20 Spring+Summer Journal -web

SPRING/SUMMER 2020 VOL. 40, NO. 2

FEATURES DEPARTMENTS

14 4 Editor’s Column
7 Staying Current on
Chronic Pain Treatment – How We Missed the Boat
By Mel Pohl, MD Government Affairs
10 Association Community
16
Liaison Report
Back to Basics: The Volatile Healthcare Environment, Dynamic Hazards, and Thorough 12 Perspectives in
Safety Culture Development
By Cory Worden, PhD(ABD), MS, CSHM, CSP, CHSP, ARM, REM, CESCO Healthcare Safety
31 Annual Treasurer's Report
20
ISSN 2168-8044
Removing the Enigma: A Methodical Risk and Control Analysis of COVID-19
By Cory Worden, PhD(ABD), MS, CSHM, CSP, CHSP, ARM, REM, CESCO

25

EXPO-S.T.O.P. 2018 – An Overview of Blood Exposure Incidence in 281 US Hospitals
By Terry Grimmond, FASM, BAgrSc, GrDpAdEd&Tr, Director, Grimmond and
Associates, Microbiology Consultants, and Linda Good, PhD, RN, COHN-S, Former
Manager, Employee Occupational Health Services, Scripps Health, San Diego, CA

29

The Perils of Perfectionism in Nursing
By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

35

Prepare and Pursue Board Opportunities: A Practical Guide for Nurse Leaders to Serve
on a Board
By Kimberly A. Cleveland, JD, MSN, RN, C-MBC, C-MPC, and Kimberly J. Harper, MS, RN, FAAN

38

Effects of Air Pollution and Other Environmental Exposures on Estimates of Severe
Influenza Illness, Washington, USA
By Ranjani Somayaji, Moni B. Neradilek, Adam A. Szpiro, Kathryn H. Lofy, Michael L.
Jackson, Christopher H. Goss, Jeffrey S. Duchin, Kathleen M. Neuzil, Justin R. Ortiz

46

More Meaningful Meetings
By Teresa Shellenbarger, PhD, RN, CNE, CNE-cl, ANEF, and Jennifer Chicca, MS, RN,
CNE, CNE-cl

49

Post-Traumatic Osteoarthritis Following ACL Injury
By Li-Juan Wang, Ni Zeng, Zhi-Peng Yan, Jie-Ting Li and Guo-Xin Ni

56

Small Changes Can Have a Big Impact on Your Work-from-Home Setup
By Kathy Espinoza, MBA, MS, CPE, CIE

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

AOHP National Conference

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Spring/Summer 2020

of the Association of Occupational Health Professionals in Healthcare MISSION

AOHP JOURNAL EXECUTIVE EDITOR Provide essential tools that empower
members to ensure the health, safety and
Kimberly Stanchfield, RN, COHN-S wellbeing of healthcare workers.
Journal of AOHP – in Healthcare This is accomplished through:
• Advocating for employee health and
2010 Health Campus Drive
Harrisonburg, VA 22801 safety
• Occupational health education and
EDITORIAL ADVISORY BOARD
networking opportunities
Darlene Buckstead, MSN, RN MaryAnn Gruden, MSN, CNRP, NP-C, • Health and safety advancement through
Employee Health Nurse COHN-S/CM
Consultant best practice and research
Cass Regional Medical Center McMurray, PA • Partnering with employers, regulatory
Harrisonville, MO
agencies and related associations
Sandra Domeracki, MSN, FNP, RN, COHN-S Lee Newman, MD, MA, FACOEM, FCCP
AOHP California Northern Chapter AOHP Conference Committee The Journal of the Association of
Manager, Employee Health Services Occupational Health Professionals (AOHP)
San Francisco VA Professor, Colorado School of Public Health – in Healthcare (© 2018 ISSN 2168-8044)
San Francisco, CA and School of Medicine is published quarterly by the Association
of Occupational Health Professionals in
Mary C. Floyd, MPH, RN, COHN-S/CM Director, Center for Worker Health and Healthcare and is free to members. For
AOHP Florida Chapter Environment information about republication of any
article, visit www.copyright.com. The
Return to Work Coordinator University of Colorado AOHP Journal is indexed in the CINAHL®
Occupational Health Services Chief Medical Information Officer database.

UF Shands Hospital Axion Health, Inc. STATEMENT OF
Gainesville, FL Aurora, CO EDITORIAL PURPOSE

John Furman, PhD, MSN, COHN-S Stacy L. Stromgren, MSM, BSN, RN, COHN-S The occupational health professional in
AOHP Research Committee AOHP Executive Secretary healthcare is vital to ensuring the health,
Executive Director Employee Health Supervisor safety and well-being of both employees
and patients. The focus of this Journal is
Washington Health Professional Services The University of Kansas Health System to: provide current healthcare information
Washington State Department of Health Kansas City, KS pertinent to the hospital employee health
professional; afford a means of networking
Olympia, WA Leslie S. Zun, MD, MBA and sharing for AOHP’s members; and
Linda Good, PhD, RN, COHN-S AOHP Conference Committee improve the quality of hospital employee
AOHP Research Committee Chair health services.
Director, Employee Health Services Professor and Chair
Department of Emergency Medicine The Association of Occupational Health
Scripps Health Rosalind Franklin University of Medicine Professionals in Healthcare and its directors
LaJolla, CA and Science/Chicago Medical School Chair, and editor are not responsible for the
Department of Emergency Medicine views expressed in its publication or any
inaccuracies that may be contained therein.
Mount Sinai Hospital Materials in the articles are the sole
Chicago, IL responsibility of the authors.

Terry Grimmond, FASM, BAgrSc, GrDpAdEd EDITORIAL GUIDELINES
AOHP Research Committee
AOHP Journal actively solicits material to
Director, Grimmond and Associates be considered for publication. Complete
Microbiology Consultants Editorial Guidelines can be found at http://
Hamilton, New Zealand aohp.org/aohp/MEMBERSERVICES/Journal/
JournalEditorialGuideline.aspx.

EDITORIAL STAFF PUBLISHED BY Send Copy to
Kimberly Stanchfield, RN, COHN-S
Executive Editor: Kimberly Stanchfield, RN, COHN-S AOHP AOHP Journal Executive Editor
Executive Director: Annie Wiest 125 Warrendale Bayne Rd., Ste 375 [email protected]

Account Coordinator: Rita Kalimon Warrendale, PA 15086 Publication deadlines for the Journal of
Copy Editor: Kathleen Fenton (800) 362-4347 AOHP-in Healthcare:
Issue Closing Date
Designer: Katina Colbert Graphic Design Fax: (724) 935-1560
Production Coordinator: TMR Print Group www.aohp.org

Edited, designed & printed in the USA Spring February 28
All material written directly for the Journal of the Association of Occupational Health Summer May 31
Fall August 31
Professionals in Healthcare is peer reviewed. Winter November 30

3

Journal of the Association of Occupational Health Professionals in Healthcare

Editor's Column

By Kim Stanchfield, RN, COHN-S
Journal Executive Editor

AOHP Executive Board Responds to the COVID-19 Pandemic

This column, and this Journal most intense, involved, and have managed over 3,000 From AOHP’s Region 3
issue, are the first written af- personally affecting event. phone calls to date. Director
ter the start of the worldwide The novelty of COVID-19 Once initial guidelines, logis- Spring came early in northern
COVID-19 Pandemic of 2020. necessitated daily, step-by- tics, and supplies were es- Virginia in 2020, with cherry
It has impacted every one of step guidance from interna- tablished and implemented, blossoms, daffodils, and cro-
us in some way. tional, national, state, and self-care was highlighted cuses emerging in the third
Your AOHP Executive Board local agencies. The guidance to every leader and team week in February after a
includes a varied group of changed rapidly as additional member because everyone snowless winter. The hope
dedicated professionals with information was learned. Ev- was working with a height- and optimism spring brings
diverse backgrounds in em- eryone had the confidence ened sense of urgency on all each year was evident.
ployee/occupational health. that they were doing the best fronts. Daily encouragement As February melted into
We are working professionals they could with the informa- and suggestions to accom- March, a rubble of activity
with different responsibilities, tion they had. plish this were offered, and soon followed; travel adviso-
job titles, and populations to A few years ago, to bet- still are. Nurses Week and ries for the staff; administra-
serve. One thing we all have ter manage large scale out- Hospital Week came at an tive meetings; and county
in common is our dedication breaks, we employed the opportune time to recognize health department meetings.
to AOHP and our members. services of a consultant com- and reward our healthcare Within two weeks, hospital
We do the jobs our members pany. A major component of personnel. The many dis- operations changed in ways
do. We understand the work, the outcome of this project plays of appreciation from the no one expected a few weeks
constant challenges, stress- established Centers of Ex- community were heartfelt before – travels bans, com-
es, and yes, the joys, of our cellence within our depart- and very much appreciated. mand center opening, daily
specialty field. Let me share ment. One of these Centers Although many wonderful, supply forecast, twice daily
the perspectives of several involved a team of nurses thoughtful things were done, administrative meetings,
AOHP board members re- (in our case, four) who pri- highlights to mention include non-essential procedures
garding this pandemic, spe- marily manage infectious a drive through by the local postponed indefinitely, hos-
cifically how they have not disease exposures as their fire and police departments pital staff reallocated, staff
only survived, but thrived. daily work. During this pan- with sirens blaring for us, and support line set up, remdesi-
From AOHP’s Executive demic, because many nurses the 145th Airlift Wing of the vir and convalescent plasma
President were furloughed or could not United States Air Force sa- trials, hospital entrances
Looking back over my career, work at the bedside due to luting us with an impressive becoming checkpoints to
I realized many outbreaks/ pregnancy per doctor’s or- fly over throughout the state screen all who entered. Visi-
pandemics were success- ders, they were redeployed on Nurse’s Day. As we stood tors were limited to birth and
fully navigated, thankfully. to our Exposures Team to there and witnessed both ac- death attendants.
Throughout the last decade help manage the more than tivities, they made our hearts The routine in the Employee
and a half, a trip down mem- 700 exposures we currently swell with pride and cement- Health (EH) Office changed
ory lane would reveal: have documented. Although ed our resolve to continue daily. Initially, two N95 fit test-
the nurses worked very long the important work we do! ing sites were set up in the
• SARS – 2004 hours, this concept truly Lydia F. Crutchfield, MA, hospital to acclimate staff to
• Avian – 2008 helped us survive the heavy BSN, RN, CLC the new supply of masks and
• Swine – 2010 workload. We communicated Director, Corporate refresh those who needed it.
• MERS – 2012 to our 38,000 team members Teammate Health I had a great group of reas-
• Ebola – 2014 a dedicated phone number to Atrium Health signed staff to help with this
• Zika – 2016 call with questions/concerns/ Charlotte, North Carolina task. Two have continued to
• Corona – 2020 return to work/testing help. staff a roaming cart to ease
The coronavirus pandemic Other furloughed nurses anxiety and orient staff to PPE
has, by far, proven to be the worked this phone line and

4

Spring/Summer 2020

and supply changes. Addition- team of caregivers. I trust the Watching her taking care of The Occupational Health Co-
ally, we had 50 new hires hope and optimism spring patients was an inspiration. ordinator worked on an Inci-
starting March 23. It was chal- and summer brings will con- Out of concern for her pa- dent Command Task Force
lenging trying to complete all tinue to rejuvenate all health- tients, she taped a picture of with Administration, Human
of the on-boarding require- care workers as the fight herself to her gown so that Resources, Infection Preven-
ments as we began to triage, continues. I pray for a vac- patients would see a “face” tion, and various other depart-
test, and trace the COVID-19 cine and antibody testing for instead of a face mask and ment heads to develop a pro-
staff and exposures. more confident treatments, shield. She labelled herself gram that would include all
March was roaring to a close less anxiety, and the strength “Dr. Love”, much to the de- staff and visitors coming into
when I was fortunate to re- needed to continue the work. light of staff and patients, and the building. Craig relied on
ceive help from two cardiac Sara (Sally) Parris wrote it on the top of her face the Centers for Disease Con-
cath lab nurses and a former Employee Health Director shield. The way she dealt trol and Prevention (CDC),
EH employee to help with Virginia Hospital Center with patients - with compas- World Health Organization
administrative duties. A sep- From AOHP’s Region 4 sion and concern - showed (WHO), and Colorado Health
arate call line was manned Director that she was truly “Dr. for guidance. Many emails
from 7:30 am to 6 pm. The On May 15, 2020, CBS News Love”! The dedicated nurses went out informing staff
hospital had organized a drive aired the one-hour program, shared their sadness at being about procedures to follow.
thru testing center, and the “Bravery and Hope – 7 Days with dying patients without A questionnaire was devel-
county was assisting with on the Front Line.” The crew their families present. oped and eventually convert-
contact tracings. followed the medical and The combination of profes- ed to an electronic program
I barely recall March end- nursing staff of the Monte- sionalism and “heart” was an by the Research Department.
ing and April beginning, but fiore Medical Center - Mo- inspiration to me personally. Staff were informed and
some important changes ses Division, the flagship I am very proud to call these aware that if they had a tem-
were adapted in EH to keep hospital of the system. The people my colleagues and fel- perature, they would be sent
the staff safe. The now program reported on the self- low healthcare workers. Our home. Each day, staff with a
greatly reduced number of less work of these dedicated AOHP motto states, “While normal temperature who an-
new hire health screens and professionals. It showed the you look after others, who swered all questions with a
in-person triages were done expertise and professional- looks after you? We do.” I NO were released to work.
through Zoom or FaceTime ism of the staff caring for consider myself truly blessed YES answers were evalu-
or telephone to eliminate in- COVID patients during the to have worked in the Mon- ated by the Health Nurse.
person meetings. We began peak of the COVID pandemic tefiore Health System for Colorado had outbreaks in the
our days with temperature/ in New York City in mid-April, 31 years as an occupational mountain towns, and employ-
symptom checks. Visits to when our inpatient census health professional, spending ees from those areas were
EH were limited to required was at its highest, when dai- my career supporting these also sent home. Over time,
vaccination administration. ly deaths in New York State brave heroes who put their the process became faster.
N95 fit testing was done out- had reached nearly 800, and health on the line to serve Staff and visitors would
side with a cart, if possible. when PPE and ventilators our patients. These workers sneak into the hospital
These past few weeks we were in scarcity. shine like the stars they are. through unlocked doors, forc-
have seen some employees More importantly, the pro- Bravery – yes! Hope – defi- ing the hospital to go on “lock
for PPE irritation; with the gram shared the emotions nitely yes! down”. Staff were given a
help of the wound care team, and thoughts of these pro- Alfred Carbuto, MS, FNP-BC, specific entrance to enter
we devised a skin care regi- fessionals, portraying their COHN-S the building, and visitors had
men. We are triaging employ- loving humanity, fears, joys, Montefiore Health System to use the Main Entrance. It
ees for mental health stress- and concerns, all while car- (Bronx, New York) became a tearful event when
ors as we talk with them ing for their patients. The From AOHP’s Executive patients were informed they
about symptoms or return to chief of critical care explained Treasurer could have no visitors, includ-
work. We are calling the sup- the details of treatment and I work for Craig Hospital, a re- ing family, but our goal was
port line for them, and a coun- management and relayed her habilitation hospital in Engle- to keep everyone safe. Sup-
selor calls them back. I have own personal fears about this wood, CO, that works with plies became an issue. One
found the staff too tired and unprecedented pandemic. patients who have suffered weekend, Craig lost over 400
overwhelmed to ask for help. The crew followed an emer- brain injury (BI) and spinal masks. Management had to
I feel very humbled and proud gency room physician who cord injury (SCI). These pa- collect boxes of masks from
to serve with an incredible showed the extent of the tients can have treatment all the floors to dispense from
work overload for the staff. here for up to three months. the health office. As a reha-
bilitation hospital, we didn’t

5

Journal of the Association of Occupational Health Professionals in Healthcare

have a large supply of masks, venienced, but these minor Early into the pandemic, Em- and without loss of livelihood.
N95s, and hoods/solutions sacrifices have been well ployee Health rescheduled Personally, my entire fam-
for testing. Local fire depart- worth it. As weeks pass by, and put on hold many routine ily to date are healthy and,
ments and various business- Craig employees remain activities and concentrated thankfully, working. My sister
es donated N95 masks and fit healthy, and our patients do on exposures, PPE, and Fit is a nurse in long term care
testing equipment. not have COVID-19. for Duty evaluations. We had and my niece is a nurse in our
Suddenly, cloth masks came Thank goodness for Zoom! to make sure that employees Emergency Department. Of
pouring in from volunteers, Stay Safe and Healthy. were not spreading disease course, we have been very
churches, and sewing groups Dana M. Jennings, RN, BSN and were not working when busy. Their spouses contin-
in the community. We contin- Occupational Health Nurse ill. We also initially followed ued with work. My parents
ue to receive donations. Craig Hospital contacts to every COVID-19 are in their mid-80s with usu-
Non-essential staff from And, to conclude, from positive patient, and then any ally good health, and they had
many departments were sent your Executive Journal staff who had contact before a hard time “staying put”.
home with work. They came Editor, Kim Stanchfield special respiratory isolation Mom just wanted the free-
into the hospital to work one On March 12, 2020, Infec- was established. Our system dom to go to Walmart, not
day per week. Like many oth- tion Control notified our site’s developed special “COVID knowing that it is a very dif-
er hospitals, we also experi- Employee Health that our Tracers”, RNs that review the ferent experience now than
enced low census and had hospital had treated our first medical record of any CO- pre-COVID.
to slim down the budget. In COVID-19 positive patient. VID-19 positive patient to de- I am proud of the work I did
addition to a freeze on hiring Employee Health changed at tect anyone who might have for the Incident Command
and overtime, changes had that moment, and the chang- had exposure. Center. I never hesitate to
to be made to some salaries, es have not stopped yet. Our site’s Incident Command speak up for the needs of
paid time off, and retirement I work for an excellent health Center celebrated many ac- employees and what I think
savings plans. Employee ed- system that had planned complishments. One of the protects them, as well as
ucation, training, and events and was organized. Having best, in my view, was “PPE comforts them.
were all put on hold. said that, as you all know, Wingmen”. These specially Never before has Employee
Daily, the CEO would use nothing about COVID-19 trained healthcare profes- Health been needed so ur-
Zoom to inform staff of the could be planned and orga- sionals on the COVID units gently at each of our work
changes going on at Craig nized, as things constantly made sure staff were safely sites. We answered the call
and in the community. The changed. My site named me and appropriately wearing with skill and compassion.
number of weekly updates the Safety Officer of our CO- PPE before entering a COVID We continue to do so. As I tell
has decreased gradually over VID-19 Incident Command positive room, including dur- everyone, “you never knew
time. Now we worry about Center. Thanks to the excel- ing code blues. how much you really needed
re-infection and what this will lent Employee Health team As I write this column, we us until now”. And they all
do for the staff and patients. here, I was able to juggle that are over 100 days into this agree. That is the best thing
As health nurses, we have responsibility and the ever- pandemic. This has been about our wonderful profes-
been fortunate to remain increasing Employee Health devastating in many ways on sion; we were ready with
working. We had to lose responsibilities. a global, national, and local both knowledge and concern
some benefits and be incon- level. I hope all of you reading when called.
and your families have sur-
vived without serious illness

AOHP is proud to recognize Dynavax as a Partner Organization for the 2020 National Conference!
Through this special sponsorship, Dynavax is helping to fund conference education and activities,
ensuring exceptional, unique, and informative programming. Thanks to Dynanvax for investing in
AOHP's mission to advance the profession of occupational health in healthcare across the nation.

