The HSE Quarterly Issue 26

elcome again!

I recently came across a quote by Sir Brian Appleton, when he commented after the Piper Alpha disaster. I had read it before but it took on a new meaning in the context of this issue on Safety Management. Sir Appleton said “Safety is not an intellectual exercise to keep us in work. It is a matter of life and death. It is the sum of our contributions to Safety Management that determines whether the people we work with live or die”.

There are many definitions for Safety Management some of them are industry specific while others focus on the process that the system is used to manage. This issue focuses on Safety Management, which can be defined as a systematic and explicit approach, outlining the activities undertaken by an organisation to achieve acceptable or tolerable safety. Recent studies point out that most accidents occurring at the workplace stem from human errors.

Nevertheless, these accidents cannot be eliminated by changing people. As a result, Safety Management is the most effective approach to guaranteeing safety in the work place.

I invite you to explore the topic with us as you read the very informative articles on Safety Management . The feature article is written by Colin Gaskin, Senior Inspector at the Occupational Safety and Health Agency (OSHA), and it explores the development of a Health and Safety Assessment Scheme for Trinidad and Tobago. I also draw your attention to an intresting Eye Care series article entiled Safety in the Workplace by Danny Jones of Value Optical Ltd. As we keep road safety in focus we thank all those persons who supported the 6th Regional Road Safety Conference in Tobago. During the conference several sobering statistics were presented on the effects of road safety on Tourism in the Region. We heard about the increase in fatalities in some Caribbean countries and the efforts of others to combat the growing epidemic that is road traffic fatalities. I again urge you to drive defensively on the roads.

I take this opportunity to thank our contributors, advertisers, our editorial board who continue to give freely of their time and expertise. Finally I thank the hard working production team who in spite of economic challenges continue to ensure the publication is always on time. I look forward to your continued support.

Thank you.

Janice Smith Editor-in-Chief

October 2014

Contents 7.

CHASTT: A Contractors Health & Safety Assessment Scheme for Trinidad and Tobago

11. Measuring the Eectiveness of Safety Management Systems

20. Eye Care Safety Series At a Glance Part 1: Safety in the Workplace

25. Indoor Environmental Quality: What Does it Mean to You?

31. The Asthma Epidemic 39. Simple Headaches or Giant Cell Arthritis?

41. Safe Management of Pressure Ulcers 49. Regional Road Safety Conference 2014 9 & 10 September,2014 Scarborough,Tobago

PUBLISHER Jaric Environment, Safety and Health Services Limited.

EDITOR IN CHIEF Janice Smith EDITOR Appleloniah Kipps EDITORIAL BOARD Kandiss Edwards Dr. Anthony J. Joseph Eric Kipps Devitra Maharaj-Dash Magdalene Robin WRITERS Chad E. Lue Choy Cherma St. Clair Colin Gaskin Danny Jones Eric Kipps Eric Kipps Jr. Linda Sheridan

CREATIVE DIRECTOR Kenneth Henry GRAPHIC DESIGNER Stefan Francis PHOTOGRAPHY Chad E. Lue Choy (ESIB) Eye Surgery in Berkshire Shutterstock Google Images BUSINESS ADDRESS The HSE Quarterly Lot 5B Trincity Industrial Estate, Trinicity Email: thehsequarterly@jaricesh.com Website: www.jaricesh.com The opinions expressed in the HSE Quarterly do not necessarily reect those of the editor, publishers or their agents.

Achieving and maintaining a sustainable framework to promote good Occupational Safety and Health (OSH) practices must be a collaborative effort among all stakeholders. Clients, inclusive of the state, must recognise their responsibility and adhere to the highest standards of procurement practice; specifically this should include ensuring the OSH competence of contractors recruited for projects. Prior to an appointment, an assessment of a firm’s organisation and arrangements for safety and health in addition to

their experience and track record must be adequately conducted. Good procurement practice also mandates that the experience of the contractor match the complexity and associated risks of the project. The Occupational Safety and Health Agency of Trinidad and Tobago (OSHA) has noted that contractor pre-qualification criteria for projects often exclude the necessary elements to ensure that the project is completed in a manner consistent with good OSH practices. Often flaws in the system and deficiencies in the procurement mechanism lead to firms of questionable competency being awarded contracts with inevitable poor management of projects, cost/time overruns and unfortunately in some instances, critical injuries and fatalities on worksites. Moreover, even if a contract is awarded to a principal/main contractor through a rigorous tendering, screening and selection process, the principal contractor subcontracting work without adherence to similar measures will logically undermine initial control measures and provide avenues for incompetence.

Previous initiatives by OSHA to promote contractor safety systems and practices include a contractors’ symposium “Small Steps to Big Change: Transforming the Workplace, Changing the Culture” held in 2009 during the construction boom to educate, inform and sensitise small contractors and self-employed persons to critical OSH-related matters. In 2011, a three-day national construction symposium and trade show “Constructing Steps to the Next Level of Safety: Beyond Compliance to Excellence”, was also hosted by OSHA as a proactive effort towards fostering a balance between economic development and Decent Work; it included a series of lectures by local and international experts and live demonstrations of safe work practices by major firms. These initiatives were in accordance with Articles 5 and 9 of the ILO Convention 81 (C81), which recommends engaging technical experts and specialists in the protection of the health and safety of workers. C81, ratified by Trinidad and Tobago on August 17, 2007, also requires the supply of information and advice to employers and workers concerning the most effective means of complying with legal provisions.

Through the Safe To Work (STOW) initiative introduced by the Energy Chamber in 2006, uniform pre-qualification requirements and an independent certification scheme were created, promoting consistency in HSE management systems for contractors in the energy sector. Operating oil and gas companies can consequently be assured of a certain level of HSE commitment by service providers prior to the award of a contract. There is no national scheme, however, to ensure that purchasers across Trinidad and Tobago, inclusive of those involved in procurement on behalf of the state are assured a similar level of OSH competency from contractors offering their services nationally. To bridge this gap Trinidad and Tobago can pattern the Contractors Health and Safety Assessment Scheme (CHAS) developed in Great Britain in 1997. CHAS is a national database of contractors who have been subjected to a safety and health assessment and have demonstrated adequate compliance and management standards. They are therefore approved to work on contracts (subject to approval of other factors, including financial integrity). The assessment scheme is dedicated to completing health and safety pre-qualification assessments to a nationally recognised and accepted threshold standard. Unlike STOW, CHAS can be applied throughout the state and across all industrial sectors.

Several contractors and consultants (suppliers) frequently apply for work with public and private sector organisations (buyers) and are required to meet the health and safety standards of the latter. The rationale for CHAS is similar to STOW; assessing the health and safety competence of a supplier is usually a lengthy and time consuming process.

