Interstitial pulmonary disease and aluminum trihydrate exposure: A single case report and detailed workplace analysis.

Exposure to aluminum compounds is clearly associated with pulmonary function decrements, and several animal models document possible mechanisms of aluminum- compound-induced pulmonary toxicity. Nevertheless, disagreements remain about the precise mechanism by which exposures lead to damage. We present a strong case for attributing a case of interstitial pulmonary disease to occupational exposure to aluminum trihydrate. This report follows a 2014 publication of another case of interstitial pulmonary disease following a similar exposure. Our patient eventually underwent double lung transplantation nearly 5 years postexposure. Detailed pulmonary particulate elemental analysis suggested that aluminum metal, including aluminum trihydrate, was the most likely cause. A detailed assessment of the worker's relevant occupational exposures accompanies this case report.

OSHA Workplace Violence Enforcement.

OBJECTIVE: To examine violence inspections at the Occupational Safety and Health Administration (OSHA). METHODS: The authors examined all inspections that involved violence against workers begun by January 1, 2019. They conducted semi-structured interviews with compliance officers who had conducted inspections on a sample of facilities that received General Duty Clause (GDC) citations (n = 22) or Hazard Alert Letters (HALs) (n = 22). RESULTS: By January 1, 2019, OSHA initiated 726 "violence" inspections, with 502 (69.1%) in healthcare. In healthcare, 45 (11.1%) resulted in GDC citations and 241 (67.7%) in HALs. GDC facilities received statistically significantly lower scores in 5 of 6 domains examined through semi-structured interviews than HAL facilities. Both groups of facilities had poorly designed recordkeeping systems. CONCLUSIONS: Health care facilities continue to generate worker complaints with poorly designed violence prevention programs.

Hospitalised heat-related acute kidney injury in indoor and outdoor workers in the USA.

OBJECTIVES: To characterise heat-related acute kidney injury (HR-AKI) among US workers in a range of industries. METHODS: Two data sources were analysed: archived case files of the Occupational Safety and Health Administration's (OSHA) Office of Occupational Medicine and Nursing from 2010 through 2020; and a Severe Injury Reports (SIR) database of work-related hospitalisations that employers reported to federal OSHA from 2015 to 2020. Confirmed, probable and possible cases of HR-AKI were ascertained by serum creatinine measurements and narrative incident descriptions. Industry-specific incidence rates of HR-AKI were computed. A capture-recapture analysis assessed under-reporting in SIR. RESULTS: There were 608 HR-AKI cases, including 22 confirmed cases and 586 probable or possible cases. HR-AKI occurred in indoor and outdoor industries including manufacturing, construction, mail and package delivery, and solid waste collection. Among confirmed cases, 95.2% were male, 50.0% had hypertension and 40.9% were newly hired workers. Incidence rates of AKI hospitalisations from 1.0 to 2.5 hours per 100 000 workers per year were observed in high-risk industries. Analysis of overlap between the data sources found that employers reported only 70.6% of eligible HR-AKI hospitalisations to OSHA, and only 41.2% of reports contained a consistent diagnosis. CONCLUSIONS: Workers were hospitalised with HR-AKI in diverse industries, including indoor facilities. Because of under-reporting and underascertainment, national surveillance databases underestimate the true burden of occupational HR-AKI. Clinicians should consider kidney risk from recurrent heat stress. Employers should provide interventions, such as comprehensive heat stress prevention programmes, that include acclimatisation protocols for new workers, to prevent HR-AKI.

A cluster of hypersensitivity pneumonitis associated with exposure to metalworking fluids.

