Committed to the health, safety and well-being of healthcare

Transcription

WINTER 2015
FEATURES
12
Ebola: A Frightening Consequence of
Unsafe Injections and Needlestick Injuries
By Ron Stoker, MS, Executive Director, International Sharps Injury
Prevention Society (ISIPS)
20
Accommodating Mental Illness
By Dori Meinert
24
Opioids Versus Physical Therapy for
Management of Chronic Back Pain
By Cassandra A. Gladkowski, RN, BSN; Chelsey L. Medley, RN,
BSN; Heather M. Nelson, RN, BSN; Angela Tallie Price, RN, BSN; and
Margaret Harvey, PhD, APRN-BC
VOL. 35, NO. 1
DEPARTMENTS
4
Organization Leadership
6
Editor’s Column
7
Vice President's Update
10
Advances in Technology
16
Call for Posters
18
Call for Award Nominees
19
Association Community
Liaison Report
ISSN 2168-8044
Committed to the health, safety and well-being of healthcare workers.
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88. 3. Harada, N., et al. (2008) J. Infect. 56, 348; 4. Diel, R., et al. (2008) Am. J. Respir. Crit. Care Med. 177, 1164.
Trademarks: QIAGEN®, QFT®, QuantiFERON® (QIAGEN Group). QM31635206B 07/2013 © 2013 QIAGEN, all rights reserved.
Winter 2015
of the Association of Occupational Health Professionals in Healthcare
AOHP JOURNAL EXECUTIVE EDITOR
Kimberly Stanchfield, RN, COHN-S
Journal of AOHP – in Healthcare
2010 Health Campus Drive
Harrisonburg, VA 22801
EDITORIAL ADVISORY BOARD
Darlene Buckstead, MSN, RN
Employee Health Nurse
Cass Regional Medical Center
Harrisonville, MO
Sandra Domeracki, MSN, FNP, RN, COHN-S
AOHP President Emeritus
Manager, California Pacific Medical Center,
Employee Health Services
San Francisco, CA
Mary C. Floyd, MPH, RN, COHN-S/CM
AOHP Florida Chapter
Return to Work Coordinator
Occupational Health services
UF Shands Hospital
Gainesville, FL
John Furman, PhD, MSN, COHN-S
AOHP Research Committee
Executive Director
Washington Health Professional Services
Washington State Department of Health
Olympia, WA
Linda Good, PhD, RN, COHN-S
AOHP Research Committee Chair
Director, Employee Health Services
Scripps Health
LaJolla, CA
Terry Grimmond, FASM, BAgrSc, GrDpAdEd
AOHP Research Committee
Director, Grimmond and Associates
Microbiology Consultants
Hamilton, New Zealand
E D I T O R I A L S TA F F
Executive Editor: Kimberly Stanchfield, RN, COHN-S
Executive Director: Annie Wiest
Account Coordinator: Jeff Longmore
Copy Editor: Kathleen Fenton
Designer: Katina Colbert Graphic Design
Production Coordinator: TMR Print Group
MaryAnn Gruden, MSN, CNRP, NP-C,
COHN-S/CM
AOHP Association Community Liaison
Manager, Employee Health Services
Allegheny General Hospital
The Western Pennsylvania Hospital
Allegheny Health Network
Pittsburgh, PA
Lee Newman, MD, MA, FACOEM, FCCP
AOHP Conference Committee
Professor, Colorado School of Public Health
and School of Medicine
Director, Center for Worker Health and
Environment
University of Colorado
Chief Medical Information Officer
Axion Health, Inc.
Aurora, CO
Stacy L. Stromgren, MSM, BSN, RN, COHN-S
AOHP Heart of America Chapter President
Employee Health Supervisor
Stormont-Vail HealthCare
Topeka, KS
Dee Tyler, RN, COHN-S, FAAOHN
AOHP Executive President
Director, Medical Management
Coverys
East Lansing, MI
Leslie S. Zun, MD, MBA
AOHP Conference Committee
Professor and Chair
Department of Emergency Medicine
Rosalind Franklin University of Medicine
and Science/Chicago Medical School Chair,
Department of Emergency Medicine Mount
Sinai Hospital
Chicago, IL
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Edited, designed & printed in the USA
All material written directly for the Journal of the Association of Occupational Health
Professionals in Healthcare is peer reviewed.
MISSION
AOHP is dedicated to promoting the
health, safety and well-being of workers in
healthcare by:
•Advocating for employee health and
safety.
•Occupational health education and
networking opportunities.
•Health and safety advancement through
best practice and research.
•Partnering with employers, regulatory
agencies and related associations.
The Journal of the Association of
Occupational Health Professionals (AOHP)
– in Healthcare (© 2015 ISSN 2168-8044)
is published quarterly by the Association
of Occupational Health Professionals in
Healthcare and is free to members. For
information about republication of any
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S TAT E M E N T O F
EDITORIAL PURPOSE
The occupational health professional in
healthcare is vital to ensuring the health,
safety and well-being of both employees
and patients. The focus of this Journal is
to: provide current healthcare information
pertinent to the hospital employee health
professional; afford a means of networking
and sharing for AOHP’s members; and
improve the quality of hospital employee
health services.
The Association of Occupational Health
Professionals in Healthcare and its directors
and editor are not responsible for the
views expressed in its publication or any
inaccuracies that may be contained therein.
Materials in the articles are the sole
responsibility of the authors.
EDITORIAL GUIDELINES
AOHP Journal actively solicits material to
be considered for publication. Complete
Editorial Guidelines can be found at http://
aohp.org/aohp/MEMBERSERVICES/Journal/
JournalEditorialGuideline.aspx.
Send Copy to
Kimberly Stanchfield, RN, COHN-S
AOHP Journal Executive Editor
[email protected]
Publication deadlines for the Journal of
AOHP-in Healthcare:
Issue
Closing Date
Spring
February 28
Summer
May 31
Fall
August 31
Winter
November 30
3
Journal
Organization Leadership
By Dee Tyler, RN, COHN-S, FAAOHN
Executive President
“11 Healthcare Buzzwords for 2015”
Applied to the Occupational Health Setting
11 Healthcare Buzzwords for 20151
1. Emotional Labor of Medicine – Displaying emotions we
may or may not feel.
2. Phone Hygiene – Keeping phones and electronic devices used in the healthcare environment clean.
3. Decision Fatigue – Mental burden of having to make
more choices than the brain can safely accommodate.
4. ICU Bounceback – Patients who take a turn for the
worse and must return to the ICU.
5. Keynote Cardio – Exercise equipment placed in the back
of conference halls for attendees to use while speakers
deliver their presentations.
6. BYOD/BYOT (Bring Your Own Device/Technology)
Breach - Allowing staff members to use their own devices, encouraging the use of technology, while maintaining data security and privacy of patient records. Data
needs to be encrypted, lost or stolen devices must be
reported, and stored data should be erased, if necessary, through cloud-based technologies.
7. PPE Adequacy – Guidelines on how much and what
kind of personal protective equipment (PPE) each type
of facility should have.
8. Infomediation – Publicly available factors, through Medicare, Medicaid and other payer data, about healthcare
cost, quality and services that influence population
health used in contract negotiations. Factors influencing population health include post-discharge settings
with better outcomes and which physicians are most
cost-effective in their treatment choices. The data can
also reveal who is billing at the highest levels.
9. Froth/Frothy – Froth is used on Wall Street to describe
market conditions preceding a bubble. Lately, hospital
and physician leaders have been using it to describe the
hype and overpricing of electronic health records (EHR)
systems.
10. Physician Numeracy – Medical statistics as they pertain to practicing evidence-based medicine and to communicating treatment outcome probability to patients.
11. Influencer – Articulating that the role of leaders is less
about managing a team of direct reports or matrixed
organizational relationships, and more about persuading
broad groups of internal and external stakeholders.
4
One might wonder how
these 11 healthcare buzzwords might apply to occupational health. While my
commentary might not be
the only consideration, I believe that as occupational
health professionals prepare
to strategize their services
and initiatives in 2015, these
might provide a different perspective or stimulate ideas
we haven’t contemplated before.
Emotional
Labor
of
Medicine – As occupational
health professionals, many of
us have had to display emotions we may or may not
feel. We may just not have
had a specific label for this
before. Learning to maintain
emotional neutrality when
addressing difficult challenges, even in the face of something that we might be highly
invested in, is certainly an art
form and a necessary tool in
the occupational health professional’s toolbox. Practice
emotional neutrality frequently to improve your execution.
Phone Hygiene – Occupational health professionals
need to consider addressing
phone and electronic device
hygiene within their facilities. If you don’t have current
guidelines for cleaning these
items, this is something to
consider developing for 2015.
Decision Fatigue – When
healthcare workers have to
make more choices than their
brains can safely accommodate, then quality patient care
is at risk. Identifying when
decision fatigue is occurring
and minimizing decisions by
removing the smaller or insignificant decisions can help
to reduce the risk of decision
fatigue. Work with the Employee Assistance Plan and
other mental health professionals to develop specific
ways that the mental burden
of decisions can be lightened
for healthcare workers. Likewise, occupational health
professionals are also at risk
for decision fatigue. Consider
ways to not mentally burden
yourself with choices that do
not impact the care or services you provide.
ICU Bounceback – ICU
patients account for 25% to
30% of the cost to a hospital.
When hospitals and health
systems struggle to meet
their budgets, this can make
or break the bottom line.
While this may not apply directly to occupational health,
it serves as a reminder of
how occupational health professionals need to analyze
what in the Occupational
Health Department budget
can make or break the bottom line, and identify strategies that result in improved
outcomes.
Keynote Cardio – The
importance of wellness and
health modeling are grow-
Winter 2015
ing within healthcare. Occupational health professionals need to keep current on
wellness trends and be able
to articulate their value for
implementation. AOHP has
incorporated wellness topics
and health walks into our National Conference activities
for years. Going forward, we
should consider placing exercise equipment in the back
of conference halls while
speakers deliver their presentations or determine other
ways to engage participants
in movement.
BYOD/BYOT Breach - Allowing staff members to use
their own devices and technology in the occupational
health environment brings
challenges of maintaining
data security and privacy of
employee records. While it
makes sense to allow electronic devices, occupational
health leadership will need
to consider technology policies, limitations, reporting
of lost personal devices, security and privacy guidelines
for specific application to occupational health. Healthcare
facilities may or may not have
considered this and have general policies available to build
upon. The application directly
to occupational health may
fall on occupational health
leadership.
