NOTE: This document is provided for historical purposes only.
Presentation by Rebecca F. Moreland, Chesapeake Occupational Health Services, Inc.
Dr. EVANOFF: I will now introduce Dr. Becky Moreland, our second speaker. Dr. Moreland is President of Chesapeake Occupational Health Services and has been newly appointed as a member of NACOSH, so has been active on the national scene for a number of years. And now I think her activities will be more visible as a part of NACOSH.
Dr. Moreland.
DR. MORELAND: Good morning. It's good to see everybody this morning. I also wish to thank NIOSH and OSHA for gathering us all together this morning and allows us this opportunity.
I will share with you that I come before you this morning with many, many hats, and I will try to describe those as I talk in the next 10 or 15 minutes. Particularly, I am a newly appointed member of NACOSH, the National Advisory Committee on Occupational Safety and Health. I join Peg and Hank in welcoming you and seeing your interest in ergonomics, and I certainly welcome any information that you can share with me that we need to use to be able to continue to guide ergonomics forward in a very successful, constructive type of a fashion.
We will see this type of a slide over and over again throughout the conference that involves the different types of components, worksite analysis, hazard prevention and control. At this particular time, we are talking about health aspects, and of course we present the middle component, medical management and health surveillance. Again, we can't provide any one of these particular components without a comprehensive program. And over and over again you will begin to hear us use those particular terms, training and education, evaluation and audit, all a part of OSHA's variety of types of components of ergonomic processes.
Certainly when we talk about medical management, Brad has done a nice job in outlining what that is. I don't want this particular session to get lost in the shuffle in reference to what health surveillance is.
At Chesapeake Occupational Health Services we are a practice of strictly health prevention and health surveillance. We do no injury care, we do not treatment of any particular problems. We strictly help set up health surveillance programs for industry, both large size, small size and medium size. And part of my experience I will share with you today, so that health surveillance is the piece that we are going to look at.
In looking at health surveillance, it makes sense for us to review what it is we are talking about, what is our definition and what are the particular factors that we may look at. The World Health Organization suggests that health surveillance includes the completion of routine measures on health and environmental indices. It involves recording and transmission of such data, and it also involves the collection and interpretation of data with a view and with a focus for its detecting changes in the health status of, in our particular situation, working populations and our respective environments.
As an active member of the American Association of Occupational Health Nurses, I, too, am very interested in their definition of health surveillance as well, screening activities which are designed to detect changes in the health status of individuals or employee groups which might be related to the occupation performed or to a particular process that we can identify in the work environment.
As individual health care providers on the scene, at a job, at a particular plant, it is critical for us to start our work early on, as Brad says, before we have disabilities, before we have significant types of changes in health status that we can diagnose and that we can measure. It is important to begin to look at those subtle types of changes, even subclinically, that may guide us towards factors or towards interventions at the outset.
In pursuing this and in working at Chesapeake Occupational Health Services, we routinely look to this model for guidance. All of you come from different types of industries, and as such, we certainly know from the industrial hygiene perspective and the safety perspective that as industrial hygienists, the workplace has been -- we have recognized certain hazards, we evaluated them, we have controlled them. And as such, we have managed to just stay atop of what may be going on in our particular workplaces.
As health care providers, recognize we have another component, namely the worker, the employee population that we represent, in which it is important to us to come up with consistent, objective written programs that guide us in reference to how are we going to recognize very subtle changes within our workers.
Once we recognize those subtle changes, what do we do to evaluate them. Is it one of these epidemics that we heard about this morning that's not really true, or indeed is it misrepresentative of how large an epidemic as far as musculoskeletal disorders that we may actually see. If we can evaluate them in a consistent type of a fashion, what can we do to control those, controlling the particular worker in the sense of making sure that we are referring them appropriately and they are getting the appropriate care that they need, as well as making sure that we are controlling the workplace and dovetailing appropriately in that sense.
Lastly, I have added in coordination implementation and evaluation, because as you heard, once we establish a program and put it into effect our work is not done, merely our work just begins.