BACKGROUND: Workers exposed to metalworking fluids (MWF) can develop respiratory illnesses including hypersensitivity pneumonitis (HP). These respiratory manifestations are likely due to microbial contamination of aerosolized MWF. This paper reports a cluster of HP and respiratory symptoms at a manufacturing plant where MWF and workplace air were contaminated with bacterial endotoxin despite frequent negative bacterial cultures of MWF. METHODS: A pulmonologist assessed and treated three workers with respiratory symptoms. The Occupational Safety and Health Administration (OSHA) inspected the plant. OSHA's investigation included bacterial culture of MWF, measurement of endotoxin concentrations in MWF and workplace air, review of the employer's fluid management program, and distribution of a cross-sectional symptom questionnaire. RESULTS: Three workers had biopsy-confirmed HP. In addition, 30.8% of questionnaire respondents reported work-related respiratory symptoms. OSHA detected endotoxin levels as high as 92,000 endotoxin units (EU)/ml in MWF and 3200 EU/m3 in air. Endotoxin concentrations and risk of MWF inhalation were highest near an unenclosed multistation computer numerical control machine. A contractor had tested this machine's MWF for bacterial growth weekly during the preceding three years, and most (96.0%) of those tests were negative. CONCLUSIONS: Contaminated MWF can cause severe occupational lung disease even if microorganisms do not grow in fluid cultures. Endotoxin testing can increase the sensitivity of detection of microbial contamination. However, employers should not rely solely upon MWF testing data to protect workers. Medical surveillance and meticulous source control, such as engineering controls to suppress MWF mist and prevent its inhalation, can reduce the likelihood of respiratory disease.

Actual and simulated weather data to evaluate wet bulb globe temperature and heat index as alerts for occupational heat-related illness.

Heat stress occupational exposure limits (OELs) were developed in the 1970s to prevent heat-related illnesses (HRIs). The OELs define the maximum safe wet bulb globe temperature (WBGT) for a given physical activity level. This study's objectives were to compute the sensitivity of heat stress OELs and determine if Heat Index could be a surrogate for WBGT. We performed a retrospective analysis of 234 outdoor work-related HRIs reported to the Occupational Safety and Health Administration in 2016. Archived NOAA weather data were used to compute each day's maximum WBGT and Heat Index. We defined the OELs' sensitivity as the percentage of incidents with WBGT > OEL. Sensitivity of the OELs was between 88% and 97%, depending upon our assumption about acclimatization status. In fatal cases, the OELs' sensitivity was somewhat higher (92-100%). We also computed the sensitivity of each possible Heat Index discrimination threshold. A Heat Index threshold of 80 °F (26.7 °C) was exceeded in 100% of fatalities and 99% of non-fatal HRIs. In a separate analysis, we created simulated weather data to assess associations of WBGT with Heat Index over a range of realistic outdoor heat conditions. These simulations demonstrated that for a given Heat Index, when radiant heat was included, WBGT was often higher than previously reported. The imperfect correlation between WBGT and Heat Index precluded a direct translation of OELs from WBGT into Heat Index. We conclude that WBGT-based heat stress exposure limits are highly sensitive and should be used for workplace heat hazard assessment. When WBGT is unavailable, a Heat Index alert threshold of approximately 80 °F (26.7 °C) could identify potentially hazardous workplace environmental heat.

Evaluation of Occupational Exposure Limits for Heat Stress in Outdoor Workers - United States, 2011-2016.

Heat stress, an environmental and occupational hazard, is associated with a spectrum of heat-related illnesses, including heat stroke, which can lead to death. CDC's National Institute for Occupational Safety and Health (NIOSH) publishes recommended occupational exposure limits for heat stress (1). These limits, which are consistent with those of the American Conference of Governmental Industrial Hygienists (ACGIH) (2), specify the maximum combination of environmental heat (measured as wet bulb globe temperature [WBGT]) and metabolic heat (i.e., workload) to which workers should be exposed. Exposure limits are lower for workers who are unacclimatized to heat, who wear work clothing that inhibits heat dissipation, and who have predisposing personal risk factors (1,2). These limits have been validated in experimental settings but not at outdoor worksites. To determine whether the NIOSH and ACGIH exposure limits are protective of workers, CDC retrospectively reviewed 25 outdoor occupational heat-related illnesses (14 fatal and 11 nonfatal) investigated by the Occupational Safety and Health Administration (OSHA) from 2011 to 2016. For each incident, OSHA assessed personal risk factors and estimated WBGT, workload, and acclimatization status. Heat stress exceeded exposure limits in all 14 fatalities and in eight of 11 nonfatal illnesses. An analysis of Heat Index data for the same 25 cases suggests that when WBGT is unavailable, a Heat Index screening threshold of 85°F (29.4°C) could identify potentially hazardous levels of workplace environmental heat. Protective measures should be implemented whenever the exposure limits are exceeded. The comprehensive heat-related illness prevention program should include an acclimatization schedule for newly hired workers and unacclimatized long-term workers (e.g., during early-season heat waves), training for workers and supervisors about symptom recognition and first aid (e.g., aggressive cooling of presumed heat stroke victims before medical professionals arrive), engineering and administrative controls to reduce heat stress, medical surveillance, and provision of fluids and shady areas for rest breaks.

