Patients referred from work to a casualty department

Injury, 7, 225-232

225

Patients referred from work to a casualty department W. H. Rutherford

and Jane S. E. Maynard

Royal Victoria Hospital, Belfast INTRODUCTION FROM 9 April to 6 May, 1973, many items from the records of all patients attending the casualty department of the Royal Victoria Hospital, Belfast, were coded and recorded on a computer. An analysis of this material to show the general working of the department has already been published (Rutherford and Maynard, 1975). Shortly after the completion of this study, we were asked to take part in a training programme for industrial nurses. We realized that it would now be possible for us to review our own experience of the patients referred to us from work. Although there had always been many patients coming from work, we had never had an easy way of abstracting and analysing their records. The previously reported study performed on the patients during this 4-week period was a pilot study to test the feasibility and the value of an information retrieval system in casualty. In the same way, this report on the illnesses and accidents referred from work in 4 weeks is a pilot study to show the possibilities of this method of study. The results shown in the tables and figures have many shortcomings, and must be treated with considerable caution.

METHOD Basic information

nature of injury, the diagnosis of illness, the employer, the occupation, age, sex and examination area (i.e., walking or stretcher case). The exact coding rules for each of these variables will be found in our report on our main study. As explained in that report, the two examination areas (stretcher and walking) have been used as an indication of whether the patient had a major or minor complaint. From these data we analysed our material on the computer and prepared the tables shown below.

Table /. Illnesses referred from work and diagnosis : major cases

by specialty

Medical

Chest pain, angina, coronary thrombosis Epilepsy Diarrhoea Duodenal ulcer, exacerbation Hypertension Vasovagal syncope Pyrexia-cause unknown Total

6 2 1 1 1 1 1 13

Surgical

sheet

The basic document was the casualty card in routine use for recording clinical details of patients attending the department. The following variables related to this study were coded: the source of reference (including from work), disposal, the circumstances of the accident (including industrial accident), the external cause of injury, the

Renal colic Appendicitis Strained back Anal fissure Total G ynaecological

Menorrhagia

1

226

Injury: the British Journal of Accident Surgery Vol. ~/NO. 3

FINDINGS Illnesses referred from work During the 4-week period under study, 48 people were referred from work with illnesses. These are analysed by specialty, diagnosis and severity in Tables I and II. Table I!. Illnesses referred from work and diagnosis: minor cases

by specialty

Medical Eczema Vasovagal syncope Anxiety Tiredness Tonsillitis Vaccinia Toothache Headache Total

2

2 1 1 1 1 1 1 10

Surgical Sepsis (hand infections, boils, etc.) Acute backache Sore hand Swollen ankle Ganglion wrist

11 3 1 1 1

Total

17

Accidents referred from work During the 4-week period there were 343 patients either referred from factories with accidents, or otherwise referred but complaining of an industrial accident. Table ZZZshows industrial accidents compared with accidents sustained in other circumstances. The age and sex distribution, the disposal, the nature of the injury, the external cause of the injury, the most common firms and the most common occupations are set out in the tables below. Table XV (p. 231) shows the nature of injury from the four most common occupations. DISCUSSION The meaning of the tables Illnesses (Tab/es I and I/) These are patients referred from work with acute illnesses. The period was short, and the numbers very small, so that little meaning can be given to these figures. The most common major medical problem was pain in the chest, which accounted for 6 of the 13 major medical patients. Sepsis accounted for 65 per cent of minor surgical cases. Pain in the back was also common. Some of the minor medical complaints suggest that patients

