Download First Aid Only! - Alliance Occupational Medicine

“First Aid Only!”
Dan Rafael Azar MD MPH QME
Medical Director
Alliance Occupational Medicine
Santa Clara & Milpitas
www.allianceoccmed.com
1
“Always Start With a Joke”
Recording Criteria
(Section 14300.4)
Basic requirement: Each employer required by
this article (>10 EE’s) to keep records of
fatalities, injuries, and illnesses must record
each fatality, injury and illness that:
 (1) Is work-related (Section 14300.5) and
 (2) Is a new case (Section 14300.6) and
 (3) Meets
– one or more of the general recording criteria of
Section 14300.7
OR
– the application to specific cases of Section
14300.8 through Section 14300.12.
Work-related?
An event or exposure in the work
environment either
 caused or
 contributed to the resulting condition or
 significantly aggravated a pre-existing
injury or illness
Determination of New Cases
Section 14300.6
(a) Basic requirement. You must consider an injury or
illness to be a "new case" if:
 (1) The employee has not previously experienced a
recorded injury or illness of the same type that affects
the same part of the body, or
 (2) The employee previously experienced a recorded
injury or illness of the same type that affected the
same part of the body but had recovered completely
(all signs and symptoms had disappeared) from the
previous injury or illness and an event or exposure in
the work environment caused the signs or symptoms
to reappear.
General Recording Criteria §14300.7
A work-related injury or illness must be recorded if it
results in one or more of the following:
(A) Death: Section 14300.7(b)(2)
(B) Days away from work: Section 14300.7(b)(3)
(C) Restricted work or transfer to another job: Section
14300.7(b)(4)
(D) Medical treatment beyond first aid : Section
14300.7(b)(5)
(E) Loss of consciousness : Section 14300.7(b)(6)
(F) A significant injury or illness diagnosed by a physician or
other licensed health care professional : Section
14300.7(b)(7)
What is the Definition of
Non-Recordable Medical Treatment?
§14300.7
1. Visits to a physician or other licensed health
care professional solely for observation or
counseling;
2. The conduct of diagnostic procedures, such
as x-rays and blood tests, including the
administration of prescription medications
used solely for diagnostic purposes (e.g., eye
drops to dilate pupils); or
3. “First aid” as defined in subsection (b)(5)(B)
of this section.
So…What is the Definition of
First Aid in §14300.7?
14 Specific Items on “The List”
1. Using a nonprescription medication at nonprescription
strength
2. Administering tetanus immunizations (other
immunizations, such as Hepatitis B vaccine or rabies
vaccine, are considered medical treatment);
3. Cleaning, flushing or soaking wounds on the surface of
the skin;
4. Using wound coverings such as bandages, Band-Aids™,
gauze pads, etc.; or using butterfly bandages or SteriStrips™ (other wound closing devices such as sutures,
staples, etc. are considered medical treatment);
5. Using hot or cold therapy;
What is the Definition of
Medical Treatment? (Continued)
6. Using any non-rigid means of support, such as elastic
bandages, wraps, non-rigid back belts, etc. (devices
with rigid stays or other systems designed to
immobilize parts of the body are considered medical
treatment);
7. Using temporary immobilization devices while
transporting an accident victim (e.g., splints, slings,
neck collars, backboards, etc.);
8. Drilling of a fingernail or toenail to relieve pressure, or
draining fluid from a blister;
9. Using eye patches;
10.Removing foreign bodies from the eye using only
irrigation or a cotton swab;
What is the Definition of
Medical Treatment? (Continued)
11. Removing splinters or foreign material from
areas other than the eye by irrigation, tweezers,
cotton swabs or other simple means;
12. Using finger guards;
13. Using massages (physical therapy or
chiropractic treatment are considered medical
treatment for recordkeeping purposes);
14. Drinking fluids for relief of heat stress.
Are Any Other Procedures
Included in First Aid?
No.
 This is a complete list of all treatments
considered first aid.

Does the professional status of the
person providing the treatment have
any effect on what is considered first
aid or medical treatment?
No.
 Similarly, treatment beyond first aid is
considered to be medical treatment
even when it is provided by someone
other than a physician or other licensed
health care professional.

What if a physician recommends
medical treatment but the
employee does not follow the
recommendation?

