Whole body biomechanical burden of healthcare workers: proposal for a complementary risk assessment and management tool (HOARA)

Introduction:

We have developed a new tool, named Holistic Approach Risk Assessment (HOARA), to support occupational safety and health professionals (OSH) in risk assessment and management when evaluating the biomechanical load of healthcare workers.

Objectives:

The primary aim of the HOARA is to support OSH in risk assessment and management of biomechanical hazards in healthcare facilities. This tool ensures a superior level of analysis by targeting independently various body compartments during all activities completed throughout the work shift. These include: head, neck, back and upper and lower limbs.

Methods:

For each body segment, ergonomic determinants were defined on the basis of previous literature, according to which task and job analyses were performed. Upon direct observation, ergonomic factors were given a score based on their temporal extent. Subsequently, action-body segment raw indices and weighted indices were calculated.

Results:

Results of the application of the method are shown. Of note, a relational database was set up to improve its usability.

Conclusions:

From an occupational health perspective, the HOARA, integrated with other methods, is expected to allow a more effective management of human resources, especially when assigning workers to specific jobs or tasks. Overall, the HOARA will be instrumental in assessing the impact of fitness for work judgments on work organization and its resources, in compliance with the guidelines from the Società Italiana di Medicina del Lavoro (SIML).

How to Assess the Biomechanical Risk Levels in Beekeeping

Beekeepers are at particular risk of developing work-related musculoskeletal disorders, but many of the studies lack detailed exposure assessment. To evaluate the biomechanical overload exposure in a specific farming activity, a multitasking model has been developed through the characterization of 37 basic operational tasks typical of the beekeeping activity. The Occupational Repetitive Actions (OCRA) Checklist and the National Institute for Occupational Safety and Health (NIOSH) Lifting Index methodologies have been applied to these elementary tasks to evaluate the exposure, and the resulting risk indices have been time-weighted averaged. Finally, an easy access, computer-assisted toolkit has been developed to help the beekeepers in the biomechanical risk assessment process. The risk of biomechanical overload for the upper limbs ranges from acceptable (maintenance and recovery of woody material and honey packaging with dosing machine tasks) to high (distribution of the top supers) risk level. The risk for back injury is always borderline in women and increases with exposure time, whereas it ranges from acceptable to borderline in men. The definition of the biomechanical risk levels allows for planning of corrective actions aimed at preventing and reducing the risk of musculoskeletal disorders through engineering, administrative, and behavioral interventions. The methodology can be used for risk assessment in other mainly manual agricultural activities.

[The Human Model, a tool for assessing preventive ergonomic postural appearance]

D.Lgs. 81/08 requires the employer to design work systems, methods and tools in accordance to the ergonomic principles. In order to check the compliance of the design with current regulation, it is appropriate and effective to make use of simulation tools since the design phase. The paper describes a tool based on multi body approach. Once the gender and the anthropometric percentile of the worker have been specified, the tool simulates the postures that the worker is likely to assume during the execution of the work task. The tool can be used in the design as well as in the re-design phase, taking into account the different percentile of workers for a proper accommodation of the same.

[Methods of risk assessment and their validation]

The review of the literature data shows several methods for the the risks assessment of biomnechanical overload of the musculoskeletal system in activities with repetitive strain of the upper limbs and manual material handling. The application of these methods should allow the quantification ofriskfor the working population, the identification of the preventive measures to reduce the risk and their effectiveness and thle design of a specific health surveillance scheme. In this paper we analyze the factors which must be taken into account in Occupational Medicine to implement a process of validation of these methods. In conclusion we believe it will necessary in the future the availability of new methods able to analyze and reduce the risk already in the design phase of the production process.

[Work-related musculo-skeletal disorders in apiculture: a biomechanical approach to the risk assessment]

The risk assessment in apiculture points out methodological problems due to discontinuities and variability of exposure. This study analyzes a comprehensive set of potential determinants influencing the biomechanical risks in apiarists using recognized technical standards to ensure the technical-scientific accuracy; it offers a simplified methodological toolkit to be used in the risk assessment process and provides a user-friendly computer application. The toolkit asks the beekeeper to specify, for each month, the total number of hours worked, specifying the distribution among different tasks. As a result, the application calculates the average index risk and the peak index risk. The evidence of the study indicates that there are activities in this occupational area with biomechanical risks that remain for some tasks, while reducing the exposure time.

[Psychiatric disability and work: assessment of a group of patients examined at the Occupational Medicine Outpatient Department of the Turin University in the period 2000-2012]

Problems at workplace with psychiatric subjects are increasing and the role of occupational physicians is basic to achieve a suitable job role. The purpose of this study is to assess the main occupational factors and to evaluate the judgement of fitness to work in 1109 patients with psychiatric diseases examined in our outpatients department during the period 2000-2012. These subjects were sent to our service by family doctors or, more frequently, by the companies seeking for judgement of the working residual capacities. The psychiatric diseases were classified according to the DSM IV; for each group considered, we evaluated the production sector, the specific job role, the pharmacological therapy as compared to the final judgement. The most frequent diagnoses were depressive and anxious disorders. The pharmacological therapy does not seem to be related to the final judgement but the small number of subjects defined as unfit to work does not allow a final evaluation. The study suggests the relevance of team work among the different actors of prevention to achieve a successful management of these workers in a specific job role.