may be sent from work for trivial reasons. It would be interesting in a further study to see whether these patients come mainly from small firms where there is no nurse or doctor on site. Works accidents and accidents in other circumstances In the 4-week period under study, it was intended that the circumstances in which every accident occurred be recorded (Table III), and 365 were recorded as being works accidents. In 41.9 per cent of all accidents the circumstances of the accident were not recorded. This is probably because previously no use had been made of this information. It is hoped that one by-product of introducing the new system will be improvement in recording. Accidents from work Three criteria were used for the selection of these patients. They had to be sent either from work or from elsewhere (yet classified as works accidents), the specialty had to be surgical and the diagnosis had to be traumatic. With these criteria there were 343 such patients. This compares with 365 patients who were recorded under the variable of ‘circumstance’ as having a works accident. It seems that 22 of the 365 patients were either medical or had a non-traumatic diagnosis. The figure 343 is reached by applying stricter criteria, and the remaining tables are all based on these patients. An examination of the records shows that it is not uncommon for a patient to be referred from work with an injury that had been sustained some time previously when the patient was not at his work. Ideally one would want to separate these two types of accidents and to treat as proper works accidents only those that had occurred in the course of work. The distinction was not made with sufficient clarity in our records, and so in this pilot study we have grouped together the two types of injury. Of the accidents where the circumstances were industrial accidents were the most known, common. The proportion of major injuries was low. Major injuries are more common in road trafficaccidents, homeaccidentsandassaults. Age and sex There is a marked preponderance of male patients, 291 of the 342 being men (85.1 per cent) and 52 (14.9 per cent) being women. Table IV shows the percentage age distribution for male patients compared with the percentage age distribution of males between 15 and 64 years of age

Rutherford and Maynard

: Referrals from Work to Casualty

227

in the population of Northern Ireland. It appears that younger workers are disproportionately prone to accidents. Disposal

(Table V)

Almost 60 per cent of patients were discharged after examination, 34 per cent were brought back for a further examination and only 2.3 per cent of patients required admission to hospital. This again emphasizes the minor nature of most industrial accidents. Though there are some fatal accidents, the main effect of industrial accidents is morbidity, disability and loss of working time. Nature of injury

1. General distribution (Table VI). Wounds form the largest group and sprains and contusions are more common than fractures. Table IV. Percentage distribution of the male population of Northern Ireland between 15 and 69 years of age compared with incidence of accidents among male patients in the same age groups Age group (years)

Distribution of population (%I

Incidence of works accidents (%I

15-19 20-29 30-39 40-49 50-59 60-69

13.9 23.7 18 16.4 15.6 12.4

22.6 24.9 19.3 17.7 11.3 4.2

2. Fractures (Table VZZ). The numbers are small, yet fractures of fingers and toes seem relatively common. 3. Sprains (Table VZZZ).The ankle is the joint most often involved, followed by the wrist. 4. Wounds (Table IX). Again, the fmgers are by far the most common site of injury. 5. Abrasions (Table X). These are more evenly spread over the whole body. 6. Contusions (Table XI). Contusions of the toes are almost as common as of the fingers, and whereas wounds and abrasions of the trunk are uncommon, contusions of the trunk are not.

External cause (Table X/Z) For this classification we used the International Classification of Disease. It might be more profitable for such a study to use the Factory classification. The largest single Inspectors’ group is that in which the external cause is

228

Injury:

Tab/e V. Works

the British

of Accident

Surgery

Vol. ~/NO. 3

: disposal

accidents

Admit to hospital

Journal

Discharge

Re-attend casualty

(419%) 192 (59.8%) 201 (58.6%)

(4&) 108 (33.6%) 118 (34.4%)

Re-attend fracture or other clinic

Total

Major (9%) Minor (I.!%) Total (2.83%)

Tab/e V/. Works

accidents

:

nature

Fractures

Sprains

3

1

Major Minor

(Z)

Tab/e VII. Works

Major Minor Total

accidents:

1 0 1

Table VI/f. Works

Major Minor Total

accidents

4 4

Table IX. Works

Major Minor Total

(4E??) (4.;;)

of injury

(144696)

Total (1 Z%)

(8.g)

(626) 321 (93.6%) 343 (100%)

(51qg)

Wounds

Abrasions

Contusions

Other

3

4

5

6 108 (34%) 114 (33.2%)

,:;,

(Z%)

&)

(2E%)

Total

(6.4:)

(So)

(93z)

(11393%)