Classic examples:
– Patient did not fill Rx for Antibiotics
– Patient does not adhere to restrictions at work or
home

You must record the case even if the injured
employee does not follow the physician’s
recommendation
 Employer should encourage the injured
employee to follow physician's recommendation
If a claim is
Not on the List of Severe Injury/Illness
and
On the List of First Aid Treatment
it is Non-Recordable
“Recordable” = need to record injury/illness in OSHA 300 log
 Current definition of First Aid and Recordability took effect
January 1, 2002
 Didn’t get changed in 2004/2005 during WC reform
 Greater clarity than previous regulation
 Less flexibility for “favorable interpretation” (manipulation)

Non-occupational causation (“not work related”) is other main
reason for “Non-Recordable”
Claim is Recordable Based on
Diagnoses / Treatment /Unique
Exposures



Death
Loss of Consciousness
Significant Injury/Illness:
–
–
–
–


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Fracture or “Cracked Bone”
Punctured eardrum
Chronic irreversible disease
Cancer
Treatment beyond “First Aid” (see “The List” of 14)
Needle stick with Blood/OPIM (Other Potentially
Infectious Material)
Hearing Loss (>25dB and >10 dB shift)
Exposure to Pesticides (CA specific)
Tuberculosis contracted at worksite
Recording Criteria for Work-Related
Tuberculosis Cases §14300.11.
Basic requirement:
1. “If any of your employees has been
occupationally exposed to anyone with a known
case of active tuberculosis (TB), and
2. that employee subsequently develops a
tuberculosis infection, as evidenced by a positive
skin test…”
You must record the case on the Cal/OSHA Form
300 by checking the “respiratory condition”
column.
What If Severe Injury/Illness can be
Treated with “First Aid Only”
Most Severe Injuries (as defined on by §14300.7) will cause

Days away from work

Restricted work or job transfer

Medical treatment beyond “first aid” as defined by “The List”… but not all.
Some Injuries/Illness on List do not require “Medical Treatment”
Classic Examples:

Minor fracture such as a broken toe for sedentary worker

Hearing Loss (if hearing aid not required)

BBP exposure (in someone current on Hepatitis vaccination)

“Loss of Consciousness”
“Some significant progressive diseases, such as byssinosis, silicosis, and
some types of cancer, for which medical treatment or work restrictions may
not be recommended at the time of diagnosis but are likely to be
recommended as the disease progresses.”
Final Answer:
List of Severe Injuries over rules List of First Aid Treatment
Most Common Reasons Claims
Become Recordable
Treatment driven by severity/duration of injury
or risk of complication:
– Physical Therapy with modalities/procedures
– Work restrictions (or a job transfer to another
–
–
–
–
position)
Rigid splint (“stays”, limit ROM)
Prescription medications
Sutures for laceration repair (full thickness wound
or for cosmesis)
Rarely at AOM: Loss time beyond the day of injury
(DOI)
First Aid as Defined by
California Labor Code Section 5401(a)
"any one-time treatment, and any
follow-up visit for
 the purpose of observation of
 minor scratches, cuts, burns, splinters,
or
 other minor industrial injury,
 which do not ordinarily require medical
care.”

First Aid as Defined by
California Labor Code Section 5401(a)
Treatment is not considered first aid in
either of the following circumstances:
 Medical care goes beyond a one-time
treatment and follow-up visit.
 The injury causes an employee to lose
time from work beyond his or her work
shift.
Sacramento Drops the Ball Again

AB 615 by Roger Neillo (R-Fair Oaks) would
adopt the Cal-OSHA definition of first-aid
injury to eliminate confusion for employers
 http://totalcapitol.com/ and enter AB 615
 The California Commission on Health and
Safety and Workers’ Compensation:
Summary of January 9, 2009 First Aid Cases
Advisory Group Meeting
Employer/Employee Reporting
Not Required for First Aid
“If treatment is considered first aid, the
employer is not required to submit an
Employer's Report of Occupational Injury or
Illness to State Fund nor provide a Workers'
Compensation Claim Form to the employee.”
 “If additional care is needed beyond first aid,
both the injury report and claim form must be
submitted.”
 “The two forms must also be submitted for
injuries that result in lost time beyond the
date of the incident.”

Doctor’s Report Required
even for First Aid:
Section 6409(a) California Labor Code
The physician is required to submit a
Doctor’s First Report of Injury or Illness (DFR
form 5021) to Insurer within five calendar
days of the initial examination.
 A DFR is not required if a physician is not
involved in the first aid treatment (for
example OHN)

Section 6409(a) of the California
Labor Code (cont.’d)


Insurer is required to send a copy of the DFR to the
Department of Industrial Relations (specifically the
Division of Labor Statistics and Research).
If, at the request of an employer, a first aid treating
physician fails to submit a DFR to the workers’
compensation carrier, the Department of Insurance
and the Department of Industrial Relations may
consider the arrangement improper. This
arrangement can be viewed as contributing to
possible criminal violations related to premium fraud
and the fraudulent denial of workers’ compensation
benefits to an injured worker.
Principles of Ethical Use
Cannot interfere with “appropriate care”
“of employee-patients
 Appropriate care based on Guidelines
(ACOEM, ODG) and Community
Standards (Good Sam., Stanford,
PAMF, Kaiser)
 The employer is ultimately responsible
for correct classification and
documentation

