Article, Emergency Medicine

Emergency department visits for work-related injuries

a b s t r a c t

Background: Work-related injuries are commonly seen in the emergency department (ED). This study sought to analyze characteristics of ED patient visits that were billed under workers’ compensation.

Methods: This was a retrospective chart review of visits during 2015 that were billed under workers’ compensation at an academic ED. The following variables were collected: age, gender, mechanism of injury/exposure, diagnoses, imaging performed, specialty consultation, operative requirement, follow-up specialty, and ED disposition.

Results: In 2015, 377 patients presented to the ED for work-related injuries. The most common mechanism of injury was fall. Frequent diagnoses included lower extremity injuries and hand/Finger injuries. The most common consult- ing service was orthopedics. Only five patients were referred to occupational medicine for follow up.

Conclusion: Knowledge of the types of occupational injuries and subsequent care required may help guide both workers and employers how to best triage patients within the healthcare system. Alternative settings such as occu- pational medicine or primary care services may be appropriate for some patients.

(C) 2018

Introduction

Work-related injuries account for a large percentage of emergency department (ED) visits. Prior literature has demonstrated that about 20% of all adult patients seen in a state’s ED system had chief complaints associated with worker’s compensation or work related injuries [1]. Ac- cording to the Bureau of Labor Statistics (BLS), 4836 fatal work injuries were reported in 2015, marking the highest total since the 5214 fatal work injuries in 2008 [2]. Additionally, fatal injury rates were generally lower among younger workers (2.3 per 100,000 workers for those age 25 to 34 years) than older workers (9.4 per 100,000 workers for those age 65 years and older) [2]. In 2015, non-fatal occupational injuries and illnesses were estimated to be at 2.9 million, occurring at a rate of

3.0 cases per 100 equivalent full-time workers [3]. The total number of fatal and non-fatal cases is likely underrepresented by the BLS Survey of Occupational Injuries and Illnesses, as it does not include all employ- ment sectors, such as self-employed individuals, companies with fewer than 10 employees, and the federal government [4]. Although declining unemployment rates place more individuals at risk, efforts from federal organizations, such as the Occupational Safety and Health Administra- tion (OSHA) and the National Institute for Occupational Safety and Health (NIOSH), have resulted in a steady annual decrease in incidence of occupational injuries from 5.0 cases per 100 full-time workers in

* Corresponding author at: 1 Medical Center Drive, PO Box 9149, Morgantown, WV 26506, United States.

E-mail address: [email protected] (A. Tadros).

2003 to 3.0 in 2015 [5]. Investigating the mechanism by which workers are injured, the types of injuries they incur and, the medical services re- quired thereafter may provide further insight into the preventing inju- ries and subsequent rehabilitation following occupational injuries.

To our knowledge, there is very limited data specifically evaluating patients presenting to an emergency department for work-related inju- ries. Therefore, the purpose of this study was to evaluate characteristics of patients seen in an ED for work-related injuries.

Material & methods

Study design, setting, and patient selection

This was a retrospective chart review of patients who presented to a tertiary care, academic ED in West Virginia from January 1, 2015 through December 31, 2015. Our ED sees approximately 48,000 patients annually. Medical records were accessed and reviewed through our electronic medical record system. Patients were identified by subse- quent billing codes for workers’ compensation. Patients were excluded if the visit was not the initial visit for the present illness or injury. This study was approved by our University’s Institutional Review Board.

Data collection and analyses

The following information was abstracted from each patient’s med- ical record by three of the co-authors (AT, SD, JR) using a standardized

https://doi.org/10.1016/j.ajem.2018.04.058

0735-6757/(C) 2018

1456 A. Tadros et al. / American Journal of Emergency Medicine 36 (2018) 14551458

data collection form: age, gender, mechanism of injury/exposure, diag- noses, imaging performed, specialty consultation, operative require- ment, follow-up specialty clinic recommended, and ED disposition. Descriptive statistics (i.e., frequencies and percentages) were used to describe all study variables.

