（预防医学）职业及环境疾病的救治方法课件.ppt

1、 Principles of management of occupational and environmental diseases:prevention,compensation,and return-to-workChung-Li Donald Du,Center for Management of Occupational Injury and Diseases,National Taiwan University Hospital Jung-Der WangInstitute of Occupational Medicine and Industrial Hygiene,Natio

2、nal Taiwan University College of Public Health Outline Occupational health Occupational injuryOccupational medicine as a specialtyOccupational health care and managementNotification or surveillance of occupational injury and diseases From ad hoc system to prevention,compensation,return to work(PCR)i

3、ntegration in Taiwan PCR model and perspective HealthWHO charter:Health is a state of complete physical,mental and social well-being and not merely the absence of disease or infirmity NOTES:Adapted from Dahlgren and Whitehead,1991.The dotted lines denote interaction effects between and among the var

4、ious levels of health determinants(Worthman,1999).Over the life spanLiving and working conditions may include:Psychosocial factors Employment status and occupational factors Socioeconomic status(income,education,occupation)The natural and builtc environments Public health services Health care servic

5、esOccupational Health Statusrapid proliferation of new industrial materials,new production methods,and new commercial products little attention to the need and assessment of their impact for the human health and environment The newly used chemicals developed by industries are even seldom tested for

6、toxicity for animals or humans Occupational Health Statuspracticing physicians take the burden of diagnosing,treating and if possible preventing work-related illness or injury Even the medical and biological professionals are exposed to microbial agents,including bacteria,virus,fungi and parasites O

7、ccupational infection could occur after contact with infected persons,with infected animal or human tissue,secretions,or excretions Occupational Health Status“ergonomics”or human factor engineering has been introduced into the workplaceworkers health problem arise from designs of workstations,tools,

8、equipments or work proceduresphysical agents such as noise or vibration,heat or cold,and ionizing or non-ionizing radiation four steps of industrial hygiene-anticipation,recognition,evaluation,and control of health hazards to reduce occupational hazard Occupational Health Statuswork stress-increasin

9、gly important health problem;the ability to predict a stress response or make diagnosis of work stress related psychological and physiological disability is poorthe number of compensation claim of work related circulatory disease increasedworkplace wellness and occupational health education program

10、evolvedquit smoking,healthy diet,exercise,stress management and cardiovascular disease preventionOccupational mortality-disease more than injury related to occupation30 LWC300 Recordable30,000 Near Misses300,000 At-Risk BehaviorsFatality,Disabling Injury1ILO Taiwans occupational disease underestimat

11、ed19901991199219931994199519961997Taiwan46262719143146142Singapore9401,07089790099913451,5211,054Korea1,3281,4139181,1201,5291,424Hong Kong24493248272369327Japan11,41511,95110,8429,6309,9159,230Thailand-6211612551Malaysia775022,942South Australia2,9952,8412,8243,145Statistics of Asian occupational d

12、isease 1990-1997Occupational Health StatusIn Taiwan there is still a underreporting of occupational disease,according to Bureau of Labor Insurance(BLI)statistics,if pneumoconiosis is excluded,the number of occupational disease is less than two hundred cases per year in recent two decades which is ar

13、ound one in ten or one in a hundred of expected number,after comparison with neighboring countries,such as Japan,Korea Singapore,or USAOccupational injuryTaiwanese workers suffered an estimated 36,000 fractures,amputations,lacerations,and hundreds of eye injury and burns out of occupational causes.T

14、he most common occupational injuries involve musculoskeletal system or musculoskeletal diseases strain,sprain,tendonitis,bursitis,myositis,arthritis-usually produced by repeated movement and muscle strain.Gradual increase of occupationalinjury temporary disability cases(19902002,BLI)0100002000030000

15、4000050000600007000080000900001000001100001200001300001400001500001600001700001800001900002000002100002200002300002400002500002600002700002800002900003000001990199119921993199419951996199719981999200020012002YearNumberOccupationalinjuries anddiseasesActualpayment forinjuries anddiseasesNationalHealt

16、hInsuranceOccupational InjuryAccording to BLI,the percentage of occupational injury with temporary disability is about one fourth of ordinary injuries among workers trend of increased occupational injury and disease esp.,after National Health Insurance System enacted in 1995 incur more than 6 billio