6

Spring/Summer 2020

Staying Current on Government Affairs

By Stephen A. Burt, MFA, BS
Government Affairs Committee Chair

COVID-19 Makes OSHA Develop New Approaches

Confirmed cases of COV- healthcare and other em- the department would have a • In areas where the com-
ID-19 have now been found ployers over alleged safety good deal of discretion in cre- munity spread of COVID-19
in nearly all parts of the coun- lapses related to COVID-19. ating such a standard. has decreased, OSHA will
try – rural and urban – and The most common concerns As part of an employer’s re- return to its pre-pandemic
outbreaks among workers in cited by healthcare employ- sponsibility to maintain a inspection planning policy
industries other than health- ees include: a general fear of healthy and safe workplace, but continue prioritizing
care, emergency response, contracting the virus; a fear OSHA requires employers COVID-19 cases.
or correctional institutions of bringing the virus home to examine COVID-19 cases
have been identified. As to family members; the lack among workers and respond • In areas where community
transmission and prevention of personal protective equip- appropriately to protect work- transmission of COVID-19
of infection have become ment (PPE) and other safety ers, regardless of whether a is experiencing sustained
better understood, both the measures; the inability to case is ultimately determined elevation or resurgence,
government and the private distance while working; staff- to be work-related. In addi- OSHA will continue priori-
sector have taken rapid and ing shortages; and being dis- tion, OSHA has expanded its tizing COVID-19 fatalities
evolving steps to slow the ciplined for raising concerns employee illness recordkeep- and imminent danger expo-
virus’s spread, protect em- or refusing to work. To date, ing requirements to all em- sures for inspection.
ployees, and adapt to new not a single citation has been ployers. All these facts—in-
ways of doing business. As issued due to a COVID-19-re- cidence, adaptation, and the • High-risk workplaces, such
the virus’s spread now slows lated employee complaint. return of the workforce—in- as hospitals and other
in certain areas of the coun- To force the issue, the Ameri- dicate that employers should healthcare facilities, will re-
try, many states are taking can Federation of Labor and be taking action to determine ceive priority attention for
steps to reopen their econo- Congress of Industrial Or- whether employee COVID-19 onsite inspection, as will
mies, permit non-emergency ganizations (AFL-CIO) and illnesses are work-related and workplaces with high num-
medical procedures, and al- National Nurses United peti- thus recordable. Given the na- bers of complaints or con-
low workers to return to their tioned OSHA in March to is- ture of the disease and ubiq- firmed COVID-19 cases.
workplaces. sue an emergency temporary uity of community spread,
Acknowledging that the num- standard under section 6(c) however, in many instances it As part of that increased pri-
bers are probably much high- of the Act. The U.S. Court of remains difficult to determine ority attention for onsite in-
er, on May 26, 2020, the U.S. Appeals for the District of Co- whether a COVID-19 illness is spection, recordkeeping and
Centers for Disease Control lumbia Circuit ordered the De- work-related, especially when effective evaluations of CO-
and Prevention (CDC) report- partment of Labor to respond an employee has experienced VID-19 infections will receive
ed that 62,344 U.S. health- to the unions’ petition by 4 pm potential exposure both in intense regulatory focus. On
care professionals have now Friday, May 29 and the unions and out of the workplace. May 19, 2020, OSHA issued
tested positive for the coro- to reply to the department’s On May 20, 2020, OSHA Revised Enforcement Guid-
navirus. (This figure includes response by Tuesday, June published its Updated Interim ance requiring employers to
people who have died, re- 2. The order would require Enforcement Plan for COV- investigate whether employ-
covered, and are still battling OSHA to issue within 30 days ID-19, which went into effect ee COVID-19 infections are
COVID-19.) In the update, the an emergency temporary on May 26, 2020. The plan “work-related” for the pur-
CDC stated 291 healthcare standard (ETS) to protect U.S. provides instructions and pose of determining wheth-
workers have died. workers from COVID-19 un- guidance to OSHA Area Of- er the infection must be
Healthcare employees have der the Occupational Safety fices and Compliance Safety recorded on the OSHA 300
filed thousands of complaints and Health Act of 1970. The and Health Officers (CSHOs) Log. This guidance, which
with the federal Occupa- petition does not specify the for handling complaints, re- became effective on May 26,
tional Safety and Health Ad- precise contents of an emer- ferrals, and severe illness re- 2020, backtracks from OS-
ministration (OSHA) against gency standard and, if com- ports related to COVID-19. HA’s prior April 10 guidance
pelled by the court to comply, that had previously relaxed
recordkeeping obligations on
all non-healthcare, emergen-
cy response, or correctional

7

Journal of the Association of Occupational Health Professionals in Healthcare

institution employers for CO- may be work-related (e.g., exposure. This should worker to contract COV-
VID-19 illnesses. a number of cases de- include reviewing in- ID-19 in their vicinity, and
As background, OSHA re- veloping among workers stances of coworkers job duties do not include
quires employers to make a re- who work closely togeth- in that environment having frequent contact
cord of a COVID-19 infection if: er without an alternative contracting COVID-19 with the general public,
(1) the case is a confirmed explanation); and illness. regardless of the rate of
(2) the evidence was reason- • The evidence available to community spread.
case of COVID-19; ably available to the em- the employer. In determin- o An employee, outside
(2) the case is work-related ployer. ing the reasonableness the workplace, closely
OSHA now requires all em- of an investigation, OSHA and frequently associ-
as defined by 29 CFR § ployers (except employers will focus on “the informa- ates with someone (e.g.,
1904.5 (an injury or illness who have less than 10 em- tion reasonably available to a family member, sig-
is work-related if an event ployees or employers who the employer at the time it nificant other, or close
or exposure in the work are otherwise partially ex- made its work-relatedness friend) who:
environment either caused empt from OSHA’s record- determination” but will also (1) has COVID-19;
or contributed to the re- keeping obligations) to make consider later information (2) is not a coworker, and
sulting condition or signifi- work-relatedness determina- learned by the employer. (3) exposes the employ-
cantly aggravated a pre-ex- tions. The Guidance specifi- Thus, an employer may
isting injury or illness); and cally requires an employer to wish to revisit work-related- ee during the period
(3) the case involves one or make a “good faith and rea- ness determinations based in which the individu-
more of the general re- sonable inquiry” into whether on new information learned. al is likely infectious.
cording criteria set forth in it is more likely than not that • The evidence that a CO- o OSHA CSHOs should
29 CFR § 1904.7 (an injury exposure in the workplace VID-19 illness was con- give due weight to any
or illness is recordable if it played a causal role with re- tracted at work. This can- evidence of causation
results in death, days away spect to a particular case of not be reduced to a ready pertaining to the employ-
from work, restricted work COVID-19. If it is, then the formula, but certain types ee illness at issue provid-
or transfer to another job, exposure should be deemed of evidence may weigh in ed by medical providers,
medical treatment beyond “work-related” and is poten- favor of or against work- public health authorities,
first aid, loss of conscious- tially recordable. In determin- relatedness. For instance, or the employee.
ness, or if it is otherwise ing the adequacy of the em- OSHA has explained that If, after the reasonable and
diagnosed by a medical ployer’s inquiry, OSHA will work-relatedness is more good faith inquiry described
professional as a signifi- consider the following: likely where: above, the employer cannot
cant injury or illness). • The reasonableness of the o Several cases develop determine whether it is more
Certain circumstances, such employer’s investigation among workers who likely than not that exposure
as work-related fatalities, into work-relatedness. Em- work closely together in the workplace played a
must not only be recorded, ployers are not expected to and there is no alterna- causal role with respect to a
but reported to OSHA within undertake extensive medi- tive explanation. particular case of COVID-19,
eight hours of discovery. Am- cal inquiries given employ- o A COVID-19 infection is the employer does not need
putations, enucleations, and ee privacy concerns and contracted shortly after to record that COVID-19 ill-
employee hospitalizations most employers’ lack of ex- lengthy, close exposure ness. In all events, it is im-
require a 24-hour notification. pertise in this area. Rather, to a particular customer portant as a matter of worker
In light of the difficulty of de- employers should: or coworker who has a health and safety, as well as
termining whether workers (1) ask the employee how confirmed case of CO- public health, for an employer
contracted COVID-19 due VID-19 and there is no to examine COVID-19 cases
to exposures at work, in an s/he believes s/he con- alternative explanation. among workers and respond
April 10, 2020 memorandum, tracted the COVID-19 o An employee’s job duties appropriately to protect work-
OSHA exercised its “en- illness; include having frequent, ers, regardless of whether a
forcement discretion” to not (2) while respecting em- close exposure to the case is ultimately determined
require work-relatedness de- ployee privacy, discuss general public in a local- to be work-related.
terminations to be made by with the employee ity with documented on- Because OSHA considers CO-
non-healthcare/emergency work and out-of-work going community trans- VID-19 a respiratory illness, it
response/correctional institu- activities that may mission and there is no should be coded on the 300
tion employers unless: have led to the CO- alternative explanation. Log as such. If an employee
(1) there is objective evi- VID-19 illness; and By contrast, work-related- voluntarily requests that their
dence a COVID-19 case (3) review the employee’s ness is less likely where: name not be entered into the
8 work environment for o An employee is the only OSHA 300 Log, the employer
potential SARS-CoV-2

Spring/Summer 2020

must not publish the employ- on OSHA’s virus enforcement COVID-19
ee’s name. — or its alleged lack thereof.
AOHP has developed a website for Updates and
Addendum: In recent months, Democratic Interim Guidance on the Outbreak of
According to Principal Deputy lawmakers, unions, and oth- 2019 Novel Coronavirus. Visit
Assistant Secretary of Labor er workers’ advocates have
for Occupational Safety and chided OSHA for not issuing https://aohp.org/aohp/TOOLSFORYOURWORK/
Health Loren Sweatt, OSHA an “emergency temporary ToolsforYourPractice/OutbreakofCoronavirus.aspx
issued its first coronavirus- standard” requiring employ-
related citation during the last ers to implement certain safe- for more information.
week of May. The embattled ty measures or face fines. On
head of the agency told law- May 22, 2020, the AFL-CIO
makers May 28, 2020 about sued OSHA in the D.C. Circuit
the first citation issued during Court seeking an order mak-
the COVID-19 pandemic at ing the agency issue an emer-
the House Workforce Protec- gency temporary standard.
tions Subcommittee hearing

9

Journal of the Association of Occupational Health Professionals in Healthcare

Association Community Liaison Report

By Bobbi Jo Hurst, BSN, RN, MBA, COHN-S
Association Community Liaison

I begin my report for this Jour- we all must, more than ever, we fit tested them to the em- doing OK. We share mental
nal issue with great thanks to pull together and assist each ployees to make sure they health and wellness numbers
AOHP and to all members other. Thank you all for shar- were still able to obtain a prop- that employees are encour-
who have been active partici- ing, giving, doing, and living er fit after decontamination. aged to call. It is understand-
pants on the Listserv. AOHP by example! We have a special COVID-19 able how difficult it must be
has proved to be a valuable Now is the time healthcare group that takes all of the to work in a COVID-19 ICU
source of information to workers need to really be employee calls related to CO- or on another floor where
help us navigate these dif- grateful for and look out for VID-19 testing and safe return critically ill patients do not
ficult times. I hope you have one another. We know that to work. It is interesting to see survive, often with limited or
found the information AOHP everyone is pitching in to help the large span of symptoms no family support. Our nurses
has provided from the Oc- where they can. Times are that some people have suf- assume the role of family as
cupational Safety and Health often scary, frequently stress- fered, from loss of smell and they provide for mental and
Administration (OSHA), the ful, and also frustrating in taste to acute respiratory dis- emotional needs, as well as
Centers for Disease Control that much remains unknown tress. One employee who ex- their physical demands. Now
and Prevention (CDC) and and uncertain. Does the PPE perienced more severe symp- more than ever, our role in
the National Institute for Oc- adequately protect? Will we toms emailed me regarding Employee Health to care for
cupational Safety and Health have enough? Are we utiliz- how she felt and the difficul- the caregivers is crucial.
(NIOSH) to be very helpful. ing it properly? How do we ties not only with breathing Our community response has
We have the benefit of receiv- live and work in an environ- but also with the inability to been wonderful! Community
ing timely information from ment where people respond actually sleep when she was members and businesses
these organizations due to re- with varying levels of social so tired. Her story was heart frequently contact us with
lationships that were started responsibility and accountabil- breaking to read. I am sure generous and varied offers
by MaryAnn Gruden during ity regarding PPE rules and you, too, have had employees of assistance. Some commu-
her tenure as Association social distancing guidelines? with these symptoms. nity volunteers made social
Community Liaison. We are all are working to en- In addition to the fit testing, masks for us out of halyard
In addition, I would like to sure we maintain safe and ad- the hard part is now deter- 100 fabric. These masks have
thank Executive Director An- equate PPE for our staff. My mining work relatedness for been a blessing for those
nie Wiest for quickly dissemi- organization followed the in- employees who have tested who are having problems
nating this information to the formation provided via AOHP, positive. Most employees with regular surgical masks.
membership in real time so and we were able to find al- feel they contracted COV- We are thankful for those first
it was immediately available ternative NIOSH-certified res- ID-19 from work, even though point of contact workers who
as we needed it. I was able pirators. Our materials man- they were wearing PPE while are monitoring temperatures
to share with my employer’s agement team continues to caring for patients. Our third and symptoms of people en-
administration much of the spend many hours obtaining party administrator will be tering the buildings. The Em-
vital knowledge AOHP dis- the appropriate PPE for our speaking with each individual ployee Health Department re-
tributed, which has helped us staff. Lots of fit testing contin- after they are triaged for work ceived a thank you card from
make decisions as we moved ues to occur so that individu- relatedness by Employee a community member, who
through and continue to man- als wear only respirators they Health. We are seeing con- probably sent one to each
age the challenges of CO- have been fit tested to wear. versions from people eating department in our facility. We
VID-19. I don’t have enough We also found a company to lunch closely together, trav- appreciate the prayers and
room even to briefly recap decontaminate and evaluate eling in the car together, and every gracious act of kind-
in this article all the informa- respirators. Each employee those disregarding PPE with ness and sharing offered by
tion AOHP has provided since must write their name and de- others who are not patients. our community.
mid-March 2020. partment, as well as tracking The mental health of our em- I do hope you are all doing
I would feel lost without the information, on the respirator ployees has been and will well and that you are looking
resources of AOHP and the so it can be sent out and then continue to be of great con- after your own health during
collaborative network of shar- redistributed to that individual. cern. We have chaplains as- this unprecedented time. You
ing we have built through the Upon receiving the first respi- signed to all of the COVID-19 are very much needed, now
Listserv. This is a time when rators back from the company, units to make sure staff are and always. Keep safe, and
God Bless You.
10

Spring/Summer 2020
11

Journal of the Association of Occupational Health Professionals in Healthcare

Perspectives in Healthcare Safety

By Cory Worden, PhD(ABD), MS, CSHM, CSP, CHSP, ARM, REM, CESCO

Opinion Overload and Misplaced Battles

With so many conflicting tially infectious people if we something different to com- or other means of preventing
messages and tensions sur- have the proper PPE and res- pletely restrict business op- exposures.
rounding COVID-19, the need pirators and have done dili- erations even with controls. Dual Accountability
for facts and data is incred- gence to ensure safety. How- Meanwhile, many other gov- Concurrently with employee/
ibly high. A methodical risk ever, businesses completely ernment leaders have been employer/government dis-
and control analysis is a vital reopening without controls quick to push businesses to putes, many employees have
tool. For example, with many demonstrate overt risk ac- reopen without acknowledg- been quick to accuse employ-
pushing to curtail quarantines ceptance that COVID-19 ex- ing that these businesses ers of expecting unsafe con-
and reopen businesses, it’s posures may occur without need to implement safe pro- ditions while the employer is
important to remember that mitigating factors. tocols first. It’s one thing to asking for the more effective
the risk of COVID-19 expo- Furthermore, for employers, ask businesses to reopen to hazard control. For example,
sures hasn’t changed. There employees, and citizens, it’s benefit the economy, but it’s if the employer asks employ-
is not currently a vaccine or important to distinguish be- another to push them to do ees to maintain social dis-
valid, reliable epidemiological tween what is actually safe so without the means to pre- tancing, this is more effec-
evidence that the virus is not and unsafe. Many business- vent exposures. Similarly, it’s tive than implementing PPE.
spreading. Further, for expo- es have been quick to ac- one thing to want employees Therefore, the employer not
sures and confirmed cases, cuse government leaders of to be able to return to work providing PPE isn’t an un-
there’s not yet a confirmed trying to control them when but another to pressure them safe condition; the employer
medical treatment for the vi- the government is simply into it without their being able is asking that employees
rus. With this, it’s not a situ- asking for safe protocols. It’s to use separate areas (engi- maintain social distancing as
ation of “it was unsafe, and one thing to ask for engineer- neering controls), maintain a safer alternative to PPE.
now it’s safe”. The only fac- ing or administrative controls social distancing (administra- Employees wanting to be in
tor that has changed is many before reopening, while it’s tive controls), and use PPE proximity to each other and
people’s opinion that the
situation is no longer as risky Figure 1 – Dual Accountability
as it was. However, without
controls in place, there is
only hope and luck that expo-
sures and virus transmissions
won’t occur.

