预防医学职业及环境疾病的救治方法

1、预防医学职业及环境疾病的救治方法Outline Occupational health Occupational injuryOccupational medicine as a specialtyOccupational health care and managementNotification or surveillance of occupational injury and diseases From ad hoc system to prevention, compensation, return to work (PCR) integration in Taiwan PCR mo

2、del and perspective HealthWHO charter: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity Occupational and environmental factors in the health circle NOTES: Adapted from Dahlgren and Whitehead, 1991. The dotted lines denote interac

3、tion effects between and among the various levels of health determinants (Worthman, 1999). Broad social, economic, cultural, health, and environmental conditions and policies at the global, national, state, and local levels Living and working conditions Social, family and community networks Individu

4、al behavior Innateindividual traits:age, sex, race, andbiologicalfactors-The biology of disease Over the life spanabLiving and working conditions may include: Psychosocial factors Employment status and occupational factors Socioeconomic status (income, education, occupation) The natural and builtc e

5、nvironments Public health services Health care servicesOccupational Health Statusrapid proliferation of new industrial materials, new production methods, and new commercial products little attention to the need and assessment of their impact for the human health and environment The newly used chemic

6、als developed by industries are even seldom tested for toxicity for animals or humans Occupational Health Statuspracticing physicians take the burden of diagnosing, treating and if possible preventing work-related illness or injury Even the medical and biological professionals are exposed to microbi

7、al agents, including bacteria, virus, fungi and parasites Occupational infection could occur after contact with infected persons, with infected animal or human tissue, secretions, or excretions Occupational Health Status“ergonomics” or human factor engineering has been introduced into the workplacew

8、orkers health problem arise from designs of workstations, tools, equipments or work proceduresphysical agents such as noise or vibration, heat or cold, and ionizing or non-ionizing radiation four steps of industrial hygiene - anticipation, recognition, evaluation, and control of health hazards to re

9、duce occupational hazard Occupational Health Statuswork stress - increasingly important health problem; the ability to predict a stress response or make diagnosis of work stress related psychological and physiological disability is poorthe number of compensation claim of work related circulatory dis

10、ease increasedworkplace wellness and occupational health education program evolvedquit smoking, healthy diet, exercise, stress management and cardiovascular disease preventionOccupational mortality - disease more than injury related to occupation30 LWC300 Recordable30,000 Near Misses300,000 At-Risk

11、BehaviorsFatality, Disabling Injury1ILO Taiwans occupational disease underestimated19901991199219931994199519961997Taiwan46262719143146142Singapore9401,07089790099913451,5211,054Korea1,3281,4139181,1201,5291,424Hong Kong24493248272369327Japan11,41511,95110,8429,6309,9159,230Thailand-6211612551Malays

12、ia775022,942South Australia2,9952,8412,8243,145Statistics of Asian occupational disease 1990-1997Occupational Health StatusIn Taiwan there is still a underreporting of occupational disease, according to Bureau of Labor Insurance (BLI) statistics, if pneumoconiosis is excluded, the number of occupati

13、onal disease is less than two hundred cases per year in recent two decades which is around one in ten or one in a hundred of expected number, after comparison with neighboring countries, such as Japan, Korea Singapore, or USAOccupational injuryTaiwanese workers suffered an estimated 36,000 fractures

14、, amputations, lacerations, and hundreds of eye injury and burns out of occupational causes. The most common occupational injuries involve musculoskeletal system or musculoskeletal diseases strain, sprain, tendonitis, bursitis, myositis, arthritis - usually produced by repeated movement and muscle s

15、train. NationalHealthInsuranceOccupational InjuryAccording to BLI, the percentage of occupational injury with temporary disability is about one fourth of ordinary injuries among workers trend of increased occupational injury and disease esp., after National Health Insurance System enacted in 1995 in

16、cur more than 6 billion NT$ in direct workers compensation costs indirect cost: production delays, damage to equipment, and recruiting and training replacement workersestimated to be five times, or about 30 billion NT$ Occupational InjuryWorkers compensation benefits - permanent total disability, te

17、mporary total disability, permanent partial disability, temporary partial disability, and survivors benefits. In Taiwan, only lump sum but no annuity paid to the insured worker. During rehabilitation period, only sick leave or designated auxiliary tools for handicapped are offeredno vocational or ps

18、ychological counseling or retraining or job placement assistance, compared to United States or most European countriesmedical expenses of five main occupational injury after NHIMeanwhile, Labor insurance compensation claim also increase dramatically !Occupational Medicine specialtyAD 1700, Bernardin

19、o Ramazzini, the father of occupational medicine and an Italian physician: De Morbis Artificum Diatriba to work without acquiring a wretched disease that would make ones work a curse rather than a lovediseases of metal digger, painters, midwives, glassmakers, potters, sewer workeraffliction by inhal

20、ing noxious gases and dusts, or from disorderly motions and improper postures of the bodyOccupational Medicine specialtythe primary care physician have taken the responsibility of health care for the industry workers compensation issues usually followed after treatmentoccupational compensation syste