PPE Adequacy – Given the
occupational health professional's role with the recent
Ebola emergence in the United States, I believe we all understand how PPE adequacy
applies to the occupational
health setting. Occupational
health professionals need to
be at the table and an integral
part of developing guidelines
on how much and what kind
of PPE their organizations
should stock.
Infomediation – Data is
power. If your Occupational
Health Department is not
already tracking statistics, it
is critical to do so, including
tracking the number of services offered, as well as their
complexity and outcomes.
Know the frequency, type
and severity of work injuries and exposures, as well
as the organization's nonoccupational health statistics
from your short-term and
long-term disability carrier,
to plan employee health and
wellness activities. Benchmark and compare your orga-
nization's statistics to other
comparable facilities, and
then communicate findings
to organizational leadership
through proper channels.
Froth/Frothy – Many of us
might consider conditions in
occupational health as frothy
or bubbling. With this fall’s
emergence of the Ebola virus
in the United States, many occupational health professionals have been on overload.
While Occupational health
has been frothy, I think occupational health professionals
need to be wary that electronic medical records systems have been overpriced
and should strive to negotiate
fair pricing contracts without
getting caught up in the hype.
Physician
Numeracy
– Occupational health professionals, as physicians,
should be expected to be
knowledgeable of medical
statistics as they pertain to
practicing
evidence-based
medicine, as well as to communicate treatment outcome
probability to the populations
they serve. Become familiar
with evidenced-based medicine guidelines and strive to
implement them within your
scope of practice.
Influencer – Occupational
health professionals need to
develop skills in persuading
broad groups of internal and
external stakeholders. Occupational Health Department
leadership needs to understand that the role of leaders is less about managing
a team of direct reports and
more about relationships, negotiations and team work.
While all of these 11 buzzwords don’t necessarily have
direct application to the occupational health setting,
they give us an opportunity to
examine occupational health
foresight for 2015. These elements offer contemplation
points as we direct occupational health policy within our
facilities, communities and
nation. How will you apply
the 2015 healthcare buzzwords to your practice?
1Clark, Cheryl. "11 Healthcare Buzzwords for 2015." 11 Healthcare Buzzwords for 2015 - HealthLeaders Media.
HealthLeaders Media Daily, 15 Jan.
2015. Web. 21 Jan. 2015. <http://www.
healthleadersmedia.com/slideshow.
cfm?content_id=312159&pg=1>.
We Need Your Photo
AOHP is planning for the celebration of Occupational Health Professionals in
April 2015. Once again, we would like to celebrate by including pictures of
AOHP members performing tasks that they do on a daily basis. AOHP is asking members to submit quality photos (Photos should be in high resolution jpg
or tif files with a minimum 300 dpi) to AOHP Headquarters by Feb 27, 2015.
For each individual picture submitted, the member who submitted will be
entered into a drawing. Four winners will each be awarded $25.00. A committee will select the pictures that will be featured on the Occupational
Health calendar that will be distributed to all members.
Please submit your photos to [email protected], and be sure to include any
caption you feel describes the picture.
5
Journal
Editor's Column
By Kim Stanchfield, RN, COHN-S
Executive Journal Editor
Communicating and Talking
We are all better at doing
some things in life than others. That’s what makes us
individuals, unique with our
own traits and talents. The
lucky ones of us have learned
to use what we are best at,
our “talents,” to become better professionals and people.
I have known for many years
that I am a fabulous talker. I
can “chatter and yak” with
anyone - and have a great time
doing it. As a child, I would
arrive home from school and
tell my mom stories of the
detailed happenings at good
‘ole Brandywine Elementary.
Mom heard everything. Talking continued to be my best
trait through college and my
early nursing career.
As a new nurse, out on the
bedside nursing units, I was
never the most proficient,
but I was popular with my patients. We would talk, laugh,
share stories, watch shows
on their TVs…..while other
nurses were starting my IVs
and giving my medications.
Patients’ families liked me,
too. I came to know some
really great people. And, we
always ate well on the units
where I worked. Families
brought me (and therefore
my co-workers) all kinds of
food. Patients and families do
not always recognize the best
clinician taking care of them,
but they always remember
the one who had time for
friendly and personal “chatter.”
My seven years in a busy
Emergency
Department
taught me to work and move
fast while talking. This is
where I really matured as
both an adult and a true professional nurse, still talking as
much and often as I could.
It was past hospital Vice
President who helped me understand that talking can be
a talent when you use that
“talking skill” to effectively
communicate with people.
I was inspired to reach and
COMING SOON...
EXPO-S.T.O.P. Survey
2013 & 2014!
AOHP plans to conduct its
signature EXPO-S.T.O.P. Survey
by the end of February 2015 for
the calendar years of 2013 and
2014. Survey questions will be
similar to those you have seen
in the past, so we recommend
that you start gathering your
information. We included a
preview of the survey questions
in the January e-Newsletter.
6
grow as a professional. I have
learned you most effectively
communicate with people
when you involve them in a
particular process. You don’t
simply talk to people; you
make them part of “it.”
Change is constant in all our
jobs. At my facility, we are
starting the second year of
full integration with a health
system. The health system
is excellent, and occupational
health is well managed, but
the need for effective communication is endless. Everything changed for over 2,600
employees.
Workers' compensation also
continues to demand clear
and effective communication.
Anxious, injured employees
deserve information they understand regarding their pay
and job status while they are
off work. Managers need
clear communication and direction while their employees
are off work and during their
re-entry into the workplace.
A fearful healthcare worker
needs information he or she
understands on the risks of
a contaminated needlestick
injury. Employees caring for a
suspected TB patient should
know the proper respiratory
protection, its efficient use,
and why we must perform
annual N95 fit tests and TB
screens.
The list of vital information occupational health professionals must clearly communicate
is endless… and challenging.
How do you measure up to
the challenge? Are you just
talking, or have you developed good communication
skills?
I am confident and proud to
report that this “talented”
talker has become a very effective communicator.
P.S. I still “yak” with the best
of them!! Hope to talk with all
of you at a meeting soon.
AOHP Announces Position Statement on Standards
for Adult Immunization Practice
As the national leader for occupational health in healthcare, the AOHP Executive
Board of Directors recently adopted a new position statement on Standards
for Adult Immunization Practice (http://aohp.org/aohp/Portals/0/Documents/
NewsAndEvents/Press%20Release/PressRelease-AdultImmunizatrionStandards
Dec2014.pdf) . AOHP encourages its members and their organizations to adopt
the Standards for Adult Immunization Practice and implement the following steps
to ensure that adult patients are fully immunized:
1. Assess immunization status of all patients in every clinical encounter.
2. Share a strong recommendation for vaccines that patients need.
3. Administer needed vaccines, or refer to a provider who can vaccinate.
4. Document vaccines received by the patients in state vaccine registries.
Winter 2015
Vice President's Update
By Dana Jennings Tucker, BSN, RN, CCM
Executive Vice President
This article brings members both a question and the answer that will keep our members updated on government affairs issues
that concern occupational health in healthcare. AOHP, under the guidance of the Executive Vice President, continues to equip all
members with essential information to enhance their practices.
An AOHP member asks “Who is responsible for compliance with OSHA when temporary or leased employees are involved?
Does the primary responsibility reside with the host employer?"
The attached article written by Stephen Burt, MFA, BS, answers this question and gives members insight and recommendations regarding temporary workers. Feel free to share this information with your Human Resources Director and those who hire
temporary workers.
Osha And Niosh Release Recommendations For Protecting Temporary
Workers
Be Careful: "Recommendations" Are Enforceable by Law!
By Stephen A. Burt, MFA, BS
Who is responsible for compliance with the Occupational Safety and Health Administration (OSHA) when
temporary or leased employees are involved? Is it the
agency supplying the temporary employees or the host
employer for whom they will
be working? The primary responsibility resides with the
host employer, which creates and controls the potentially hazardous conditions at
the workplace.
On August 25, 2014, the
National Institute for Occupational Safety and Health
(NIOSH) and the Occupational Safety and Health Administration (OSHA) jointly
published a document that
outlines best practices for
temporary workers. (https://
www.osha.gov/Publications/
OSHA3735.pdf) These recommendations are specific
to employers who use workers from staffing agencies
and include practices for
providing proper safety and
health protections for these
workers. Some of these recommendations are merely
suggestions, but others carry
the force of law, so please review this document carefully.
This guidance publication
follows the July 15, 2014
memorandum issued to regional administrators providing instructions to compliance officers who conduct
inspections at worksites with
temporary workers. That
memorandum
instructed
compliance officers to review contracts between the
host employer and the staffing agency to determine if
safety and health responsibilities are spelled out in the
contract, and also instructed
compliance officers to consider whether host employers and staffing agencies
have met their responsibilities for the safety and health
of temporary workers.
Temporary workers are at increased risk for work-related
injury and illness. OSHA
launched what it called its
Temporary Worker Initiative
in April 2013 after receiving
a series of reports of fatal
injuries suffered by temporary employees, many during their first days on the job.
OSHA's Temporary Worker
Initiative includes outreach,
training and enforcement
to assure that temporary
workers are protected in
their workplaces. Besides
stepped-up
enforcement,
the agency has issued guidance on the respective roles
of employers and their staffing agencies for the safety
and health of temporary staff
and on injury and illness recordkeeping requirements.
In recent months, OSHA has
received and investigated
many reports of temporary
workers suffering serious or
fatal injuries, some in their
first days on the job. The
Recommended
Practices
publication focuses on ensuring that temporary workers
receive the same training
and protection that existing
workers receive.
In Recommended Practices
for Protecting Temporary
Workers, OSHA and NIOSH
recommend that staffing
agency and host employer
contracts include clear definitions of the tasks the worker
is expected to perform and
state clearly which employer
is responsible for specific
safety and health duties.
NIOSH has found that temporary employees are more
prone to injury, largely because they are not always
made aware of all safety
practices at the host company. And, if the staffing agency is not fully involved with
the temporary employee,
there may not be a proper
dissemination of safety procedures. Best practices also
includes jointly reviewing all
worksites the worker may
7
Journal
potentially visit, identifying
and eliminating hazards, defining necessary trainings
and protections the worker
will need, and reviewing
both agency and employer
injury and illness prevention
programs.