Controls are necessary. For
businesses that want to re-
open, controls can be estab-
lished within safe protocols.
If employers want their em-
ployees to come in to work,
this can be done using engi-
neering controls, administra-
tive controls, and/or Personal
Protective Equipment (PPE)/
respirators. Those content
with quarantine can continue
to do so. As we (painfully)
know about healthcare, law
enforcement, and other pub-
lic services, it is possible to
get “up close” with poten-

12

Spring/Summer 2020

not being provided PPE to do time and take personal ac- employee an opportunity pense of safety, the employ-
so isn’t an unsafe condition. countability for safe work to voice the concern and ee will have a negative image
That said, if the employer de- practices. Well-developed seek a resolution. of safety.
mands that employees work safety culture conversations 3. If the situation is invariably Due diligence is important,
in proximity to potentially in- provide opportunities for unsafe, the task can be and methodical decision-
fectious persons (not allow- employees to ask questions stopped. making and hazard control
ing engineering or adminis- and raise concerns to correct Perceptions are what prevent incidents
trative controls) but refuses unsafe situations or seek ad- Each step of the employee’s and disease exposures. In
to provide PPE, this would be ditional knowledge. Ultimate- journey with an employer af- the case of COVID-19, if
an unsafe condition. ly, as I was taught early on fects her or his perception of each leader, employee, and
Likewise, if an employer sets by my friend and colleague safety. If the take-away from government official replaced
up administrative controls Debi Deavers, three benefits each interaction is that the opinions with facts, followed
(such as contamination con- come from safety conversa- employer cares about safety, by methodical application of
trol areas) and provides PPE, tions: wants to hear about con- those facts into a science-
but employees refuse to use 1. If the situation is already cerns, and takes preventive based analysis, many un-
the PPE or refuse to remain measures to avoid incidents, necessary battles could be
in ”cold”/uncontaminated ar- safe, it gives the leader the employee will have a avoided.
eas, this is not an unsafe con- an opportunity to explain positive image of safety.
dition. This would actually be why it’s safe and prevent a However, if the take-away is
an unsafe work practice on misperception. that the employer only cares
the employee’s part. Howev- 2. If the situation requires about productivity at the ex-
er, if the employer does not more safety, it gives the
designate between contami-
nated and uncontaminated Figure 2 – Employee and Safety Interactions During the Employee/Organizational Journey
areas, does not provide PPE,
does not provide Fit Testing
or another prerequisite for
safe operations, this would
be an unsafe condition. It’s
very important to understand
what constitutes safe and
unsafe so that battles aren’t
mis-fought and unnecessary.
Both the employer and the
employee have very impor-
tant parts to play in safety
and, with COVID-19, it’s even
more so.

When it comes to prevent-
ing infectious disease ex-
posures, opinions of what’s
safe and unsafe won’t stop
droplets from contaminating
an area or a person. Science
and methodical decision-
making will. However, half
of the battle of developing
a safety culture is ensuring
each employee understands
why hazard controls are im-
plemented and why safety
is important. This is what
enables each team member
to use hazard controls in real

13

Journal of the Association of Occupational Health Professionals in Healthcare

Chronic Pain Treatment
– How We Missed the Boat

By Mel Pohl, MD

Chronic pain affects millions of people responding, has a persistence of pain, ther/or” question. It is “both/and”.
around the world. We’ve missed the and is dependent on opioids. While 80% of the experience of pain is
boat because we treat persistent pain Next, we go after the tissue damage emotional and cognitive, usually we end
as if it were acute pain. This occurs be- with a surgeon's knife. What we of- up focusing on the 20% that’s physical.
cause the patient wants us to “fix it”. ten see when a patient is referred to a We miss the bulk of the problem, and
We assume the hero role and try to help functional restoration program is that we also miss the bulk of the options for
find the cause of their “pain” so it can surgeons feel like they have taken care the solution.
be treated and “cured”. What we miss of the problem, but the patient is still Chronic pain occurs in the insula, the pre-
in this process is the obvious fact that suffering. Sadly, the messaging to the frontal cortex, the nucleus accumbens,
chronic pain is “chronic” and unlikely to patient then becomes that, since the and the ventral tegmental area. Brain
be cured. When it comes to treatment, problem has been surgically fixed, the activity with chronic pain is different
the only thing acute pain and chronic pain must be “all in your head”. “You’re than with acute pain. Acute pain occurs
pain have in common is the word pain. histrionic!” Or worst of all, “your pain in the thalamus, the relay station of the
They represent different processes. isn’t real”. brain. Several studies from Northwest-
Acute pain is a signal from the hardware In the spirit of best practices, I would ern University show that on functional
of the nervous system related to tissue like to suggest five key principles that I MRI scans, the thalamus lights up with
damage. It’s like an alarm going off, tell- have learned in the course of working as acute pain. The nucleus accumbens and
ing you that something is wrong and an addiction specialist in a clinical setting the ventral tegmental areas light up with
that you should do something about it. treating chronic pain: chronic pain. The nucleus accumbens
When the wound is treated and the tis- 1. All pain is real. and ventral tegmental area are where
sue damage heals, the pain goes away. An article by Newton speaks powerfully we experience motivation and reward,
Acute pain is a useful, functional, and about the cost of disbelieving a patient: and where addictive substances act.
temporary signal. mistrust develops between the medical The experience of chronic pain relates
Chronic pain is an entirely different pro- team and a patient when it is implied to hippocampal inputs of the memory;
cess. It may or may not start with tissue that a patient’s pain isn’t real. Pill-seek- thoughts, anxiety, fear, and depression
damage, but the real significance of the ing isn’t necessarily nefarious. It’s all the that come along with the physical expe-
experience of chronic pain is that the patient knows to do to try and relieve rience. This complex process must be
signal is transmitted to the brain’s lim- pain. And when providers disbelieve treated with a complex and comprehen-
bic system. This is where emotions are that a patient’s pain is real, they do the sive approach. Yet our medical system
mediated. patient a disservice. We must start with treats it as if it’s as simple as acute pain,
Clinicians have medicalized chronic pain a position of belief that the pain is real. and we unsuccessfully go after it as a
as if it were just a longstanding version A clinician’s first job is to listen, and then unimodal condition. We separate mind
of acute pain. We do MRIs and function- to use certain simple trainable skills to and body, and this doesn’t make sense.
al MRIs and CTs with contrast and stand move that patient out of the rut of suf- We need to treat the whole patient –
the patient on their head and do another fering. mind and body.
MRI or injection, and we “prove” that 2. Thoughts and emotions drive Chronic pain is a brain experience involv-
the cause of the pain is, let’s say, a bulg- the experience of pain. ing thoughts and feelings, and the pain
ing disc. Then we treat it with epidural I am often asked by colleagues who re- is very real. We must begin by believ-
injections and radiofrequency ablations fer patients and families if the patient’s ing the patient and affirming the reality
– this may help temporarily. We clobber pain is physical or emotional. I answer, of their experience of pain, or we will
the pain with an opioid, which is basi- “Yes, the pain is physical, and of course, completely miss addressing the larger
cally a blunt object, and at the end of the the pain is emotional.” It is not an “ei- emotional and cognitive aspects of the
process, we have a patient who is not pain experience.

14

Spring/Summer 2020

3. Opioids often make the pain “How much is your function affected an acute condition. What I am suggest-
worse. by your pain?” Rather than, “What’s ing is we need to treat the whole person
Although I’m not an opiate nihilist, I’m the matter?” I ask, “What matters to with chronic pain; that is, the mind as
starting to lean in that direction because you? How far can you walk? Are you en- well as the body.
I have seen the negative consequences gaged in your life? Do you go to work? To truly be effective, we must harness
of long-term opioid use. I work in a ter- Are you in bed part of the day? Are you the science of pain and educate patients
tiary care center, and we see people in bed more now than you were before to reframe their experience through mul-
who have not done well on opioids. opioids?” Approaches that focus on the tiple modalities that empower them to
Some patients do fairly well on opioids, pain promote pain and suffering, often take an active role in owning both the
but not the majority. making matters worse. Emphasizing problem and the solutions. It takes cour-
Opioids do several things: there is a roll- function provides a more successful age to face chronic pain. People in pain
ercoaster-like effect of ON and then OFF treatment approach. who might feel hopeless must be able
that eventually causes the development 5. Expectations influence out- to rely on their clinicians for understand-
of tolerance and physical dependence. If comes. ing and compassion. And once they do,
the patient is physically dependent on a Pessimists have a more realistic view of they often find that the best things will
drug, they are going to have a re-emer- life, but optimists live longer. A National come from within.
gence of symptoms between doses. In Academy of Science study suggests that About the Author:
other words, patients with chronic opi- people who are optimistic sleep better Dr. Mel Pohl is the Chief Medical Officer
oid use often have higher pain levels in and live longer. Pain focus and negative of Las Vegas Recovery Center (LVRC).
between doses. Further, opioids cause thoughts increase a person’s experience Dr. Pohl was a major force in developing
opioid-induced hyperalgesia – glutamate of pain and contribute to suffering. Re- LVRC’s Chronic Pain Recovery Program.
levels rise and NMDA (N-methyl-D-as- search has demonstrated that in chronic He is certified by the American Board
partate receptor) levels rise, causing a pain patients, the nine areas of the brain of Addiction Medicine (ABAM) and is a
stimulation of the central nervous sys- dedicated to experiencing pain have re- Distinguished Fellow of the American
tem. This increase in sympathetic activ- cruited more brain cells to participate in Society of Addiction Medicine (ASAM).
ity results in the activation of glial cells, the process. This neuroplastic change He is the former chairman of ASAM’s
elevating the tone of the nervous sys- has a significant role to play in how we AIDS Committee, a member of the
tem even more. Opioids are proinflam- treat chronic pain and can reduce it as planning committee for ASAM’s Annual
matory in most patients. well. “Common Threads, Pain and Addiction”
Clinically, I have found that most pa- Conclusion Course and co-chair of ASAM’s Pain and
tients experience less pain off their opi- As we face the challenge of treating Addiction Workgroup. Dr. Pohl is a Fel-
oids than on. One thing that happens at chronic pain, creative and adaptive ap- low of the American Academy of Family
the Las Vegas Recovery Center is when proaches help us to see beyond the Practice and a Clinical Assistant Profes-
patients arrive, they have this belief that physical and lead to effectively address- sor in the Department of Psychiatry and
they need their opioids. They “know” ing the cognitive and emotional aspects Behavioral Sciences at the University
this because they’ve tried to go off – of suffering. When we face chronic pain of Nevada School of Medicine. He was
they’ve even gone a whole day without head-on as a chronic condition, we avoid elected by his peers for inclusion in
the opioid – and their pain increased sig- the unnecessary trap of pretending it is Best Doctors in America® from 2009 to
nificantly. Therefore, they conclude they the present.
cannot stop taking opioids. Increased
pain when lowering or discontinuing
the opioid is the result of physical de-
pendence and withdrawal. Physical de-
pendence may be associated with ad-
diction, but it isn’t necessarily the same
as addiction. It’s a complex dependence
process about seeking pain relief and
reward. The best solution for many pa-
tients is to discontinue the opioid under
close medical supervision.

4. Treat patients to improve their www.aohpconference.com
function.
When I meet a patient, I don’t ask,
“What is your pain score?” but rather

15

Journal of the Association of Occupational Health Professionals in Healthcare

Back to Basics: The Volatile Healthcare Environment,
Dynamic Hazards, and Thorough Safety Culture
Development

By Cory Worden, PhD(ABD), MS, CSHM, CSP, CHSP, ARM, REM, CESCO

Safety culture development is absolutely tenance can be completed. In turn, this hazard (such as a Respiratory Protec-
necessary to prevent incidents, especial- will cease operations, pull employees tion Program for an identified possible
ly in the healthcare environment. Hazards off duty, and cost money, in addition to disease exposure or a panic button for
must be identified, controlled, and com- other indirect costs (Worden, 2018). a possible workplace violence situation),
municated, and the resulting hazard con- Furthermore, when these dynamic haz- safe work still cannot be accomplished.
trols must be validated as safely used. ards are identified, regulatory compliant This is setting workers up for failure and
Finally, any incidents still resulting must programs must already be in place for harm (Worden, 2018).
be recorded, measured, and investigated each one. For example, should a po- For example, an Emergency Room - or
to determine preventive measures. The tential airborne chemical exposure be any healthcare environment - contains
first step in all of this is identifying the identified as part of a non-consistent many stagnant hazards. Using a needle
hazards. maintenance operation, a Respiratory to draw blood or to administer medica-
In some environments, operations are Protection Program (OSHA, n.d.) must tion is a hazard that is known, trained,
consistent (e.g., factories with blow- already be implemented to ensure a and handled many times each day. The
mold, filler, packer, and/or palletizer hazard analysis, including acquisition of basic use of the needle doesn’t change.
operations). Hazards can often be pin- proper respirators and medical question- Once the process is learned, the team
pointed, assessed, and controlled with naires, and training and fit testing for af- member knows how to use the needle.
standard operating procedures, lock out/ fected employees. With these programs However, there are also many dynamic
tag out procedures, personal protective in place, workers must then have training hazards that require attention and situ-
equipment (PPE), and similar controls. and conditioning to correlate the newly- ational awareness. For example, while a
Provided these controls are followed identified hazard with the necessary haz- team member may be expert in using a
rigorously, validated through observa- ard control program and use it to work needle, using the needle while treating a
tions and inspections, and continuously safely. Should this not happen, hazard combative patient is a different situation.
improved, if/when a deviation, injury, or control will not happen (Worden, 2018). Using the needle while being yelled at
exposure occurs, it can be mitigated. Healthcare by a visitor is a different situation. Using
However, other, non-stagnant hazards The healthcare environment, with its the needle while working a third 12-hour
are more challenging to control. For ex- multitude of dynamic hazards, demands shift in a row and being fatigued is a dif-
ample, in the same factory environment these elements more so. While main- ferent situation. Situational awareness
with stagnant, procedure-driven hazard tenance operations may require the allows for the dynamic hazards to be
controls, mechanics may need to deter- identification of unforeseen hazards and identified so they can be addressed be-
mine why and how a piece of equipment real-time hazard control, healthcare op- fore working with the known, stagnant
is not operating as intended. In this case, erations centered on patient care require hazard. Only then can incident preven-
the standard operating procedure for the this same situational awareness, critical tion be addressed.
equipment would not be sufficient to thinking, and hazard control with each For these reasons, safety preparedness
ensure safety. Even with the equipment patient. With hazards such as workplace is necessary through inspections and ob-
properly locked out to isolate and neu- violence (Worden & Johnson, 2016), servations to validate hazard identifica-
tralize all forms of energy, new hazards needlesticks (Worden, Gresham & Yuill, tion and control.
such as panels or doors snapping shut, 2016), and disease exposures (Worden, Inspections
falling hazards if working at heights, or 2015) ever-present in the workplace, Within the workplace environment, in-
crushing hazards must be identified in lack of situational awareness regarding spections can be used to identify safe
real time before someone is affected by patient condition, symptomology, and and unsafe conditions, as well as the
them. Should workers not maintain situ- more can easily lead to an injury or ex- presence or lack of hazard controls. For
ational awareness to identify these new, posure. However, even with good situ- example, inspections allow for the iden-
dynamic hazards in real time, injuries or ational awareness, if a reciprocal hazard tification of tripping hazards, slipping haz-
exposures will occur before any main- control is not in place for the identified
16

Spring/Summer 2020

ards, unsafe equipment, and other un- if 10 observations are completed dur- also provide a clear leading indicator as
safe conditions. Likewise, they allow for ing a week and it is observed that eight to the diligence being paid to safety and
the identification of lacking PPE, missing employees are not using the expected incident prevention. For example, if 10
equipment, missing compliance program equipment to move patients, there is a incidents occurred during the previous
elements, and more. These unsafe con- high probability that an incident is immi- month, but only five of them were inves-
ditions can be identified and resolved nent, and also that the safety culture is tigated, this provides a clear indication
through inspections before a worker is lacking. that safety is not a value and also means
harmed or before something is missing Criteria that the valuable information to be gained
when needed (Worden, 2015). When determining viable factors to in- from these investigations is not known. If
Observations spect (conditions) and observe (behav- not known, nobody can use the informa-
While inspections can be used to identify iors), these should be the items that can tion to prevent future incidents. Ultimate-
safe or unsafe conditions in the work- cause safe (or unsafe) work. For exam- ly, every incident requires an investiga-
place, observations provide real-time ple, recapping needles is a huge risk fac- tion; with these investigations pertaining
data as to whether the hazard controls tor for needlesticks. Observations check- to incidents having already occurred, this
(provided they are in place, accessible, ing for recapping of needles can help to is the least anyone can do.
and convenient) are being utilized as proactively prevent the hazard and risk. Lagging Indicators
expected. For example, if the expecta- Targeted Hazard Controls Lagging indicators provide measure-
tion is to utilize a patient lift to transfer With the information derived from lead- ments of incidents that have already
or ambulate a patient, observations can ing indicators, hazard controls can be tar- occurred. For this reason, caution must
provide data as to whether this is hap- geted for improvements. For example, if be taken to ensure prevention of future
pening. If it’s not, the probability of a fu- observations show PPE not being used, incidents takes priority over previous
ture incident increases. inquiries can be made as to why not. Was incidents. Many organizations have dif-
Near-Miss and Good Catch the PPE not available? Was it not acces- ficulties with overlooking necessary pre-
Reports sible? Was it not conveniently placed? ventive measures in lieu of arguing about
Near-miss or good catch reports docu- These questions must be answered to what data factor into lagging indicator
ment potential incidents so preventive improve hazard control usages; without measurements. (Do calculations only
measures can be developed for possi- this information, unsafe behaviors will include Occupational Safety and Health
bly overlooked hazards before real harm continue, and employees will continue Administration [OSHA]-recordable inci-
occurs. In some cases, team members to believe leadership is not interested in dents, all incidents, only compensable
may be hesitant to report near-miss bettering the situation. This is a danger- incidents, or other delineations?) Ad-
events, as they may think these will ous cultural scenario. ditionally, many organizations will have
position them negatively, but this is a Lagging Indicators and difficulty arguing about whether or not
great opportunity for the organization to Investigations particular incidents meet OSHA record-
encourage and promote these reports, At this point in the process, Hospital X’s keeping criteria instead of focusing on
recognizing team members who submit metrics (key performance indicators) will what happened, how it happened, and
them so they become a matter of pride no longer be a guessing game or a mys- how to prevent future reoccurrences.
rather than fear. tery. In the past, the hospital wondered OSHA (OSHA, n.d.) provides a calcula-
Measurements how and why its injury rate was so high, tion for lagging indicators to provide a
Participation and behaviors are the two but now it can definitively see - through rate of incidents per 100 employees:
ways to measure leading indicators. For participation rates and safety observa- # of incidents x 200,000) / total hours
example, if the expectation is for each tions/inspections - how and why injuries worked during the calculation period
employee to complete a certain number and exposures have been occurring. When calculating this rate, there are sev-
of inspections/observations each day/ Furthermore, in analyzing lagging indica- eral options. A total incident rate can be
week/month, the actual completion rate tors, the hospital can also see what inju- calculated using all incidents – regardless
is indicative of the employee popula- ries and exposures have fallen between of OSHA-recordability, compensability, or
tion’s participation in the safety culture. the proverbial cracks and further target even near-miss status – as the incident
If these expectations are not being met, hazard controls based on incident inves- number. An OSHA-recordable rate using
the teams’ participation in the culture tigation findings. To this point, incident only OSHA-recordable incidents – those
needs to be re-examined. investigations now become Hospital X’s meeting criteria defined in the OSHA re-
If inspections/observations are being hybrid leading and lagging indicator. cordkeeping handbook (OSHA, n.d.) – are
completed, the findings from these in- While investigations are, by nature, a lag- the incident count. A rate can be calcu-
dicators must be analyzed to determine ging indicator pertaining to injuries or ex- lated only using compensable incidents
any possible discrepancies. For example, posures that have already occurred, they as the incident count. In any case, to cre-