Risk Factors for Heat-Related Illness in U.S. Workers: An OSHA Case Series.

OBJECTIVE: The aim of this study was to describe risk factors for heat-related illness (HRI) in U.S. workers. METHODS: We reviewed a subset of HRI enforcement investigations conducted by the Occupational Safety and Health Administration (OSHA) from 2011 through 2016. We assessed characteristics of the workers, employers, and events. We stratified cases by severity to assess whether risk factors were more prevalent in fatal HRIs. RESULTS: We analyzed 38 investigations involving 66 HRIs. Many workers had predisposing medical conditions or used predisposing medications. Comorbidities were more prevalent in workers who died. Most (73%) fatal HRIs occurred during the first week on the job. Common clinical findings in heat stroke cases included multiorgan failure, muscle breakdown, and systemic inflammation. CONCLUSION: Severe HRI is more likely when personal susceptibilities coexist with work-related and environmental risk factors. Almost all HRIs occur when employers do not adhere to preventive guidelines.

Development and Validation of the Work-Related Well-Being Index: Analysis of the Federal Employee Viewpoint Survey.

OBJECTIVE: To describe development and validation of the work-related well-being (WRWB) index. METHODS: Principal components analysis was performed using Federal Employee Viewpoint Survey (FEVS) data (N = 392,752) to extract variables representing worker well-being constructs. Confirmatory factor analysis was performed to verify factor structure. To validate the WRWB index, we used multiple regression analysis to examine relationships with burnout associated outcomes. RESULTS: Principal Components Analysis identified three positive psychology constructs: "Work Positivity", "Co-worker Relationships", and "Work Mastery". An 11 item index explaining 63.5% of variance was achieved. The structural equation model provided a very good fit to the data. Higher WRWB scores were positively associated with all three employee experience measures examined in regression models. CONCLUSIONS: The new WRWB index shows promise as a valid and widely accessible instrument to assess worker well-being.

Does Employee Safety Matter for Patients Too? Employee Safety Climate and Patient Safety Culture in Health Care.

OBJECTIVE: We examined relationships between employee safety climate and patient safety culture. Because employee safety may be a precondition for the development of patient safety, we hypothesized that employee safety culture would be strongly and positively related to patient safety culture. METHODS: An employee safety climate survey was administered in 2010 and assessed employees' views and experiences of safety for employees. The patient safety survey administered in 2011 assessed the safety culture for patients. We performed Pearson correlations and multiple regression analysis to examine the relationships between a composite measure of employee safety with subdimensions of patient safety culture. The regression models controlled for size, geographic characteristics, and teaching affiliation. Analyses were conducted at the group level using data from 132 medical centers. RESULTS: Higher employee safety climate composite scores were positively associated with all 9 patient safety culture measures examined. Standardized multivariate regression coefficients ranged from 0.44 to 0.64. CONCLUSIONS: Medical facilities where staff have more positive perceptions of health care workplace safety climate tended to have more positive assessments of patient safety culture. This suggests that patient safety culture and employee safety climate could be mutually reinforcing, such that investments and improvements in one domain positively impacts the other. Further research is needed to better understand the nexus between health care employee and patient safety to generalize and act upon findings.

Occupational chemical exposures: a collaboration between the Georgia Poison Center and the Occupational Safety and Health Administration.