(1 Z)

fractures

0 1 1

1 0 1

0 3 3

0 4 4

0 7 7

1 4 5

0 5 5

0 2 2

3 26 29

5 5

2 2

4 4

14 14

2 2

1 6 7

4 4

1 46 47

11 11

1 62 63

1 2 3

5 5

5 5

6 108 114

: sprains

5 5

accidents

3 18 21

: wounds

1 1

1 4 5

Rutherford and Maynard

: Referrals from Work to Casualty : abrasions

Table X. Works accidents

Major Minor Total

Head

Trunk

2 3 5

1 1

Tab/e X/. Works accidents

Major Minor Total

229

Arm/ forearm

Hand

Fingers

Thigh/ leg

Foot/ toes

3 3

8 8

6 6

5 5

3 3

Total 3 28 31

: contusions

Head

Trunk

5 5

1 10 11

Shoulder

3 3

Elbow/ wrist

9 9

unknown, which again reflects the lack of interest taken by doctors. In the care of individual patients this may not always matter. It is only when one is trying to study accidents as a whole and understand the relationships between specific mechanisms and injuries that it becomes important to record the external cause in every case. This is another example of how an information retrieval system can be a stimulus to good record keeping. Among those recorded, the most common external causes are falls (on the same level), being struck by a falling object, being struck by any object, being caught between objects and being injured by cutting or piercing instruments. Firms (Table X//l) The proportion where the firm was not recorded, or was recorded as unknown, was unacceptably high. Recording by name of firm gave an unsatisfactory classification. We would prefer in the future to use a classification by industry. Occupation (Table XIV) Classification again proved difficult, and our coding was made up as the study proceeded. In any further study we would use the classification of occupation issued by the Department of Employment. With the larger firms we would try to ensure that they referred patients with a form which specified clearly both the firm (including its industrial classification) and the occupation of the patient. There would remain many patients, self-employed or from small firms, where such procedures were inapplicable. Further study is needed to see whether it is possible to classify all occupations correctly.

Hand

Fingers

Legs

1 5 6

19 19

2 12 14

Feet1 toes

18 18

Total 4 81 85

If this difficulty can be overcome, the value of this classification should increase year by year, as the numbers within any single occupation reach the point where analysis is valuable. Nature of injury in four occupations Table XV shows a preliminary analysis of the injuries in the four most common occupations. Even with the small numbers available in the 4-week period, it appears that wounds are the commonest injuries in butchers, that labourers andjoinershadfractures, whilst butchersandfitters did not. With larger numbers one could find out whether therewere particular wounds or particular fractures associated with various occupations. A similar analysis could also be made for any particular external cause. Discussion of the method and implications of its development In their paper ‘Study of the statistics relating to safety and health at work’, Shipp and Sutton did not even consider statistics from casualty departments as a possible source of information (Shipp and Sutton, 1972). This is probably because until now these departments have had no information retrieval systems and no reports have been available on this aspect of their work. In our department, accidents from work provide 12 per cent of new patients. If this figure is taken as a rough guide for similar departments over the whole United Kingdom, there must be approximately 1 million patients coming from work to casualty departments in a year. This compares with a total of 327,000 lost-time injuries reported annually through the factory and other inspectorates.

230

Injury: the British Journal of Accident

Surgery Vol. ~/NO. 3

Shipp and Sutton draw a distinction between statistics which are useful as measures of performance and those which can form a basis for expertise. Casualty statistics, especially those of a single hospital, are obviously unsuitable as measures of performance. There are many reasons why some patients with a certain type of injury report to hospital, while others with an exactly similar injury may be treated at work, by their general practitioner, at another hospital or even have no treatment. This does not apply to accidents severe enough to require admission to hospital, and if such accidents were carefully classified as to the circumstances in which they took place, they could be further analysed through the hospital activity analysis. To make this valuable, all such cases would also need their occupation classified as an item in hospital activity analysis. A nationwide analysis of accidents using hospital material (both casualty and in-patient) would be interesting in that it would give a different viewpoint from the present figures derived from the inspectorates. The inspector’s figures are likely to be accurate in detailing the type of employment and the type of occupation, but much less reliable on the nature of the injury. The hospital statistics would be more accurate about the injuries than about the industry and occupation. At present statistics from those claiming industrial injury benefit form one kind of crosscheck with factory and other inspectorate figures. However, if one were to take amputation of the finger as an example, some patients so injured might appear in the factory inspector’s report, others might appear in the injury benefit statistics, yet there will be others who attend hospital and appear in neither of these categories. One can see the value of research with a computer record linkage system as suggested by the Medical Research Council in their evidence to the Robens Committee (Safety and Health at Work, 1972b). A linkage between casualty records and industrial injury benefit would be especially valuable, as hospital departments are often unaware of the time their patients are away from work after an injury. While statistics about patients referred from work to hospital may some day be nationally valuable, an exercise of this type is of much more direct use to the department and the hospital where it is carried out. The way in which this study originated is a good example. There had been no course for nurses in industrial medicine in Northern Ireland till 1974. When it was decided