The Sudden Rise of
Temporary Workers
The growing employment of
temporary workers has provided benefits to employees
and employers across the
United States. According to
data from the U.S. Bureau
of Labor Statistics, 2.06%
of the U.S. workforce consisted of temporary workers
in March 2014 — an all-time
high. Multiple factors have
led to the rise of temporary
workers. Many employees
desire flexibility in their jobs,
while companies wish to remain nimble in an uncertain
economy. Moreover, many
firms desire to employ fewer
than 50 full-time employees
to avoid fines and coverage
requirements for larger businesses under the Affordable
Care Act.
Approximately 1.7% of the
healthcare industry's workforce is now composed of
temporary or contract workers, according to data compiled by the American Staffing Association. That's about
240,000 employees, compared to the nearly 14 million
full-time healthcare workers
in the United States.
Experts warn that there will
be a shortage of skilled doctors and nurses to handle
increased demand in the
coming years. According to
the Association of American Medical Colleges, the
United States could face a
shortage of about 150,000
doctors in the next 15 years.
8
In terms of nursing, a study
by The Council on Physician
and Nurse Supply has determined that 30,000 additional
nurses need to be graduated annually to meet future
healthcare needs. That would
require a 30% increase over
the current number of annual nursing graduates. With
a shortage of skilled medical
providers at hand, hiring of
contract workers is expected
to grow.
Who is the Actual
Employer?
Employees are not defined
by OSHA based on who
pays them. What matters
is whether there is an employer-employee relationship
between the parties. Criteria OSHA uses to determine
that relationship include:
•The nature and degree of
control the hiring party asserts over the manner in
which the work is done.
•The degree of skill and independent judgment the
temporary worker is expected to apply.
•The extent to which the
services provided are an
integral part of the employer’s business.
•The right of the employer
to assign new tasks to the
worker.
•
Control over when the
work is performed and
how long it takes.
Recommended Practices for
Protecting Temporary Workers
Following is a list some of
those practices, with key information for each one. The
guidance document stresses
that the provided information
is for guidance and that legal
research should be conducted to identify what is legally
required by all parties.
1.Evaluate the Host Employer’s Worksite: Before an
employer hires a staffing
agency, both should work
together to review all worksites to which the temporary worker might be sent.
Task assignments
and
job hazards should also
be identified by the host
employer to eliminate any
safety hazards,
and the staffing agency
should provide a document
to the host employer that
specifies each temporary
worker’s training and competencies.
tion, hazard communication, respiratory protection
and control of hazardous
energy (lock-out/tag-out.)
4.Assign Occupational Safety
and Health Responsibilities, and Define the Scope of
Work in the Contract: Responsibilities between the
staffing agency and host
employer should be clearly
described in their contractual agreement, as one or
the other might be better
suited to handle a task. Job
responsibilities, work and
personal protective equipment, and work hazards
should all be included in
the agreement to protect
all parties involved.
2.Train Agency Staff to Recognize Safety and Health Hazards: Many staffing agencies do not have dedicated
occupational safety and 5.Injury and Illness Reporting:
The supervising employer
health (OSH) professionis required to set up a
als. By teaching staffing
method for employees
agency
representatives
to report work-related injuabout basic safety princiries and illnesses promptly
ples and hazards, the agenand must inform each
cy is in a better position to employee how to report
identify hazards when evalwork-related injuries and
uating the host employer's
illnesses. However, both
worksite.
the staffing agency and the
host employer
should
3.Ensure the Employer Meets or
inform the temporary emExceeds the Other Employer’s
ployee on this process and
Standards: A host employer
how to report a work-relatand staffing agency should
ed injury or illness.
exchange and review each
other’s injury and illness
prevention program, when 6.Injury and Illness Recording and Tracking: One area
feasible. This way, an emwhere confusion may arise
ployer knows whether or
is recordkeeping. The guidnot the agency it is hirance clarifies that illness
ing meets or exceeds
and injury recordkeeping
its own hiring standards.
for temporary employees
Likewise, staffing agenshould be accounted for
cies can better inform their
on only one employer’s
temporary worker pool of
300 log. The employer suthe prospective workplace.
pervising the temporary
Employers are required
workers on a day-to-day
to have hazard-specific
basis is the employer that
programs when workers
should record illnesses
are exposed to certain
and injuries (29 C.F.R. §
hazards. Such programs
1904.31(b)(4).) According
include bloodborne pathoto OSHA, this will be the
gens, hearing conserva-
Winter 2015
host employer, as they will
“control conditions presenting potential hazards
and direct the workers’
activities around, and exposure to, those hazards.”
Once an injury has been reported, the staffing agency
should then be promptly notified. Procedures
should be in place before
an agreement is executed
for the exchange of information regarding injuries
to temporary workers.
of many of the jobs. Finding
a temp who has documented
training on hazardous waste
operations and emergency
response awareness, hazard
communication,
personal
protective equipment, forklift
operation and hearing conservation is certainly a logistical challenge. However, it
does not change the requirement for all of this and more
to be in place before workers
are exposed to workplace hazards.
7.Conduct Safety and Health
Training and New Project
Orientation: Training may be
the most commonly violated requirement of all. Every OSHA standard that requires training requires the training before an employee is exposed to the hazard. OSHA standards require site- and task-specific
safety and health training.
Host employers should
provide temporary workers
with safety training that
is identical or equivalent
to the training provided to
the host employers’ own
employees
performing
the same work. Staffing
agencies should provide
general safety and health
training applicable to different occupational settings,
and host employers should
provide specific training tailored to the particular hazards at their workplaces.
Again, all training provided
by either the host employer and staffing agency
should be communicated
to one another. This way,
any required training that
has elapsed or not been
completed can be provided
to the temporary worker.
Although not specifically
mentioned in the guidance
document, another area of
compliance overlap and concern is Hazard Communication (“hazcom.”) A 1994
standard interpretation letter from OSHA states that
staffing agencies would be
responsible and expected
to provide some generic
hazcom training under 29
C.F.R. § 1910.1200(h)(1.)
Host employers “would
then be responsible for providing site-specific training
and would have the primary
responsibility to control potential exposure conditions.”
The 1994 letter also states
that host employers “would
be responsible for providing
[personal protective equipment] for site-specific hazards to which employees
may be exposed.”
The problem for temporary
workers is the often short
notice and transient nature
The Bottom Line
To recap, here’s why the
changes were needed:
• In 2011, 12% of the 4,693
fatal work injuries in the
United States were suffered by temporary workers. This represents a
disproportionate number
of fatalities, as temporary
workers represent only 2%
of the total workforce.
•In 2012, overall fatalities
dropped to 4,383, but, according to OSHA, “Companies are expected to employ many more temporary
workers as the Affordable
Care Act is implemented.”
•In February 2013, OSHA
cited Bacardi Bottling Corp
$192,000 for the death of
a 21-year-old temporary
worker his first day on
the job. Lawrence Daquan
“Day” Davis was crushed
to death by a palletizer machine at the Jacksonville facility in August 2012. As a
result, OSHA’s new guidelines call for much stricter
supervision of workplace
conditions, better employee training and stronger
communication between
agencies and host companies.
While the duties of temporary workers and safety and
health-related training duties
should be determined in the
contracts between employers and staffing agencies,
both entities can be held liable if a temporary worker
is injured. They will be held
liable by the courts and by
OSHA. Under best practices,
bring your staffing partner
out to your healthcare facility to best understand your
jobs’ requirements and working conditions. Work closely
with a staffing partner you
trust to ensure that safetyconscious employees are
being sent to your healthcare
facility. Ask them about their
interviewing and screening
procedures to ensure that
your business is being protected upfront – remember,
your healthcare facility is ultimately responsible.
Stephen A. Burt is the President of Healthcare Compliance Resources. He has
been involved in surveying
healthcare facilities to ensure
compliance with OSHA, EPA,
HHS, CMS and TJC regulations since the early 1980s.
Burt continues to be one of
the most popular speakers
in the southeast on OSHA,
EPA, HIPAA and legal management topics for healthcare providers, conducting
over 30 full-day seminars per
year. He is currently the PastNational Executive Vice President of the Association of
Occupational Health Professionals in Healthcare (AOHP)
and a current member of
AOHP Virginia Chapter.
Exhibitors and Sponsors
Needed for 2015 AOHP
National Conference
AOHP is seeking exhibitors and sponsors for the 2015
AOHP National Conference. By featuring quality speakers, the conference draws a strong attendance, and
the exhibitors and sponsors help us to keep the AOHP
conference affordable. We ask that all AOHP members
become engaged in helping to support the National
Conference in this way, even if you are unable to attend.
Each AOHP member can make a difference! Contact
[email protected] for ideas, suggestions and referrals, or
volunteer yourself TODAY!
9
Journal
Advances in Technology
By Cindy Brumley, RN
Technology Today
“Innovation
Disruption.”
Sounds like an action flick,
doesn’t it? Well, it’s not. I
hadn’t heard of this until
recently
through
www.
TEDtalks.com, and it was
quite a revelation. This
phrase was coined by Clayton
Christensen, who describes
it as “a process by which a
product or service takes root
initially in simple applications
at the bottom of a market and
then relentlessly moves up
market, eventually displacing
established competitors.”
Examples
Remember back in the day
when one either saw the
family doctor or went to
the hospital? Appointments
weren’t always easy to get.
The wait time was prolonged
for
hospital
admissions
because patients were kept
for several days or weeks.
Today, there are several
options and specialties borne
out of need for convenience,
cost or location: standalone urgent care centers;
day surgery and LASIK
centers; cardiac triage and
endoscopy centers; etc.
Additional examples include
mobile mammography, home
pregnancy tests and virtual
databases for sharing patient
records. Initially, these were
great ideas and so out of
the box that many people
thought
wouldn't work.
Today, those technologies are
commonplace, expected and
have changed the delivery of
healthcare.
10
An unexpected example
may be the Google Glass
technology. This is wearable
technology that fits on a frame
over the wearer’s eyebrow.