17、n NT$in direct workers compensation costs indirect cost:production delays,damage to equipment,and recruiting and training replacement workersestimated to be five times,or about 30 billion NT$Increased percentage of occupational injuryamong total injury related temporarydisability(19902002,BLI)0%10%2

18、0%30%40%50%60%70%80%90%100%1990199119921993199419951996199719981999200020012002YearOccupationalinjuries anddiseasesActualpayment forinjuries anddiseasesOccupational InjuryWorkers compensation benefits-permanent total disability,temporary total disability,permanent partial disability,temporary partia

19、l disability,and survivors benefits.In Taiwan,only lump sum but no annuity paid to the insured worker.During rehabilitation period,only sick leave or designated auxiliary tools for handicapped are offeredno vocational or psychological counseling or retraining or job placement assistance,compared to

20、United States or most European countriesmedical expenses of five main occupational injury after NHIMeanwhile,Labor insurance compensation claim also increase dramatically!1996-1999Cost due to hospitalization1996-1999Cost due to hospitalization2.492.101.771.420.860.890.991.170.190.210.300.641.200.840

21、.920.930.350.260.240.3300.511.522.51996199719981999HundredMillionFractureOpen wounds ofupper extremityRolling overBurnHead traumaOccupational Medicine specialtyAD 1700,Bernardino Ramazzini,the father of occupational medicine and an Italian physician:De Morbis Artificum Diatriba to work without acqui

22、ring a wretched disease that would make ones work a curse rather than a lovediseases of metal digger,painters,midwives,glassmakers,potters,sewer workeraffliction by inhaling noxious gases and dusts,or from disorderly motions and improper postures of the bodyOccupational Medicine specialtythe primary

23、 care physician have taken the responsibility of health care for the industry workers compensation issues usually followed after treatmentoccupational compensation system emerged from Germany since mid-19 centurystate(or government)run vs.private insurance carriersmost are compulsory,and even with p

24、enalties for not having insuranceOccupational Medicine specialtyThe employers responsibility which includes providing medical treatment and compensation benefits transferred to the insurance agencies preventing injury or disease shared by the employer and the insurers or related authoritiesreporting

25、 of occupational injury-employerreporting of occupational illness-physicians Occupational Medicine specialtyoccupational physician system accompanied the progress and change of industrynew legislation to protect the workers health and enhance their benefitshigh-tech ages-labor force subjected to con

26、ditions never before confronted in the small shop or craftsman era Production and profit are still the primary concern of company,not employee safety practice of occupational medicine cover even a broader scopeOccupational Medicine specialty-to meet the demand of societymodern society occupational h

27、azard-stress and related disease,musculoskeletal disorderoccupational physicians have to realize the regulatory or compensation system,able to design suitable occupational health program To integrate occupational medicine with environmental,occupational safety and healthto serve for both the employe

28、r and employeeto discover new techniques or strategiesOccupational health care&ManagementHealth care industry-cost containment,managed care system Change is a requirement of life and an integral part of all complex endeavors of society,including the financing,provision and organization of health car

29、e serviceTaiwan-National Health Insurance system,cover nearly all hospitals and clinics.Occupational health care&Managementclinical managed care-to change the number or mix of services provided and to reduce the price paid for servicecase management is a process,one component in the managed care str

30、ategythe inclusion of salary replacement is not inherent to the health insurance managed care market evaluation of quality of care,and timely return to work by injured employees more important in occupational health care Definition of case management”case management is a collaborative process which

31、assesses,plans,implements,coordinates,monitors,and evaluates the options and services required to meet an individuals health needs,using communication and available resources to promote quality,cost-effective outcomes.”major areas of activity-medical,financial,behavioral/motivational,vocational the

32、Commission for Case Manager Certification(CCMC)Occupational health care&ManagementIn workers compensation,managed care must address a different objective-restoring a worker to health and productivity at the lowest cost.New South Wales,Australia,the original Workers Compensation Act in1987 was later

33、amended and renamed as“Workplace Injury Management and Workers Compensation Act”in 1998.Occupational health care&ManagementThe act begins with notification of an injury by the employer,physician or patient WorkCover New South Wales,make early contacts with all parties,assess the claim and performing

34、 medical examination at the request of employer or employee The goal of injury management is to achieve optimum results in terms of the timely,safe and durable return to work for workers following workplace injuryOccupational health care&ManagementAll parties-the insurer,employer,injured worker and

