eatures m

Albert Prossin
Developing an Occupational Health Program:
The Team Approach
SUMMARY
Occupational health and safety programs
involve professionals in occupational medicine
and nursing industrial hygiene, safety and
accident prevention, psychology, sociology
and health ph,ic. Occupational health
programs should allow regular health
evaluations of workers, and the recognition,
evaluation, and control of environmental
hazards. When designing in-plant medical
facilities, accommodation should be made for
possible future expansion, disabled people,
and an access route for an ambulance.
Treatment and prevention facilities should be
separate. Patients' records must be complete
and kept confidential. The occupational health
program must also be evaluated regularly.
Education of management and the work force
is necessary to ensure that the environment is
safe and to prevent accidents. Special
programs may be introduced, based on the
particular risks, toicants, and problems in
different industries. (Can Fam Physician 1985; Key words: Occupational health, health care
31:1911-1915.)
SOMMAIRE
La sante au travail et ses programmes de securite
necessite des professionnels en medecine du travail
et en nursing, en hygiene industrielle, en pr6vention
des accidents et en securite, en psychologie, en
sociologie et en facilites physiques. Les programmes
de sante au travail doivent permettre des evaluations
regulieres de l'etat de sante des travailleurs et
l'identification, I'evaluation et le contr6le des risques
environnementaux. Lorsqu'on planifie les facilites
medicales a l'interieur de l'usine, il faut prevoir une
expansion future possible, des facilites pour les
handicapes et une voie d'acces pour ambulance. Les
facilites de prevention et de traitement doivent etre
situdes dans des locaux separes. Les dossiers des
patients doivent etre complets et demeurer
confidentiels. I1 faut prevoir une evaluation reguliere
du programme de sante au travail. nI est necessaire
de proceder a l'education du personnel administratif
et des travailleurs pour s'assurer que
l'environnement est securitaire et pour pr6venir les
accidents. nI faut prdvoir la mise en place de
programmes speciaux, selon les risques particuliers,
les substances toxiques et les differents problemes
sp&cifiques a chaque industrie.
team, safety

Dr. Prossin is president and
special advisor for the Atlantic
Foundation for Occupational and
Environmental Health, and
professor and head, occupational
health and safety studies,
University College of Cape Breton.
Reprint requests to: Atlantic
Foundation, P.O. Box 867, Sydney,
NS. BlP 6J1.
T HE MAIN GOAL of an occupa-
tional health program is a healthy
work force, including everyone from
the chief executive officer to the
newest unskilled worker. It should
CAN. FAM. PHYSICIAN Vol. 31: OCTOBER 1985
lead to health maintenance and im-
provement, less absenteeism, in-
creased productivity, and the achieve-
ment of worker and corporate goals.
All the basic elements of preven-
tion, acute care, counselling and reha-
bilitation must be included. The scope
of each program will depend on the
size of the business or industry, on its
geographic location, on the potential
hazards in the operation, and on the
philosophy of management and labor.
The program must be defined in
written policy. This is true whether
the plan is for a small, single estab-
lishment involving only a few
workers or a large multi-plant cor-
porate program. The policy should in-
clude the program's basic objective,
the duties, authority and reporting re-
lationships within the organization. It
should clearly indicate that manage-
ment understands and fully supports
the program, because without the
complete understanding and the philo-
sophical and financial support of man-
agement, the best conceived program
has little chance of success.
Occupational health and safety pro-
grams involve several disciplines, in-
cluding occupational medicine, occu-
pational nursing, industrial hygiene,
1911
safety and accident prevention, psy-
chology, sociology, and health phys-
ics. These health professionals must
work closely not only with each
other, but also with other members of
management. This is especially true
when working with personnel and
labor relations groups. Cooperation
can be accomplished if the primary
objective-the health and safety of
the worker-is continually kept in
mind. This will have a positive effect
not only on the worker but also on per-
sonnel and labor relations in areas such
as workers' compensation, sickness,
absence and group insurance.
