Doctors Conference 20 May 2015 Slides

Examining Doctors’ Conference Wednesday 20 May 2015

Introduction & Welcome Robert Paterson Health, Safety and Employment Issues Director Oil & Gas UK

2014 – 2015 Update Dr Graham Furnace Medical Advisor Oil & Gas UK

Examining Doctor Conference 2015

Oil&Gas UK Update

Update 2015 Examining Doctor Facts and Figures Ebola

Smoking/e-cigarettes Helicopters

Regulation of Offshore Medics Administration Alternative medicals Complaints and comments

Facts and Figures

2010

2014

2015

Countries

37

50

55

Doctors

796

968

1047

% in UK

54

49.9

48.8

Medical Assessments Activity 2008-14 Year

Returns

Total

Fail (%)

2008

367

39780

503 (1.2)

2009

402

48941

108 (0.2)

2010

626

56850

784 (1.4)

2011

580

59900

665 (1.0)

2012

707

93219

1284 (1.4)

2013

809

113006

1333 (1.2)

2014

931

118597

1285 (1.1)

Reasons for Failure 2010

2013

2014

Cardiac (15%)

Cardiac (13%)

Cardiac (13%)

Diabetes (10%)

Hypertension (12%)

Hypertension (9%)

Weight (10%)

Diabetes (11%)

Weight (9%)

Psychiatric (7%)

Weight (9%)

Diabetes (8%)

Hypertension (7%)

Dental (6%)

Drug Abuse (7%)

Drug Abuse (6%)

Drug Abuse (5%)

Dental (4%)

Ebola: mid 2014

Ebola: early 2015

Liberia – ebola-free May 9th Sierra Leone & Guinea – cases continue, but at much reduced rate from peak

Dr Lanre Ajay – Nigeria experience

Smoking & e-cigarettes : latest

US Preventative Services Task Force: draft statement May 2015 http://www.uspreventiveservicestaskforce.org/Page/D ocument/draft-recommendationstatement147/tobacco-use-in-adults-and-pregnantwomen-counseling-and-interventions1

Smoking & e-cigarettes: papers

Bullen et al, Lancet 2013: http://www.thelancet.com/journals/lancet/article/PIIS014 0-6736%2813%2961842-5/abstract (full text/pdf) ECLAT study (Italy) 2013: http://journals.plos.org/plosone/article?id=10.1371/journ al.pone.0066317 (full text/pdf)

Smoking & e-cigarettes: Oil&Gas UK

Advisory Notes circulated H&S Forum May: E-cigs not permitted Same-as-shops pricing Remove from view

Stop sales No smoking

Helicopters

UK SAR service contract award Peter Lowson, Coastguard CAP1145: ‘compatible with helicopter exit’ – bideltoid breadth Emily Taylor, Step Change

Offshore Medics

OPITO standard First meeting May 26th

Oil&Gas UK Administration

Guidelines on Webpage List administered directly Refresh network

‘Alternative’ Oil&Gas UK Medicals

Oil Price $56 per barrel (down from $100) Aberdeen Press & Journal, May 15th 2015: ‘Ithaca Energy cuts costs by 30%’

Complaints

Mr ‘A', ROV Supervisor - email 4th May:

I need to renew my Offshore Medical this week and I would like get some information regarding what tests are required for obtaining an Offshore Medical for an ROV pilot. I'm not on any fire-fight or rescue teams. I work in Asia, UK and Norway. Any PDF documents would be great, Reason why I'm asking is that I live in 'x' and every time I do my medical they always try and force me to do running tests, Psych tests and others.

A question...

If a test to detect a disease whose prevalence is 1/1000 has a false positive rate of 5%, what is the chance that a person found to have a positive result actually has the disease, assuming you know nothing else about the person's symptoms or signs? Martyn, C. Statistics in Medicine: Risky Business. BMJ 2014; 349: g5619 (20th Sept)

A question...



disease prevalence 1/1000



test false positive rate 5%



what probability that a positive result actually means the disease is present?

A question... 

disease prevalence 1/1000



test false positive rate 5%



what probability that a positive result actually means the disease is present? 5%

95% something else

I just don't know!

A question...



disease prevalence 1/1000



test false positive rate 5%



what probability that a positive result actually means the disease is present? 2%

The Answer: 

disease prevalence 1/1000



of 1000 people 'through the door', 1 of them has it, 999 don't



test false positive rate 5%



(i.e. the condition is absent, but the test is positive)



1000 tests on 1000 people



1 person has the condition and tests positive (1 positive)



5% of 999 (=49.95 ~ 50) false positive (50 positives)



total positives = 49.95(50)+1 = 50.95 (51)



what probability that a positive result actually means the disease is present?



probability = 1 true positive / 50.95(51) total positives = 0.019 (0.02) i.e. 2%



so 2% of people with a positive result actually have the disease

An unfair question because:

'doctors don't generally work in circumstances where the background prevalence of disease is 1 in 1000’ 'doctors are rarely in a position where they know nothing about a patient beyond a test result'

Condition (as determined by “Gold Standard")

Total population

Condition positive

Test outcome positive

True Positive

Condition negative

False Positive (Type 1 error)

Prevalence = Σ Condition positive/ Σ Total population

Positive Predictive False Discovery Rate = Value (PPV, Precision) = Σ False positive/ Σ True positive/ Σ Test outcome positive Σ Test outcome positive

Test outcome Test outcome negative

False Negative True Negative

False Omission Rate = Σ False negative/ Σ Test outcome negative

Accuracy = Σ True positive + Σ True negative/ Σ Total population

(Type 2 error)

Positive Likelihood Ratio (LR+) = TPR/FPR

True Positive Rate (TPR, Sensitivity) = Σ True positive/ Σ Condition positive

False Positive Rate (FPR) = Σ False positive/ Σ Condition negative

Negative Likelihood Ratio (LR−) = FNR/TNR

False Negative Rate (FNR) = Σ False negative/ Σ Condition positive

True Negative Rate (TNR, Specificity) = Σ True negative/ Σ Condition negative

Diagnostic Odds Ratio (DOR) = LR+/LR−

Negative Predictive Value (NPV) = Σ True negative/ Σ Test outcome negative

Condition (as determined by “Gold Standard")

Total population

Condition positive

Test outcome positive

True Positive

Condition negative

False Positive (Type 1 error)

Test outcome Test outcome negative

False Negative True Negative (Type 2 error)

True Positive Rate (TPR, Sensitivity) = Σ True positive/ Σ Condition positive

False Positive Rate (FPR) = Σ False positive/ Σ Condition negative

True Negative Rate (TNR, Specificity) = Σ True negative/ Σ Condition negative

Prevalence = Σ Condition positive/ Σ Total population

Positive Predictive Value (PPV, Precision) = Σ True positive/ Σ Test outcome positive

