National accident statistics The HSE produces the Safety Statistics Bulletin which contains summary data on fatal injuries to workers, subdivided into employees and self- employed. N on-fatal injuries to workers are subdivided into: \200 Over 3-day injuries to workers \200 Injuries to the member of the public \200 Dangerous occurrences \200 Gas safety. Further information HSE (2011). Health and Safety Statistics . Available at: M http://www.h se.gov.uk/statistics/ 36_Smedley_Chap36.indd 736 1/2/2013 1:00:36 PM PERFORMANCE IN HEALTH AND SAFETY MANAGEMENT 737 Measuring performance in health and safety management Performance needs to be measured to a ssess how well risks are control- led. Monitoring also reinforces management commitment to health and safety. Two types of monitoring systems are used: \200 Active systems, which m onitor the design, development, implementation, and operation of management systems and compliance with standards, i.e. mon itoring achievement of speci \201 c plans and providing feedback on performance before acc idents or ill health occur Reactive systems involve monitoring incidents, accidents, cases of ill health, damage to property, and other evidence of de \201 cient health and safety performa nce, i.e. monitoring is triggered after an event. Active (proactive) monitoring data \200 Staff perception of management commitment to heal th and safety \200 Periodic review of documents, e.g. risk assessments, maintenance programs Exposure and health surveillance data to assess adequacy of controls \200 Extent of compl iance with standards \200 Observation of work and behavior \200 Training in health and safety: numbers trained and its effectiveness \200 Knowledge among staff of risks and con trols \200 Time taken to implement actions \200 Actual use of personal protective equip ment \200 Frequency of inspections, safety tours, audits \200 Competence of staff with responsibilities for health and safety \200 Number of staff suggestions for health and sa fety improvements \200 Staff attitudes to risk and use of controls. Reactive monitoring data \200 Regulatory agency enforcement action \200 Sickness absenc e data \200 Reported accidents and injuries (lost time, property damage) \200 Damage to property. Outcome of performance assessment For the risks that are identi \201 ed during active and reactive monitoring, actions should include the following: \200 Identify reasons for unde r-performance \200 Identify underlying failure in health and safety management systems \200 Prevent recurrence \200 Satisfy legal requirements, e.g. reporting under RIDDOR. Further information HSE website. Available at: M http://www.hse.gov.uk. Information about h ealth and safety manage- ment, including risk assessment tools for slips, trips, and falls, industry-speci \201 c advice on machine safety, and other aspects. 36_Smedley_Chap36.indd 737 1/2/2013 1:00:36 PM CHAPTER 36 Safety science 738 Fire safety \200 Fire is a constant threat to all premises. In the UK in 2008 there were 1800 \201 res in industrial premises For a \201 re to start there must be adequate fuel, a source of oxygen, and an ignition source Fires may start accidentally, but the threat of arson should also be considered and appropr iate measures taken to reduce this risk \200 Good housekeeping, effective maintenance (es pecially of electrical equipment), rigorous health and safety procedures, and effective \201 re detection, warni ng, and \201 re \201 ghting systems all reduce \201 re risks. Fire regulations \200 Current regulations governing \201 re prevention in England and W ales came into force from October 2006 \200\224the Regulatory Reform (Fire Safety) Order 20 05. Similar legislation applies in Scotland \200\224the Fire (Scotland) Act 2005 Fire authorities no longer issue \201 re certi \201 cates \200 The regulations cover n on-domestic premises: of \201 ces and shops \200 factories and warehouses \200 residential care \200 sleep ing accommodation \200 education \200 places of assembly \200 theaters/cinemas \200 outdoor events \200 health care \200 transportation facilities Enforcement of the Fire Safety Regulations is the responsibility of the local \201 re and rescue service, except for Crown property where HM Fire Safety inspectors take this role. Other relevant regulations Where a workplace contains dangerous substances which can create an explosive atmosphere, e.g. gasoline, gas, solvents, paints, \202 our or wood dusts th en DSEAR 2002 and the Equipment and Protective Systems intended for use in Potentially Expl osive Atmospheres Regulations 1996 will likely also apply. Main requirements The main requirement is to carry out a \201 re risk assessment. The Dep artment for Communities and Local Government guidance on \201 re safety identi \201 es \201 ve steps for \201 re risk assessment. Identify hazards \200 The person in control of premises must undertake a \201 re risk assessment This assessment should identify sources of: fuel \200 ignition \200 oxygen. 