2008 occupational medical update: new millennium challenges for occupational respiratory...
TRANSCRIPT
2008 Occupational Medical Update:
New Millennium Challenges for Occupational Respiratory Exposures/Disorders
Are Medical Examinations Worth Doing?
A Presentation to:
ASSE
Howard M. Sandler, M.D.Sandler Occupational Medicine Associates, Inc.
October 6, 2008
© 2008 Sandler Occupational Medicine Associates, Inc.
Deposition in Respiratory Tract
Particle Size (m)
> 15 m
10-15 m
5-10 m
<5 m
LocationOuter Portion Nasal Passage
Nasal Turbinates, Pharynx
Considered INHALED – Major Airways Trachea, Major Stem Bronchi
Considered RESPIRABLE –Terminal Bronchioles, Alveoli
© 2008 Sandler Occupational Medicine Associates, Inc.
Range of Occupational Respiratory Concerns
• Irritation• Inflammation• Chemical Pneumonitis• COPD• RAD (e.g. Asthma)• Reactive Airway Dysfunction Syndrome (RADS)• Interstitial Lung Fibrosis (IPF)• Lung Cancer• Hypersensitivity Pneumonitis• Allergic Disorders
© 2008 Sandler Occupational Medicine Associates, Inc.
Workplace Influence Potential
• Causation
• Contribution
• Aggravation
• Exacerbation
• Increased Decline in Pulmonary Function
• Symptoms vs. Pathogenicity
© 2008 Sandler Occupational Medicine Associates, Inc.
Ubiquity/Specificity of Respiratory Symptoms
• Cough
• Dyspnea• SOB• Wheeze
• Phlegm• DOE• Chest Pain/Pressure• Colds, Flu, other
URI’s
© 2008 Sandler Occupational Medicine Associates, Inc.
Common Symptom Prevalence
Symptom Mean PrevalenceCough 20%Difficulty breathing 17.7Wheezing 15%UR Symptoms 18%Stuffy or blocked nose 43.4Flu-like illness 10.6Eye dryness 30.3Eye, itching, watering 27.8Runny nose 25.8Dry throat 30.8Lethargy 62.6Headache 52.0
© 2008 Sandler Occupational Medicine Associates, Inc.
New Millennium Concerns
• Emerging Occupational Pulmonary Diseases – Popcorn Workers Lung, WTC Lung, Infectious Diseases
• Developing Technologies – Nanotechnology• Regulatory Activity – Sensitizers/Flour Dust,
Flavoring Agents and Silica• Workers Compensation – Symptoms v.
Pathogenesis, Enhanced Decline in Pulmonary Function
© 2008 Sandler Occupational Medicine Associates, Inc.
New Millennium Concerns (Cont’d)
• Business Response – Reactive v. Proactive, Programs v. Regulatory Compliance
• Impact of General Population Trends – Obesity, GERD, Allergies, Asthma
© 2008 Sandler Occupational Medicine Associates, Inc.
Food Flavorings
• Approximately 1,037 possible respiratory hazard flavorings
• Aldehydes, ketones, acids, thiols, sulfides • Few with PELs, RELs, TLVs
© 2008 Sandler Occupational Medicine Associates, Inc.
Microwave Pop-Corn Processing – Missouri Plant
• 8 workers with BO (ages 29 – 53) • Equal gender distribution • Latency – 0.5 – 5 years • One smoker (protective factor?)
© 2008 Sandler Occupational Medicine Associates, Inc.
Popcorn Workers Lung (Diacetyl?)
• There are numerous substances and conditions (e.g., heating) involved in the manufacture of MW pop-corn; specifically various particulates (oil/grease and salt) and numerous volatile organic compounds (over 100 VOCs) have been identified by the lead governmental agency, NIOSH in this research effort (Kullman, 2005)
• It is unclear whether diacetyl is the actual etiologic agent in whole or, part or is simply an indicator of exposure (OSHA, 2003; Harber, 2006; Hubbs, 2002)
© 2008 Sandler Occupational Medicine Associates, Inc.
Popcorn Workers Lung (Diacetyl?) (Cont’d)
• Kreiss, 2007 – Review, Causation?• Egilman, 2007 – Industry Conspiracy, NO Threshold• Schlesinger, 1998 – Critical Review for BO Risk Factors –
Flavorings/Diacetyl not Identified• Dr. Cecile Rose – National Jewish Medical and Research Center,
Denver– “Prior” Consultant to Flavorings Industry (FEMA)– July 18, 2007 Letter to FDA– Consumer with BO and Hx of Making Several Bags of
Extra Butter Flavored MW Popcorn for Several Years– Found Similar Diacetyl Airborne Levels to Those
Reported in QA Unit of Popcorn Manufacturing Plant
© 2008 Sandler Occupational Medicine Associates, Inc.