17

Journal of the Association of Occupational Health Professionals in Healthcare

ate a valid and reliable measurement and Failure Modes and Effects Analysis in its safety processes. If each depart-
to trend this measurement, the inputs to A Failure Modes and Effects Analysis ment is not expected to know its haz-
these calculations must be determined provides a breakout of process compo- ards, ensure hazard controls are in place,
up front and remain consistent. nents, potential failure modes, and nec- validate safe behaviors and conditions,
Investigation essary improvements to avoid failure and investigate incidents, no ownership
To complete the continual improvement modes. This can be done preventively or will take place. By extending ownership
cycle, each incident must be investigat- reactively (Stephans, 2004). into empowerment through increased
ed to determine what happened, how, There are many other options in terms communication and engagement, safety
and why, and what must be done to of reactive investigative tools. The main can increase exponentially.
prevent it in the future. This information factor is that the causal factors of the in-
must then be placed into the ongoing cident must be determined and resolved References
hazard analysis. Hazard controls must before continual improvement can be as-
be reassessed using this information, sessed. Occupational Safety and Health Administration (OSHA).
and the hazard controls must be com- Full Circle (n.d.). 29 CFR 1910. Retrieved on February 1, 2015 from
municated. They must then be validated With hazards known and hazard controls https://www.osha.gov/pls/oshaweb/owastand.display_
using leading indicators, measured us- in place and communicated, and with standard_group?p_toc_level=1&p_part_number=1910
ing lagging indicators and, if necessary, safe behaviors and conditions validated Stephans, R.A. (2004). System safety for the 21st cen-
investigated and reassessed for further through leading indicators, healthcare tury. New Jersey: Wiley-Interscience.
continual improvement. teams can work to prevent both stag- Worden, C. (2015). Workplace safety and emergency
Tools nant and dynamic hazards from causing management must be integrated. Industrial Safety and
Several resources are available to deter- harm. Furthermore, by making sense of Hygiene News. Retrieved from http://www.ishn.com/
mine the root cause(s) of incidents. lagging indicators and targeting them articles/102162-workplace-safety-and-emergency-man-
Fault Tree Analysis through investigations, Hospital X was agement-must-be-integrated?v=preview
Using critical events in the progression able to work toward safe behaviors and Worden, C. (2018). Countering insurgent behaviors.
of the incident and delineating them with conditions. It was also able to affect cul- Houston, TX: Organizational Impact Safety Solutions.
and/or gates, a Fault Tree Analysis can ture change through expectations of ro- Worden, C., Yuill, N., & Gresham, M. (2016). Like a load-
delineate multiple factors leading to an bust participation from each department ed gun: Preventing needlesticks and sharps injuries.
incident (Stephans, 2004). ASSE Healthbeat. Retrieved from http://healthcare.
asse.org/assets/18/17/Healthbeat_1116.pdf?10934

Fault Tree Analysis

Failure Modes and Effects Analysis

18

Spring/Summer 2020

You Can Be a ROC Star!
AOHP Recruit Our Colleagues (ROC) –

A Better and Greater Campaign.

The Recruit Our Colleagues (ROC) campaign is back, and it’s bigger and better than ever! ROC is a great way for members to
help AOHP grow while earning rewards that can be used toward education and membership. The new ROC campaign offers
five levels of individual awards, as well as an award for the chapter recruiting the most new members.
AOHP members are the organization’s most valuable asset, and the best way to spread the word about the value and benefits
of our organization. When looking for ways to recruit new members to AOHP, consider the following:

• Connect with colleagues in your own organization who are not AOHP members. AOHP is not just for nurses. Reach out
to physicians and advanced practice professionals who are involved in your occupational health program.

• Connect with providers outside your organization who partner with you in your program.
• Reach out to colleagues from other facilities in your local area.
• Obtain a list of facilities in your chapter’s geographic area, and make “cold calls” to the occupational/employee health

employees in those facilities. (Lists were recently provided to chapter presidents). Briefly introduce them to AOHP and
refer them to the AOHP website, or offer to send them information. Be sure to let them know what you value about
your membership in AOHP.
• Connect with occupational/employee health providers in non-hospital facilities such as clinics and post-acute care.
The new ROC campaign offers a grand prize that includes free registration to the next AOHP National Conference, three nights
hotel, airfare reimbursement up to $250, round trip transportation from the airport to the conference hotel (up to $50), and a
free AOHP membership for the following year. The total value of this prize is approximately $1,500.
The current ROC campaign period runs from July 1, 2020 through June 30, 2021. There is still plenty of time to work toward a
ROC reward, so get busy!

LET’S ROC! The following ROC awards are available:
• The Whole Shebang – one award to the member recruiting the most new members (must recruit at least 10 to
qualify).
• Kit and Caboodle – awarded to members recruiting 10 or more new members, but not the winner of The Whole
Shebang.
• Half Kit and Caboodle – awarded to members recruiting six to nine new members.
• Caboodle – awarded to members recruiting three to five new members.
• Feather in My Cap – awarded to members recruiting one to two new members.
• Pie in the Sky Chapter Award – awarded to the chapter recruiting the most new members.

For full details of the awards and campaign rules, please visit
http://www.aohp.org/aohp/MEMBERSERVICES/RecruitOurColleagues(ROC).aspx. You can download a ROC Flyer -
http://www.aohp.org/aohp/Portals/0/Documents/MemberServices/ROC%20Flyer.pdf to share with your colleagues.
Every new member strengthens our organization. Participate in our ROC Revival by sharing the benefits of AOHP
membership with your colleagues, and earn rewards that will benefit your practice. For more information, visit
www.aohp.org, call Headquarters at 800-362-4347, or email [email protected].
***In order to count as your recruit, new members must list your name as their recruiter when completing their AOHP
Membership Application!

Let’s ROC someone’s world!!! Recruit Our Colleagues!
Reach out and share the benefits of AOHP membership with your area colleagues.

19

Journal of the Association of Occupational Health Professionals in Healthcare

Removing the Enigma:
A Methodical Risk and Control Analysis of COVID-19

By Cory Worden, PhD(ABD), MS, CSHM, CSP, CHSP, ARM, REM, CESCO

As the worldwide response to the CO- can be air transmitted from sneezing, Also, since each exposure could be-
VID-19 pandemic continues, the death coughing, talking, or even breathing. come a conversion/confirmed case,
toll in the United States has exceeded In any case, if the droplets can trans- the severity is very high. In fact, each
120,000 and, with testing still very much fer from an infected person’s mouth or conversion/confirmed case could pos-
underway, the extent of the infected is nose to another person’s mouth, nose, sibly be fatal, and each confirmed case
unknown. Risks of continued outbreaks or eyes, the virus can be spread. In the could mean exponentially more cases
and deaths from the virus are ongoing. case of COVID-19, the virus is highly in society. This increases the possibility
Many questions continue to be asked: contagious, virulent (the droplets have that hospitals could be over capacity and
• Who’s at risk for contracting and trans- been documented to live up to nine days without medical and protective equip-
on surfaces), and persons can be infec- ment. In addition, there is not currently
mitting the virus? tious while asymptomatic. Watching a vaccine or valid and reliable treatment
• When and how do we return to work for evident symptoms is not enough to for COVID-19. Based on these factors,
avoid the virus. the severity is extremely high, more so
safety from quarantine? Risk Assessment than any infectious disease since the
• How do we protect personnel from vi- Within the context of infectious disease Spanish Influenza of 1918.
exposure prevention, methodical deci- Risk Level Changes
rus exposures? sion-making based on a scientific risk Knowing the frequency and severity of
• How do we medically treat patients? management and hazard control pro- COVID-19, there are two valid and reli-
These questions and many others have cess is needed. This allows for opening able methods to reduce the risk of a CO-
been discussed in globally-projected society and business operations within VID-19 outbreak and continuation of the
press conferences as matters of opin- safe parameters. Based on the process pandemic:
ion with limited communication on the below, organizations can determine the 1. Epidemiological data that the virus is
scientific analyses behind the decisions safest protocols within the risk manage-
being discussed. The scientific analysis ment construct deemed appropriate. not spreading.
includes the hazard, hazard controls, The objective is to control the risk and 2. A vaccine.
communication, leading and lagging in- hazard in the most effective manner Both of these risk reduction methods
dicators, and investigations. With this while being feasible for operations as are currently unavailable, as is a valid
limited discussion and the risk manage- needed. However, if an operational want and reliable medical treatment. At this
ment decisions serving as inputs and cannot be accomplished in a safe man- time, the risk level for COVID-19 is very
outputs from it, many tertiary arguments ner, it would need to be reconsidered. high due to high frequency of exposure
and conflicts have come up. However, Finding a balance between operations (potentially each person) and high sever-
using a facts-driven risk management and safety is of the utmost importance. ity of exposure (potentially fatal). This
decision-making process and a subse- Risk Level will only be lowered by changes to fre-
quent hazard analysis, COVID-19’s acute Within the scope of frequency and se- quencies of exposure or changes to se-
and chronic risks can be managed while verity, disease exposures are very fre- verities of exposure.
optimizing exposure prevention. quent in that they occur every time an The risk level can only change with a
Hazard Analysis individual is exposed to another’s drop- vaccine and/or epidemiological evidence
To begin the process of developing lets. In fact, because asymptomatic validating that the risk level is lower.
safety protocols, the hazard must first persons can be infectious, every single Furthermore, without valid and reliable
be analyzed. In this case, COVID-19 is a person is a potential exposure. The fre- data that the risk level is lower, contin-
virus, a pathogen. It is transmitted from quency of exposure is higher than any ued exposures could continue to lead to
person to person through contaminated infectious disease since the Spanish In- emergency situations worldwide. With-
droplets from an infected person. These fluenza of 1918. out exposure control at the employee
droplets can come from surface contam- level, continued exposures can continue
ination such as droplets left on a table or
a door handle or from contact such as a
handshake or a hug. Also, these droplets

20

Spring/Summer 2020

to lead to public safety situations and Figure 1 – Risk Levels (Worden, 2015)
infection control situations, all of which
lead to emergency management situa- With the risk function meaning increases in frequency of hazard exposures and hazard severity equaling
tions and patient safety situations. increases in risk, this model illustrates that this is also true for different at-risk groups. For example, while Em-
Risk Management ployee Safety hazards are very frequent, their overall severity - relatively - is not as severe in that these hazards
In the case of infectious disease expo- rarely stop healthcare operations. However, Campus/Visitor Safety hazards are not as frequent but can lead to
sure and a pandemic, all risk areas ap- litigation, media exposure, and other negative effects and are thereby more severe. Infection Control hazards
ply. Because of this, due diligence in risk are less frequent than these but are more severe in that they, too, can lead to major concerns of outbreaks and
management aids in preventing losses the resultant consequences. Finally, full emergency situations are less frequent than the rest but more severe
regarding personnel safety and health, in that they can effectively stop all operations. With this, it's imperative to note that, if Employee Safety hazards
finances, and organizational viability. are not controlled (such as bloodborne pathogen contamination, patient handling hazards, disease exposures,
etc.), the resultant injuries and exposures will lead to inabilities to properly prevent campus safety situations,
infection prevention situations and, by default, emergencies due to employees either being injured, ill, or unable
to work safety during emergencies with heightened operational tempos and increased risk factors. This, in turn,
illustrates why Employee Safety sets the precedent for safe work practices across the entire organization.

Risk Areas
1. Strategic Risk – long-term ability to
operate and/or survive.
In the case of a pandemic, the strategic
safety and health risk is an ongoing pan-
demic with continued outbreaks and per-
sonnel exposures with sickness and/or
death. The strategic business risk is long-
term disruption of business operations
including solvency, employee losses, liti-
gation, and more. Additionally, otherwise
community-based exposures to an infec-
tious disease can be considered occupa-
tional disease exposures if employees
are without safety controls at work.

2. Operational Risk – day-to-day op- exposed to the virus while performing the possibilities for disease exposures,
erational risk. organizational activities, hazard controls personnel losses, regulatory noncompli-
In the case of a pandemic, the opera- are needed to show due diligence in ance, litigation, insolvency, and more.
tional risk is the inability to perform op- workplace safety. This is regulated under 2. Risk Avoidance – completely elimi-
erations with safety and quality. For ex- the General Duty Clause of the Occupa- nating the risk, for better or worse.
ample, employees may be ill and unable tional Safety and Health Act of 1970 and In the case of a pandemic, risk avoid-
to work or refuse to work without safety through individual applicable regulations ance would mean not operating to avoid
controls. Or, PPE or disinfectants may related to specific hazard control options the risk of personnel contracting or
be difficult to obtain. There are many such as Respiratory Protection (29 CFR transmitting the virus during organiza-
operational risks posed by infectious 1910.134), Personal Protective Equip- tional activities.
disease exposures. ment (29 CFR 1910.132), and more. 3. Risk Transfer – outsourcing the risk
3. External Risk – “imported” risk. Risk Treatments to another organization or individual.
External risk is often uncontrollable, For each risk area, risk treatments de- In the case of a pandemic, risk transfer
such as a natural disaster. In the case termine the way the organization will would mean outsourcing or displacing
of a pandemic, the appearance of the handle the risk. operations. For example, if asking an
disease in the United States was un- 1. Risk Acceptance – accepting the employee to check others’ tempera-
controllable. However, now that there is risk as is and whatever losses come tures is deemed too risky, another could
knowledge of the virus, its transmission, with it. be contracted to perform the task. Or,
and the need to prevent exposures, it is In the case of a pandemic, this means re- if an organization’s location is deemed
difficult to claim an uncontrollable risk. suming operations without controls and too risky, personnel could be asked to
4. Hazard Risk – risk that causes harm
to people. 21
Occupational disease exposures, or dis-
ease exposures during employee du-
ties, are a workplace hazard. If there is
reason to believe an employee could be

Journal of the Association of Occupational Health Professionals in Healthcare

telecommute. They’d still be perform- ployees provides operational quarantine cross-contamination of people and ar-
ing work in the course of their organi- and isolation when working at home is eas. PPE is used based on the type(s)
zational activities, but the location risk not possible. of potential exposure and requires
would be transferred to the individual If not possible: diligence to applicable regulations and
employee’s home. 3. Administrative Controls (processes national consensus standards such as
4. Risk Control – acknowledging the to prevent, limit, and reduce potential the Respiratory Protection standard (29
risk but mitigating it to the lowest exposures) – third most effective. CFR 1910.134) and more.
level possible. Many individual and organizational prac- Communication
In the case of a pandemic, risk control is tices can help prevent potential dis- With the hazard analyzed, risk as-
performing organizational activities but ease exposures. These include: staying sessed, and controls implemented,
within safety protocols to show due dili- home if ill or awaiting test results; social these controls and expectations must
gence in preventing disease exposures. distancing by maintaining at least six now be communicated to all affected.
For the determined risk treatment feet between each other; routine disin- For example, if employees are expected
option(s), the means of operationaliza- fection of common surfaces and items to stay at home, maintain social distanc-
tion requires adherence to applicable (such as shared tables, pool vehicles, ing, or provide services within six feet
safety protocols. Ultimately, this means door handles, pens); consistent hand of potentially infectious persons, these
that the organization can determine the hygiene throughout the day; avoiding expectations must be communicated.
level of risk it is comfortable with, but handshakes, hugs, and other physical Further, each employee requires train-
safety protocols must be developed ac- contact; avoiding sharing vehicles and ing as necessary on how to perform the
cording to that risk level. For example, other close quarters; limiting personal expectation (such as using PPE or main-
if the organization wants to operate and interactions; and other methods. taining social distancing).
have personnel come in to work, there Another administrative control is each
must be safety protocols for them to facility or work area checking employ- Leading Indicators
do so safely. These protocols must be ees’ temperatures for indicators of a With the hazard analyzed, risk assessed,
aligned with regulatory requirements. potential infection such as a rising tem- controls implemented, and communica-
Risk and Hazard Control perature or fever (100.4 F or higher). tion taking place, leading indicators are
If a risk is accepted, operations would Additionally, each employee wearing the means to validate if the safety ex-
resume as they were prior to the pan- a face mask over the mouth and nose pectations are being met before an inci-
demic. If a risk is avoided, operations helps by containing each person’s drop- dent occurs. Leading indicators can be
would be cancelled or postponed. If a lets (from sneezing, coughing, talking, accomplished in several ways:
risk is transferred, another agency with or even breathing). Face masks do not • Observations to validate safe work
more particular training, equipment, ex- filter air-transmitted particles and do not
perience, or other qualifiers would per- protect from someone else’s droplets, practices/safe behaviors.
form the operation instead. However, if but they do serve to contain each per- • Inspection to validate safe work con-
a risk is controlled, this too must be as- son’s own droplets. This allows each of
sessed and analyzed to determine the us to “do our part’” to not transmit our ditions.
most effective means of hazard control. germs. • Surveys to validate perceptions of
1. Hazard Elimination - most effective. 4. Personal Protective Equipment
When possible, having employees work (PPE). safety among employees, citizens, or
at home and rescheduling meetings, PPE is necessary for employees who another group.
trainings, and other non-essential activi- are not able to maximize other elimi- • Near-miss reports to check for pos-
ties allows for quarantine and isolation nation, engineering, and administra- sible/probable incidents in the future.
from potential COVID-19 exposures by tive controls due to requirements to • Recognition/incentive programs to
eliminating congregations. provide services to persons known to provide positive reinforcement.
If not possible: be potentially infectious. PPE provides • And more.
2. Engineering Controls (mechanical, protection for the user’s skin, clothing, For example, if the expectation is to
barriers, or other physical means) – and respiratory tract (protection from maintain social distancing, this can be
seocnd most effective. contact with liquid droplets and from done with observations to see if em-
When possible, use of individual work breathing air-transmitted particles). PPE ployees are maintaining at least six
areas, placement of glass barriers/parti- is subject to proper donning and doffing feet from one another. Also, inspec-
tions, and other means to separate em- procedures (putting PPE on and taking tions can detect if facilities are set up
it off) to ensure protection and to avoid accordingly so that six-foot distances
are possible. Surveys can identify if
employees feel supervisors are taking
the virus seriously and monitoring for
safety. Near-miss reports can show if
situations exist in which employees are
within six feet of each other and risking

22

Spring/Summer 2020

Figure 2 – The Safety Improvement Cycle

exposures. Recognition and incentive dent reports, workers’ compensation Investigations and Preventive
programs can be implemented to rec- claims, financial reports, or other means Measures
ognize those helping with observations, to project events where safety hasn’t The last step of the safety analysis cycle
inspections, and near-miss reports and happened as it should have. In the case is the investigation of the lagging indi-
to recognize those actively maintaining of COVID-19, this could mean exposure cators and preventive measures. Now
social distancing. Ultimately, leading in- reports, medical reports for confirmed that we know the lagging indicators
dicators provide information on whether cases, Americans with Disabilities Act and where the existing safety protocols
the team is heading for safety or for in- (ADA) accommodations, and more. It’s weren’t as effective as necessary, we
cidents through promoting participation, also important to note that all these lag- can investigate to determine where the
engagement, and safe work practices ging indicators are subject to the Health- gaps were and how to prevent them in
and conditions. care Insurance Portability and Account- the future. For example, with COVID-19,
In some schools of thought, teams are ability Act (HIPAA), especially where were employees working among each
asked to communicate expectations employee illnesses are concerned. With other where they could have been work-
and information 100 times while others COVID-19, this is a very important fac- ing remotely? Were employees working
are asked to communicate seven dif- tor; employees with COVID-19 cannot among citizens where there could have
ferent ways, seven times each. In any be called out to others, even when their been barriers or social distancing? Were
case, it’s important that communication areas require disinfection. These issues employees providing services within
be frequent and consistent so the mes- require handling with tact and care. six feet without proper respirators and
sage is clear. Ultimately, lagging indicators are very PPE? Each of the hazard controls and
Lagging Indicators important because they provide insight their preceding risk assessment can
Lagging indicators are reports of what into where the existing safety protocols be reviewed to determine if and where
has gone wrong. These could be inci- didn’t work as intended. preventive measures are possible and
feasible. From there, continual improve-
ment is possible to prevent exposures.

