A key role for all clinicians advising about return to work, is to acquire some understanding of the task requirements of their patient’s work and to assess and advise about the patient’s functional capability both in the short term and in the context of their prognosis.
In the current COVID-19 pandemic, clinicians in many settings may be asked to provide guidance on return to work for individuals. This will be particularly important during the phased relaxation of the current lockdown measures. Many of the millions of workers returning to work will have underlying health conditions and they, and possibly their employers, will be seeking advice from their General Practitioners, hospital specialists, nurse practitioners, allied health professionals and others, as well as occupational health (OH) specialists.
In doing so, these clinicians will need to take into account the COVID-19 infection risk arising from underlying health conditions (i.e medical/clinical vulnerability) as well as the individual’s workplace, work activities and work environment.
Figure 1 illustrates the key areas for consideration in providing such guidance. A brief summary guide and resource list are provided in Section 2. This section provides more detailed guidance in navigating each step of the process and working through the risk assessment and risk judgement processes. Specific tools and illustrative examples are provided for this purpose.
Medical vulnerability risk will require clinical assessment of the clinical history and risk factors. Workplace infection transmission risk assessment remains the duty of the employer and guidance and references to assist with this are provided. The employer has significant responsibilities for ensuring an adequate risk assessment is carried out and that all reasonable control measures are implemented and maintained. Many workers may also be able to access advice from their employer’s Occupational Health (OH) service.
Discussion of risks and recommendations with individual employees is important for a successful return to work.
All employers will require to undertake a risk assessment of their workplace and work activities and to implement control measures to reduce COVID-19 related risks for transmission of infection, in accordance with the 5 steps approach adopted by the Health & Safety Executive (HSE) for all risk assessments.
The lowest risk position is likely to be working from home however, there are many occupations whereby this is not reasonably practicable.
COVID-19 transmission arises mainly from:
• Contact with contaminated surfaces
• Droplet spread – e.g. coughs and sneezes
Aerosol spread can occur mainly in healthcare settings and aerosol generating procedures (AGPs) would be regarded as high risk.
Figure 2 outlines some main considerations for employers. An awareness of these work-based COVID-19 transmission risk factors will also assist clinicians in discussing return to work risks with their patients. This list is not exhaustive and there may be other risk factors specific for particular workplaces.
Work Tasks
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Work Location
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Work Organisation
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Workplace Travel
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Work Movement
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Personal Protective Equipment (PPE)
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Workplace Hygiene
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Personal Hygiene
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Avoidance of symptomatic people
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Fighure - 2 Main Work Risk Factors for COVID-19 Transmission |
Once risk factors for the transmission of COVID-19 infection in the workplace have been identified, implementation of control measures should be considered to reduce this risk. Not all controls will be applicable or practicable in all workplaces. Figure 3 uses the Hierarchy of Control approach to provide examples of control measures that can be considered.
Graphic (3) uses the Hierarchy of Control approach to provide examples of control measures that can be considered.
Administrative controls | • Travel to and from work- parking space provision, alternatives if no car/cannot drive • Social distancing compliance supervisor – for monitoring each shift- to oversee compliance with COVID-19 control measures (i.e. maintenance of social distancing and effective use of PPE) • Staggered arrival times and shifts/staggered breaks and lunch • Online/remote meetings (e.g. Microsoft teams, Skype business, Zoom) • Clear guidance for workers who have COVID-19 symptoms not to present for work – clarity on timeline for self- isolation and clarity on when to contact HR/manager once this has passed for return to work assessments to take place timeously • Increasing COVID-19 safety precaution signage |
Engineering controls |
• Individual workspaces • 2m social distancing of work colleagues- restructure of work environment layout • Floor markings for flow of movement and safe ‘box’ parameter for each employee • Segregate employees by methods such as enclosing or guarding screens, if at higher exposure e.g. customer facing roles. • Temperature checks- pre-shift (consider most appropriate types of devices and defined temperature cut off point) • Hand hygiene measures/ Regular disinfection of common surfaces • Social distancing in break out spaces- canteens/lunch-rooms • Social distancing measures for toilet facility use – traffic light system |
PPE | • PPE (masks/face coverings, gloves, aprons) – (advice on adequacy of PPE and overall risk applying other hierarchy of control, control measures) • FFP3 or suitable alternative if close working proximity required for specific tasks. |
Figure 3 – A Hierarchy of control model for COVID-19 transmission risk |
Once risk factors for transmission of COVID-19 infection have been considered and practicable control measures have been applied, an overall workplace risk judgement should be made. Specifically, in the context of this document, it is the risk of transmission of COVID-19 through work activities that needs assessed. Figure 4 below outlines a simple table of risk factors that can be used to summarise the residual risk of COVID-19 transmission through work activities. It describes some of the main situations related to work whereby the risk of exposure to infection can occur. This list is not exhaustive and the notes in Appendix 2 provide more detailed explanation of each risk factor.