Remote care providers can
see what is going on with a
patient almost through the
eyes of another. How is this
innovation a disrupter? Critical
patients who would not
survive transit to a specialty
center have ready access to
a specialist to provide instant
feedback via the technology.
Golden minutes saved = lives
and resources saved.
How about Peek Retina,
the brainchild of Dr. Andrew
Bastawrous (http://mashable.
com/2014/11/26/peekretina-smartphone-app/)?
Imagine using a Smartphone
(Samsung S3) instead of
lugging around expensive,
heavy, bulky eye exam
equipment across an underdeveloped country. This is
a tremendous example of
innovation disruption (see
www.TEDtalks.com
for
additional examples.)
So why would Occupational
Health/Employee
Health
Services
care?
Working
(even) leaner and smarter –
not harder – can happen if we
are willing to adopt innovation
disruption philosophy. We’ve
looked at a few examples
of disruptive innovation.
Now, let’s discuss how
innovation grows, inevitable
roadblocks and possibilities
for Occupational Health.
Promoting Innovation
Since the publication of
Christensen’s book “The
Innovator’s Dilemma,” other
forward thinkers have held
the magnifying glass over
the
healthcare
industry.
Some of those successes
were mentioned earlier. Each
started from an unmet need
that required change and a
willingness to try something
different.
Perhaps
your
department has unmet needs.
One doesn’t have to think too
hard to come up with the
usual staffing or budgeting
issues as we are tasked to
provide quality, cost-effective
care of employees. The
domino effect of a healthy,
on the clock employee
enhances unit teamwork and
promotes patient safety – and
that’s what we want for the
organization. For innovation to
be adopted and flourish, five
key concepts must happen:
•Relative advantages over
what currently exists.
•Compatibility with existing
values and behaviors.
• Lack of complexity.
• Ability to withstand
experimentation.
•Producing results that are
obvious to all.
Stifling Innovation
Promoting innovation brings
change.(Yes, there's that
word – again.) Whenever
change is on the horizon,
there are inevitably those
who will fight it, regardless
of obvious success. Dr.
Robert Corona’s presentation
“Disruptive Innovations in
Medicine” sums up the
good (promoting innovation,)
the bad (dilemmas) and the
ridiculousness (my opinion,
not his) of healthcare. (See
http://ewh.ieee.org/r1/
syracuse/EMBSWeb/Archies/
Events/Disruptive%20
Innovations%20Healthcare.
pdf.) Conversely to his key
concepts outlined earlier,
he sums up the innovator’s
dilemmas as:
•
Disruptive innovation is
almost always ignored
or opposed actively by
leadership.
•Doing and improving what
innovators do best causes
them to overshoot the
needs of the many they
serve and miss great but
simpler opportunities.
•Great and powerful people
design robotic surgeons,
while those with chronic
illness are still not having
their basic needs met.
Opportunity Knocks
If you look at Corona’s
presentation,
you’ll
see
his analogy of the Gordian
knot is timeless. If we’ve
been repeating the same
behaviors years on end and
aren’t
making
progress,
cut through the mess (or
knot!) Think about your
Gordian knots – those unmet
needs: high blood/body fluid
exposure rates; inadequate
staffing; repeat visits for
blood sugar checks from
diabetic employees; chasing
down arms for TB skin test
reads; and so on. Applying
those concepts of disruption
Winter 2015
innovation, what would your
best day of work look like?
No needlesticks or splashes?
Having all the supplies
delivered as promised? No
follow-up emails for arm
checks? Each return to
work release includes all the
required
documentation?
Adequate staffing to meet
daily demands? Space larger
than a shoebox to do your
work?
Think outside the box – the
stuff of your dreams. Staffing
issues might be permanently
fixed with a job share. Is there
a phlebotomist who needs an
extra day or two a week to
become full time?
Another nurse would be
acceptable, but if your budget
is already stretched, a medical
assistant or phlebotomist
might be your bridge. What
about assistance from an
associate hospital?
How about some really
wild ideas? Transform your
shoebox-sized work space
into a telemedicine kiosk.
This
badge-access
only
confidential space could be
utilized to treat ill employees.
A badge swipe activates
remote physician access via
live feed video, where the
employee is assessed and
a script is electronically sent
to the outpatient pharmacy,
if required. The printer
generates a return to work
2014 14th Edition
release for both the employee
(to present to manager)
and Occupational Health. If
restrictions or follow-up care
are necessary, the employee
gets the additional checklist
of expectations or medical
information. Pretty disruptive,
huh?
What about the uncontrolled
diabetic who stops by
repeatedly
for
random
blood sugar checks? How
about another kiosk for the
diabetic employee to use
a non-invasive blood sugar
monitoring device? Although
this technology is expensive,
there are many benefits:
preservation of health; safer
patient care; potentially no
exposures from sharps; more
productive hours; comfort;
etc. Why not? It’s similar to
those blood pressure cuffs in
local pharmacies.
Conclusion
For me, the bottom line is to
think about unmet needs and
what life could be like if those
needs were met. Give rein to
creativity ("fun" department
meeting or video chat with
a colleague.) Thoroughly vet
every idea by working around
those inevitable roadblocks.
And, most of all, remember
that sometimes processes
don’t
need
high-end
technology to be disruptive.
Getting STARTED
Make my job easier!
The 2014 edition of the Getting Started Manual is now available.
This manual will help you
• Communicate the value of occupational health within your
organization
• Provide an overview of information essential to OH services to
the healthcare worker
• Assist in risk management and other services important to
your employer
Order your copy today!
Getting Started Manual 2014 Edition
Cost includes shipping & handling in U.S.
Binder: Members $200 Non-Members **$225
CD:
Members **$150 Non-Members **$165
Package: (Binder +CD) Members **$300 Non-Members **$335
Getting Started Manual –Reference Only in CD format Only
Members: $30.00**
Non-Members: $45.00**
Download an order form at http://aohp.org/aohp/MARKETPLACE/GettingStartedManual.aspx
11
Journal
Ebola: A Frightening Consequence of
Unsafe Injections and Needlestick Injuries
By Ron Stoker, MS, Executive Director, International Sharps Injury Prevention Society (ISIPS)
The Ebola epidemic in West Africa (as
well as the several recent cases outside
of Africa) highlights both the necessity
for, and fragility of, healthcare systems.
And, at the heart of healthcare systems
are, of course, healthcare workers. According to the World Health Organization
(WHO,) the “high proportion of doctors,
nurses and other healthcare workers
who have been infected” is “unprecedented.”1 As of October 8, 2014, 416
healthcare workers had developed the
disease in West Africa, and 233 of them
had died.2 Recently, healthcare workers
in Spain and the United States contracted Ebola as a result of caring for patients
with that disease.
Ebola was first discovered in 1976 in
what is now the Democratic Republic of
the Congo.3 It is known that the early
Ebola epidemic was, in part, fueled by
the reuse of syringes. Peter Piot, a scientist at the London School of Hygiene
and Tropical Medicine, was involved in
the investigation of the first Ebola outbreak. When traveling to villages in central Africa in response to the first reports
of Ebola, he and his team of scientists
noticed that many people who had contracted the disease were young women
who had received treatment at a mission hospital.
“...local nurses were running it
[the hospital] frankly in a heroic
way, but they had a major shortage of materials, including syringes and needles. And they [syringes and needles] were reused
and reused and reused.”4
“It quickly became clear that this
was how the virus was being
spread from person to person.”5
12
Human-to-human transmission of Ebola
occurs “through direct contact (through
broken skin or mucous membranes in,
e.g., the eyes, nose or mouth) with:
• Blood or other bodily fluids (including,
but not limited to, the urine, saliva,
sweat, feces, vomit, breast milk and/
or semen) of a person who is sick with
Ebola.
• Objects (like needles and syringes)
that have been contaminated with the
virus.
• Infected animals.”6
The spread of disease by unsafe injections is not a new phenomenon;
it has been going on for decades, and
that fact is well documented. Ebola is
a high profile, deadly illness on the list
of bloodborne pathogens (such as HIV
and hepatitis) that can be transmitted by
contaminated sharps.
Studies of HIV have shown exponential
spread in African populations beginning
in the 1950s.
Unsafe injections constitute one hypothesis for the increased transmission
rates of HIV. This theory is supported by
studies that link the role of iatrogenic
(or health-related) transmissions to the
spread of hepatitis C virus (HCV) and
hepatitis B virus (HBV.)7
“Since 2001, at least 49 outbreaks have occurred because of
extrinsic contamination of injectable medical products at the point
of administration. Twenty-one of
the outbreaks involved transmissions of HBV or HVC; the other
28 represented outbreaks of bacterial infection, primarily invasive
bloodstream infections.”8
In addition to the hundreds of infections resulting from these outbreaks,
an estimated 150,000 patients during
2001-2012 were notified that they had
been potentially exposed to bloodborne
pathogens as a result of unsafe injections.9 Increasing cases of HIV/AIDS in
the United States have resulted in increased healthcare worker exposures. In
1991, following the first documented occupational transmission of HIV, the U.S.
Occupational Safety and Health Administration (OSHA) issued its Bloodborne
Pathogens Standard (BBPS.) Among
other control measures, the BBPS called
for engineering controls (e.g., syringes
with safety features, needleless connectors, etc.) as the primary means to
eliminate or minimize worker exposure
to bloodborne pathogens.10 These regulations were revised in 2001 following President Clinton’s signing of the
Needlestick Safety and Prevention Act
into law in November 2000.
In the recently released “Detailed Hospital Checklist for Ebola Preparedness” issued by the Centers for Disease Control
and Prevention (CDC,) hospital staff are
reminded to review protocols for sharps
injuries11 and to educate healthcare personnel about safe sharps practices to
prevent sharps injuries. Unfortunately,
the CDC bulletin did not encourage the
use of sharps injury prevention products
directly. However, the CDC has included needlestick injury (from an Ebolacontaminated needle) in the highest risk
category when evaluating a person for
exposure to Ebola.12 In a recent NBC
News article by Maggie Fox, Dr. Nahid
Bhadelia, an infectious disease specialist at Boston University, indicated how
quickly the body fights off any virus
depends on several factors, such as
Winter 2015
how the virus was transmitted. “For example,” she said, “We have seen that
those who have a needlestick injury with
Ebola do worse than those with just exposure via mucous membrane.”13
It is important to apply standard measures of precaution in all healthcare facilities, such as prevention of needlesticks
and sharps injuries and safe phlebotomy
practices. One of the most important
prevention methods is to use sharps injury prevention products whenever and
wherever possible. These include the
use of needleless connectors, safety
lancets and safety syringes.