SAR Arrangements in the UK Sector Peter Lowson Staff Officer (Offshore Energy) Maritime And Coastguard Agency

HM Coastguard SAR Arrangements in UK Sector

Pete Lowson Staff Officer (Offshore Energy)

[email protected] 01224 597911

UK SAR Organisation - Responsibilities

Inland SAR

Civil Maritime SAR

Civil Aeronautical SAR

Department for Transport

Police

Maritime & Coastguard Agency HM Coastguard MRCC

Military SAR

Ministry of Defence ARCC

United Kingdom Search & Rescue Region Approximately 1.5 million square nautical miles

30 degrees West

45 degrees North

Coastguard MRCCs May 2015 MRCC Shetland

NMOC Fareham 6 MRCCs with limited interoperability & resilience 4 CGOCs (Falmouth, Holyhead, Milford Haven and Humber now in the network)

MRCC Stornoway MRCC Aberdeen

London Coastguard

MRCC Belfast

CGOC Humber

CGOC Holyhead

MRCC Thames closes June 2015 MRCC Thames

CGOC Milford Haven

CGOC Falmouth

London Coastguard NMOC Fareham

MRCC Dover

National Coastguard Network December 2015

National Maritime Operations Centre (NMOC) CGOC Shetland

9 Coastguard Operations Centres (CGOCs) + London Coastguard CGOC Stornoway

NMOC operational Sep 2014 CGOC Aberdeen

Steady State Dec 2015 National network with built in resilience & following Missions -

CGOC Belfast

CGOC Humber

CGOC Holyhead

CGOC Milford Haven

London Coastguard CGOC Dover National Maritime Operations Centre

CGOC Falmouth

Search and Rescue Pollution Response Vessel Traffic Management Maritime Safety Information Accident and Disaster Response Maritime Security

SAR Resources Declared Resources Declared facilities have been designated as being available for civil Maritime SAR according to a specific standard or set criteria.

Additional Resources Facilities which may be available from time to time but not to a specific standard.

Declared Resources

Criteria for SAR Helicopter Coverage  Airborne within 15 minutes by day (0800 - 2200) and 45 minutes by night (2200 - 0800), after tasking notification – “scramble”

 At least 1 aircraft available at each SAR base for 98% of the declared operating time.

SAR Helicopters - current  12 Bases in UK  1 aircraft available at each base  Tasking controlled by ARCCK; subsequent co-ordination by MRCC  Selection and tasking is based on greatest need, availability, National SAR picture, weather conditions etc.  Nearest base may not be nearest available.

Long SAR – 2015 to 2025  10 Year contract – Department of Transport - MCA  UK SAR Helicopter fleet replacement  Commencing 2015 - Sea King Out of Service Date

 10 bases - loss of Boulmer & Portland  Mixed fleet:

Longer range / higher capacity Shorter range / lower capacity

 Contract awarded to Bristow Helicopters March 2013

S92

AW139

AW189

Additional Facilities 

Masters of Vessels



Offshore Installations and facilities



Pilotage Services



Local Authorities



Fire, Police, Ambulance



Beach Lifeguard Units



Meteorological Office



Mountain Rescue Teams



Diving clubs

Additional Facilities - Industry SAR Helicopter  One AS332 L2 Super Puma helicopter in Aberdeen + backup aircraft.  Capacity for at least 21 survivors: rescue time 1.5 min – 2.5 min per survivor.  Operational control currently remains with Jigsaw coordinator (JigCo)  Currently available for “life threatening or life changing”  Rear crew similarly qualified as National SAR Assets.

Background to Radio Medical Advice (RMAS)  E.C. Directive requiring member states to provide Medical Advice on land, sea or in the air  MCA is required to provide RMA for ships at sea  Contracts awarded to Aberdeen Royal Infirmary & Queen Alexandra’s, Portsmouth  ALL calls to HMCG of a medical nature must be channelled through either hospital  HMCG CANNOT make decision to evacuate without a Doctors approval However……..

There are exceptions……  Diving casualties  Military medical evacuation  Requests from offshore installations where the advice has originated from the installation’s or company doctor  Doctor or paramedic part of the ships crew  Flights requested by Irish Authorities on authority of Irish TMA  Evacuations authorised by foreign following medical advice from their medical authorities under TMAS

Also………….

“ A request for medical assistance sometimes requires immediate assessment and response without qualified medical advice. A possible scenario for example could include a severed limb. Nevertheless, after alerting the appropriate service, medical advice must always be sought…..”  If the incident is not diving related and if Topside medical advice has not been sought, someone must speak to a RMA doctor via the MRCC Medic OIM Runner

What Coastguard needs to know from the Doctor, medic and installation. Casualty details incl. name, age, nationality, previous medical history, medication (current and prescribed) Confirm position of installation Any update on casualty condition Helideck rating and availability On scene weather conditions including cloud cover On scene radio frequency Doctors name, company and phone number Have they been to West Africa in the last 21 days.

What the Coastguard have to consider before tasking a SAR asset  Resource Safety  Consider the risk to resource; can the patient wait? Does the risk to resources outweigh the need of the casualty?  Selection and tasking is based on greatest need, availability, National SAR picture, weather conditions etc

Timescales Evacuation to be carried out and patient to be seen ashore:

 As soon as possible  Within 6 hours  Within 12 hours  Longer than 12 hours.

HIERARCHY OF RESCUE

 Who comes first?  Aircrew and Aircraft will ALWAYS come before the casualty.  The final decision to conduct a medevac will always be at the aircraft captains discretion

Aircrew medical qualifications • Winchman – Paramedic registered by the Health and Care Professions Council (HCPC). • Winch Operator – Hostile Environment Medical Trainers (HEMT) / Intermediate immediate emergency care (IIEC) • Pilot – First aid and Automated External Defibrillation (AED) trained.

February 2006 – icing on the blades during a rescue operation

Technical fault during rescue

15th July 2002 - Portland Coastguard Helicopter engine fire

Any questions ?

Pete Lowson Staff Officer (Offshore Energy) [email protected] 01224 597911

Passenger size: Response to CAP 1145 Emily Taylor Project Co-ordinator Step Change In Safety

Anaphylaxis Dr Cecilia Trigg Consultant Allergist The London Allergy Clinic And St Mary’s Hospital (Imperial NHS Trust)

Definition of anaphylaxis Severe, potentially life threatening systemic hypersensitivity reaction Rapid in onset with life-threatening breathing or circulatory problems Usually, but not always, associated with skin and mucosal changes World Allergy Organisation anaphylaxis guidelines: J Allergy Clin Immunol 2011

Case history 1 17 year old male student Immediately after two bites of a chocolate and pecan cookie Tongue swelling, lip swelling and a burning sensation in his mouth. Taken to the local pharmacy (abroad) and given 150 mg of Hydrocortisone tablets Within 15 minutes he was having problems with swallowing, his breathing became rapid, he developed a generalised rash, his eyes were bloodshot, there was swelling in his neck and he was shivering. The ambulance that finally arrived after some delay had no emergency medication, he was taken blue light to hospital but there was considerable further delay and it was 45 minutes until adrenaline was actually given. His oxygen saturation was only 90%, his blood pressure 107/45. After adrenaline was given, his condition rapidly improved.

