Occupational injury severity among healthcare workers: a retrospective study

This study investigates the determinants of injury severity among HCWs at a tertiary hospital, over a five-year period. To our knowledge, this is the first study that explores the severity of injuries sustained by HCWs while performing their clinical duties. Several studies have been conducted across various industries and sectors [15, 18], but few have focused on hospitals. The findings highlight the critical need for tailored safety measures and interventions to reduce the severity of injuries sustained by HCW on the job. By identifying key determinants of injury severity, the results can provide insights to guide the development of effective prevention strategies and improve workplace safety in healthcare environments. This study showed that approximately 27% of all reported injuries required urgent evaluation at the ED. The key findings indicated that injury severity, defined by the necessity of an ED visit, is significantly associated with sex and type of injury, but not with occupation.

Within the context of this study, males sustained more severe injuries than females. This aligns with previous research documenting a male predominance in injury severity and ED visits in different industries [21,22,23]. In a study investigating the characteristics of occupational injuries among Spanish nurses, men were found to suffer more severe injuries than women [24]. Similarly, in the healthcare setting, evidence has shown that the rate of fatal injuries was the highest among older men [25]. This sex disparity could be multifaceted, involving differences in job roles, physical demands, and reporting behaviors.

As for age, the analysis failed to confirm any significant association. Some evidence suggested that older workers sustain more severe injuries [22, 26, 27]. However, according to a recent systematic review, nearly half of the examined studies showed no severity difference between older and younger workers [28], introducing uncertainty into classifying age as a risk or protective factor for occupational injury severity [28]. The rationale behind such inconclusive results could be that younger workers are involved in more hazardous jobs, while older workers are more susceptible to injuries.

Exposure to bloodborne pathogens (BBP) through needle pricks and contact with blood and other body fluids was found to be less severe compared to other injury mechanisms. However, such injuries are known to carry a substantial psychologic burden and serious emotional distress among HCWs who experience a needle-stick by fear of transmission of a virus [29]. BBP exposures contribute to 39%, 37% and 4.4% of hepatitis C, hepatitis B and HIV infections respectively, among HCWs [30]. Moreover, BBP impose high cost on the healthcare system, particularly as exposed employee are required to undergo comprehensive serologic testing at various time intervals and follow-up assessments at the clinic if the source was positive for any of the BBP [29].

Exposure to harmful substances or environments was also found to be less severe compared to other injury mechanism. HCWs who reported such injuries were mainly exposed to chemicals at the hospital. According to a review on occupational chemical exposures, HCWs are mainly at increased risk of irritant and allergic contact dermatitis [31]. They are commonly exposed to biocides used for application such as the sterilization of medical devices, quaternary ammonia compounds for disinfection, and allergens found in medical gloves and sanitizers [31]. These common conditions are usually treated in the clinic and rarely require an urgent ED visit.

Transport-related injuries were found to be more severe compared to other injury mechanism. This finding aligns with previous evidence from the literature in both the healthcare setting [22, 25] and other industries [17]. In Lebanon, injuries sustained by employees while commuting to work are considered work-related by Labor law. Shift work (which is the case of most HCWs) is correlated with higher incidence of road traffic injuries [32]. This issue is highly noticeable in LMIC, where the infrastructure may be less developed, traffic regulations less strictly enforced, and public transportation frequently unavailable [33]. In such settings, the combination of shift work and challenging commuting conditions may increase the risk of transport-related injuries among HCWs. Few studies have been conducted in the healthcare industry, indicating that transportation work-related injuries tend to be severe [22] and result in higher fatality rates [25].

Finally, our findings at the bivariate level showed that PNs sustain more severe injuries compared to other HCWs. PNs and other assistant nursing personnel are involved in physically demanding jobs that require lifting, positioning, toileting and ambulating patients [34]. Such repetitive and fast-paced tasks, often completed when standing in awkward postures, put HCWs at an increased risk of musculoskeletal injuries, mostly back and other joints injuries [34]. The burden of such injuries among nurses is reflected by the increased rate of sick leaves and worker’s compensation claims [35].