CONTEXT: In the United States, regional poison centers frequently receive calls about toxic workplace exposures. Most poison centers do not share call details routinely with governmental regulatory agencies. Worker health and safety could be enhanced if regulators such as the Occupational Safety and Health Administration (OSHA) had the ability to investigate these events and prevent similar incidents. With this goal in mind, the Georgia Poison Center (GPC) began referring occupational exposures to OSHA in July 2014. METHODS: GPC began collecting additional employer details when handling occupational exposure calls. When workers granted permission, GPC forwarded call details to the OSHA Regional Office in Atlanta. These referrals enabled OSHA to initiate several investigations. We also analyzed all occupational exposures reported to GPC during the study period to characterize the events, detect violations of OSHA reporting requirements, and identify hazardous scenarios that could form the basis for future OSHA rulemaking or guidance. RESULTS: GPC was informed about 953 occupational exposures between 1 July, 2014 and 7 January, 2016. Workers were exposed to 217 unique substances, and 70.3% of victims received treatment in a healthcare facility. Hydrogen sulfide was responsible for the largest number of severe clinical effects. GPC obtained permission to refer 89 (9.3%) calls to OSHA. As a result of these referrals, OSHA conducted 39 investigations and cited 15 employers for "serious" violations. OSHA forwarded several other referrals to other regulatory agencies when OSHA did not have jurisdiction. At least one employer failed to comply with OSHA's new rule that mandates reporting of all work-related hospitalizations. This collaboration increased OSHA's awareness of dangerous job tasks including hydrofluoric acid exposure among auto detailers and carbon monoxide poisoning with indoor use of gasoline-powered tools. CONCLUSIONS: Collaboration with the GPC generated a useful source of referrals to OSHA. OSHA investigations led to abatement of existing hazards, and OSHA acquired new knowledge of occupational exposure scenarios.

Under-recording of work-related injuries and illnesses: An OSHA priority.

INTRODUCTION: A 2009 Government Accounting Office (GAO) report, along with numerous published studies, documented that many workplace injuries are not recorded on employers' recordkeeping logs required by the Occupational Safety and Health Administration (OSHA) and consequently are under-reported to the Bureau of Labor Statistics (BLS), resulting in a substantial undercount of occupational injuries in the United States. METHODS: OSHA conducted a Recordkeeping National Emphasis Program (NEP) from 2009 to 2012 to identify the extent and causes of unrecorded and incorrectly recorded occupational injuries and illnesses. RESULTS: OSHA found recordkeeping violations in close to half of all facilities inspected. Employee interviews identified workers' fear of reprisal and employer disciplinary programs as the most important causes of under-reporting. Subsequent inspections in the poultry industry identified employer medical management policies that fostered both under-reporting and under-recording of workplace injuries and illnesses. CONCLUSIONS: OSHA corroborated previous research findings and identified onsite medical units as a potential new cause of both under-reporting and under-recording. Research is needed to better characterize and eliminate obstacles to the compilation of accurate occupational injury and illness data. PRACTICAL APPLICATIONS: Occupational health professionals who work with high hazard industries where low injury rates are being recorded may wish to scrutinize recordkeeping practices carefully. This work suggests that, although many high-risk establishments manage recordkeeping with integrity, the lower the reported injury rate, the greater the likelihood of under-recording and under-reporting of work-related injuries and illnesses.

Federal workers' compensation programs: Department of Defense and Veterans Health Administration experiences.

OBJECTIVE: The objective of this article is to introduce the reader to this special supplement to the Journal of Occupational and Environmental Medicine regarding Federal Workers' Compensation Programs. METHODS: The short history of both the VHA and DoD Federal Workers' Compensation Programs are provided and a short synopsis of each author's article is provided. RESULTS: The lessons learned from the articles in the supplement are summarized in this article and 6 key findings are highlighted. CONCLUSIONS: Cooperation between human resources workers' compensation personnel, safety and occupational health personnel is a must for successful management of the WC program. Information and data sharing are critical for root cause and injury prevention, case management, and cost containment efforts. Enhancing efforts in these areas will save an estimated $100 million through cost avoidance efforts.