Case history 1 – key points

• Immediate reaction to a food containing a likely allergen • Oral symptoms • Breathing difficulty with hypoxaemia • Hypotension • Angioedema and urticaria • Delayed treatment of clear cut anaphylaxis • Fortunately not asthmatic

Pathophysiology

Simons FE, Allergy 2011

Time course of serum mast cell tryptase

Resuscitation council: Emergency treatment of anaphylactic reactions 2012

The rapidity of anaphylactic arrest depends on the trigger:

Pumphrey R, Clin Exper Allergy 2000

Fatalities from food anaphylaxis (Pumphrey J Allergy Clin Immunol 2007)

48 deaths in UK 2001-2006 18 to nuts, 6 milk 26 aged 11-30 34 away from home (restaurant, takeaway) Only 7/19 with Epi pen in date and used 42 asthmatics 10/32 with full data on asthma had exacerbation

Epidemiology of anaphylaxis

Turner P et al, J Allergy Clin Immunol April 2015

Food anaphylaxis is most common in the young whereas drug and venom affects more older patients

Turner P et al, J Allergy Clin Immunol April 2015

Food anaphylaxis fatality is predominantly caused by nuts and milk

Turner P et al, J Allergy Clin Immunol April 2015

Causes of fatal anaphylaxis: 1992-2001 Venom (47)

Suspected food (62)

Stings: Wasp(29) Bee (4) Unknown (14)

Nuts (32) Other food (13) At a meal (17)

Iatrogenic (102) Antibiotics (27)

Other drugs (18)

General anaesthetics (39)

Radiocontrast (11)

NSAIDs (6)

Latex (1)

Resuscitation council: Emergency treatment of anaphylactic reactions 2012

Food Allergy

Identifying Food allergy Highly likely

• Oropharyngeal itch, tingling or swelling • Symptoms within 5-30 mins of eating • +/- Wheeze, dyspnoea, hypotension, rash

Highly unlikely • Inconsistent temporal relationship to food • No oral symptoms • Isolated GI symptoms • Fatigue syndromes • Eczema, Chronic Urticaria etc

Investigation of food allergy

All food eaten

Less likely if hours after food

Timing ( 10 cm diameter – Prednisolone 30 mg 3-5 days NO increased risk of Anaphylaxis Referral not needed unless very large reaction or other vulnerability

•

•

Mild SR: Pruritus, urticaria, erythema, mild angioedema, rhinitis, conjunctivitis Moderate SR: Mild asthma, moderate angioedema, abdominal pain, vomiting, diarrhoea, minor/transient hypotension (lightheaded/dizzy) Severe SR: Asthma attack, laryngeal oedema, hypotension, collapse, loss of consciousness Rarely – double incontinence, seizure, loss of colour vision

• REFER ALL

The role of the specialist

Clinical history (inc hospital records)

Skin prick tests, IgE, components, intradermals, Basal mast cell tryptase

Management plan: immunotherapy?, anaphylaxis kit, avoidance advice

Immunotherapy suitable for severe anaphylaxis: prevents 80% of subsequent bee venom and 95% wasp venom systemic reactions. Some with moderate reactions may be eligible (eg mastocytosis, occupational exposure)

Idiopathic Anaphylaxis

10 – 30 % anaphylaxis is unexplained “idiopathic” Must exclude mastocytosis: raised basal mast cell tryptase - Confirmed by Haematologist (bone marrow examination – C-kit mutation positive mast cell infiltrate)

May be one isolated episode or many Patient would be unsafe in a remote location Must carry anaphylaxis kit at all times Diagnosis of exclusion, c/o Allergist (exclude co-factor dependent food reactions) Note: there may be no cutaneous signs of mastocytosis

Thank you! Anaphylaxis kits are only of use if in date, carried and the patient knows how to use them. Asthma must always be well-controlled (BTS/SIGN guidelines) Useful Resources Resuscitation Council Guidelines (www.resus.org.uk) British Society of Allergy and Clinical Immunology (www.bsaci.org): find a specialist, guidelines, news Patient support: Anaphylaxis campaign (www.anaphylaxis.org) Epi-pen (www.epi-pen.co.uk) Jext (www.Jext.co.uk) Emerade (www.emerade.com): how to use, demonstrator pens

ADHD Dr Michael Craig Consultant Psychiatrist & Clinical Senior Lecturer In Neurodevelopmental Psychiatry Maudsley And Nightingale Hospitals Institute Of Psychiatry, KCL

Dr Michael Craig Consultant Psychiatrist My professional qualifications, accreditations and memberships:

• • • • • •

Bachelor of Psychology (BSc (Hons)), University of Bristol Doctor of Neuroscience (PhD), Kings College London Bachelor of Medicine & Surgery (MB BS), University of London Member British Neuropsychiatric Association Fellow Royal College of Obstetrics & Gynaecology (FRCOG) Fellow Royal College of Psychiatry (FRCPsych)

My Professional Experience: ADHD / Autism: (1.) Clinical Lead, Nightingale Hospital London Adult ADHD Clinic; (2.) Clinical Lead of the National Autism Unit, Bethlem Royal Hospital; (3.) Specialist Consultant, Adult ADHD & Autism service, National Services Directorate Maudsley Hospital. General Psychiatry: Management of treatment resistant depression, mood/anxiety disorders, PTSD, OCD, sleep disorders, dual diagnosis within the NHS (Maudsley Hospital) and Private sectors. International Second Opinion Service: For complex psychiatric cases Perinatal Psychiatry: Chairman of the UK and Ireland Marcé Society for Perinatal Mental Health – An International society for the understanding, prevention and treatment of mental illness related to childbearing Reproductive Psychiatry: (i) Clinical lead of the Female Hormone Clinic, National Services Directorate, Maudsley Hospital; (ii) Medical advisor for Menopause Alliance – an independent, non-profit, global women’s health initiative created to address the many issues that affect women as they enter midlife and beyond (www.menopausealliance.org). (iii) Trustee and medical advisor for the National Association of Premenstrual Syndrome My Personal Statement: I am a clinical academic psychiatrist delivering evidenced based pharmacological and non-pharmacological (e.g. psychological and TMS) treatments within a holistic framework

Adult ADHD Dr Michael Craig PhD FRCOG FRCPsych Consultant Psychiatrist, Maudsley & Nightingale Hospital. Senior Lecturer, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), KCL Founder, MagnaCentre

What is ADHD?

