed health care professional solely for observation or counseling; 2. The conduct of diagnostic procedures, such as x-rays and blood tests, including the administration of prescription medications used solely for diagnostic purposes (e.g., eye drops to dilate pupils); or 3. “First aid” as defined in subsection (b)(5)(B) of this section.

So…What is the Definition of First Aid in §14300. 7 So…What is the Definition of First Aid in §14300.7? 14 Specific Items on “The List” 1. Using a nonprescription medication at nonprescription strength 2. Administering tetanus immunizations (other immunizations, such as Hepatitis B vaccine or rabies vaccine, are considered medical treatment); 3. Cleaning, flushing or soaking wounds on the surface of the skin; 4. Using wound coverings such as bandages, Band-Aids™, gauze pads, etc.; or using butterfly bandages or Steri-Strips™ (other wound closing devices such as sutures, staples, etc. are considered medical treatment); 5. Using hot or cold therapy;

What is the Definition of Medical Treatment? (Continued) 6. Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc. (devices with rigid stays or other systems designed to immobilize parts of the body are considered medical treatment); 7. Using temporary immobilization devices while transporting an accident victim (e.g., splints, slings, neck collars, backboards, etc.); 8. Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister; 9. Using eye patches; 10.Removing foreign bodies from the eye using only irrigation or a cotton swab;

What is the Definition of Medical Treatment? (Continued) 11. Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs or other simple means; 12. Using finger guards; 13. Using massages (physical therapy or chiropractic treatment are considered medical treatment for recordkeeping purposes); 14. Drinking fluids for relief of heat stress.

Are Any Other Procedures Included in First Aid? No. This is a complete list of all treatments considered first aid.

Does the professional status of the person providing the treatment have any effect on what is considered first aid or medical treatment? No. Similarly, treatment beyond first aid is considered to be medical treatment even when it is provided by someone other than a physician or other licensed health care professional.

What if a physician recommends medical treatment but the employee does not follow the recommendation? Classic examples: Patient did not fill Rx for Antibiotics Patient does not adhere to restrictions at work or home You must record the case even if the injured employee does not follow the physician’s recommendation Employer should encourage the injured employee to follow physician's recommendation

If a claim is Not on the List of Severe Injury/Illness and On the List of First Aid Treatment it is Non-Recordable “Recordable” = need to record injury/illness in OSHA 300 log Current definition of First Aid and Recordability took effect January 1, 2002 Didn’t get changed in 2004/2005 during WC reform Greater clarity than previous regulation Less flexibility for “favorable interpretation” (manipulation) Non-occupational causation (“not work related”) is other main reason for “Non-Recordable”

Claim is Recordable Based on Diagnoses / Treatment /Unique Exposures Death Loss of Consciousness Significant Injury/Illness: Fracture or “Cracked Bone” Punctured eardrum Chronic irreversible disease Cancer Treatment beyond “First Aid” (see “The List” of 14) Needle stick with Blood/OPIM (Other Potentially Infectious Material) Hearing Loss (>25dB and >10 dB shift) Exposure to Pesticides (CA specific) Tuberculosis contracted at worksite

Recording Criteria for Work-Related Tuberculosis Cases §14300.11. Basic requirement: “If any of your employees has been occupationally exposed to anyone with a known case of active tuberculosis (TB), and that employee subsequently develops a tuberculosis infection, as evidenced by a positive skin test…” You must record the case on the Cal/OSHA Form 300 by checking the “respiratory condition” column.

What If Severe Injury/Illness can be Treated with “First Aid Only” Most Severe Injuries (as defined on by §14300.7) will cause Days away from work Restricted work or job transfer Medical treatment beyond “first aid” as defined by “The List”… but not all. Some Injuries/Illness on List do not require “Medical Treatment” Classic Examples: Minor fracture such as a broken toe for sedentary worker Hearing Loss (if hearing aid not required) BBP exposure (in someone current on Hepatitis vaccination) “Loss of Consciousness” “Some significant progressive diseases, such as byssinosis, silicosis, and some types of cancer, for which medical treatment or work restrictions may not be recommended at the time of diagnosis but are likely to be recommended as the disease progresses.” Final Answer: List of Severe Injuries over rules List of First Aid Treatment

Most Common Reasons Claims Become Recordable Treatment driven by severity/duration of injury or risk of complication: Physical Therapy with modalities/procedures Work restrictions (or a job transfer to another position) Rigid splint (“stays”, limit ROM) Prescription medications Sutures for laceration repair (full thickness wound or for cosmesis) Rarely at AOM: Loss time beyond the day of injury (DOI)

First Aid as Defined by California Labor Code Section 5401(a) "any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care.”

First Aid as Defined by California Labor Code Section 5401(a) Treatment is not considered first aid in either of the following circumstances: Medical care goes beyond a one-time treatment and follow-up visit. The injury causes an employee to lose time from work beyond his or her work shift.

Sacramento Drops the Ball Again AB 615 by Roger Neillo (R-Fair Oaks) would adopt the Cal-OSHA definition of first-aid injury to eliminate confusion for employers http://totalcapitol.com/ and enter AB 615 The California Commission on Health and Safety and Workers’ Compensation: Summary of January 9, 2009 First Aid Cases Advisory Group Meeting

Employer/Employee Reporting Not Required for First Aid “If treatment is considered first aid, the employer is not required to submit an Employer's Report of Occupational Injury or Illness to State Fund nor provide a Workers' Compensation Claim Form to the employee.” “If additional care is needed beyond first aid, both the injury report and claim form must be submitted.” “The two forms must also be submitted for injuries that result in lost time beyond the date of the incident.”