Two other areas should be consid-
ered: the effect of effluent from the
company on the surrounding environ-
ment or community and the effect of
the items or materials produced on the
health of users or consumers.
Administering The Program
Management plays a major role in
health and safety programs at the cor-
porate or plant level. Management
must agree that the program is pre-
ventive and not simply a tool to re-
"The main goal of an occupational health program is a healthy workforce."
1912
duce compensation costs or mechani-
cally improve the safety record.
Authority and responsibility must be
given to the chief health and safety
professional in the organization.
Health Professionals In
The Management Structure
The physician should report to a se-
nior member of management at both
the plant and corporate level. The
plant physician reports to the plant
manager and the medical director re-
ports to the president or a senior vice-
president.
Occupational health nurses should
report to the physician in charge, ad-
ministratively and tactically. If the
company is not large enough to have
a fulltime physician, the nurse should
report to the part-time doctor on tech-
nical matters but may report to the
personnel manager administratively.
Industrial hygienists may report at
plant or corporate levels to the medi-
cal organizations or directly to the
same reporting level as the physician.
This is best determined within each
company. The needs, philosophy, ex-
pertise, and the full or part-time status
of the hygienist must be considered.
The role of other health profes-
sionals such as the health physicist,
psychologist, or social worker should
be determined in a similar way.
Whatever the reporting relationship,
each health professional must be re-
sponsible for planning, justifying and
administering his or her own budget.
Also, a close relationship must be
maintained among the disciplines of
occupational medicine, nursing, hy-
giene, accident prevention, psychol-
ogy, and health physics. It may be
best to consolidate these activities,
both at the local and corporate levels.
The safety or accident prevention
professional has traditionally reported
to the personnel department. As
safety activities expand in the plant
and the community, the reporting re-
lationship must be re-examined and,
if necessary, realigned to meet mod-
em requirements.
First-aid workers report to the plant
physician on technical issues, and ad-
ministratively to the personnel depart-
ment.
Paramedical personnel, who are
sometimes called physicians' assis-
tants, report directly to the plant phy-
sician technically and administratively
because most are employed in plants
with a full-time physician.
Occupational Health
Examinations
Preplacement health evaluations
An automated or check-off type of
history will often give the physician
enough information to categorize the
patient's health status without further
examinations. Traditionally, physical
examination, chest X-ray, urinalysis,
and minor blood tests have been done
to 'weed out' hernias, bad backs, or
other physical disabilities. The results
of pre-employment screening should
be used to describe applicants' health
and determine their physical ability to
perform a job. Initial examination is
used for job placement and as a base-
line for further periodic health exam-
inations based on work exposure.
Selective job placement
Considering a job's physical re-
quirements in relation to workers'
physical limitations will frequently
prevent accidents and ill health, and
increase productivity. Applicants'
physical capabilities must be matched
CAN. FAM. PHYSICIAN Vol. 31: OCTOBER 1985
to the work they are expected to per-
form. This may allow willing workers
with some physical defects to work.
Periodic health evaluation
Management must agree with the
purpose of the periodic examination,
which should be clearly defined in a
well-developed program. It is to eval-
uate the employee's health, with em-
phasis on 'target organs' which may
be affected by actual or potential en-
vironmental exposure. This examina-
tion relies heavily on a check-off
questionnaire, and selected tests such
as audiometry for noise, spirometry
for air-borne particles, and blood tests
for specific metals and/or chemicals.
If all test results are normal, the phy-
sician may eliminate the personal ex-
amination and review only the record.
Such a procedure lends itself to multi-
phasic screening.
Environmental Hazards
Hazards in the work environment
must be recognized, evaluated, and
controlled. There must be a high
index of suspicion for environmental
hazards such as air-borne particles
and vapors, and physical agents such
as radiation. The health program must
assess the ability of raw materials and
industrial processes to do harm. The
intermediate steps and their exposures
must also be considered. Finally, the
finished product should be reviewed
to determine the possible effects on
the worker. Each step in production
must be considered for its effect on
workers over a long period and in
emergencies, such as acute spills or
breakage.