DSM-V diagnostic criteria Onset Before 12y (7y) Pervasive Impairment in 2 or more settings Inattention At least 5(6) symptoms or Hyperactivity-impulsivity At least 5(6) symptoms Subtypes

Combined type Predominantly inattentive type (ADD) Predominantly hyperactive-impulsive type

Biological Basis

inattentive group

c

p

b

30.0

***

ADD > HyD (ventral FP)

HyD > ADD (right dorsal FP)

Resting-State Connectivity

a

hyperactive-impulsive group

0.001

0.05

20.0

***

10.0

0

d

e

Fronto-parietal Right ventral FP

Fronto-striatal Right Caudate

So why haven’t we been treating adults with ADHD until now?

Developmental delay

ADHD symptoms ADHD NORMAL 5

10 AGE

15

Persistence of ADHD: meta-analysis of longitudinal follow-up studies

15% retain full diagnosis (F) by age 25 50% in partial remission (R) by age 25 Faraone et al., Psych Med 2006; 36, 159-165

Developmental deficit

Revised view ADHD symptoms ADHD NORMAL 5

10 AGE

15

UK prevalence of ADHD

F

Children & adolescents 4% Adults

M

1% 0.1%

0.5%

Is there a quick screening tool?

Then what?

Timmy’s Diagnosis

Assessment

• • • • •

Semi-structured interview (patient) Brown & Berkley scales (parent/partner) Interview of parent/partner (telephone) Analysis of old school reports Psychometric tests

Risk Assessment Oil & Gas UK medical guidelines ‘ … Individuals need to be assessed with regard to impulsivity and lack of awareness of the effects of their behaviour on others.

These risks may be significant such that they are incompatible with the safety requirements of offshore work or the ability to live in a community …’

Determination of Risk for Specific Medical Conditions; Issue 6 March 2008

Who is being referred?

1 - New Patients Annual methylphenidate prescriptions 7 0-2 3-5 6-9 10-12 13-15 16-18

Prevalence per 1,000

6 5 4 3 2 1 0 1992

1993

1994

1995

1996 1997 Year

1998

1999

2000

2001

Hsia & de Vries, University of Surrey, unpublished data

2 - Returnees Stimulant prescriptions 2001-2005 2001

2002

2003

2004

2005

Predicted decrease (2005)*

Prevalence (per 1000 patient years)

16 14

13.78

12

11.44

10

9.88

9.49 7.88

8

6.54

6

5.72

5.43 4.51

4

3.31 1.63

2

0.84

0.61

0 15

16

17

18

19

20

21

Age (years)

Faraone et al., Psych Med 2006; 36, 159-165

oo d

M oo d sy m

di ab so us rd e/ er de s pe A nd nx en ie cy ty di so rd A er nt s is oc ia lP B or D de rli ne P D

M

A

pt om ng er s ou S en tb D ur sa us st t io ru s n pt se ed ek sl in ee D g ep p re pa ss tte iv rn e s co m pl ai nt s A nx H ie yp ty A er gg se re ns ss it i io vi n ty to no is e

D ru g

3 - Hidden

100

90

80

70

60

50

40

30

20

10

0

78% had one or more co-occurring disorders Kooij JJ, PhD thesis, 2006

Treatment - Pharmacological - Psychological

Pharmacological

“… Medications should only be initiated by an appropriately qualified healthcare professional with expertise in ADHD after a comprehensive assessment …”

“ … Continued prescribing and monitoring of medications may be performed by GPs, under shared care arrangements …”

Pharmacological 1st line: Stimulants (Controlled Drugss) 2nd line: 3rd line:

Atomoxetine Modafinil Buproprion NA ADs (e.g.imipramine, reboxetine)

RESPONSE = 40-80%

Pharmacological

Side Effects Headache:

wait, reduce dose or switch.

Appetite loss:

wait, take with meals, eat smaller more frequent meals, eat when medication effects have worn off.

Sleep loss:

avoid medication in the evening & long acting medication late in the

day. Raised BP: rarely clinically significant,occasionally appropriate to use a antihypertensive.

Psychological • • • • •

CBT Psychoeducation Skills training / Coaching and counselling Neurofeedback Support groups Formal studies not yet been carried out, but many adults with ADHD report they gain benefit from these approaches (NICE 2008)

Treatment of co-morbid disorders - Addiction Counselling - Family and Couple Therapy

Thank You Questions?

Contact Us Dr Michael Craig Counselling Psychologist Nightingale Hospital 11-19 Lisson Grove London NW1 6SH Tel: 0207 535 7700 Secure referrals fax: 020 7224 5976

Pinero House 115A Harley Street W1G 6AR T: 020 7224 1717 F: 020 3137 6869 E: [email protected]

Referrals for outpatient assessment, therapy or inpatient admission can also be made via email: [email protected] Deborah Casserly Nightingale Hospital Liaison Tel: 07957 645357 [email protected]

Ebola Virus Disease: Challenges and Contingencies for the Nigeria offshore Industry Dr. ‘Lanre Ajayi Director, Occupational Health Clinics Medbury Medical Services

Ebola Virus Disease: Challenges and Contingencies for Nigeria’s Offshore Industry Dr. ‘Lanre AJAYI

M.B.Ch.B, MFOM

At the Oil & Gas UK Examining Doctors’ Conference London 20th May 2015

Outline  Background / Key Facts

 The Nigeria Story  Governmental Response  Nigeria Offshore Industry Preparedness  What we have learnt so far.....  Questions

Intro……

Background / Key Facts  The largest ever outbreak of Ebola virus disease (EVD) was first reported by Guinea to the World Health Organization in March 2013. “….unprecedented in scale and geographical reach” – WHO  Since that time, the outbreak spread to other West African countries of Liberia, Sierra Leone, Nigeria, Mali and Senegal.  Spread to 3 continents – Africa, Europe and North America

 PHEIC declaration by WHO  The recent outbreak is attributed to the Ebola virus Zaire strain. It is the most extensive outbreak of Ebola, since the discovery of the virus in 1976.

 By September 2014, cases of EVD from this single outbreak exceeded the total of all cases from previous known outbreaks.

