I’ve written previously about the inferior care that some workers experience when they go to their company’s in-plant nurses’ station for a work-related injury (e.g., here, here.)  A worker with unaddressed tendinitis is given ibuprofen week after week.  A worker with a deep laceration is bandaged up, but then sent back to a task where her bandage will get wet.  I’ve heard poultry and meatpacking workers describe the unhelpful encounters they’ve had with company nurses or EMTs.  I’ve also read communications from OSHA (e.g., here, here) that document such practices, some of which may have caused further harm to the injured worker.

I don’t know if these examples constitutes malpractice, but it certainly is a worker health and safety issue that deserves comment by experts.  That’s why I was pleased to read a new paper on this topic written by three occupational medicine physicians.

Drs. Aaron Tustin, Kathleen Fagan, and Michael Hodgson dig into the topic of on-site workplace clinics where injured workers receive health care.  Many worksite nurses’ stations or on-site worker clinics (OWC) are staffed today by licensed practical nurses (LPNs) or emergency medical technicians (EMTs) who follow protocols signed-off by a consulting physician.  Although the physician may never see any of the injured workers, their signature on the protocols comes with responsibility.  Tustin, Fagan, and Hodgson describe circumstances at OWC that can lead to medical mismanagement of work-related injuries. They provide guidance to identify the problem and ways to remedy it.  Here are a few topics the authors examine in their paper:

Supervision of LPNs and EMTs.  In many OWC, LPNs and EMTs report to non-clinical supervisors, such as someone in the employer’s human resources or safety department.  But under state laws, LPNs and EMTs staff must have adequate clinical supervision and must only perform duties within their “scope of practice.”  LPNs and EMTs are not trained to diagnose or make decisions about work restrictions for an injured employee. The authors caution consulting physicians to ensure that OWC staff “do not offer assessments or treatments that are outside their scope of practice.”

Documentation of clinical encounters.  Based on their own examination of OWC, the authors report that written records of encounters between OWC staff and workers are often incomplete or nonexistent.  They urge consulting physicians to conduct periodic “chart reviews” to ensure that encounters are properly documented.  The authors note that chart reviews are standard, expected practice in healthcare delivery.  Moreover, the reviews have added benefits: an opportunity to identify trends in work-related injuries and hazards which can be brought to the attention of the employer.

Standards of Care.  The authors urge consulting physicians to ensure that their medical protocols for OWC represent good clinical practice.  That’s not what the authors have observed. For example, some protocols are vague, telling EMTs or LPNs to refer a worker to a physician “if indicated.”  Other protocols give inappropriate instruction for care, such as one that “allowed EMTs to manage work-related pain for up to two weeks before referring the injured worker to a physician.”

At some workplaces, LPNs and EMTs are trained to discourage workers from seeing a physician. They participate in management practices that require workers to sign agreements that they will not seek outside medical care without permission from the employer.  The authors again urge consulting physicians to assess how care is being delivered, such as by chart reviews and interviewing workers and OWC staff.  The authors write:

“Physicians should not provide services to company-run OWC that have outdated, incomplete, or erroneous protocols until they are corrected and comply with all applicable requirements and professional guidelines.”

The paper by Drs. Tustin, Fagan, and Hodgson appears in the Journal of Occupational and Environmental Medicine and is written for physicians.  I think the article also has value for workers and their advocates.  Workers should know that the LPNs or EMTs they encounter at the OWC are supposed to have a clinical supervisor. The LPNs and EMTs should not be following medical protocols that are outdated. And a consulting physician—even though hired by the employer—must abide by her profession’s code of ethics. That is, to place a patient’s welfare above her own.