Occupational diseases

Elizabeth E Cooper,* Stephen L Blamey† * Sterilisation and Infection Control Coordinator, Southern Health Infection Control and Epidemiology, Southern Health, Locked Bag 29, Clayton, VIC 3168; † Head, Department of GastrointestinaI Surgery, Monash Medical Centre, Melbourne, VIC. elizabeth.cooperATsouthernhealth.org.au In reply: Emmett and colleagues request more information and analysis about the mistaken use of stored serum samples. The pathology staff member correctly labelled the specimen of the patient being bled but did not follow the protocol in identifying that the patient was the same as on the request slip. It had not been highlighted that there were two patients with the same surname (but different first names) in the ward, and blood was collected from one patient with a request slip labelled for another. At specimen reception, the protocols were again not followed, as the staff did not check that the minimum identifiers on the specimen label and request form matched. It is recognised that violations of procedures are not root causes and are not directly manageable. The cause of the procedural violation must be managed.1 The collection and labelling of blood protocols were reviewed after this incident and found to be appropriate. The root-cause analysis identified that the protocols were not followed and that unacceptable “informal norms” had become practice in the collection and labelling of specimens. Staff training was examined and revised to ensure that staff were aware of the content of the protocols and that they followed them accordingly. All staff members were counselled about the importance of following correct procedures and the consequences of not doing so. Up to 1000 specimens are received at specimen reception each weekday. New “front end processing” technology is to be introduced at the end of 2003. This electronically scans the specimen and request slip to ensure details match. In the interim, in recognition that mislabelling will occur, all specimens relating to occupational exposures are collected at the time of the incident. Previously available results and serum stored in the laboratory are not relied on.

Elizabeth E Cooper · Stephen L Blamey

De-stressing doctors. A self-management guide. Valerie Sutherland, Cary L Cooper. Edinburgh: Butterworth Heinemann, 2003 (xii + 193 pp). ISBN 0 7506 8783 5. The prevalence and consequences of stress associated with medical practice have been a subject of research and reflection for at least three decades. Despite enormous advances in medical care over that period, there is no evidence of a decline in the experience of stress or its sequelae among our medical colleagues. This book is intended, as the name implies, as a self-help guide for practitioners. The authors are well credentialled and well versed in the literature relating to the topic, and the book is set out in a useful and readable format. The first sections deal with an explanation of the traditional stress construct, with remaining sections dealing with prevention and management strategies. These are presented as primary prevention (strategies for stress minimisation in the work environment), secondary prevention (coping strategies for situations in which stress can not be altogether eliminated), and tertiary prevention (stress management strategies for situations where stress is established and adversely affecting the practitioner’s life). The evidence for adverse psychoneuroimmunologic effects of chronic or recurrent stress is reviewed, and the book achieves a balance between behavioural, psychological and physical reasons for individual doctors to manage stress in their lives more effectively. The academic underpinnings are presented in a clear and integrated style, and the practical strategies, while not new or revolutionary for readers, are a good summary of commonsense principles that medical practitioners routinely prescribe for their patients, but often neglect in their own lives. Although the British authors do not deal particularly with some current local stressors, including the indemnity insurance crisis and medicolegal concerns, the principles espoused are generic and the book is relevant to an Australian audience. Simon M WillcockLecturer, Department of Academic Medicine Hornsby Hospital, NSW

Simon M Willcock

The increasing rate of hepatitis C virus (HCV) infection in the community means that there is increased risk of occupational exposure for healthcare workers. In metropolitan hospitals in Victoria, we found that 80–150 healthcare workers have occupational exposures from HCV-infected patients annually. As there is a 1.8%–3% risk of transmission of HCV from a needlestick injury, two to five healthcare workers are likely to acquire HCV each year in Victoria. These needlestick injuries pose a personal, legal and professional risk to healthcare workers and their patients. Recent information shows that early antiviral treatment of acute HCV infection has high cure rates. Current local and international protocols for management of healthcare workers exposed to HCV do not address these issues. We propose a management protocol after needlestick injury that is stratified according to the likelihood of HCV acquisition and potential risk of staff-to-patient transmission, and that is consistent with the current legal and clinical context of HCV infection in Australia.

Patrick GP Charles MB BS · M Lindsay Grayson MD, FRACP, FAFPHM · Peter W Angus MD, FRACP · Joseph J Sasadeusz PhD, FRACP

Clinical record At 03:00 on a Friday in 2002, a clinical staff member in the intensive care unit sustained a needlestick injury involving a suture needle through a glove. An unrelated cardiac arrest occurred soon after, causing a delay in reporting of the injury. At 07:00 (4 hours after the injury), the staff member (recipient) reported the injury, using the paging arrangement and occupational exposure protocol at the time (ie, a message was left for the staff health nurse, as no designated person was on-call for occupational exposures overnight). At 10:00 (7 hours), the recipient received a response to the report from the staff health nurse who initiated action in accordance with the protocol in place at the time. The source patient had a recently recorded negative HIV antibody result by enzyme-linked immunosorbent assay (ELISA). At 10:30 (7.5 hours), a further blood sample was collected from the source patient, along with a baseline blood sample from the recipient. These were processed at 12:30 (9.5 hours). At 13:00 (10 hours), the source patient’s ELISA test gave a positive result for HIV antibody. However, because of the previous negative result, this was assumed to be a false positive. On Sunday, a repeat (western blot) HIV test was performed for confirmation and was again positive for HIV antibody. On Monday at 10:00 (79 hours), the infectious diseases unit was notified of the positive HIV antibody result. At 15:00 (84 hours), the recipient was counselled by an infectious diseases physician and commenced post-exposure prophylaxis. The laboratory subsequently tested stored serum samples from the source patient; all four samples were positive for HIV antibody. Investigation of the previous negative result revealed that the test specimen was not from the source patient, but from another patient with the same surname in the same ward. This report documents a multifactorial failure of the system of reporting and responding to occupational exposures, which led to a substantial delay in instituting prophylaxis for HIV exposure. About half the percutaneous sharps injuries sustained by healthcare workers in the United States go unreported.1 At our 621-bed institution, 66 needlestick injuries were reported in 2001–2002, translating to a rate of 10.6 per 100 beds per year. As data from the US Exposure Prevention Information Network suggest that hospital healthcare workers incur about 30 needlestick injuries per 100 beds per year,2 our rate of 10.6 probably reflects significant underreporting. Increased staff confidence in the quality and confidentiality of follow-up for occupational exposures may help increase reporting.3 The average risk of HIV transmission for healthcare workers after percutaneous exposure to HIV-infected blood is about 0.3%.4 However, post-exposure prophylaxis with zidovudine has been shown in a retrospective case–control study of healthcare personnel to reduce transmission by about 81%.4 The Department of Human Services (Victoria) recommended in 1997 that post-exposure prophylaxis be initiated promptly, preferably within 1–2 hours of exposure (based on 1996 recommendations from the US Centers for Disease Control and Prevention).5 The US Department of Health and Human Services recommends that employers protect healthcare workers from needlestick injuries by providing a safe working environment with effective programs and safer needle devices, notwithstanding additional costs. This includes a combination of prevention strategies for reducing needlestick injuries, and involving workers in the effort.6 Improving response to occupational exposuresAt Southern Health, the occupational exposure protocol was under review before this incident occurred. Root-cause analysis of the incident led to the following changes to occupational exposure and pathology protocols: A uniform system of notification that was under development was implemented across all sites in the Southern Health service of Melbourne. Changes included: A dedicated pager number, operating 24 hours a day 7 days a week, was provided at each site for reporting of occupational exposures and was advertised by posters displayed prominently in clinical areas. Previously, there were different contact numbers for different times of the day, and cover was not around the clock. Occupational exposure coordinators were appointed (one per shift at each site) and attended inservice education about occupational exposure, provided by the infection control unit. Staff were informed of the new pager number and notification process through a memorandum sent to all nursing and clinical support staff and an internal flyer sent to all senior medical staff from the Chair of the Infection Control Advisory Committee for Southern Health; the latter highlighted the urgency in reporting exposures. The new notification process is described in the orientation material for new staff. The pathology department implemented a streamlined testing protocol for all specimens related to occupational exposures; these are processed urgently, and all results are reported to the occupational exposure coordinator. The pathology department also reviewed protocols for blood collection and reception; use of informal “norms” rather than strict adherence to protocol was deemed unacceptable, and inservice education and review were conducted in all areas. All high-risk exposures are discussed by the occupational exposure coordinator with the on-call infectious diseases physician to develop an action plan. Future quality assurance activities will include surveys of staff awareness of the notification process and training status of occupational exposure coordinators. Outcome of measures to improve responseTen weeks after this adverse event, 58 health service staff had been trained as occupational exposure coordinators. The senior infection control practitioner conducted nine education sessions for these coordinators, providing course notes and contact details for troubleshooting or general enquiries. An infectious diseases physician discussed issues of informed consent for testing for bloodborne viruses at each session. Initially, reports of occupational exposures increased threefold, from 1 every 48 hours before implementation of the new protocol to 3 per 48 hours after implementation. Within 4 weeks of implementation, reporting returned to the previous level. The posters displayed in clinical areas appeared to prompt reporting; some exposures occurred before implementation of the new protocol but were reported only after the posters were displayed. The time from occupational exposure to reporting of HIV results for source patients decreased from a range of 7.5–192 hours to 1.1–23 hours (including any delay in reporting by healthcare workers, as well as laboratory processing time). This report demonstrates the importance of effective mechanisms for reporting exposures, accurate specimen labelling, urgent processing of pathology tests and accurate reporting of results with appropriate follow-up, in achieving timely and appropriate action after an occupational exposure. Recognition of the system failure in this incident led to a system change at our institution designed to minimise future incidents and improve quality of care. The education and reporting systems have been revised to be efficient and robust and to achieve long-term effectiveness in reducing morbidity from occupational exposure. Lessons from practice The system for staff to report an occupational exposure needs to be simple and available 24 hours per day, 7 days per week. Testing after an occupational exposure needs to be prioritised and processed urgently to ensure results are available as soon as possible. High-risk exposures need to be discussed with the on-call infectious diseases physician to develop an action plan. All serum should be collected with strict adherence to blood collection and labelling protocols. Serum from the source patient should be collected and tested at the time of the incident to confirm HIV status, even if a recent negative result is known.