[Bus drivers' biomechanical risk assessment in two different contexts]

The application of standardize methods for the biomechanical risk assessment in non-industrial cycled activity is not always possible. A typical case is the public transport sector, where workers complain of suffering for shoulder more than elbow and wrist pains. The Authors present the results of two studies involving two public transport companies and the risk of biomechanical overload of upper limbs for bus and tram drivers. The analysis has been made using three different approaches: focus groups; static analysis by using anthropometric manikins; work sampling technique by monitoring worker's activity and posture at each minute, for two hours and for each binomial vehicle-route, considering P5F e P95M drivers and assessing the perceived efforts thorough the Borg's CR10 Scale. The conclusive results show that the ergonomic analysis managed by multiple non-standardized techniques may reach consistent and repeatable results according to the epidemiological evidences.

[Exposure talc effects on lung function: longitudinal study on variability of respiratory parameters in talc workers]

The study analyzes the variability of respiratory parameters in 59 workers exposed to talc at least 5 years. Cigarettes smoke seems to be the only one variable causing a FEV1 decrease while cumulative exposure doesn't influence any variable analyzed. The talc dust exposure below TLV ACGIH value has not effects on lung function. The function alterations showed are not correlated to task and to cumulative exposure.

[Silica classification and labelling under REACH and CLP regulation]

Following literature data the evaluation CLP classification and labelling criteria doesn't support the decision to classify respirable crystalline silica (RCS) as carcinogen and suggests to consider RCS as:--STOT (Specific Target Organ Toxicant) RE (Repeated Exposure) cat.l by inhalation in case of concentration > or = 10%--STOT RE cat. 2 by inhalation in case of concentration 1 divided by 10%--Not classifiable as dangerous for human in case of concentration < 1%.

[The radon exposure in mine: risk evaluation, risk assessment and health effects]

In mining sector, the natural presence of radon determines an exposition which deserves substantive consideration. The results of radon measure from '90 years in a talc mining show levels of radon below to the threshold limit of 400 Bq/m3, values influenced from air forced systems. The epidemiologic studies updated in a cohort of talc workers between 1946 and 1995 showed no excess for lung cancer mortality. No excess was found for lung cancer mortality in miners exposed to low dose of radon.

[The issue of medico-legal assessment of noise induced hearing loss: comparison of methods]

Audiogram classification is crucial for hearing protection of workers occupationally exposed to noise. The methods that have been proposed are based on two principles: the morphological evaluation of the audiometric curve (eg. Merluzzi-Pira-Bosio--MPB) or the average hearing loss on different frequencies (eg. Albera-Beatrice--AB). The purpose of this study was to classify audiograms compatible with chronic acoustic trauma performed at the Occupational Medicine Outpatient Clinic of CTO Hospital in Turin from 2004 to 2011 with the methods outlined in Guidelines published by SIMLII. A substantial agreement among the methods was observed. While MPB is the most appropriate method for secondary prevention, the AB would seem more appropriate for the verification of a permanent weakening that has to be reported to the competent legal authorities.

[Ergonomic risk assessment: aspects applicable in the light of current standards]

The Italian decree law 81/2008 mentions the application of ergonomic principles as a basic tool for the prevention. In this regulation we can not find the definition either of Ergonomics nor of the competences required for its correct application. The Authors consider that occupational physicians have a suitable competence and knowledge on the matter, thanks to their highly specialized training. Actually, the ergonomic doctrine shows up in the daily practice of occupational physicians, who regularly base their activity on the evaluation of the binomial "worker-task": in the management of fitness to work judgements they try to combine operating conditions with worker's psychophysical state, not confining themselves to a simple expression ofa medico-legal certificate. However, the legislative references to specific regulations raise difficulties to occupational physicians in dealing with aspects such as gender, age, reference values and methodological choices. The Authors debate these difficulties in the application of rules.

[Risk assessment of manual handling of loads: the choice of reference values in light of Leg. 81/2008]

Italian law on safety at work does not clarify specific levels of load for safe manual material handling. For this reason professionals appointed for safety need to define new target range value for the correct application of D.Lgs. 81/2008 law. Authors, discussing about indication of the national laws and international rules, suggest the assumption of a load of 25 and 20 kg as reference values for male and female adult and healthy workers. They also examine the graduation of the acceptable loads in relation to workers' age and the Lifting Index values to be adopted as action limit and exposure limit.

[The evaluation of workplace visual characteristics and ophthalmologic requirements to define fitness to work]

It's necessary to proceed to an evaluation of visual function to define principal ophthalmologic requirements and fitness to work in relation of workplace characteristics. We also have to consider the effects of age on visual function, the specific work risks on eyes and sight care especially for near sight. The evaluation of these parameters permits to verify the compatibility between the psychophysics characteristics of workers and the requests of tasks and then to define fitness to its work. Moreover to the visual functions we have to consider organic visual conditions like conjunctivitis, blepharitis, stenosis of lacrimal gland, dacriocystitis, retinic diseases, muscular motility alteration of the eyes, glaucoma. Our study shows the relation between ophthalmologic requirements of workers and some job groups like professional drivers, technical clerks, precision work, height level workers and proposes a standard method to define fitness to work. Our standard method permits a specific and homogeneous evaluation of fitness to work.

