Close call

When Hyder’s new OH team came on board at the water business, they
identified their first call of duty as setting up a confined space medical
procedure.  By Caroline Whittaker and
Jenny McCarthy

Hyder occupational health department was set up in late 1998.

Senior adviser Caroline Whittaker and practice nurse Jenny McCarthy were
given the remit of developing an occupational health department able to meet
the operational requirements of a large multi-utility and to provide employees
with a proactive, coordinated approach to occupational health.

Hyder – which translates as "confidence" in Welsh – had been in
existence for over two years and was the result of a merger between Welsh Water
and South Wales Electricity. The utility employs about 5,600 personnel employed
in various roles throughout Wales.

The utility is divided into three main functions: Operations – manages all
operational activities, associated with the supply of fresh water, waste water,
sewerage, electricity and gas to customers throughout Wales; Services –
provides customer training, IT, and transport; and Markets – competes in the
utilities supply market.

A further 4,000 staff are employed in three additional divisions: Hyder
Infrastructure, Hyder Consulting and Hyder Industrial. This part of the company
was not originally included in the provision of the occupational health
service. But with the recent introduction of service level agreements
throughout the business, the department is now being extended to them.

Fit for work

The health of Hyder’s employees was seen as a key resource in meeting the
company’s challenge of creating a "world class" organisation. The OH
department was initially awarded a year’s contract to demonstrate to the
organisation the benefits and cost effectiveness of developing an in-house
service.

Being well aware of the tight time frame, the department set about proving
their worth and Whittaker and McCarthy began to travel extensively to locations
around Wales. Their aim was to raise the profile of OH among staff, as
Whittaker says, "to tell them we were here". It was also crucial that
the department gained an insight into the culture and needs of the business and
to identify key areas that would make the biggest impact.

The pair set about transforming the administration of the department. A
computerised OH database was installed which would manage a recall system and
allow analysis of health trends within the organisation.

A critical needs analysis of the business was also undertaken and presented
to management within the first three months. This pointed to two main areas:
attendance management and confined space medicals. The first, as Whittaker
explains, was not an area in which the team could have demonstrated any
short-term benefits given their limited resources. "I did not want to put
all our resources into something where we would be unable to quickly
demonstrate our worth," she says.

With the introduction of the confined space regulations in 19971, however,
the second key area was a particularly pertinent issue for all operational
staff employed within the water and electricity side of the business – some
1,500 staff.

The regulations define a confined space as "any place, including any
chamber, tank, vat, silo, pit, trench pipe, sewer, flue, in which by virtue of
its enclosed nature, there arises a reasonably foreseeable specified
risk".

Various medical officers used by the company were charging Hyder between £50
and £100 per medical and with a company requirement to carry out over 500
medicals per year, this represented a cost of £25,000 to £50,000 a year.

It also became apparent that the diversity in the professional expertise and
medical criteria they were using, was leading to inconsistencies in the medical
approach to the assessment.

The confined space legislation 1997 is relatively new, so little is known
and written about the subject, particularly in relation to aspects of employee
health and fitness to work.

This led to the OH department questioning whether the current medical
criteria were appropriate.

The aim

To develop a new medical and procedure for confined space work, which would
not only set a corporate medical standard, but would also encompass an element
of health education and promotion for employees. This approach would ensure
consistency across the business and importantly allow an opportunity for the
department to demonstrate the quality and cost savings to the business of the
medical being carried out by the occupational health nurses.

The plan

Part of the investigation was to gain a better understanding of what working
in a confined space entailed. To further their awareness of the health
requirements for work in confined spaces, the OH nurses attended a company
training course.

Ideas for developing new criteria began to form. To assist with this
process, agencies were contacted, ranging from The Water Services Association,
to Emas, the local authority, and the Public Health Laboratory. The Hyder
health and safety team was also consulted for advice and guidance, as well as a
senior occupational health physician.