Further, suppliers satisfying the OSH standards of one buyer may not necessarily meet those of another. CHAS approval reduces duplication as the supplier compliance will be accepted by all CHAS buyers as a standard set of health and safety compliance criteria is provided.

As indicated at www.chas.co.uk the following three stages are described to assess supplier competency, “from the time a supplier applies for a CHAS assessment, through to working for a buyer: The CHAS assessment: if a supplier passes this assessment they have demonstrated that they can adequately manage health and safety.

The employer (buyer) checks that a potential supplier has the ability, experience and resources to carry out the specific work they have applied to do. The buyer will consider criteria such as method statements, specific risk assessments, references, examples of previous similar work, training and available resources.

Monitoring the supplier when they are doing the work.

Buyers will check that suppliers are managing the work safely, carrying out the method statements properly, have enough resources, liaising suitably, managing the site effectively and providing adequate supervision.”

In accordance with the scheme, the level of assessment at stages 2 and 3 are normally proportionate to the level of risk involved.

Implementation of CHASTT The implementation of a “Contractor Health and Safety Assessment Scheme of Trinidad and Tobago” (CHASTT) will be an ambitious undertaking. Similar to the STOW scheme, CHASTT will also reduce the excessive costs caused by pre-qualification duplication, but on a national level. It is also recognised that some prospective buyers do not have the necessary skills or resources to undertake supplier assessments. CHASTT approved contractors will be subjected to a safety and health assessment consistent with the requirements of the Occupational Safety and Health Act No. 1 of 2004, as amended by the OSH Act No. 3 of 2006, relevant OSH regulations and will have to demonstrate

adequate compliance with management standards. To ensure effectiveness CHASTT must be made compulsory and even supported by legislation to adequately address the shortcomings experienced nationally regarding the incorporation of OSH into procurement processes. The effectiveness of STOW in Trinidad and Tobago is due to the mandatory requirement of STOW certification via the STOW Charter; the Energy Chamber and participating companies in the energy industry ensured that it is obligatory that contractors be STOW certified prior to working with those companies who are signatories to the Charter.

Registration and Licensing of Contractors A single national register for all contractors operating in Trinidad and Tobago is recommended to support a CHASTT initiative. Registration and licensing of contractors would be pivotal in raising the performance bar for contractors operating nationally, furthermore transparency, accountability and efficiency would be positively affected.

The Trinidad and Tobago Contractors Association recognises the value of contractor registration and licensing and has been engaged in an exercise with the Ministry of Works and Transport (now the Ministry of Works and Infrastructure) for the establishment of a legal framework to give effect to this. A single register, similar to “Constructionline” of the UK, backed by legislation will support a CHASTT initiative and provide a platform to incorporate the OSH element of pre-qualification.

In procuring contractor services via CHASTT there will be a greater assurance of a reasonable and robust judgement prior to the award of a contract; the contractor’s organisation and arrangements for safety and health will be assessed in addition to their experience and track record. Most significantly this scheme will apply to contractors providing their services throughout Trinidad and Tobago.

Over the last twenty years Safety Management Systems have become common place in many industries around the world; Trinidad and Tobago is no exception. There are now more Safety Management Systems in place and available than ever before. Yet little is known about the eectiveness of these systems on employee health and safety and on relevant economic outcomes.

This article seeks to investigate three key issues which can have an impact on the issue: 1 What is the relative effectiveness of Safety Management Systems on employee health and safety and associated economic outcomes?

2 What enablers and barriers are there to the adoption and the effectiveness of Safety Management Systems?

3 What is the evidence on the cost-effectiveness of Safety Management Systems?

In trying to answer these questions the first challenge is the lack of consensus on the definition of a Safety Management System and how it might be distinguished from other occupational health and safety programs. For example The Health and Safety Executive in its definition says that “A Health and Safety Management System can be defined as ‘the means by which an organisation controls risk through the management process’. The British Standards Institution defines a Safety Management System as the ‘part of the overall management system that facilities the management of the occupational health and safety (OHS) risks associated with the business of the organisation. This includes the organisational structure, planning activities, responsibilities, practices, procedures, processes and resources for developing and achieving, reviewing and maintaining the organisation’s OHS policy. Additionally the International Labour Organization (ILO, 2001): defines it as “A set of interrelated or interacting elements to establish OSH policy and objectives, and to achieve those objectives.”

After reviewing the many definitions available, the following definition by Robson (2005) will be used for the purpose of this article. Robson said that “A Safety Management System is the integrated set of organizational elements involved in the continuous cycle of planning, implementation, evaluation, and continual improvement, directed

toward the abatement of occupational hazards in the workplace. Such elements include, but are not limited to, organizations’ OHS relevant policies, goals and objectives, decision-making structures and practices, technical resources, accountability structures and practices, communication practices, hazard identification practices, training practices, hazard controls, quality assurance practices, evaluation practices, and organizational learning practices.”

From the definitions above it is clear that Safety Management Systems are generally distinguished from traditional occupational health and safety programs by being more proactive, better internally integrated and for incorporating stronger elements of evaluation and continuous improvement.

Some Safety Management Systems documents (e.g., ILO, 2001; Chemical Industries Association, 1995; HSE, 1997) explicitly ascribe their basic source as the Plan-Do-Check-Act model of continuous quality improvement that W. Edwards Deming introduced to the management field (Tartorella, 1995).

Many Safety Management Systems involve the following continuous cycle:

Plan (i.e., goals, objectives, standard-setting, accountability, etc.)

Do (i.e., implementing organisational processes like training and joint-health-and-safety-commit tee meetings), Check (i.e., evaluate through injury statistics reviews, inspections, root-cause analyses, audits, etc.), and Act (i.e., based on the evaluation results, make changes to improve the SAFETY MANAGEMENT SYSTEMS and its effectiveness).

The four steps Plan, Do, Check and Act should be repeated over time to ensure continuous learning and improvements in a function, product or process.

In contrast, traditional safety management programs can be characterised as having relatively little in the Check and Act domains. Furthermore, action tends to be reactive in response to workplace accidents, legislation, or enforcement, rather than proactive. Redinger and Levine (1998) gave detailed consideration to what constitutes a safety management system in their research.

Controversy Surrounding Safety Management Systems There are several areas of controversy regarding safety management systems.

For instance, there is concern that safety management system strategies, which foster self-regulation of occupational health and safety by workplaces, will weaken the external regulatory approaches developed to date (Bennett,

2002). Indeed, there is evidence that authorities view Safety management system strategies as a means of saving on the costs of enforcement (Frick and Wren, 2000, p. 40). In addition, Quinlan and Mayhew (2000) argue that the current labour market trends towards precarious employment, outsourcing and subcontracting suggest that mandatory safety management system strategies will not affect substantial portions of the population. The corresponding growth of smaller organisations means that workplaces will be more difficult to reach through either voluntary or mandatory initiatives. It is also thought that the ability and motivation for employers to undertake health and safety innovations will be weakened, due to the complexity of modern organisations and the lowered degree of responsibility they have towards some workers. It is also predicted that as union membership and leverage decreases, so will their influence over safety management systems and occupational health and safety in general.

needs; developed with stakeholder input; senior executives committed to occupational safety and health performance, willing to commit resources and make line managers accountable, and to lead by example; integration of safety management system operations and other organisational functions; encouragement for employee participation and independent employee representation.