36_Smedley_Chap36.indd 738 1/2/2013 1:00:36 PM FIRE SAFETY 739 Identify people at risk \200 Employers need to consider all persons who may be affected i n the event of a \201 re on their premises, including staff, visitors, and the public Particular consideration needs to be given to making adequate provision for those at special risk: \200 disabled people \200 elderly people \200 ch ildren or parents with babies \200 lone workers. Evaluate, reduce, and remove risks The employer must provide adequate \201 re prevention measures and main- tain them. Record, plan, inform, instruct, and train \200 The main \201 ndings of the risk assessm ent, including those regarding people at special risk, must be recorded in writing Employers must prepare an emergency \201 re plan \200 Staff must be provided with suf \201 cient information, instruction, and training on \201 re prevention and the actions necessary in the event of a \201 re. Thi s may include measures such as training in the use of \201 re extinguishers, \201 re sa fety brie \201 ngs, and regular \201 re drills to rehearse \201 re evacuation procedur es. Review Any signi \201 cant changes, e.g. to premises or work practices, requires review of the \201 re plan. Legislation and guidance \200 National Archives. Available at: M http://webarchive.nation alarchives. gov.uk/+/http://www.communities.gov.uk/pub/394/Fireguidesseries_ id1500394.pdf Scottish Government. Available at: M http://www.infoscotland.com/ \201 relaw 36_Smedley_Chap36.indd 739 1/2/2013 1:00:36 PM CHAPTER 36 Safety science 740 Electrical safety Epidemiology According to HSE \201 gures approximately 25 people die fr om electric shock or electrical burns at work each year. General principles \200 Electrical equipment should be suitable for the environment in wh ich it is used In environments that are damp or wet, electrical equipment should be suitably insulated to prevent electrocution Where electrical equipment is to be used in areas where there is a potential for explosion, suitable equipment should be employed \200 Only competent persons should be allowed to w ork on electrical equipment or installations The normal policy should be that work is only undertaken on equipment or installations known to be dead and electrically isolated \200 Live system/eq uipment working should be the exception rather than the rule. It should only be carried out where it is unreasonable for work to be done on dead systems/equipment and where a suitabl e risk assessment has been carried out by a competent person Any equipment provided, e.g. voltage meters, should be suitable for use and adequately maintained Before commencing work on electrically isolated equipment it should be con \201 rmed, through the use of a suitable test procedure by a competent person, that the equipment is dead Wherever possible, equipment should be disconnected (and protected against accidental recon nection) from electrical power before any work is attempted Any equipment to be worked on should be isolated and secured by \200\230locking out \200\231 using an inter-lock. In addition, a notice should be posted a t the point of disconnection so that all personnel are aware that electrical work is being undertaken on the dead system As a \201 nal precaution, any high-voltage equipment should be earthed so that, in the ev ent of equipment failure, the operator will be protected Where work has to be carried on any high-voltage electrical equipment/installations a permit to work system will be required. Legislation and guidance HSE (2004). Electricity at work: safe working practices , HSG 85. HSE Books, Sudbury. Available at: M http://www.hse.gov.uk/electricity/precautions.htm 36_Smedley_Chap36.indd 740 1/2/2013 1:00:36 PM This page intentionally left blank CHAPTER 36 Safety science 742 Road safety Epidemiology The independent Work-Related Road Safety Task Group estimated that ; \200 One-third of all road accidents involve someone at work \200 1000 people die in work-related road crashes in the UK each year \200 250 people are seriously injured each week in work-related road crashes. General principles \200 All road users must comply with road traf \201 c legislation \200 The Health and Safety at Work, etc. Act 1974 places duties on employers to manage occupational risks to prevent harm to workers and the public and this i ncludes road safety. The organization \200\231s health and safety policy should address roa d safety \200\224a speci \201 c road safety policy may be required Commuting to and from a worker \200\231s home is not covered by the Health and