OSHA. First-aid vs Recordables. Workers' Comp. Return to Work.

1. Occupational Medicine
&
the Workplace Clinic
Quick overview
Myiesha Taylor MD FACEP FAAEM
Medical Director

2. Objectives: To understand...
● What is Occupational Medicine?
● What is a Workplace Clinic?
● OSHA Recordables:
○ What is Work-relatedness?
○ What is First Aid?
○ What is Recordable?
○ What is recordable hearing loss?
● Use of Opioids in Occupational Medicine
● Non-work related situations
● What is Workers’ Comp?
● Return to Work Guidance & Resources
● What do do about a (suspected) Malingering Patient?
● Resources

3. What is Occupational Medicine?
Occupational medicine is a subspecialty of preventive medicine that focuses on the interrelationship between
the health of workers and their workplaces. Whether providers are embedded in a corporation or contracted
to provide services to an employer, or they simply work in a community setting, they often find themselves
evaluating and treating conditions related to their patients’ work.

4. Occupational Health Practice
For clinicians establishing or working in an occupational health practice, many protocols and procedures will depend on the practice situation (i.e. freestanding
clinic, corporate clinic, large clinic network) and on the industry or industries being served.
However, the following are important considerations for any clinician providing occupational health services:
● Review (or create) policies and procedures to assure compliance with OSHA standards as well as compliance with other certification and licensing
bodies.
● Identify occupational health hazards, such as biological, chemical, physical, ergonomic and psychological, for all worker groups and industries
being served.
● Consider these risks, along with OSHA regulations, when designing and performing worker examinations and medical surveillance.
● Implement preventive measures that address occupational health risks in your practice such a protecting workers from Bloodborne Pathogens and
Hazard Communication.
● Understand applicable state and local regulations related to issues such as pharmaceutical and vaccine storage, workplace safety requirements
and medical waste.
● Be familiar with the screening protocols, procedures and calibrations required for equipment used, such as spirometers and audiometers, and
with the certification requirements for staff performing the testing.
● Integrate worker health and safety education into clinical practice whenever possible. Be aware of the health and safety training that employers
provide to workers. (https://www.osha.gov/dts/oom/clinicians/)

5. What is an Onsite Clinic?
A workplace “onsite clinic” is a setting where an employer offers one or
more medical and wellness services, delivered by licensed providers, to
all or a designated portion of its active population and other eligible
individuals.
Today’s clinics are often referred to as “health and wellness centers,”
due to the wide range of first aid, occupational health, acute,
primary, specialty, condition management, wellness and
ancillary services offered at the location.
Many started as occupational health clinics, treating minor injuries and
serving workplace health and safety needs, but have expanded in to
primary care and other areas.
https://www.nawhc.org/What-is-an-Onsite-Clinic#:~:text=A%20workplace%20%E2%80%9Consite%20clinic%E2%80%9D%20is,population%20and%20other%20eligible%20individuals.

6. What is First Aid?
How does OSHA define first aid?
○ Using a non-prescription medication at nonprescription strength (for medications available in both prescription and non-prescription form,
a recommendation by a physician or other licensed health care professional to use a non-prescription medication at prescription strength is
considered medical treatment for recordkeeping purposes);
○ Administering tetanus immunizations (other immunizations, such as Hepatitis B vaccine or rabies vaccine, are considered medical treatment)
○ Cleaning, flushing or soaking wounds on the surface of the skin
○ 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);
○ Using hot or cold therapy;
○ 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 for recordkeeping purposes);
○ Using temporary immobilization devices while transporting an accident victim (e.g., splints, slings, neck collars, back boards, etc.). Drilling of a
fingernail or toenail to relieve pressure, or draining fluid from a blister;
○ Using eye patches
○ Removing foreign bodies from the eye using only irrigation or a cotton swab;
○ Removing splinters or foreign material from areas other than the eye by irrigation, tweezers, cotton swabs or other simple means;
○ Using finger guards;
○ Using massages (physical therapy or chiropractic treatment are considered medical treatment for recordkeeping purposes); or
○ Drinking fluids for relief of heat stress

7. OSHA Recordable & Work Relatedness
How does OSHA define a recordable injury or illness?
● Any work-related fatality.
● Any work-related injury or illness that results in loss of consciousness, days away from work, restricted
work, or transfer to another job.
● Any work-related injury or illness requiring medical treatment beyond first aid.
● Any work-related diagnosed case of cancer, chronic irreversible diseases, fractured or cracked bones or
teeth, and punctured eardrums.
● There are also special recording criteria for work-related cases involving: needlesticks and sharps injuries;
medical removal; hearing loss; and tuberculosis.
https://www.osha.gov/Publications/OSHA4045.pdf
Work Relatedness:
Section 1904.5(a) states, "[the employer] must consider an injury or illness to be work-related if an event or exposure in the
work environment either caused or contributed to the resulting condition. Work-relatedness is presumed for injuries and
illnesses resulting from events or exposures occurring in the work environment, unless an exception in Section 1904.5(b)(2)
specifically applies." Under this language, a case is presumed work-related if an event or exposure in the work environment
is a discernible cause of the injury or illness or of a significant aggravation to a pre-existing condition. The work event or
exposure need only be one of the discernable causes; it need not be the sole or predominant cause.