The overall workplace risk judgement would be the highest risk level reached (i.e. coloured risk category) for any specific risk factor, after control measures are implemented.
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Based on risk after control measures are implemented** |
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Risk ID |
Risk Factors |
Very Low * |
Standard |
Medium |
High |
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1 |
Patient/Service user/Public Facing |
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2 |
Ability to maintain social distancing at work >2m |
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3 |
Number of different people sharing the workplace |
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4 |
Travel to and from work |
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5 |
Workplace entry and exit |
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6 |
Availability and use of PPE |
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7 |
Ability to maintain hand hygiene |
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8 |
Workplace environment cleanliness control |
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9 |
Ability to avoid symptomatic people |
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Figure 4 - Summary of residual COVID-19 workplace transmission risk |
*a low risk environment is likely to be home working or isolated, non-shared office working
**The overall workplace risk judgement would be the highest risk level reached (i.e. coloured risk category) for any specific risk factor, after control measures are implemented.
Illustrative examples of risk judgements are included in Appendix 1. Low risk is likely to mean working from home or isolated, non-shared office working.
The overall workplace COVID-19 transmission risk together with the medical vulnerability risk will be necessary in order to make an overall OH risk assessment and provide return to work advice to individual workers tailored to their specific work environment/activities.
Many patients with underlying health conditions will need individualised guidance on their vulnerability risk of severe COVID-19 infection. The UK Government have produced guidance on shielding and increased vulnerability groups. Many patients in the increased vulnerability group will be able to present to workplaces, depending on the overall residual workplace risk, as described in Section 1.
Clinicians can consider the following points when providing guidance to patients:
Government and clinical guidance are frequently being updated so be vigilant for this.
The main objective of this guide is to assist clinicians in providing individual patient advice on return to work. Figure 6 details return to work advice recommendations taking into account both work transmission risk and medical/clinical vulnerability risk levels and Figure 5 demonstrates the interaction of these factors.