Results

From January 1 to December 31, 2015, there were a total of 377 pa- tient visits to our ED specifically for work-related injuries that were billed to Worker’s Compensation. Almost 80% of patients were male. Fig. 1 demonstrates a full breakdown of groups by age and gender.

injury mechanisms and ED disposition is shown in Table 1. The most common mechanisms of injury were falls (n = 96) and Crush injuries (n = 78). The most common diagnosis was lower extremity injuries (n = 73), as seen in Table 2.

Plain X-rays were performed on almost 67% of patients (average of 2.8 X-rays/patient), while CT imaging was obtained on approximately 30% of patients (average of 1.9/patient) (Fig. 2). The most common con- sulting services were orthopedics and trauma surgery. However, most patients (56%) did not receive any consult in the ED from an outside ser- vice (Table 3). Only 13% of patients required surgical intervention.

The majority of patients were discharged from the ED (78.2%). The most common recommended follow up service at discharge was with orthopedics. Only 5 patients were referred to occupational medicine. About 34% of patients received no outpatient referrals upon being discharged from the ED.

Discussion

Despite the dramatic decline in work related injuries over the past century, occupational accidents continue to be a potentially preventable cause of morbidity and mortality. Multiple studies have shown that im- plementation of Safety measures can be successful in reducing risk and improving workplace safety. A comprehensive study revealed a clini- cally significant reduction in workers’ compensation injury claims after implementation of fall prevention regulations for carpenters [6]. An additional study suggested a reduction in mortality from falls and electrocutions with implementation of the NIOSH Fatality Assessment and Control Evaluation (FACE) program [7]. Since the introduction of NIOSH and OSHA in the 1970s, workplace injuries, illnesses, and

Table 1

Mechanisms of injury versus ED disposition.

Admit

Discharge

Deceased

Total

Abdominal pain

0

1

0

1

Allergic reaction

0

1

0

1

Animal exposure

0

4

0

4

Arm pain

0

1

0

1

Assault

0

5

0

5

Back pain

0

3

0

3

Bee sting

0

1

0

1

Blast injury

0

2

0

2

Body fluid exposure

0

8

0

8

Chemical exposure

0

10

0

10

Chest pain

1

1

0

2

Crush injury

18

60

0

78

Electrical injury

4

1

1

6

eye injury

1

15

0

16

Fall

30

66

0

96

Foot pain

0

1

0

1

Foreign body

0

3

0

3

Head injury

1

22

0

23

Heavy lifting

1

16

0

17

Hit in the face

1

10

0

11

Hit in the leg

0

2

0

2

knee injury

0

1

0

1

Laceration

0

31

0

31

Leg injury

0

1

0

1

Leg pain

0

2

0

2

Puncture wound

0

4

0

4

Shoulder injury

1

2

0

3

Smoke inhalation

0

1

0

1

Strain to arm

0

1

0

1

Syncope

0

2

0

2

Vehicle crash

21

19

0

40

fatalities have been drastically reduced, despite the near doubling of U.S. employment. This suggests that Preventative measures can be developed and implemented successfully.

Examining work-related injuries facilitates the development and in- tegration of appropriate safety measures. The current study had a higher male predominance compared to prior literature looking at work-re- lated ED visits [8]. Consistent with prior studies, the current study found that falls and crush injuries were among the most common work-related injuries, with the extremities being most commonly af- fected [8]. Although a study by Bhandari found that the hand was the

Fig. 1. Age and gender categorical breakdown for work-related injuries and illnesses.

A. Tadros et al. / American Journal of Emergency Medicine 36 (2018) 14551458 1457

Table 2

Most common diagnoses, broken down by gender.

Table 3

Number of consults performed in the ED by specialty services and number of follow up referrals.