Prevalence of New or Worsened Respiratory Symptoms Among WT Workers by Date of Arrival for Work at WTC Site and by Exposure to the
Dust Cloud (n= 9,442)
All responders
(n = 9,442) (%)
Lower respiratory symptoms
Dry cough 28.7
Cough with phlegm 14.1
Shortness of breath 17.3
Wheeze 15.1
Chest tightness 15.4
Any lower respiratory symptom 46.5
Upper respiratory symptoms
Sinus - relatedb 37.3
Nasal - relatedc 48.4
Throat - relatedd 43.9
Any upper respiratory symptom 62.5
Any respiratory symptom 68.8
aOne-sided p-values using the Cochran - Armitage trend test. bFacial pain or pressure, head or sinus congestion, or postnasal, stuffy nose, sneezy, runny nose, or irritation in nose. dThroat irritation, hoarseness, sore throat or losing your voice (laryngitis)
© 2008 Sandler Occupational Medicine Associates, Inc.
Prevalence of New or Worsened Respiratory Symptoms Among WT Workers by Date of Arrival for Work at WTC Site and by Exposure to
the Dust Cloud (n= 9,442) (Cont’d)
Arrived on 11 SeptemberIn dust cloud Not in dust cloud(n= 1,878) (n= 1,934)(%) (%)
Lower respiratory symptoms Dry cough 34.2 30.6Cough with phlegm 17.6 13.4Shortness of breath 20.9 15.6Wheeze 18.3 15.5Chest tightness 18.5 14.4Any lower respiratory symptom 54.2 47.2
Upper respiratory symptomsSinus - related 41.9 36.9Nasal - related 52.4 48.6Throat - related 47.2 43.9Any upper respiratory symptom 65.8 62.4
Any respiratory symptom 73.4 69.7
aOne-sided p-values using the Cochran - Armitage trend test. bFacial pain or pressure, head or sinus congestion, or postnasal, stuffy nose, sneezy, runny nose, or irritation in nose. dThroat irritation, hoarseness, sore throat or losing your voice (laryngitis)
© 2008 Sandler Occupational Medicine Associates, Inc.
Prevalence of New or Worsened Respiratory Symptoms Among WT Workers by Date of Arrival for Work at WTC
Site and by Exposure to the Dust Cloud (n= 9,442) (Cont’d)
Arrived Arrived Arrived on or 12-13 September 14-30 September after 1 October(n=2,801) (%) (n=2,133) (%) (n=666) (%)
Lower respiratory symptomsDry cough 28.0 25.5 21.3Cough with phlegm 13.5 13.0 12.7Shortness of breath 17.1 16.1 16.6Wheeze 14.6 13.4 13.0Chest tightness 14.3 15.2 14.1Any lower respiratory symptom 44.2 43.8 40.8
Upper respiratory symptomsSinus – related 36.6 37.0 30.1Nasal – related 47.9 46.3 45.1Throat – related 43.1 43.6 39.7Any upper respiratory symptom 61.7 62.1 59.2
Any respiratory symptom 67.3 67.7 64.5
aOne-sided p-values using the Cochran - Armitage trend test. bFacial pain or pressure, head or sinus congestion, or postnasal, stuffy nose, sneezy, runny nose, or irritation in nose. D Throat irritation, hoarseness, sore throat or losing your voice (laryngitis)
© 2008 Sandler Occupational Medicine Associates, Inc.
Spirometry results (prebronchodilator) by date of arrival for work at WTC site and exposure to the dust cloud among the WTC MSP study population (n = 8,384). a
In dust cloud(no (%))
Not in dustCloud (no (%))
Arrived 12-13 Sep (no (%))
Arrived 14-30
Sep (no (%))
Arrived on or after 1 Oct (no (%))
Trend test p-value
Normal 1.160 (68.5) 1.222 (69.9) 1.78 (71.6) 1.397 (75.3) 453 (78.6) --
Obstructive 81 (4.8) 96 (5.5) 140 (5.6) 104 (5.6) 26 (4.9) 0.418
Low FVC 408 (24.1) 400 (22.9) 506 (20.3) 318 (17.1) 84 (14.6) <0.001
Obstruction and low FVC 44 (2.6) 29 (1.7) 61 (2.5) 36 (1.9) 11 (1.9) 0.095
Arrived on 11 Sep
*Only acceptable quality spirometric examinations are included as described by Miller et al (2005). *One-sided p-values using the Cochran-Armitage trend test. FVC FVC ratio less than 5th percentile of predicted and normal FVC FVC less than 5th percentile of predicted value and a normal FEV FVC ratio. FEV FVC ratio less than 5th percentil of predicted value and FVC less than 5th percentile of predicted value
© 2008 Sandler Occupational Medicine Associates, Inc.
