Occupational Medicine for Health Care Organizations
The OSHA regulations on treatment and reporting of work-related injuries and on surveillance for toxic workplace exposures apply to hospitals, nursing homes, and most clinics. In recent years, with privatization and management contracts, even many county hospitals no longer fall under the local government exemption from OSHA regulation. Yet few hospitals have adequate occupational medicine programs and most have very poor compliance with OSHA regulations.
Hospitals must learn to do OSHA compliance and recordkeeping properly. As hospitals have moved from being government or religious charitable institutions to being privately owned or managed, federal and state prosecutors have demonstrated their willingness to treat hospitals like any other business. Health care is a dangerous business by almost any standard. Nurses have one of the highest rates of back injuries of any occupation. The risk of death from infectious disease exposures has always been a part of medical practice, and medical care workers have some of the worst toxic exposures. Hydrocarbon exposures in manufacturing industries are nothing compared to the risk to the pharmacist who is handling chemotherapeutics that are themselves carcinogenic and which may have an LD50 measured in grams. Exposure to X rays, ultraviolet light, and other forms of radiation is an everyday fact of life in a hospital. This very familiarity can cause damaging carelessness.
Hospitals are also the natural home of curbside consults. Busy nurses and physicians find it easier to ask for help or information informally than to make an appointment and go to the office. It also allows everyone to avoid insurance forms and copays. The problem is that it also avoids proper recordkeeping. Providing medical care informally without records is usually a poor idea. If it involves a work- related injury, it is probably illegal.
As with other businesses, hospitals should have a well-planned system for dealing with occupational injuries and exposures. There should be one place or person that takes care of all the occupational medicine for the institution, and it must be available all hours the business is open. If the work injuries are handled in the emergency room, there must be proper forms and procedures in place. Staff should not be sent to the ER when they are hurt because it is the easiest place to find their own bandages. The employee should be checked in and all care should be documented in the medical record. Even first aid for an injury that is not severe enough to be OSHA recordable should be in a medical record. The injury or exposure may also be reportable under state laws even if it is not OSHA recordable. Doing care off the record to avoid OSHA recordability or workers’ compensation filings is illegal and carries hefty fines. Once proper care has been given, all the applicable forms must be completed. A workers’ compensation claim must be filed and, if applicable, an OSHA- entry made. Even if the hospital does not have to make specific payments to the doctor or the profit center where care was rendered, most workers’ compensation programs require that the value of the care be on record.
Control of workplace exposures to communicable disease is a major consideration in medical care occupational medicine. [Holleman WL, Holleman MC. School and work release evaluations. JAMA. 1988;260:3629–3640.] Most hospitals are aware of federal bloodborne pathogen regulations and make an attempt to comply. Far fewer understand and follow the rules on the control of tuberculosis. These regulations are discussed at length later in the section. The important thing to remember is that there are extensive regulations on how these problems are to be handled and they are mandatory requirements, not guidelines.
Hospitals should also keep in mind that their responsibilities as employers are not limited to people on their payroll. Volunteers, physicians, professional students, and employees of contractors such as laundry or food service may be the hospital’s legal responsibility when it comes to prevention of illness or injury from work in the hospital. Both the medical care providers and the hospital administration should know the federal and state rules and should follow them carefully.