Diagnoses Male (%) Female (%) Total (%)

Lower extremity injury

55 (19)

18 (21)

73 (19)

Service

Number of consu

lts Number of referrals

Hand/finger injury

62 (21)

9 (10)

71 (19)

Cardiology

0

1

upper extremity injury

47 (16)

16 (18)

63 (17)

Concussion clinic

0

9

Back injury

14 (5)

10 (11)

24 (6)

ED

0

25

Eye injury

18 (6)

4 (5)

22 (6)

Employee health

0

1

All other body regions

94 (33)

30 (35)

124 (33)

ENT

0

4

Gastrointestinal

1

0

Medicine

8

3

Nerosurgery

7

6

most commonly injured area of the body, lower extremity injuries were slightly more common in our study. Comparable injury types were found in a study by Groenewold, whose data revealed approximately 62.7% of their visits over four years were for extremity injuries; a differ- ent review also showed that extremity injuries were the most common type of work related injuries [9,10]. Both studies also showed a male predominance. However, these studies did not examine the mechanism of injuries, imaging, consultations during the initial ED presentation or follow up referrals.

In order to evaluate these injuries, many patients underwent radio- graphic imaging. Patients in our study received an average of almost three X-rays, and 30% received CT imaging, with an average of about two CT scans per patient. Trauma surgery and orthopedics were the most frequent consulting services. Despite receiving multiple imaging studies and specialty consultations, approximately 78% of patients were able to be discharged from the ED.

Future studies should examine mechanisms to prevent avoidable work-related injuries. As Shishlov identified, despite being recognized as a high risk population, the rates of falls in construction workers remained unchanged between 1998 and 2005 remained unchanged when compared to other occupations [7]. For those occupations that are at high risk for falls, crush injuries, or other extremity injuries, mod- ifying or creating programs that help to monitor and prevent injuries may help reduce future incidents.

Future studies should also examine the appropriate triage of occupa- tional injuries within the healthcare system. Although the present study only examined patients presenting to the emergency department, we found that only a small number of visits (13%) required inpatient treat- ment. Certain injury mechanisms such as motor vehicle crashes, high- elevation falls, and major crush injuries are probably most appropriately evaluated in the ED. However, minor injuries could potentially be di- rected to other health care settings such as Primary care clinics or ur- gent cares. Knowledge of the types of work-related injuries and illnesses requiring evaluation within the emergency setting could help to guide protocols for both employers and employees. Additionally,

Occupational medicine

0

5

Opthomology

12

20

Oral surgery

5

6

Orthopedics

101

97

Otolaryngology

6

0

PCP

0

34

plastic surgery

11

14

Spine

1

0

Sports med

0

7

Surgery

0

2

Trauma

55

30

Wound care

0

1

Vascular surgery

1

0

only a fraction of our patients were referred to occupational medicine, which we view as an underutilized resource that could be able to care for patients suffering from many types of work related injuries, particu- larly for follow up care.

Limitations

Although this study sought to evaluate all work-related injuries in an academic, tertiary care ED that were billed under workers compensation, it is limited by under-reporting, as many occupational sectors do not mandate worker’s compensation claims. In addition, this study would miss patients who did not seek medical care or who presented to other healthcare settings, such as primary care, urgent care clinics or workplace medical clinics. As organizations such as OSHA and NIOSH work to im- prove occupational safety, it is important to continue evaluating the mechanisms and characteristics of visits for all work-related injuries.

Conclusions

In conclusion, among this ED population of work-related injuries, most injuries did not require hospital admission despite a large number of patients undergoing imaging studies and specialty consultation. The

Fig. 2. Number and type of images conducted during patient visits in ED.

1458 A. Tadros et al. / American Journal of Emergency Medicine 36 (2018) 14551458

most common injuries included falls and crush injuries. Knowledge of injuries suffered by workers can not only guide future prevention programs but also guide proper triage of patients within the healthcare system.

Funding

The authors report that there was no funding source for the work that resulted in the article or the preparation of the article.

Presentations

This study was presented at the American Occupational Health Conference in April 2017.

References

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