Safety at Work, etc., Act 1974 Employers should undertake a risk assessment of their work-related road safety, consult wit h employees and their representatives and act on their \201 ndings Interventions should initially focus on high risk drivers based on: annual business mileage \200 accident records \200 young drivers Employers should consider induction training on road safety for new employees The need for road travel should be reviewed and either safer transportation methods such as rail be substituted or teleconferences be used instead. Vehicles \200 Vehicles should be \201 t for purpose \200 Well maintained \200 Safet y and ergonomic features should be considered when purchasing new vehicles Tachographs, where \201 tted, should be regularly inspected to con \201 rm drivers are complying with legislation, e.g. speed limits Privately owned vehicles must be insured for business use and if over 3yrs old, have a valid MOT. Drivers \200 Drivers should be competent \200 Medically \201 t to drive that category of vehicle \200 Licenses should be inspected at employment and regularly reviewed thereafter Drivers should be: trained in the safe operation of their vehicle, e.g. pre-journey checks of warning lights, tire pressures trained in adjusting seating and head restraints 36_Smedley_Chap36.indd 742 1/2/2013 1:00:37 PM ROAD SAFETY 743 trained in securing loads and ensuring their correct distribution in the vehicle aware of their vehicle height, width and weight (laden and unladen) \200 trained to respo nd to a vehicle breakdown safely. Journeys \200 The journey plan should take an appropriate route (e.g. large vehicles should avoid low bridges, narrow roads) Where possible avoid rush hours \200 Should take account of prevailing weather and road c onditions \200 Work patterns and delivery timetables should be realistic to avoid placing inappropriate demands on drivers, which might lead them to speed Driving rosters should take account of total hours worked and not just hours at the wheel to reduce driver fatigue Long journeys should be broken by an overnight stop. Legislation and guidance \200 HSE Driving at work: managing work-related road safety , HS E INDG 382. Available at: M http://www.hse.gov.uk/pubns/indg382.pdf HSE Report of the Work-related Road Safety Task Group. Available at: M http://www.hse.gov.uk/roadsafety/report.htm 36_Smedley_Chap36.indd 743 1/2/2013 1:00:37 PM This page intentionally left blank Section 11 Practical procedures 37 Clinical tasks and procedures 38 Non-clinical tasks and procedures 747 771 37_Smedley_Chap37.indd 745 1/2/2013 1:35:08 PM This page intentionally left blank 747 Chapter 37 Clinical tasks and procedures Recording an occupational health consultation 748 Assessing mental health: tools 750 Psycho logical therapies 752 Chronic pain management 754 Night worker health assessment 756 Method s for alcohol and drug screening 758 Lung function testing 760 Serial peak \202 ow testin g 762 Screening audiometry 764 Color vision testing 766 Clinical assessment of hand \200 \223arm vibration syndrome 768 37_Smedley_Chap37.indd 747 1/2/2013 1:35:08 PM CHAPTER 37 Clinical tasks and procedures 748 Recording an occupational health consultation Every new consultation should start with an e xplanation to the patient/ employee of the role of occupational health and the rules of com munica- tion (see b p. 360, Ethical principles in clinical occupational health prac- tice, b p. 362, Con \201 dentiality, consent, and communication, b p. 444, General principles of \201 tness for work assessments). Checklist for clinical consultations Handwritten notes \200 Notes should be written clear ly (preferably in black ink) or dictated and typed Every sheet should be labeled with the patient/client \200\231s name, and at least one other identi \201 er (e.g. DOB or address) or preferably a unique serial number Essential details of referral: by whom? (self, manager, other) \200 reason (short-term absence, long-term absence, perfo rmance issues, other) job title, employer, duration of employment \200 membership of pension scheme if applicab le Clinical history with a focus on current symptoms and function: ask about day-to-day activi ties in suf \201 cient detail to judge whether the Equality Act applies. 