It is extremely important to minimize the
potential of sharps injuries when working
with Ebola patients. The use of a passive
or semi-passive safety syringe becomes
critical. When working in a high-pressure
situation, such as taking care of an Ebola
patient, the use of safety products that
do not require two-handed activation of
the safety feature is very important.
Mary Foley, PhD, MS, RN, Past President of the American Nurses Association, has indicated that it is understandable—given human nature, coupled with
the frenzied pace of healthcare delivery—that being safe can be difficult to
remember. If you have to remember to
be safe, you likely will not be.14
Many first generation syringes and other
safety needle devices have demonstrated limited effectiveness in preventing
needlestick injuries and little, if any, reuse prevention. Some manually activated safety devices provide only marginal needlestick protection compared
to conventional devices (i.e., syringes
with no safety features,) while other
so-called safety devices actually require
increased manipulation and opportunity
for a needlestick injury.
After the adoption of the first generation manually activated safety devices,
needlestick injury statistics initially improved slightly, but then plateaued.
Studies show that needlestick injuries
have not decreased very much over the
past decade.15 In contrast, passive or
semi-passive automated retraction safe-
ty devices have demonstrated dramatic
decreases in needlestick injuries,16 and
they also effectively reduce the risk of
reuse.
Disease transmission resulting from syringe reuse and unsafe injection practices often have been naively considered
public health issues confined to developing countries. However, documented
outbreaks of disease have occurred and
“grown substantially over the recent
years” in the United States.17 Occupational Ebola exposure and transmission
outside Africa already has occurred. A
Spanish nurse’s assistant at the Carlos
III Hospital in Madrid contracted Ebola
after caring for a patient who had been
infected in Sierra Leone and medically
evacuated to Spain, according to WHO.
In Russia, two individuals suffered
needlestick injuries with Ebola-laden
needles.18 At the time of writing this
article, an American doctor who was
volunteering at an Ebola treatment unit
in Sierra Leone remains under observation for signs of the disease following a
needlestick injury, which is considered a
“high-risk exposure.”19 Two healthcare
workers in Dallas, TX, have tested positive for Ebola; these healthcare workers
had provided care for an Ebola patient
in Texas Health Presbyterian Hospital.
It has not yet been reported how these
healthcare workers became infected,
despite wearing protective gear. Another doctor in New York City, NY, who recently returned from treating patients in
Guinea, became the first person in New
York City to test positive for the virus.20
According to Dr. Thomas R. Frieden, director of the CDC, “The care of Ebola
patients can be done safely, but it’s hard
to do it safely. Even a single, inadvertent, innocent slip can result in contamination.”21 While healthcare workers
can use personal protective equipment,
such as gowns, gloves and face shields,
for protection from some exposures,
these items do not provide protection
from needlestick injuries. Needlestick
injuries have been associated with a
large percentage of occupational transmissions of bloodborne pathogens to
healthcare workers.22
There is no question that the appearance of HIV in the United States prompted legislation for safer medical devices.
However, little attention has been paid
to the continued needlestick danger
faced by healthcare workers. The resurgence of the Ebola virus brings renewed
focus to the risks of needlestick injuries
faced by healthcare workers, as well as
the risks of syringe and needle reuse.
History has proven that the spread of
disease and the medically-related risks
do not recognize borders. It is disheartening that it may require a deadly epidemic to effectively address this issue.
There already are far too many healthcare workers and patients who have
been needlessly injured.
Syringes with effective needlestick prevention and reuse prevention are neither
a luxury nor an option. They are a matter
of life and death.
Ron Stoker is the Executive Director of
the International Sharps Injury Prevention Society (ISIPS.) He graduated from
the Brigham Young University and received a master's degree in biomedical
engineering from the University of Utah.
He authors articles and books on sharps
safety and infection control issues and is
a frequent speaker at national and international meetings. For more information
on ISIPS, visit www.isips.org or call 801783-3817.
References
1 “Unprecedented Number of Medical Staff Infected
with Ebola,” World Health Organization News, August
25, 2014, available online at: http://www.who.int/workforcealliance/media/news/2014/hw_infected_ebola/
en/. Accessed on October 13, 2014.
2 “Ebola Facts: How Many Health Care Workers Have
Contracted Ebola?” New York Times, Updated October
12, 2014, available online at:
http://www.nytimes.com/interactive/2014/07/31/
world/africa/ebola-virus-outbreak-qa.html?_r=0.
Accessed on October 13, 2014.
3 “About Ebola Virus Disease,” Centers for Disease
Control and Prevention, available online at:
http://www.cdc.gov/vhf/ebola/about.html. Accessed
on October 13, 2014.
4 Peter Piot in Surviving Ebola, a NOVA documentary
television program broadcast on PBS stations on October 8, 2014.
5 “Voice-over” narrator in Surviving Ebola documentary.
13
Journal
6 “Ebola (Ebola Virus Disease) Transmission,” CDC
website, available online at: http://www.cdc.gov/vhf/
ebola/transmission/index.html. Accessed on October
14, 2014.
7 Nuno R. Faria, et al., “The Early Spread and Epidemic
Ignition of HIV-1 in Human Populations,” Science, October 3, 2014 (Vol. 364, Issue 6205), pp. 56-61. This is
the reference for the whole paragraph.
8 CDC Grand Rounds: Preventing Unsafe Injection
Practices in the U.S. Health-Care System, MMWR,
May 31, 2013 (Vol. 62, No. 21), pp. 423-425.
9 Ibid.
10 U.S. Department of Labor, Occupational Safety
and Health Administration, Bloodborne Pathogens
Standards – 29 CFR 1910.1030, especially Section
1910.1030(d)(2)(i), available online at:
http://www.osha.gov/pls/oshaweb/owadisp.show_
document?p_table=STANDARDS&p_id=10051.
11 “Detailed Hospital Checklist for Ebola Preparedness,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention
(CDC), and Assistant Secretary for Preparedness and
Response, available online at: http://www.cdc.gov/vhf/
ebola/pdf/hospital-checklist-ebola-preparedness.pdf.
12 “Epidemiologic Risk Factors to Consider When
Evaluating a Person for Exposure to Ebola Virus,” CDC
website, updated October 27, 2014, available online at:
http://www.cdc.gov/vhf/ebola/exposure/risk-factorswhen-evaluating-person-for-exposure.html. Accessed
on October 29, 2014.
13 Maggie Fox, “Why Has Nurse Amber Vinson Recovered from Ebola So Quickly?” NBC News, available
online at:
http://www.nbcnews.com/storyline/ebola-virusoutbreak/why-has-nurse-amber-vinson-recovered-soquickly-n232431. Accessed on October 24, 2014.
14 Kelly Pyrek, “Needlestick Safety and Prevention Act
10-Year Anniversary,” SURGistrategies, December 8,
2010.
15 Terry Grimmond, FASM, BAgrSc, GrDpAdEd and
Linda Good, PhD, RN, COHN-S, “EXPO-S.T.O.P.: A
National Survey and Estimate of Sharps Injuries and
Mucocutaneous Blood Exposures among Healthcare
Workers in USA,” AOHP Journal, Fall 2013 (Vol. 33,
No. 4), pp. 31-36 (especially p. 36); and “Sharps Injuries
among Hospital Workers in Massachusetts: Findings
from the Massachusetts Sharps Injury Surveillance
System, 2012,” Occupational Health Surveillance Program – Massachusetts Department of Public Health,
August 2014.
16 Ashleigh J. Goris, MPH, BSN, RN, CIC, et al., “Reducing Needlestick Injuries from Active Safety Devices: A Passive Safety-Engineered Device Trial,” AHOP
Journal, Spring 2014 (Vol. 34, No. 2), pp. 14-18.
17 CDC Grand Rounds: Preventing Unsafe Injection
Practices in the U.S. Health-Care System, MMWR,
May 31, 2013 (Vol. 62, No. 21), pp. 423-425.
19 Greg Botelho, “Ebola Doctor: Cameraman `Reasonably Stable’ but Not Out of Woods Yet,” CNN,
October 8, 2014, available online at: http://edition.cnn.
com/2014/10/07/health/ebola/index.html?htp=hp_t2.
20 Marc Santora, “Doctor in New York City Is Sick with
Ebola,” New York Times, October 23, 2014, available
online at:
http://www.nytimes.com/2014/10/24/nyregion/craigspencer-is-tested-for-ebola-virus-at-bellevue-hospitalin-new-york-city.html. Accessed on October 27, 2014.
21 Manny Fernandez, “2nd Ebola Case in U.S. Stokes
Fears of Health Care Workers,” New York Times, October 12, 2014, available online at: http://www.nytimes.
com/2014/10/13/us/texas-health-worker-tests-positivefor-ebola.html?module=Search&mabReward=relbias
%3Aw%2C%7B%222%22%3A%22RI%3A12%22%
7D&_r=0. Accessed on October 13, 2014. A version
of this article was published in the October 13, 2014
New York print edition, under the title: “Dallas Nurse
Contracts Ebola Virus, Elevating Response and Anxiety,” p. A1.
22 ALERT: Preventing Needlestick Injuries in Health
Care Settings, National Institute for Occupational Safety and Health (NIOSH), U.S. Department of Health and
Human Services (DHHS)/(NIOSH) Publication no. 2000108, November 1999, p. 2, available online at:
http://www.cdc.gov/niosh/docs/2000-108/pdfs/2000108.pdf. Accessed on October 15, 2014.
18 Dina Fine Maron, “Ebola Diagnosed in More Health
Care Workers,” Scientific American, October 7, 2014,
available online at:
http://www.scientificamerican.com/article/ebola-diagnosed-in-more-health-care-workers/. Accessed on October 13, 2014.
ROC Someone’s World!!! Recruit Our Colleagues!
The “Recruit Our Colleagues” (ROC) campaign has been
successful for many years. The AOHP Board of Directors has
approved continuing this valued incentive to help grow our
organization.
Suggested ideas for recruitment:
•Contact your chapter president for a list of non-renewing
members. Give them a call, and encourage them to re-join.
