1. 1 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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3. 3 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

4. 4 Learning Objectives Understanding Workers’ Compensation Understanding OSHA Recordability Effect of Treatment Decisions Optimal Medical Management Treating Occupational Injuries / Illnesses

5. 5 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

6. 6 Learning Objectives Understanding OSHA Recordability Understanding Workers’ Compensation Effect of Treatment Decisions Optimal Medical Management Treating Occupational Injuries / Illnesses

7. 7 OSHA Recordable Must post last years completed OSHA 300 Log in public area for employees to view Federal States?

8. 8 Define OSHA Recordability New Case Work Related (results from an event occurring in the work environment) Treatment Provided General Recording Criteria

9. 9 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

10. 10 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 disease 2.Cancer

11. 11 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

12. 12 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

13. 13 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

14. 14 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

15. 15 Using Finger Guards Removing Foreign Bodies from Eye Massage Drinking Fluids Removing Foreign Objects (other than eye) First Aid List

16. 16 Clearing the Air on Terms… Compensability RecordableReportable

17. 17 Learning Objectives Understanding OSHA Recordability Optimal Medical Management Understanding Workers’ Compensation Effect of Treatment Decisions Treating Occupational Injuries / Illnesses

18. 18 Optimal Approach to Treating an Occupational Injury / Illness TreatmentDiagnosis Causation At first encounter these 3 issues need to be addressed

19. 19 Treatment Use same standard of care regardless of causation!!! 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 Evidence Based Guidances

20. 20 Learning Objectives Effect of Treatment Decisions Understanding Workers’ Compensation Understanding OSHA Recordability Optimal Medical Management Treating Occupational Injuries / Illnesses

21. 21 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

22. 22 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 hoursthree or more 200 mg every 4-6 hours Naproxen:one 220 mg every 8-12 hourstwo or more 220 mg every 8-12 hours Impact of Treatment Decisions on OSHA Recordability

23. 23 Rigid Splints (that immobilize) Elastic or Neoprene Wraps (that don’t immobilize) VS Impact of Treatment Decisions on OSHA Recordability

24. 24 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

25. 25 Sutures for Laceration Repair Steri-Strips & Butterfly Bandages Sutures, Staples & Glue VS Impact of Treatment Decisions on OSHA Recordability

26. 26 Physical Therapy with Modalities/Procedures Chiropractic Physical Therapy Impact of Treatment Decisions on OSHA Recordability

27. 27 Section 3 Review 5 Minutes Review 5 Minutes

28. 28 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. Exercise OSHA Recordability Scenarios 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.

29. 29 Exercise Dispense Ibuprofen 200 2 tab QID or acetaminophen 650 q6 alternating with IBU ScenarioOne 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

30. 30 Exercise Dispense Ibuprofen 200 2 tab QID or acetaminophen 650 q6 alternating with IBU ScenarioOne 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.

31. 31 Exercise Dispense Ibuprofen 200 2 tab QID or acetaminophen 650 q6 alternating with IBU ScenarioOne 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

32. 32 Section 4 Call to Action 5 Minutes

33. 33 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

34. 34 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

35. 35 What challenges do you anticipate implementing these actions into your daily practice ? Discussion Questions?