He also cited barriers: failure to meet the abovementioned conditions, especially those involving manager commitment and employee involvement; inappropriate use of audit tools; specific contextual barriers, e.g. areas in which safety management system implementation is especially difficult, such as small business, part-time or temporary employment, or contractors. The overall conclusion by Gallagher et al.

(2003) is that although the evidence is “suggestive rather than conclusive”, it would seem that safety management systems can work, if/when a set of very demanding conditions are met.

Gallagher et al. (2003) emphasised some conditions he felt necessary for safety management systems to succeed: safety management systems customised to organisational

Research identifies three kinds of barriers to safety management system success. These relate primarily to the way that safety management systems are being implemented in organisations.

What Barriers Exist to Safety Management System Success?

Perhaps because of their increasing popularity, their introduction often occurs under inauspicious circumstances. The barriers are: Failure to meet necessary conditions for safety management systems success (by not customising systems to organisational needs, imposition without consultation, weak senior management commitment and poor employee involvement).

The inappropriate use of audit tools (where they become an end in themselves, are governed by misplaced management objectives, and are conducted without sound auditor skills, standards and criteria).

Application in hostile contexts (small business, precarious employment, contractors and labor hire companies).

The evidence from the consultations suggests that many applications of safety management systems are likely to fail for these reasons. One common concern is that safety management systems may then get a bad name as another ‘failed fad’. For this reason it may be necessary to address voluntary means to improve understanding in industry of the proper nature of safety management systems, of the necessary conditions for success (including senior management support and employee involvement), of the existence of a range of types of system for different settings,

and the necessity to customise workplace applications. The factors contributing to effective safety management systems and the barriers to effective safety management systems are summarised in Table 1.

Measurement and Evaluation There is now considerable evidence to suggest that quality management system interventions improve business performance if the right conditions are met. It is plausible to conclude that a similar approach to continuous improvement in occupational safety and health should pay off. There are also lessons to be learnt from quality management system about performance measurement. Occupational safety and health outcomes and safety management systems performance are not easily measured. The complexity of occupational safety and health is such that simple quantified measures are often inadequate and traditional incident/claims data has also proved unreliable. Whilst there is agreement on the need to improve basic injury/illness/claims data, the main need is to develop supplementary measures. In recent years, increased attention has been given to positive performance indicators and audit tools as measures of some aspects of safety management systems performance. However, such data can also prove difficult to interpret and to integrate. A Balanced Scorecard approach tailored to the special characteristics of safety management systems is advocated as an effective way of combining multiple measures, and reflecting different stakeholder interests in an operational occupational safety and health management plan.

Evaluating and Measuring Safety Management Systems Performance By way of comparison quality management is examined in this article as the challenges of evaluating effectiveness and performance measurement are similar to those confronting safety management systems. However, quality management has historically been evaluated more extensively than safety

area to the other, research upon the effectiveness and evaluation of quality management system may suggest indicators for safety management systems. Quality management originated in the 1920’s with the development of statistical techniques for assessing actual quality against standards. Over time a number of different approaches to quality management have evolved including quality control, statistical quality control, total quality control, quality assurance and total quality management (Nettle, 1995). A distinction is sometimes drawn between ‘hard’ techniques such as statistical analysis of quality variation, and ‘soft’ techniques. Total quality management is an example of the latter, emphasising social processes by which employees, often in teams, assume responsibility for monitoring and improving quality (Dawson, 1996).

Quality management system performance measurement relevant to occupational safety and health measures include the following: A hierarchy of measurement techniques may be identified spanning ‘robust’ and ‘persuasive’ tools. Whilst technically feasible, the former will be impractical and unnecessary in many businesses.

Traditional outcome indicators (financial and sales measures for quality management and Lost Time Injury Frequency Rates for occupational safety and Health) have well documented limitations in terms of diagnosing

problems and measuring motivating discretionary effort.

and

Multiple outcome measures are preferable to single measures, to balance various stakeholder interests (the Balanced Scorecard Approach) and to link internal efforts to external standards. Whilst internal measures may be customised to the organisation, external measures (Benchmarks) are more likely to capture common industry measures.

Employee involvement in the development of measures is widespread in quality management and serves to ensure the functionality and acceptance of KPIs. For these purposes, simple measures seem to be preferred.

In the occupational safety and health arena, widespread support exists for the use of Positive Performance Indicators to measure occupational safety and health performance. The principles on which PPIs have been developed appear to owe much to quality management innovations such as benchmarking, KPIs and the Balanced Scorecard approach (Worksafe Australia, 1994). It is not known to what extent quality management systems have grown in use to match the general use of benchmarking and KPIs. Trends in quality management performance measurement, as discussed before, have contributed to

a re-appraisal of performance measurement in occupational safety and health, in theory if not in practice. Of particular note is the trend away from reliance on traditional outcome measures towards a preference for multiple measures which can take account of various stakeholder interests and assist external benchmarking. Less attention has been given to the trend in quality management towards employee involvement in the development of measures. The discussion of quality management also draws attention to the differences between quality management and quality assurance, the former focused on empowered work teams and continuous improvement and the latter on external audit and accreditation.

Quality audits have a particular and limited role in the overall measurement of quality performance.

However, in the Occupational Safety and Health arena, audits of safety management systems appear to be assuming a larger and perhaps inappropriate role as a primary measurement tool. Generally, there are two main types of measures for evaluation of Safety management systems performance. First are the conventional outcome measures of incidents and compensation claims.

Second and more novel are Positive

Performance Indicators which may be developed on a workplace or industry basis, may involve employees and other stakeholders in the development of relevant measures, and may also monitor aspects of the management system.

Analysis of the effectiveness of safety management systems requires valid and reliable measures of system performance. The difficulties associated with measuring performance in occupational safety and health constrains both effective measurement of safety management systems performance in the workplace and the efforts of researchers to assess their worth. Most studies on safety management systems effectiveness have relied on ‘best available’ recorded injury or workers’ compensation data as the measure of performance despite acknowledged limitations on their use as objective evaluation criteria. The limitations of traditional outcome measures are well documented. At one level, the very nature of the worker’s compensation processes and systems limits the usefulness of claims data as a measure of performance. James (1993:34) for example, notes the considerable margin for error in the process of claims reporting and acceptance. Quinlan and Bohle (1991:20) note the omission of short-term injuries and illnesses and particular work-related illnesses from claims

statistics, the historical delays in recognition of particular injuries and diseases and resulting short-term bulges, in some systems the exclusion of populations such as the self-employed and subcontractors, and in others the lack of encouragement of these groups to participate in the compensation process.