21、m emerged from Germany since mid-19 centurystate (or government) run vs. private insurance carriersmost are compulsory, and even with penalties for not having insuranceOccupational Medicine specialtyThe employers responsibility which includes providing medical treatment and compensation benefits tra

22、nsferred to the insurance agencies preventing injury or disease shared by the employer and the insurers or related authoritiesreporting of occupational injury - employerreporting of occupational illness - physicians Occupational Medicine specialtyoccupational physician system accompanied the progres

23、s and change of industrynew legislation to protect the workers health and enhance their benefitshigh-tech ages - labor force subjected to conditions never before confronted in the small shop or craftsman era Production and profit are still the primary concern of company, not employee safety practice

24、 of occupational medicine cover even a broader scopeOccupational Medicine specialty- to meet the demand of societymodern society occupational hazard - stress and related disease, musculoskeletal disorderoccupational physicians have to realize the regulatory or compensation system, able to design sui

25、table occupational health program To integrate occupational medicine with environmental, occupational safety and healthto serve for both the employer and employeeto discover new techniques or strategiesOccupational health care & ManagementHealth care industry- cost containment, managed care system C

26、hange is a requirement of life and an integral part of all complex endeavors of society, including the financing, provision and organization of health care serviceTaiwan- National Health Insurance system, cover nearly all hospitals and clinics. Occupational health care & Managementclinical managed c

27、are - to change the number or mix of services provided and to reduce the price paid for servicecase management is a process, one component in the managed care strategythe inclusion of salary replacement is not inherent to the health insurance managed care market evaluation of quality of care, and ti

28、mely return to work by injured employees more important in occupational health care Definition of case management ”case management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individuals health needs,

29、 using communication and available resources to promote quality, cost-effective outcomes.” major areas of activity - medical, financial, behavioral/motivational, vocational the Commission for Case Manager Certification (CCMC) Occupational health care & ManagementIn workers compensation, managed care

30、 must address a different objective-restoring a worker to health and productivity at the lowest cost. New South Wales, Australia, the original Workers Compensation Act in1987 was later amended and renamed as “Workplace Injury Management and Workers Compensation Act” in 1998. Occupational health care

31、 & ManagementThe act begins with notification of an injury by the employer, physician or patient WorkCover New South Wales, make early contacts with all parties, assess the claim and performing medical examination at the request of employer or employee The goal of injury management is to achieve opt

32、imum results in terms of the timely, safe and durable return to work for workers following workplace injuryOccupational health care & ManagementAll parties- the insurer, employer, injured worker and treating doctors, are required to cooperate and participate in the injury management process to ensur

33、e that optimum return to work results are achieved This injury management code - the return to work program, the return to work coordinator, accredited rehabilitation provider, provision of suitable duties, keeping information confidential, and training and employment programsNotification or surveil

34、lance of occupational injury and diseases notification is a basic obligation in Australia as well as in Singapore and Germany, followed by the insurer or authorities to assist if the injured worker are eligible for compensation Most occupational compensation system have an effective reporting system

35、no mandatory notification program in occupational compensation system in Taiwan would greatly cause the injured worker to be neglected, poorly rehabilitated, and at risk of job lossNotification or surveillance of occupational injury and diseases Department of Health of Taiwan had launched a “work re

36、lated disease notification system” since 1996, which encourage physicians, either from clinic, hospital or factory to be reporting resources Until now, there are more than ten thousand cases reported. Most of them are injures, decompression sickness, hearing impairment and sharp injury However, foll

37、owing management process is not linked to compensation or jurisdiction system in Council of Labor Affairs Notification or surveillance of occupational injury and diseases In National Taiwan University Hospital, an in-hospital emergency room (ER) surveillance system was started since last Sep (2003)E

38、R : chemical injury, eye injury, occupational trauma, electrocutions and welders disease. Taipei county government independent law in 2002 to punish those employer or practicing physicians within geographical boundary not to report occupational diseaseIn summary, the reporting of occupational injury

39、 or disease is still not “Notifiable” From ad hoc system to prevention, compensation & RTW integrationWHO “ Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”occupational injuries and illness may cover social consequences includi

40、ng workers psychological and behavioral responses, vocational function and family and community relationship 5 Levels of public health principle : Health promotion - special protection - early diagnosis & treatment - restriction of disability rehabilitation and return to workFrom ad hoc system to pr

41、evention, compensation & RTW integrationmost injured workers report that the primary treating physician did not give them any advice about the prevention of further injurya large proportion (38%) of injured workers experience a reinjury after returning to workmany return to their jobs after a work i

42、njury continue to experience residual pain Satisfaction with medical care provided through workers compensation generally lower than for general health care provided for non-occupational conditions Dr. Pransky et al. AJIM, 2001PCR case management modelPCR- Prevention Compensation Rehabilitation (Ret

43、urn-to-work)Benefits as :reduction of injury with disabilityencouraging return to worksave medical and insurance costCenter for Management of Occupational Injury & DiseaseJoint collaboration among Council of Labor Affairs (Bureau of Labor Insurance) and the hospitalDevelop intra-and extra- mural sur