• Contact hospitals in your geographic area that do not have
an AOHP member.
•If you have a separate occupational health provider, talk
with him/her about becoming a member of AOHP. MDs,
NPs and PAs would benefit from many of our educational
offerings and could also potentially be conference speakers.
Grand Prize: "Whole Shebang" for the member who recruits 10 or more new members. This prize includes National
Conference registration and four hotel nights. In the event
14
that no member recruits 10 or more members, the member who recruits at least four new members will receive a
National Conference registration at the conclusion of the annual campaign.
• 2nd place: Annual membership fee for the year after the
conclusion of the annual campaign.
• Chapter Award: The chapter that recruits the most new
members will receive a check for $250 to be used at their
discretion.
Reach out and share the benefits of AOHP membership
with your area colleagues.
Membership brochures are available through Headquarters,
or encourage potential new members to visit
http://aohp.org/aohp/
Remind new members to list your name as their recruiter!
Winter 2015
Get Involved Today! AOHP Needs Volunteers
AOHP has a number of needs for volunteers at both the local chapter and national levels.
Make a difference by giving back to YOUR association!
Continuing Education Committee
The Continuing Education Committee is a small but energetic group that works behind the
scenes so Chapters and the AOHP National Conference can be awarded nursing contact
hours for providing quality educational content to members. We are in need of a few
more members to assist our committee. The time commitment can be more in-depth in
the summer while preparing for our Conference, but is typically minimal the rest of the
year, depending on the number of requests submitted. We have great resources to help
new participants learn the process. Mary Cox and I are also always available to assist you,
and Annie at Headquarters is tremendously supportive in making the process as easy as
possible. Minimal requirements: RN-bachelor’s degree preferred but not mandatory.
Previous continuing education experience is helpful, but we do offer on-the-job training.
Please contact Mary Cox at [email protected] or Denise Knoblauch at
[email protected] with any questions.
Volunteers Still Needed - Leadership
Opportunity as a Work Group Leader
We still need Strategic Initiative Work Group
Leaders for Goal #3 - Member Communication,
Engagement and Volunteerism, and Goal #4 Industry Authority. The AOHP Board is looking for
strong leaders for these groups. No strategic
planning experience is needed, just a willingness to
get involved at the national level with AOHP.
Develop your business skills and career by
volunteering for AOHP in this way. Please contact
AOHP Headquarters at [email protected] or Dee
Tyler, Executive President at [email protected].
Strategic Initiative Committee
Ad Hoc Member
An Ad Hoc Member is needed to serve on the
AOHP Strategic Initiative Committee. This
person would be responsible to facilitate the
Strategic Initiative Work Groups, keep the
groups on task and promote the identified
association strategic initiatives. Strategic
planning experience is important for this
position. If you think this is a fit for you, contact
Vice President Dana Jennings at
[email protected] or AOHP
Headquarters at [email protected].
Government Affairs Chair
AOHP needs a Government Affairs Chair. If you have an interest in public policy and legislative activities
as they impact healthcare, especially in relationship to occupational health professionals in healthcare,
this may be a good fit for you. This position tracks happenings with the government that could affect
the organization and occupational health professionals in healthcare. Qualifications include: being an
active AOHP member and actively employed; articulate and knowledgeable with regard to the issues
that face the discipline and the association; demonstrates the ability to problem-solve while developing
creative approaches for the accomplishment of the association’s strategic plan; exhibits excellent
written and verbal communication skills and critical thinking skills; and is committed to working within
established timelines. Knowledge and experience with the legislative process is preferable. If you are
interested in this position, contact Vice President Dana Jennings at [email protected] or
AOHP Headquarters at [email protected].
15
CALL FOR POSTERS
CALL FOR POSTERS
AOHP 2015 National Conference
September 9 – 12, 2015
Hyatt Regency San Francisco, CA
Abstracts are due by April 17
We peer review all abstracts for relevance to force
health protection and the author’s area of expertise.
We will notify you by May 29, 2015 the status of your
submission and will include information on our conference brochure. Please complete the “Call for Poster”
submission below.
Download Submission Form from
http://www.aohp.org/aohp/Portals/0/Documents/conference/2015CALLFORPOSTERSsubmission.doc.
The AOHP 2015 National Conference provides occupational health professionals the
opportunity to share their experiences, ideas, and research with others. In addition to platform
presentations, workshops, networking and exhibits, conference participants may view posters
prepared by their peers.
Posters are an excellent, low stress venue in which to present your research and innovations. A
poster is an opportunity to publish a very short article and discuss it with your peers. It may be an
overview of a technical topic, problem, question, research, case study or success story. Your poster
will be view throughout the conference, so the main ideas should be clear without explanation.
Posters will be displayed nearby the registration area and exhibit hall. This will give all conference
attendees the opportunity to read your posters, and/or for your to discuss your posters with your
colleagues. Poster authors are responsible for setting up and taking down their poster. All posters are
judged and eligible for recognition.
Each submission must include the following to be considered for the review process:
1) The title of poster
2) Author(s) information-include name, degree, title, employer’s name, city & state and contact
information (phone, address and email address).
3) Abstract- a submission must include an abstract of not more than 100 words. The abstracts of
accepted submissions will be used on our conference brochure and final program. By agreeing
to present your poster at AOHP 2015 National Conference, you also give permission to AOHP to
publish the poster information on the marketing material and website.
4) Presenter(s) who listed on the submission will receive a discount of $100 from the main
conference registration fee.
AOHP will provide display board. Poster Session open for set up from Noon to 5:30 pm on
September 9, 2015. The poster board surface area is 4 ft h x 8 ft w. Note that this is landscape
orientation. The poster board surface is felt. Bring your own push pins or Velcro to adhere your
poster to the board.
For questions regarding the submission, please contact Annie Wiest at AOHP Headquarters,
phone 724-935-1531 email: [email protected].
16
AOHP hosts one of the largest national conferences
for Employee/Occupational Health Professionals in Healthcare every year. It offers professional
development, networking and information-sharing opportunities to all Employee/Occupational
Health Professionals nationwide.
Start planning now to attend the AOHP 2015 National Conference in San Francisco. It
is never too early to make plans and to ensure that your time and expenses are budgeted to attend.
If you need help to justify your conference attendance with your supervisor, you can find help in
the guideline “Articulating AOHP Conference Attendance Value.”
Articulating AOHP Conference Attendance Value Guideline
http://aohp.org/aohp/Portals/0/Documents/Conference/ConferenceAttendanceValueguideline2014.doc
Articulating AOHP Conference Attendance Value Quick Overview
http://aohp.org/aohp/Portals/0/Documents/Conference/ConferenceAttendanceValueQuickOverview2014.pdf
Sponsors and Vendors for the 2015 AOHP National Conference are needed.
Consider encouraging vendors that you know and work with to be an AOHP Conference vendor
or sponsor. By recruiting vendors and sponsors, we are able to keep conference costs low for
attendees. Take time to survey who you work with that would be a great asset to the AOHP
Conference. If you contact AOHP Headquarters at [email protected] with the potential sponsor or
vendor’s contact information, Headquarters will guide you through making the request and then
they will follow up on your behalf.
BRID GING
Innovation and Knowledge
for Best Practice
Development
SEPTEMBER 9 -12, 2015
17
Journal
Call for Award Nominees
Nominees for the following awards are being sought:
Ann Stinson President’s Award for Association Excellence
–recognizes a chapter that has demonstrated outstanding
performance and enhanced the image of occupational health
professionals in healthcare.
Joyce Safian Scholarship Award – recognizes a past or
present association officer who best portrays an occupational health
professional in healthcare role model.
Extraordinary Member Award – recognizes a current association
member who demonstrates extraordinary leadership.
Honorary Membership Award – recognizes a person(s) who has
made a significant contribution to the field of occupational health in
healthcare.
Business Recognition Award – recognizes a business(es) that
supports occupational health professionals, and membership and
participation in AOHP.
Nominations need to be submitted to the national office by July 1st.
Contact your chapter president or regional director for award criteria,
or visit www.aohp.org.
18
Winter 2015
Association Community Liaison Report
By MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM
Association Community Liaison
OSHA Revisions to
Recording Requirements
Implemented
On January 1, 2015, the Occupational Safety and Health Administration’s (OSHA) revised
recordkeeping rules went into
effect. The revisions include
two key changes:
First, the rule updates the
list of industries that are exempt from the requirement
to routinely keep OSHA injury and illness records due
to relatively low occupational
injury and illness rates. The
previous list of industries was
based on the old Standard
Industrial Classification (SIC)
system and injury and illness
data from the Bureau of Labor
Statistics (BLS) from 1996,
1997 and 1998. The new list
of industries that are exempt
from routinely keeping OSHA
injury and illness records is
based on the North American
Industry Classification System (NAICS) and injury and illness data from the BLS from
2007, 2008 and 2009. The
new rule retains the exemption for any employer with 10
or fewer employees, regardless of their industry classification, from the requirement
to routinely keep records.
Second, the rule expands the
list of severe work-related injuries that all covered employers must report to OSHA.
The revised rule retains the
current requirement to report all work-related fatalities
within eight hours and adds
the requirement to report all
work-related in-patient hospi-
talizations, amputations and
loss of an eye within 24 hours
to OSHA. There are three options to report these injuries
to OSHA:
1.
Calling OSHA’s free and
confidential number at
1-800-321-OSHA (6742.)
2.Calling your closest OSHA
Area Office during normal
business hours.
3.Using the new online form
that will soon be available
at https://www.osha.gov/
report_online/index.html.
Only
fatalities
occurring
within 30 days of the workrelated incident must be reported to OSHA. Further, for
an in-patient hospitalization,
amputation or loss of an eye,
these incidents must be reported to OSHA only if they
occur within 24 hours of the
work-related incident. Note:
Establishments located in
state plan states that operate
their own safety and health
programs should check with
their state plan for the implementation date of the new
requirements.
The final rule will allow OSHA
to focus its efforts more effectively to prevent fatalities
and serious work-related injuries and illnesses. The final
rule will also improve access
by employers, employees,
researchers and the public to
information about workplace
safety and health. It will enable employers and workers
to prevent future injuries by
identifying and eliminating
the most serious workplace
hazards.