Industrial hygienists assess sever-
ity, length of exposure, and engineer-
ing control methods. Proper protec-
tive equipment, education about
hazards, and correct use of equipment
are also important.
Environmental Data And
Physical Examination
Environmental contaminants, expo-
sures, and stressors must be elimi-
nated wherever possible. If they can-
not be eliminated completely,
personal protective devices must be
provided. As the environment is mea-
sured, physical examinations should
be made of the organ systems affected
by particular materials, etc. Informa-
tion about exposure can be compu-
terized. This system must involve a
CAN. FAM. PHYSICIAN Vol. 31: OCTOBER 1985
coordinated, epidemiological ap- personnel and cardiopulmonary re-
proach. Industrial engineers determine suscitation courses, directed by St.
workers' location and movements. In- John Ambulance and plant medical
dustrial hygienists monitor the envi- staff. An applicant or an employee's
ronment and atmospheric exposures. health record should not be discussed
The medical department gives with other personnel, except as re-
workers physical examinations and quired in the performance of their
conducts multiphasic screenings. duty. Diagnoses are confidential, be-
tween the occupational physician and
Functions and Duties of the employee.
Health Professionals Any biased judgment or opinion
Occupational physician which might be used to further the
company's or the employee's interest
Occupational physicians must be at the expense of the other is unpro-
familiar with the industrial process in
the plant, with the potential and actual fessional and highly inappropriate.
health hazards associated with the Occupational health nurses
manufacturing process, and with the
physical requirements of the job. Nurses should be well trained and,
if possible, certificated in occupa-
They often step out of their offices
into the plant environment or 'shop tional health nursing. Duties include
prevention, treatment, education, and
floor' atmosphere for discussions with
supervisors and workers. Only then rehabilitation. Nurses' preliminary
will the physician be able to advise testing and completion of medical
management about health conditions, questionnaires in preplacement and
health hazards, and safeguards to pro- periodic examination enable occupa-
tect health and safety. Occupational tional doctors to spend more time
physicians must have basic informa- with abnormal findings. With written
tion to conduct preplacement and pe- orders from the physician, the nurse
riodic examinations, and health edu- can handle many major accidents and
cation programs in the plant. They injuries. Written orders are necessary
must also have a basic knowledge of to define the nurse's limits and re-
prevention, industrial hygiene, engi- sponsibilities in treating patients.
neering control measures, ergo- Sometimes rehabilitation is carried
nomics, standards, etc. out in the unit or in the local hospital.
Family physicians are important Nurses should be in contact with the
contacts for occupational physicians. rehabilitation team. Nurses educate
Emergency cases may be seen but re- individual workers or groups of
ferred to the family physician or other workers in proper health techniques,
specialists. However, it is important diets, hypertension, and the proper
that the physician in the plant be con- use of personal protective equipment.
tacted at frequent intervals about con- Also, nurses serve as counsellors for
ditions which are adversely affecting personal, physical, and mental health
the health of employees. An em- problems. They can often be espe-
ployee who has a non-occupational cially effective in alcohol and drug
disease, and who consults the physi- abuse.
cian in the plant should be seen but Occupational health nurses should
referred as soon as possible to the visit the shop floor and other areas in
family physician for more definitive the plant periodically, in order to un-
care. derstand the relationship between em-
Clear ground rules must be estab- ployees' symptoms and works.
lished between the physician, the
company, and the local medical soci- Industrial hygienist
ety about health care. If the occupa- Industrial hygienists may be an in-
tional physician is male, all women tegral part of the plant health and
employees should be examined in the safety team, or may be hired as out-
presence of a third party, preferably a side consultants to monitor the work-
female nurse. Reportable communica- place. Hygienists must make cor-
ble diseases should be reported to the porate management aware of potential
local health department. Plant physi- in-plant environmental hazards, how
cians must review preplacement, peri- to measure these hazards, and appro-
odic, transfer, and re-entrance health priate engineering controls. They
examinations. They should arrange must periodically monitor the con-
for ongoing first aid courses for plant trolled environment and must work
1913
closely with physicians and nurses to
achieve and maintain proper environ-
mental control. Hygienists have spe-
cial knowledge in hygiene, toxicol-
ogy, and ergonomics. They must also
be familiar with the shop floor.