35、treating doctors,are required to cooperate and participate in the injury management process to ensure that optimum return to work results are achieved This injury management code-the return to work program,the return to work coordinator,accredited rehabilitation provider,provision of suitable duties

36、,keeping information confidential,and training and employment programsNotification or surveillance of occupational injury and diseases notification is a basic obligation in Australia as well as in Singapore and Germany,followed by the insurer or authorities to assist if the injured worker are eligib

37、le for compensation Most occupational compensation system have an effective reporting systemno mandatory notification program in occupational compensation system in Taiwan would greatly cause the injured worker to be neglected,poorly rehabilitated,and at risk of job lossNotification or surveillance

38、of occupational injury and diseases Department of Health of Taiwan had launched a“work related disease notification system”since 1996,which encourage physicians,either from clinic,hospital or factory to be reporting resources Until now,there are more than ten thousand cases reported.Most of them are

39、 injures,decompression sickness,hearing impairment and sharp injury However,following management process is not linked to compensation or jurisdiction system in Council of Labor Affairs Notification or surveillance of occupational injury and diseases In National Taiwan University Hospital,an in-hosp

40、ital emergency room(ER)surveillance system was started since last Sep(2003)ER:chemical injury,eye injury,occupational trauma,electrocutions and welders disease.Taipei county government independent law in 2002 to punish those employer or practicing physicians within geographical boundary not to repor

41、t occupational diseaseIn summary,the reporting of occupational injury or disease is still not“Notifiable”From ad hoc system to prevention,compensation&RTW integrationWHO“Health is a state of complete physical,mental and social well-being and not merely the absence of disease or infirmity.”occupation

42、al injuries and illness may cover social consequences including workers psychological and behavioral responses,vocational function and family and community relationship 5 Levels of public health principle:Health promotion-special protection-early diagnosis&treatment-restriction of disability rehabil

43、itation and return to workFrom ad hoc system to prevention,compensation&RTW integrationmost injured workers report that the primary treating physician did not give them any advice about the prevention of further injurya large proportion(38%)of injured workers experience a reinjury after returning to

44、 workmany return to their jobs after a work injury continue to experience residual pain Satisfaction with medical care provided through workers compensation generally lower than for general health care provided for non-occupational conditions Dr.Pransky et al.AJIM,2001PCR case management modelPCR-Pr

45、evention Compensation Rehabilitation(Return-to-work)Benefits as:reduction of injury with disabilityencouraging return to worksave medical and insurance costCenter for Management of Occupational Injury&DiseaseJoint collaboration among Council of Labor Affairs(Bureau of Labor Insurance)and the hospita

46、lDevelop intra-and extra-mural surveillance systemSetup of standard diagnosis and case management modelWorkability evaluation technique and occupational rehabilitationSince Apr,26,2003Case Demand&ManagementOccupational disease diagnosisTreatment of injury and diseasePrevention of occupational injury

47、RTW demand Compensation demandlPhysical examinationlJob evaluationlMedical consultation lSpecial exam.lFactory walkthroughlDrugslP.TlO.TlotherlHealth screenlSafety advise&educationlWork hardeninglnegotiationlCertificationlFree charge of visitlSupport resourcesSeven ways of reactive prevention of occ

48、upational injury/diseaseHealth screening SurveillanceOccupational disease diagnosisDisability evaluationWorksite visitCase management and counseling Epidemiological studyPrevention by Health Screening Process to Factory workers walkthrough exposure and HE items questionnaire Qualified medical screen

49、ing/assuranceComputerization of database screening of possible exposure workers chronic illness factors evaluation data management(risk assessment）follow up and health promotionPersonal health evaluation Action：weight reduction、quit smoking、body fitness 疑似重金屬中毒、鉛中毒、砷中毒、錳中毒、黃磷中毒汞中毒、鉻中毒、疑似氣體、蒸氣危害疑似異常氣

50、壓疾病疑似農藥中毒疑似皮膚病疑似外傷疑似塵肺症疑似聽力損害疑似腕隧道症候群疑似針扎事件疑似肌肉骨骼傷害疑似職災死亡其他與環境或職業相關疾病Electrical&Chemical burnsIntoxication/pesticideOccupational asthma,T.B.,allergic pneumonitis,dermatitisHand injury(cut,tear,compression)Amputation/fractureMusculoskeletal disorderYoung stroke,CVDHIVD,Peripheral neuropathyOthersNTUH