For more information, including FAQs, visit Reporting Fatalities and Severe Injuries/
Illnesses at
https://www.osha.gov/recordkeeping2014/reporting.
html.
Ebola Preparations
Take Priority: Online
Resources Available
We are all well aware that
Ebola is a severe and often fatal disease in humans. Many
of us have been involved in
either Ebola preparedness
in our organizations or may
work in facilities where these
patients have received care.
Ebola preparedness and implementation of care protocols have demonstrated the
need for effective interdisciplinary teams with both internal and external partners and
the ability to ramp-up training,
especially related to proper
donning and doffing of personal protective equipment.
The U.S. Centers for Disease
Control and Prevention (CDC)
and partners have been identifying precautions to prevent
the spread of Ebola within the
United States. The following
is a partial list of available
websites that offer reliable,
updated information on Ebola.
• CDC Ebola at http://www.
cdc.gov/vhf/ebola/index.
html
• OSHA Safety and Health
Topics at https://www.
osha.gov/SLTC/ebola/
• NIOSH Workplace Safety
and Health Topics at http://
www.cdc.gov/niosh/topics/ebola/ andhttp://www.
cdc.gov/niosh/topics/ebola/
healthcare.html
• AOHP Ebola Toolkit at
http://aohp.org/aohp/
TOOLSFORYOURWORK/
ToolsforYourPractice/EbolaToolkit.aspx
• Emory Healthcare Ebola
Preparedness Protocols at
http://www.emoryhealthcare.org/ebola-protocol/
ehc-message.html
• The Nebraska Method of
Ebola – for Clinicians at
https://www.unmc.edu/
cce/neb_ebola.htm
NIOSH Updates List of
Antineoplastics and
Other Hazardous Drugs
The National Institute for Occupational Safety and Health
(NIOSH) Alert Preventing
Occupational Exposures to
Antineoplastic and Other Hazardous Drugs in Health Care
Settings was published in
September 2004. In Appendix
A of the Alert, NIOSH identified a sample list of major
hazardous drugs. The list was
compiled from information
provided by four institutions
that had generated lists of hazardous drugs for their respective institutions, as well as a
list from the Pharmaceutical
Research and Manufacturers
of America. The 2004 list was
updated in 2010 and 2012.
The current update (2014)
adds 27 drugs and includes
a review of the 2004 list and
the consequent removal of
12 drugs that did not meet
the NIOSH criteria for hazardous drugs. The revised list
can be found at http://www.
cdc.gov/niosh/docs/2014-138/
pdfs/2014-138_v3.pdf.
19
Journal
Accommodating Mental Illness
By Dori Meinert
Copyrighted content. Please contact AOHP
Headquarters at 800-362-4347 or [email protected] to
purchase a copy of this Journal issue.
20
Winter 2015
Julie Schmid Research
Scholarship
AOHP is accepting proposals for original research
projects on current and/or anticipated issues in
hospital-related occupational health. The Research
Scholarship Award is $2,000. For more details, visit
Awards and Scholarships at www.aohp.org or call
Headquarters, 800-362-4347.
Deadline for submissions is
July 1.
23
Journal
Opioids Versus Physical Therapy for
Management of Chronic Back Pain
By Cassandra A. Gladkowski, RN, BSN; Chelsey L. Medley, RN, BSN; Heather M. Nelson, RN, BSN; Angela Tallie Price,
RN, BSN; and Margaret Harvey, PhD, APRN-BC
Abstract
Chronic low back pain (CLBP) is a common disabling disorder managed by a variety of interventions. The
purpose of this article was to review the literature and critique the evidence to determine if opioid analgesics
improved patient outcomes compared with physical therapy. No research was found that directly compared
the efficacy of opioid analgesics with physical therapy. Although the evidence supports the use of physical
therapy in chronic back pain, the study results are conflicting regarding the usefulness of opioid analgesics
in CLBP management. More research involving the efficacy of opioid analgesic in treating CLBP is needed.
In Western societies, chronic low back
pain (CLBP) is a common disabling disorder that leads to work absence and
high economic costs and presents a
clinical challenge with national implications for resource utilization.1,2 Healthy
People 2020 approximates that 2%-8%
of Americans suffer from CLBP, and 1%
of the working-age population is completely disabled because of CLBP.3 Each
year $50 billion is spent on low back pain
(LBP) management.3
Comprehensive pain management consists of a variety of interventions, including physical therapy, pharmacologic
therapy, surgery, and numerous alternative treatments.1 Also, a systematic review showed significant evidence that
therapeutic aquatic exercise is beneficial
for patients with chronic back pain.4 The
Institute for Clinical Systems Improvement5 recommends using the Diagnosis, Intractability, Risk, and Efficacy
Score to predict if a patient is a suitable
candidate for long-term opioid treatment
for chronic pain. The risk category is
divided into 4 subcategories: psychological health, chemical health, reliability,
and social support. Each factor is rated
1-3, with 1 indicating the lowest favorable case for long-term opioid use and
3 indicating the highest favorable case
for long-term opioid use. Total scores
range from 7 to 21. Patients with scores
less than 14 are not considered good
candidates for chronic opioid analgesics,
24
and patients with scores that are 14 or
higher are considered suitable candidates.5 The use of narcotics is controversial in the literature. Many providers
believe opioids are a mainstay of CLBP
treatment, whereas others are hesitant
to prescribe opioids because of negative
side effects, resulting in poor functioning, abuse potential, and general ineffectiveness.6 Despite the use of opioids to
manage CLBP, the risks and benefits of
both modalities require further investigation.
Methods
An extensive literature review was conducted using the Cumulative Index to
Nursing and Allied Health, MEDLINE,
Cochrane Database of Systematic Reviews, Google Scholar, and PubMed databases. Our initial search limited articles
to the past 5 years, from 2008 to 2013.
The keywords used included chronic
back pain, back pain, physical therapy,
opioid analgesics, narcotics, low back
pain, back pain management, randomized controlled trial (RCT), and qualitative analysis. Inclusion criteria included
adults with CLBP, defined as greater
than 3 months, who were treated with
either physical therapy or narcotic pain
medication. Exclusion criteria included
children, pregnant women, acute back
pain with duration less than 3 months,
and any form of addiction. A limited
amount of relevant literature for the topic was discovered during the literature
review, and the search was expanded to
include articles from the past 8 years,
2005-2013. The search with this expanded time frame retrieved 44 relevant
articles. After subsequent review, 11
articles met our criteria, answered our
research question, and were included in
the study. The 11 studies included in the
review are detailed in the Table.
Results
Exercise Therapy
With the knowledge that exercise is
a common therapy for LBP, Hayden et
al7 sought to compare the effectiveness of exercise therapy in adults with
CLBP compared with other conservative
methods or no treatment at all by conducting a systematic review and metaanalysis. The study included RCTs that
evaluated exercise therapy for back pain
as measured by pain, function, ability to
work, and overall improvements. Data
were collected by 2 reviewers and chosen in relation to the quality of the study,
its characteristics, and the presence of
follow-up throughout treatment.
Sixty-one RCTs met these criteria. Results indicated that exercise therapy was
at least as beneficial as other conservative modalities, such as trunkstabilizing
or strengthening exercises. Study limitations noted were low quality with inconsistent outcome measures, inconsistent
reporting, and possible publication bias.
Overall, exercise therapy appeared to
Winter 2015
25
Journal
26
Winter 2015
reduce pain and improve function in patients with CLBP. Mean improvements
were small but statistically significant.
This was found to be especially true in
health care settings, where exercise
therapy was more consistent and regulated as opposed to home exercises performed independently.
Bronfort et al8 sought to assess the
relative efficacy of supervised exercise,
spinal manipulation, and home exercise
in the treatment of CLBP. The study
achieved this by examining both the
short-term (12 weeks) and long-term
(52 weeks) efficacy of supervised lowtechnology trunk exercise, as well as
home exercise in an observer-blinded
and mixedmethod RCT. Qualitative interviews were also performed at the end
of the 12-week treatment phase. The
authors measured the patient outcomes
of pain, disability, general health status,
medication use, global improvement,
and satisfaction in order to determine
the efficacy of the interventions. A limitation of the study was the apparent lack
of prior research on the effect of opioids
on long-term CLBP, defined as greater
than 16 weeks’ duration. The results
of the study recognized that all 3 treatment groups showed improvement, but
the individuals who received supervised
trunk exercise were the most satisfied
and experienced the greatest improvement in trunk muscle endurance and
strength. Supervised exercise was significantly better than at-home exercise in
terms of satisfaction with treatment and
trunk muscle endurance and strength.
Although the short-term and long-term
differences between groups in patientrated pain, disability, improvement,
general health status, and medication
use consistently favored the supervised
exercise group, the differences were
relatively small and not statistically significant for these individual outcomes;
therefore, more research is needed.
Chou and Huffman9 conducted a systematic review and evaluated the benefits and harms of multiple nonpharmacologic measures on LBP, including
exercise therapy. Overall, they found
good quality of evidence that exercise
is slightly to moderately effective for
CLBP. The Cochrane review found exercise to be slightly to moderately superior
to no treatment for pain relief at the first
follow-up but not for functional outcomes. Exercise therapy was associated with statistically significant but small
effects on pain and function compared
with other noninvasive interventions. A
metaregression analysis also found that
exercise therapy using individualized
regimens, supervision, stretching, and
strengthening was associated with the
27
Journal
best outcomes. Delitto et al10 sought to
develop evidencebased practice guidelines with a purpose to further describe
and make recommendations related to
(1) the treatments matched to LBP
subgroup responder categories, (2) the
treatments determined through evidence to prevent recurrence of LBP, and
(3) the treatments shown through evidence to influence the progression of
back pain and disability from acute to
chronic. The study measured the patient
outcomes of pain, function, and disability
through the use of self-report questionnaires that were tested for quality using
the Oswestry Disability Index and/or the
Roland Morris Disability Questionnaire.
The evidence was graded and assigned
a letter grade that corresponded with
its significance of recommendation (A
for highly recommended and C or D for
not recommended). Finally, the authors
addressed the limitations of the review,
which included poor study quality.