Background / Key Facts

The 2014 Ebola outbreak is the largest, the worst and the first to affect multiple countries in history

Geographic scope: --‐ 7 countries: Guinea, Liberia, Sierra Leone, Senegal, Nigeria, Spain & USA --‐ 3 continents: Africa, Europe & North America

Background / Key Facts  The Filovirus is transmitted firstly by human-to-animal contact (fruit bats, monkeys, other primates, etc). Human-to-human transmission occurs when direct contact is made with fluid and secretions (blood, sweat, vomit, diarrohea, urine, breast milk, semen) from an infected person or corpse, or any surface contaminated by an infected person. Mode of entry is essentially muco-cutaneous.  Symptoms of EVD may include: Fever, severe headaches, muscle aches, weakness / fatigue, diarrhoea, vomiting, abdominal pain, unexplained haemorrage  Ebola can only be spread to others after the appearance of symptoms. Symptoms may appear anywhere from 2 to 21 days after exposure to the virus, but the average is 8 to 10 days.  Recovery from Ebola depends on good supportive clinical care and the patient’s immune response. People who recover from Ebola infection develop antibodies that last for at least 10 years.  The recent outbreak has an overaall CFR of ~ 50% (past outbreaks CFR range = 25% to 90%)

Background / Key Definitions related to Ebola  Contact – A person who has:  Unprotected care of a patient of Ebola  Participated in burial of Ebola death  Washed linen, bathed patient or cleaned body fluids  Slept in same room with Ebola patient  Suspect case – A person who has  History of fever of 380C or more, or  History of vomiting and / or diarrhoea, or  History of any 2 of the following symptoms:  Headache, Malaise, Muscle pains, Joint pains, Abdominal pain, Measles like rash, Red eyes, chest pain, bleeding from body openings  Probable case – Any Person  Meeting the suspected case definition criteria and has had contact with a confirmed case  Any unexplained death in a contact  Confirmed case – Lab positive case

The Nigeria Story  20 July 2014: The index case, a Liberian-American, flew from Liberia to Nigeria's commercial city of Lagos. Lagos: Population = 22.58mil (2014 estimate), Av population density 6,300/Km2 (50,000 – 100,000/Km2 in some places) He became severely ill upon arriving at the airport and died five days later.

In response, the Federal Ministry of Health in collaboration with partners (local and int’l – WHO, CDC, MSF, etc) initiated a multi-sectoral response through an Incident Management System. The response included case isolation and management, the tracking and observation of all of the case’s contacts for signs of infection and increased surveillance at all entry points to the country.

The outbreak spilled over from Lagos to Port Harcourt. As part of the response interventions, a total of 365 contacts were traced and monitored in Lagos and 525 in Port Harcourt. (Total contacts = 890) As of 27 September 2014, the Federal Ministry of Health had registered 20 cases (including the index case), and 8 deaths. The last confirmed case was discharged on September 9th, 2014. Since then, there have been no new cases detected. The outbreak was declared over on October 20th 2014 (after two incubation periods totaling 42 days without any new case being detected, as per the WHO recommendations).

EVD case dashboard as at 10th Sept. 2014 New case(s)

0

Deaths 6+2

Total Confirmed cases (till date) 16 + 4 (LOS + PHC) Discharged Under treatment 10 + 2 0+0

Suspected cases

Under Surveillance

Released from Surveillance

0+0

27 + > 500

363

The Nigeria Story: 20th July – 20th Oct. EBOLA INFECTION - SAWYER / NNPC CLINIC CASE TIMELINE

3 new suspected 5 new suspected Cases reported Cases reported

4

3

2

Child immunization visit while P.Swayer was still @ FCH

Several people @ FCH exposed

Woman diagnosed with Ebola @ NNPC Clinic Another visit to FCH, decided to visit another clinic when she realized it was shut

2 HCWs confirmed 2nd death infected Nurse

FCH shut for decontamination

New Case 3rd reported Death

4th Death

5th Death Dr. A. Stella

6 other cases reported

1

P.Swayer admitted at FCH

1st death P.Swayer

Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Within theoretical incubation period of index case Within theoretical incubation period (from time of last possible contact with index case)

within theoretical Incubation period of possible primary contacts

Governmental Response  Multi-agency RRT – FMOH (NCDC, Port Health servs), State WHO co-ord, CDC (US), UNICEF, UNFPA, MSF

 Immediate Response measures (within 48Hrs) o o o o o o o o o o o

Ste up of Ebola Emergency Operations Center (EEOC). ICS approach. Met 2x daily Sensitization of all tiers of hospitals via the relevant trade associations Public awareness (Power of the media – print, bulk SMS, e - and social media) Emphasis on basic public health & hygiene practices. Use of “appropriate technology” EBOLA ALERT Help line (0800-EBOLA-HELP) Prompt contact tracing of co-travellers of Mr. Sawyer (airline pax manifest) Level 3 pandemic PPE resupplied to HCW. Training on donning and un-donning Special alert on handling and disposal of medical waste Crematorium services – same day cremation of remains of index case after due prep Restrictions to and Decontamination of affected healthcare facilities following WHO guidelines Regular Press Conferences

Governmental Response  Setting up of committees of the center o Epid / Lab  Lab confirmation of cases  Aggressive contact tracing of 10, 20 and 30 cases  Decontamination of health facilities and homes of suspected / confirmed cases admitted  Evacuation of corpses and disposal / burial activities o Point of Entry (PoE)  Screening of persons entering Lagos via the ports – Air, Sea and ground crossings (IR thermometers)

o Case Management / Infection Control  Setting up of isolation & treatment centers and associated support structures  Burn & bury pit for waste management  Development & implementation of SOPPs and guidelines  Provision of psycho-social support for cases and family members o Health Promotion  Advocacy to / sensitization of relevant stakeholders (community engagement – market, house-tohouse, traditional and religious leaders, schools, morgue operators, etc.) . Use of local TV and music stars  Development of messages in different formats and languages (jingles, advertorials, )  Development and printing of IEC materials (fact sheets, FAQs, and hand‐washing)  Regular press briefings and updates on containment and allied efforts o Data Management o Logistics / Secretariat

Governmental Response

Airport temperature screening

Community engagements / Road shows

Governmental Response

Epi / Surveillance Team

Alert Investigation and Response

Contact tracing

Data Management

Operational Research

Administration and Logistics

Governmental Preparedness  Following the declaration of Nigeria as being Ebola free on 20 th October 2014, the WHO gave its consolidated EVD preparedness checklist  The 10-component checklist is aimed at identifying key capacity gaps for preparedness at National level & help countries to cope better should they be faced again with another outbreak

Nigeria Offshore Industry Preparedness  Why prepare? – Nigeria essentially a mono-product economy. Major revenue for Govt.  Considered complimentary to the government control / response efforts  Forum of Medical / HSE depts of major stakeholders met to discuss  Staged Preparedness (Stage 1 - 4)  Stage 1: No case in country  Stage 2: Case in country but contained  Stage 3: Uncontrolled spread in community  Stage 4: Case or suspected case in company  Daily Risk Monitoring: A trigger tool    

Case following Media & Social networks scanning Other Stakeholders’ measures Social infrastructure impacted