Nanotechnology
• UFPs v. NPs• $1 Trillion Market by 2015• Next “Asbestos”• Specific Properties v. Toxicity• What do you measure?• Human Effects?• NIOSH - MMS
© 2008 Sandler Occupational Medicine Associates, Inc. [Source: Royal Academy of Engineering, Nanoscience and nanotechnologies, July 2004]
© 2008 Sandler Occupational Medicine Associates, Inc.
Quantum Effects
• The reduced size of nanoparticles results in property changes, in comparison to the bulk material:
– Electrical
– Mechanical
– Chemical
– Optical
TiO2 microspheres from sunscreen
© 2008 Sandler Occupational Medicine Associates, Inc.
Particle Comparison
• Theoretically then . . .
– 1,000,000 10 nm sized nanoparticles can be created from a single 10 um sized dust particle, and
– The effective dose (surface area) is 1,000 times greater even though the mass is unchanged
© 2008 Sandler Occupational Medicine Associates, Inc.
Silicosis & Asbestosis Deaths in the U.S. by Year
Silicosis
Asbestosis
© 2008 Sandler Occupational Medicine Associates, Inc.
Current Occupational Exposure Limits for Respirable: Quartz, Cristobalite, Tridymite and Amorphous Silica
(mg/m3)QUARTZ CRISTOBALITE TRIDYMITE AMORPHOUS
ACGIH*
0.025 0.025 Withdrawn 10 (Total Dust)
OSHA*
10mg/m3
%SiO2+ 2
½ value calculated from
the mass formulae for
quartz
½ value calculated from the
formulae for quartz
80mg/m3
%SiO2
MSHA*
SAME AS OSHA
SAME AS
OSHA
SAME AS OSHA
NIOSH**
0.05 0.05 0.05
*8-Hour Time Weighted Average ** For Up To 10-Hour Workday During A 40-Hour Workweek
© 2008 Sandler Occupational Medicine Associates, Inc.
NUMBER OF MSHA AND OSHA INSPECTOR SILICA SAMPLES AND PERCENT EXCEEDING THE PERMISSIBLE
EXPOSURE LIMIT (PEL) 1974- 1994
© 2008 Sandler Occupational Medicine Associates, Inc.
Exposure, Morbidity and Mortality
• Silicosis Risk– 1 – 95% of Workers at OSHA PEL Over
40 to 45 Years Working Lifetime– 1 – 7% at ½ NIOSH REL – 0.025 mg/m3
– 20% Increased Risk at 0.04 mg/m3 for 45 Years
– Current Prevalence Unknown– 300 Deaths Per Year
© 2008 Sandler Occupational Medicine Associates, Inc.
SOMA Exposure and EPI Study
• 6,000 Cohort, Stone/Gravel/Mining• Long-term – Morbidity (Various Endpoints)• Exposure Modeling Precision• Confounding Control• Objectives
– Dose-response Refinement– Health Effects Non-Silicosis– Disease Progression
© 2008 Sandler Occupational Medicine Associates, Inc.
Medical Monitoring SurveillanceB-Read X ray
Chest Xrays 2006
Changes, 0
Stable, 15
0
2
4
6
8
10
12
14
16
Stable
Changes
© 2008 Sandler Occupational Medicine Associates, Inc.
Aggregate FEV1 Data
Average FEV1 from Aggegate Data
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
2001 2003 2005
Year
Val
ue
FEV 1
© 2008 Sandler Occupational Medicine Associates, Inc.
Meta – Analysis of Risk for Idiopathic Pulmonary Fibrosis Associated with Environmental and
Occupational Exposures
Exposure Risk Summary Estimates*
Agriculture/farming 1.65 (1.20 – 2.26)
Livestock 2.17 (1.28 – 3.68)
Wood dust 1.94 (1.34 – 2.81)
Metal dust 2.44 (1.74 – 3.40)
Stone/sand/silica 1.97 (1.09 – 3.55)
Smoking 1.58 (1.27 – 1.97)
© 2008 Sandler Occupational Medicine Associates, Inc.