Impact of clinical quality on employee choice of providers for workers' compensation-related medical care.

OBJECTIVE: The study examined the relationship between onsite occupational health practice characteristics, provider choice, and workers' compensation outcome metrics. METHODS: Cross-sectional survey of 140 medical center occupational health clinics within the Department of Veterans Affairs. Multivariate regression models examined how specific clinical quality factors influenced provider choice and workers' compensation measures. RESULTS: Several practice characteristics were associated with higher rates of in-house care selection-longer hours of operation, greater availability of workers' compensation-related medical services, clinic administration by a board certified physician, physician tenure, and adherence to clinical practice guidelines. Access to onsite, occupational and environmental medicine certified physician-directed care was associated with reductions in disability duration among injured healthcare workers. CONCLUSIONS: These findings suggest that occupational medicine board certification can positively impact provider choice among fully insured patients, which may have implications for other healthcare systems.

Quality management and federal workers' compensation: the Veterans Health Administration workers' compensation program model.

OBJECTIVE: The federal workers' compensation program includes under a single employer five commonly encountered roles and responsibilities-injured patient, clinical provider, third-party administrator, adjudicator, and insurer. Data within the Veterans Health Administration (VHA) provide a unique opportunity to apply a simple model of health care quality improvement, exploring interactions between structures, processes, and outcomes. METHODS: A facility survey identified reporting structures, levels of education and training, policies and processes, tool availability and use, and perceptions of role adherence. Administrative data included process and outcome metrics, including short-term disability, long-term disability, and lost time cases. RESULTS: Improved collaboration between clinical and administrative staff within VHA and with the Department of Labor was associated with improved performance. CONCLUSIONS: Applying a clinical quality improvement model clarifies roles, expectations, and likely relationships for improved program management.

A brief summary of workers' compensation performance improvement projects 2008 to 2012 in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration undertook a series of performance improvement projects (PIP) using local initiatives identified through a national committee of regional workers' compensation representatives. METHODS: A steering committee identified five types of risks and interventions that were considered worthwhile. They defined performance metrics as outcome measures and distinguished short-term from long-term disability management success. RESULTS: Eight specific PIPs were implemented. No statistically significant differences in the planned outcome metrics were identified, although cost-benefit evaluations did identify a benefit. CONCLUSIONS: Conducting quantitative PIPs in a large system requires top management commitment, sequestration of funds, and mature systems.

Implementation of a novel occupational and environmental medicine specialty teleconsultation service: the VHA experience.

OBJECTIVE: Occupational and environmental medicine (OEM) physician specialty practices continue to grow in scope and intensity across the Veterans Health Administration. This study characterizes the implementation of a novel, nationwide telemedicine program that provides OEM specialty consultation to providers across the Veterans Health Administration. METHODS: We examined provider requests and specialist responses for a 6-month pilot from May to October 2013. Characteristics of consult users, determinants of case complexity, and specific applications of OEM specialty expertise were identified. RESULTS: Over a 6-month period, employee occupational health providers consulted the OEM telemedicine pilot a total of 65 times. Employee occupational health providers without formal training repeatedly identified complex cases related to work and disability. CONCLUSIONS: The program has created a new system management solution to deliver expert, in-depth consultation and real-time provider education in OEM.

Patient handling in the veterans health administration: facilitating change in the health care industry.

OBJECTIVE: To describe a 15-year process creating an industry standard of practice without regulatory support through organizational leadership. METHODS: Description of the development and rollout of a safe patient-handling program, including the initial scientific development, a cultural history, and agency data. RESULTS: Patient-handling injuries represent more than 20% of injuries to nurses. These declined by more than 40% throughout the program. In parallel, program scope and implementation evolved through collaboration across facility program managers in one organization, among various organizations, and between users and equipment manufacturers. Program success required a shift from a technology focus to culture change and behaviors. CONCLUSION: Program evolution arises from collaborative practice and interactions between individual practitioners, organizational needs and interests, and manufacturers. Creation of a public forum was critical to changes in a meanwhile internationally accepted standard.