Nigeria Offshore Industry Preparedness Stage I Action Plan

NOT APPLICABLE

Nigeria Offshore Industry Preparedness Stage II Action Plan Shore-side Offices 

Awareness & Communication

Offshore sites 

 staff sessions, posters, intranet, publications,

emails, etc 

 staff sessions, posters, intranet, publications, emails, etc



Hygiene and Sanitation

disinfection, etc 





 dedicated training for cleaning staff on PPEs & disinfection, etc



 Contractor Forum



T0 screening



Specific procedure for dealing with T0 >380C

Medical preparedness  minimum stock PPEs

Access Control  Helicopter pre-board T0 screening @ heliports

Access Control 

Stakeholder Engagements  Supply chain liaison

Stakeholder Engagements  company unions

Hygiene and Sanitation  Hand washing, EtOH sanitizers,

 Hand washing, EtOH sanitizers,

 dedicated training for cleaning staff on PPEs &

Awareness & Communication

 Provision of holding tents and dedicated / configured ambulances

for suspected cases 

Medical preparedness  Dedicated offshore medical team training on Ebola & infection

control (including decontamination + medical waste mgt)

 referral clinic engagements,

 Daily T0 screens onboard to detect earliest sign of Ebola

 holding areas & isolation tents

 risk-based approach to diagnosing a high-grade fever,  Strategic decision for single-occupancy Medevacs for cases of

fever,  Identification of suitable isolation rooms,  Provision of containment chambers for Medevac of suspected

cases

Nigeria Offshore Industry Preparedness Stage II Action Plan

Isolation tents

Negative pressure Isolation chamber

Nigeria Offshore Industry Preparedness Stage III Action Plan Shore-side Offices 

Awareness & Communication

Offshore sites 

 Reinforce infection control message (limit touch “Ebola

 Reinforce infection control message (limit touch

“Ebola greeting”)

greeting”)

 Regular updates to staff & families on measures

 Regular updates to staff by OIM on measures put in place

put in place  Prompt reporting of any flu-like illness

 

Hygiene and Sanitation  Strengthen hand washing, EtOH sanitizers,



Stakeholder Engagements  Liaison with Ebola EOC, Airline + helicopters, Embassies



Movement / Travel restrictions

Movement / Travel Restrictions  Helicopter pre-board T0 screening @ heliports

 Restriction indoors after work

 Minimum (4wks) stocking of consumables and groceries

 Minimum (2wks) stocking of consumables and

 Consider de-manning platform / rig to minimum safe levels

groceries  No school for children  Consider controlled repatriation of expat families





Stakeholder Engagements  Liaison with Ebola EOC, Airlines, Embassies



 Prompt reporting of any flu-like illness

Hygiene and Sanitation  Strengthen hand washing, EtOH sanitizers,

Awareness & Communication

Medical preparedness  minimum stock PPEs  referral clinic engagements,  holding areas & isolation tents  HR Crisis Call center



Medical preparedness  Maintain Stage II Action Plans (importantly, daily T0 checks)

N.B: The offshore environment affords some level of protection from contact with the community, and so considered to be a “haven” at this stage

Nigeria Offshore Industry Preparedness Stage IV Action Plan Shore-side Offices 

Awareness & Communication



 Stage III communications

 In event of suspected case, controlled

 In event of suspected case, controlled communication



Hygiene and Sanitation Stakeholder Engagements

 Single-use cutlery



 Liaison with Ebola EOC / WHO / CDC, State



helicopter operators 

Movement / Travel restrictions

supply

 Authorities will ensure “shutdown” of offices for

 OIM to enforce the concept of QUARANTINE of asset

decontamination

 Offshore security vessels to maintain “Quarantine Perimeter”

 Invoke full complement of Business Continuity &

 All onboard crew to have T0 monitored at least daily for 21 days

Crisis Management processes

 Invoke full complement of Business Continuity & Crisis

Medical / Psychological Support  Regular liaison with EOC for the suspected case  Follow up with state authorities for

decontamination  Psychological support + counselling for colleagues

Movement / Travel Restrictions  Minimum (4wks) stocking of consumables and groceries each

 Staff stay at home.



Stakeholder Engagements  Liaison with Ebola EOC / WHO / CDC, State health agencies,

health agencies  Contractors, Suppliers, Partners, Regulators

Hygiene and Sanitation  Strengthen hand washing, EtOH sanitizers,

 Strengthen hand washing, EtOH sanitizers,



Awareness & Communication

 Stage III communications

communication 

Offshore sites

Management processes 

Medical / Psychological Support  Regular liaison with EOC for the suspected case  Follow up with state authorities for decontamination  Psychological support + counselling for colleagues

What we have learnt so far……

 Infectivity:  Someone in contact with any surface in contact with body fluid of an EVD patient can themselves contract the virus  Urban spread of recent outbreak poses epidemiological curiosity

 National Responsibility:  Government will assume responsibility and will take over response at Country level  Cases of EVD in expatriates will be managed using diplomatic channels for repatriation  International MEDEVAC:  Most medical assistance companies will not be able to offer Int’l medevac  Most likely will be realised as a military mission  Suspected case offshore  No national or industry guideline (Pandemic preparedness)  The offshore facility will be “shutdown” like any other facility reporting a case  Concept of “Quarantine” will be enforced even offshore

 Business Continuity / Crisis Management  Incident Management Approach – proven methodology (Crisis Communication)

Dr. ‘Lanre Ajayi

M.B.Ch.B, MFOM

Director, Occupational Health Clinics Medbury Medical Services Lagos, Nigeria T: +234 809 304 4754 www.medburymedicals.com

Alternative Methods of Medical Assessment Dr David Leiper Screening Physician Capita Health and Wellbeing

Alternative Methods of Medical Assessment- Update 2015 Dr David B Leiper

Energy Medical Services

Personal History 1997 Glasgow Medical School

2000 GP Principal Lanarkshire

2004 GP Unscheduled Care Grampian

2010 Topside and Diving cover Capita

2013 Occupational Medicine Capita

Clinical supervision NHS GP Unscheduled Care Grampian

163

History within Oil and Gas Industry

164

What we do

Medical Assessments

Topside and Diving

Clinics

Provision of Medical Staff

Sickness Absence Management

Clinical Governance

Energy Medical Services

International Assistance

Energy Medical Services

Energy Medical Services

Energy Medical Services

Potential uses

• Remote Health Surveillance Respiratory Skin Noise Hand Arm Vibration Working at Heights/Confined Spaces • Remote OGUK medicals • Additional information for working in other sectors • Remote Primary Care consultations when no medic Energy Medical Services

169

Offshore Medicals

Non-medical practitioner led care • Pre-operative assessment • Chronic disease management in primary care • Nurse and paramedic practitioners in unscheduled care and primary care

Energy Medical Services

170

Offshore Medicals

Criteria• Current, valid OGUK certificate (with at least one month remaining until expiry) • Only those with unrestricted certificates would be considered.