Elizabeth E Cooper BN, MPubHlth(Melb) · Stephen L Blamey FACS FRACS

Work and mental health: an employer’s guide. Doreen M Miller, Maurice Lipsedge, Paul Litchfield (editors). London: Royal College of Psychiatrists, 2002 (176 pp). ISBN 1 901242 85 4. This useful book is a joint effort by the Royal College of Psychiatrists and the Faculty of Occupational Medicine, Royal College of Physicians to give practical advice on mental illness in the workplace. Contrary to the subtitle, however, it will be of more use to doctors than employers because of its clinical focus. Most chapters are written jointly by a psychiatrist and an occupational physician, which helps to maximise relevance to the workplace. There are a few chapters written by others such as a human resource manager and an organisational psychologist. The book falls roughly into two sections; one dealing with specific psychiatric conditions and the other with workplace stress. The former begins with a superb chapter “Assessing mental health problems in the workplace”. There are also chapters on anxiety, depression, substance abuse, critical incidents, chronic fatigue syndrome, schizophrenia and organic states. These combine a good resume of salient clinical points with a discussion of the issues in managing the employability of the patient. The high quality information on these difficult topics will be appreciated by many clinicians. On the other hand, the chapters dealing with workplace stress are disappointing and emphasise how little progress has been made in this area over many decades. Several case studies of stress programs in various organisations are presented, including pharmaceutical, electricity and telecommunications companies. Each is claimed to have been beneficial. However, there is a distinct lack of candour in the presentations, which lessens their credibility. It is highly unlikely that so many programs were successful without some setbacks, but none are reported. Also, there is no substantial statistical data presented to support the claims of benefit even though it is stated that surveys of “staff opinion” (or similar stress indices) were done periodically. The main advance appears to arise from major legal decisions under disability discrimination law which require employers to make reasonable adjustment for the employment of those affected by work stress or other mental illness. The book is a timely summary of mental illness in the workplace, showing both the strengths and weaknesses of current practice. It will be of much interest to those who provide medical care to workers and workplaces. Bruce HockingOccupational Physician Camberwell, VIC

Bruce Hocking

The most direct way to reduce percutaneous injuries is to make devices safer In this issue of the Journal, Whitby and McLaws (page 418) provide a thorough epidemiological account of occupational exposure to bloodborne pathogens by hollow-bore needles in one hospital.1 More studies such as theirs are needed in Australia, where there has been relatively little attention focused on this issue, as indicated by the few references to studies by Australian investigators cited in their article. As an American I find this surprising, because many successful prevention programs introduced in Australia have earned the admiration of public health professionals in other countries. Three examples come to mind: laws requiring seatbelt use and advanced passenger protection in motor vehicles; progressive HIV prevention programs; and programs to prevent ultraviolet light exposure and skin cancer. I am among the admirers of Australia's strong prevention record. In light of these progressive programs, how might one explain the relative neglect in Australia of such a serious occupational risk as bloodborne pathogen exposure? Some answers may be extrapolated from the United States, where I have observed a culture of self-sacrifice among healthcare professionals that compels them to place self-interest at the bottom of their priority scale. I have also seen administrators make healthcare worker safety a low priority when protective measures for their employees require a financial commitment. Finally, resistance to new prevention policies for healthcare workers is likely to be strongest where there is a lack of surveillance data. This is the "no data, no problem" syndrome. In Australia, an awareness of the significance of the problem of exposure to bloodborne pathogens is necessary before a national commitment can be made to its solution. Percutaneous injuries are the most frequent type of injury sustained by healthcare workers, and the most life-threatening.2 This remains true despite important advances, including the availability of the hepatitis B vaccine and post-exposure chemoprophylaxis for HIV-exposed healthcare workers.3,4 Therefore, I am convinced that the only choice is to accept the responsibility of caring for our caregivers — in Australia and elsewhere. The first step towards overcoming neglect is documenting the problem. The report by Whitby and McLaws provides a fine example, on a small scale. With reported annual percutaneous injury rates of 4–15 injuries per 100 full-time-equivalent staff,1 and device-specific injury rates occurring usually in the range of 1–20 injuries per 100 000 devices used,5 the participation of numerous institutions and a long term commitment are required to maintain a database that can guide and sustain large-scale prevention programs.6,7 Active surveillance programs support strong policy initiatives, as has been seen in the US, where surveillance data have supported new regulations, guidelines and advisories issued by our government agencies, as well as state and national legislation.8,9 Widespread surveillance should become a national goal for Australia. There is a global network of countries in Europe, Asia and South America with advanced surveillance programs eager for collaborative exchange. Surveillance data reveal the causes of bloodborne pathogen exposures and they lead to conclusions that are difficult to ignore. Surveillance data from the International Health Care Worker Safety Center, University of Virginia, from 1996 to 2000 (84 hospitals, 23 243 injuries) show that 98.5% of percutaneous injuries sustained by healthcare workers were caused by sharp medical devices (exceptions include injuries from windshield glass, teeth, fingernails and bone fragments). Therefore, the most direct route to preventing percutaneous injuries is to make injurious devices safer to handle. I find it incredible that the debate still persists whether educational programs or safer devices should be the preferred method of protecting healthcare workers. If you asked a soldier dispatched to the frontlines of battle whether he would prefer a protective shield or an educational poster, there would be no need for discussion. Let us move quickly to get protective devices into the hands of healthcare workers, while providing the best educational methods to support the use of safer technology. The lack of data on the effectiveness of safety devices is often raised as a barrier to their adoption. Although there are several studies demonstrating the efficacy of safety-engineered needle devices, there nevertheless remains a need for further well-designed clinical trials as new and safer technology comes into the market place.10-11 But where data are lacking on potentially life-saving technology there should also be a responsibility to collect those data, rather than merely rejecting the technology by reason of their absence. But we should also not dismiss the use of common sense in weighing the potential safety impact of many safer devices: intravenous infusion systems with needleless access ports and needleless line connections cannot cause needlestick injuries (as long as one does not override the system and use needles with them); plastic capillary tubes and vacuum tubes all but eliminate the possibility of lacerations; blunt-tipped suture needles do not cause needlestick injuries. Not every device category requires a clinical trial to prove a reduction of injuries, especially if that device eliminates a needle or sharp item. Another area of time-consuming debate is whether safety devices are cost-effective. We now have a law in the US, the first in the world, requiring healthcare employers to provide safety-engineered devices for the prevention of percutaneous injuries, without consideration of their financial impact on individual healthcare facilities.9 Whitby and McLaws say that "such a situation should not be allowed to occur in Australia". Perhaps they need not worry about the potential cost burden in Australia. As the first customers of this new technology, US healthcare institutions, which comprise the largest medical device market in the world, are bearing the brunt of the cost burden. The new law has caused medical device companies to shift into high-volume production of safety-engineered devices. Economies of scale are already bringing prices down, as is the intense competition to gain market share in this new product area. These benefits will no doubt spill over to other countries. But I would hope for the sake of its healthcare workers, and in keeping with its strong tradition in the field of prevention, that Australia's response would be more active than simply waiting to see what washes up on shore.