Rutherford and Maynard

: Referrals from Work to Casualty

Tab/e X/U. Works accidents

231

: employers most frequently sending patients No. of patients

Employer Mackies (Textile machinists) Royal Victoria Hospital Belfast Corporation Michelin (Tyre factory) Harland Et Wolff (Shipbuilders) Post Office McLaughlin Et Harvey (Building and civil engineers) Bass Charrington (Brewery) Hughes Bakery Firms sending less than 5 patients Firms unknown Total

Tab/e X/V. Works accidents

% of all 343 patients

21 13 9 9 8 8

6.1 3.8 2.6 2.6 2.3 2.3

7 5 5 42 216 343

2.0 1.5 I.5 12.3 63.0 100

: occupations No. of patients

Occupations Labourer Fitter Joiner Butcher Clerk Machine operator Textile worker Cleaner From occupations sending less than 10 patients Total

% of all 343 patients

42 22 17 11 11 11 11 IO

12.2 6.4 5.0 3.2 3.2 3.2 3.2 2.9

208 343

60.7 100

Tab/e XV. Nature of injury in 4 occupations Occupation

Fractures

Wounds

Abrasions

Contusions

(63?6%)

(Or&

(2733%)

(0;)

(A%)

(7.1346)

(4Y5%)

(1463%)

(2?2%)

(0;)

(4.i%)

(9.l2%)

(40?9%)

(9.?%)

(225I%)

(0;)

(18p2%)

(4781%)

(1128%)

(2345%)

(5A%)

Sprains

Burns

Other

Butcher (0:)

(0:)

Labourer (7.:: %) Fitter A) Joiner (1128%)

to start one, the doctors

(0;)

and nurses of the casualty department of the Royal Victoria Hospital were asked to help. By analysing the accidents and emergencies referred from work, it was possible to select topics of importance. It helped us in the preparation of our lectures, and we gained insight into this component of our work which we had never had before.

CO”%)

Some large firms have highly organized medical departments, and they can investigate and monitor accidents in their own units. But there are also many people who work in places where there is no medical staff. Butchers’ shops are dangerous places, but have no organized medical services. The hospital’s injury figures might offer a useful basis for investigating the causes and

232

Injury

possible preventive measures in such situations. The Robens Report refers to the necessity of a multi-disciplinary approach to accident safety (Safety and Health at Work, 1972a). It seems obvious that those who run the accident services should play their part in this. Yet until these people understand the industrial component of their own field, it is unlikely that they will be able to make any valuable contribution.

Journal

of Accident

Surgery

Vol. ~/NO. 3

perhaps on a national basis. Casualty statistics can be useful in the development of expertise within the medical services. The staff of accident services should play their part in a multidisiplinary effort to reduce the mortality and morbidity of works accidents.

RUTHERFORD W.

This pilot study has demonstrated certain difficulties and weaknesses in the collection of some items of information concerned with works illnesses and accidents. Further study is required to see whether these difficulties can be overcome. Statistics from casualty departments cannot alone give the kind of quantitative information required for monitoring the effects of safety procedures. Statistics of in-patients through hospital activity analysis could give important information on the more severe industrial injuries, for reprints

British

REFERENCES

CONCLUSION

&&ysts

: the

H.

and

MAYNARD J. S. E. (1975)

An Information Retrieval System for the Accident and Emergency Department. Belfast, Royal Victoria

Hospital. Safety-and

Health at Work (1972a) Report of Robens

Committee

1970-72. Cmnd 5034. London. HMSO.

Safety and Health at Work (1972b) Report of Robens

Committee 197G72, vol. 2, Selected written evidence. London, HMSO. SHIPP P. J. and SUTTON A. S. (1972) A Study of the Statistics

relating

to Safety

and Health

at

Work,

chap. 4, p. 25. Research paper of Committee Safety and Health at Work. London, HMSO.

on

should be addressed to: W. H. Rutherford,OBE, FRCS, Royal Victoria Hospital,GrosvenorRoad, Belfast,BT12