The Covid-19 menace has brought into light the extreme vulnerability of health care workers (HCW), particularly the direct patient care providers in Bangladesh and beyond. HCWs face frequent workplace stressors: patient lifting and transfers leading to upper or lower extremity injuries; sharp injuries and splashes exposing blood/body fluids that may contain HIV, hepatitis B and C virus among others; exposures to chemical agents; work-related anxiety and depression; and workplace harassment and violence. Worker injury rates in the healthcare industry in Canada and USA have been reported to be consistently higher than the average rate in many other employment sectors. In Bangladesh, there are additional risk for them associated with higher patient overload, understaffing, poor ratio of support staff and direct care providers (nurses and doctors), meagre supply of and accessibility to assistive or supportive equipment and tools, unhygienic working conditions, long working hours, widespread harassment and abuse by owners or managers, colleagues, and patients and their family members or relatives.
The aging of patients, rise in prevalence of chronic health conditions and the very complex work nature and environments inside hospitals further complicate HCWs' work-life. Covid-19 underscored the need to develop and implement a comprehensive surveillance system that tracks occupational exposures and stressors as well as injuries and illnesses among healthcare workers particularly in Bangladesh where the healthcare delivery system has always been suboptimal.
Many work-related injuries are not reported in Bangladesh to the authorities because of discouragement by supervisors and co-workers, procedural complications, unawareness regarding the need to report, job insecurity, casual work status, degree of severity of injuries, and social or professional stigma. Previous research in the garment sector focusing on the North American (e.g., Alliance) and the European (e.g., Accord) led worker helpline initiatives showed that workers seldom report their concerns despite extensive efforts and training by the Western retailers.
The surveillance of work-related injuries and illnesses of HCWs is vital for hospital and health facility managers, health and safety professionals, and investigators, trainers and educators to develop injury/illness deterrence policies and programmes. Such a system involves the documentation and categorisation of a variety of work-related exposures and stressors that comprise chemical, biological and physical agents and ergonomic hazards. The surveillance of occupational injury makes it possible to estimate the magnitude of a problem; describe injury trends; design, implement and evaluate preventive programs; advance knowledge of injury among health professionals, policy-makers and the workers; and recognise research needs.
Medical reports, hospitalisation records or prescription copies represent important sources of information on work-related injuries or illnesses. In addition to these, other passive surveillance data sources have been explored, but these after-the-fact data may not be that useful to act to prevent future injuries and illnesses proactively. These can help create some lagging indicators; however, leading indicators based on real-time and updated data are needed on an ongoing basis so that major losses can be prevented.
To develop and implement a comprehensive system for health, injury and hazard surveillance for healthcare workers in Bangladesh, an illustration of a similar system from another country along with practical applications and research potential of the system that has a focus on incident tracking may be useful.
First the employer should conduct reviews on the injury management needs of a hospital or facility and identify the key modules to capture injury data and then have a system to translate injury reports and payroll data into preventive efforts. The goal should be to capture and report on detailed injury trends which can be applied by interventionists to identify information for return-to-work and disability management programs, evaluate effectiveness of preventive programs, and conduct health and safety assessments.
A similar system developed and implemented in British Columbia, Canada has five modules: Incident Investigation, Case Management, Employee Health, Health and Safety, and Early Intervention/Return to Work. The Incident Investigation Module identifies the causes and details of each incident that can later be linked to the Case Management Module. The Employee Health Module is important for tracking the health of each HCW to develop disability management programs. The primary and secondary Prevention Modules are used specifically for musculoskeletal injury incidents, which constitute the greatest proportion of injuries for HCWs and result in high insurance compensation costs. The Health and Safety Modules are used for risk assessments with respect to specific tasks.
The next steps of an employer should be to include the development of specific workplace assessments. To enable the analysis and production of macro level reports, the hospital should create a database to merge data from each wing, facility, floor or department. This is commonly known as a data warehouse and can be used as a repository to hoard all historical data. This warehouse will allow for multidimensional analysis and comprise data from incident reports, payroll and insurance claims costs. The adding of payroll data (e.g., working hours) permits for more accurate reporting, such as injury and incident rates. Payroll/human resources information contains employment status (casual, full time, part time, etc.), job start date, hourly rate, pay period start and end date, pay type (hourly, salaried, etc.), sick leave, work disability hours, casual leave, overtime hours, etc. To expedite the amalgamation of data, a programmatic mapping table needs to be created to systematically group departments or occupations. A data mapping process should be used to chart occupations and departments.
Such a surveillance system requires cautious attention regarding the security of confidential data including personal identifiers (name, date of birth, national id number, and employee id number), insurance claims details, and health records (e.g., immunizations, exposures). Use of encryption at multiple security levels is needed. Users of the database should be limited in number and meet certain eligibility requirements.
This database will be convenient for descriptive studies, monitoring health risk factors, benchmarking, and evaluating programmes. Such a health surveillance project requires the use of data collected through various departments, managers within each department. Teamwork with the human resources department is critical as the personnel level data required to define the populations-at-risk are collected through this department. A set of performance indicators can then be developed for healthcare employers in addition to conducting cost-benefit and effectiveness analysis of ongoing health and safety initiatives.
The patterns of injury incurred over time will assist developing appropriate interventions to target high-risk areas and reduce the human and financial costs of preventable injuries within the hospital. Findings from the descriptive, analytical and prevention evaluation studies using this database can be ideally generalised for broader application to other industrial settings in Bangladesh.
Hasnat M Alamgir is a Professor of public Health. hasnat.md.alamgir@gmail.com