What that teaches us is that in looking at surveillance, the ergonomic elements that we have talked about this morning, commitment by top management, a written program, employee involvement, regular program review and evaluation, are no different when we deal with health surveillance. It is important to make sure that each one of these particular actions is taken care of as you begin your endeavor into health surveillance and medical management.
And, in addition, as we begin to look at the objectives of our surveillance, as you begin to review your program or to establish your program, realize that it is important to have goals and objectives at the very outset. What is it that we are hoping to accomplish? Are we going to identify at a very early stage health changes? Are we going to then allow prompt evaluation before disability sets in? Are we going to look at conservative treatment of these signs and symptoms?
In some situations, we find that on our OSHA 200 if we are looking at illnesses and injuries, this may cause an indirect increase in these particular cases, but we also know that we are conservatively treating them so that our restricted days and our lost days should ultimately go down as well.
We are looking at implementing interventions to prevent a reoccurrence of a particular situation, and we are also using health surveillance to assist in program evaluation for effectiveness. As we have heard this morning, it is critically important to make sure that we have a direction in which we are going when we talk about surveillance and that as we do so, we have some way to begin to evaluate how well our efforts have done.
We also know that as we take a look at different types of surveillance -- my colleagues at the University of Michigan have talked about passive surveillance. Passive surveillance meaning assessing different types of data sources that are already in existence.
What do we know about reviewing or compiling the OSHA 200? Have we just taken a look at the OSHA 200 and looked at mere counts, or have we gone the next step to take a look at incidence rates to know how many particular individuals are complaining of repetitive stress injuries compared to the denominator, or the total number in that particular department.
Have we reviewed restricted and lost work days? Do we have some idea of what the workers' compensation data is telling us? Recognize that this is a very easy and potentially simple step to take, but it is laden with a number of pitfalls. There may be misclassification in the sense of what type of injury we are looking at. Is it carpal tunnel syndrome, really a tendinitis? What is it that we are seeing? There may be a lack of reporting, or there may be an over-reporting. And there may also be a reluctance on behalf of the working population to come forward and to share with you that they may have these particular problems.
Lastly, health insurance summaries are important to look at, too. I sit as one of a four-member scientific advisory committee with Chrysler and the UAW. I have been in that capacity for about the past ten years. And, obviously, with the UAW and Chrysler, ergonomics takes an extreme lead.
In looking at that, we have also found that in just looking at your strict health insurance carrier, in some situations employees are still going to those particular carriers, Blue Cross/Blue Shield, those types of carriers, talking about their carpal tunnel syndrome and their tendinitis, not understanding what the mix or what the fit may be between work, between hobby, and between other types of factors.
So again, these passive surveillance activities are important to at least begin to incorporate within any particular surveillance program you may have.
One of the particular issues that has gotten an extreme amount of attention certainly is the issue of active surveillance. What is it that we are doing as far as establishing programs within our companies to tell us more about what indeed may be going on. Have we looked at, again, Hales and Birchey certainly in 1992 outlined a number of different steps that could be taken -- looking at a symptom survey, providing a survey throughout the entire working population or certain types of department -- to give you identifying information or information at the outset to give you a feel for what the baseline might be. Not necessarily of an individual worker, but of what is going on in that particular workplace. Looking at periodic types of updates to give us a better feel for are we on track, are things improving, or, heaven forbid, are they getting worse. Because, certainly, as we make changes, we want to make sure that the changes are on tap.
Annual special project types of surveys, symptom surveys, again very, very helpful. In your packet, the OSHA Red Meat Packing Guidelines were given to you. Any of these particular types of survey forms have proven very useful. There are many different ones that are on the market today, but again that particular one represents what you can begin to look for in a survey. And, again, you will find that as you begin to implement it in your particular workplace, you will change it and you will alter it to make sure that it answers your particular needs.
Surveillance examinations, again a hot topic, as well. Should we actually be doing physical exams, and if we should, what should they consist of. Should they be done as pre-assignment and baseline. My experience in a brief survey I did with the AAOHN membership suggests that again they are not done to exclude workers from the workplace but indeed to give you a feel for what baseline measurements the individual may be coming to the workplace with you.