1 Ask routinely a bout alcohol and recreational drug intake. Alcohol is often used as a maladaptive coping st rategy by those with anxiety or depression. \200 Previous medical history and sickness ab sence history \200 Details of the current job including information about tasks, or preferably a job description: r emember to consider psychosocial (demand, control, support, job satisfaction) as well as physical aspects of the job Occupational history including duration of previous similar jobs or exposures: episodes of job change or loss because of health problems; any applications for compensation or Industrial Injuries Bene \201 t. Be alert for relevant co-exposures Clinical examination: relevant physical examination, and mental state examination where appropriate Summary and conclusions: it is useful to include a brief formulation or justi \201 cation of conclusions, especially where there is likely to be dispute \200 Output: list in hand written record all outputs from the consultation including telephone calls, other conversations, written reports, or letters 37_Smedley_Chap37.indd 748 1/2/2013 1:35:08 PM RECORDING AN OCCUPATIONAL HEALTH CONSULTATION 749 always record a brief summary of the content of verbal outputs \200 See b p. 406, Long-te rm sickness absence, b p. 444, General principles of \201 tness for work assessments, for the content of outputs to the referring manager Print your name and job title \200 Sign and date every record \200 Record that the empl oyee has been informed about their rights of access to the report from the consultation, whether they wish to have a copy of the report, and (if so) if they wish to see the report before it is released. File copies of the following documents \200 Informed consent for referral: this is someti mes included on a referral pro forma . Where consent has not been gained prior to referral, it is good practice to obtain it at the beginning of the consultation. This is particularl y important if the OH physician is concerned that the employee is unhappy or poorly informe d about the referral. An example of an information sheet for referred clients is given in b p. 839, Appendix 2: Consent for an occupational health assessment Written referral from employer \200 Supporting material where appropriate: e.g. job descr iption, musculoskeletal or mental health symptoms questionnaires if used in the clinical assessment , relevant test results (e.g. lung function) Reply to manager \200 Letters to GP or specialist consultant where applicable \200 Writ ten consent for reports (see b p. 580, Access to Medical Reports Act 1988). Workplace visits \200 Workplace visits should be carried out where indicated by the initi al clinical assessment. Functional assessment in the workplace can be very useful in offeri ng practical advice about adjustments to work File handwritten notes of the visit (including interview with manager or co-workers) and typed report File any supporting material, e.g. COSHH or other risk assessments, occupational hygiene data. 37_Smedley_Chap37.indd 749 1/2/2013 1:35:08 PM CHAPTER 37 Clinical tasks and procedures 750 Assessing mental health: tools Things to ask yourself before using assessment tools \200 Why am I using a tool? \200 Am I clear about the distinction between a screening tool and a diagnostic tool? Do I refer a patient just because of their score? \200 What will I do if my clinical impr ession differs from the score on the tool? Advantages of using assessment tools \200 As an aide memoire: ensure all important questi ons asked \200 To provide an \200\230objective \200\231 measure of severity \200 To ge nerate a score to assist communication with other health professionals To measure response over time, e.g. following treatment \200 Can be completed by the pati ent at home or in waiting room Disadvantages of using assessment tools \200 Crude measures: patients can score highly wi thout being especially \200\230ill \200\230 \200 Falsely reassuring: distinction between screening and diagnosis \200 Don \200\231t take into account your own clinical impressio n of the patient \200 Have the potential to lead to unnecessary referrals \200 Only exa mine symptoms in one (occasionally two) domains, e.g. most depression tools ignore anxiety and vise versa Tools assess symptoms rather than function \200 Many tools are under copyright Checks and calibration Depression and anxiety assessment tools have not been validated in t he occupational health setting. Ad hoc use is to be discouraged. Many psychia- trists do no t use rating scales at all. There is a recognition, for example in medico-legal circles, th at a number of factors, including occasionally frank exaggeration, can contribute to the sc ore on a questionnaire. The choice of rating scale needs consideration; the choice will vary depending on why a sca le is thought necessary. The use of assessment tools may be best considered as part of a wi der strategy for identifying and managing depression in the workplace. Training might be ne eded. Policies for how to respond to high scores or unexpected scores should be estab- lish ed before they occur. 