Whittaker felt that the range of tests and referral criteria to be used in
medicals should be set for the OH nurses. This would provide clear guidelines
and would ensure a consistent approach. The procedure could then be audited to
ensure high standards of care.

Once the information had been received it was assimilated in a format which
would provide the department with the clinical information required to make a
judgement on a person’s capability to perform confined space work. This
included a health questionnaire and a range of clinical tests to be undertaken
written into a nurse procedure.

It became clear that the medical examination of the employee must be carried
out prior to the employee’s training every three years. Due to the physical
demands of the job, the medical would also be carried out annually for rescue
workers and employees over the age of 50 years.

A number of NHS trusts and organisations were contacted to gain a general
picture of what departments were charging other agencies for their services.
The medical then had a cost applied, which included the expense of moving the
mobile health screening unit.

This information was then loaded onto an Excel database. In this way the
cost saving could be demonstrated in the monthly OH activity report to senior
management.

Review

The medical procedure was put on trial and a number of minor adjustments made
to the questionnaire. For example, a new question was added, which specifically
asked about knee problems. The OH database was altered to take account of these
changes, enabling more information to be gleamed for producing OH reports for
the directors. For example, the number of employees who smoke, cholesterol
levels within the workforce, levels of hearing and so on.

Evaluation

Initially, the confined space medical was carried out during the morning,
allowing for reflective practice during the afternoon.

Schon2 differentiated between a reflection that follows action and that
which occurs during action. The latter may range from informal, mental
assessments of practice to the systematic, formal assessment of practice
outcomes, for example thinking on one’s feet, difficult for practitioners to
articulate3.

The reaction from operatives and the managers to date has been very
positive. Comments included "it was less intimidating than going to the
doctor" and "we never had all these excellent tests before".

The most common point made was the fact that the medical has taken into
consideration each part of their work in confined spaces. It was also well
received that the nurses had been on the confined space training course to
appreciate what the employees go through.

A formal audit tool is being developed. But because of the lack of resources
and the fact the system has been in place for only nine months, this will be a
target for this year.

Conclusion

The implementation of the confined space medical has taken much longer than
first expected, with much research being required before formulating the
"Fit for Work" procedure.

The liaison with outside agencies has proved fruitful and has allowed the OH
department the opportunity of building up outside contacts.

As confined space legislation is a relatively new concept to the business,
the instigation of new procedures for confined space working has involved
occupational health, managers, employees and the health and safety department.
A collaborative approach between the above parties has allowed the department
to make a rapid favourable impression upon the business and has meant that:

– Communication levels have been quickly raised between the occupational
health department and other parts of the business.

– The OH profile within the company has been raised and the benefits of OH
acknowledged.

– Managers have been appreciative and receptive to the professional and
efficient way the medicals have been carried out, all good from the aspect of
good public relations.

– Employees have welcomed the chance to give feedback on the medicals and
have found communication with the nurses easier than with a medical officer.

– The department has been able to demonstrate to the firm that by carrying
out the medicals in house, there are considerable cost savings to the business.

Review of the format the medical takes is an ongoing process. The format of
the questionnaire will be under constant review and the test procedures
upgraded where necessary. This is an important part of continual monitoring and
evaluating procedures.

Many employees within the group require Fit for Work assessments for other
jobs. Once the programme has been running for a year, the confined space
medical will be evaluated. Discussion is already centred on whether the name
should be changed to "operational medical" which will then encompass
a whole range of operational activities.

"In any business you have to be able to deliver what you set out to do
or you can quickly lose all credibility," says Whittaker, "therefore
targets have to be attainable".

Baseline tests

– BP height weight urinalysis – cholesterol levels were not necessary
for the medical, but the employees drove the introduction of this, as they were
keen to know their levels. This was seen by the OH department as a way of
opening up discussion around promoting a healthy lifestyle. This simple test is
offered to those who have high blood pressure, smoke or who request it. But all
staff actually request the test to be undertaken.