23

Journal of the Association of Occupational Health Professionals in Healthcare

In Summary effective as neces-
Ultimately, to protect against COVID-19 sary, lagging indica-
and to minimize possibilities for expo- tors will then pro-
sures, each organization must deter- vide that information
mine its acceptable level of risk and the (if not already identi-
controls necessary for that level of risk. fied through leading
To implement these controls, many are indicators), and in-
implemented simultaneously for each vestigations provide
applicable work area. While some can insight into how and
quarantine and work remotely, others why the incident oc-
are able to maintain separate work spac- curred and what pre-
es. Meanwhile, others work together ventive measures
but maintain social distancing, utilize can be implemented
disinfecting procedures, hand hygiene, to prevent reoccur-
and temperature checks and implement rences. Through this
other administrative controls. Between ongoing cycle, the
these, they minimize the number of safest possible work
employees not in quarantine and pos- can continue.
sibilities for exposures, and then they
provide redundant disinfecting and dis- References
tancing as an added control. Then, while
all these protocols are being followed, The Institutes. (n.d.). Holis-
others needing to provide services to tically assessing risk. The
already-known-to-be infectious persons Institutes: Malvern, PA.
have PPE and the proper preparedness
to do so and avoid cross-contamination. Worden, C. (2014). Safety
With these controls implemented, we diligence. Organization
can then communicate these expecta- Impact Safety Solutions:
tions and validate them through lead- Houston, TX.
ing indicators. If any controls aren’t as
Worden, C. (2015). Situa-
tional safety. Organizational
Impact Safety Solutions:
Houston, TX.

Getting2019 16th Edition STARTED

New Getting Started Manual

The 16th edition of AOHP’s flagship publication, Getting Started:
Occupational Health in the Healthcare Setting, is now available
for purchase! This comprehensive resource is the result of a
major revision with expanded content detailing the many areas of
responsibility for today's OHP. The revised Getting Started was
developed by a core team of editors working with content experts
who contributed in-depth expertise in a wide variety of subject areas.

To order a copy, go to
https://aohp.org/aohp/MARKETPLACE/GettingStartedManual.aspx

24

Spring/Summer 2020

EXPO-S.T.O.P. 2018 – An Overview of Blood Exposure
Incidence in 281 US Hospitals

By Terry Grimmond, FASM, BAgrSc, GrDpAdEd&Tr, Director, Grimmond and Associates, Microbiology Consultants,
and Linda Good, PhD, RN, COHN-S, Former Manager, Employee Occupational Health Services, Scripps Health, San
Diego, CA. Corresponding author: Terry Grimmond, [email protected]

Background requested on: total sharps injuries (SI) with nil or nonsensical data for a specific
Since 2011, the Association of Occupa- and mucocutaneous exposures (MCE) question had the data excluded from cal-
tional Health Professionals in Healthcare from all staff; SI in nurses; SI in doctors; culations pertaining to that question.
(AOHP) has annually conducted The SI in surgical procedures; and hospital Hospital incidence rates for SI and MCE
Exposure Survey of Trends in Occupa- bed size, teaching status, and the state per: 100 ADC; 100 FTE; and 100 Nurse
tional Practice (EXPO-S.T.O.P.) of blood in which it operates. Three denominator FTE were calculated for Teaching and
and body fluid exposures (BBFE) in the metrics were requested: Total full-time Non-teaching facilities, and these, to-
hospitals of participating members and equivalent staff (FTE) (Total FTE was “all gether with nurse, doctor, and surgical
others. The EXPO-S.T.O.P. surveys are staff, all roles, all sites” whether or not proportions, and the number of states
a high-level, national overview of BBFE they have BBFE risk); Nurse FTE; and contributing data, were compared with
rates among hospitals,1-6 and they sup- average daily overnight-patient census previous EXPO-S.T.O.P., EPINet, and
plement the detailed annual surveys (ADC) (also termed “occupied beds”). MSISS surveys. The official MSISS re-
of the International Safety Center (ISC) The questionnaire was available online sults for 2002-2015 (2016-2018 not pub-
EPINet7 and the Massachusetts Sharps or upon email request. To insert their lished) are reported using licensed beds
Injury Surveillance System (MSISS).8 data, participants used either Survey as the denominator. To compare this da-
The EXPO-S.T.O.P. surveys have been Monkey™ or emailed data directly to the tabase with EPINet and EXPO-S.T.O.P.
conducted by Dr. Linda Good and Terry authors. An Excel spreadsheet of the results, the MSISS data were converted
Grimmond and, with Dr. Good now re- questions was also available to enable to rates per occupied beds (ADC) using
tired, the 2018 survey is to be her last. multi-hospital systems to conveniently hospital-specific occupancy data for all
For the immediate future, surveys will supply data on their individual hospitals. MSISS-licensed hospitals as published
be conducted by the ISC under Dr. Am- Accompanying the survey was an expla- by the Massachusetts Department of
ber Mitchell. She, with Ginger Parker, nation of the purpose and goals of the Public Health.
has adapted EPINet software to facili- survey and investigator contact informa- WinPepi v11.26 was used to calculate
tate EXPO-S.T.O.P. data collection and tion. Chi2 and log-transformation risk ratios
analysis. The transition to ISC for data Participants were given the option of (RR) at 95% confidence limits (CL95),
collection and collation has been gener- providing contact information if they with statistical significance set at p ≤
ously sponsored by an annual grant from were willing to be contacted for further 0.05.9
Daniels Health, a healthcare waste-ser- information about their data and/or the Summary of EXPO-S.T.O.P.
vice and safety-product provider. hospital’s exposure management pro- 2018 Results
This report presents the results of the gram. The survey was strictly anony- • Exposure data were received from
EXPO-S.T.O.P. 2018 survey, and, using mous, and participants were assured
tables and figures, compares the results no hospital name or details would be re- hospitals in 37 U.S. states and territo-
with previous EXPO-S.T.O.P.,1-6 EPINet,7 vealed without their permission. To en- ries (Fig 1).
and MSISS surveys.8 courage participation, AOHP provided a • 161 participants supplied data on 281
Methods free conference registration as the prize hospitals, the largest EXPO-S.T.O.P.
An 18-item questionnaire was made in a drawing for those completing the study to date (Table 1) (a 25% increase
available to all AOHP members and survey by a specified deadline. in participating hospitals over the 2017
other hospitals expressing an interest Participants with contact details were survey).
in participating. Data on reported expo- contacted if their data were incomplete • An additional 14 non-hospital facili-
sures from the 2018 calendar year were or contained “outlier” data. Participants ties supplied exposure data (excluded
from report).

25

Journal of the Association of Occupational Health Professionals in Healthcare

• Hospital sizes ranged from 1 to 925 Fig 1. Participating states and territories in EXPO-S.T.O.P. 2018
ADC and from 27 to 31,117 FTE (Table
1). Fig 2. Sharps injury incidence by hospital FTE size (all hospitals)

• Of the 216 participants supplying SI - sharps injury; FTE – full-time equivalent staff
AOHP membership status, 66.7%
were AOHP members. Fig 3. Sharps injury incidence by year 2000 – 2018 comparing databases (ADC as denominator)

• Of the hospitals participating, 42.7% ADC - average daily census of overnight-occupied beds; EPINet - Exposure Prevention Information Network;
were Teaching hospitals (38% - 53% EXPO-S.T.O.P. - Exposure Survey of Trends in Occupational Practice; MSISS - Massachusetts Sharps Injury
in past years) and, as this is a higher Surveillance System (Data for 2016-2018 not published); BPS - Bloodborne Pathogen Standard; SI - sharps injury
proportion than the 20% nationally,
EXPO-S.T.O.P. exposure rates are like-
ly higher than national rates.

• 16,119 reported exposures were
submitted by participating hospitals
(11,523 SI; 4,596 MCE).

• In hospitals where both SI and MCE
exposures were collected, MCE were
27.0% of total reported exposures
(Table 2).

• Incidence rates for SI and MCE, us-
ing three denominators, together with
results for the three previous EXPO-
S.T.O.P. surveys, are shown in Table 2.
Of significance, compared to 2017:
o SI/100 ADC (for Total hospitals;
Teaching hospitals) was lower.
o SI/100 FTE (for Total, Non-teaching
and Teaching hospitals) was lower.
o Nurse SI/100 Nurse FTE was lower
in Non-teaching but higher in Teach-
ing hospitals.
o MCE/100 ADC incidence (All hospi-
tals) was unchanged.
o MCE/100 FTE incidence (All hospi-
tals) was lower.
o MCE as a percentage of Total Expo-
sures was higher.

• Fig 2 shows an (almost) linear relation-
ship between SI incidence and hospi-
tal FTE size.

• Table 3 shows, of total reported SI:
o 40.5% were during surgical proce-
dures (rising steadily over last four
years).
o 29% were reported by doctors (low-
er than previous three years).
o 39.8% were reported by nurses (ris-
ing steadily in last three years).

• Fig 3 examined historic SI/100 ADC
rates and shows both EPINet and
EXPO-S.T.O.P. hospitals had a lower
SI/100 ADC rate in 2018 than the pre-
vious year, but this rate is still above
the SI/100 ADC rate of 2001.

• The 2018 EXPO-S.T.O.P. SI/100 FTE
rate was lower than that reported by
EPINet hospitals in 2001 (Fig 4).

26

Spring/Summer 2020

Table 1. Overview of EXPO-S.T.O.P. Surveys Study Limitations
Table 2. Sharps injury and mucocutaneous exposure incidence 2015-2018 using multiple The survey is voluntary and, as such,
denominators may exhibit participant bias. At 281
hospitals, the survey samples less than
Table 3. Reported sharps injuries: proportions among nurses, doctors, and surgery staff 5% of the 6,200 hospitals in the United
States and may not be representative of
national exposure rates. Survey results
are biased toward teaching hospitals,
and overall incidence rates may be high-
er than rates nationally. The same hos-
pitals do not participate each year, and
variation in results from year to year may
not be due to time or participant risk-re-
duction strategies. The survey is limited
to results from hospitals only – how-
ever, more than half of U.S. healthcare
personnel (HCP) work outside hospitals
and, with potentially less access to safe-
ty-engineered devices, may have higher
exposure rates than HCP in hospitals.
The data used for MSISS comparisons
are not official MSISS results: they are
a denominator-conversion using Mas-
sachusetts hospital-specific occupancy
rates. In examining EPINet, MSISS, and
EXPO-S.T.O.P. databases, the ratio of
acute to non-acute hospitals and per-
centage of teaching hospitals may differ
in each database. Although the authors
cross-triangulate all denominator an-
swers and confirm outliers with partici-
pants, the survey relies on participants
correctly and similarly interpreting the
questions.

In some states, hospitals are precluded
by state law from employing medical
staff, and in these hospitals, non-em-
ployee medical staff exposures are not
required by the Occupational Safety and
Health Administration (OSHA) Standard
to be recorded. Notwithstanding state
and OSHA laws, hospitals vary widely as
to whether they include employee and
non-employee medical staff in their ex-
posure recordings. Hospitals are asked
to include results for “all staff, all roles,
all sites for the hospital and its satel-
lites”; however, hospitals vary widely
as to whether their satellite services
(e.g., clinics, ambulatory surgery cen-
ters, home healthcare) come under their
hospital license or are set up as separate
business entities. As such, their numer-
ator and denominator answers may or
may not include satellite services.

27

Journal of the Association of Occupational Health Professionals in Healthcare

Conclusions Fig 4. SI incidence trends 2000 – 2018 (FTE as denominator)
Accepting the above limitations:
• The significant fall in overall SI and SI - sharps injury; FTE – full-time equivalent staff; EPINet – Exposure Prevention Information Network; EXPO-
S.T.O.P. - Exposure Survey of Trends in Occupational Practice
MCE rates in 2018, as opposed to sig-
nificant increases in each of previous References 6. Grimmond T, Good L. EXPO-S.T.O.P. 2016 and 2017
three years, may indicate that more blood exposure surveys: An alarming rise. Am J
effective exposure-prevention strate- 1. Grimmond T, Good L. EXPO-S.T.O.P.: A national sur- Infect Contr 2019;47:1465-1470. DOI: https://doi.
gies are being implemented in partici- vey and estimate of sharps injuries and mucocuta- org/10.1016/j.ajic.2019.07.004.
pating hospitals. neous blood exposures among healthcare workers
• A fall in overall SI rates among nurses in USA. J Assoc Occ Hlth Prof 2013;33(4):31-36. 7. International Safety Center. EPINet Sharps Injury
was not evident in 2018 and may in- and Blood and Body Fluid Data Reports. Years 2000
dicate increased reporting, or it may 2. Grimmond T, Good L. EXPO-S.T.O.P.-2012: Year to 2018. https://internationalsafetycenter.org/expo-
indicate increased education and train- two of a national survey of sharps injuries and mu- sure-reports/. Accessed Mar 7, 2020.
ing in frequency and correct use of cocutaneous blood exposures among healthcare
safety devices is warranted. workers in USA hospitals. J Assoc Occ Hlth Prof 8. Massachusetts Department of Public Health, Oc-
• The downward trend in the proportion 2015;35(2):52-57. cupational Health Surveillance Program. Sharps In-
of reported SI from nurses and doc- juries among Hospital Workers in Massachusetts.
tors may indicate that the increase 3. Brown C, Dally M, Grimmond T, & Good L. Exposure Findings from the Massachusetts Sharps Injury
among non-nurse, non-doctor staff re- Study of Occupational Practice (EXPO-S.T.O.P.): An Surveillance System (MSISS). Data and Statistics
quires investigation. update of a national survey of sharps injuries and – years 2002 to 2015. https://www.mass.gov/lists/
• Overall, with 17 years having elapsed mucocutaneous blood exposures among HCW in needlesticks-and-other-sharps-injuries-data-and-sta-
since enactment of the Bloodborne US hospitals. J Assoc Occup Hlth 2016;36(1):37-42. tistics. Accessed Mar 7, 2020.
Pathogen Standard (requiring manda-
tory safety-engineered device (SED) 4. Grimmond T, Good L. Exposure Survey of Trends in 9. Abramson JH. WinPepi v11.65, 2016. Computer
use and training), the 2018 rates have Occupational Practice (EXPO-S.T.O.P.) 2015: A na- Programs for Epidemiologic Analysis. http://www.
not decreased as expected, and in- tional survey of sharps injuries and mucocutaneous brixtonhealth.com/pepi4windows.html. Accessed
creased resources and determination blood exposures among healthcare workers in US Mar 7, 2020.
are indicated to increase the safety hospitals. Am J Infect Control 2017;45(11):1218–
and correct use of SED. 1223. doi.org/10.1016/j.ajic.2017.05.023.
Acknowledgements
The authors wish to thank the Execu- 5. Grimmond T, Good L. EXPO-S.T.O.P. 2016 and 2017
tive Board of the Association of Occupa- Report. J Assoc Occ Hlth Prof (Winter) 2019; 39(1):
tional Health Professionals in Healthcare 9-11.
(AOHP) for the grant of $3,000 toward
the cost of this research project. We
also wish to heartily thank all the par-
ticipants who contributed their hospital
exposure data.

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28

Spring/Summer 2020

The Perils of Perfectionism in Nursing

Don’t let perfectionism derail your leadership career.

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Copyrighted content. Please contact AOHP
Headquarters at 800-362-4347 or [email protected] to

purchase a copy of this Journal issue.

29

Spring/Summer 2020

AOTHrPeaAsnunreura’sl Report

Year Ending 2019

This report includes the January to De- revenue-producing income for AOHP, • Membership income declined by 2%.
cember 2019 financial year for AOHP. with national dues being the second- • National dues decreased by .5%.
As Treasurer, I conduct a monthly re- largest revenue producer. AOHP uti- • Annual National Conference income
view of the financial report, specifically lizes the services of a management
looking at income and expenses. AOHP company, Kamo Management Services, and expense ratio continues to be
strives to maintain a positive financial which strives to keep our expenditures positive.
position while providing resources, as- within the budget by carefully managing Questions concerning this report, or
sistance, and educational opportunities Journal ads, subscriptions, CEUs, and requests for additional information,
that are beneficial and of interest to broadcast mailings. Kamo handles the can be obtained by contacting me by
the membership. The Executive Board day-to-day activities of the AOHP orga- email at [email protected] or
continues to explore opportunities to nization and is paid a fixed monthly fee by emailing Headquarters at a.weist@
expand membership, produce positive with separate charges for certain other kamo-ms.com. The financials are avail-
marketing strategies, and investigate services. AOHP’s contract with Kamo able for members to review upon re-
other sources of revenue to grow as an runs through December 31, 2021. quest.
organization. Overview for 2019: Respectfully Submitted,
The attached graphs depict AOHP’s fi- • Total income and expenses for 2019 Dana Jennings, RN, BSN
nancial position for the year 2019. The AOHP Executive Treasurer
National Conference provides the most remain stable.