Janine C Jagger MPH, PhD

Objective: To describe the frequency, cause and potential cost of prevention of hollow-bore dirty needlestick injury (NSI) sustained by healthcare workers.Design and participants: Ten-year prospective surveillance study, 1990–1999, with triennial anonymous questionnaire surveys of nursing staff.Setting: 800-bed university tertiary referral hospital in Brisbane, Australia.Main outcome measures: Rates and circumstances of NSI in medical, nursing and non-clinical staff; knowledge of NSI consequences in nurses; and minimum costs of safety devices.Results: Between 1990 and 1999, there was a significant increase (P < 0.001) in the trend of the reported rate of NSI. Of the 1836 "dirty" NSIs reported, most were sustained in nursing (66.2%) and medical (16.8%) staff, with 62.7% sustained before disposal. Hollow-bore injuries from hypodermic needles (83.3%) and winged butterfly needles (9.8%) were over-represented. Knowledge among nursing staff of some of the risks and outcomes of NSI improved over the decade. A trend (χ2 = 9.89; df = 9; P = 0.0016) with increasing rate of reported injuries in this group was detected. The estimated cost of consumables only, associated with the introduction of self-retracting safety syringes with concomitant elimination of butterfly needles, where practicable, would be about $365 000 per year. Conclusion: More than one NSI occurs for every two days of hospital operation. Introduction of self-retracting safety syringes and elimination of butterfly needles should reduce the current hollow-bore NSI by more than 70% and almost halve the total incidence of NSI.

R Michael Whitby FRACP, FRCPA · Mary-Louise McLaws MPH, PhD

In reply: What Carroll says is correct, but Section 3.6 of the general explanatory notes of the Medicare benefits schedule book also states that "The only exception to this is where a person has entered into a reimbursement arrangement with a compensation insurer. In such cases a Medicare benefit is not payable".1 While it may be arguable as to what actually constitutes a reimbursement arrangement, the situation is further clarified by Section 13.2.1 of the same schedule, which states: "Medicare benefits are not payable in respect of a professional service in the following circumstance: (b) where the medical expenses for the services are in relation to a compensable injury or illness for which the patient's insurer or compensation payer has accepted liability. However, if medical expenses relate to a compensable injury or illness and the insurer or compensation payer is disputing liability, Medicare benefits are payable until liability is accepted".

Ian D Steven · Michael Shanahan

Stress is a normal part of everyday life, but it can lead to psychological strain and difficulty coping with life's demands. Although a variety of non-specific symptoms such as headaches, disturbed sleep, depression, anxiety, irritability or substance misuse may result when individuals are stressed, there is generally little evidence that such symptoms are a direct result of particular stressful events. Rather, they are non-specific and can be precipitated by a variety of other causes, including other stressors to which the individual may be exposed. The issue becomes more complex when stress occurs in the occupational arena because of issues of confidentiality and the sometimes competing interests of patients, insurers and employers. In addition, organisational problems related to work stress, such as high absenteeism, high staff turnover, industrial disputes and poor quality control (leading to inferior products and reduced competitiveness for the organisation) may further complicate matters. In this issue of the Journal, the cross-sectional survey of Western Australian general practitioners by Russell and Roach (page 367) attempts to start gathering information on the variety of approaches taken by GPs when faced with symptoms of anxiety which are apparently caused predominantly by occupational stress.1 Obviously, the article has been written in the context of a political agenda in Western Australia, with a desire by some to consider accreditation for general practitioners in managing work-related stress claims. This was clearly opposed by about 70% of respondents to the survey. The findings of Russell and Roach suggest that GPs with experience in the practice of occupational medicine are less likely to recommend time off work. Additionally, those who had knowledge of the specific requirements for lodging a work-related stress claim (which is likely to include those with experience in occupational medicine) were more likely to recommend initiating a claim. Many of the GPs surveyed were concerned about practising medicine in a workers compensation environment, and the implications this has for patient confidentiality. Many also reported reluctance to get involved in the workers compensation system. Some of the reasons for this include a lack of confidence in their knowledge of legislative requirements for opening workers compensation claims and concerns that such an approach has the potential to further compromise their patients' health. In Australia, whether a claim is eligible for compensation is determined by the relevant insuring authority. While some jurisdictions have the option of allowing payment of medical and rehabilitation expenses and reimbursement of salary while claims are being determined, until a claim is accepted no benefits are technically payable, and, if reimbursements have been paid, these may have to be repaid if the claim is subsequently rejected. Thus, incurring treatment expenses while the claim is being determined can have substantial financial complications for an already stressed worker. This is further compounded by the sometimes significant time delays in the determination of some stress claims. For example, in South Australia (which is the only jurisdiction from which I was able to obtain data), 500 claims with stress as the primary cause of injury were lodged in the 1998–99 financial year. It took an average of 77 days to determine whether a claim was compensable or not; 223 claims were initially rejected, but 88 of these were eventually accepted after litigation (H Woznitza, Program Manager – Education, WorkCover Corporation SA, personal communication). There is no reason to expect that this sobering picture is substantially different in other jurisdictions. Obviously, this uncertainty and tardiness cannot assist the mental health of someone who already has a stress-related illness. As Russell and Roach note, guidelines support a therapeutic benefit from early return to work,2 although the evidence for this is scanty. There is some support for the benefits of early return to work in the South Australian data. For claims lodged between July 1996 and 30 June 1998 (see Box ), in cases of occupational stress where there was an early return to work the likelihood of patients requiring long term ongoing support was reduced. However, these data need to be treated with caution because they are not controlled for severity of illness. In contrast, there is good evidence to suggest that people who are injured and claim compensation for the injury have poorer health outcomes than those not involved in the compensation process.3-5 A recent report produced by the Australasian Faculty of Occupational Medicine of the Royal Australasian College of Physicians highlighted the deficiencies in knowledge in this area.5 In particular, research into causes of poor health outcomes for individuals in the compensation system is limited and inconclusive, and not enough is known of the effects of different types of schemes or methods of case management. Not so long ago in the Journal, Cameron outlined some of the technical and ethical problems doctors face when working within the workers compensation system framework.6 Issues of role confusion (gatekeeper versus patient advocate), objectivity in the face of coercion, and patient and insurer mistrust all contribute to many practitioners shying away from workers compensation cases. These concerns were reflected in the issues perceived by the GPs in the survey by Russell and Roach as barriers to effective management of patients with work-related stress.1 So, what messages can be drawn? Given the recognised adverse health outcomes that commonly occur after lodging a compensation claim, and the obvious stress involved in the process, it is not surprising that many general practitioners elected to temporise rather than immediately commence a compensation claim. However, patients have rights under workers compensation legislation to receive benefits for work-related illness and injury. These benefits are more generous than those available under the Medicare system (eg, the payment of treatment from a psychologist is able to be reimbursed through workers compensation). Indeed, claiming benefits from Medicare for a workers compensation injury is specifically precluded. There is also a need for systems that enable treatment to occur with certainty of reimbursement of costs while claims are being determined and disputed. Obviously, practitioners would benefit from increased education and skills, and the proposed Western Australian accreditation system may be one way to assist this process. Increased education and skill sharing of all participants (including consumers and the legal profession) in the compensation system may address some of the concerns about the adversarial system. Another approach may be to change the system itself, particularly by reducing its adversarial nature so that more time and effort is available for patient care. Exploring solutions that recognise "work stress" as a multifactorial problem, often with some of its origins outside the workplace, may be a worthwhile approach. This would necessitate a collaborative approach to managing work-related stress, with all stakeholders contributing their particular skills and perspectives. Finally, confidentiality issues in workers compensation stress claims remain significant barriers in the minds of medical practitioners and their patients. Clearly, there is a need for appropriate research strategies to examine and address these issues systematically to optimise health outcomes in a cost-effective way. Stress claims for which salary reimbursements were received from the South Australian WorkCover Corporation between 1 July 1996 and 30 June 1998* Claims still receiving reimbursement of all or part of salary Time from date of injury to return to work Number of claims 12–15 months from date of injury 24–27 months from date of injury Up to 4 weeks 81 16 (20%) 11 (14%) 4 weeks to 3 months 87 23 (26%) 14 (16%) 3–15 months 90 36 (40%) 24 (27%) * H Woznitza, Program Manager – Education, WorkCover Corporation SA, personal communication.

Ian D Steven MB BS, MD, MPH, FRACGP, FAFPHM · E Michael Shanahan BM BS, MPH, FAFOM, FRACP

Objectives: To identify approaches to and barriers associated with the management of patients with work-related stress by general practitioners (GPs).Design: Cross-sectional postal survey using a self-administered questionnaire which included a case vignette of a patient with work-related stress and questions ascertaining perceived barriers to the effective general practice management of work-related stress.Participants and setting: 450 Western Australian GPs on the mailing list of a GP journal. The survey was conducted between 22 March and 28 April 2000.Main outcome measures: Likelihood that GPs would (i) choose to open a workers compensation claim and (ii) provide time off work for the patient described in the vignette.Results: Response rate was 50.1%. Eighty-five per cent (95% CI, 79.6%–89.7%) of respondents advised the hypothetical patient to take time away from work; however, only 44.0% (95% CI, 37.2%–50.7%) chose to initiate a workers compensation claim. GPs with training or experience in occupational health were less likely to advise the patient to stay away from work (odds ratio [OR], 0.30; 95% CI, 0.12–0.73), but were just as likely to initiate a claim. GPs were reluctant to involve the employer in management decisions, because of concern about patient confidentiality and the potential to make matters worse for the patient. These, and the adversarial nature of the workers compensation system, were the strongest perceived barriers to effective management of the condition.Conclusions: Our findings indicate that general practitioners take a pragmatic and varied approach to the management of work-related stress. The perceived difficulties with contacting employers challenges the principles of injury management within a workers compensation system which is dependent on liaison between system stakeholders.