8. Recordable Hearing Loss
Has the employee suffered a STS (Standard Threshold Shift)?
Is the employee’s overall hearing level at 25dB or more above audiometric zero?
Is the hearing loss work-related?
If the answer is YES to these 3 questions, record this as a hearing loss case.
Source: https://drive.google.com/file/d/1FIdzbyjQwJ5bOaYz5TOPLtwPLfWF1qMU/view?usp=sharing
Source:
https://cihconline.com/images/documents/presentations/CIHC_Conf_2017_pdf_
Presentations/R_Brauch-CIHC_2017_FINAL_REV_1.pdf

9. Recordable (Medical Treatment) Non-recordable (First Aid)
Visits to Clinic Any injury or illness that is treated that’s not on the
first aid list
Observation, testing, evaluation, counseling.
Diagnostic procedures.
Wound care Laceration repairs, treatment of infection,
debridement.
Bandages, cleaning, flushing, Steri-strips.
Innoculations Rabies Tetanus, flu
Foreign bodies FB to the eye (unless only use irrigation and cotton
swab). Any removal that requires more than the use
of small simple tools.
Removing FB from eye using only irrigation
or a cotton swab. Removing splinters or FB
with tweezers, cotton swabs, or pins, needles,
small tools.
Burns, rashes, blisters,
bruises
anything that results in days away from work,
restricted work, or medical tx beyond first aid.
Draining fluid from a blister. Soaking
therapy. Hot/cold therapy.
Sprains Casts & rigid immobilization. Chiropractic care. PT. Hot/cold therapy. Non-rigid support. Finger
guards. Temporary immobilization for
transport (splints, neck collars, long back
boards).
Medications Prescription meds or OTC meds administered at
prescription strength
OTC meds
Oxygen symptomatic treatment precautionary treatment
Loss of Consciousness Result from workplace exposure or event Result from a prior h/o epilepsy, DM,
narcolepsy, etc. Due to voluntary
participation in a wellness program (i.e.
vasovagal syncope during voluntary blood
draw)
Source: https://www.jjkeller.com/learn/guide-to-
OSHA-recordable-injuries-and-illnesses

10. Opioid use in Occupational Medicine
The use of opioids are generally
discouraged.
Treat patients with NSAIDS and muscle
relaxants as indicated.
Use physical therapy, exercises, ice/heat
modalities.
Referral to community specialists are
appropriate.
Typically, if a patient has enough pain to
warrant opioids, they should be managed
by a comprehensive pain
management team which is beyond
the scope of practice of most workplace
clinics.

11. Non-Work Related Situations
An injury or illness occurring in the work environment that falls under the following exceptions is not work-related and therefore not recordable.
Source: https://drive.google.com/file/d/1bRCUzjof_d9a4mpKxXQK2OzlyAdw49qS/view?usp=sharing

12. What is Workers’ Comp?
Workers’ compensation insurance is a type of business insurance that provides
benefits to employees who suffer work-related injuries or illnesses. Specifically, this
insurance helps pay for medical care, wages from lost work time and more.
In the event that a work-related injury or illness should occur, workers compensation
coverage helps provide protection for employers and employees.
Workers’ compensation insurance benefits can vary by state.
Workers’ compensation coverage helps protect the business in three ways.
● Covering employee illnesses and workplace injuries
● Protecting the business from lawsuits
● Keeping the business compliant with state regulations.
For confidentiality purposes, clinicians should be very careful to avoid recording non-
work-related medical information in the workers compensation medical records.
Workers compensation medical records should be kept separate from
personal medical records.
(https://www.osha.gov/dts/oom/clinicians/)
Source: https://www.thehartford.com/workers-compensation/definition

13. MD Guidelines - Return to Work Guidance
A great place to access EBM articles that assist with decision making
https://www.mdguidelines.com/
MDGuidelines includes recovery timeframe estimates as well as evidence-based guidelines from the American College of
Occupational and Environmental Medicine (ACOEM). Along with robust analytics and clinical expertise, MDGuidelines
supports better decision-making, case management and improved health outcomes.