Most individuals have found a demonstration project to be most helpful. Evaluate those, alter the program, modify the program to make sure that it gives you the best information possible. An exam or an assessment just to take a look at workers after they have been on the job for six months to find out after they have been conditioned, after they have worked, after they have hardened at the job, are indeed they doing things correctly or is there something else we can modify.
Taking a look at period health surveillance, either on a yearly basis, an every-three-year basis, affords us an opportunity for collaboration and communication with the working staff to find out if they come to you and say, "Well, you know, I'm fine, except it hurts when I go like this," or, "It hurts when I do this." And if you ask them what "this" is, they will demonstrate very nicely for you exactly what they are doing when they perform their jobs. And it affords a wonderful opportunity for health counseling in which we can alter that particular activity to a more appropriate ergonomic posture from that sense.
Referral evaluation and treatment Brad has talked about very nicely. Again, I mention it here under active surveillance not because that is included as a part but because it is important for you to begin to keep information data that suggests to us what is going on in that particular realm. Summary information that doesn't betray anyone's confidentiality but that gives us a better feel for what is going on in that particular situation.
Those workers returning to work to know what is going on with them, as well as potentially looking at intervention surveys after we have made major engineering changes, after we have looked at different types of work production issues, to make sure that our efforts are on the right track.
I think the other thing that we find is that in looking at active surveillance, although it has been hotly contested and extremely controversial, what we are beginning to find is that it does serve several purposes for us. Again we can detect unrecognized ergonomic hazards, we can identify jobs requiring intervention to eliminate the particular ergonomic hazards. We can definitely dovetail with that issue of what are we looking at in the workplace versus what are we looking at in reference to the workers.
It also allows us a wonderful opportunity to monitor changes and the effectiveness of ergonomic interventions, as well as a triage function for employees that may need health care evaluation at this early point, as we have all talked about over and over and over again, but for some reason there is a reluctance for that particular employee to come forward.
In reference to the surveillance examinations, again, a questionnaire which may include a survey type of a symptom survey or a survey response. There are a number of these that are out on the market that are available. OSHA and NIOSH both have listed a number of these for you. My sense is to choose one that is going to be close to your particular industry. And you probably will make changes that are going to happen as well. View the particular questionnaire as an opportunity for collaboration, for communication, for better understanding of what's going on with the employee population.
Again, physical examination and assessment has included many different types of things, as we can imagine, inspection, palpation, the general types of things that we may use. And we find different types of subtleties that when looked at in a group type of process may be very meaningful and very helpful to us.
Range of motion, strength testing as far as a subjective type of response have been fairly helpful. But in our experience the physical examination and the assessment has basically provided a means in which we can counsel and communicate and make sure that people understand their body mechanics and what they need to be doing.
Screening tests, I can't agree with Brad more. If there is an ammeter out there that does it or tells you that it is going to solve your problems, certainly beware. I am going to comment on that in just a few minutes. But certainly recognize there are a number of them, vibratory perception threshold, strength testing, range of motion testing, goniometers, all of these are certainly tests that are available. Use caution with them.
In my work initially with Johns Hopkins, I took a look at the medical evaluation of carpal tunnel syndrome. And in looking at that -- again, I use carpal tunnel syndrome because at least it had the easiest point of a case definition. We used nerve conduction studies, changes in motor and sensory function as far as the nerve conduction goes to identify who had carpal tunnel syndrome and who did not.
We then compared both groups and took a look at vibratory perception, that perception of vibration in the median innervated index finger compared to the ulnar innervated little finger, to find out if we could come up with a surveillance took that was quick, accessible, acceptable, easy, that would identify for us or predict for us who would get carpal tunnel syndrome at the outset. As far as a cross-sectional approach, it wasn't that helpful, but I think there is great merit to consider in prospective approaches here, too.
Diagnostic evaluations, nerve conductions and other types of things. Again, the point here is in surveillance examinations, that they be consistent, they be objective, and there be a plan and a protocol.