COPD in Diesel – Exposed Railroad Workers, Hart et al, 2006
• Garshick/Harvard• Case – Control – Workers Deaths, 1981-1982• 536 COPD Cases• OR – 1.61 After Confounding Adjustment• Smoking History Cases
Cases (%)Controls (%)
Never 4.3 17.4
Current 29.1 26.6Former 50.0 36.4
© 2008 Sandler Occupational Medicine Associates, Inc.
Other PF Decline “Accelerators”
• Silicon Metals and Alloys (Soyseth et al, 2007)• Passive Smoking (Yin et al, 2007)• Wood Dust (Jacobsen et al, 2007)• Particulate Matter (Down et al, 2007)• Grain Dust (Paawa et al, 2007)
© 2008 Sandler Occupational Medicine Associates, Inc.
Trends in SEER Incidence Rates by Primary Cancer Site 1973 - 1990
-34.8-28.8-24.8
-10.2-9.5-8.3-4.7
0.22.14.39.29.510.212.1
18.320.421.123.8
33.748.7
65.584.989.5
110.5
-150 -100 -50 0 50 100 150
Lung (Female)Melanomas of Skin
ProstateNon-Hodgkin’s
TestesLiver & Intrahep
Kidney/RenalBrain
Breast (Female)Thyroid
All CancersEsophagus
Urinary BladderMultiple Myeloma
Lung (Males)Ovary
Colon/RectumLarynx
Oral Cav & PhynxHodgkin’sPancreasLeukemiaStomach
Corpus&Uterus,NOSCervix Uteri
© 2008 Sandler Occupational Medicine Associates, Inc.
Obesity
• Increased Asthma Severity (Taylor et al, 2008)
• GERD (Choi et al, 2008; El – Sorag et al, 2007)
© 2008 Sandler Occupational Medicine Associates, Inc.
GERD
• High Correlation with IPF (Raghu et al, 2006; Salvioli et al, 2006)
• Highly Related to Asthma, Chronic Cough, Hoarseness (Multiple References)
© 2008 Sandler Occupational Medicine Associates, Inc.
Occupational Respiratory Health Program Impact
• Infectious Disease Plan– Written Program– Targeted TB Testing– Travel Considerations– Quarantine, Masks
• Medical Monitoring and Surveillance– Baseline Exams– Modification in PFT Parameters– Immune System Markers– Biomarkers
© 2008 Sandler Occupational Medicine Associates, Inc.
Occupational Respiratory Health Program Impact
• Worker Placement Considerations– Continued Exposure when Occupational
Respiratory Disease Present– Placement Medical Standards– FMLA for Chronic Respiratory Conditions– ADA Reasonable Accommodations
© 2008 Sandler Occupational Medicine Associates, Inc.
Occupational Respiratory Health Program Impact (Cont’d)
• Health Trend Analysis– Integration of HB, MMS, Internal “Sensor” Reporting, OSHA, WC and other Data
• Personal/Occupational Risk Factor Reduction and Control– Weight, Smoking, Aerobic Conditioning– Enhance COPD, ILD, Allergy, RAD, GERD Disease
Management– Reconsider Standard Toxicity Testing Approaches– Enhance Exposure Modeling – Peaks, Epidemiologic
Considerations– Setting “Internal” Exposure Standards
© 2008 Sandler Occupational Medicine Associates, Inc.
What is a Work-Based Medical Evaluation?
An historical assessment, physical/functional examination and laboratory/procedure evaluation of a worker or a person to whom a job offer has been extended, potential employee to determine their functional work status, potential adverse work-related exposures. Additional purposes may include assessment of personal risk factors and identification of health promotion needs.
© 2008 Sandler Occupational Medicine Associates, Inc.
Types of Occupational Medical Examinations
• Exposure Driven (Medical Monitoring and Surveillance)
• Placement– Initial Hire– Periodic Fitness for Duty– Occupational and Non-occupational RTW
• Regulatory Required (PPE, HAZWOPER, DOT, FAA)
© 2008 Sandler Occupational Medicine Associates, Inc.
Types of Occupational Medical Examinations (Cont’d)
• Legally-focused (IMEs for WC, Litigation)
• Health Promotion for Health Risk Factor Identification
• Health Care Cost Containment in Disease Management
© 2008 Sandler Occupational Medicine Associates, Inc.