14. Early Return to Work
● Early return-to-work benefits the employees and the bottom line.
● The longer an employee is off work due to an on-the-job injury, the less likely it becomes that the employee will
ever return to work.
● Employers and injured workers benefit from strong return-to-work programs.
● Even if injured employees can’t return to their regular jobs right away, bringing them back as soon as possible by providing
modified-duty tasks or reduced hours helps them:
➔ Recover faster
➔ Stay in the routine of working
➔ Feel productive
➔ Maintain workplace relationships
● Employers benefit by bringing injured employees back to work as soon as they’re medically able because it:
➔ Reduces the likelihood of litigation
➔ Helps control workers' compensation claim costs, which affect future premium

15. Return to Work Criteria for HCP with SARS-CoV-2 Infection
CDC Aug 10, 2020
Symptom-based strategy for determining when HCP can return to work.
● HCP with mild to moderate illness who are not severely immunocompromised:
○ At least 10 days have passed since symptoms first appeared and
○ At least 24 hours have passed since last fever without the use of fever-reducing medications and
○ Symptoms (e.g., cough, shortness of breath) have improved
Note: HCP who are not severely immunocompromised and were asymptomatic throughout their infection may return to work when at least 10 days have passed
since the date of their first positive viral diagnostic test.
● HCP with severe to critical illness or who are severely immunocompromised:
○ At least 10 days and up to 20 days have passed since symptoms first appeared
○ At least 24 hours have passed since last fever without the use of fever-reducing medications and
○ Symptoms (e.g., cough, shortness of breath) have improved
○ Consider consultation with infection control experts
Note: HCP who are severely immunocompromised but who were asymptomatic throughout their infection may return to work when at least 10 days and up to
20 days have passed since the date of their first positive viral diagnostic test.

16. ● It's very difficult to maintain a feigning of symptoms over a long period. They're going to slip up.
● Documentation is key. Keeping detailed charts about a patient's presentation and testing results leaves a necessary paper trail and helps other
specialists who later examine the patient.
● Physicians should focus on the facts of a medical visit.
○ When doctors interact with the legal system, they are constantly exposed to the legal system's misdirected emphasis on opinion.
○ The issues of malingering and validity can be addressed purely based on fact, without any interference from opinions.
● The patient needs to know you're going to do an objective assessment, and you might be providing them some information that they don't agree with
at the end of the day.
○ Setting expectations early is really important, and that helps you pick up on when there's an agenda present.
● Doctors should be cautious when confronting patients suspected of malingering.
● When doctors have a question, they should not make an accusation, but rather act neutrally and professionally.
● In some cases, physicians must simply say no to patients.
○ We are taught to do the best for our patients and support them, but there are times when we can't help people.
○ Sometimes it's appropriate to say: 'No further treatment will be beneficial.'
https://amednews.com/article/20120910/profession/309109942/4/
Malingering

17. Useful Certifications & Credentials for Occupational
Medicine & the Workplace Clinic
● First aid training program
● Advanced Cardiovascular Life Support (ACLS)
● Pediatric Advanced Life Support (PALS)
● Department of Transportation Medical Exam Certification (DOT)
● CAOHC Training (Council for Accreditation in Occupational Hearing Conservation)
● Experience in Emergency Medicine & Urgent Care (sutures, splints,
dehydration)

18. Resources
Occupational Health Practice
https://www.osha.gov/dts/oom/clinicians/
OSHA Courses Online Training
https://www.osha.com/courses/30-hour-construction.html?gclid=CjwKCAjwiOv7BRBREiwAXHbv3IaWf2XxgAWS4oAbsveQica61QWJSjQfLDmt5_qCg6r0coGROsN34RoCLIYQAvD_BwE
CAOHC Training
https://www.caohc.org/
Workers’ Comp under 45
https://www.benefitnews.com/opinion/whats-in-store-for-workers-comp-under-the-trump-administration?brief=00000152-14a5-d1cc-a5fa-7cff48fe0001
Return to Work
https://ww3.workcompcentral.com/columns/show/id/319a7a7d36889d44e8aafdd9089f50562db72d0b
MD Guidelines
https://www.mdguidelines.com/
OSHA Recordable and COVID-19
https://www.osha.gov/memos/2020-05-19/revised-enforcement-guidance-recording-cases-coronavirus-disease-2019-covid-19
https://www.osha.gov/Publications/OSHA4045.pdf
Determination of work-relatedness.
https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904.5
Real or fake? Revealing workers’ compensation fraud
https://www.propertycasualty360.com/2019/04/16/real-or-fake-revealing-workers-compensation-fraud/?slreturn=20200905115309
Workers' Compensation Frequently Asked Questions
https://www.uth.edu/safety/risk-management-and-insurance/workers-compensation-faq.htm