Safety and accident
prevention coordinator
All safety and accident prevention
programs in the plant are the coordina-
tor's responsibility. The coordinator
must attend to unsafe actions by em-
ployees and the unsafe environment.
The safety supervisor must make pefi-
odic checks of the working environ-
ment and be familiar with the number
and severity of accidents. The coordin-
ator must be in close contact with the
physician and nurse, in order to effec-
tively work as a team member. These
professionals have traditionally re-
ported to the personnel department,
but it may be more appropriate for
them to report to the same company
official as the medical officer does.
First-aid personnel
Often, where there is no full-time or
part-time physician or nurse, employ-
ees are selected and trained to provide
emergency first aid in the plant. They
should obtain certification from a first-
aid course such as those given by the
St. John Ambulance or the Red Cross.
Where there are physicians or nurses
in the plant, these programs are organ-
ized by the health services department,
which must ensure that enough em-
ployees are trained to do emergency
first aid.
Other health professionals
Other health professionals may be
involved in the medical department,
such as a health physicist, a psycholo-
gist, or a social worker. The need for
these will be governed by the size and
the type of operation.
Facilities
When designing an in-plant medical
facility, allowances should be made
for future expansion. The size of the
operation, the number of employees,
and the activities of the plant deter-
mine the location, size, layout, and
equipment necessary. Accommodation
for disabled people should be made
and the facilities should be established
on the first floor if possible. An access
route for an ambulance should be de-
veloped. It is difficult to determine
1914
size but this is usually based upon the cident or illness report completed
extent of the program and the number jointly by the first-line supervisor, the
of employees. The usual rule is one to plant safety coordinator, and the medi-
1.5 square feet for each employee up cal officer. If each of these people
to 1,000. When there are more than completes their portion of the report
1,000 employees, square footage per accurately, unsuspected problem areas
employee can be reduced. may be identified and controlled. Such
These medical units serve the basic a report helps reduce accidents by
functions of prevention, treatment and making all employees more aware of
rehabilitation. There should be sepa- the in-plant environment. The report
rate areas for prevention and treat- also demonstrates to employees that
ment. The facility should allow pri- the company takes the matter of their
vacy during examinations. Larger health and safety seriously. Such re-
units should have specialized rooms ports, with certain modifications, can
for treatment of minor illness or in- be used as Workers' Compensation re-
jury. For example, there should be a ports.
separate room, with such aseptic con-
ditions, for minor suturing, and an Industrial hygiene records
area for observing patients. There The hygienist should do enough ex-
should be rooms for storage and for aminations to characterize inplant ex-
health counselling. Rooms must have posure to environmental hazards at dif-
a sink, dressing cabinet, treatment ferent locations. These reports should
chair, examination table, desk, and be more than a list of numerical val-
files for medical records. ues; they should also interpret the find-
The training, background, and time ings and discuss corrective action. Ac-
that the medical personnel are at the ceptable exposure concentration
plant should determine the type and should be emphasized.
sophistication of emergency and thera-
peutic medical equipment, and drugs Industrial hygiene surveys
that will be kept on the premises.