Shaw and Blewett (2000:466) have detailed further limitations of injury/ill-health outcome data. First, they have particular difficulty measuring the effectiveness of control of high consequence, low probability risks. Second, they measure failure, not success. Third, they fluctuate at random. Fourth, they reflect the success, or otherwise, of safety measures undertaken in the past.

Fifth, they measure injury frequency and severity, not necessarily the potential seriousness of the incident.

Sixth, they conceal the range of other influences on outcomes. Finally, they focus attention on the individual worker, not the environment.

Conclusion In conclusion, as defined in a National Occupational Health and Safety Commission (NOHSC) publication

(1999a:4); Positive Performance Indicators focus on assessing how successfully a workplace or enterprise is performing through monitoring the processes which should produce good Occupational Safety and Health outcomes. Positive performance indicators can be used to measure relevant occupational safety and health systems, processes, management and compliance with occupational safety and health practices in the workplace. Examples of positive performance indicators include the number of safety audits conducted; the percentage of sub-standard conditions identified and corrected as a result of the safety audit; and the percentage of workers receiving occupational health and safety training.

The NOHSC publication goes on to identify the advantages of using process or positive performance indicators as: • The ability to measure and evaluate the effectiveness of occupational health and safety management.

• The provision of immediate feedback mechanisms regarding the management of occupational health and safety.

• The capacity to make immediate improvements if required.

A dilemma arises in the search for the best measures of occupational health and safety and safety management systems performance.

Most businesses would like simple, low cost measures – a single indicator or composite measure of performance.

However, occupational health and safety experts agree that no such measure can be completely adequate.

What this has shown is the scope for unreliabilty if each of the main alternatives – incident and claims data, PPIs, and audit – are used in isolation from each other. Most occupational health and safety experts agree that different measures need to be combined to give a satisfactory overall evaluation.

References Caple, D. 1996. Identification of the most effective methods for

disseminating known solutions across industries, Report to WorkSafe Australia, June, Sydney.

Dawson, P. 1996. Technology and Quality: Change in the Workplace, International Thomson Business Press, London.

Eisner, H., & Leger, J. 1988. The International Safety Rating System in South African Mining, Journal of Occupational Accidents, 10, 141-160.

Gallagher, C. 1994. Occupational Health and Safety Management Systems: Links with Performance, Paper presented at the Belts to Bytes, WorkCover, Adelaide.

Gallagher, C. 1997. Health and Safety Management Systems: An Analysis of

System Types and Effectiveness, National Key Centre in Industrial Relations, Monash University, Melbourne.

Health and Safety Executive .1991.

Successful Health and Safety Management, HMSO, London Kaplan, R., & Norton, D. 1996. The Balanced Scorecard: Translating Strategy into Action, Harvard Business School Press, Boston.

Nettle, D. 1995. The quality movement in Australia: Past and problems, Labour & Industry, 6 (3), 27-49.

Get familiar with your organisation’s Safety Management System (SMS). You cannot communicate what you do not understand.

Be visible. Your visible involvement in safety activities demonstrates this importance and motivates employees to take a greater interest in their own safety.

Set a positive example. Research shows that the manager's example sets the tone for the employee.

Make informal worksite visits a part of your routine. Frequent visits demonstrate a constant concern for safety.

Look for problems with equipment guards, access limitations, fall hazards, code violations, and other dangers associated with the environment of the worker, rather than just the actions of the worker.

Compliment people on their use of safe work practices.

Be accessible to workers. They should be able to ask you questions and make informal comments about safety issues and concerns.

Encourage workers to give feedback on safety performance.

Provide training for workers so that they too understand the Safety Management System.

Honest communication, handled properly, should gain you the cooperation you need.

If you are exposed to dust, acids, molten metals, grinding wheels, hazardous flashes you need to take the proper precautions and protect your eyes. If you don’t, it’s possible to lose the precious gift of sight, and it should not be forgotten that your eyes cannot be replaced. Many common misconceptions exist amongst workers; for example, many wearers of contact lenses believe that their eyes are better protected because of the lenses.

However, a contact lens was not designed to provide eye protection and cannot protect the eye from a high velocity particle such as a metal filing.

It is a good thing to remember that OSHA rules establish minimum standards for both employer and employee. Here is a portion of that standard. It deals with eye and face protection standards: OSHA STANDARD: 1910.133; TITLE: EYE AND FACE PROTECTION 1910.133(a) General requirements.

1910.133(a)(1) The employer shall ensure that each affected employee uses appropriate eye or face protection when exposed to eye or face hazards from flying particles, molten metal, liquid chemicals, acids or caustic liquids, chemical gases or vapors, or potentially injurious light radiation.

1910.133(a)(2) The employer shall ensure that each affected employee uses eye protection that provides side protection when there is a hazard from flying objects. Detachable side protectors (e.g. clip-on or slide-on side shields) meeting the pertinent requirements of this section are acceptable.

1910.133(a)(3) The employer shall ensure that each affected employee who wears prescription lenses while engaged in operations that involve eye hazards wears eye protection that

incorporates the prescription in its design, or wears eye protection that can be worn over the prescription lenses without disturbing the proper position of the prescription lenses or the protective lenses.

1910.133(a)(4) Eye and face PPE (Personal Protective Equipment) shall be distinctly marked to facilitate identification of the manufacturer.

1910.133(a)(5) The employer shall ensure that each affected employee uses equipment with filter lenses that have a shade number appropriate for the work being performed for protection from injurious light radiation. The following is a listing of appropriate shade numbers for various operations.

1910.133(b) Criteria for protective eye and face protection.

1910.133(b)(1) Protective eye and face protection devices must comply with any of the following consensus standards: 1910.133(b)(1)(i) ANSI Z87.1-2003, "American National Standard Practice for

Occupational and Educational Eye and Face Protection," which is incorporated by reference in § 1910.6; 1910.133(b)(1)(ii) ANSI Z87.1-1989 (R-1998), "American National Standard Practice for Occupational and Educational Eye and Face Protection," which is incorporated by reference in § 1910.6; or 1910.133(b)(1)(iii) ANSI Z87.1-1989, "American National Standard Practice for Occupational and Educational Eye and Face Protection," which is incorporated by reference in § 1910.6.

1910.133(b)(2) Protective eye and face protection devices that the employer demonstrates are at least as effective as protective eye and face protection devices that are constructed in accordance with one of the above consensus standards will be deemed to be in compliance with the requirements of this section.