37_Smedley_Chap37.indd 750 1/2/2013 1:35:09 PM ASSESSING MENTAL HEALTH: TOOLS 751 Examples of assessment questionnaires \200 Patient Health Questionnaire (PHQ9): commonly used in 1 care in the UK so may assist communication with GP. Is free and accessible online. Limited range of questions and possibility of over-scoring \200\224 false positive. No anxiety questions Beck Depression Inventory (BDI-II): lengthier more detailed questionnaire, but takes longer to complete. Includes questions about somatic symptoms. No anxiety questions. Copyright Hospital Anxiety and Depression Scale (HADS): speci \201 cally designed for use in hospita l settings where patients have several possible causes for somatic symptoms such as fatigue \200\224 is this your patient population ? Includes anxiety symptoms which can be scored s eparately. Utility of cut-offs (8 and 10) not clear. Copyright. Further information Mitchell AJ, Coyne JC (eds) (2010). Screening for depression in clinica l practice: an evidence-based guide . Oxford University Press, New York. 37_Smedley_Chap37.indd 751 1/2/2013 1:35:09 PM CHAPTER 37 Clinical tasks and procedures 752 Psychological therapies Overview Psychological interventions are best viewed in the same wa y as pharmaco- logical or physical interventions. There are many to choose from: \200 An evidence-based approach, where available, is recommended \200 Bene \201 ts and adverse e ffects need to be carefully weighed \200 Speci \201 c interventions are effective for sp eci \201 c disorders \200 Cost is likely to be part of any treatment decision. 2 One dif ference to consider is that the effectiveness of many psychologi- cal therapies depends in part on the relationship between the patient and the therapist. Counseling Pros \200 Readily available \200 Can be relatively inexpensive \200 High r eported levels of patient satisfaction Cons Little good evidence to suggest effective in tr eatment of psychiatric disor- der (compared to lower levels of distress or upset). Further information BACP. Available at: M www.bacp.co.uk Henderson M, Hotopf M, Wessely S ( 2003). Workplace counseling Occup Environment Med , 60 , 899 \200\22390. McLeod J (2010). The effectiveness of workplace counseling: a systematic review. Counsel Psychother Res , 10 , 238 \200\22348. Cognitive behavioral therapy Pros \200 Excellent evidence base \200 Effective for a wid e range of common mental disorders including depression, phobias, post-traumatic stress disorder Also effective for chronic fatigue syndrome and irritable bowel syndrome Provides patients with \200\230tools \200\231 they can use should dif \201 culties recur \200 Can be delivered effectively online (e.g. beating the blues). Cons \200 Is hard wo rk! Patients need to do homework and keep detailed diaries \200 Trained therapists in sho rt supply \200 Can be expensive \200 Patients require a minimum of 6 \200\2238 sessions ; some need many more. Further information Royal College of Physicians (2012). Cognitive behavioral therapy. Avail able at: M http://www. rcpsych.ac.uk/mentalhealthinfoforall/treatments/cbt.aspx Beating the Blues (2006 \200\2232012). Beat depression and anxiety . Available at: M http:/ /www.beatingth- eblues.co.uk 37_Smedley_Chap37.indd 752 1/2/2013 1:35:09 PM PSYCHOLOGICAL THERAPIES 753 Gilbert P (2009). Overcoming depression: a guide to recovery with a complete self-help prog ram . Constable & Robinson, London. LTTFF. Living life to the full . Available at: M http://www.llttf.com Psychodynamic psychotherapy Pros \200 Can help with complex and longstanding dif \201 cu lties \200 Allows patients time to think why things might have happened as well as how they might make changes. Cons \200 Is a major commitment: sessions are at least weekly and continue for many months or longer Model not necessarily easily understood \200 Many different forms (e.g. Freudian, Jungian , Lacanian, etc.) and not always clear which is indicated Can be expensive \200 Relatively little evidence of bene \201 t for diagnosable psychiat ric disorders. Further information Royal College of Physicians. Psychotherapies. Available at: M http://ww w.rcpsych.ac.uk/mental- healthinfo/treatments/psychotherapies.aspx Tavistock and Portman. Available at: M www.tavistockandportman.nhs.uk Improving access to psychological therapies \200 NHS program to improve the delivery of t reatment for common mental disorders according to NICE guidelines Since 2011 its remit has broadened to include support to patients of all ages, and patients with long-term physical conditions \200 Widely though not yet universa lly available in England \200 CBT and other talking therapies available in a range of dif ferent intensities Keeping patients in, or returning patients to, work is a priority and trial of employment a dvisors working alongside Improving access to psychological therapies (IAPT) therapists und erway. Further information Improving access to Psychological Therapies (2012). Relieving distress, transforming