AOHP Income Summary AOHP Expense Summary

January through December 2019 January through December 2019

Total income $428,202.97 Total Expense $427,206.10

31

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of hepatitis B virus in adults 18 years of age and older. who received Engerix-B. The mean age was 54 years for both groups. The primary analysis compared the
seroprotection rate at week 12 for HEPLISAV-B with that at week 32 for Engerix-B. Noninferiority of the
IMPORTANT SAFETY INFORMATION seroprotection rate induced by HEPLISAV-B compared to Engerix-B was demonstrated.3

Do not administer HEPLISAV-B to individuals with a history of severe allergic †Trial 3 study design: A clinical trial in adults aged 18 to 70 years who received HEPLISAV-B (N=4537) or Engerix-B
reaction (e.g., anaphylaxis) after a previous dose of any hepatitis B vaccine or (N=2289). The primary analysis evaluated the noninferiority of the rate of protective immunity at week 28 induced by
to any component of HEPLISAV-B, including yeast. HEPLISAV-B (n=640) to Engerix-B (n=321) in patients with type 2 diabetes mellitus. A secondary immunogenicity
Appropriate medical treatment and supervision must be available to manage objective was to demonstrate the noninferiority of the rate of protective immunity with HEPLISAV-B at week 24
possible anaphylactic reactions following administration of HEPLISAV-B. compared with Engerix-B at week 28 in all subjects and in subgroups defined by age, sex, body mass index, and
Immunocompromised persons, including individuals receiving immunosuppressant smoking status among adults aged 18 to 70 years.6
therapy, may have a diminished immune response to HEPLISAV-B.
Hepatitis B has a long incubation period. HEPLISAV-B may not prevent Abbreviation: ACIP, Advisory Committee on Immunization Practices.
hepatitis B infection in individuals who have an unrecognized hepatitis B infection
at the time of vaccine administration. REFERENCES: 1. Mast EE, Weinbaum CM, Fiore AE, et al. A comprehensive immunization strategy to eliminate
The most common patient-reported adverse reactions reported within 7 days transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee
of vaccination were injection site pain (23%-39%), fatigue (11%-17%), and on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep. 2006;55(RR-16):1-33.
headache (8%-17%). 2. Louther J, Feldman J, Rivera P, Villa N, DeHovitz J, Sepkowitz KA. Hepatitis B vaccination program at a
New York City hospital: seroprevalence, seroconversion, and declination. Am J Infect Control. 1998;26(4):423-427.
Please see Brief Summary of Prescribing Information on the following pages. 3. HEPLISAV-B [package insert]. Emeryville, CA: Dynavax Technologies Corporation; 2020. 4. Kim DK, Hunter P; for
the Advisory Committee on Immunization Practices. Recommended adult immunization schedule, United States,
2019. Ann Intern Med. 2019;170(3):182-192. 5. Schillie S, Harris A, Link-Gelles R, Romero J, Ward J, Nelson N.
Recommendations of the Advisory Committee on Immunization Practices for use of a hepatitis B vaccine with
a novel adjuvant. MMWR Morb Mortal Wkly Rep. 2018;67(15):455-458. 6. Jackson S, Lentino J, Kopp J, et al.
Immunogenicity of a two-dose investigational hepatitis B vaccine, HBsAg-1018, using a toll-like receptor 9
agonist adjuvant compared with a licensed hepatitis B vaccine in adults. Vaccine. 2018;36(5):668-674.

Visit HeplisavB.com to learn more.

© 2020 Dynavax Technologies Corporation. All rights reserved. May 2020 US-20-00-00168

Spring/Summer 2020
33

Journal of the Association of Occupational Health Professionals in Healthcare

34

Spring/Summer 2020

Prepare and Pursue Board Opportunities:
A Practical Guide for Nurse Leaders to Serve on a Board

By Kimberly A. Cleveland, JD, MSN, RN, C-MBC, C-MPC, and Kimberly J. Harper, MS, RN, FAAN

Copyrighted content. Please contact AOHP
Headquarters at 800-362-4347 or [email protected] to

purchase a copy of this Journal issue.

35

Journal of the Association of Occupational Health Professionals in Healthcare

Effects of Air Pollution and Other Environmental
Exposures on Estimates of Severe Influenza
Illness, Washington, USA

By Ranjani Somayaji, Moni B. Neradilek, Adam A. Szpiro, Kathryn H. Lofy, Michael L. Jackson,
Christopher H. Goss, Jeffrey S. Duchin, Kathleen M. Neuzil, Justin R. Ortiz

Ecologic models of influenza burden may be confounded by other exposures that share winter seasonality.
We evaluated the effects of air pollution and other environmental exposures in ecologic models estimating
influenza-associated hospitalizations. We linked hospitalization data, viral surveillance, and environmental
data, including temperature, relative humidity, dew point, and fine particulate matter for three counties in
Washington, USA, for 2001–2012. We used negative binomial regression models to estimate the incidence
of influenza-associated respiratory and circulatory (RC) hospitalizations and to assess the effect of adjust-
ing for environmental exposures on RC hospitalization estimates. The modeled overall incidence rate of
influenza-associated RC hospitalizations was 31/100,000 person-years. The environmental parameters were
statistically associated with RC hospitalizations but did not appreciably affect the event rate estimates. Mod-
eled influenza-associated RC hospitalization rates were similar to published estimates, and inclusion of en-
vironmental covariates in the model did not have a clinically important effect on severe influenza estimates.

Seasonal influenza is associated with events inform public health actions, mental exposure covariates, we under-
an estimated 3,300–48,000 annual such as vaccine or treatment recom- took this study to evaluate the effect of
deaths in the United States1 and has a mendations, as well as patient and including environmental exposures in
major global impact on economies and healthcare provider communications. traditional models on estimates of in-
health2–4. Prospective surveillance with In the United States, influenza and most fluenza disease. We hypothesized that
specific laboratory testing for influenza other respiratory infections are seasonal environmental exposures would be as-
is expensive and may underestimate the and follow an approximately sinusoidal sociated with severe respiratory and
true burden of influenza if such tests are curve with winter peaks. Climatic and circulatory (RC) hospitalizations and that
underused or insensitive or if influenza air pollutant parameters, such as tem- adjustment for these covariates would
results in complications or hospitaliza- perature, humidity, and ambient fine have a clinically meaningful effect on
tions beyond the period in which virus particulate matter, vary during the puta- estimates of severe influenza disease
may be detected in patient samples5. tive influenza season and are associated incidence.
Therefore, the Centers for Disease with acute respiratory infections21. Be- Materials and Methods
Control and Prevention (CDC) and other cause these other factors share a sea- Design Overview
public health organizations use model- sonality similar to influenza, neglecting We conducted a study using aggregat-
ing studies to estimate the incidence of them may overestimate the effects of ed datasets from three counties (King,
severe influenza illness to inform public influenza on health outcomes. Influen- Pierce, and Snohomish) in western
health actions1,3,6–10. Typically, modeling za models that include meteorological Washington state during 2001–2012.
of the influenza disease burden links ag- data have improved predictive accuracy We used administrative hospitaliza-
gregate data for outcomes identified in for viral circulation and peak seasonal- tion data, respiratory virus surveillance
vital statistics or hospitalization admin- ity21–23. National and global models of in- data, and environmental exposure data
istrative databases to influenza virologic fluenza disease burden do not account collected prospectively from the study
surveillance data over time. The differ- for environmental and meteorological area. The primary analysis was to esti-
ence between estimates with and with- parameters, which may be important mate the incidence of influenza-associ-
out influenza covariates is attributed to confounding variables1–3,6–8. ated RC hospitalizations using standard
influenza activity. Such models have Given the importance of influenza dis- CDC ecologic models and to assess the
been used extensively in the United ease burden estimates on public health effect that inclusion of environmental
States10–14, in other countries15–17, and decision making and the reliance on exposure variables in these models had
to produce global estimates of influenza ecologic models that exclude environ- on the incidence estimates.
disease burden2,3,18–20. The resulting es-
timates of excess influenza-associated

38

Spring/Summer 2020

In a secondary analysis, we added respi- scription PCR (RT-PCR), with an increas- ures 1–5, https://wwwnc.cdc.gov/EID/
ratory syncytial virus (RSV) as an addi- ing use of RT-PCR over the study period. article/26/5/19-0599-App1.pdf). The val-
tional exposure covariate into the model. We did not include influenza data from ues for the six stations were highly cor-
This study received exempt review sta- Tacoma and Snohomish counties. Public related (Pearson correlation coefficient
tus from the Human Subjects Division health respiratory virus surveillance was range 0.93–0.99). Because the data
at the University of Washington and the not conducted in the counties during from Boeing Field station in King County
Washington State Department of Health the study period. We reviewed limited were the most complete and the station
Institutional Review Board. influenza testing data from the largest was the closest to the urban centers,
Hospitalization Database hospital systems in each county. Total we used data from this station to rep-
We obtained the Washington State influenza tests from Tacoma (23,741) resent the meteorological exposures for
Department of Health Comprehensive and Snohomish counties (<3,000) were the entire study area. For the meteoro-
Hospital Abstract Reporting System very low compared with those from logical data, including temperature, rela-
(CHARS) dataset for the study area and King County (372,022) and were avail- tive humidity, and dew point, 680 weeks
time periods. The CHARS database able for only part of our study period (4,736 days) of data were available, leav-
contains publicly available deidentified (2007–2008 and 2008–2012 for Tacoma ing <0.005% of days with missing data
discharge information derived from and 2010–2013 for Snohomish). Influ- during the study period.
hospital billing systems for patients in enza seasonality and peak seasons were
all of the public and private hospitals in similar in all three sites. Laboratory re- We also used daily ambient outdoor air
Washington24. The CHARS data contain ports did not consistently distinguish be- pollution data in the form of concentration
information on age, home ZIP code, tween influenza A subtypes or influenza of particulate matter with a diameter <2.5
and other demographics, as well as pa- B lineages; therefore, we included only μm (PfPoMMr 222.15.5)cs29ot,a3n0tcioe(AnnsptrpfaretoinomdniexdaacFthiagouwfreethsree6tah,vrae7ie)l-.
tient diagnoses, procedures, and billed influenza A and B as exposure variables. The
charges. We defined RC hospitalizations The seasonality and temporal peaks of able
as any listed hospitalizations with codes the proportion positive of influenza A and counties, giving a total of 4,581 days of
390–519 from the International Classifi- influenza B data among these sites were data. Some of the stations were distant
cation of Diseases, 9th Edition5,6,8. We similar, so we aggregated each across all from urban centers (e.g., the Mount Rain-
categorized age as 0–6 months, 7–23 three counties for analyses. ier National Park station in Pierce County);
months, 2–4 years, 5–14 years, 15–49 RSV laboratory data were collected as others had substantial periods with miss-
years, 50–64 years, and >65 years. We part of routine care by the University of ing data during the study period. Three
calculated aggregate RC counts per day, Washington Clinical Virology Laboratory stations, Seattle–Beacon Hill (King Coun-
age category, and county and merged and reported to the National Respiratory ty), Tacoma (Pierce County), and Marys-
them with the other datasets for statisti- and Enteric Virus Surveillance System; ville (Snohomish County), were close
cal analysis. The unit of observation was these data were available for the pe- to urban centers and had less missing
RC hospitalization, which we also call riod September 30, 2007–December 29, data; we used these sites to define the
“event” in this report. 201226. RSV tests used antigen detec- PwdaMeilry2e.5PheMixg2ph.5olyesuxcpreoosrsruefrloaertse.dthBeewcitathhurseoeentlshyteastdimoanialsyll
Respiratory Virus Surveillance tion, viral culture, and RT-PCR testing, systematic differences (Pearson correla-
Data with RT-PCR use increasing over the pe- tion coefficients among pairs of stations
We accessed influenza virus surveillance riod. RSV subtypes were not available. 0su.7re4s–0a.9cr1o),sws ethaevearvaagileadbldeavilyalPueMs2.f5oerxtphoe-
data from three sources in the study We used weekly surveillance data for stations. The resulting daily average was
area: University of Washington Clinical our model. We divided the weekly num- available in 96% of the study period.
Virology Laboratory, Public Health–Se- ber of influenza A and influenza B detec-
attle & King County, and Seattle Chil- tions by the weekly number of influenza Population Estimates
dren’s Hospital. Each laboratory was tests performed and multiplied the re- We obtained annual age-specific popula-
in King County and participated in the sult by 100 to calculate a weekly per- tion estimates for each of the three coun-
United States Influenza Virologic Surveil- centage of positive tests. We calculated ties for 2001–2012 from Washington
lance System during the study period. the weekly percentage of positive RSV State Office of Financial Management
Influenza testing data were available for tests similarly. (OFM)30. OFM population estimates for
September 30, 2001, through December Environmental and Meteorology 2000–2010 are based on the 2000 and
29, 2012, except for the third quarter of Exposure Time Series 2010 US Census and an interpolation in
200225. Clinical specimens collected as We accessed daily meteorology data the intermediate years31. OFM popula-
part of routine care were tested in labora- including temperature, relative humid- tion estimates for 2011 and 2012 were
tories for evidence of influenza virus, and ity, and dew point for six meteoro- developed using the component meth-
results were reported to local and state logical stations from each of the three od, which derives the estimated popula-
health departments and CDC. The three counties studied27,28 (Appendix Fig- tion by adding natural population change
sites used viral culture or reverse tran-
39

Journal of the Association of Occupational Health Professionals in Healthcare

(births minus deaths) and net migration Figure 1. Influenza detections and respiratory and circulatory hospitalizations in western
to the base-year population32. Population Washington, USA, 2001–2012. A) Total detections of influenza by clinical laboratories and
estimates for the 0–6 month, 7–23 public health surveillance. B) Incidence of all-cause respiratory and circulatory hospital-
month, and 2–4 year age groups were izations by age group.
not available from OFM data and were
estimated from the annual birth data
from the Washington State Department
of Health32. We carried the annual birth
numbers for each county forward in time
to estimate the population sizes for the
0–6 month, 7–23 month, and 2–4 year
categories at a specific time point. Be-
cause births were reported annually and
our age categories included half-year
fractions (0–6 month and 7–23 month),
we used halves of the appropriate annu-
al birth numbers to estimate population
sizes in these age categories.

Statistical Analysis
To describe all-cause RC hospitaliza-
tions, we calculated rates of any RC hos-
pitalization divided by person-time under
observation for each age category. To
estimate influenza-associated events,
we adapted negative binomial regres-
sion models used previously by CDC to For each age category, we fit a base rates, and PARs using the nonparamet-
estimate the incidence of influenza-asso- model, which was similar to CDC eco- ric bootstrap35.
ciated hospitalizations from surveillance logic models and excludes environmen- To assess the effect of inclusion of RSV
data and administrative hospitalization tal exposures, and an expanded model, in our models, our secondary analysis
datasets5,6,8,33,34. We fitted age-specific which included the environmental ex- expanded the model by adding an addi-
negative binomial regression models to posures. Using each fitted model, we tional term, β35RSV, for the effect of the
daily events in the three counties of in- calculated the number of age-specific percentage of specimens testing posi-
terest (Appendix). Covariates were time influenza-associated RC hospitaliza- tive in the corresponding week for RSV.
(day expressed as a fraction of the year), tions as the difference between model- We calculated the numbers of virus-
daily RC hospitalizations in a particular predicted RC hospitalizations estimated specific (disaggregated) and the total (in-
county on a particular day, the county’s from the original data and model-pre- fluenza + RSV) attributable RC hospital-
population size in that calendar year, dicted RC hospitalizations with all in- izations as the corresponding rates and
the percentage of specimens testing fluenza terms set to 0. We calculated PARs. We calculated incidence rates for
positive in the corresponding week for the number of type-specific influenza- RSV-associated outcomes similarly to
influenza A and influenza B, daily envi- associated RC hospitalizations (influ- the influenza outcomes. We limited the
ronmental effects, and terms account- enza A or B) in a similar fashion but fit of the RSV model to the period of RSV
ing for secular and seasonal trends. The by setting only one of the influenza data availability.
offsets for county and population in the terms to 0. To express the influenza- We conducted three sensitivity analyses
model account for different population associated RC hospitalizations as rates, based on the primary analysis model to
sizes across counties and years. The we divided them by the age-specific assess the effect of alternative model-
environmental effects include the effect population estimates (presented as the ing choices: 1) analysis with the environ-
of the temperature, humidity, dew point, number of events per 10,000 person- mental exposure modeled as linear in-
and ePffMec2t.5 concentration. We modeled months or 100,000 person-years). We stead of as the cubic B-spline; 2) analysis
the of each of these four variables calculated population-attributable risks without the one-day-lag environmental
by exposure on the same day and by (PARs) for influenza-associated RC hos- exposure variables; and 3) analysis with
exposure on the previous day (one-day pitalizations for each age category as weekly events instead of daily events.
lag term). We used a cubic B-spline with the number of influenza-associated RC We compared the results of the primary
three degrees of freedom for both the hospitalizations divided by the number analysis to these alternative modeling
same day and one-day lag terms for a to- of all-cause RC hospitalizations. We cal- choices and found no major differences.
tal of 24 adjustment coefficients for the culated 95% CIs for the number of in-
four environmental variables. fluenza-associated RC hospitalizations,

40

Spring/Summer 2020
Table 1. Influenza-associated respiratory and circulatory hospitalizations by age group modeled with and without environmental covariates,
October 2001–December 2012*