Doctor’s Report Required even for First Aid: Section 6409(a) California Labor Code The physician is required to submit a Doctor’s First Report of Injury or Illness (DFR form 5021) to Insurer within five calendar days of the initial examination. A DFR is not required if a physician is not involved in the first aid treatment (for example OHN)

Section 6409(a) of the California Labor Code (cont.’d) Insurer is required to send a copy of the DFR to the Department of Industrial Relations (specifically the Division of Labor Statistics and Research). If, at the request of an employer, a first aid treating physician fails to submit a DFR to the workers’ compensation carrier, the Department of Insurance and the Department of Industrial Relations may consider the arrangement improper. This arrangement can be viewed as contributing to possible criminal violations related to premium fraud and the fraudulent denial of workers’ compensation benefits to an injured worker.

Principles of Ethical Use Cannot interfere with “appropriate care” “of employee-patients Appropriate care based on Guidelines (ACOEM, ODG) and Community Standards (Good Sam., Stanford, PAMF, Kaiser) The employer is ultimately responsible for correct classification and documentation

Common Misconceptions Don’t need to file Doctor’s First Report (form 5021) with carrier or TPA Legal requirement for clinic and employer Employer can still choose to be billed directly as a standing request or on a case by case basis Cannot recommend non-prescription medications in prescription dosages “take 3 Advil” (Ibuprofen 200mg x 3 = 600 mg)

First Visit @ Alliance: Diagnosis? Industrial Causation? First Aid Only?

First Aid @ AOM: Can injury be managed equally well with first aid only treatment? All providers trained to consider “first aid only” treatment option Requires creativity Requires patient education around self-care Requires aggressive follow-up with early recheck If medically necessary increase intensity of treatment on recheck

First Aid Issues The more aggressive a given provider is with using “first aid only” the higher percentage will fail this attempt A provider can be too aggressive with FA only Read the patient

First Aid Issues Not OSHA recordable if restrictions don’t apply to “usual” job duties: Example: administrative assistant that “never” requires lifting over 20lbs. Restrictions are providers way of cautioning against aggravating activities at work or home Example: lifting 40 lb 3-year old child from car seat.

Patient Satisfaction with First Aid Treatment Need to be careful not to “turn patients off” or decrease confidence in provider Important to understand treatment to date Saw own MD Treated as F.A. for several weeks by OHN at worksite “Read patient” Educate Reassure Do not discuss cost savings/benefit to employer of FA Only treatment

Patient Satisfaction Dispense OTC meds to address pain & inflammation: Generic Advil = Ibuprofen 200mg Generic Aleve = Naproxen 220mg Generic Tylenol = Acetaminophen 500mg Use at dosages and at frequency recommended on label Initially encourage regular use (not PRN: “as needed”) for better pain and inflammation control

Patient Satisfaction Dispense FA pain management/self-care items as medically indicated: Reusable hot/cold packs Muscle creams Elastic exercise bands Cervical roll (not collar) Soft splints (no stays)

Practical Issues Use incident form for all injuries 2 Options: All injuries logged on to OSHA 300 and use single line to cross out those that are ultimately closed as First Aid Only. Those that return as Recordable from clinic are logged on to OSHA 300

Why is the First Aid Issue Frustrating? Labor Code definition of FA is different Last chance for injury not to be recordable You or your manager use the retro scope to analyze the case You are caught in the middle Unreasonable expectations of the physicians

Suggestions for Coping with Recordable Injuries Don’t take it personally when things don’t go as well as hoped for Anxious or high maintenance employees can get frustrated at the system “Bad” employees get injured too – its just harder to be compassionate Be supportive of all injured workers Be communicative

First Aid Isn’t Prevention It’s Damage Control According to the National Safety Council, 75 percent of all accidents are preceded by one or more close calls.. a close call is a call to action. There are few "real" accidents that come completely out of nowhere, Most accidents can be predicted and prevented. something is wrong and requires immediate attention the near miss this time will be an accident next time. So if your employees and supervisors just go back you have a big safety problem. A close call means that the worker was lucky

Strike While the Iron Is Hot Most close calls result from a combination of factors. Although human error is often one cause, other hazards often play a role These include: Poor lighting Inadequate ventilation Lack of a warning sign A missing machine guard Lack of effective safety rules Inadequate training or experience.

Incident Report & Investigate Find Out What Happened and Why Every close call needs to be investigated just like an actual accident. Examine the scene and look for clues about exactly what happened. Talk to everyone involved and to witnesses as well. Look for circumstances that might have contributed to the close call. For example, were new or untrained workers involved? Were any safety rules ignored? Or were rules specific to the incident lacking?

Don’t Rush to Judge Look for underlying causes. An immediate cause may be a mechanical failure, or it could be an unsafe action by a fellow employee. The underlying cause could be poor machine maintenance, a missing guard, a crowded work area, or a lack of training. Discuss the incident with supervisors, employees, and also with outside experts, if necessary, to get ideas and perspective.

Complete an accident/ near-miss report Getting the incident on paper will help prevent it from being forgotten or ignored. Take Action Share your report with employees and management alike. Make sure everyone knows what you’re doing to prevent it from happening again. then take the necessary actions to eliminate or control the hazards If you don’t act now, you’ll pay the price later…

Summary First Aid is not as good as Prevention If a provider doesn’t consider First Aid you will miss the one of the last opportunities to control costs Refer to the Regulations when complying with OSHA 300 log requirements