lives . Available at: M www.iapt.nhs.uk 37_Smedley_Chap37.indd 753 1/2/2013 1:35:09 PM CHAPTER 37 Clinical tasks and procedures 754 Chronic pain Persistent pain in the absence of signs of tissue injury is now recognized as re \202 ecting a dysfunctional sensory system. Changes occur at receptor level in both the peripheral and central nervous system. Although there is no speci \201 c predisposing per sonality type, pain is associated with catastrophiz- ing (excess worry about a situation). Classi \201 cation of pain \200 Somatic \200 Visceral \200 Neuropathic (nerve injury ) \200 Idiopathic. Epidemiology of chronic pain \200 In the UK, 7.8 million people have chronic pain; 50% ha ve depression \200 50% of loss of quality of life is attributable to pain \200 Low back pain is the commonest pain-related cause of work loss \200 Of the top ten health problem s impacting productivity, three speci \201 cally relate to pain (back/neck pain, other chronic pain, and arthritic pain). Risk factors for disability and sickness absence \200 High pain intensity \200 High per ceived disability \200 Beliefs and fears about the harmful effect of work \200 High phy sical job demands \200 Inability to modify work \200 High job stress \200 Poor workpl ace social support or dysfunction \200 Poor job satisfaction. New Zealand Yellow Flags system Predicts absence risk: \200 Have you had time off work in the past with pain? \200 What do you understand is the cause of your pain? \200 What a re you expecting will help you? \200 How is your employer responding to your pain? Your c o-workers? Your family? What are you doing to cope? \200 Do you think that you will return to work? When? 1 If th e worker expects the pain to be a sign of harm or they are reliant on passive behaviors to manage pain, then they are at risk of long term absence from work. The Keele STarT Back Tool identi \201 es those at risk of chronic disability. Pain management Based on three key principles \200\224reassurance it is safe to move, rehab ilita- tion to support movement and relief of pain. General approach includes: 37_Smedley_Chap37.indd 754 1/2/2013 1:35:09 PM CHRONIC PAIN 755 Referral to local exercise initiatives and simple analgesia \200 Paracetamol for mild to moderate pain \200 Anti-in \202 ammatories for in \202 ammatory pain ( 1 but side effec ts) \200 Amitriptyline, and other tricyclics or anticonvulsants (gabapentin or pregabalin) as \201 rst line medication for neuropathic pain Referral to specialist pathways and services for those who fail to improve or have complex pain issues CBT approach if signi \201 cant psychosocial factors are present \200 Unless speci \201 c serious medical pathology is suspected (red \202 ags), diagnostic tests such as x-ray or MRI scans are not appropriate \200 Facilitate modi \201 cations to work, including li mits to the duration of concentrating on a task or a reduction in physical demands The Pain Toolkit describes 12 steps to managing pain. 2 The prognosis for return to work fa lls dramatically after 12 weeks, so the focus should be on early, rapidly phased, goal-base d, rehabilitation. The pain toolkit \200 0 \200\2232 weeks: provide support and reassurance to stay active \200 2 \200\2236 weeks: develop a speci \201 c plan which identi \201 es obstacles and p rovides a structure to return to work, including modi \201 cations \200 6 \200\22312 wee ks shift up a gear: provide vocational rehabilitation and cease ineffective healthcare interventions 12+ weeks: establish communication between all players, avoid unnecessary medical intervent ions and ensure social solutions in place. Dif \201 cult cases These should be managed by a multidisciplinary pain service. \200 Pa in medications: Opioids (cid:2) There is little evidence for the ef \201 cacy of strong opioids in many pa in conditions. Long acting preparations are recommended and avoidance of variable effect me dications, such as pethidine Radiofrequency denervation can be cost effective in highly selected cases Management of depression including CBT and other cognitive approaches, including meditation techniques If struggling at work, explore reduction in hours, retraining/ redeployment or (as a last r esort) ill health retirement. Further guidance NICE. Management of long-term sickness and incapacity for work , PH19. Ava ilable at: M http://www. nice.org.uk/PH19 NICE. Low back pain: early management of persistent non-speci \201 c low back pain , CG88. Available at: M http://publications.nice.org.uk/low-back-pain-cg88 Keele University. Keele STarT Back Tool . Available at: M http://www.keele.ac.uk/sbst/ 37_Smedley_Chap37.indd 755 1/2/2013 1:35:09 PM CHAPTER 37 Clinical tasks and procedures 756 Night worker health assessment Under the European Working Time Directive employers