Statistical diagnostics of the models rates varied across age groups and influenza B, 10.3/100,000 person-
included added variable plots and likeli- had a marked winter seasonality over years). The influenza-associated event
hood ratio tests for distributed lags (day the study period (Figure 1). In the base rates were highest in the 0–6 month
2 through day 6 lags) and illustrated ade- model, influenza-attributable event rates (111.9/100,000 person-years) and the
quate model fit. We performed analyses were highest in the 0–6 months age >65 years (147.3/100,000 person-years)
with R version 3.1.0 statistical software group (118.7/100,000 person-years) and age groups. PAR was highest in the
(https://r-project.org). the >65 years age group (157.0/100,000 5–14 years age group (4.8%; 95% CI
Results person-years). Of these, the influenza 3.7%–6.0%) (Table 2). When assessed
The study populations ranged from A attributable event rate was highest in by influenza type, influenza A had a
1,758,779 (King), 708,230 (Pierce), the same two age groups (0–6 months, greater number of attributable events
and 615,435 (Snohomish) in 2001 to 159.9/100,000 person-years; >65 years, in all age groups with the exception of
1,960,782 (King), 808,316 (Pierce), and 81.3/100,000 person-years), and the in- the >65 years age group (influenza A,
723,301 (Snohomish) in 2012. A total fluenza B rate was highest in the >65 69.3/100,000 person-years; influenza
of 1,503,081 all-cause RC hospitaliza- years age group (76.2/100,000 person- B, 78.4/100,000 person-years). Simi-
tions occurred in these 3 counties dur- years) (Table 1). Overall, influenza A larly, PAR was greater for influenza A
ing September 30, 2001–December 29, was associated with higher hospital- across age groups with the exception of
2012, for an overall incidence rate of ization rates than influenza B (21.3 vs. the >65 years group (Table 2). PAR for
4,600/100,000 person-years. Incidence 10.3/100,000 person-years). influenza was similar in both the base
rates were highest at the extremes of In the expanded model incorporating (without environmental covariates) and
age (0–6 months, 5,949/100,000 per- environmental covariates, all the envi- expanded (with environmental covari-
son-years; 50–64 years, 6,503/100,000 ronmental and air pollution covariates ates) models.
person-years; and >65 years, were significantly associated with RC Secondary Analysis—Influenza
23,077/100,000 person-years). hospitalizations (p<0.01) for each of and RSV Models
Using the base model, incorporating the seven age groups (Appendix Table Among data with other covariates avail-
time and seasonality, and excluding 2); however, the influenza-associated able, RSV data were available for 1,811
environmental exposures, the overall event rates did not change appreciably days and were analyzed with influenza
incidence rate of influenza-associated in any age group (Table 1; Figure 2). The in models with and without environ-
RC hospitalizations was 31/100,000 overall influenza-attributable rate was mental covariates (Appendix Table 1). In
person-years with 0.7% PAR. Event similar at 31.4/100,000 person-years (in- the base model incorporating time and
fluenza A, 21.3/100,000 person-years; seasonality, similar to influenza, RSV-

41

Journal of the Association of Occupational Health Professionals in Healthcare

Figure 2. Influenza-associated hospitalization risk by age, with and without inclusion of en- models, including linear adjustments for
vironmental covariates, western Washington, USA, 2001–2012. A) influenza A; B) influenza B. environmental parameters (instead of
cubic-splines), models without lags for
environmental parameters (versus mod-
els with lags), and models on weekly-ag-
gregated data (versus daily-aggregated),
which led to the same conclusions and
added confidence to our results.

attributable event rates were highest in Discussion Several environmental parameters have
the youngest and oldest age groups. In We conducted a population-based study been found to improve forecasts of in-
the expanded model incorporating en- incorporating hospitalization, labora- fluenza activity, and they may contrib-
vironmental covariates, the attributable tory, and meteorological data from three ute to influenza illness in several ways.
event rates for influenza or RSV did not Washington counties over 12 years to Climatic variables, such as tempera-
appreciably change. PAR for influenza- estimate the burden of influenza- and ture and humidity, increase the survival
or RSV-associated RC hospitalizations in RSV-associated RC hospitalizations. and spread of influenza in the environ-
the expanded model was 1.0%–12.9% Hospitalization rates peaked during the ment23,36. These same factors change
and did not differ from the base model winter, corresponding to periods of in- human behaviors and enhance virus
results (Table 3). fluenza circulation, and the highest rates transmission by driving people indoors
were at the extremes of age for both and increasing crowding. Air pollution in-
Sensitivity Analysis—Examining influenza and RSV events. Our overall creases every winter and is significantly
Alternative Modeling Choices influenza-associated hospitalization rate associated with respiratory infections37.
We performed sensitivity analysis eval- estimate was 31/100,000 years. This is Certain climate conditions, including
uating alternative modeling choices: similar to CDC estimates of 55.0/100,000 temperature, humidity, and particulate
environmental covariates modeled as person-years (95% CI 22.5–125.4) over matter can affect susceptibility to upper
linear; environmental covariates mod- a period including the 1990s, which was respiratory infections38–41. Despite these
eled without lag terms; and models run notable for high rates of severe influ- well-known associations between en-
on weekly aggregates. We ran these enza6,7. Our age-specific models with all vironmental exposures and respiratory
alternative models for influenza alone assessed environmental and air pollu- events, our study found that their inclu-
(primary analysis) and for influenza with tion parameters demonstrated that fac- sion in a model designed to estimate
RSV (secondary analysis). We found, as tors of temperature, relative humidity, influenza illness in western Washington
in our primary analysis, that age-specific dew point, and particulate matter were had a negligible effect. Whether their
models with all assessed environmental significantly associated with RC hospi- influence on disease burden estimates
and air pollution parameters were sig- talizations (p<0.01 for each age group). remains small in regions with more ex-
nificantly associated with RC hospitaliza- However, the inclusion of environmen- treme weather or air pollution is unclear.
tions (p<0.05 for each age group). How- tal covariates did not result in clinically Our study should be interpreted in light
ever, we saw no meaningful changes in meaningful changes in respiratory vi- of its strengths and limitations. Because
the attributable event rates (Appendix rus–associated event estimates. In ad- our data were from western Washington
Figures 8, 9). dition, we conducted several alternative state, the study may not be generalizable
42 to other regions in which environmental
factors may differ. Our focus on a lim-
ited geographic area can increase con-
fidence that the population studied was
truly exposed to the environmental co-
variates used in our models, but this de-
sign choice limits our ability to evaluate
rarer outcomes, such as critical illness
or death. We used clinical and virologic
surveillance data to model the incidence
rates for severe influenza but did not
have specific data relating to influenza
vaccine, and we were not able to incor-
porate other respiratory viruses because
we lacked robust surveillance data for
the study period. For influenza and RSV,
the use of percent positive rather than

Spring/Summer 2020
Table 2. Population attributable risk of influenza-associated respiratory and circulatory hospitalizations by age group modeled with and
without environmental covariates, October 2001–December 2012

Table 3. Secondary analysis of population attributable risk (PAR) of influenza or respiratory syncytial virus (RSV)-associated respiratory and
circulatory hospitalizations by age group modeled with and without environmental covariates, September 2007–December 2012

43

Journal of the Association of Occupational Health Professionals in Healthcare

absolute numbers in the model corrects Acknowledgments 3. Iuliano AD, Roguski KM, Chang HH, Muscatello DJ,
for changing surveillance intensity over We thank Helen Powell for her advice on Palekar R, Tempia S, et al.; Global Seasonal Influenza-
time but may decrease estimates of dis- study methods.This work was support- associated Mortality Collaborator Network. Estimates
ease incidence during intense seasons ed by the Robert Wood Johnson Harold of global seasonal influenza-associated respiratory
when testing volume also increases. We Amos Medical Faculty Development mortality: a modelling study. Lancet. 2018;391:1285–
did not have subtype information for in- Program (grant 67423 to J.R.O.; http:// 300. https://doi.org/10.1016/S0140-6736(17)33293-2
fluenza or RSV available, which limited www.amfdp.org). 4. World Health Organization. Vaccines against influ-
our ability to assess whether certain enza WHO position paper—November 2012. Wkly Epi-
circulating strains were more affected Data availability: The study code is avail- demiol Rec. 2012;87:461–76.
by environmental covariates. Of the me- able by request to the corresponding 5. Ortiz JR, Neuzil KM, Cooke CR, Neradilek MB, Goss
teorological and pollution factors, we did author. In accordance with Washington CH, Shay DK. Influenza pneumonia surveillance among
not assess absolute humidity, wind ve- law, the Comprehensive Hospital Ab- hospitalized adults may underestimate the burden of
locity, sunshine duration, ozone, or other stract Reporting System dataset can severe influenza disease. PLoS One. 2014;9:e113903.
measures of pollution, and it is possible only be distributed by Washington State https://doi.org/10.1371/journal.pone.0113903
that one or more of these factors either Department of Health, and we are un- 6. Thompson WW, Shay DK, Weintraub E, Brammer
independently or in addition may have able to publish an aggregated dataset L, Bridges CB, Cox NJ, et al. Influenza-associated hos-
modified the effect on influenza- or RSV- due to state guidelines regarding pub- pitalizations in the United States. JAMA. 2004;292:
associated RC hospitalizations. Finally, lication of aggregated data that include 1333–40. https://doi.org/10.1001/jama.292.11.1333
this is an ecologic study, and the results cells with small numbers. 7. Thompson WW, Shay DK, Weintraub E, Brammer
may not necessarily be representative of About the Author L, Cox N, Anderson LJ, et al. Mortality associated
patient-level associations. Regardless, Dr. Somayaji is an infectious disease with influenza and respiratory syncytial virus in the
this comprehensive study spans over a physician and an assistant professor in United States. JAMA. 2003;289:179–86. https://doi.
decade of data using expanded standard the Departments of Medicine and Mi- org/10.1001/jama.289.2.179
ecologic models to assess the relation- crobiology, Immunology and Infectious 8. Zhou H, Thompson WW, Viboud CG, Ringholz
ships of respiratory virus–associated Disease at the University of Calgary. Her CM, Cheng PY, Steiner C, et al. Hospitalizations as-
hospitalizations and meteorological and research interests include understand- sociated with influenza and respiratory syncytial vi-
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study in western Washington state over L, Singleton JA, et al. Annual estimates of the burden
12 years assessed how incorporation of Author affiliations: University of Calgary, of seasonal influenza in the United States: a tool for
environmental and air pollution covari- Calgary, Alberta, Canada (R. Somaya- strengthening influenza surveillance and prepared-
ates can influence influenza- and RSV- ji); University of Washington, Seattle, ness. Influenza Other Respir Viruses. 2018;12:132–7.
associated disease burden estimates. Washington, USA (R. Somayaji, A.A. https://doi.org/10.1111/irv.12486
Our modeled estimates for influenza and Szpiro, C.H. Goss, J.S. Duchin); The 10. Thompson WW, Weintraub E, Dhankhar P, Cheng
RSV hospitalization rates were similar Mountain-Whisper-Light Statistics, Se- PY, Brammer L, Meltzer MI, et al. Estimates of US
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Dis. 2009;49:861–8. https://doi.org/10.1086/605435 Apr 18]. http://www.netmigration.wisc.edu Justin R. Ortiz, Center for Vaccine Development and
22. Axelsen JB, Yaari R, Grenfell BT, Stone L. Multi- 33. Ortiz JR, Neuzil KM, Rue TC, Zhou H, Shay DK, Global Health, University of Maryland School of Medi-
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hensive Hospital Abstract Reporting System (CHARS). CCM.0000000000000545 Goss; Jeffrey S. Duchin; Kathleen M. Neuzil; Justin R.
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HospitalInpatient DatabaseCHARS 36. Lowen AC, Steel J. Roles of humidity and tem- 2020;26(5):920-929.
25. Centers for Disease Control and Prevention. Over- perature in shaping influenza seasonality. J Virol.
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2020;26(5):920-929. doi:10.3201/eid2605.190599.

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Journal of the Association of Occupational Health Professionals in Healthcare

More Meaningful Meetings

Preparation and follow-up can keep
meetings productive and on track.

By Teresa Shellenbarger, PhD, RN, CNE, CNE-cl, ANEF, and Jennifer Chicca, MS, RN, CNE, CNE-cl

Copyrighted content. Please contact AOHP
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46

Spring/Summer 2020

Post-Traumatic Osteoarthritis Following ACL
Injury

By Li-Juan Wang1†, Ni Zeng2†, Zhi-Peng Yan2, Jie-Ting Li2 and Guo-Xin Ni1*

Abstract cytokine and chemokine interventions, Five major risk factors may contribute to
Post-traumatic osteoarthritis (PTOA) most of them are investigated in animal PTOA: anterior cruciate ligament (ACL)
develops after joint injury. Specifically, studies and have not been applied to injury, meniscus tear, glenohumeral in-
patients with anterior cruciate ligament humans. A complete understanding of stability, patellar dislocation, and ankle in-
(ACL) injury have a high risk of develop- mechanisms to stratify the patients into stability1. Obviously, there are differenc-
ing PTOA. In this review, we outline the different subgroups on the basis of risk es between these factors regarding the
incidence of ACL injury that progresses factors is critical. And the improvement mechanisms by which the primary joint
to PTOA, analyze the role of ACL recon- of standardized and quantitative assess- disorder initiates the subsequent devel-
struction in preventing PTOA, suggest ment techniques is necessary to guide opment of OA and the way in which the
possible mechanisms thought to be intervention. Moreover, treatments tar- disease process is maintained. The inci-
responsible for PTOA, evaluate current geted toward different pathogenic path- dence of ACL injury in particular is high
diagnostic methods for detecting early ways may be crucial to the management especially in adolescents playing sports
OA, and discuss potential interventions of PTOA in the future. that involve pivoting. The reported inci-
to combat PTOA. We also identify im- Introduction dence of PTOA following ACL injury is
portant directions for future research. Osteoarthritis (OA) is the most common as high as 87%5. This narrative review
Although much work has been done, the type of arthritis and a leading cause of will outline the incidence of ACL injury
incidence of PTOA among patients with mobility-related disability, affecting near- that progresses to PTOA, analyze the
a history of ACL injury remains high due ly half of the population1. It is suspected role of ACL reconstruction in preventing
to the complexity of ACL injury progres- to be a collection of distinct subtypes, PTOA, suggest possible mechanisms
sion to PTOA, the lack of sensitive and each with a different etiology and clini- thought to be responsible for PTOA,
easily accessible diagnostic methods to cal characteristics. Classifying OA into evaluate current diagnostic methods for
detect OA development, and the limita- multiple disease entities may help to un- detecting early OA, and discuss poten-
tions of current treatments. A number of derstand its heterogeneity and develop tial interventions to combat PTOA. Final-
factors are thought to be involved in the potential interventions targeted toward ly, we will identify important directions
underlying mechanism, including struc- individual disease processes. Post-trau- for future research.
tural factors, biological factors, mechani- matic osteoarthritis (PTOA), a subtype of ACL injury and PTOA
cal factors, and neuromuscular factors. OA, develops after joint injury such as an The ACL plays an important role in the
Since there is a clear “start point” for intra-articular fracture, a ligament injury, stabilization of the knee by restricting
PTOA, early detection and intervention or other cartilage (articular or meniscus) anterior translation of tibial and rotation-
is of great importance. Currently, imag- injuries within a joint. It accounts for al forces at the tibiofemoral joint6. As a
ing modalities and specific biomarkers nearly 12% of all cases of symptomatic common orthopedic injury, the annual in-
allow early detection of PTOA. However, OA2. Unlike idiopathic OA, PTOA repre- cidence of isolated ACL injury in the gen-
none of them are both sensitive and eas- sents a cause of functional disability in a eral population is 68.6 per 100,000 peo-
ily accessible. After ACL injury, many pa- disproportionately young population be- ple7. ACL injury may cause pain, range
tients undergo surgical reconstruction of cause primary injuries are more likely to of motion limitation, muscle weakness,
ACL to restore joint stability and prevent be sustained by younger individuals3, 4. knee instability, altered biomechanics,
excessive loading. However, convincing Besides, PTOA commonly has a known and reduction in physical activity levels,
evidence is still lacking for the superiority “starting point,” which means that inter- which place a great economic burden on
of ACL-R to conservative management ventions could theoretically be initiated the health care system6. It commonly
in term of the incidence of PTOA. As at an early stage to prevent the progres- occurs during sudden deceleration and
for non-surgical treatment such as anti- sion of the disease3.

* Correspondence: [email protected]
†Li-Juan Wang and Ni Zeng contributed equally to this work.
1School of Sport Medicine and Rehabilitation, Beijing Sport University, Beijing, China
Full list of author information is available at the end of the article

49

Journal of the Association of Occupational Health Professionals in Healthcare

direction change in non-contact situa- ACL reconstruction (ACL-R). It is be- showed that the expression of inflam-
tions3. Adolescents and young adults lieved that ACL-R helps to restrain the matory cytokines, especially IL-1β, IL-6,
who participate in sports requiring pivot- anterior translation of tibia, regain proper and TNF-α, which are correlated with the
ing and frequent direction changes have joint kinematics, restore knee stability, morphological score of PTOA, increased
a high incidence of ACL injury. The risk and prevent excessive torsional loading, after an idealized ACL-R16. Thirdly, mo-
in young women performing pivoting thus resulting in pain relief, functional lecular and cellular alterations to joint
sports is 3–5 times higher than in men5. recovery, low complication rates, and tissues caused by injury are not readily
As reported, 50–90% of ACL injuries highly predictable improvements1, 11. No- reversible through joint stabilization11.
progress to PTOA6. After ACL injury, tably, reconstruction methods, including Early detection of PTOA
grade III or IV radiologic changes in the graft choice, attachment point, fixation, PTOA is a progressive pathogenetic
Kellgren–Lawrence classification sys- and tension, as well as rotational stabil- process, and it could be too late to inter-
tem are nearly 5 times more likely than ity, could affect the biomechanical load vene when it progresses to a late stage.
in contralateral knees without a history of the knee joint1. Evidence shows that Therefore, there is a compelling need to
of ACL injury8. A number of factors may hamstring autografts demonstrate low- improve diagnostic techniques in order
mediate the risk of PTOA after ACL in- er incidence, less knee pain, and better to detect PTOA at an early stage. Cur-
jury, such as gender (female), age, high self-reported function than bone-patellar rently, imaging modalities such as bone
body mass index (BMI), obesity, physi- tendon-bone autografts6. scans, radiographs, computed tomogra-
cal activity level, smoking, low education Interestingly, arthroscopic surgery phy (CT), and magnetic resonance imag-
level, subsequent surgery, time interval seems to have almost the same inci- ing (MRI) and specific biomarkers (bio-
between injury and surgery, and varus dence as open surgery6. However, con- specimen: blood, serum, synovial fluid,
alignment of the uninjured knee2, 5, 9, 10. vincing evidence for the superiority of and other tissue samples)3, 17–19 allow
Older age leads to a disturbance of the ACL-R to conservative management in early detection.
balance between anabolic and catabolic terms of PTOA incidence is still lacking Radiography is a commonly used tech-
processes5. Evidence suggests that it 12, 13. A number of reasons may explain nique to diagnose OA. However, current
is related to medial compartment joint why ACL-R does not provide protective clinical criteria such as the Kellgren–
space narrowing9. Similarly, BMI is as- benefits for long-term joint health. First- Lawrence and Outerbridge classification
sociated with joint space narrowing after ly, surgery cannot completely restore schemes are not sensitive enough to
ACL injury5. Obesity is also believed to normal joint mechanics1. The disruption detect early changes of OA, and there is
have a great influence on OA progress in of normal loading distribution and biome- interobserver disagreement when clas-
many ways. One is increased joint load- chanics may result in loading on articular sifying patients17. Additionally, radiogra-
ing. Another could be the catabolic effect areas that are not accustomed to load phy is a two-dimensional imaging mo-
of inflammatory substances released by during weight-bearing activities14. Gait dality and has limited ability to provide
adipose tissue, including free fatty acids, analysis reveals that patients with ACL- information on ligaments, the synovium,
reactive oxygen species cytokines, and R knees exhibit altered joint loading pat- the meniscus, and the articular carti-
adipokines on joint tissues. Additionally, terns and tibial rotation compared with lage17, 20.
obesity is related to increased levels of uninjured contralateral knees or healthy As a repeatable, non-invasive, and multi-
IL-6 and TNF-α, which are pro-inflamma- patients14. The average knee center of planar imaging modality, MRI has been
tory indicators of PTOA development11. rotation (KCOR) during the stance phase widely used to longitudinally evaluate
Although the level of physical activity is of gait after ACL-R changes. Compared joint tissues following traumatic inju-
also considered a risk factor, no consen- with an uninjured contralateral knee, the ries20. It can perform more sophisticated
sus has been reached to date. On one KCOR of an ACL-R knee is more lateral analysis of various structures within the
hand, physical activity is often recom- and anterior at two years after surgery, joint and even quantify the severity of
mended to improve function and pro- leading to greater motion between the the injury, for instance, characterizing
mote overall health. A lack of mechanical femur and the tibia in the medial com- metabolic-triggered subchondral bone
loading contributes to thinning of articu- partment relative to the lateral compart- damage, evaluating bone marrow le-
lar cartilage. A low level of physical activi- ment15. Secondly, inflammation of the sions, detecting biochemical changes
ty is associated with a higher BMI, which synovium at early time points has been in the cartilage matrix and early carti-
may lead to the progression of OA. On observed15. It is supposed that surgery lage matrix loss, and analyzing cartilage
the other hand, the repetitive use of itself could lead to knee joint trauma, matrix composition3, .20–22 T1rho is a
joints and joint overload may result in and postsurgical hemarthrosis could technique used to assess proteoglycan
matrix loss and chondrocyte apoptosis2. result in prolonged joint inflammation13. content of the extracellular matrix of
ACL reconstruction and PTOA Postoperative inflammation may dam- articular cartilage. And T2 mapping has
Patients who wish to return to high-level age synovial stem cells and lead to a been used to detect the structural integ-
activities commonly choose to undergo compromised joint environment, thus rity, organization, and water content of
50 affecting the ability of tissues to heal. A
study using mini pigs as animal models