44、veillance systemSetup of standard diagnosis and case management modelWorkability evaluation technique and occupational rehabilitationSince Apr,26,2003Case Demand & ManagementOccupational disease diagnosisTreatment of injury and diseasePrevention of occupational injuryRTW demand Compensation demandPh

45、ysical examinationJob evaluationMedical consultation Special exam.Factory walkthroughDrugsP.TO.TotherHealth screenSafety advise & educationWork hardeningnegotiationCertificationFree charge of visitSupport resourcesSeven ways of reactive prevention of occupational injury/diseaseHealth screening Surve

46、illanceOccupational disease diagnosisDisability evaluationWorksite visitCase management and counseling Epidemiological studyPrevention by Health Screening Process to Factory workers walkthrough exposure and HE items questionnaire Qualified medical screening / assuranceComputerization of database scr

47、eening of possible exposure workers chronic illness factors evaluation data management (risk assessment） follow up and health promotionPersonal health evaluation Action：weight reduction、quit smoking、body fitness 疑似重金屬中毒、 鉛中毒 、砷中毒、 錳中毒、 黃磷中毒汞中毒、 鉻中毒、疑似氣體、蒸氣危害疑似異常氣壓疾病疑似農藥中毒疑似皮膚病疑似外傷疑似塵肺症疑似聽力損害疑似腕隧道症候群

48、疑似針扎事件疑似肌肉骨骼傷害疑似職災死亡其他與環境或職業相關疾病Electrical & Chemical burnsIntoxication/pesticideOccupational asthma, T.B., allergic pneumonitis, dermatitisHand injury (cut, tear, compression)Amputation/fractureMusculoskeletal disorderYoung stroke, CVDHIVD, Peripheral neuropathyOthersNTUH SurveillanceDOH, TaiwanCMO

49、ID OPD statistics Cases Management: registration, compiling, advise, communication & follow-up fascisticPEPneumoconiosisNeedle stickchemicalMental StressfracturenoisejurisdictionretinopathyCTSAmputationHIVDT.BdermatitisinsomniaSolvent expo.RSI481216Disability Evaluation & Return To Work flowchartW.E

50、 need verified by Physician or OT Refer for physical trainingJob Hx.content analysis、ADL、Pain、FCE & other tests (eg. interest、altitude、IQ、personality)Worksite Job evalu.Work hardeningExercise & trainingRTW From ad hoc system to prevention, compensation & RTW integrationquestionnaire and telephone in

51、terview to 390 patients occupational injury workers hospitalized followed 3 to 6 months - cause of their injury, medical treatment process, rehabilitation condition, return to work status, the compensation or subsidiary awarded34 % of the injured workers are not back to their former job, of them mor

52、e than one third were even with poor medical recoveryemployees already return to work - residual pain is usually a problem and demand for health and compensation informationThe Center for Management of Occupational Injury and Disease (CMOID), NTUHExtramural surveillance programFrom ad hoc system to

53、prevention, compensation & RTW integrationFactors affecting return to work for workers with occupational upper extremity fracture - 110 patients with telephone interviewCensored at six month - more than 20 % of workers unable to return to workthe most important factors are fracture site, without fix

54、ed employer, and poor self perceived workabilitytimely ambulance to the hospital, compensation assistance, functional capacity evaluation - influential though quality of life improved with time, not all the four domains, physiological, psychological, social, and environmental aspects presented a con

55、sistent progress (WHOQOL)The Center for Management of Occupational Injury and Disease (CMOID), NTUH Epidemiological studyFrom ad hoc system to prevention, compensation & RTW integrationan integrated health care model unification of prevention, compensation and return-to-work is expected to meet the

56、purpose of protecting occupational injured workers Generalizability to different health conditions, eg. lower extremity injury, occupational low back pain may be neededother key issues disability phases, settings, improving measurement instrumentscombining research methods- satisfaction, demand/supp

57、ly, cost/effectivenessSuccessful Return To Work John- Hopkins COEH study of before(1989-1992) and after RTW program(1993-1999):reduction of workday loss55 %injury workers proportion from 26.3% down to 12 %Partial workability recovery proportion from 0.63 % up to 13.4 %Case management cut down the co

58、st of compensation 23%Joint effort of occupational physician, nurse, case manager, safety specialist, insurance company, employee and injured workerPCR model and perspectiveGeneral health care to the workers has focused more on treatment; prevention is not part of many clinical health practicesPCR i

59、s a multi-disciplinary team work to meet the diversified needs of the working populationPCR is evidence-based and coincide with WHO, public health spirit efficiently incorporating worker-centered case management health care deliverytechnical development and in-depth research warranted PCR model and

60、perspectiveTo intervene and to reduce the economic and social impact would be the destiny of occupational & environmental medicineIt is expected through effective surveillance and PCR model, we would be able to improve the well-being of those workers who are unfortunately injured in the workplace Th