[59 FR 16360, April 6, 1994; 59 FR 33910, July 1, 1994; 61 FR 9227, March 7, 1996; 61 FR 19547, May 2, 1996; 74 FR 46356, Sept. 9, 2009]

On-the-job you may be exposed to several hazards at the same time. The right equipment can protect your eyes against irritation and injury. Your safety department should help you select the right eye protection once you don’t have a prescription. Regular prescription wearers are advised to always visit your local eye care professional for assistance. If you wear contact lenses, be extra cautious around gases, vapours, fumes and dust. Always follow the specific management policies on contact lenses in your workplace and wear eye protection equipment in addition to your contact lenses.

Eye safety is not just limited to organisational worksites. Four out of ten accidents that cause blindness happen during projects at home. Off-the-job eye injuries happen because of: 

Accidents during do-it-yourself work on cars and homes.



Cooking accidents.



Chemical splashes from pesticides, fertilizers, drain cleaners and cleaning sprays.



Sports injuries while playing tennis, racquetball, baseball, etc.



Yard work from cutting grass, trimming trees/bushes and using a weed wacker.

It is therefore important that the appropriate safety eyewear is worn for the task at hand (see Table 1)

Eye safety is a collaborative effort. While the employer has specific responsibilities to assist their workers to be safe, it is also incumbent on you, the worker, to perform your duty as well. These duties include: 









Chemical Splashes 

Don’t squeeze eyes shut. Hold them open with thumb and index finger.

Follow safe work practices to minimise the risk of eye injury.



Flood eyes with cool, clean water for 15-20 minutes.

Manage your eye health at work and outside work.



Use PPE in accordance with any instructions given by your employer to ensure safe and proper use—especially for tasks with an elevated risk of eye injury.

Ensure that you know how to appropriately respond to an eye injury and who to contact for first aid in the event of an accident.

Advise your employer of any concerns, including visual or eye discomfort or injury in the workplace.



Cooperate with your employer to identify and correct any factors contributing to visual or eye discomfort strain or the risk of eye injury in your workplace.



Seek advice from an optometrist or medical professional if you have any concerns about your eye health or eyesight.



Set up appropriate personal health care arrangements to manage your own eye health.

Taking all the necessary precautions will ensure that your eyes are sufficiently protected, but in the event of an emergency, immediate medical help will be required.

Here is a list of things to do in specific emergencies:



Get medical help as soon as possible. If you can, have the chemical container and its label available for evaluation.

Do not use another chemical to neutralize the spilled chemical.

Flying Particles 

Do not try to remove anything embedded in the eye. You could cause further damage.



Do not pull or squeeze the eye.



Cover both eyes to prevent movement.



Get medical help as soon as possible.

Radiation Injuries, Burns 

If the eyes are exposed to intense heat, flames, lasers or welding radiation, apply ice packs to relieve the pain.



Get medical attention as soon as possible.

Blows to the Eyes 

Apply ice packs to control swelling and relieve the pain.



Cover both movement.



Get medical attention as soon as possible.

eyes

to

prevent

The effective management of eye health is an important contribution to a healthy and safe workplace. Both the employer and you have responsibilities to fulfil.

Always remember, your eyes are among your most important, and most vulnerable, parts of your body. A little care and diligent protection can prevent injury to, and strain on, your eyes and preserve your vision for years to come.

Do you have sinus-related allergies? If you work in an office building, do you find that your sinuses are worse after you arrive to work in the morning? Do you feel lethargic as the day progresses? These and other human health effects could very well be related to the quality of the indoor environment at your workplace. Mold, excess carbon dioxide and other pollutants could be in your office, causing allergies, lethargy and other conditions. Asthma, other respiratory illnesses, reproductive and development problems, and even some forms of cancer have been linked to exposure to indoor pollutants (US EPA, 2001). We spend more than 90% of our time indoors so proper Indoor Environmental Quality plays a crucial role in our health, productivity and wellbeing. But what exactly is Indoor Environmental Quality (IEQ)?

The Centers for Disease Control and Prevention (2013) defines IEQ as “the quality of a building’s environment in relation to the health and wellbeing of those who occupy space within it”. Various factors such as lighting, air quality, heating and ventilation contribute to IEQ. The green building industry identifies IEQ as a critical issue and all recognised green building certification schemes include some aspects which address IEQ. One such system is the Leadership in Energy and Environmental Design or LEED Green Building Certification Program.

Indoor Air Quality (IAQ) forms an important part of IEQ. For mechanically ventilated spaces it is important that there is sufficient fresh air intake flow. Good Indoor Air Quality includes sufficient ventilation rates to dilute indoor pollutants while introducing contaminant-free outdoor air. Fresh air is critically important in mechanically ventilated buildings, to reduce the build-up of carbon dioxide, for example, and to provide safe air for us to breathe. Proper Indoor Air Quality reduces the potential for sick building syndrome (US EPA, 1991).

However, it is important to understand the use of fresh air in office buildings in Trinidad and Tobago and the region; too little fresh air and we have a build-up of pollutants and CO2 ; too much and we could risk allowing excessive outdoor moisture (humidity) into our buildings. This often leads to mold growth, and possibly condensation. For mechanically ventilated spaces, LEED encourages that outdoor air intakes be fitted with sensors and monitors to ensure sufficient outdoor air flow rates. Additionally it is recommended that naturally-ventilated, occupied spaces be monitored and/or fitted with CO2 monitors.

Second Hand Smoke Tobacco smoke is another IAQ concern addressed by most green building programs. The link between tobacco smoke and various forms of cancer and heart disease is widely documented.

Secondhand smoke known as Environmental Tobacco Smoke (ETS) also exposes non-smokers to the risk of these illnesses. In 2010, Trinidad and Tobago introduced the Tobacco Control Act which prohibits the smoking of tobacco in enclosed public spaces including workplaces. Jamaica and Barbados have also since legislated similar public smoking bans. Typically an IEQ rating system would prohibit smoking inside a building. LEED extends this by prohibiting smoking within 25 feet of all entries, outdoor air intakes, and operable windows as well as the posting of related signage at all entrances. For schools, LEED goes even further by prohibiting smoking on the entire school site.

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Thermal Comfort Thermal comfort is another factor associated with healthy IEQ. Thermal comfort, especially in hot tropical climates such as ours, is most commonly associated with air temperature.

However in IEQ terms, thermal comfort expands to include such factors as surface temperature, humidity, air movement and even occupants’ metabolic rate and clothing. These manifest in various ways; we may feel cooler during the rainy season months than during the dry season; in industrial environments, factory workers may complain about not getting enough “breeze”. IEQ design takes all these factors into consideration when designing and selecting thermal conditioning systems. Thermal comfort is also very subjective. How often do we see air conditioner thermostats set so low only to have occupants wearing sweaters, jackets and cardigans while seated at their desks? As with lighting, systems which allow individuals the ability to

adjust conditions to suit their personal thermal comfort levels are an important consideration. The use of fans, thermostats, adjustable vents and operable windows all allow for individual control and improved IEQ. Because thermal comfort is so subjective, occupant comfort surveys play a critical role in determining if buildings are hitting the mark on thermal comfort.