Spring/Summer 2020

cartilage20. Physiological MRI has also graphic evidence. Elevated concentra- grams, such as strengthening, plyomet-
been used to detect early changes dur- tions of degradative enzymes, for in- rics, agility, balance, and flexibility, along
ing OA development. Na18F positron stance matrix metalloprotease (MMP)-1 with feedback and proper technique for
emission tomography with computed and MMP-3, in synovial fluid are also improving lower extremity biomechan-
tomography (PET/CT) co-registered with measurable after ACL injury. Increased ics and decreasing landing forces, offer
MRI has been demonstrated to be a ratio between MMPs and tissue inhibi- great benefits for the protection against
sensitive imaging modality in an in vivo tor of metalloproteinase indicates an ACL ruptures26. Prevention programs
canine model to detect molecular and increase in degradation relative to syn- have been developed for specific sports.
cellular changes in bone metabolism thesis24. Given that the alteration of syn- For instance, FIFA 11+ is a dynamic field
before morphological signs appear4. oviocytes and adjacent chondrocytes warm-up program designed to decrease
The lower delayed gadolinium-enhanced may decrease the level of lubricin, the the injury risk in soccer. A study demon-
MRI of cartilage (dGEMRIC) index has latter is promising as a biomarker of car- strated that its use decreases the rate
been shown to have prognostic value tilage degradation3. of ACL injuries in competitive collegiate
for OA development after ACL injury23. Prevention of PTOA male soccer players by 77%28.
However, MRI scans are expensive and Obviously, prevention of the initial injury Suggested mechanisms of PTOA
not available everywhere17. is the most effective tool to manage after ACL injury
A variety of molecular and biochemical PTOA since there is still a lack of treat- Although accumulating evidence dem-
processes play important roles in the ment methods3, 25. ACL injury prevention onstrates that patients with ACL injury
pathogenesis of PTOA. The detection programs play a significant protective are predisposed to PTOA, the precise
of molecules in the acute phase pro- role, reducing the incidence of ACL inju- mechanism remains unclear6. Structural,
vides indications of the future disease ry by 53%26. A systematic review shows biological, mechanical, and neuromuscu-
process. Breakdown of ECM structures that neuromuscular and educational in- lar factors are thought to be involved in
including type II collagen, proteoglycans terventions reduce the incidence of ACL this process. The involvement of ACL
(PGs), and glycosaminoglycans (GAGs) injuries by approximately 50%27. It has injury in the development of OA may
may be one of the earliest signs of OA also been suggested that multicom- be associated with the mechanisms de-
and could be detected before radio- ponent injury-prevention training pro- scribed in this section (Fig. 1).

Fig. 1 Suggested mechanisms of PTOA after ACL injury. An up arrow (↑) indicates an increase and a down arrow (↓) indicates a decrease

51

Journal of the Association of Occupational Health Professionals in Healthcare

Structural factors balance between bone resorption and the articular ECM encompassing GAGs,
In addition to ACL, many other associat- formation is disturbed following ACL in- proteoglycans, and collagen, triggering
ed structures may be compromised dur- jury30, 31. The alteration of SB mineraliza- further activation of MMPs, which cre-
ing initial injury and secondary instability. tion may change the morphology of the ates a positive feedback cycle1. The loss
Compared to patients with isolated ACL SB plate, leading to abnormal mechani- of proteoglycan and collagen in the ar-
rupture, those with concomitant intra- cal loading on the articular cartilage31. ticular cartilage is a significant alteration
articular injuries have a higher incidence These changes in the subchondral bone from which it is difficult for the tissue to
of PTOA5. Injury to the articular cartilage may initiate the progression to PTOA fol- recover13. Increased permeability of the
(chondral injury), meniscus, ligamentous lowing ACL injury. ECM and water content in the articular
capsular structures, and subchondral Biological factors cartilage induced by catabolic pathways
bone1–3, 5, 6 may contribute to the devel- Following the initial ACL trauma, vari- results in alteration of the biochemical
opment of clinically significant OA. ous biological factors, together with the and biomechanical properties of the ar-
Almost half of patients with ACL injury damage to associated structures, may ticular cartilage14.
also suffer from articular cartilage dam- trigger progressive joint degeneration. Mechanical factors
age of the medial and lateral femoral Low-grade synovial cellular infiltration, Mechanical pathways play a vital role
condyles3. Higher impact energy during cytokine production, and inflammatory in the progression of OA. After injury,
the initial trauma causes more severe activation of joint tissue cells put patients an ACL may fail to maintain the joint as
damage to the articular cartilage, with at risk of progressive OA development11, stably as before. Consequently, chronic
over 25MPa initiating chondrocyte ne- 32. Oxygen free radicals from chondro- changes in the static and dynamic load-
crosis and apoptosis10. Increased chon- cytes released during impact injury may ing of the knee may lead to the degrada-
drocyte expression of matrix-degrading lead to progressive chondrocyte damage tion of the cartilage and other joint struc-
enzymes and inflammatory cytokines and matrix degradation. In addition, a tures5. Reasons that could contribute to
caused by mechanical impact results in large number of cytokines are produced abnormal mechanical loading of knee
chondrocyte apoptosis1, 3. As cartilage immediately after injury with longlasting joints include damage to static stabiliz-
has a poor healing capacity, damage to effects, which may disturb homeostasis ing structures, proprioception loss of
the articular chondral surface may direct- in the joint and lead to joint degeneration dynamic stabilizers such as quadriceps
ly lead to OA development5. via various metabolic pathways, includ- and hamstrings, psychological factors
One fourth to two thirds of ACL-injured ing inflammatory cytokines IL-1, IL-6, IL- such as emotional distress caused by
knees have concomitant meniscal dam- 8, IL-17, and TNF-α3, 5, 12, 33 and molecular pain and fear of re-injury, residual mus-
age16. It seems that meniscus status is a biomarkers such as stromal cell-derived cle weakness and disuse atrophy1, joint
critically important factor that may con- factor 1 (SDF-1) and cartilage extracellu- derangement, and biomechanical vari-
tribute to the progression of PTOA. Pa- lar matrix fragments3. For example, IL-1 ables35. Adaptive changes during am-
tients with meniscus tear are more likely downregulates the synthesis of cartilage bulation due to mechanical factors may
to develop radiographic OA compared extracellular matrix (ECM). IL-6 and IL-17 lead to the disruption of joint homeosta-
with patients with isolated ACL injury29. work synergistically with IL-1 to acceler- sis36. Given that chondrocytes are very
Damage to the meniscus decreases the ate the breakdown of the ECM. TNF-α sensitive to mechanic environment al-
capacity of the joint to attenuate energy. plays a role in the increased activity in terations, abnormal mechanical loading
Besides, as a biologically active tissue, the apoptotic caspase pathway. The in- caused by various factors could change
the meniscus may synthesize various creased levels of IL-1β, TNF-α, and IL-6 chondrocyte metabolism, proteoglycan
soluble enzymes and inflammatory me- are associated with a decreased level of production, collagen fiber orientation,
diators in response to trophic trauma lubricin. Lubricin provides anti-adhesive and MMP expression, lead to ECM deg-
that may accelerate the degradation of and chondroprotective properties to the radation, alter the mechanical proper-
adjacent cartilage3. articular cartilage, and the decrease in ties of the cartilage itself, and ultimately
Notably, 80–90% of patients also show synovial fluid lubricin following ACL in- cause functional disability1, 3.
signs of subchondral bone (SB) injuries jury increases the risk of degradation33. Kinematic abnormalities and kinetic al-
after ACL injury5. When bone marrow Moreover, these inflammatory biomark- teration following joint injury are associ-
lesions are associated with the disrup- ers may stimulate angiogenesis, osteo- ated with OA development37. Knee joint
tion of adjacent cortical bone and articu- phyte formation, and catabolic enzyme structures, such as the ACL, the medial
lar surface, they may result in osteocyte expression14. collateral ligament, and the lateral col-
necrosis in the bone marrow, significant The alteration of gene expression in lateral ligament, work synergistically to
proteoglycan loss, chondrocyte injury, chondrocytes and the activation of limit the motion of anterior tibial transla-
and matrix degeneration in the overly- various degradative enzymes, such as tion. In patients with ACL injury, load is
ing cartilage. Subchondral damage is co- MMPs, during injury cause progres- distributed to other structures to com-
localized with bone remodeling, and the sive cartilage loss1, 34. Increased MMP pensate for ACL deficiency15.
52 levels contribute to the degradation of

Spring/Summer 2020

Neuromuscular factors crease the degradation of the articular indicating that CPM has a significant
Impairment of neuromuscular functions cartilage ECM, and inhibition of resistin effect in protecting against PTOA44. In
may also contribute to the development and TNF-a may decrease synovial in- Frobell’s study, for young patients with
of PTOA5, 6. The alteration of neuromus- flammation and boundary lubrication3. acute ACL tear, structured rehabilitation
cular feedback caused by persistent Extracellular matrix–blood composite plus early ACL-R did not result in better
ligament laxity14 and impaired muscle injection relieved the pain during weight outcome of Knee Injury and Osteoarthri-
function10 poses a risk of progressive bearing and attenuated cartilage damage tis Outcome Score than patients with
degradation of structures within the after ACL transection in a rat model37. structured rehabilitation plus optional
joints. The ACL not only restricts tib- Studies on genetically engineered mice delayed ACL-R. Moreover, for patients
iofemoral motion passively but also show promising interventions target- using latter strategy, 61% of ACL-R
serves as a dynamic sensor transmitting ing certain gene transcriptions3. Using could be avoided without adverse out-
afferent information to the central ner- p16-3MR transgenic mice, Jeon et al.41 come, indicating that structured rehabili-
vous system. The loss of joint mechano- demonstrated that selective removal of tation program is of great importance in
receptors within the ACL after traumatic senescent cells retards OA progression, the management of ACL injury45. For pa-
injury results in altered information in- reduces pain, and creates a pro-regener- tients undergoing ACL-R, early rehabili-
put, decreased motor output, and poor ative environment. Nonpharmacological tation both preoperatively and postoper-
neuromuscular control38. Patients with treatments such as cryotherapy improve atively is needed5. Exercise is an integral
ACL injury suffer from quadriceps and footprint patterns and reduce synovial part of rehabilitation programs and has
hamstring strength deficit due to disuse inflammation42. Weight loss is often rec- positive effects46. Patients with limited
atrophy or arthrogenic muscle inhibition. ommended in treatment programs, as it range of motion have a higher incidence
As shock absorbers and dynamic sta- decreases joint loading and IL-7 levels of PTOA. Those with a quadriceps and
bilizers, the quadriceps distribute load through biomechanical and inflamma- hamstring strength deficit fail to main-
across the articular surface and stabilize tory pathways11. tain normal loading patterns and absorb
the knee joint38, 39. When the quadriceps Surgical techniques such as reconstruc- impact, which may lead to joint space
are weak, articular loading of the knee tive procedures have been improved narrowing. Therefore, returning to the
joint increases, which may initiate a de- and new ones, such as arthroscopic normal range of motion and quadriceps
generative process2, 40. surgery, have been introduced. As men- and hamstring strength training should
Treatment of PTOA tioned earlier, the use of hamstring au- be essential parts of rehabilitation pro-
As a progressive and chronic condi- tografts in ACL-R exhibits good clinical grams14.
tion, PTOA should be treated at an early outcomes6. Notably, the functional out- Education also plays a crucial part that
stage to minimize its long-term effects come in quadriceps autograft groups cannot be ignored. It is necessary to
and prevent the development of end- is equal to or better than in hamstring raise patients’ awareness of reinjury and
stage OA3, 15. Unlike idiopathic OA, there autograft groups43. For patients with PTOA risk, help them understand the
is a clear injurious event involved in the concomitant meniscus injury, the more importance of re-injury prevention and
case of PTOA. A known “starting point” of the meniscus is preserved, the bet- return-to-play criteria, and educate them
presents the opportunity for targeted ter the outcome will be. Thus, menis- in modifying physical activity and weight
treatments3. Intervening immediately cal repair instead of partial meniscecto- management and diet.
after injury plays an important role in the mies during surgery is recommended5. Conclusions and future directions
prevention of future degradation. Removing a part of the meniscus de- Patients with ACL injury have a high risk
A better understanding of pathogenic creases the distribution of the transmis- of developing PTOA5, 6. Although much
pathways makes it possible to devel- sion force, and partial meniscectomy work has been done, the incidence of
op targeted interventions to prevent decreases quadriceps strength, which PTOA among patients with a history
clinically significant disease. The most could be associated with altered lower of ACL injury remains high due to the
discussed treatment methods in the extremity biomechanics6. complexity of ACL injury progression to
literature are biological interventions, Regardless of treatment by surgical or PTOA, the lack of sensitive and easily
including anti-cytokine and chemokine nonsurgical means, an integrated reha- accessible diagnostic methods to detect
interventions (intra-articular injection bilitation program that helps to improve OA development, and the limitations of
of IL-1Ra)5, 11, anti-resorptive thera- neuromuscular control, strength, power, current treatments1.
pies (bisphosphonates and strontium and muscular symmetry is necessary1, PTOA development is a chronic and pro-
ranelate, etc.)35, anti-oxidant treatment 5. Rabbits treated with early continuous gressive condition. At its late stages, the
(methylsulfonylmethane and pycno- passive motion (CPM) after ACL tran- changes in the knee joint are irrevers-
genol, etc.)18, and joint aspiration to section have normal articular surfaces, ible, and arthroplasty might be the only
remove hemarthrosis at the time of thicker articular cartilage, better tide- treatment choice17, 34. Therefore, early
injury17. Selective inhibition of IL1, IL6, mark continuity, lower levels of inflam- detection and assessment of OA sever-
IL-17, and metalloproteinases may de- matory cytokine, and abundant GAG,
53

Journal of the Association of Occupational Health Professionals in Healthcare

ity is necessary to guide therapy and developed to restore normal mechanics Funding
prevent irreparable damage to the knee and reduce the risk of OA5.
joint34. Though detection methods such The effect of pharmacological treat- This work was supported by National Natural Science
as imaging modalities and biomarkers ment has also been widely investigated Foundation of China (81871848) and Medical innova-
now exist, none of them are both sensi- in animal studies. As our knowledge tion project of Fujian Province (2017-CX-25). The fund-
tive and easily accessible3, 17. Future re- of biological mechanisms triggered by ing source had no role in the design or conduction of
search directions should be the improve- ACL injury increases, selective inhibi- the study nor the decision to submit the manuscript
ment of standardized and quantitative tion of inflammatory chemokines such for publication.
assessment techniques to detect PTOA as IL-1 and TNF-α has shown potential
at an early stage, monitor the progres- for preventing the degradation of injured Consent for publication
sion and severity of OA development, joints in animal studies3. Intra-articular
and evaluate the efficacy of treatments. injection of dexamethasone has been All authors gave consent to publish.
At present, the way to prevent the shown to decrease joint swelling, sup-
progression of PTOA remains unclear, press catabolic gene expression, lower Competing interests
as a number of risk factors may be at the histological grade, and reduce the
play25. Animal models and experiments formation of osteophytes in rabbit mod- The authors declare that they have no competing in-
in vivo allow the study of pathological els13, 32. AMD3100 can prevent trabecu- terests.
pathways triggered by ACL injury19, 47. A lar bone loss and mitigate cartilage de-
complete understanding of its mecha- generation in PTOA mice by inhibiting Author details
nisms to classify patients into different the SDF-1α/CXCR4 signaling pathway27.
subgroups on the basis of risk factors Intra-articular injection of triamcinolone 1School of Sport Medicine and Rehabilitation, Beijing
is critical3. Treatments targeted toward acetonide after ACL transection attenu- Sport University, Beijing, China. 2Department of Re-
different pathogenic pathways may be ates synovitis and collagen degradation habilitation Medicine, The First Affiliated Hospital of
key to the management of PTOA in the in Yorkshire pigs51. Further work is war- Fujian Medical University, Fuzhou, China. Received: 17
future. ranted for clinical application of targeted January 2020 Accepted: 16 March 2020
Unlike idiopathic OA, PTOA has a clear therapy.
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