Risk
• As expressed in patient evaluations, or in laws, semi-quantitative
• “Low”, or “Moderate”, and “High” risk, usually definitions are not stated
© 2008 Sandler Occupational Medicine Associates, Inc.
Risk (Cont’d)
• Inexact guesses, based on:?– Science (?) (literature, scientific studies)– Consensus (?) (published position paper)– Experience (?) (limited, anecdotal, biased)
• If we are honest, most risk assessment in real patient evaluations is based on the anecdotal EXPERIENCE of the physician
© 2008 Sandler Occupational Medicine Associates, Inc.
Risk: Legal StandardAmericans with Disabilities Act
• Employer may require that the worker Not pose a direct threat to Self or Others High Probability (not clearly defined) of specific Substantial Harm (not ↑ symptoms) that is imminent (< 3 months, not future)
• Based on Objective Medical Evidence related to the particular individual
• Law & Definitions will differ in different countries
© 2008 Sandler Occupational Medicine Associates, Inc.
Risk: Probability under ADA
• As expressed in patient evaluations, or in laws, semi-quantitative
• “Low”, “Moderate”, and “High” risk, definitions not clearly stated
• Inexact guesses
High = Probable Direct Threat (usually, if significant harm is imminent)
Moderate = Possible Direct Threat (usually not) Low = Remote Chance of Direct Threat
(rarely)
© 2008 Sandler Occupational Medicine Associates, Inc.
Risk with Return to Work:Of What Consequence?
• Objectively verifiable, serious, single incident.
Examples: Disc Herniation, Myocardial Infarction
• Objectively verifiable, but less immediately serious
Example: Increase in Pre-existing Hypertension
• Subjective: Not verifiable
Example: Increase in current Back Pain
© 2008 Sandler Occupational Medicine Associates, Inc.
Cardiology:Return to Work Post - MI
• “Following both myocardial infarction and myocardial revascularization, symptomatic and functional improvement correlate poorly with the return to work and resumption of pre-illness lifestyle, with psychosocial status appearing as a more important determinant.”
Hurst’s The Heart, 9th Edition (1998), McGraw Hill page 1628 (0-07-912951-X)
© 2008 Sandler Occupational Medicine Associates, Inc.
Possible Examination Sites
Onsite Mobile Vans
Onsite Provider (MD, PT, RN, Med Tech, PA)
Clinic based
Hospital based
© 2008 Sandler Occupational Medicine Associates, Inc.
What is the Magic Number for Exam Periodicity?
Traditional Approach – Annual or Per Regulatory Requirements where Applicable
New Approach -- Functional Data for Decision Making (and Regulatory)
© 2008 Sandler Occupational Medicine Associates, Inc.
What is the Magic Combination of Exam Components?
Traditional Approach -- Multiphasic Screening (SMAC, CBC, PFTs, Visual, Audio, CXR, Urine, Hx, PE)
New Approach -- Functional Information and
Exposure Specific Assessment (functional physical assessment and biological monitoring)
Tiered Structured (age, risk factors such as
smoking, etc.)
© 2008 Sandler Occupational Medicine Associates, Inc.
Recent Pre-Employment Evaluation Study (Moshe et al, 2008)
WC Workers and Laborers Type of Evaluation Restriction Rate (%)
- OP examination 2.1 - GP exam with OP MR Review 1.2 - OHQ with OP Review 2.3 Highest Restriction Rates - 50 yo and higher 3.6 (CV and MS)
© 2008 Sandler Occupational Medicine Associates, Inc.
Decisions, Decisions, Decisions (The Real Value in Medical
Examinations)
• Right person for the job without increased, significant, near-term, material harm/injury
• Time away from work
• Restrictions
• Reaching MMI
© 2008 Sandler Occupational Medicine Associates, Inc.
Decisions, Decisions, Decisions (The Real Value in Medical
Examinations) – (Cont’d)
• Diagnostic Criteria
• Evidence-based treatment protocols
• Information that management CAN and will USE
© 2008 Sandler Occupational Medicine Associates, Inc.
Current Decision Making Criteria/Rationale
• Treat 'em and Street 'em
• No evidence-based criteria
• Little training even for Occ Docs
• Fear of making "THE CALL"
© 2008 Sandler Occupational Medicine Associates, Inc.