A body mass index of over 30 was not only an issue for the general health of
the employee, but because some of the confined spaces the employee is asked to
enter are very small and restrictive, a medium to small frame is beneficial.
The body mass index, which is calculated by the height/weight for men and, puts
a BMI of 26 just inside the "healthy" category, therefore a BMI of 30
makes an acceptable allowance.

– Spirometry – carried out because of the employee being exposed to
micro-organisms from breathing aerosols or dust. Pathogens may enter the body
by inhalation of the following:

Dust from dried sewage sludge – although the processing of sludge and in
particular thermal drying will substantially reduce the pathogen count; fine
mist or aerosol produced by activated sludge tanks, turbulent sewage flow, the
action of wind on the surface of open sewage tanks, distribution arms on filter
beds and high pressure water-jetting of contaminated surfaces.

Dead organisms can also cause health problems. Because they contain proteins
that are foreign to the human body, they may cause allergic reactions, like
occupational asthma and alveoli’s, if inhaled into the lungs repeatedly.
Inhalation of poisons called endotoxins may also cause illness".

Spirometry can also be used as a helpful health education tool. For those
who smoke the results can show the employee any damage that has been done by
smoking.

This can be particularly revealing on the FEF 25 to 75 per cent. The act of
smoking can pose a problem when holding the butt close to the mouth with
unwashed hands. As the ingestion of micro-organisms can cause diarrhoea in
sewage workers.

– Eye test – vision of at least 6/60 without spectacles is necessary.

– Audiometry – carried out due to the use of generators within the
plant, but adequate hearing is also a necessity for communication and listening
for danger signs such as rushing water.

– Step test (Chester Step test) – is carried out to assess fitness
levels and joint movements. It also invites conversation about how employees
keep fit. Some of the operational depots within Hyder have a gym and as part of
health education the benefits of the facility on site are emphasised.

Further reading

Access to Medical Report Act (1988) HMSO. London.

Control of Substances Hazardous to Health (1994). HMSO. London.

Croner (1988) Handbook of Occupational Hygiene Croner Publications Ltd.
London

Health and Safety at Work Act 1974

Hawkins L (1992) Cholesterol Countdown Occupational Health Vol 44, No 10, p
291

HSE (1998) 5 Steps to Risk Assessment. HMSO.London.

Hyder Health and Safety Department (1999) Confined Space Procedures Hyder
1999. Cwmbran. South Wales.

London Electricity (1993) Leptospirosis. London Electricity PLC, p 93.

Management of Health and Safety at Work Regulations (1992). HMSO. London

Manual Handling Regulations (1996). HMSO, .London

Marchant C. (1992) A fresh Start Occupational Health Vol 50 No 4, pp 16-19

Harrington JM, Gill F. S (1987 Occupational Health 2nd Edition. Blackwell
Scientific. Oxford.

Polit DF, Hungler B. P (1995) Essentials of Nursing Research Method,
Appraisal and Utilisation 5th Edition J.B Lippincott. USA.

The Construction (Health, Safety and Welfare) Regulations (1996). HMSO. London.

The Department of Health (1995) Standing Nursing and Midwifery Advisory
Committee. London Workplace Health and Safety and Welfare Regulations (1992).
HMSO. London

References

1. Confined Space Regulations (1997). HMSO. London.

2. Schon (1983) Reflective Practice in Oakley (1997) Occupational Health
Nursing. Whurr Publishers Limited. London.

3. Oakley K. (1997) Occupational Health Nursing. Whurr Publishers Limited.
London.

4. Water Services Association (1995) Guidance on the health hazards of work
involving exposure to sewage. Sheffield.

Devising the health questionnaire

The nurses centred on developing a forward-thinking occupational health
department which would not only meet the needs of legislation, but also address
the employer’s business needs. Individual employee’s requirements also needed
to be met and elements of health assessment and health promotion included.

The health questionnaire was designed to incorporate relevant health
information and health education and was well researched. It asked relevant
past and current medical history and also incorporated health advice.