Extremely High Clinical Risk (Shielder) - Home Working Required
Low workplace transmission risk environments/tasks only (i.e. homeworking) |
Very High Clinical Risk - Home Working Required
As for shielders- Homeworking LIKELY TO BE REQUIRED Low workplace transmission risk environments/tasks only (i.e. homeworking) OH assessment to be considered, if case more complex |
High/Increased Clinical Risk - Can Work in a Low Risk Environment
Homeworking if possible, but if not, can attend workplace provided appropriate workplace hygiene measures and stringent social distancing (2m rule) are operationally feasible/can be reliably implemented (specific recommendations from Figure 3 menu list above bearing in mind hierarchy of controls). *Exceptions can apply for critical and essential services e.g. direct patient care and community care where social distancing is not possible, but COVID-19 transmission can be reduced by high-level PPE and diligent hand and workplace hygiene. Avoidance of public transport use recommended, if possible. Low (Homeworking), Standard or Medium workplace transmission risk environments/tasks (subject to individual risk assessment). OH assessment to be considered, if case more complex. |
Increased Clinical Risk - Can Work in a Medium Risk Environment
Homeworking if possible, but if not, can attend workplace provided appropriate workplace hygiene measures and stringent social distancing (2m rule) are operationally feasible/can be reliably implemented (specific recommendations from Figure 3 menu list above bearing in mind hierarchy of controls). *Exceptions can apply for critical and essential services e.g. direct patient care and community care where social distancing is not possible, but COVID-19 transmission can be reduced by high-level PPE and diligent hand and workplace hygiene. Avoidance of public transport use recommended, if possible. Low (Homeworking), Standard or Medium workplace transmission risk environments/tasks (subject to individual risk assessment). OH assessment to be considered, if case more complex. |
Standard Clincal Risk - Can Work in a High Risk Environment, if Essential
Homeworking if possible, but if not, can attend workplace provided appropriate workplace hygiene measures and social distancing (2m rule) are operationally feasible/can be reliably implemented (specific recommendations from menu list above bearing in mind hierarchy of controls). *Exceptions can apply for critical and essential services where social distancing is not possible e.g. direct patient care and community care but also other specific work sectors [9] where the particular activity is considered necessary for the business to continue to operate. If so, all mitigating actions possible to reduce workplace transmission risk should be taken and social distancing guidelines should continue to be adhered to, ‘wherever possible’. Can use public transport, if cannot be avoided (with appropriate face covering). Low (Homeworking), Standard, Medium and possibly High risk (e.g. with higher level PPE) workplace transmission risk environments/tasks (subject to individual risk assessment). |
Figure 6 - Overall OH risk assessment judgements and corresponding individual RTW advice |
The advice above is on the proviso that employers ensure control measures are reliably implemented and maintained and employees also have a duty to comply with these control measures.
Discussion with employee on health promotion activities tailored to their current health behaviours, lifestyle, emotional health and wellbeing and any specific concerns they have. Potential interventions may include:
• Diet and physical activity- signpost to appropriate online apps and resources.
• Consideration of multivitamin and Vitamin D supplements (particularly, if BAME)
• BMI- signposting to online weight management programmes
• Smoking- signpost to online smoking cessation programmes/websites
• Alcohol – signpost to online alcohol support services
• MH First Aid/ Emotional resilience and signpost to online support e.g. www.llttf.com/corona. Employee counselling services may also be available in some organisations.
Discussion with employee regarding their psychological wellbeing during this pandemic, their views on a return to work, any concerns practically (for example travel to work, childcare or care commitments) or specific to the workplace, explore their ideas on practical strategies or workplace measures that could address these concerns and their expectations on the likely adequacy of COVID-19 work- related control measures and workplace safety.
Return to work recommendations should be based on the level of medical vulnerability risk (Standard-Increased-High-Very High-Extremely High/Shielder) AND the COVID-19 workplace transmission risk. See Figure 6 for corresponding individual RTW advice for each overall OH risk assessment judgement
A return to work recommendation would be on the proviso that the employer maintains control measures and the employee complies with those recommendations until such time that the community and workplace risk from COVID-19 infection is reduced.
As the knowledge about COVID-19 risk develops further, risk assessments for individual and workplace risk factors will need to be reviewed.
[1] Staying at home and away from others (social distancing)”
[2] Guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19.
[4] Scottish Government COVID-19 Guidance for people with specific medical conditions
[6] Royal College of Obstetricians and Gynaecologists
[7] NHS Coronavirus (COVID-19): Shielded patients list
[8] John Hobson and Julia Smedley. Fitness for Work: The Medical Aspects. 6th Edition. Feb 2019. Faculty of Occupational Medicine.
[9] Social distancing in the workplace during coronavirus (COVID-19): sector guidance
Authors
Dr Drushca Lalloo,
Honorary Clinical Senior Lecturer, Healthy Working Lives Group, University of Glasgow
Consultant Physician in Occupational Medicine, Integral Occupational Health
Dr Munna Roy
Medical Director, Integral Occupational Health
Prof Ewan Macdonald
Head of Healthy Working Lives Group, University of Glasgow
Chair of UK Academic Forum for Health and Work
Director, MacOH Ltd.