Overview of FTW Talk. Safety Sensitive? 10/09/2012. Fitness to Work & Safety Sensitive Occupations

Transcription

1 Fitness to Work & Safety Sensitive Occupations Chris Stewart-Patterson, MD, CCBOM, FACOEM Occupational Physician Program Director Harvard Medical School No Disclosures Overview of FTW Talk Why? Top 3 US Occupational MD activities 1. Dx & Tx 39% 2. Work ability 13% 3. Medico-legal 5%» (Harber et al 2010) Emphasis on fair & defendable opinions Short on specifics but heavy on resources! Look at controversial areas Brief focus on SUDs & FTW Safety Sensitive? Danger to self Danger to work mates Danger to general public Pre-placement examination Periodic examination Hazmat Fitness to return to work 1

2 Safety Sensitive Work Assessment Know the medical aspects of the industry 1. Job descriptions 2. Job demands analysis 3. Bonafide occupational requirements? 4. Specific medical fitness guidelines Exclusionary diagnosis? Exclusionary treatment or medications? 5. Ideally job site visits 13 Firefighter Essential Duties 1. Firefighting tasks 2. Wear SCBA 3. Exposure to toxic fumes 4. 6 or more flights of stairs 5. Wear fire personal protection ensemble 50 lb (+20 to 40 lb tools) 11. Complex problem solving 13. Sudden incapacitation can result in death NFPA

3 VFRS JDA Maximal values for active fire suppression Lift50 kg Carry Push 50 kg 100 kg Pull 100 kg Time pressure Attention to detail constant constant Fit to Work Decisions Fair & consistent Defendable! Could be challenged by: Employee Employee s MDs Employer or union Arbitration Court Industry Occupational Medicine Guides RAC Canadian Railway Medical Rules Handbook CMA Driver s guide, 7 th ed. Transport Canada Handbook for Civil Aviation Medical Examiners NFPA 1582 Standard on Occupational Medical Program, 2007 ed. ACOEM LEO Medical Evaluation Guides DOT Medical Examination: A Guide to Commercial Drivers Medical Certification 3

4 Medical Academic Sources AAPL Practice Guideline Psychiatric Disability Fitness to Work: The Medical Aspects, 4 th ed. K Palmer et al AMA Guides to the Evaluation of Work Ability & RTW, 2 nd ed. FTW Basic Terminology Impairment is about Inability of a function Disability is about Duty (role or job) Case: Physician fractures an arm Impairment: Strength, ROM, pain Disability: Surgeon Yes FP No with accommodations Medical lecturer No Basics: Work Fitness Terms Capacity Limitations Restrictions Tolerance Accommodation A Physician s Guide to Return to Work, 2 nd ed. (AMA) 4

5 Assessing Fitness for Safety Sensitive Work Any diagnosis? Degree of impairment? Capacity & limitations? Temporary or permanent? Risk & restrictions? Temporary or permanent? Fit to work/disabled? Know the job Review industry RTW SUD guidelines Safety Sensitive Fitness to Work Demonstrate normal or adequate capacity Good health after acute condition Chronic disease in remission Chronic disease with documented period of medical stability No immanent relapse risk No significant risk of sudden incapacitation Capacity vs. Risk Worker has capacity but may become incapacitated. Who s at risk? Nature & severity of harm Likelihood that harm will occur 1% guideline? 5

6 Hazmats & Periodic Medicals Industry-specific toxicology screen In addition to fitness to work, the employer may provide for preventive interventions Age & risk appropriate preventive counselling & investigations Sleep Exercise Diet RAC OSA EEs with severe sleep apnea (RDI > 30) cannot be considered fit to work in an SCP until written confirmation and data have been provided to the medical officer Effective treatment must be achieved The individual must be compliant with therapy NFPA Hypertension Members unfit if : severe uncontrolled (BP > 180/90) MSBP > 120 malignant hypertension (end organ damage) beta-blockers, high-dose diuretics or clonidine require limitations until changed 6

7 ACOEM LEO Pregnancy Risks by trimesters Heavy physical activity Long hours Shift work Noise Infections Trauma Chemicals Post-delivery return to work ACOEM LEO Medication Guides Medication categories Acceptable unlikely to adversely impact job functions Temporary consider restrictions initially to assess possible side effects Shift may be taken while off duty with adequate time before returning to duty Restricted very likely adversely impact safety or performance Diagnosis the diagnosis for which the medication is prescribed may require evaluation DOT Medical Exam, 5 th ed. Schedule II Opioid Use 5 conditions Licenced MD or DO Know the medical history & job duties Warned them the medication may impair ability to drive a CMV Improper use is not covered Review of a driver-signed form regarding SE, denying current impairment & will stop if impaired 7