Common Misconceptions

Don’t need to file Doctor’s First Report
(form 5021) with carrier or TPA
– Legal requirement for clinic and employer
– Employer can still choose to be billed
directly as a standing request or on a case
by case basis

Cannot recommend non-prescription
medications in prescription dosages
– “take 3 Advil” (Ibuprofen 200mg x 3 = 600
mg)
First Visit @ Alliance:
Diagnosis?
Industrial Causation?
3. First Aid Only?
1.
2.
First Aid @ AOM:

Can injury be managed equally well
with first aid only treatment?
–
–
–
–
–
All providers trained to consider “first aid
only” treatment option
Requires creativity
Requires patient education around selfcare
Requires aggressive follow-up with early
recheck
If medically necessary increase intensity
of treatment on recheck
First Aid Issues
The more aggressive a given provider is
with using “first aid only” the higher
percentage will fail this attempt
 A provider can be too aggressive with
FA only
 Read the patient

First Aid Issues

Not OSHA recordable if restrictions
don’t apply to “usual” job duties:
– Example: administrative assistant that
“never” requires lifting over 20lbs.

Restrictions are providers way of
cautioning against aggravating activities
at work or home
– Example: lifting 40 lb 3-year old child from
car seat.
Patient Satisfaction
with First Aid Treatment
Need to be careful not to “turn patients off” or
decrease confidence in provider
 Important to understand treatment to date

– Saw own MD
– Treated as F.A. for several weeks by OHN at
worksite

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“Read patient”
Educate
Reassure
Do not discuss cost savings/benefit to
employer of FA Only treatment
Patient Satisfaction

Dispense OTC meds to address pain &
inflammation:
–
–
–
–
Generic Advil = Ibuprofen 200mg
Generic Aleve = Naproxen 220mg
Generic Tylenol = Acetaminophen 500mg
Use at dosages and at frequency
recommended on label
– Initially encourage regular use (not PRN:
“as needed”) for better pain and
inflammation control
Patient Satisfaction

Dispense FA pain management/selfcare items as medically indicated:
– Reusable hot/cold packs
– Muscle creams
– Elastic exercise bands
– Cervical roll (not collar)
– Soft splints (no stays)
Practical Issues
Use incident form for all injuries
2 Options:
 All injuries logged on to OSHA 300 and
use single line to cross out those that
are ultimately closed as First Aid Only.
 Those that return as Recordable from
clinic are logged on to OSHA 300

Why is the First Aid
Issue Frustrating?
Labor Code definition of FA is different
 Last chance for injury not to be recordable
 You or your manager use the retro scope
to analyze the case
 You are caught in the middle
 Unreasonable expectations of the
physicians

Suggestions for Coping with
Recordable Injuries
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Don’t take it personally when things don’t go
as well as hoped for
Anxious or high maintenance employees can
get frustrated at the system
“Bad” employees get injured too – its just
harder to be compassionate
Be supportive of all injured workers
Be communicative
First Aid Isn’t Prevention
It’s Damage Control

According to the National Safety Council, 75 percent
of all accidents are preceded by one or more close
calls..
 a close call is a call to action.
 There are few "real" accidents that come completely
out of nowhere,
 Most accidents can be predicted and prevented.
 something is wrong and requires immediate attention
 the near miss this time will be an accident next time.
 So if your employees and supervisors just go back
you have a big safety problem.
 A close call means that the worker was lucky
Strike While the Iron Is Hot
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Most close calls result from a combination of
factors.
Although human error is often one cause,
other hazards often play a role These include:
Poor lighting
Inadequate ventilation
Lack of a warning sign
A missing machine guard
Lack of effective safety rules
Inadequate training or experience.
Incident Report & Investigate
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Find Out What Happened and Why
Every close call needs to be investigated just like an
actual accident.
Examine the scene and look for clues about exactly
what happened.
Talk to everyone involved and to witnesses as well.
Look for circumstances that might have contributed to
the close call.
For example, were new or untrained workers
involved?
Were any safety rules ignored?
Or were rules specific to the incident lacking?
Don’t Rush to Judge
Look for underlying causes.

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An immediate cause may be a mechanical failure, or
it could be an unsafe action by a fellow employee.
The underlying cause could be poor machine
maintenance, a missing guard, a crowded work area,
or
a lack of training.
Discuss the incident with supervisors, employees,
and
also with outside experts, if necessary, to get ideas
and perspective.
Complete an accident/
near-miss report
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Getting the incident on paper will help prevent it from
being forgotten or ignored.
Take Action
Share your report with employees and management
alike.
Make sure everyone knows what you’re doing to
prevent it from happening again.
then take the necessary actions to eliminate or
control the hazards
If you don’t act now, you’ll pay the price later…
Summary
First Aid is not as good as Prevention
 If a provider doesn’t consider First Aid
you will miss the one of the last
opportunities to control costs
 Refer to the Regulations when
complying with OSHA 300 log
requirements