After an initial plant evaluation, the
Health Records industrial hygienist will do a baseline
The health record at work should survey of the working environment,
contain all information about employ- including vapors, dusts, etc. The hy-
ees' health at preplacement, periodic- gienist will also periodically monitor
ally throughout their career, and at the the plant. The number of individual
termination of employment. It must samples can usually be reduced after
record all occupational injuries, ill- the baseline is obtained. Emergency
nesses, and treatments. When design- surveys are done when there are sud-
ing a preplacement health question- den spills or explosions.
naire, consider the average applicant's Management should consult the
education, so that the history may be doctor and the industrial hygienist
completed with a minimum of assis- early in the planning and pilot stages
tance from medical staff. Consider- of a new process or operation, so that
ation should also be given to compu- necessary environmental control and
terized programs. Records must be medical monitoring can be included in
kept confidential; the personnel office economic feasibility studies. Environ-
and management are entitled to know mental and occupational health are es-
whether or not a worker can fulfill a sential business expenses. Everyone
job properly, but must not have access should be aware that minimal changes
to confidential information. in the process can cause maximal en-
vironmental problems.
Evaluation
In order to evaluate the program's Safety and
effectiveness and to determine costs of Accident Prevention
medical services and a realistic bud- Property, machine, fire, mechani-
get, statistical reporting should cover cal, and electrical safety should be
costs, number of patients, tests, etc. considered. Management and workers
must be educated about safety proce-
Accident and illness investigation dures. Safety begins the moment that a
reports worker is employed and continues
The causes of occupational injury throughout employment. There must
and illness can be determined by an ac- be a systematic inspection of new, re-
CAN. FAM. PHYSICIAN Vol. 31: OCTOBER 1985
vised, and existing production and
safety equipment to identify potential
safety hazards and to ensure compli-
ance with government requirements. A
systematic accident investigation pro-
gram should be coordinated with first-
line supervision in the medical ser-
vice.
Special Programs
In addition to basic occupational
health and safety procedures, there are
special risks and special toxicants in
many industries, needing programs to
identify, monitor, and control them.
The worker must be properly moti-
vated to cooperate in recognition,
evaluation, and control, for the protec-
tion of his health. Some common haz-
ard control programs include: hearing
conversation against noise; eye protec-
tion against flying particulate; respira-
tory protection against air-borne
agents such as lead, silica, asbestos,
cotton, and solvent vapor; thermal pro-
tection against heat or cold, and pro-
tection of the skin against sensitizers
or irritants. Other special programs
could include: medical disaster con-
trol, alcohol and drug abuse control,
consultation and management on
group insurance benefits, absentee
control (prevention rather than polic-
ing), occupational mental health, con-
trolling hazards and toxins that escape
from the plant into the community, ex-
pansion of community services, and
health evaluation of new or modified
products as they affect consumers.
Conclusion
Prevention of illness and injury,
promotion of health through proper
evaluation of the employee and the
working environment, and measures to
combat emergencies and other stres-
sors are features of a comprehensive
occupational health program. The
breadth of such a program depends
upon the number of employees, the en-
lightenment of management and labor
unions, the costs that may be borne by
the industry and the community, and
the priority given to these preventive
approaches in the total spectrum of
health care in the community. A
proper program should enable employ-
ees to develop their potential and
maintain their health. The returns to
management and to the community are
decreased absenteeism, increased pro-
ductivity, and a healthier and happier
work force. ) in plasma creatinine arid serum
CAN. FAM. PHYSICIAN Vol. 31: OCTOBER 1985
Tagamef (cimetidine, SK&r)
Brief Prescribing Information
for Adult Oral Use
PHARMACOLOGICAL
CLASSIFICATION
Histamine H2-Receptor Antagonist
ACTION
Cimetidine competitively inhibits the
action of histamine at the histamine
H2-receptor. It inhibits daytime and noc-
turnal basal gastric acid secretion and
also gastric acid secretion stimulated by
food, histamine, pentagastrin, caffeine
and insulin. Total pepsin output is reduced
as a result of the decrease in volume of
gastric juice. Cimetidine has no effect on
the rate of gastric emptying or lower
esophageal sphincter pressure.
INDICATIONS
* Duodenal ulcer and prophylaxis
of recurrent duodenal ulcer
* Non-malignant gastric ulcer and
prophylaxis
* Gastroesophageal reflux disease
CONTRAINDICATIONS
None known.