Again, so that as you put your protocol together, it is a point at which other colleagues can review it, can take a look at certain deficiencies, can comment on it. And certainly what you are looking for is to make sure that your screening tools are going to work appropriately. Is there a particular standardized format? Is there a way in which the procedure should be done? Is there a standardized way in which it should be recorded? And is there a way in which we should be able to collect the information? Is there an estimated sensitivity and specificity?
Can we count on the fact that if we are screening individuals, those that are positive are truly positive or those that are negative are truly negative and what is the interplay between the two? Not only is there an estimated sensitivity and specificity, but is there a reproducible factor that we can get from the manufacturer or from the scientific community as well.
Are there predicted values? A lot of the screening tests that we use in a hospital situation with individuals that are there because they are being treated for carpal tunnel syndrome or they are being treated for tendinitis is a much different population than our working populations. We need to begin to better understand what these predicted values may be.
Are there calibration issues that we have to deal with on our goniometers or on our different types of pieces of equipment so that the information is giving us information that we are counting on, and do we have an acceptable test format as well as interpretive criteria that is going to guide us and tell us who may be positive, who may be negative, who may be normal, who may be abnormal, or is there a gray area that we can also cut into that says early intervention is important here, let's re-instruct, re-look at the job, and re-correct and different pieces of the puzzle.
So that as we take a look at this issue of health surveillance, certainly know that this is the big preventive type of an activity that is going on within a company. It is that particular person that is there for doctors or for physicians or for other folks that are actually treating people with different types of repetitive stress disorders. But it also means that there is usually a case management type of an activity that is going on, as well.
Brad nicely showed you the paradigm once before, and I think here it behooves me to at least mention to you that those individuals who are on site at a company can give you a feel for what is going on with the cases of carpal tunnel syndrome or tendinitis. We certainly know that if somebody gets prepared or gets recommended for surgery, especially in cases of CTS and trigger finger, the case management function here is critical to take a look and make sure that conservative therapy has been adequately assessed and that indeed it has consciously failed.
So that conservative therapy among everyone that we talk about certainly is the approach we appreciate taking. And almost without question those that I telephone surveyed, a second opinion is almost always obtained that corroborates the initial recommendations for surgery.
If we expand the definition of case management just a little bit further, certainly recognize on site the health care provider that is the point of contact almost always will know for you a review of symptom surveys, a review of cases, what's going on with those and what do they entail, descriptions of the particular surgical cases and what activity that might involve, a review of restricted limited duty types of cases to give us a better feel for what's going on with those individuals.
What is our conservative therapy experience? Are we using cold, are we using heat? Heaven forbid, are we using wrist splints in the workplace and is that creating more of a difficulty than it is attempting to solve? All of these are important from a case management perspective to know are we moving in the right direction, not have we substituted one wrong or one particular ergonomic risk factor for another.
Return to work, rehabilitation, and, lastly, program review and evaluation. This issue of case management, the process that we go through can be very instructive and very helpful in our health surveillance activities.
So again, symptom surveys and reports. Recognize that the activity here is identifying conservative effective treatments that are working in your place of employment. It is helping us to monitor employee responses. It also allows us the opportunity to re-review the progress and to ensure that improved interventions are truly working.
Lastly, it also gives us the opportunity when we take a look at, again, those that have restricted duty or limited duty. In my experience in consulting with a couple of companies, we very nicely have gone through and identified the areas where we can have limited duty. We have identified those individuals that may profit from conservative treatment. But when we have really taken a look at it, all we have managed to do is complement or supplement one particular ergonomic high-risk thing for another.
So here, looking at case management type of an approach, we can ensure the appropriate assignment, we can review any aggravating characteristics of job assignment, we can identify co-workers who may be reluctant to report concerns, and allow us that early point of intervention, that early recognition that we are looking for.
Return to work issues, assess with counseling needs, those particular activities of daily living, the trauma that the individual has been through, and allow them to accommodate to work a little bit easier. We can review the correction of ergonomic risk factors that we may have overlooked or continue to complement them and make them better. And also it allows us to, again, re-review this issue of job accommodation. What are those essential job functions that are required on the job from that perspective.