Grant M Russell FRACGP MFM (Monash) · Sally M Roach PhD, PostGradDip, BAppSc

In a recent issue of the Journal, Blake and colleagues described a cluster of three cases of measles from western Sydney.1 The index patient acquired measles overseas, while the other two patients acquired the infection during a hospital visit and probably in the waiting room of a general practice, respectively. Measles is highly contagious and can spread with relative ease in healthcare settings, especially if there is a failure to diagnose the infection, to isolate the infectious patient or to notify the case so that other infection control measures can be implemented. Other recent Australian outbreaks of measles have also been associated with virus importation from overseas and subsequent nosocomial transmission.2-4 Measles was imported in nine separate incidents investigated in Western Australia between March 1999 and October 2000, and subsequently transmitted among hospital patients, visitors and healthcare workers on two separate occasions. Victoria has experienced two outbreaks in the past three years,3,4 and a third is evolving (Dr Sean Tobin, Medical Officer, Communicable Diseases Section, Department of Human Services, Victoria, personal communication). In two of the three outbreaks, the index patient had returned from overseas during the incubation period, and genotyping provided strong evidence that the viruses were imported. All three outbreaks involved predominantly young adults. Healthcare staff aged in their 20s or early 30s accounted for six of the 75 cases in the 1999 Victorian outbreak (a doctor, three nurses, a social worker and a medical student3), and for two of the 51 cases in the first of the 2001 Victorian outbreaks (a medical student [the index case] and a nurse who remained unvaccinated despite being identified as susceptible in the previous outbreak5). In the latter outbreak, an unvaccinated 11-year-old child also became infected after attending an emergency department at the same time as an infectious patient. In the current outbreak, one case was in a 36-year-old hospital orderly, and another in a 30-year-old pharmacy assistant, both almost certainly infected while at work (Dr Sean Tobin, personal communication). The hospital orderly, born in 1965, might have been expected to be immune to measles, having grown up when measles virus was circulating in the community and measles epidemics occurred every two years.6 However, people born between about 1968 (when measles vaccine was first licensed in Australia) and 1981 (when a measles–mumps combination vaccine was introduced to the Australian childhood schedule) grew up when exposure to wild measles virus was decreasing. Because of initial poor vaccine coverage, there was inadequate compensation for the subsequent decline in natural immunity in the population, leaving a proportion of this age group, now aged 20–33 years, at risk of measles infection.7 These cases of measles transmission in healthcare settings in Victoria, Western Australia and New South Wales illustrate failure to implement the published guidelines for measles control.8 These involve four key components: isolate the patient, confirm the diagnosis, identify other cases and identify and protect all susceptible persons. However, the failures may be caused by a general lack of awareness of the guidelines rather than an unwillingness to follow their recommendations. In particular, the guidelines are not useful if measles has not been diagnosed. Measles is now relatively uncommon and more likely to affect young adults than children.2 A high index of suspicion is needed, and measles should always be considered in the differential diagnosis of fever and rash in an unwell adult, especially if the person was born between 1968 and 1981. Had the four key components of outbreak control been implemented in some or all of the reported measles outbreaks, some or all of the infections in these outbreaks may have been prevented. As recommended in the guidelines for measles control,8 vaccination of some or all of the young adults involved in these outbreaks may also have prevented further cases. Australia has recently spent more than $30 million on a highly successful mass-vaccination campaign that has effectively protected school-aged children against measles.9 It seems extraordinary that measles transmission can still occur in hospitals or general practice surgeries. Case reports are very unlikely to reveal the extent of the problem. It might be said that transmission of measles — or any other vaccine-preventable disease — in a healthcare setting is a sentinel sign of system failure. Offering susceptible healthcare workers measles–mumps–rubella vaccine has been made a quality standard for all healthcare workers in the United States,10 and a similar approach may be warranted in Australia. Healthcare providers in hospitals and the wider community should record which staff members are susceptible to vaccine-preventable diseases that may be occupationally transmitted, and should provide facilities for vaccination of all those who wish to protect themselves and their patients. As recommended in the Australian guidelines for measles control, young adults intending to travel to measles-endemic countries should be advised to check and update their measles vaccination status. At a time when measles transmission has probably been interrupted in several Australian States,2,11 it is important to suspect the diagnosis of measles in young adults with rash and fever, especially those with a history of international travel, and to take pro-active infection control measures to prevent measles transmission in healthcare settings.

Heath A Kelly · Michaela A Riddell · Ross M Andrews

Editorial What's in a name? The labelling of back pain We need a taxonomically correct term for back pain that reassures patients that they can confidently resume normal activities MJA 2000; 173: 400-401 When compiling the second edition of the taxonomy of pain,1 the taxonomy subcommittee of the International Association for the Study of Pain (IASP) wrestled with the diagnosis of spinal pain. It recognised that many diagnostic labels were illegitimate, inappropriate, or fanciful. Nevertheless, it allowed certain labels drawn from the osteopathic, physical medicine, and mainstream literature. In doing so, however, the subcommittee stipulated strict criteria that had to be satisfied if a particular diagnostic label was to be used. The purpose of doing so was to ensure consistent, disciplined and accountable use of terms. However, in many instances, the criteria were such that they could not be satisfied using history and examination alone, or even conventional investigations. The purpose of setting such stringent criteria was to highlight the deficiencies of contemporary practice and to indicate the need for research into the reliability and validity of traditional diagnostic practices. In effect, the exercise established that it was essentially impossible to render any conventional or traditional diagnosis for low back pain. The means to do so were simply not available, not reliable, or not valid. Consequently, the subcommittee argued that the only intellectually and clinically honest diagnosis for most cases of low back pain was "lumbar spinal pain of unknown or uncertain origin".1 This rubric serves well enough for purposes of classification and coding, but it is cumbersome and unappealing for everyday use. Despite its accuracy and honesty, the term is long and conveys the sense that the doctor does not know what is going on. Against this background it is not surprising that general practitioners lack a decent vocabulary for labelling a patient's back pain. The study of Schönstein and Kenny,2 of this issue of the Journal, highlights the implicit difficulties that GPs have in this regard when completing workers compensation certificates. Their sample showed considerable variation in the terms used. Yet, we cannot blame GPs; they are doing as best they can in the absence of a satisfying, official term. Nevertheless, the study reveals the need for standardisation. Diagnostic labels are important in the management of patients. Patients expect a name for their condition. A label shows that the doctor knows what is wrong. But such labels should not be incorrect or specious, lest they lead to therapeutic misadventure. Zygapophysial joint pain and discogenic pain can not be diagnosed clinically3,4 and are, at best, suppositions. Other labels, such as "segmental dysfunction", are only metaphors, with no established biological correlates. Some labels are simply wrong and can have deleterious effects. "Degenerative disc disease" conveys to patients that they are disintegrating, which they are not. Moreover, disc degeneration, spondylosis and spinal ostoearthrosis correlate poorly with pain and may be totally asymptomatic.5 They are age changes and do not constitute diagnoses. For this reason they were not admitted by the IASP.2 "Nominated treating doctors", in recording a diagnosis for back and neck pain, can at least approach standardisation by avoiding these presumptive and specious labels. "Sprain" or "strain" are inferences about what caused the back pain, but are based on what the patient reports. They can not be proven clinically and therefore may or may not be correct inferences. Nevertheless, these labels convey the notion that the pain and its cause are not serious. This is the issue that Schönstein and Kenny raise.2 Because it is not possible to render a pathoanatomical diagnosis of back pain, it becomes imperative to distinguish serious from non-serious conditions. In this regard, it has become conventional to refer to serious conditions as "red flag" conditions, the red flags being aspects of history or examination that should warn doctors of the possibility of a tumour or infection being the cause of pain. Mercifully, these conditions are rare. Another term that has emerged is "yellow flags". This pertains to certain beliefs, attitudes and responses that patients may have to their pain that are counterproductive to recovery. They include believing that activity will make their condition worse, blaming work for their pain, avoiding social activity, and relying on passive therapy.6 These are psychosocial features that are unrelated to the cause of pain, and can occur even with simple causes of pain; but they require attention lest they impede, retard or prevent recovery. What is lacking, however, is a term for back pain that is not associated with red flags or yellow flags. Such a term should be more than taxonomically correct. It should positively reassure patients that they can confidently resume normal activities, without developing fears or inappropriate behaviours. It is such a term that Schönstein and Kenny are looking for.2 In the context of workers compensation certificates such a term would provide more than a convenient label. It would indicate a favourable prognosis and convert the certificate from a disconcerting or confusing document to a propitious and enabling one. The terms "simple back pain" or "uncomplicated back pain" lack these latter properties. The challenge remains to help Schönstein and Kenny, and others, find a new term: one that is palatable to doctors, satisfying to patients, and which not only means that there is nothing seriously wrong, but also conveys the message that the patient has no grounds for fear, and can expect recovery with straightforward, even minimal, management. Nikolai Bogduk Newcastle Bone and Joint Institute University of Newcastle, Royal Newcastle Hospital, Newcastle, NSW mgillamATmail.newcastle.edu.au Merskey H, Bogduk N, editors. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms, 2nd edition. Seattle: IASP Press, 1994. Schönstein E, Kenny DT. Diagnoses and treatment recommendations on workers compensation medical certificates. Med J Aust 2000; 173: 419-422. Torgerson WR, Dotter WE. Comparative roentgenographic study of the asymptomatic and symptomatic lumbar spine. J Bone Joint Surg Am 1976; 58: 850-853. Schwarzer AC, Aprill CN, Derby R, et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine 1995; 20: 1878-1883. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994; 19: 1132-1137. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long-term disability and work loss. Wellington, NZ: Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee. Make a comment