PRECAUTIONS
Use in Pregnancy, Nursing Mothers:
Experience in pregnant patients is lim-
ited. Animal studies have revealed no
evidence of impaired fertility or harm to
the fetus. TagametR crosses the placental
barrier. It is secreted in human milk.
Anticipated benefits should be weighed
against potential risks. Tagamet' has
been used in clinical trials for the preven-
tion of acid aspiration pneumonitis in
women undergoing cesarean section or
vaginal delivery without harm to the fetus.
In impaired renal function: Dosage
should be reduced - see Product
Monograph.
Drug Interactions: Tagamet" may reduce
the hepatic metabolism of warfarin-type
anticoagulants, phenytoin, propranolol,
chlordiazepoxide, lidocaine, diazepam
and theophylline, thereby increasing
blood levels of these drugs. Benzodiaze-
pines metabolized by other systems do
not exhibit this effect. Since clinically
significant effects have been reported
with warfarin anticoagulants, close
monitoring of prothrombin time is recom-
mended, and adjustment of anticoagulant
dose may be necessary.
Use in Gastric Ulcer: Symptomatic
response to TagametK does not preclude
the presence of a gastric malignancy.
ADVERSE REACTIONS
Mild and transient diarrhea, tiredness,
dizziness and rash have occurred in a
s,mall number of patients. A few patients
have developed mild, reversible
gynecomastia during prolonged treat-
rnent A few cases of the following have
been reported decreased white blood
cell counts (including agranulocytosis),
thrombocytopenia, aplastic anemia:
reversible confusional states, usually in
elderly and/or severely ill patients with
renal Insufficiency or organic brain syn-
drome; fever: hepatitis; interstitial
nephritis; pancreatitis; small increases
transamina.ses.
OVERDOSAGE
Oral ingestion of up to 20 grams has
caused no untoward effects. Recovery
has been uneventful.
Treatment: Emesis and/or gastric lavage,
monitoring and supportive therapy.
Assisted respiration may be of value.
DOSAGE AND ADMINISTRATION -
ADULTS
In clinical studies, TagametR has been
used in divided doses of up to 2400 mg
per day.
ACTIVE DUODENAL ULCER
400 mg or 600 mg twice daily (breakfast
and bedtime) or 300 mg four times daily
(with meals and at bedtime) or 2 x 400 mg
(at bedtime) for at least 4 weeks.
NON-MALIGNANT GASTRIC ULCER
400 mg or 600 mg twice daily (breakfast
and bedtime) or 300 mg four times daily
(with meals and at bedtime). Continue
therapy for at least six weeks.
PROPHYLAXIS OF RECURRENT
DUODENAL OR GASTRIC ULCER
400 mg at bedtime or 300 mg twice daily at
breakfast and bedtime. Continue therapy
for at least 6-12 months.
GASTROESOPHAGEAL REFLUX
DISEASE
600 mg twice daily (breakfast and bed-
time) or 300 mg four times daily (with
meals and at bedtime). Continue therapy
for 8-12 weeks.
Refer to Product Monograph for informa-
tion on dosage adjustment for patients
with impaired renal function.
AVAILABILITY:
Tablets: 200, 300, 400 and 600 mg
cimeti ine.
PatientPakT: Each PatientPak'" contains
Tagamet` in blister-packed strips and
disease-specific patient information in
audiotape cassette and booklet formats.
TagametR UlcerPakT': 28 days' supply of
300, 400, or 600 mg cimetidine tablets.
Tagameti RefluxPakT" 28 days supply of
300 mg cimetidine tablets. Tagamet'K
PreventPakT: 56 days' supply of 400 mg
cimetidine tablets.
Liquid: Cimetidine hydrochloride
equivalent to 300 mg cimetidine per 5 mL.
(Alcohol content 2.85K/6 v/v.)
Complete Product Monograph available
to physicians and pharmacists on request.
Tagamet
(cimetidine, SK&F)
_SK&
_~~~~aSshKiecmat
NO SUBSTITUTION
1915