Turn Down the Noise A relatively new IEQ consideration under the LEED rating system is acoustic performance. While this has been included for special purpose buildings such as schools and health care facilities, acoustic performance has now been included for new building construction and design. We all know the difficulty in concentrating when we can hear phones ringing, a noisy humming air conditioning unit or colleagues chatting nearby. Reduced noise is believed to lead to better

communication and productivity, higher test scores by students (Ronsse and Wang, 2011) and faster recovery times in patients (Orfeu et al., 2012).

Effective noise control considers the background noise of the buildings electro-mechanical systems, sources of external noise, and the acoustical properties of wall and ceiling materials and finishes.

As you can see, the issue of Indoor Environmental Quality affects virtually all indoor spaces. Many factors come together to create a healthy IEQ. Ignoring some may have serious and critical effects on occupants’ health and well-being. Other factors affect productivity and disrupt communication.

Some remedies, like those for dealing with second hand smoke, are absolute and prescriptive in nature while others, like thermal comfort, are very subjective and highly dependent on the building’s occupants. One thing is for certain; with proper IEQ, building occupants will lead healthier and more productive lives.

This paper explores the asthmatic disease in its entirety and begins by giving a brief history of the disease while also giving definitions of what the disease does and its different manifestations. The paper then continues to show what anatomical body parts are affected and then shows what treatments are available. Things that the asthmatic patient should look out for which includes all of the many signs and symptoms can be clearly identified. This paper is meant to leave the reader with a full understanding of the disease and how people diagnosed can live comfortably and treat the disease effectively.

Asthma Asthma is a common disease that affects people all over the world. But the question, ‘what is asthma’ is always asked. What causes it? How can it be controlled? The word asthma itself comes from an ancient Greek word 'asqma'. The medical problem known as asthma can be traced back to the seventh or eighth century BC. Zeus had awoken to find the Trojan army spread out by the Greeks and the leader Hector was lying with his comrades surrounding him while he was gasping with painful breath and vomiting blood (Jackson,2009).

\ Asthma has gotten more prominent in today’s modern society with more and more people being diagnosed every year.

The two main types of asthma are cardiac asthma and bronchial asthma. The two types both cause difficulty in breathing.

However, r in cardiac asthma which is also r, called acute heart failure, the heart does not pump blood to the body efficiently and the lungs fill with fluid causing problems to breathe. In bronchial asthma the air is having difficulty getting to the part of the lungs that it needs to get to

(Levy, 2005). Along with the development of the disease, there have also been many advances in treatments.

In order to fully understand asthma and the causes of it, it is first necessary to understand the different parts of the body that are affected and how these body parts work. When someone breaths air in, it enters through the nose and mouth, goes through the trachea and enters the lungs. At the connection between the trachea and the lungs, there is a split into two bronchi which go into the left and right lungs. These bronchi are then separated into smaller bronchioles and eventually turn into alveoli where the exchange of oxygen and carbon dioxide takes place (Boutin, 1995). Asthma occurs due to constriction of the muscles that surround the bronchi. When someone comes down with an asthma attack, the walls around the bronchi swell and restrict the amount of air that the person receives. Oxygen is needed by the body to survive and any lack of oxygen can cause problems for many of the different vital organs.

In the United States there are approximately fourteen to seventeen million asthmatics. These people are able to carry on with their daily lives by ensuring that they do not overexert themselves and keep their medication nearby. However, r out of every ten r, people, one person will visit the

emergency room in any given year.

Successful management of the symptoms ultimately resolves asthma in most patients but there are still a great number of people who need to be admitted for in-patient care (Brenner, r 1999). There are many risk r, factors when it comes to asthma and the disease affects both adults and children. Starting maternally, y children y, are most times born with asthma due to prenatal smoking, stress and delivery by cesarean section. After birth, children are still at risk of developing asthma from allergies, exposure to animals, decreased lung function and constant exposure to tobacco from relatives. Even as an adult, asthma can be obtained mainly due to occupational exposures (Subbarao, 2009).

When someone has been diagnosed with asthma, they are most likely put on a plan in which they and treat the disease in an effort to decrease or eliminate the symptoms and reestablish normal lung function. What medications someone takes varies according to the severity of the asthma in that particular person.

Everyone has different reactions and where one person may be able to control the symptoms with one medication, another person may need more intensive treatment. The main thing about asthma is making sure that the person who has the condition knows and understands how to use the medication provided.

The two main types of medications are bronchodilators and oral tablets or syrups. Even though they are different they work very well in treating all the symptoms of asthma such as wheezing, shortness of breath and tightening of the chest. For these common symptoms a bronchodilator could be used in order to relax the muscles of the airway and allow more air to pass through. For some people however treatment is needed at the source of the problem which is inflammation. These people are prescribed bronchial anti-inflammatory drugs such as inhaled steroids (Boutin, 1995).

Asthma can be deadly if not taken care of and treated appropriately. People who have asthma should avoid extreme sports and other activities related to it and should also have a broncodilator for temporary emergency use. Another key thing to know is that when going to the emergency room, any asthmatic case is always taken with the highest priority. The most important thing that someone with asthma can do is to keep in good physical shape. Have a sensible, well balanced diet and ensure that a lot of water, fruits and vegetables are consumed on a daily basis. Smoking is bad for everyone, but for someone who has asthma, the effects are a whole lot worse. Smoking irritates the airways and can prevent your asthma medications from doing what they were designed to do (Levy, 2005). Overall, asthma affects millions of people every day but given the correct treatment and knowledge, asthmatic patients can live long, prosperous lives.

References Boutin, Hélène, and Boulet, Louis-Philippe. 1995. Understand and Control Your Asthma. Montreal, QC, CAN: McGill-Queen's University Press, ProQuesebrary. Web. Brenner, Barry E., ed. 1999. EmergencyAsthma. New York, NY, USA: Marcel Dekker. ProQuest ebrary. Web. Jackson, Mark.2009. Asthma : The Biography. Oxford, GBR: OUP Oxford. ProQuest ebrary. Web. Levy, Mark, Weller, Tricia, and Hilton, Sean. Asthma. 2005. The ‘At Your Fingertips’ Guide. London, GBR: Class Publishing, ProQuestebrary. Web. Subbarao, Padmaja., Mandhane, Piush J., and Sears, Malcolm.

2009. Asthma: Epidemiology, etiology and risk factors.

Canadian Medical Association.Journal, 181(9), E181-90. (accessed September 19, 2014).

The action of protecting, or the state of being protected.

Safety management aims to reduce ________ make the workspace as safe as possible.

A statement of intent, and is implemented as a procedure or protocol .

To actively acquire information from a primary source.