Medical interview

With reference to the medical questionnaire, questions were asked about:

– Alcohol consumption and substance abuse – an ever increasing
problem within the workplace. Some 11 per cent of all injuries sustained in the
workplace are substance-related and 60 per cent of fatal accidents at work are
alcohol-related (BMA/HSE).

– Circulatory disorders – caused by cold and damp environments the
employees are called to work in, in particular they may strike those who suffer
Raynaud’s disease.

– Claustrophobia – A condition employees may not be aware of
suffering and very difficult to ascertain at a medical. Confined space training
course usually uncovers sufferers.

– Hand and arm vibratory syndrome (Havs) – a large number of the
operations staff have used vibratory tools in their working history and it was
beneficial for the department to gain a base line in view of the risk.

– Hernia or rupture – relevant due to the cramped, conditions that
employee may be working in. It is conceivable they may be asked to carry out
quite a strenuous task hence putting extra strain on any weaknesses they may
have.

– Hygiene – for anyone working in a confined space the main health and
safety advice will apply to good hygiene. It is important to remember to wash
hands before and after going to the toilet and prior to eating and smoking.
Personal protective equipment is also an essential part of health education,
due to members of the public disposing of used needles and syringes via the
waste water treatment works.  

– Recurrent diarrhoea or any chronic bowel disease – all Welsh Water
operatives have to be aware of the dangers of leptospirosis and are issued with
a "leptospirosis card" that they carry with them, in the event of an
unexplained illness. They are informed at the medical interview that if they
have recurrent diarrhoea or flu-like illness or fever they must report their
illness to their supervisor and go to see their GP. There is a question also
asked about any history of jaundice, again with leptospirosis/ hepatitis in
mind.  

– Sinus problems which may affect sense of smell – the relevance of
this is somewhat out of date, as all employees now carry gas monitors in a
confined space. Following discussions with the health and safety manager, it
was agreed that a greater sense of awareness is needed and a general alertness
to their environment rather than relying on a sense of smell.

– Joint or back pain – must be investigated, because of cramped and
damp working conditions.

– Skin conditions – These can be aggravated by the variance in
temperature and climatic conditions in a confined space.  If the skin is cracked it could if not
covered allow micro-organisms to enter the skin and cause septic lesions. It is
also more difficult for employees with chronic eczema and dermatitis to wear
the correct personal protective equipment. Open wounds and cuts should always
be covered with a waterproof dressing.

Fitness test

The standard of fitness required for confined space training is extremely
high, as they often have to work in tight spaces, crawl along dark subways and
climb up and down ladders. Employees may also have to carry a large amount of
personal kit; therefore the medical must ascertain certain fitness levels. This
was achieved by incorporating the recognised Chester Step Test.

Health advice

The OH department aims to review the vaccination status of employees and is
keen to implement an in-house vaccination programme. However at the present
time with the limited resources this is not possible. Employees are, however,
advised to be immunised against the following diseases:

– Poliomyelitis – an acute illness following invasion of the
gastro-intestinal tract.  Transmission
is through contact with the faeces or pharyngeal secretions of an infected
person.

– Tetanus – an acute disease characterised by muscular rigidity with
superimposed agonising contractions. Tetanus spores are present in soil and may
be introduced into the body during injury, often through a puncture wound, but
also through burns.

– Typhoid fever – spread by the faecal-oral route, usually through
contaminated food or drink with the excreta of a human case or carrier.  

– Hepatitis A – an organism fairly common among the general
population. There is no clear evidence that contact with sewage increases the
risk of infection, but until further research is carried out within the water
industry vaccination cover is advised.  

– Hepatitis B – this virus can survive for up to one month in dried
blood and the quantity of blood required to transmit the disease is only 0.4ul.
It is therefore prudent to take reasonable steps to prevent accidents, such as
needlestick injuries from discarded hypodermic needles.

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