Real World Dataon MDs Certifying Disability
• W Zinn, et al; Physician perspective on the ethical aspects of disability determination J Gen Intern Med 1996; 11 (9): 525-532
• Survey:– 184 Internists and FPs (Random Sample, RS)
(53% of 347), and– 76 “Neighborhood Health Center” (NHC) MDs
(76% of 100)
• Physician willingness to exaggerate clinical data to help a patient he/she thought was deserving of disability– 39% of Random Sample MDs– 56% of NHD MDs
© 2008 Sandler Occupational Medicine Associates, Inc.
Similar to Prior Study
• 87% of cases in which primary care physicians could not justify “sick-listing” certification, a certification was issued anyway.
– L England & K Svardsudd; Sick-listing habits among general practioners in a Swedish county. Scand J Prim Health Care 2000; 18: 81-86
© 2008 Sandler Occupational Medicine Associates, Inc.
Ethics?JAMA 2000; 283; 1858-1865
• Random sample questionnaire of 1124 MDs• Use of 3 “tactics” to help patient get health
insurance coverage/permission:– Exaggerated complain severity– Changed billing diagnosis– Reported signs or symptoms patient didn’t have
• 39% of MDs has used at least on “tactic” “sometimes” or more often in the last year.
• Use unrelated to worry about prosecution for fraud.
• 54% reported using these tactics more frequently than 5 years ago.
© 2008 Sandler Occupational Medicine Associates, Inc.
Medical Evaluations – The Right "Flow Process"
• Approach – Job Specific Functionality• Decision Criteria - Medical Standards• Managerially "Doable" - Preset
Restrictions/RJAs• Systems Integrated
• Real Time Designations• Real Time Communication• Real Time Decisions• Real Time Oversight• Real Time Expert Validation
• Regulatory Compliant/Evidence-Based - ADA, FMLA, OSHA, EPA, DOT, ACOEM
© 2008 Sandler Occupational Medicine Associates, Inc.
About SOMA
• Celebrating 25 years, founded in 1983• Nationally recognized staff
– Industry, Regulatory, Research and Academic Experience
• Advanced information technology solutions• State-of-the-art equipment and facilities• Evidence-based practices
– Occupational Health and Ergonomics– Industrial Hygiene and Toxicology– Safety
© 2008 Sandler Occupational Medicine Associates, Inc.
SOMAVIP Suite Vision
A comprehensive Occupational and Environmental Health Suite of services and
tools designed to extend clients’ Occupational Safety, Health and Hygiene
Program Implementation and Management
© 2008 Sandler Occupational Medicine Associates, Inc.
SOMAVIP Suite Vision
• Corporate targets for healthful and safe workplace
– Big Picture View• Occupational Health (Exam Management,
Medical Standards, Medical Case Management, Wellness)
• Industrial Hygiene (Exposure Sampling, Exposure Risk Reduction)
• Safety Management (Incident, Audit, Training, Trends)
– Consistent Approach (i.e. Risk Type and Analysis) with documented strategy
© 2008 Sandler Occupational Medicine Associates, Inc.
Components of an Exam Management and Quality Assurance Program
• Medical standards for job classes• Examination Program • Web-based exam tracking and notification
system-SOMAVIP-OH• Medical review by occupational health
specialists for all exams• Follow-up by occupational health specialists
for abnormal exams
© 2008 Sandler Occupational Medicine Associates, Inc.
Medical Standards for Job Classes
• Specific job classes for defined work • Based on job descriptions and field
analysis• Describe in terms of functional categories • Job functions are ranked according to
demand level
© 2008 Sandler Occupational Medicine Associates, Inc.
MEDICAL STANDARD MATRIX
Company: XYZ Corporation
Job Class 1 – PMHE Warehouse Distribution: Material Handler, Warehouse Distribution, Receiving Clerk, Inventory Clerk, STET Clerk, Warehouse Attendant, Order-Picker Replenishment, Material Handler Shipping, Material Handler Receiving, Material Handler Turrett Driver, M. U. V. Coordinator, Bulk Storeman, High Racker Driver, Fork Lift Driver, Warehouse Keeper, Block Puller, Shipping and Receiving Worker, Raw Materials Warehouse Keeper
Job Summary: Manual and Vehicular transport/ inspection/receiving/shipping of product and materials within warehouse facility departments
Length of a Normal Shift (In Hours): 8 hrs/day; 40 hr. week; optional overtime; some 4 hours shifts at select locations.