The surroundings or conditions in which a person, animal, or plant lives or operates.

They had an _____________ at the factory now he can't walk.

The process of dealing with or controlling things or people.

An individual who works part-time or full-time under a contract of employment.

Manager should prove training __________ to employees to educate them on safety procedure.

Internal _____ is needed to safe guard employees and customers.

A set of detailed methods, procedures and routines created to carry out a specific activity.

Safety has a high ROI ( Return On ________)

A device designed to protect the wearer from inhaling harmful dusts, fumes, vapors, or gases.

A manager should protect his subordinates from ________ from working.

A posted notice bearing a designation, direction, or command.

The _____________ is the physical location where someone works.

A state or condition in which one did not meeting a desirable or intended objective .

A the state of being "safe".

A positive declaration intended to give confidence.

The action of teaching a person.

Headaches are a very common symptom experienced by most of us, which can be as a result of simply not drinking enough fluid (dehydration) or receiving unexpected or bad news. A headache is a trigger that something is not quite right, present as symptom of many minor illnesses, chronic conditions or ill health of a more sinister nature. Is your headache the symptom of a Large Vessel Vasculitis?

Put simply, the word Vasculitis refers to the histologic findings of inflammation (swelling) in the blood vessel walls. However, for most practitioners it’s in reference to clinical syndrome associated with the pathologic findings.

Syndromes where the primary site of inflammation are blood vessels, are known as Primary Systemic Vasculitides of which Gaint Cell Arthritis (GCA) is the most common form, but almost never occurs in patients younger than 50 years old. The incidence of GCA increases with age, is ten times more common in patients over 80 years than the 50 – 60 age group and is twice as common in women than men.

The pathological consequence of such inflammation is destruction of the blood vessel wall seen histologically as Fibrinoid Necrosis (Bartlett, Bingham, Maricic et. al., 2006 and West, 2003).

GCA is inflammation of large blood vessels namely the Aorta and its major branches. The patient presents with cranial symptoms that include superficial headaches, scalp tenderness, jaw and tongue claudication, visual disturbance which maybe as severe as sudden blindness, fever of unknown origin, fatigue and malaise as non-specific symptoms. The patho-physiological changes of the inflamed blood vessels may lead to aneurysms, stroke, myocardial infarction, cerebral dysfunction and hearing loss. Early diagnoses and safe management is critical, aimed at preventing serious complications, disability and premature mortality.

Table 1: ACR criteria for Giant Cell Arthritis - At least three of these five criteria are required for diagnoses

Together with clinical presentation and abnormal laboratory findings of liver function test and raised C-reactive protein and ESR, biopsy of the abnormal segment of the temporary artery should be performed to confirm diagnosis. The biopsy should be done before treatment is initiated or must be within 1-2 weeks of initiating therapy, as the mainstay of treatment for GCA is oral corticosteroids. After this time, the steroids may be starting to work making the test less reliable.

An ultrasound scan of the arteries underlying the temple may also be helpful to aid diagnoses and evaluate effectiveness of treatment. Patients need to receive close periodic reviews once treatment has started to identify potential harbingers of complication and to allow the gradual tapering down to discontinuation of steroid therapy. Active treatment usually continues for six months and often low-dose Prednisolone is required for years.

In conclusion we are the best judges to identify when a headache is not just a headache, despite not knowing its status. The best advice is to seek help early.

References Bartlett, S; Bingham, C; Maricic, M; Iversen, M; Ruffing, V .2006. clinical Care in the Rheumatic Diseases, 3rd Edition, Pub – Association of Rheumatology Health Professionals.

Bijlsma, J .2009. Eular Compendium on Rheumatic Diseases, p329-339. : BMJ publishing group LTD. Hunder, G; Bloch, A; Michael, A; et al . 1990. The American College of Rheumatology. Criteria for the classification of Gaint Cell Arthritis. Arthritis Rheum 1994; 37: 187-92.

West, S .2003. Rheumatology Secrets. Hanley & Belfus, INC.

Pressure ulcers, also known as decubitus ulcers or bedsores, are localised injuries or areas of necrosis to the skin and or underlying tissue that usually occur over a bony prominence as a result of pressure, and or pressure in combination with shearing forces (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel [EPUAP and NPUAP], 2009). A signiďŹ cant number of pressure ulcers occur in the hospital setting. However, it should be noted that the true numbers of pressure ulceration in the community are not fully known, due to the sheer numbers of people cared for in other care organisations such as nursing homes, and in their own homes.

Pressure Ulcers create signiďŹ cant psychological, physical and clinical diďŹƒculities for patients, caregivers and their families (McIntyre et al., 2012); accounting for approximately 43,000 deaths globally (Lozano, 2012). It is therefore imperative that prevention of skin damage and safe management of existing pressure ulcers remain a priorty for care organisations.

The most common sites for skin and tissue damage resulting from Pressure ulcers are the sacrum, coccyx, heels and hips, but other sites such as the ears, Shoulders, elbows, knees, ankles or the back of back of the cranium (head) can be affected (Figure 1).

Damage to the skin results in depleted and, or compromised functions. The development of pressure ulceration is regarded as a key indicator of the quality of care provision (DH, 2010). According to the NationaI Institute for Health and Care Excellence (NICE, 2014), pressure ulceration results from inadequate or a disruption in the blood supply due to pressure, shear or a combination of these. Pressure of 32mm/HG or greater to an area, or sustained pressure for an extensive period of time, without repositioning, leads to lack of blood to the cells causing hypoxia (lack of oxygen), occlusion, and ultimately cell necrosis (cell death). Below is a flow diagram (Figure 3) of the stages of pressure ulcer development.

Skin is the largest organ of the body, made up of three layers (Table1) which contain many structures (Figure 2) and has a pH of between 4.5 and 5.5. The skin has multiple functions apart from giving us structure and providing a canvas for the expression of a person’s social being and sexuality. It interfaces with the environment and plays the key role in protecting the body against pathogens (guarding against infections) and excessive water loss. Other functions of the skin include temperature regulation, sensation, metabolism and synthesis of vitamin D, and vitamin B folates. Also, the ancillary structures (hair and nails), within the skin give additional protection for risk areas.

Immobility is the main risk factor for the development of pressure ulcer skin damage. Those most at risk are the elderly – possibly due to reduced subcutaneous fat and capillary blood flow – together with those with reduced or poor mobility, dehydration and malnutrition or impaired nutrition.

Individuals can be predisposed to developing pressure ulcers due to the effects of medication such as steroids and other co-morbidities. Also, cognitive impairment can make prophylactic (preventative) measures difficult to implement and as such these patients are also at risk.

The overall aim for patients with elevated risk is to prevent the development of pressure ulcers. If this fails, early detection is paramount. Once a pressure ulcer is identified, critical actions must be taken immediately to prevent further deterioration, inhibit infection and to treat underlying causes together with contributing factors.