In summary, certainly what it allows us is not necessarily medical management, medical intervention, it allows us counseling, it allows us an opportunity for education and training, it allows us to review ergonomic risk factors, like we all know, abnormal awkward postures, force, repetitive motion, issues of the job station, and it also allows a review of job activities and assignments, as well as to collaborate ergonomic changes and make sure that as an ergonomic team we have done the appropriate process.
So again, the goal of the surveillance programs. I took a little more of a positive stance, but my words of wisdom are, again, that it is a comprehensive approach. No one single person can pull it off. Everyone's efforts are needed. It is a problem that is so large, it is going to continue to involve our comprehensive approach. There is no single solution. And if someone tells you there is, I beg to differ.
Again, we are looking at effective, constructive communication, and lastly, proactive strategies that are going to begin to take the place of these reactive strategies. So the words that we are talking about here in Chicago, comprehensive, constructive, communication, all these particular "c" words here in Chicago that hopefully are going to bring us forward in ergonomics.
The last one, please.
I just wish to share with you, those of my colleagues who are in the audience, I am not sure who moved me to Grand Junction, Colorado, but I still am very active and well in Baltimore, Maryland. I look forward to hearing from you.
I challenge you, is the last of the "c" words. OSHA and NIOSH very graciously offered us the opportunity to participate in this conference. It is now our job to communicate back to them, to let them know what is working in our communities, both as a letter or both as a summary, so that we have some way of doing it. I certainly welcome such input and will certainly help to guide the process through, at least on behalf of the National Advisory Committee for Occupational Safety and Health.
Thank you for your attention.
DR. EVANOFF: I think we have time for one quick question for Dr. Moreland, if someone has a question at this point.
Yes, in the back. Can you go to the microphone, please. The questions and answers are all being taped and will be part of the transcript that you receive after the meeting.
MR. : I was wondering how easy it is to convince management to convince management to somehow address this issue with the employees of having their own personal physicians cooperate with management in that type of medical management protocol that we would prefer to have established. In particular, it seems like the conservative interventions that you talk about being the preferred route, that gets just run over all the time. They go immediately to the surgery and the expensive options. How do we intervene in that situation without --
DR. MORELAND: Let me choose to comment on that, as well. And I think from the perspective at looking at health surveillance, my advice is that if we have summary data, if we have group data, not the data from employee A, employee B, and employee C, it is extremely helpful. If we as a company have begun to identify a source that is going to provide us our referral, our diagnostic evaluation, our treatment that is one particular facility, or facility that we know, then we have done our job in describing in a written procedure what we are going to do, at least from a symptom survey, what is going to happen if somebody has positive symptoms, are we going to do conservative treatment, what is going to happen, that issue of communication and collaboration on the plant side, on the employee side, and on the diagnostic side, or on the medical management side, all begin to come together pretty closely.
So it allows us a better way to monitor that, to provide summary data that is going to be more helpful than just looking at specific instances in which it gets lost in the shuffle given different individual personalities or whatever it is. It is important to continue to go forward in as consistent a process as possible that is appropriate for your workplace, as well as an objective type of a process, looking at how are we going to summarize this activity and this experience in the end.
DR. EVANOFF: Two quick additions to that. The question is how in a state where employees have free choice of provider can you try to control some of the inappropriate or overly aggressive medical care that's done.
I think two successful approaches. One has been to work with your insurer, whether it is a state as in Washington State, which is an insurance -- individual insurance. Many of them are starting to now put in practice guidelines and starting to look at the provision of medical care. Another is to make sure that your employees are well educated.
And I find that most patients, given the choice between surgery tomorrow or conservative treatment for four weeks and then reconsider surgery if you are not better, not many people who choose surgery tomorrow. And I think it is making sure your employees have access to reasonable conservative second opinions or make sure that they get appropriate medical advice.
MR. : Okay. Thank you.
DR. EVANOFF: We are going to have to hold the rest of the questions to the end.