Nikolai Bogduk

Medicine and the Community Diagnoses and treatment recommendations on workers compensation medical certificates Eva Schönstein and Dianna T Kenny MJA 2000; 173: 419-422 For editorial comment, see Bogduk Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Occupational health Abstract Objective: To review the diagnostic descriptions and treatment recommendations for back and neck pain on the new workers compensation medical certificates and compare these with evidence-based guidelines. Design: Retrospective analysis of 251 medical certificates of workers with compensable neck and back pain held by a workers compensation insurer. Main outcome measures: Diagnoses given and treatments prescribed by the nominated treating doctors. Results: The diagnoses most frequently used were "sprain/strain" and "pain/ache". Physiotherapy was the most frequently prescribed treatment, followed by rest and medication. Rest was prescribed for 68 (27%) workers, 87% of whom were classified as having an acute injury. Activity-based treatments were prescribed for 45 (18%) workers. Conclusions: Not all doctors used diagnostic terms consistent with recommended anatomical taxonomy. The drug therapy prescribed was consistent with current evidence-based treatment guidelines. However, the prescribing of rest, and the omission, in most cases, of explicit recommendations to resume normal activities, including work, are not consistent with current guidelines. The cost of managing workplace back injuries is increasing. Figures for 1997-98 show that back injuries accounted for 30% of the cost of all workplace injuries (gross cost, $224 million),1 while comparable figures for 1996-97 were 36% and $212.5 million.1,2In an effort to reverse the growing WorkCover Authority (WCA) debt ($1.7 billion at the time of writing),3 the 1997 Grellman Report4 made recommendations which resulted in the Workplace Injury Management and Workers Compensation Act 1998 (NSW). A new medical certificate intended to streamline reporting and management of compensable work-related injuries was introduced, as well as the concept of the "nominated treating doctor" (NTD) -- a general practitioner nominated by the injured worker who agrees to provide continuity of care until a return to work is achieved (Box 1). In recent years, national and international guidelines and systematic reviews -- some evidence-based -- have established standards for diagnosis and treatment of people with back or neck pain,5-10 including the most recent National Health and Medical Research Council (NHMRC) guide to acute pain management11 and the definitive publication on classification of pain by the International Association for the Study of Pain (IASP).12 To streamline management and reduce the costs associated with prolonged disability and time off work, it is important that the NTDs' diagnoses and treatment recommendations conform with evidence-based guidelines. We compared the diagnoses and treatments given on Part 1 of a sample of medical certificates of workers (who had work-related back or neck pain) with the taxonomic guidelines for diagnosis and the emerging guidelines for management. Methods We examined retrospectively all the medical certificates related to neck and back pain of a NSW workers compensation insurer for the period 1 October 1998 - 15 February 1999. Medical certificate entries were de-identified. Diagnosis and treatment were coded according to the most common wording used by doctors. Diagnoses were further grouped into those indicating and those not indicating a specific pathological condition. Treatments were further coded according to the amount of rest and/or activity prescribed. Active treatments involved exercise, work conditioning/work hardening, and maintenance of normal activity (including work). Diagnoses were then compared with taxonomic guidelines, and treatments were compared, wherever possible, with evidence-based guidelines for the management of spinal pain. According to the time between the date of injury on the certificates and the date of the medical certificate, the worker's condition was classified as acute (< 6 weeks), subacute (6-12 weeks) or chronic (> 12 weeks). Ethical approval: Approval for the study was obtained from the Human Ethics Committee, The University of Sydney. Results Diagnosis On 227 of 251 certificates examined (90%), doctors did not specify a patho-anatomical diagnosis: on 92 certificates (37%) the diagnosis was sprain/strain; on 68 (27%) ache/pain; and on 67 (26%) injury (mechanical, lumbago, dysfunction, whiplash, discopathy, myalgia). The location of the pain was lumbar spine (131; 52%), back (42; 17%), cervical spine (39; 16%), and other (39; 16%). Thirty-four doctors (14%) used at least two diagnostic descriptors, and, of these, six used at least three. Examples included "back pain due to low back strain", "thoracolumbar spinal pain, right sciatica", and "lumbar disc degeneration, right low back pain, and right sciatica pain". Treatment The most frequently prescribed treatments (Box 2) were physiotherapy (116; 46%); rest (68; 27%); non-steroidal anti-inflammatory drugs (NSAIDs) (64; 25%); and analgesia, analgesics or "painkillers" (56; 22%). Specific active management advice, such as exercise, a return to work, suitable duties, work conditioning, hydrotherapy or work rehabilitation, was recommended for 45 (18%) workers. Many had more than one treatment prescribed, with the total sample of 251 being prescribed 455 treatments. Most workers were seen by their doctors in the acute phase of injury (208; 83%), with the remainder in the subacute (18; 7%) or chronic (21; 8%) categories. Of the workers prescribed rest, 87% were classified as having an acute injury. Fifty-six workers (22%) were certified fit for suitable duties, 24 of these (43%) on their initial visit to their NTD. Ninety-two workers (37%) were deemed unfit for work. This information was not included on the remaining certificates. Of the 92 workers deemed unfit for work, 59 (64%) were on their first visit to their doctor, 13 (14%) were being issued with a progress medical certificate, and 8 (9%) were making their final visit. The remaining 20 (22%) certificates did not have this information. The treatments prescribed on the medical certificates and available evidence for their efficacy are summarised in Box 3. Wherever possible, the evidence is presented according to the NHMRC level-of-evidence ratings. Discussion We found that doctors completing medical certificates for workers with back and neck pain generally did not indicate a specific pathoanatomical diagnosis. This is consistent with epidemiological evidence:6,7 in 85%-90% of back complaints, a pathoanatomical diagnosis can not be made from the history, examination or even medical imaging. One of the primary aims of the initial assessment is to exclude "red flag" conditions such as tumours, fractures, disc prolapses, herniations, or infections. According to the NHMRC,11 this exclusion is the key to managing acute spinal pain, and for this purpose the history is the most valid tool.13 The diagnoses given on medical certificates for back and neck pain should explicitly reflect the exclusion of "red flag" conditions, and the presence of a benign, self-limiting condition which generally resolves within four weeks of onset of pain.14The certificates showed that the doctors used a variety of (implicit) taxonomic systems to describe "non red flag pain"; for example, anatomical (eg, "back pain", "thoracolumbar spinal pain"), aetiological or mechanical (eg, "mechanical back pain", "injury"), or descriptive pathological (eg, "sprain", "tear", "degeneration"). Only anatomical classification is consistent with the IASP classification.12 However, the precise terminology used to describe pain of this type is contentious. Terms such as "non-specific back pain",6,15 "simple back pain",14 or "back pain of unknown or uncertain origin"12 have been proposed. NSAIDs and analgesics were the most frequently prescribed medical therapy. Their use for spinal pain is consistent with current evidence-based practice,9 but support for the use of NSAIDs is limited and applies only in the short term.9,11 Although physiotherapy, either alone or in combination with other treatments, was the most frequently prescribed treatment, the NTD generally did not specify the exact nature of the physiotherapy intervention. While scientific evidence for the efficacy of specific physiotherapy treatments for neck and back pain has been published,8,9,16 there is great variability in treatments among physiotherapists,17,18 and the extent to which they adhere to evidence-based practice has not been studied. The Australian Physiotherapy Association has made a concerted effort to educate and inform its members by producing position statements on neck pain and back pain. These as yet unpublished statements are based on randomised controlled trials and systematic reviews (some by the Cochrane Collaboration). A Physiotherapy Evidence Database has also been created (PEDro).19 When reviewing their patients, doctors need to consider the evidence for the efficacy of the specific physiotherapy treatment received. "Rest" was the second most common word included in treatment recommendations (27% of cases), and most workers for whom rest was prescribed were in the acute phase of their injury. In contrast, activity-based treatments were recommended in only 18% of cases. Both in terms of what was prescribed and what