Energy Medical Services

171

Energy Medical Services

172

Energy Medical Services

173

Energy Medical Services

174

Medic Training

Energy Medical Services

The competencies required by the medicTo be able to perform a medical to a level where the doctor only needs to review the paperwork and sign off

Energy Medical Services

176

Clinical Supervision and Mentoring • Medics will spend full day at Capita under the supervision of a clinician • Shadowing • Supervised medicals

• Further day spent with the equipment.

Energy Medical Services

177

Offshore Medicals

• 126 medicals performed to date • 3 Installations in UKCS • 2 “failures” • 4 time-restricted certificates – Bp, weight, lung function, haematuria

Energy Medical Services

178

Patient Demographics

Gender 3

Male Female

123

Energy Medical Services

179

Patient BMI

Body Mass Index 9%

1% 11% 21% 40

58%

Energy Medical Services

180

Offshore Medicals

Blood Pressure 100 80 60 40 Blood Pressure

20 0 < 140/90

140/90 160/100

> 160/100

Energy Medical Services

181

Patient Demographics

Smoking Status

39 Smoker Non Smoker

87

Energy Medical Services

182

Examination findings • Assymptomatic haematuria / proteinuria – 6 • 5 aged 40 – time restricted 3 month certificate- satisfactory GP report

Energy Medical Services

183

Examination findings Lung function • One case severe COPD • GP report- failed

Energy Medical Services

184

Examination findings BMI • One case BMI over 40 • No certificate issued- further information required

Energy Medical Services

185

Examination findings Others• Mild eczema • OA (clinically) of knee • Psoriasis • Fungal nail infection

Energy Medical Services

186

Offshore Medical Satisfaction Survey

Client Feedback

We would be grateful if you could spare a few minutes to complete this Client Satisfaction Survey to help us improve our standard of customer care Name:

Company:

Date of Appointment:

Type of Appointment:

Offshore Medical

Please tick the appropriate box to indicate your degree of satisfaction 1 = Excellent; 2 = Good; 3 = Satisfactory; 4 = Unsatisfactory; 5 = Poor Offshore Medical Experience 1

2

Yes

No

Yes

No

3

4

5

COMMENTS

How would you rate you offshore medical experience? How would you rate the quality of the service you received? How does your experience compare to that of a medical performed in an onshore clinic? COMMENTS

A doctor will be reviewing your medical information, but does it concern you that you are not seeing a doctor face to face? Would you have your medical performed offshore again? Why? N/A

COMMENTS

If you had any health related questions today, was the medic able to address these? Offshore Onshore

COMMENTS

Do you prefer having your medical done offshore or onshore? Why? COMMENTS Is there anything that can be done to improve the experience? Additional Comments

Thank you very much for taking the time to complete our survey

Energy Medical Services

187

Benefits

Medics • Medical task rather than administrative task • Familiarisation with the core crew • Examination experience

Energy Medical Services

188

Benefits

Client • Convenience • No time taken from “field break” • Problems identified can be monitored during the hitch

Energy Medical Services

189

Benefits

Customer • Cost savings •

Travel

•

Accommodation

•

Day rate

Energy Medical Services

190

Thank you

Energy Medical Services 191

Alternative Methods of Medical Assessment Dr Olgha Asatiani Director Of Remote Medical Care RS Occupational Health, A DISA Company

OGUK Nurse Led Medical Assessments – CROSSING THE RUBICON

Dr Olgha Asatiani Director of Remote Medical Care RS Occupational Health, a DISA Company 20 May 2015

Outline •Pre-history – an alternative view •Journey so far •Future steps and goals

Golden Rule of Journalism • Tell them what you will tell them; • Then tell them; • Then tell them what you have told them

Pre-history •Beginnings: RSOH Research One man's empirical findings Development of concept – efficient utilisation of a medical professional for the role, extra value: 











Assessment of fitness – initial nurse 'screen' Refer 'difficult cases' to doctor Incorporating risk profiling

Pre-history •Project implementation:  29 January 2014  Medical Algorithms  4 stages: Training Initial implementation Incorporate into normal working Evaluation •OGUK conference 2014 







OGUK Conference 2014 •Next steps

Continue stage 3 to end June Formal and comprehensive review ?Fit for purpose l

l

l

Journey So Far •“The Shakkin Briggie” across the Rubicon – first 6 months •Management decision •Clinical Audit

Dr Diack’s Audit April/ August 2014 (272 medicals)

•April - 79 •Referred to Doctor indicator - 4 (5%) • Discussed with doctor but not identified by referred to doctor indicator – 4 (5%)

•August -193 •Referred to doctor indicator – 18 (9.3%) • Discussed with doctor but not identified by referred to doctor indicator - 20 (10.4%)

Dr Diack’s Audit April/ August 2014 (272 medicals)

• A few medicals with no referral and no comment but potentially significant medical conditions: o April - 14 (17.7 %) o August - 7( 3.6%)

Dr Diack’s Audit April/ August 2014 (272 medicals)

• Examples: • 30 year old Rope Access fabricator on Champix • 39 year old Service Delivery Manager with ? suboptimal control of asthma • 39 year old Field Engineer identified GI problem – no details recorded • 57 year old Maintenance Supervisor random blood sugar of 8.0, known hypertension on treatment BP 164/100

Journey So Far September 2014 • Clinical issues –Algorithms; –Training; –Inconsistency of advice; –Confidence

• Administrative issues –Reporting process; –Dr’s notification; –Medicals not reported –Other tasks for DRs

Nurse Led OGUK Medicals Project Improvement Plan

• Working group – Drs, nurses, business support team; • Identifying priorities – process, algorithms, training/ nurses’ training pack; • Audit – questionnaire; • Topics – diabetes, hypertension, asthma, BMI, depression, vision and hearing; • Training schedule

Plans are only good intentions unless they immediately degenerate into hard work.” Peter Drucker

Nurse Led OGUK Medicals Project Improvement Plan

Journey So Far – Algorithms Review

Journey So Far – Algorithms Review

Presentation title

Presentation title

Presentation title

December 15

Journey So Far – Nurses Training/ Training Pack

• Provided training – Back Pain – History Taking in Occ Medicine – Depression & Anxiety

• Planned Training: – Diabetes – Asthma – Case Studies

Journey So Far –

Statistical Data - 2758 Medicals (29.01.14 -15.05.15)

Journey So Far –

Further Medical Audit February/ April 2015 (470 medicals)

• February - 221 –Referred to doctor indicator - 57 (25.8%) –Discussed with doctor but not identified by ‘referred to doctor’ indicator - 3 (1.35%)

• April - 249 –Referred to doctor indicator - 59 (23.6%) –Discussed with doctor but not identified by ‘referred to doctor’ indicator – 24 (9.6 %)

Journey So Far –

Further Medical Audit February/ April 2015 (470 medicals)

• A few medicals with no referral and no comment but potentially significant medical conditions: o February - 6 (2.7%) o April - 5 (2%)  Only 2 certificates were deferred, none failed

