Content of preplacement exam depends on goals
EHPs advised to assess their hospitals’ needs
Preplacement physical examinations are a basic function of all hospital occupational health services, but few guidelines exist to help practitioners construct an effective program for new employees. The question of what to include in preplacement exams is a frequent one.
The answer largely depends on the individual institution’s goals, says Sarah Gipson, RN, MS, COHN-S, CCM, a nurse consultant in occupational health at Hancock Memorial Hospital and Health Services in Greenfield, IN. Gipson has presented a seminar on the subject for the Midwest states chapter of the Association of Occupational Health Professionals in Health Care (AOHP), a national organization based in Reston, VA.
The primary objective of all preplacement exams is to ensure that new hires who have been offered jobs contingent upon completion of the exam are physically and psychologically capable of performing that job, with or without accommodation, she explains.
ADA specifies rejection criteria
Employee health clinicians must know the work tasks and health hazards associated with each job to determine if new hires have illnesses or impairments that would prevent them from performing jobs safely without jeopardizing themselves, co-workers, or patients. Under the Americans with Disabilities Act, rejection following physical examination must be job-related and justified by business necessity (i.e., the necessary accommodation is unrealistically expensive, infeasible, or impossible).
Other preplacement exam objectives may be based on a hospital’s mission or financial resources, Gipson says.
For example, "some hospitals expand the employee health service into a clinic for employees, particularly if they are self-insured for health insurance. They sometimes find it more convenient and cost-effective to offer optional services" such as Pap smears and prostate screens, she explains.
Hospitals also might use preplacement assessments as a way to decrease workers’ compensation injuries/illnesses and associated costs, or increasing morale by positioning the occupational health service as an employee benefit provided by a caring organization.
In any case, Gipson says all components of preplacement exams and screenings should be analyzed to ensure they are required or meet a specific purpose or goal.
Required components include mandates of individual state boards of health. To determine other requirements, she advises referencing the infection control section of the Joint Commission on Accreditation of Healthcare Organizations’ manual, as well as certain applicable Occupa tional Safety and Health Administration (OSHA) standards, such as respiratory protection (1910.134), noise (1910.95), and bloodborne pathogens (1910.1030). Laser eye exams and baseline screenings for employees who will handle chemotherapeutic drugs are recommended for compliance with OSHA’s general duty clause.
While Centers for Disease Control and Preven tion recommendations are not legally required, many are regarded as "standards of care," she notes. Those include tuberculosis screenings and some health care worker vaccinations.
Don’t forget possible DOT requirements
Department of Transportation driver exams also are required preplacement for workers who will drive ambulances, deliver oxygen tanks as part of a home health care program, or whose duties will require crossing state lines, she says.
Gipson notes that optional preplacement screenings, physical exams, and nursing assessments might include:
• drug screening;
• medical history (including obtaining records of past injuries/surgeries);
• vital signs, height, and weight;
• vision screening;
• audiometry;
• color testing;
• range of motion;
• tetanus-diphtheria boosters;
• spirometry;
• functional capacity exams;
• back assessments;
• agility testing;
• hands-on physical exams;
• mammography, Pap smears, prostate screens;
• occult blood screens, flexible sigmoidoscopy;
• latex questionnaire, testing;
• specific lab baseline tests based on exposure risks.
The EHS’ main focus in preplacement assessments is making sure there’s a match between the applicant’s physical capabilities and the essential functions of the job, says Charlene M. Gliniecki, RN, MS, COHN-S, director of employee health and safety at El Camino Hospital in Mountain View, CA. Gliniecki also is co-author of an AOHP manual that includes a section on preplacement assessments (see box, p. 80) and has led workshops on the subject at the organization’s national conference, as well as for the Northern California AOHP chapter.
Gliniecki uses screening questionnaires (see p. 81 and insert) to obtain a focused history and performs a physical exam to determine if there are health problems that might interfere with an applicant’s ability to do the job.
Spending about a half-hour with each person, Gliniecki and staff establish whether a need exists for work restrictions or accommodations. She notes that within the last 10 years, a much higher percentage of applicants have permanent restrictions already imposed from previous injuries, perhaps due to the aging work force.
"About 5% of applicants have some kind of restriction coming in. Our job in the employee health service is to identify what kind of restriction or accommodation this person might need from a health point of view," she says. "Then it’s up to the manager or human resources [department] to determine if it can be accommodated.
"Ideally, managers should already have shared functional job requirements with candidates, so it should not be a surprise when they come to see us and we tell them, for example, that they would have to lift 25 pounds, and their doctor has already given them a restriction of less than 10 pounds."
Gabor Lantos, MD, PEng, MBA, president of Occupational Health Management Services in Toronto, Ontario, Canada, says honing in on particulars of the job is an important aspect of preplacement evaluations because applicants may have conditions that could be dangerous to themselves or patients. Examples include not only back strength assessment (history of back injury) for jobs requiring heavy lifting, but also whether applicants for jobs entailing rotating shifts have severe diabetes, whether a nurse who is epileptic will be flying on helicopters (which is not permitted), or if lab animal handlers have severe allergies.
In addition to a general, thorough assessment for immune status related to illnesses such as measles, mumps, rubella, diphtheria, tetanus, polio, tuberculosis, and hepatitis B, Lantos notes that occupational health practitioners also must focus on diseases such as malaria or hepatitis A for employees from other countries where those diseases are prevalent.
In recent years, preplacement assessments have been complicated by higher employee turnover rates, he adds.
"In the good old days, a typical hospital might have had 5% to 10% turnover, but many have 33% turnover now," he states. "Downsizing, too, often means that occupational health departments are working with less resources and higher turnover."
One way practitioners can shorten the time needed for each evaluation is to have new employees fill out their health histories at home and bring the completed forms with them to their assessment appointment, Lantos advises.
"An experienced occupational health nurse will need only a few minutes to review it," he says. "If [new hires] complete the forms at home at their leisure, they can take the time to check with their family doctors about their medical history, or to ask Mom or Grandma if they had chickenpox, and the rest of the assessment can be completed quickly in the office."
In addition to functional evaluations and baselines, preplacement assessments can be an ideal time for health promotion, explains Kathleen McAndrew, MS, ARNP, COHN-S, CCM, occupational medicine department director at Dartmouth-Hitchcock Medical Center in Lebanon, NH, and president of the New Hampshire Association of Occupational Health Nurses.
Evaluating employees’ work fitness is a basic EHS responsibility, but many departments, including hers, also emphasize health promotion and prevention. Those departments might choose to go beyond what is minimally required or expected in a preplacement assessment, she says.
McAndrew’s department coordinates a full health promotion program, encouraging healthy behaviors such as exercise, good nutrition, and smoking cessation. She sees the preplacement setting as a chance to provide education and training at the same time as more conventional services such as obtaining health histories and updating immunizations.
"We take the opportunity at our preplacement screening process not just to get our baseline evaluations and the updates we need, and not just to evaluate whether they can perform the job duties they were hired for, but also to educate them on our services and opportunities within the medical center, such as our employee assistance program, nutrition services, women’s health programs, stress reduction classes, and corporate memberships to health spas," McAndrew says.
Even if an EHS doesn’t provide wellness services, practitioners still can "assess the person in total" and refer new employees to other health care providers in the medical center or community, she adds.
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