was omitted, this is contrary to current evidence. There is now Level I evidence that bed rest should not be prescribed for acute back pain;20 and Level II evidence that advising patients to return to normal activity (including work),21-24 providing reassurance, and discouraging fear of activity and illness behaviour, are effective for managing acute and subacute spinal pain. It is acknowledged that the use of the word "rest" may not necessarily mean "bed rest". However, even when used in combination with an activity-based treatment, the word "rest" may be construed to mean a cessation of all, most, or some of a person's normal functional and work activities. Recommendations As a result of our study, we recommend that: The new workers compensation medical certificates should be changed to assist nominated treating doctors (NTDs) to indicate that "red flag" conditions have been excluded. The use of the word "rest" on medical certificates should be restricted and the resumption of normal functional and work activities should be explicitly included. There should be a taxonomic standard for describing neck and back pain which clearly communicates that the condition is benign and has a good prognosis. This should reduce fear-avoidance and illness behaviours in workers,25 and assist employers to provide suitable temporary duties for workers. The medical profession and other appropriate authorities need to encourage dissemination and use of evidence-based guidelines and best practice in the management of compensable spinal pain. Acknowledgements We thank HIH Insurance (Injury Management Department) for providing access to workers compensation medical certificates, and Dr C Maher and Dr J Latimer, from the School of Physiotherapy, Faculty of Health Sciences, The University of Sydney, for their support and helpful comments. Competing interests: No conflict of interest exists and the study received no funding. References WorkCover NSW. Statistical bulletin. NSW workers compensation. Sydney: WorkCover NSW, 1997-1998. WorkCover NSW. Back injuries statistical profile, 1996/1997. WorkCover NSW, 1997/98 Annual Report. Sydney: WorkCover NSW, 1998. Grellman RJ. Inquiry into workers compensation system in NSW. Sydney: KPMG, 1997. Agency for Health Care Policy and Research (AHCPR). Clinical Practice Guidelines Number 14. Acute low back problems in adults. Rockville, Md: AHCPR, 1994. Fordyce WE, editor. Back pain in the workplace. Management of disability in nonspecific conditions. International Association for the Study of Pain. Seattle, Wash: IASP Press, 1995. Victorian WorkCover Authority. Guidelines for the management of employees with compensable low back pain. Melbourne: Victorian WorkCover Authority, 1996. Gross A, Aker P, Goldsmith CH, Peloso P. Conservative management of mechanical neck pain: systematic overview and meta-analysis. BMJ 1996; 313: 1291-1296. Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain. A systemic review of randomized controlled trials of the most common interventions. Spine 1997; 22: 2128-2156. Waddell G, Feder G, McIntosh A, et al. Low back pain evidence review. London: Royal College of General Practitioners, 1998. National Health and Medical Research Council. Acute pain management: scientific evidence. Canberra: NHMRC, 1999. Merskey H, Bogduk N, editors. Classification of chronic pain. International Association for the Study of Pain. Seattle, Wash: IASP Press, 1994. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992; 268: 760-765. Croft PR, Macfarlane GJ, Papageorgiou AC, et al. Outcome of low back pain in general practice: a prospective study. BMJ 1998; 316: 1356-1359. Cedraschi C, Nordin M, Nachemson AL, Vischer TL. Health care providers should use a common language in relation to low back pain patients. Baillieres Clin Rheumatol 1998; 12: 1-15. Gross A, Aker P, Goldsmith C, Peloso P. Physical medicine modalities for mechanical neck disorders (Cochrane Review). Cochrane Library; Issue 1, 2000. Van der Valk RWA, Dekker J, van Baar ME. Physical therapy for patients with back pain. Physiotherapy 1995; 81: 345-351. Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of care for patients with low back pain. Phys Ther 1994; 74: 101-114. The Physiotherapy Evidence Database (PEDro). May 2000. <http://ptwww.cchs.usyd.edu.au/pedro/> (accessed 6 September 2000). Koes BW, van den Hoogen HMM. Efficacy of bed rest and orthoses of low back pain. A review of randomized clinical trials. Eur J Phys Med Rehabil 1994; 4: 96-99. Malmivaara A, Hakkinen U, Aro T, et al. The treatment of acute low back pain -- bed rest, exercise or ordinary activity? N Engl J Med 1995; 332: 351-355. Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine 1995; 20: 473-477. Lindstrom I, Ohlund C, Eek C, et al. Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain. A randomized prospective clinical study with a behavioural therapy approach. Spine 1992; 17: 641-652. Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioural approach. Phys Ther 1992; 72: 279-293. Loeser JD, Sullivan M. Doctors, diagnosis and disability: a disastrous diversion. Clin Orthop Rel Res 1997; 336: 61-66. (Received 3 Sep 1999, accepted 31 Jul 2000) Authors' details Faculty of Health Sciences, The University of Sydney, Sydney, NSW. Eva Schönstein, BAppSc(Phty), MHPEd, Lecturer, School of Physiotherapy. Dianna T Kenny, PhD, MAPsS, Associate Professor of Psychology. Reprints will not be available from the authors. Correspondence: Ms Eva Schönstein, School of Physiotherapy, Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe 1825. E. SchonsteinATcchs.usyd.edu.au Make a comment 1: The new medical certificate Part 1: Requires the nominated treating doctor (NTD) to give a diagnosis, recommend treatment and determine the worker's fitness for work and suitable duties, including specific restrictions. It must be completed for those who are likely to return to pre-injury or suitable duties within 7 days of injury. Part 2: Requires doctors to specify nature and restrictions to proposed suitable duties (only completed for workers expected to return to work after more than 7 days from the date of injury). Part 3 (Return to Work Form): Requires recommendations on when the worker should resume work and the restrictions on activities arising from the work-related injury (must be completed for all workers who need a graded return to pre-injury or other permanent duties). Back to text 2: Treatments most commonly prescribed on the 251 medical certificates Treatment (examples) Number (%) Physiotherapy only 48 (19%) Physiotherapy + activity 12 (5%) (Physiotherapy and exercise, or rehabilitation, or hydrotherapy, or modified duties, or graded return to work) Physiotherapy + passive treatment 56 (22%) (Physiotherapy and medication or rest or massage or heat or ice or a combination of these) Medication only 25 (10%) (Analgesics, NSAID, drug not specified, Brufen [Knoll], Voltaren [Novartis], Panadeine Forte [Sanofi- Synthelabo]) Medication + activity 9 (4%) (Analgesia and home exercises , paracetamol and back exercises, NSAID and light duties) Medication + rest 24 (9%) (NSAID or analgesics and rest) Rest only 6 (2%) (Rest, bed rest) Rest + activity 12 (5%) (Rest and exercise or modified duties or return to work) Specified single treatment other than rest, medication or physiotherapy 17 (7%) (Acupuncture, chiropractic, manipulation) Other combinations of two or more treatments 8 (3%) (NSAID and heat and massage, rest and local heat and massage) Other treatment descriptors not elsewhere classifiable 17 (7%) ("Conservative management", "restricted daily", "nil", "rehabilitation medicine") Treatment not specified 17 (7%) Total 251 (100%) Back to text 3: Treatments recommended on more than one of the 251 medical certificates and NHMRC levels of evidence for their efficacy (wherever possible)* Treatment prescribed n (%) RCGP10 Van Tulder et al9 Physiotherapy 116 (46%) -- -- Rest, bed rest 68 (27%) Ineffective, Level I Ineffective, Level I NSAID 64 (25%) Effective, Level I Effective, Level I Analgesics, analgesia 56 (22%) Effective, Level III Effective, Level II Exercise, swimming 29 (12%) Ineffective, Level I Ineffective, Level I Light, modified duties, gradual return to work 13 (5%) Effective, Level IV -- Massage 11 (4%) -- -- Manipulation, mobilisation, chiropractic 11 (4%) Effective, Level I Effective, Level III Heat (electromagnetic or source unspecified) 9 (7%) -- -- Ice 4 (2%) -- -- Muscle relaxants 3 (1%) Effective, Level I Effective, Level I Ultrasound 3 (1%) -- -- Work conditioning 2 (0.8%) Effective, Level III -- Acupuncture 2 (0.8%) -- -- Victorian WCA7 Gross et al8 IASP6 AHCPR5 Beneficial -- -- -- Beneficial (48 hours) -- Ineffective Ineffective, Level I Beneficial Inconclusive Effective Effective, Level II Beneficial Inconclusive Effective Effective, Level III Beneficial -- Effective Effective, Level III Beneficial -- Effective Effective, Level IV Beneficial -- -- -- Beneficial Effective short term, Level I Effective Effective, Level II Beneficial Effective short-term Level I Ineffective Self-application, Level IV Beneficial -- -- Self-application Level IV Beneficial short term Inconclusive Ineffective Effective, Level III -- -- -- -- -- -- -- -- Beneficial Inconclusive Ineffective Ineffective, Level IV *For some of the guidelines cited (IASP6 and Victorian WCA7) levels of evidence were not given. For others (RCGP10 and AHCPR5), the levels of evidence given were converted to match the NHMRC levels. Back to text

