COVID-19 return to work guide for health professionals advising patients and employers (9/2020)

Introduction

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.

Workplace transmission risk assessment and control

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.

Identify risks of COVID-19 transmission

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.

COVID-19 workplace infection control measure examples (Hierarchy of controls)

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.

Workplace risk judgement after control measures are implemented

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. 

*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.

Medical vulnerability risk assessment overview

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: 

• Assessment of underlying medical conditions (current and past) 
  • Number of medical conditions/Detailed history of each condition- date of onset, course, current or recent activity/flare ups, treatment (past, current or recent) 
  • Past history of admission to hospital because of asthma/COPD or other condition (when? If not in last 12 months, how bad was it as this may have a bearing on overall judgement) or any ITU admission ever?
• Medications
  • specific names and doses – particularly relevant in asthma/COPD severity assessment and immunosuppressive medication assessment.
  • Frequency of oral steroid courses, particularly within past 12 months.
• Evaluation of co-morbidities and their potential interaction in further increasing risk.
  • Specific co-morbidities that further increase risk
    • Age over 60 years
    • Pregnancy and specifically gestation period (in light of 28-week threshold for risk management)
    • BMI ≥ 40
    • BAME groups- increased risk group from current data although aetiology/risk associations unknown
    • Smoking/Vaping
• Have they received a ‘shielding’ letter from the Health Board/GP identifying them as severely increased risk?
• Clinically vulnerable risk identification
  • Refer to Government/PHE guidance on social distancing [1] for their list of specific ‘increased’ risk/‘clinically vulnerable’ health groups (i.e. to be particularly stringent with social distancing) and shielding [2] i.e. high risk/clinically extremely vulnerable health groups (shielders- stay at home, avoid face to face contact). 
  • For interpretation of this guidance in practice and identification/evaluation of other potentially increased or high-risk groups not directly referred to in Government guidance useful resources include: the Working Fit website (COVID-19) [3], FOM special groups document, Scottish Government Guidance [4] and speciality specific guidance e.g. Association of British Neurologists [5]. Another useful resource is the NHS Digital website to understand how ‘shielding’ groups were applied/defined by PHE/Government. 
• Sources of advice
  • For interpretation of this guidance in practice and identification/evaluation of other potentially increased or high-risk groups not directly referred to in Government guidance useful resources include: the ALAMA website (COVID-19) [3], Scottish Government guidance [4] and speciality specific guidance e.g. Association of British Neurologists [5] and Royal College of Obstetricians and Gynaecologists [6]. Another useful resource is the NHS Digital website [7] to understand how ‘shielding’ groups were applied/defined by PHE/Government. General fitness for work resources are also available [8]. See Sources of advice list at the end of this brief guide. Government and clinical guidance are frequently updated so be vigilant for this. 

Government and clinical guidance are frequently being updated so be vigilant for this.

Overall individualised Occupational Health risk assessment 

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.

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.

Health promotion

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.

DEICE – Discussion of employee’s ideas, concerns and their expectations

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. 

OH advice

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.

References

[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.

[3] ALAMA website (COVID-19)

[4] Scottish Government COVID-19 Guidance for people with specific medical conditions

[5] Association of British Neurologists Guidance on COVID-19 for people with neurological conditions, their doctors and carers

[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

Acknowledgements

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.