Malnutrition, poor circulation (hypo-perfusion), and underlying diseases that impair mobility should be

recognised if present and treated. Other manifestations, such as pain, must be managed symptomatically.

A repositioning schedule that is best for the individual patient is one that permits pressure reduction through frequent changes of position and promotes movement to the greatest possible extent.

Patients consent and concordance is vital in the patients planned care.

The safe management of pressure ulcers must follow national and local treatment guidelines based on the classification/stage of pressure ulcer identified. The International EPUAP NPUAP Pressure Ulcer Classification System comprising of four main and two additional categories / stages are described below (see Figure 4), together with management approaches. In clinical practice, category / stages are documented as GRADES of pressure ulcers: • Category/Stage I: Intact (unbroken) skin with non-blanchable redness of a localised area usually over a bony prominence.

Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.

Stage I may be difficult to detect in individuals with dark skin tones. At this stage good skin care and the implementation of all preventative measures are imperative. Application of skin protection (barrier creams, film sprays and or wipes) is required at this stage.

• Category/Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. This may also present as a shiny or dry shallow ulcer; can be an intact or de-roof (open/ruptured serum-filled) blister. It should be noted that skin tears, tape burns and moisture lesions (perineal dermatitis, maceration or excoriation) are often misinterpreted under this category / stage which is incorrect, misleading and unsafe. For this stage, a

comprehensive assessment is needed to inform the choice of dressing aimed at enhancing healing. The dressing choice will be dependent on the presentation of the pressure ulcer (wet or dry).

Consideration must be given to managing existing co- morbidities and at risk factors to achieve best outcome.

• Category/Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle, are not exposed or directly palpable. Slough may be present but does not obscure the depth of tissue loss and might include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have significant amounts of subcutaneous (adipose) tissue, therefore stage III ulcers can be shallow if occur in these areas. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. The aim of managing these pressure ulcers is to debride devitalised tissue as necessary, and promote healing without complication.

Measures mentioned as for category / stage II is critical.

Examples of types of dressings are tabulated in Table 2. It must be iterated that normal saline solution is the only recommended irrigation fluid for cleaning non infected pressure ulcers. This is because as an isotonic solution, it doesn’t interfere with the healing process (Gabriel 2013; Sardina 2013).

• Category/Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle, and can extend into supporting structures (e.g., fascia, tendon or joint capsule) that pre-disposes to the development of osteomyelitis. Slough or eschar may be present on some parts of the wound bed.

Exposed bone/tendon is visible or directly palpable; often include undermining and tunneling and as for stage III, the depth of a stage IV pressure ulcer varies by anatomical location. Management principles follow the same as for Category III with the addition to consider alternatives therapies such as Negative wound pressure therapy (NWPT) and the use of Larval Therapy (maggots). These advance therapies must be initiated by a suitable qualified practitioner who has experience in this field.

According to EPUAP and NPUAP (2009), these two additional categories are used in some countries worldwide, excluding the United Kingdom. Unstageable refers to full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Management in the first instance is debridement, which can be done either surgically or through conventional means. However, stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels is normally protective and should not be removed (See Figure 5).

Once the slough is removed and the true stage is established, treatment therapy targeted at healing the pressure ulcer will revert to measures for at least category / stage III.

Figure 6: Suspected Deep Tissue Injury on a Heel

Figure 5: Unstageable Pressure Ulcer on a Heel

The second of the additional categories is the Suspected Deep Tissue Injury which is a purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler when compared to adjacent tissue. A deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Good skin care is crucial within a wait and watch approach. Progression may be rapid exposing additional layers of damaged tissue, therefore optimal treatment to enhance healing, must be initiated timely taking into consideration the full clinical picture (see Figure 6).

In conclusion Pressure ulcers or bed sores are damage to skin and underlying tissues resulting from pressure to those with risk factors, which results in significant physio-psychological impact to patients, families and carers, as well as repetition shortfall for care organisations.

Safe management includes preventative measures, early detection, accurate assessment and appropriate timely implementation of treatment of the Ulcer, underlying and risk factors.

Basic Skin Care Tips for Prevention and Management of Pressure Ulcers: • Wash your skin with warm water and dry it well.

• Minimise the use of soap or soap derivatives on skin as it can adversely affect the pH of the skin.

• Apply an appropriate barrier product to help prevent moisture breakdown as per manufacturer’s instructions.

• Be sure to treat any skin redness or skin changes right away, when the problem is still small.

• Avoid skin-cleaning products that contain alcohol. These can make your skin too dry.

• Do NOT massage the area of the ulcer because massage can cause tissue damage under the skin.

• Donut-shaped or ring-shaped cushions are NOT recommended because they can interfere with the blood flow to that area and cause complications.

• The use of hypochlorite solutions, such as Eusol, Potassium permanganate, Hydrogen peroxide ARE NOT RECOMMENDED due to concerns about tissue toxicity, as it has been found to be toxic to fibroblasts in vitro (Hayward and Morrison, 1996).

• Use of appropriate pressure relief equipments.

References European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel.2009. http://www.epuap.org/guidelines/Final_Qu ick_Treatment.pdf (accessed June 9, 2014).

Gabriel, A. Medscape.

2013. Wound

Irrigation.

Hayward P.G and Morrison W.A.1996.

Current concepts in wound dressings.

Australian Prescriber: 19:11-3.

Lozano, R .2012. Global and regional mortality from 235 causes of death for age groups in 1990 and 2010: a systemati anaysis for the Global Burden of Disease Study 2010. Lancet 380 (9859): 2095.

NationaI Institute for Health and Care Excellence .2014. Pressure ulcers: prevention and management of pressure ulcers. NICE Guideline 179. London. UK. Sardina, D .2013. Is your wound-cleansing practice up to date? Wound Care Advisor Illinois, USA.

“Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force.” ~ W. Edwards Deming “If we accept that there is no such thing as ‘zero risk’ then we should not spin the meaning of words with assertions such as all accidents are preventable’.” ~Dr Rob Long "Concern for man himself and his safety must always for the chief interest of all technical endeavours." -Albert Einstein "What is now proven was once only imagined. Hindsight is a wonderful thing but foresight is better, especially when it comes to saving life, or some pain.” ~ William Blake "Safety is not an intellectual exercise to keep us in work. It is a matter of life and death. It is the sum of our contributions to safety management that determines whether the people we work with live or die" ~Sir Brian Appleton after Piper Alpha “Occupational Health and Safety is about change for the future not blame for the past” ~ Author Unknown

afety Mate is the leading Emergency Instruction Device developed for the lay responder.

Safety Mate is a portable and interactive electronic safety device, providing a reliable and convenient way to reinforce emergency response knowledge and skills. Safety Mate gives users confidence to respond with accuracy when an actual emergency occurs.