ESSENTIAL JOB FUNCTIONSTRANSPORT: Operation of forklifts to transport product within facility; also may use hand trucks, hi/lo, transporter, hand jack, pallet jack, handcart, drum handcart, motorized picker with lifter, motorized transporter, and manual lifting for retrieval or placement of product. Work is performed in variable indoor conditions . RETRIEVE: Travel along aisles and/or throughout facility and between pallets, racks, conveyors, trucks, trailers, to place and retrieve product and equipment, using up to full arm reach, and in areas of limited access; work at heights; use of hand tools and equipment to retrieve and package product; placement or inspection of appropriate marker on product for inventory. Completion of job tasks performed according to specified performance requirements. TRANSFER: Manual transport of product to and from stock areas and pallets; retainment of order sheet during product selection; use of personal protective equipment as required. IDENTIFY: Visual determination of product placement and retrieval based on written and verbal instructions; use of computer to provide shipping/receiving instructions. COMMUNICATE: Recognition of auditory sounds and signals; verbal communication; observe written symbols; individual work performed with coordination with coworkers to ensure task completion.
Functional Categories Rank Job-Specific Data Requirements Does NOT Meet Requirements
(Check Those that apply)
A. Physical Forces (lift, carry, push/pull)
2 Transport, Retrieve, Transfer: Max. lift 50 lbs, avg. lift < 25 lbs.; carry 20-40 ft. max.; push/pull 30 lbs.
Arms, legs, neck, back ROM, strength, endurance for moderate lifting/pushing/pulling; hernia concern; chronic musculoskeletal stable
___NO
B. Lower Extremity (postures, balance - squat, stoop, crouch, etc.)
3 Retrieve, Transfer: Squat, stoop, crouch, kneel; work in limited space; use foot pedals for driving; may work at heights when using equipment for retrieval or placement of product.
Leg ROM, strength, endurance for squat, stoop, crouch, kneel (P); balance (P)
___NO
C. Locomotion (walk, climb, jump, run)
3 Retrieve, Transfer: Walk, climb to move product.
Back and leg ROM, strength, endurance for walking (F); climbing (I)
___NO
D. Upper Extremity (movement, coordination - grip/ grasp, repetition, reaching, etc.)
2 Transport, Retrieve, Transfer: Grip/grasp, pinch; object transfer, reach, overhead reach, fine motor coordination; repetition, full motion hand/wrist
Arm ROM, strength, endurance for object transfer, reach, pinch, gross motor (P); grip/grasp full reach (F);Overhead reach (I)
___NO
E. Back/Neck Postures (bending, twisting/ turning)
2 Transport, Retrieve, Transfer, Identify: Bend, twist/turn to perform warehouse duties/use material handling devices.
Back/neck ROM, strength, endurance for bending, twist/turning (P)
___NO
F. Standing/Sitting 2 Transport, Retrieve, Transfer: Stand; sit (forklift operation)
Leg and back strength, endurance for standing (C); sitting (I)
___NO
© 2008 Sandler Occupational Medicine Associates, Inc.
Functional Categories Rank Job Specific Tasks Requirements Meets Requirements
G. Special Senses (visual, hearing, touch, taste-smell)
Transport, Identify, Communicate: Product identification and retrieval, observe written instructions; verbal communication, auditory signal recognition, computer use, work around moving equipment, operate controls.
* Use job-specific colors to test color vision if applicable
3 Vision Distant Objects: 20/40 Better Eye, Field 125o; *Color vision if applicable
___NO
3 Hearing Speech, Warning Sounds: 40 dB .5,1,2 Better Ear ___NO
4 Tactile Tactile: Object Recognition ___NO
5 Taste-Smell No requirements ___NO
H. Mental Activities Transport, Identify, Communicate: Task performance by standards; coworker interaction
___NO
3 Attention/Cognition LOC risk (N/D/C) low; verbal/visual analysis, judgment (F) ___NO
3 Social Interaction No active psychosis; group work (F) ___NO
I. Aerobic 3 Retrieve, Transfer: Physical work performed in variable indoor conditions
Moderate: NYHA Class I; ATS Grade 0 ___NO
J. Environment (ambient conditions, environmental factors)
3 Transport, Retrieve, Identify: Indoor variable temperatures, may be extreme; vibration; reduced lighting; protective equipment
Indoor variable (C) ___NO
K. Work Schedule 3 All: Up to 8 hours/day, 40 hours per week Overtime Optional ___NO
L. Medical Conditions/ Special Regulatory Requirement
3 All: Medical conditions stable; pregnancy considerations (ACOG); personal protective equipment use
No undiagnosed or unstable condition; no restricting medication effect; potential pregnancy limitations for job performance
___NO
KEY:C = 100% of shift LOC = loss of consciousness F = 25-50% of shift ROM = range of motion P = >50%, less than 100% N/D/C = neurologic, diabetic, cardiac I = <25% of shift NYHA = New York Heart Association functional scale ATS = American Thoracic Society breathlessness scale ACOG = American College of Obstetrics pregnancy guidelines
RANK STRUCTURE:Rank 1 - most demanding/maximal capacity
↓2↓
Rank 3 – average demand/capacity↓4↓
Rank 5 - least demanding/minimal or no capacity
© 2008 Sandler Occupational Medicine Associates, Inc.