Journey So Far – Further Medical Audit

Clients’ Satisfaction Questionnaire N=200

Clients’ Satisfaction Questionnaire Analysis Comments 2, 3%

1, 1%

15, 20%

1, 1% 1, 1% 2, 3%

44, 58%

10, 13%

Excellent Medical/Staff New style preferred Informative Medical Less stressful Medical carried out well Copy of results COMMS Feedback of results

Clients’ Satisfaction Questionnaire Analysis The Most Helpful Part

Future Steps and Goals • Training process - new starts; video lectures; • Implementation of the project at RCMC, Great Yarmouth and Inverness clinics • Qualitative questionnaire; • RSOH Doctors’ internal OGUK algorithms To avoid criticism say nothing, do nothing, be nothing Aristotle

Summary •Pre-history – an alternative view •Journey so far •Future steps and goals

Golden Rule of Journalism • Tell them what you will tell them; • Then tell them; • Then tell them what you have told them

Nurse Led OGUK Medicals – ONE of Success Stories •Client’s ( YD,DOB - 05.09.88) Questionnaire: “Work with radiation sources and a radiation generator. •Nurse’s notes on COMMS: • “Continues to work with radiation source and has not had a IR medical. Will continue to work with radiation source in workshop. Only goes offshore on occasional visits.” •“Health screening completed and satisfactory. Works with radiation in workshop but has not had IR medical, company informed and to be arranged.”

Revisions to Oil & Gas UK Medical Guidance Dr Graham Furnace Medical Advisor Oil & Gas UK

Examining Doctor Conference 2015

Revisions to Guidelines

Present Guidelines

Edition 6, 2008

Booklet format (pdf) Available to purchase

Time to change

Edition 7, 2015

Web-based format Open-access

Topic List

Anticoagulants Emergency Response Teams

Hearing Aids Medications

Obesity Pacemakers/Implanted Defibrillators

Cost Control?

Medic involvement Employee of Oil&Gas UK member company Employer can name a medical advisor Advisor has UK qualification in Occupational Medicine Advisor has access to previous medicals Agreement of Installation Operator Medical Advisor Assessment includes:

Medic report (medevac, treatment notes, medication declarations) Employer report (medevac, sickness absence, missed trips)

Nurse involvement

Program is under direction of UK MFOM-qualified OP Work to defined protocols

Protocols approved by OGUK

Going further…..

Calculating PPV – an example

‘near-patient’ Hb test – screen for anaemia ‘adds value’ near-patient test – convenient, inexpensive a good thing?

An example Prevalence of anaemia UK males – 3% Near-patient test vs. laboratory Hb: Sensitivity – 80% (0.8)

Specificity – 90% (0.9) PPV?

Condition (as determined by “Gold Standard")

Total population

Test outcome positive

Condition positive

Condition negative

Prevalence = Σ Condition positive/ Σ Total population

False Positive

Positive Predictive Value (PPV, Precision) = Σ True positive/

True Positive (Type 1 error)

Test outcome Test outcome negative

False Negative True Negative (Type 2 error)

True Positive Rate (TPR, Sensitivity) = Σ True positive/ Σ Condition positive

False Positive Rate (FPR) = Σ False positive/ Σ Condition negative

True Negative Rate (TNR, Specificity) = Σ True negative/ Σ Condition negative

Σ Test outcome positive

Condition (as determined by “Gold Standard")

Total population 1000 (assume)

Test outcome positive

2. Condition positive 30 (solved by calc from 1.)

3. Condition negative 970 (solved by calc: = 1000-30)

7. True Positive 24 (solved by calc from 6. = 0.8 x 30)

9. False Positive (Type 1 error) 97 (solved by calc from 3. and 5. = 970 – 873)

Test outcome

1.

Prevalence (known 0.03) = Σ Condition positive/ Σ Total population (known 1000)

10. Positive Predictive Value (PPV, Precision) = Σ True positive/ Σ Test outcome positive = 7./(7.+ 9.) = 24/121 = 19.8%

Test outcome negative

8. False Negative (Type 2 error) 6 (solved by calc from 2. and 7. = 30 – 24)

5. True Negative 873 (solved by calc from 4. = 0.9 x 970)

6. True Positive Rate (TPR, 11. False Positive Rate (FPR) = Sensitivity – known 0.8) = Σ False positive (known from 9.)/ Σ True positive/ Σ Condition negative (known Σ Condition positive (known from from 3.) = 97/970 = 10% 2. is 30)

4. True Negative Rate (TNR, Specificity – known 0.9) = Σ True negative/ Σ Condition negative (known from 3. is 970)

An example

1000 workers : 24 who do have anaemia found – success! 6 who do have anaemia missed 97 false positives - do not have anaemia

Positive Predictive Value is 20%. 24 out of 1000 (2.4%) benefit for 6+97 = 103 of 1000 (10.3%) ‘get it wrong’

Choosing Wisely

www.choosingwisely.org (US, Canada) Academy of Medical Royal Colleges (UK) ‘Top 5’ tests or interventions of ‘questionable value’ Occupational Medicine? Oil&Gas UK Medical?

Choosing Wisely – Oil&Gas UK medical

‘routine’ blood tests ‘routine’ urinalysis ‘routine’ spirometry

Routine dipstick urinalysis in daily practice of Belgian occupational physicians Braeckman et al. Archives of Public Health 2012, 70:15 http://www.archpublichealth.com/content/70/1/15 Abstract Background: Little work has been done to assess the quality of health care and use of evidence-based methods by occupational physicians in Belgium. Therefore, the main objective is to describe the common use of dipstick urinalysis, and to compare the current practice with international guidelines.

Methods: A self-administered questionnaire was mailed to 211 members of the Scientific Association of Occupational Medicine in the Dutch speaking part of Belgium. Results: A total of 120 occupational physicians responded; response rate of 57%. Dipstick urinalysis was a routine investigation for the majority (69%) of physicians. All test strips screened for protein, and 90% for blood. Occupational health services offered clinical tests to satisfy customer wants - international guidelines do not recommend screening for haematuria and proteinuria in asymptomatic adults. A lack of knowledge concerning positive testing and referral criteria was demonstrated in almost half of the study participants. Conclusions: Belgian occupational physicians still routinely perform dipstick testing although there is no evidence to support this screening in healthy workers. To practice evidencebased medicine, occupational physicians need more instruction and training. Development and implementation of more guidelines is not only of use for the individual practitioner, it may also enhance professionalization and efficiency of occupational health care

Choosing Wisely – Oil&Gas UK medical

What are your suggestions?

Panel Session Chaired By: Robert Paterson Health, Safety and Employment Issues Director Oil & Gas UK

Closing Remarks Robert Paterson Health, Safety and Employment Issues Director Oil & Gas UK