Eva Schonstein · Dianna T Kenny

Snapshot! Occupational hazard for Father Christmas No, this is not the dejected figure of Santa on Christmas morn, awaiting the tender ministrations of Mrs Claus after a run-in with a reindeer on ritalin. Reindeer have large, wide hooves, while the cloven-hoofed beast behind these injuries, the fallow deer, is smaller, with sharp, small hooves. Figure A shows the back of a farmer who was trampled by a fallow deer and Figure B shows the hooves of the deer. The deer assures us that the whole thing was an accident. David J Williams Professor and State Pathologist Brisbane, QLD Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

David J Williams

Fundamental reform of hours worked by junior doctors is required It has long been recognised that the rites of passage for junior doctors in public hospitals require extended hours of work with inadequate provision for rest and recovery. Not only are the junior doctors on a very demanding learning curve, but, at the same time, they are required to establish effective working relationships with patients, families and senior colleagues, and deal with the complexity of the modern hospital administration. Add to this a stressful workplace environment and, at times, the necessity to make critical decisions within a limited time frame and you have a situation no other professional group would be prepared to tolerate. Yet the research1 indicates that this is the situation most doctors face at the beginning of their careers. While Olson and Ambrogetti2 in this issue of the Journal present some criticisms of the methods of such research, there is considerable evidence to support the view that junior doctors' hours of work are, at times, excessive.3 The most recent Australian survey, undertaken as part of the current AMA Safe Hours Project, has produced further evidence to support this view.4 Why is this practice, which exerts a very heavy personal toll on the health and work performance of doctors, allowed to persist? No doubt there are respected members of the medical profession who argue that it is an essential component of the "toughening up" process. Clearly the hospital environment and the professional medical work ethic contribute to the excessive hours of work so ingrained in the hospital culture. The depth of this tradition was demonstrated recently in New York, where amendments to the Health Code5 were introduced in 1989 following the death of Libby Zion in a New York hospital. The circumstances of this unfortunate event are outlined by Nocera and Khursandi6 in this issue of the Journal. Libby's father, Sidney Zion, a newspaper columnist, was instrumental in launching a successful campaign restricting the hours of work of junior doctors working in hospital emergency departments. However, recent reports in the New York Times7 indicate there are still a large number of hospitals flouting this law. While legislative reform is one part of the solution, there is clearly a need to look at the attitudes which continue to support the practice. Until recently, little attention was given to the statutory responsibility of the employer to provide a safe system of work for doctors employed in hospitals.8 Currently, under occupational health and safety laws, there is increased emphasis on employers undertaking a hazard identification approach, followed by risk assessment and the application of risk controls. Applying this approach to the work regimen of junior doctors will present particular challenges to hospital administrators. An added consideration is the increasing recognition of the extent to which latent organisational failures may contribute by creating the circumstances leading to mishap.9 A hospital administration which fails to identify hazards and assess risks arising from extended hours of doctors' work could be in breach of a duty of care owed to doctors. Further, permitting a doctor to carry out duties while so fatigued that a patient's safety is endangered could be a breach of duty owed to the patient. The comments of the acting coroner in the recent inquest into the death of a New Zealand woman, the innocent party in a car crash, reinforce the importance of addressing the issue of fatigue.10 The patient survived the accident, but died following a mishap while in hospital. A significant issue for the coroner was the extent to which the fatigue of one of her doctors may have played a part in her demise. The coroner remarked that there was a growing level of concern, both nationally and internationally, over the hours of work of doctors in hospitals, and suggested that the medical professional bodies address the issue of extended periods of work. The hospital work practices of junior doctors appear to be common to many countries. Although the weekly hours worked by doctors in training are variable, it is reasonable to conclude that these routinely exceed 55 hours per week in many European countries.11 While the European Union originally excluded doctors in training from its 1993 Directive on Working Time,12 the Union's Council of Ministers indicated more recently that the directive should also apply to doctors in training.13 In 1990, the United Kingdom adopted an agreement, the New Deal, to phase in reduced hours for junior doctors.14 In March 1996, the AMA Federal Council adopted a policy to promote a safer workplace for junior doctors and patients in public hospitals.15 Part of the strategy involves the development of a national code of practice for the hours of work and rostering arrangements of junior doctors employed in hospitals. The Commonwealth Department of Health and Family Services has provided financial assistance to undertake a number of research projects to support the development of this national code. A draft of the code should be available for public comment in June/July 1998, to be followed by a national symposium in November 1998. Undoubtedly the major challenge is the professional medical culture, which, while it recognises the hazards and risks of excessive hours of work, appears to lack the collective will to resolve the problem. Nocera and Khursandi raise the question "Can the medical profession afford to let the courts decide what is reasonable?". In the absence of the medical profession's commitment to support fundamental reform of hours worked by junior doctors, where else can the victims turn? Gerry Holmes Manager, Occupational Health and Safety University of Wollongong Legal Advisor AMA Steering Committee, Safe Hours Project Swan, N. Juniors' Hours: International Overview. BMJ 1990; 301: 830-832. Olson LG, Ambrogetti A. Working harder -- working dangerously. Fatigue and performance in hospitals. Med J Aust 1998; 168: 614-616. Williamson A. The effects of workload and long hours of work on medical officers. Sydney: National Institute of Occupational Health and Safety (WorkSafe Australia), 1995. Australian Medical Association (AMA). Systems of work and overview of current arrangements. Canberra: Australian Medical Association, 1998. In press. New York State Health Code (10 NYCRR 405.4). New York: Department of Health, 1989. Nocera A, Khursandi DS. Doctors' working hours: can the medical profession afford to let the courts decide what is reasonable? Med J Aust 1998; 168: 616-618. Fein EB. Flouting law, hospitals overwork novice doctors. New York Times, 14 December 1997; 1. Holmes G. Hospital medical officers: hours of work and workloads, A strategic approach to occupational health and safety. Canberra: Australian Medical Association, 1995. Department of Transport. Investigation into the Kings Cross Underground Fire. London: HMSO, 1998. Coroner's Court. In the matter of the death of Patricia Margaret Ross. Rotorua, New Zealand: 15-17 October 1997; 18-20. Permanent Working Group of European Junior Hospital Doctors. Working conditions for doctors in training. Conference Proceedings, Executive Summary. Brussels: European Union Publications Office, December 1995. European Union. Directive on Working Time, 93/104. Brussels: European Union Publications Office, 1993. European Union. Sectors and activities excluded from working time directive. Brussels: European Union Publications Office, 1997. NHS Management Executive. Hours of work of doctors in training: guidance on regional task forces. London: Department of Health; 1991. Federal Council, Australian Medical Association. Executive minutes, 1-2 March 1996. Canberra: Australian Medical Association; 1996. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia ".