Examination Program
• Standardized examination forms (“packet”)• PDF Format• Systematic process for various exam types• Results (forms containing personal health
information) are separate from other personnel documents
© 2008 Sandler Occupational Medicine Associates, Inc.
Web-based exam tracking and notification system-SOMAVIP-OH
• Schedule notification & tracking• Automated form creation (PDF) • Status management with notes• Automated Email notifications • Updated online resources: Manuals, Forms,
Bulletins
© 2008 Sandler Occupational Medicine Associates, Inc.
Medical Review
• Quality checks against medical standards
• Review by trained specialists for every examination
© 2008 Sandler Occupational Medicine Associates, Inc.
SOMAVIP-OH
Schedule Exam
Medical Examination and Quality Assurance Process
ClinicFaxReceived
Review Against Protocol
Quality Assurance
Checks
Status Update
Recommendation
© 2008 Sandler Occupational Medicine Associates, Inc.
SOMA Review
• Clinic results received via e-fax (electronic faxing with privacy protection)
• Exam evaluated against medical standards• Recommendation provided • Email update for each action • Abnormal exams require further clarification
© 2008 Sandler Occupational Medicine Associates, Inc.
Occupational Medical Evaluation – Return to Work Review Criteria
• Identification of "problem cases" for potential evaluation:– Represented by an attorney– Significant prior claim history– Inappropriate injury behavior/unsupported pain – Severe trauma/fracture– Noncompliance with treatment plan– Treatment duration - more than 4 Physicians Visits– Specialist involvement– Treatment “outside” of the established network– Not seen by physician for extended period of time– ER visit/personal choice of physician (bounce out)– Off work/lost time– Restrictions of 5 pounds or less weight limit– No verifiable diagnosis– Prolonged/delayed recovery
© 2008 Sandler Occupational Medicine Associates, Inc.
Occupational Medical Evaluation – Return to Work Review Criteria (Cont’d)
• Common "Problem" Diagnoses– Recurrent Low Back Condition(s)– Reflex Sympathetic Dystrophy– Myofascitis/Myofascial Syndrome– Spondylolisthesis/Spondylitis– Scoliosis– Carpal Tunnel Syndrome– Thoracic Outlet Syndrome– Degenerative Joint Disease/Other Arthritis– Post‑traumatic or Other Stress Syndrome– Heart, Respiratory or Other Organ Disease– Cumulative Trauma Disorders/Repetitive Motion– Chemical Sensitivities– Indoor Air Problems/Chemical Exposure– Occupational Respiratory Disorders/Asthma
© 2008 Sandler Occupational Medicine Associates, Inc.
Operational Hints: Comments are read from top to bottom.
DescriptionCancelled-Closes exam-used by both SOMA and the site user may originate from a cancelled exam or no activity for several weeks.
Cleared-Meets Medical Standards-closes and exam-used by SOMA, indicates that exam findings meet established requirements.
Cleared with Respirator-closes and exam, used by SOMA, indicates medical clearance and respirator clearance.
Cleared with Restrictions-closes an exam, used by SOMA, indicates clearance with restrictions.
© 2008 Sandler Occupational Medicine Associates, Inc.
Client Cleared-No SOMA QC-closes and exam, used by SOMA, indicates that an individual is working, but the exam may not have bee completed or conducted.
Clinic Delay-informational, does not close an exam-indicates that an exam has not been received by SOMA, or there may be missing information.
Clinic Fax Received-informational does not close and exam-indicates that the packet has been received by SOMA.
Communication-informational, does not close an exam, indicates information about the exam.
Deferred-informational, does not close an exam, indicates that further medical evaluation is required.
Escalated for review-informational, does not close an exam, indicates that physician review is required.