8 DOT Medical Exam, 5 th ed. Schedule II Opioid Use Consider driving hx, psychiatric hx, comorbidity, dose & pharmacokinetics Excluded if: Parenteral administration (transdermal) Dose changes in the last 2 weeks Hx of abuse or addiction Requires ingestion while driving 2011 ACOEM Guidelines for the Chronic Use of Opioids Opioids may be associated with adverse effects that will decrease driving safety Each patient should be evaluated individually Rx opioids to operators of a commercial motor vehicle or pilot an aircraft generally precludes work Same for safety-sensitive positions in industry (e.g., forklift, construction, heavy equipment operations) Systematic Review of the Effects of Opioids on Driving certain patients on stable doses of opioids are able to drive provided they.. Lack co-prescriptions or other substance use that may exert significant CNS effects Do not experience high levels of pain No sleep disorder or daytime somnolence Do not have significant depression, anxiety or other Psych Dx Clin J Pain 2012;28: ) 8

9 Hardest FTW Assessment? A valued safety-sensitive worker Finishes residential treatment I ve stopped using/drinking But fit to work.? Risk of relapse? Co-morbid conditions? Denial? Hidden Substance Use Disorder Impairment Undiagnosed comorbid conditions Denial is a part of dependence Unrecognized severity of impairment Cognitive Sleep disruption Adaptation Active deception: Faking well? Co-workers or family cover up? Chronic Alcohol Use Disorder Comorbidity Psychiatric comorbidity is high! Suspect polysubstance use Medical comorbidity Hepatitis & Cirrhosis Wernicke s encephalopathy & Korsakoff s amnesia Cardiomyopathy Peptic Ulcer Many more.. Comorbid conditions contraindicated? 9

10 Cognitive Testing Screening Mental status examination Trail Making Tests A & B MoCA Review safety protocols If abnormal results. Still abstinent? Full neuropsychological testing battery? Early Wernicke s encephalopathy SUD RTW Cases Alcoholism & post CVA Anoxic brain injury Physician Relapse Study Retrospective cohort study of 292 MD/PAs 25% had at least 1 relapse in 10 yrs Relapse risk after the first relapse: HR 1.69 A family history of an SUD: HR of 2.29 Major opioid use with coexisting psychiatric disorder: HR of 5.79 All 3 factors major opioid use, dual diagnosis, and family history: HR of Domino K.B et al. JAMA. 2005;293:

11 2011 RAC SUD Guides Individuals with DSM-IV Substance Dependence must: Have documented abstinence for 3 months Complete an intensive addiction treatment program Sign and demonstrate compliance with a Relapse Prevention Agreement for a period of at least 2 years of stable abstinent remission Have a written report provided by a physician with recommendation to RTW SUD RTW Guides RAC Canadian Railway Medical Rules Handbook Excellent! Free! Author: Dr. Ray Baker ACOEM LEO to be published 2013 Comorbidity Denial Relapse risk Fitness to Work: The Medical Aspects, 4 th ed. Palmer et al Assessing Fitness for Safety Sensitive Work Any diagnosis? Degree of impairment? Capacity & limitations? Temporary or permanent? Risk & restrictions? Temporary or permanent? Fit to work/disabled? Know the job Review industry RTW SUD guidelines 11

12 Limitations or Restrictions Sit, stand & walk Lift & carry Stoop & crouch Heights & ladders Overhead or repetitive reach Shift work Attention & memory DOT 4 th ed. Frequency Rating Definitions Term Time per Day Percentage of Shift Never 0 minutes 0% Rare 0 5 minutes 0 1% Infrequent 6 25 minutes 2 5% Occasional 26 minutes 2.5 hours 6 33% Frequent hours 34 66% Constant hours % Temporary or Permanent? If temporary restrictions or limitations: How long? Need reassessment? By who? If permanent Are they at Maximal Medical Improvement? The condition has stabilized and is unlikely to change substantially in the next year» (Rondinelli 2008) 12

13 If in doubt? 2nd Occupational Medicine opinion Specialist review Return to non-safety sensitive work trial Attendance reports Performance reports Reassess Supervised RTW 13