Gerry Holmes

Fatigue and performance in hospitals Patients in hospital don't stop requiring medical care at night. That means either overtime or shift work for somebody. "Somebody" is usually a junior doctor. The early postgraduate years are not easy -- the problems of professional responsibility, study and combining a career and a personal life are difficult enough, but to these challenges are added hours of work that society does not expect of any other occupational group. The routine 50- hour shifts of not so long ago have, we believe, disappeared, but hospital doctors still commonly work long hours and unreasonable shifts. What impact this has had in our hospitals -- how it contributes to mistakes, suicides, drop-outs and divorces -- is unknown. However, fatigue undoubtedly impairs professional performance, learning and quality of life. For legal, educational and humanitarian reasons, hospitals need to do whatever can be done to limit excessive hours of work. A physiological, not an industrial, problem How many hours are "excessive"? We do not know. It depends on what we are trying to achieve, and the answer will be different if we want to maximise teaching and learning than if we just want to avoid disastrous errors. How many hours are doctors working? We do not know that either. Most data derive from retrospective self-reports, which is obviously unsatisfactory, and concern average hours per week, which is not the issue. The issue is the existence of any work weeks that do not allow adequate recovery between shifts or which impose excessive periods of continuous work. The Association of American Medical Colleges has suggested that residents should not work more than 80 hours per week averaged over four weeks.1 This approach is irrational -- it is like saying you are fit to drive at any time if your blood alcohol level averaged over four weeks is less than 0.05%. We have practically no data on the frequency with which doctors work exceptionally long hours. Hospitals may have data on rostered hours, but this is only a portion of the total hours worked, and the information is not entirely accurate. Rosters change because swaps are unregulated, and unrostered overtime is usually not included in hospital estimates of hours worked. Time sheets would be a better source of data, but their use raises confidentiality problems, and they miss unpaid overtime. Unrostered overtime, whether obligatory or self-imposed, is unregulated and mostly unrecorded because the pressure to work and not complain is overwhelming. The only accurate source of data on total hours worked would be direct observation, and no such study has been done. It is critical that this is seen not as an industrial issue but as a physiological problem. An 80-hour work week including 40 hours of unpaid overtime and no days off, however unacceptable industrially, could be acceptable physiologically if the worker had eight hours' sleep between shifts. A 24-hour shift at double-time with paid meal breaks is not acceptable physiologically, however attractive it may be to a junior doctor with a mortgage. Imposing a 24-hour shift once a year because all the other medical staff are off sick may not be unfair, but it is unsafe. The body clock keeps ticking at night Humans have a marked circadian preference for sleep at night and, even under optimal conditions, being awake at night is associated with impaired performance. When long hours and sleep deprivation are added to the circadian problem, the performance deficit is exacerbated. The effects of fatigue on performance are well defined.2 Concentration, data processing and short-term memory are impaired. The variability of performance increases, so that normal performance alternates with periods of poor work, and astute decisions are mixed with lapses of judgement. Performance declines sharply as the duration of a task increases, and fatigued workers sacrifice accuracy to speed. Fatigue causes less performance decrement in workers with more control over their work because they can schedule non- urgent tasks for periods when they are at their best. Doctors will thus cope better than staff with less job flexibility, such as nurses. Effort can compensate for fatigue, but as fatigue worsens the ability to summon an effort of concentration declines and the time for which it can be maintained shortens. Performance in crises, however, is preserved until fatigue is extreme. Mistakes caused by fatigue are most likely to occur during routine tasks and tasks which require sustained vigilance, especially when the factors that trigger an effort of concentration (such as an obviously ill patient) are absent. Fatigue mistakes characteristically involve failure to recognise the existence of a serious problem. Giving the wrong antibiotic to a patient recognised as having sepsis is not a typical fatigue mistake, but failing to recognise sepsis at all is. For this reason fatigue-related errors of judgement are difficult to prevent and often disastrous. Are doctors seriously impaired by fatigue? We are not sure. Some studies have found performance decrements attributable to fatigue,3 but others have not.4 The methodological issues that make most existing studies of limited use are twofold. Firstly, the psychometric tests usually used to assess fatigue have never been shown to predict real-life medical performance.2Secondly, many studies use unrealistic definitions of fatigue. In one often-quoted study of junior doctors with work weeks of 100 hours, "fatigued" was defined as less than four hours' sleep in 24 hours, and "rested" as more than four hours' sleep in 24 hours.4 It is little wonder that no difference was discernible between the "fatigued" and "rested" doctors! Doctors and army officers are the only occupational groups reported to be unaffected by fatigue,2 but this is generally regarded as an artefact of methodology.2,5 A "healthy worker effect" is a possible explanation (people who need a lot of sleep don't last very long as surgical registrars or army cadets), but not needing a lot of sleep is hardly the best basis for choosing doctors. Willingness to work when fatigued is widely seen as "professional". This view goes back to acts of genuine heroism in wars and epidemics and to some of the noblest traditions of medicine. But the diurnal rhythm of alertness and the drive to sleep are basic physiological processes, and commitment does not affect physiology. Heroic workloads are out of place in the routine organisation of the urban teaching hospital. Many doctors, junior and senior, voluntarily undertake long hours of work for reasons of money, professional advancement or altruism. Neither money nor seniority is an antidote to fatigue, however, and fatigue is no less damaging to performance when it is incurred voluntarily. It is just as inappropriate for a consultant surgeon to perform emergency operations all night and a routine list the next morning as it is for a junior doctor to be forced to stay at work to assist. Hospitals must not only stop forcing staff to work dangerous hours, they must also prevent them choosing to do so. Hours ain't hours Given that night work is inevitable, and that it inevitably impairs performance and quality of life, it seems obvious to insist on the use of minimally damaging patterns of shift work. The reality in hospitals is different: a number of practices known to cause particularly severe impairment are common. The most obvious suspicion about shifts is true: long ones are worse than short ones.6 Data from a number of occupational groups suggest that eight-hour night shifts are optimal and that 12-hour night shifts are acceptable only if workloads are light. Night shifts longer than 12 hours, and daytime shifts longer than 16 hours, have consistently been found to be associated with reduced productivity and more accidents.6 It is also important to note that the later the night shift ends, the less sleep is obtained that day.7 Even when the night shift has officially ended, casual extension of night shifts into the morning for hand-over rounds and morning report is common. In addition, libraries and medical administration offices rarely have opening hours that allow night workers access without intruding on their sleep time. Physiological adaptation to night work is largely a myth8 and there is no reason to extend periods of night work in the hope that adaptation will occur. For intellectually demanding tasks, short periods of night work (one or two shifts) are better tolerated than longer periods because the accumulated sleep deficit is less. It is easy to demonstrate that the progressive sleep loss of a seven-night roster causes a progressive rise in accidents and a fall in productivity.9 Sleep deficits cannot be repaired immediately. Night-shift workers seldom sleep more than five or six hours in each 24- hour period, so that after seven nights the accumulated sleep deficit is 15 to 20 hours. At least 48 hours off duty are usually needed to recover this deficit,7,10and rosters that require workers to go from night shifts to day or afternoon shifts with no break are dangerous. The pattern of long work days followed by nights interrupted by calls is regarded as normal by the medical profession. These calls are, at best, simple telephone calls. At worst, they may entail returning to the hospital several times a night. Few other workers do this, and data on its long-term effects are entirely lacking. Being on-call impairs sleep even when there are no calls,11 and as five or six hours' uninterrupted sleep is needed to avoid performance decrement10 perpetual or frequent on-call work is probably damaging. Solving the problem We have very little of the knowledge that we need to understand fatigue in medical work. Studies are required to determine whether there is a serious problem of fatigue-related impairment of performance in some or all Australian hospitals. Such studies need to focus on how learning and quality of life, as well as professional performance, are affected by fatigue. Junior doctors are not the only ones affected by fatigue, and senior staff also need to be studied. We need controlled trials to determine optimal work schedules and to test countermeasures to fatigue (eg, benzodiazepines to assist daytime sleep, and bright light and caffeine for stimulation). We do know enough, however, to eliminate the worst abuses of the human sleep-wake cycle, and we need to see a shift by both hospital employers and the medical profession towards addressing this issue. References Executive Council, Association of American Medical Colleges. Resident supervision and hours: recommendations of the Association of American Medical Colleges. J Med Educ 1988; 63: 417-426. Dinges DF, Kribbs NB. Performing while sleepy: effects of experimentally induced sleepiness. In: Monk TH, editor. Sleep, sleepiness and performance. Chichester: Wiley, 1991: 97-128. Rubin R, Orris P, Lau SL, et al. Neurobehavioural effects of the on-call experience in housestaff physicians. J Occup Med 1991; 33: 13-18. Deaconson TF, O'Hair DP, Levy NW, et al. Sleep deprivation and resident performance. JAMA 1989; 260: 1721-1727. Leung L, Becker CE. Sleep deprivation and house staff performance. J Occup Med 1992; 34: 1153-1160. Rosa RR. Extended work shifts and excessive fatigue. J Sleep Res 1995; 4 (Suppl 2): 51-56. Kecklund G, kerstedt T. Effects of timing of shifts on sleepiness and sleep duration. J Sleep Res 1995; 4 (Suppl 2): 47-50. Dahlgren K. Long-term adjustment of circadian rhythms to a rotating shiftwork schedule. Scand J Work Environ Health 1981; 7: 141-151. Knauth P. Speed and direction of shift rotation. J Sleep Res 1995; 4 (Suppl 2): 41-46. Carskadon M, Roth T. Sleep restriction. In: Monk TH, editor. Sleep, sleepiness and performance. Chichester Wiley, 1991: 155-167. Torsvall L, Akerstedt T. Disturbed sleep while being on call. An EEG study of apprehension in ships engineers. Sleep 1988; 11: 35-38. Authors' details Sleep Disorders Centre, Royal Newcastle Hospital, Newcastle, NSW. Leslie G Olson, FRACP, Sleep and Respiratory Physician. Department of Medicine, University of Newcastle, Newcastle, NSW. Antonio Ambrogetti, MD, FRACP, Sleep and Respiratory Physician. Reprints will not be available from the authors. Correspondence: Dr L G Olson, Department of Medicine, University of Newcastle, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, NSW 2310. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".

Leslie G Olson · Antonio Ambrogetti