must off er a health assessment to night workers ( b p. 574, Working Time Regulations 1998). Process A night worker \200\231s assessment is a two-stage process, consisting of: \200 A screening questionnaire (see Fig. 37.1) \200 A medical examination for those in whom the screening questionnaire identi \201 es a medical problem that might be caused or made wor se by night work, and which needs further detailed assessment. Role of occupational health This will depend upon the arrangements for access to OH service s: \200 Where there is an in-house OH department, both screening questionnaires and subsequent examinations will usually be carried out by the OH team However, in organizations which have contracted or ad hoc access to OH advice, the screenin g questionnaire is often administered by the HR department or a manager. This is permissibl e under the Working Time Regulations, provided that the advice of an appropriate health pro fessional is sought when designing the questionnaire Medical examinations (where appropriate) must be carried out by a suitably medically quali \201 ed person. Communication of results \200 The rules that apply to all OH reports are relevant for com municating the outcome of night worker health assessments. Medical or con \201 dential information sh ould not normally be disclosed (and if so, only with the individual \200\231s consent). Con clusions should be con \201 ned to practical advice about \201 tness for night work and any adjustments required, including transfer to day work Where there is no OH department (and the screening questionnaires are handled by HR of \201 cers or others), the screening questionnaire should be designed to protect con \201 d entiality. One method is to ask workers to tick a single box (following a checklist of heal th problems that are relevant for night work) to declare the existence of a health problem, but not to disclose its nature . This approach is supported by the Department of Trade and Industry. 37_Smedley_Chap37.indd 756 1/2/2013 1:35:09 PM NIGHT WORKER HEALTH ASSESSMENT 757 PERSONAL DETAILS Last Name: Forename(s): Date of birth: Gender: Job title: delete: M/F Manager: Contact address (internal or home address): HEALTH DECLARATION Please tick this box if you have any of the following health disorders: Diabetes \200 Heart or circulatory disorders \200 Depression/anxiety \200 Stomach or intestinal disorders \200 Chronic chest conditions \200 Any condition that causes diffi culty with sleeping \200 Any medical condition for which you are taking medicines accordi ng to a strict timetable NEXT STEPS If you have declared a health problem, you may be referred to a doctor or nurse for further assessment. This will be done in confidence, and no medical details will be pas sed to your employer without your consent. The medical adviser will make a simple declarati on of your fitness for night work, and the need for any adjustment to working hours on heal th grounds. SIGNATURE : DATE : Fig 37.1 Example of night worker health assessment questionnaire. 37_Smedley_Chap37.indd 757 1/2/2013 1:35:09 PM CHAPTER 37 Clinical tasks and procedures 758 Methods for alcohol and drug screening Managers are responsible for the health, safety, and welfare of those work- ing under their supervision. This responsibility includes ensuring employee \201 tness for work. Managers must be alert to intoxication from alcohol or drug misuse. This can be established by simple observations and assessment of cog- nition, speech, posture, and movements witho ut recourse to screening tests. Screening tests (cid:8)(cid:8)2 Testing for drugs and alcohol should not be undertaken ligh tly, and must be part of a substance abuse policy (see b p. 378, Substance abuse policies). \200 There are many different forms of screening tests for alcohol and drugs of misuse that may be conducted (see Table 37.1); \200 directly at the \200\230poi nt of contact \200\231 \200 indirectly using specialist laboratory services Alcohol may be measured by breath, saliva or urine testing \200 Drug testing may use bloo d, saliva, hair or urine with differing considerations as shown in Table 37.1. 