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Study limitations and strengths

This study has some limitations. First, the findings are based on data from a single tertiary care center, which may limit the generalizability of results to other healthcare settings or regions with different reporting systems, organizational practices and cultural contexts. Second, using ED visits to estimate injury severity could be considered a limited proxy measure. In the context of this study, the only available information was the occurrence of an ED visit. It was not possible to access additional data since the incident report form is maintained separately from the electronic medical chart of the workers. However, the exclusion by design approach of the injuries recorded during the UHS clinics closure times can potentially address this limitation. Third, the data might have over-reported BBP exposures, since HCWs fear transmissions of viruses and wish to conduct regular testing and follow ups as indicated. This is in contrast with a potential under-reporting of musculoskeletal injuries, because many HCWs might be apprehensive to declare such incidents by fear of retaliation or job transfer [36, 37]. Finally, routinely collected data allow for a minimal amount of data to be collected and do not serve as an accurate and complete source of information. While our study provides valuable insights into injury determinants, the absence of post-injury care data (incident related sick leave, hospitalizations, surgeries, and resulting modified work) limits the ability to categorize injuries based on clinical severity beyond incident report classifications. Future research utilizing electronic health records and administrative sick leave data will provide a more comprehensive analysis of injury severity, including hospitalization, surgical interventions, and return-to-work timelines.

This study has several strengths that are worth emphasizing. First, it involves a comprehensive dataset collected over five years, encompassing a large number of incidents. The multifactorial analysis, through employing a multiple logistic regression model, effectively identifies and adjusts for various confounding factors, providing a clear understanding of the simultaneous impact of different predictors on injury severity. Second, the incident reports were completed in an accurate, reliable, and consistent way. The de-identified injury dataset was retrieved from the online incident report. This electronic system is user-friendly, and the injured worker can easily submit an incident immediately when it occurs on the day of the injury. Using such records ensures greater data accuracy, reliability, and objectivity, instead of relying on participants’ retrospective recollection of injuries. Third, the study examines occupational injury severity within the broader context of socio-economic crisis, workforce restructuring and the COVID-19 pandemic in an LMIC setting. It provides valuable insights specific to the MENA context, which is underrepresented in the occupational health literature. Despite its global burden [38], occupational injuries tend to be under-reported, especially in LMIC due to the low resource setting and the lack of surveillance systems [39, 40].

Recommendations

Occupational injuries are preventable causes of morbidity and mortality. In the light of the findings of this study, we propose a series of recommendations to mitigate the risk of sustaining severe injuries by HCWs.

Engineering controls: Hospitals should prioritize engineering measures to enhance workplace safety and minimize injury risks for HCWs. This includes the adoption of safety-engineered devices (such as retractable needles), ergonomic workplace design, and well-maintained lifting equipment to reduce the physical strain associated with patient handling. Additionally, hospitals should install slip-resistant flooring in high-risk areas, ensure adequate lighting and hazard signage, and provide adjustable workstations to accommodate different HCWs’ needs. The use of personal protective equipment (PPE) should also be promoted. HCWs commuting to work by motorcycle (a common practice in LMIC) should be required to wear a helmet, protective clothing, such as knees and elbows pads. The use of slip-resistant footwear is also essential to avoid slips, trips, and falls.

Safe patient handling and motility (SPHM) program: The implementation of an evidence-based SPHM program through a minimal lift policy and the promotion of lifting equipment is highly encouraged [41]. Targeted training for PNs, a group of employees with higher rates of severe injuries, and other high-risk groups on safe handling practices and injury prevention can mitigate the risk of severe injuries. Hospitals should establish regular safety audits, compliance monitoring, and feedback mechanisms to assess program adherence and identify areas for improvement.

Occupational health documentation: The incorporation of a standardized measure of injury severity in occupational health records is needed. This improvement would facilitate more accurate assessments in future studies and support better workplace safety interventions.

Psychosocial support: Continuous support of HCWs’ mental health and well-being is important. Stress management resources and wellness programs can help alleviate the negative effects of job strain. A culture of open communication is essential to address the psychological and emotional needs of HCWs. These initiatives closely align with the NIOSH Total Worker Health^® (TWH) program that integrates health promotion and workplace safety, to advance workers’ well-being [42]. By adopting the TWH approach, hospitals can develop more holistic support systems and promote injury-prevention efforts for a healthier workforce [42].

Behavioral change interventions: Safety measures aiming at reducing injury risk and fostering a culture of safety are instrumental to be implemented at both individual and organizational levels. Behaviors, such as unsafe driving when commuting to work and not respecting safety signs should be changed. Training sessions, education and strengthening safety protocols, especially for activities prone to causing severe injuries are essential. Furthermore, since in the context of our study there was no way of knowing how many of the transport injuries were from people commuting to work versus those conducting hospital/university business in a vehicle, one suggestion is to modify the occupational health record to more easily identify these two groups. This is important for planning future interventions, including general transport, safety awareness, campaigns, and dedicated mandatory training for drivers and other university employees that are more highly exposed to transport injury.

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