The guidelines suggested a grade A
recommendation for the inclusion of
manual therapy, trunk coordination,
strengthening and endurance exercises,
progressive endurance exercises, and
centralization and directional preference
procedures and exercises in the treatment of CLBP to help minimize pain and
disability. The guidelines also indicated
a grade C recommendation for the inclusion of flexion exercises in CLBP
treatment because this form of physical
therapy did not adequately show any significant impact on decreasing pain and
disability when used with other forms of
exercise in the treatment of CLBP.
The American College of Physicians and
the American Pain Society’s joint practice guideline on the diagnosis and treatment of LBP addressed the overall management of patients with CLBP.11 The
effectiveness of both opioid analgesics
and exercise therapy were investigated, in addition to many other interventions. Exercise therapy was defined as
a supervised exercise program or formal
home exercise regimen, ranging from
programs aimed at general physical fitness or aerobic exercise to programs
aimed at muscle strengthening, flexibility, stretching, or different combinations
28
of these elements. Exercise therapy
was found to have good evidence and
moderate net benefit and was given a
grade B by the panel for use in CLBP.
(16 weeks or more) remained uncertain,
thus indicating that additional research is
necessary for further understanding of
the topic.
Opioid Therapy
Kuijpers et al1 conducted a systematic
review investigating the effectiveness
of opioids and other pharmacologic interventions in the treatment of CLBP.
Cochrane reviews for opioid intervention
were screened to assess for appropriate
criteria. Inclusion was limited to RCTs
of adults with CLBP. At least 1 of the
following aspects of CLBP had to be
included: pain, function, perceived outcomes, or ability to work.
Carey et al13 performed a cross-sectional
telephone survey and interviewed 732
adults with CLBP. The objective was to
describe health care use such as medications, treatments, and diagnostic tests
used in the management of CLBP. The
study found that patients taking narcotics in the last 30 days had greater disability than patients not taking narcotics.
This study also found that patients taking narcotics had a greater 3-month pain
severity score than patients not taking
narcotics. These findings were statistically significant. As a cross-sectional
study, this study was limited by the inability to track patients over time.
Seventeen studies were included in
the final systematic review, 8 of which
looked at opioids specifically. Only shortterm effects were investigated (< 3
months). The overall quality of evidence
supporting opioid use in CLBP was low.
Opioids do appear to offer more relief
than a placebo in the short-term for the
management of CLBP. However, opioids
appear to have only a small effect in improving function and appear to result in
an exacerbation of symptoms after stopping their use. It is important to note that
the use of opioids was shown to result
in more adverse effects than the placebo. The adverse events most noted
were headache and nausea. Limitations
of the study may have included overestimation of positive effects and underestimation of negative effects because
patients who were responding well to
opioids were included only if they
showed worsening LBP during a period
of no opioid use. Overall, opioids may be
beneficial for the treatment of CLBP in
the short-term.
Martell et al12 conducted a systematic
review to determine the prevalence
of opioid treatment and whether opioid medications were effective in the
treatment of CLBP. The study reported
limitations regarding retrieval and publication bias and poor study quality. After
conducting 2 separate meta-analyses
of the data, the authors identified that
opioids were commonly prescribed for
CLBP and may be efficacious for shortterm pain relief, but long-term efficacy
Chapparo et al6 conducted a systematic review to determine the efficacy
of opioids in the management of back
pain. Low-quality evidence suggested
that tramadol is better than placebo in
improving pain, and moderate-quality
evidence suggested tramadol is better
than placebo in improving functional
outcomes. This review also analyzed 6
trials that compared strong opioids with
placebo. Moderate-quality evidence suggested strong opioids are better than
placebo in reducing pain. Moderate-quality evidence also suggested strong opioids are better than placebo in improving
functional outcomes.
Although there is some evidence for the
shortterm efficacy of opioid narcotics to
treat CLBP, there are no placebo RCTs
supporting the safety and effectiveness
of long-term opioid therapy for CLBP.
The initiation of opioids for long-term
management should be done with caution only after a comprehensive assessment of potential risks.
Chu et al14 performed an RCT that analyzed 103 participants between the ages
of 18 and 70. The 1-month study compared patients treated with morphine
with patients treated with placebo. The
morphine group had a significantly
greater reduction in disability from baseline when compared with placebo. Both
Winter 2015
treatment groups showed improved
pain relief at the end of the month, but
the morphine group had significantly
greater pain relief compared with the
placebo group. This study was limited
by its short duration of 1 month.
The purpose of a separate systematic
review by Chou et al15 was to gather
evidence regarding the use of medications, including opioids, in the management of CLBP. Studies selected for this
review included systematic reviews
and randomized trials of dual therapy
or monotherapy with 1 or more of the
medications for acute or CLBP that reported pain outcomes, back-specific
function, general health status, work
disability, or patient satisfaction. Specifically, regarding the effectiveness of
opioid use for LBP, they found that the
overall quality of evidence was fair, and
the net benefit was moderate. Opioids
seem to be associated with particularly
high rates of short-term adverse events,
especially constipation and sedation.
The limitations were numerous and included the following: there were no systematic reviews on opioids, only 9 trials
on opioids met the inclusion criteria, not
all trials looked specifically at LBP, most
trials lasted < 4 weeks, and reliable data
on serious and long-term harms were
sparse.
The joint practice guideline by the American College of Physicians and the American Pain Society11 addressed the effectiveness of both exercise and opioids on
CLBP. They found opioids to have fair
evidence (primarily indirect evidence
from trials of patients with other chronic
conditions), moderate net benefit, and a
grade B for use in patients with CLBP.
They further stated that opioids should
only be used on a short-term basis when
first-line therapies have failed and the patients are experiencing severe, disabling
pain. Because of substantial risks, such
as addiction, abuse, and side effects,
opioids should be used very cautiously.
If patients do not respond to a trial of
opioids, they should be re-evaluated and
reassessed for either referral or the use
of alternative therapies. The limitations
of this guideline primarily rest in the lack
of research available involving opioid use
for CLBP. The authors relied on evidence
from studies involving opioid use in other chronic pain conditions.
Conclusion
Given the fact that no research was
found that directly compared the effectiveness of opioid analgesics with physical therapy in CLBP, we examined the
efficacy of physical therapy and opioids
separately. Although the evidence supports the use of physical therapy, study
results are conflicting regarding the usefulness of opioid analgesics in patients
with CLBP. The potential benefits of
physical therapy generally outweigh any
risks involved. However, nurse practitioners must do a risk-benefit analysis before prescribing opioids for patients with
CLBP and should recognize that current
evidence does not show that this treatment modality is necessarily beneficial.
There is a lack of research analyzing the
use of opioids specifically for CLBP, and
there is very little research that looks
at the effects of opioid use beyond 16
weeks. Most research suggests opioids
should only be used short-term. More
research involving the long-term efficacy
of opioid analgesic use for patients with
CLBP is needed.
Cassandra A. Gladkowski, RN, BSN,
Chelsey L. Medley, RN, BSN, Heather
M. Nelson, RN, BSN, and Angela Tallie
Price, RN, BSN, are all in the MSN/FNP
graduate program at Belmont University
in Nashville, TN. Margaret Harvey, PhD,
APRN-BC, is an associate professor of
nursing at Belmont University and can
be reached at carrie.harvey@belmont.
edu.
In compliance with national ethical
guidelines, the authors report no relationships with business or industry that
would pose a conflict of interest.
References
4. Waller B, Lambeck J, Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic
review. Clin Rehabil. 2009;23:3-14.
5. Hooten WM, Timming R, Belgrade M, et al. Institute for Clinical Systems Improvement. Assessment
and management of chronic pain. https://www.icsi.
org/_asset/bw798b/chronicpain.pdf. Updated November 2013. Accessed November 18, 2013.
6. Chaparro L, Furlan A, Deshpande A, et al. Opioids
compared to placebo or other treatments for chronic
low-back pain (review). http://onlinelibrary.wiley.com/
doi/10.1002/14651858.CD004959.pub4/abstract. Accessed November 4, 2013.
7. Hayden J, van Tulder M, Malmivaara A, Koes B. Meta-analysis: exercise therapy for nonspecific low back
pain. Ann Intern Med. 2005;142:765-775.
8. Bronfort G, Maiers M, Evans R, et al. Supervised
exercise, spinal manipulation, and home exercise for
chronic low back pain: a randomized clinical trial. Spine
J. 2011;11(7):585-598.
9. Chou R, Huffman L. Nonpharmacologic therapies
for acute and chronic low back pain: a review of the
evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern
Med. 2007; 147:492-504.
10. Delitto G, George S, Van Dillen L, et al, National
Guideline Clearinghouse. Low back pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the
Orthopaedic Section of the American Physical Therapy Association. http://www.guideline.gov/content.
aspx?id¼36828. Accessed November 4, 2013.
11. Chou R, Qaseem A, Snow V, et al. Diagnosis and
treatment of low back pain: a joint clinical practice
guideline from the American College of Physicians
and the American Pain Society. Ann Intern Med.
2007;147:478-491.
12. Martell B, O’Connor P, Kerns R, et al. Systematic
review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146:116-127.
13. Carey T, Freburger J, Holmes G, et al. A long way to
go: practice patterns and evidence in chronic low back
pain care. Spine. 2009;34(7):718-724.
14. Chu L, D’Arcy N, Brady C, et al. Analgesic tolerance
without demonstrable opioid-induced hyper-analgesia:
a double-blinded, randomized, placebocontrolled trial
of sustained-release morphine for treatment of chronic
nonradicular low-back pain. Pain. 2012;153:1583-1592.
15. Chou R, Huffman L. Medications for acute and
chronic low back pain:a review of the evidence for
an American Pain Society/American Collegeof Physicians clinical practice guideline. Ann Intern Med.
2007;147(7):505-514.
Reprinted with permission,
© 2014 Elsevier, Inc. All rights reserved.
1. Kuijpers T, van Middelkoop M, Rubinstein S, et al. A
systematic review on the effectiveness of pharmacological interventions for chronic non-specific lowback
pain. Eur Spine J. 2011;20:40-50.
2. Grabois M. Management of chronic low back pain.
Am J Phys Med Rehabil. 2005;84(3 Suppl):S29-S41.
3. HealthyPeople.gov. Healthy people 2020. http://
www.healthypeople .gov/2020/default.aspx. Accessed
November 4, 2013.
29
Journal
WHILE YOU LOOK AFTER OTHERS,
WHO LOOKS AFTER YOU?
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30
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