New ACOEM guidelines have significant changes

Better communication emphasized

Many second editions of lengthy publications are little more than minor rewrites and an updating of a smattering of facts here and there, but that hardly is the case with the Arlington Heights, IL-based American College of Occupational and Environmental Medicine’s (ACOEM) second edition of Occupational Medicine Practice Guidelines — a comprehensive guide that is the gold standard in effective treatment of workplace injuries and diseases.

In this edition, according to Lee Glass, MD, the chair of ACOEM’s Practice Guidelines Committee and chief editor of the publication, more than one chapter has been completely rewritten, and several new elements have been added.

First published in 1997, the guidelines provide evidence-based, peer-reviewed recommendations for care, written by physicians and reviewed by a wide range of medical specialty organizations. The guidelines were developed to improve the efficiency and specificity of medical diagnosis of workplace-related injuries and diseases, enhance the effectiveness of treatment, and help occupational and environmental medicine physicians and other health care professionals manage growing caseloads.

The 516-page publication includes chapters on prevention of injuries and disease; assessment, medical examinations and diagnosis; the relationship of injury or disease to workplace circumstances; pain management and restoration of function; and more detailed analysis of specific conditions — ranging from back pain to carpal tunnel syndrome. The guidelines also include detailed information about mental health and stress-related illnesses, as well as a completely updated chapter on eye injuries in the workplace.

Fundamental goal unchanged

Despite these changes, says Glass, the publication’s fundamental goals still are the same. "Our goal is to try to ensure that injured workers get the highest quality medical care delivered as efficiently as possible, with the right decision made the first time," he asserts. "That was the intent of the first edition and of the second edition."

This does not negate the fact, however, that the new version is significantly different than the first. "We have completely rewritten the chapter on pain," notes Glass. "It now deals much more extensively with acute and chronic pain. There has been a lot of knowledge gained in the last number of years, and we’ve tried to incorporate that knowledge. Also, clearly in workers’ comp, pain is a critically import component — often a driver of care." That’s why, he says, Pain, Suffering, and the Restoration of Function is a major topic.

The chapter on eye injury was also totally rewritten. "It is very lengthy; it could even be a handbook all by itself for the occ-med physician on the treatment of industrial eye conditions," says Glass. The 58-page chapter "has in one place everything someone who’s caring for a worker with an eye injury needs to know; it’s an exceedingly valuable tool," he asserts.

New duration table data

There also is important new data in this edition, Glass observes. The first edition, for example, had disability duration tables. "They were based on consensus derived from groups of people who were knowledgeable about the expected duration of disability for each of a number of conditions," he explains. These tables have been revamped, but the major change, Glass explains, is additional information that comes from a CDC (Centers for Disease Control and Prevention) database.

"Every three years, the CDC oversees a national interview survey of a carefully, randomly selected segment of the population to look at health-related issues," notes Glass.

Called The National Health Interview Survey (NHIS), the data actually are available to the public. "Through a contractor, we obtained the data from the most recent survey and abstracted data related to disability for the conditions that are covered by the ACOEM guidelines, and excluded any data related to workers’ comp injuries, so what we were looking at were the self-reported ACOEM guidelines conditions. We looked to see the median average length of the disability and included that data," Glass says.

What is the significance of this new information? "Disability duration data is what is thought to be reasonable to expect in workers’ comp absences," he says. "It turns out there can be a significant difference [between data for workers’ comp and the CDC data]. For example, take knee injuries — cruciate ligament strain. The recommended [duration table] target was zero to one day with modified duty, and without, seven to 10 days. NHIS data was 14 days, and 19% of the people actually lost no time from work. For sciatica, the recommended target for disability duration without modified duty is seven to 14 days. The median NHIS was eight days. For regional low back pain, return to work without modification is seven to 10 days; NHIS is five days."

These new CDC data, Glass explains, provide "a bigger body of benchmarks. There often is a belief that the presence of a workers’ comp injury affects the disability duration. This data are intended to allow people who care for injured workers to ask the question, if we do not have a workers’ comp concern, what’s the duration?"

Learning to communicate

Finally, he says, this second edition aims at helping members of the various professions involved with occ-health learn to communicate more effectively with each other. "We recognize that our audience is principally health care providers, but there are also others who have to communicate together in our complex legal-medical system," says Glass. "The various players often don’t get training on how to communicate in someone else’s language; that creates disruptions in efficiency of claims management and health care delivery. So, we have tried to provide a lot of different information to help folks understand the needs of parts of the system other than their own."

Two different professionals might have entirely different reactions to the same word, Glass offers. "If a physician hears the word causation, he thinks what you have to do is to demonstrate that an agent is in fact the infectious agent causing a patient illness. But a lawyer thinks about a Supreme Court ruling, which has nothing to do with the doctor’s thinking. If each of these parties does not have some ability to understand the issue from the other’s point of view, there will not be an optimal outcome for the injured worker/patient."

[Editor’s note: The Occupational Medicine Practice Guide-lines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers, 2nd Edition, is published by OEM Press in Beverly, MA. To order a print version, call OEM Press at (800) 533-8046, or visit their web site at www.oempress.com. The guidelines are $175 for ACOEM members; $199 for nonmembers.]