[The role of occupational physician in the application of the 2006 "agreement on workers' health protection through the good handling and use of crystalline silica and products containing it": the experience in mining sector]

The 2006 "Agreement on Workers' Health Protection Through the Good Handling and Use of Crystalline Silica and Products Containing it" between social parts defines a standardization of exposition control methods and medical surveillance. The Occupational Physician is integral part in exposition evaluation process and risk stratification in which derives the medical surveillance program. This study presents a first application of the European agreement in mining sector and the role of Occupational Physician in the evaluation of the risk to define methods of prevention. In particular it will be precised the choice of homogenous groups, the classification of exposed workers from results of workplace monitoring, the choice of technical prevention and individual protection equipments, and then the strategy of medical surveillance.

[Application of a protocol for assessing occupational fitness of workers with UE-WMSDS in a second-level hospital center: first results]

It's presented a cluster of 99 workers affected by UEWMSDs examinated in the Occupational Medicine Department--University of Turin. The object of the evaluation is the critical exam of ergonomic informations, the evalution of the fitness to work and the customed return to work.

[Criteria to notify to the authorities the occupational lumbar trait diseases]

To carry out the requirement of notification according to the Italian law D.M. 27/4/04 in relation to the item "Manual handling of loads made continuously during working shift" it is necessary to clarify some quantitative and chronological aspects regarding the exposure and to precise the nature of the diseases to be notified. To fulfil their choices doctors at the moment can not rely on quantitative referrings based on the evidence and wide spread accepted, but they basically have operative indications partly taken from literature and stil under validation. However, to carry out the requirement of the law and to avoid choices not based on considered criteria, we propose some operative criteria deriving from the knowledge that at the moment seems more consolidated and accepted in the occupational and previdential medicine.

[A rapid model of risk assessment of the biomechanical overload to the whole skeletal system]

A tool easy to apply is presented that can be used in ergonomic analysis of 1st level to identify the risk factors of biomechanical overload of the skeletal structures. The model is an evolution of a previous proposal, published in 2001, which was aimed at evaluation of the only upper arms: the present model also permits the evaluation of the spine (cervical and torso-lumbar tract) and of the inferior arms. A red flag judgement criterion has been maintained and, if an item is marked, there is the possibility to recognise the cause of the ergonomic criticality and to plan the correction according to a scale of ergonomic priority. The aim of this communication is to stimulate a wide participation in the project to develop a model for the risk assessment of biomechanical overload to the whole skeletal system.

[Work-related musculoskeletal disorders and diseases of the arm]

Among work-related diseases, musculoskeletal disorders of the upper extremities have obtained increasing attention in recent last decades. Because of their relevance, the Italian Society of Occupational Medicine and Industrial Hygiene has decided to draw up a set of National Guidelines on the subject. This paper discusses their production and contents, including definitions, rationale, physiopathogenesis, occupational physician's contribution to biomechanical overload risk evaluation, medical surveillance of exposed workers.

[Proposal and preliminary validation of a check-list for the assessment of occupational exposure to repetitive movements of the upper lims]

Over the last few years the Authors developed and implemented, a specific check-list for a "rapid" assessment of occupational exposure to repetitive movements and exertion of the upper limbs, after verifying the lack of such a tool which also had to be coherent with the latest data in the specialized literature. The check-list model and the relevant application procedures are presented and discussed. The check-list was applied by trained factory technicians in 46 different working tasks where the OCRA method previously proposed by the Authors was also applied by independent observers. Since 46 pairs of observation data were available (OCRA index and check-list score) it was possible to verify, via parametric and nonparametric statistical tests, the level of association between the two variables and to find the best simple regression function (exponential in this case) of the OCRA index from the check-list score. By means of this function, which was highly significant (R2 = 0.98, p < 0.0000), the values of the check-list score which better corresponded to the critical values (for exposure assessment) of the OCRA index looked for. The following correspondance values between OCRA Index and check-list were then established with a view to classifying exposure levels. The check-list "critical" scores were established considering the need for obtaining, in borderline cases, a potential effect of overestimation of the exposure level. On the basis of practical application experience and the preliminary validation results, recommendations are made and the caution needed in the use of the check-list is suggested.

Longitudinal study of workers of an aluminium die casting factory

We conducted a 5-year longitudinal study on 76 workers of a high and medium aluminium alloy die-casting factory. As in a previous cross-sectional study conducted in 1986 and in accordance with the data in the literature, the 1990 follow-up study showed: a low prevalence of chronic bronchitis (as defined by the ECSC questionnaire on respiratory symptoms); normal mean functional values of FVC, FEV1, FEV1/FVC%. We did not find any significant difference in the levels of lung function over the period of 1986-90. These results show that workers in the secondary aluminium industry are not exposed to a significant risk of chronic pulmonary disease.