1 All test subjects must be invited to pre-declare any prescribed or over- the-counter medi cines and any special foods or supplements that they have taken, to enable accurate test in terpretation. Table 37.1 Summary of screening methods Breath Saliva Urine Blood Hair Advantages Easy to collect + + + + Observable test + + + + Minimal training + + + Equipment readily available + + + + + Low cost + + + Long-term detection + Disadvantages Dif \201 cult to collect + Potential for deliberate interference by subject + Limited application (substances that can be tested) + + + 37_Smedley_Chap37.indd 758 1/2/2013 1:35:10 PM METHODS FOR ALCOHOL AND DRUG SCREENING 759 For-Cause Random Pre-employment Urine Sample Chain of Custody ensures integrity of sample Sample A Sample B Near Person Testing Appeal Process Independent Lab Test Lab Test Review Medical Officer RMO interprets test result Result communicated as \200\230+ or \200\223 \200\231 to manag er Employee opportunity to question Manager Occupational Health provide case management support Employee Fig. 37.2 Alcohol and drug screening process. Chain of custody \200 This is the process for managing the collection, handling, storage, and testing of biological samples to prevent any possible contamination or interference (s ee Fig. 37.2) Normally, the sample is divided at collection into samples A and B and sealed, with a tampe r evident seal, in the presence of the test subject. In the event of a positive sample A te st result, the test subject has the opportunity to arrange an independent test of sample B. Who should be tested? \200 The selection of test subjects must be clearly de \201 ned in the policy and selection procedures should avoid any possible discrimination Possible options may include: announced or unannounced testing of all employees \200 only those in de \201 ned safety critical roles \200 those involved in accidents ( \200\230for cause \200\231). Positive test results \200 Alcohol testing often uses the Road Traf \201 c Act standards to de \201 ne \201 tness for work Drug testing reports only the presence of an illicit drug as a marker for drug-taking behavior The Review Medical Of \201 cer (RMO) will interpret and report test results, but managers are responsible for deciding possible employment implications. Further information Faculty of Occupational Medicine (2006). Guidance on Alcohol and Drug M isuse in the Workplace . FOM, London. 37_Smedley_Chap37.indd 759 1/2/2013 1:35:10 PM CHAPTER 37 Clinical tasks and procedures 760 Lung function testing In occupational medicine lung function is most commonly measured: \200 During the assessment of \201 tness for work in individuals with respiratory disorders As part of respiratory health surveillance and subsequent investigation ( b p. 428, Respiratory health surveillance). Common measurements and de \201 nitions \200 FVC is the maximum volume of gas that can b e expired from the lungs during a forced expiration from a position of full inspiration Forced expiratory volume in 1s (FEV 1 ) is the maximum volume of gas that can be expired from the lungs in the \201 rst second of a forced expiration from a position of full inspiration FEV 1 /FVC gives an indication of airways obstruction. A ratio below 70 \200\22375% indicates signi \201 cant obstruction PEF is the maximum \202 ow achievable from a forced expiration starting at full inspirati on with an open glottis. It occurs early in the expiratory maneuver when the lungs are expa nded and the airway diameter is large Simple self-paced tests of walking distance (e.g. the 6-min walk test) can be used in the o bjective assessment of functional disability. However, such tests depend on motivation. In the shuttle walk test the subject increases his/her walking speed each minute. This test is more reproducible than simple paced walk tests. The gold standard test uses a bicycle ergo meter to measure VO 2 max and other physiological parameters. However, this requires standa rdized testing in a laboratory and is not usually practicable for routine clinical OH work. Nomograms FEV 1 , FVC, and PEF vary with height, age, and sex, and with ambient tem- peratu re and pressure. Conversely, FEV 1 /FVC is useful because it is self- normalizing (unaffect ed by height, age, and sex). Individual recordings of lung volumes should be compared with nomograms (reference graphs of the normal readings in healthy adults for a given age, heigh t, and sex). This can be done manually using standard graphs (given in Appendix 6: Lung vol - umes). However, most modern automated spirometers provide a print-out that includes a com parison with normal \200\230expected \200\231 values. Quality control in lung function testing It is important that measurements are reproducible . This is particularly important for health surveillance, where serial measurements are use d to identify temporal changes in function. Therefore, lung function testing should be gove rned by a written protocol. The British Thoracic Society recommends the following. \200 S tandard training and procedures for staff who carry out testing: record patient \200\231s height, weight, age \200 record medication including timing of l atest dose of bronchodilators 37_Smedley_Chap37.indd 760 1/2/2013 1:35:10 PM LUNG FUNCTION TESTING 761 record temperature and barometric pressure for BTPS standard 1 corrections patient should be seated for 5 \200\22310min prior to testing, and sit