Guidelines for Authorised Health Professionals conducting Health Assessments for Rail Safety Workers
Annexe to Code of Practice for Health Assessment and Certification for Rail Safety Workers
Draft Version for Industry Comment
May 2003
Safety Branch Department of Infrastructure Victoria Department of Infrastructure
Annexe to the Code of Practice for Health Assessment and Certification for Rail Safety Workers
GUIDELINES FOR AUTHORISED HEALTH PROFESSIONALS CONDUCTING ASSESSMENTS FOR RAIL SAFETY WORKERS
Safety Branch Department of Infrastructure
20 May 2003
Working Draft Version for Industry Comment Acknowledgements
This document, Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers, accompanies the Code of Practice for Health Assessment and Certification for Rail Safety Workers and was researched and developed on behalf of the Department of Infrastructure by: Dr Bruce Hocking FAFOM. FAFPHM. FRACGP. Fiona Landgren B Pharm, Grad Dip Hosp Pharm.
Assistance was provided by: Rob Blackwell Works Infrastructure Dr Jeff Brock Australian Transport Safety Bureau Brian Busch Australian Rail Track Corporation Gina Ciccone Freight Australia Malcolm Davidson President, Association of Tourist railways Trevor Dobbyn State Branch Secretary, Rail, Tram and Bus Union (Vic Branch) Warren Doubleday Council of Tramway Museums of Australasia David Edwards Pacific National Catherine Herriman State Rail Authority of NSW Jeff Jaraie Manager Rail Safety, Yarra Trams Brian McIntosh Department of Infrastructure Marc Marotta Secretary Rail, Tram and Bus Union, Locomotive Division Michelle Nation Connex Trains Adrian Ponton Freight Australia Jan Powning (Project Manager) Department of Infrastructure Susan Price Pacific National Geraldine Sharman Department of Infrastructure Craig Tooke President, Council of Tramway Museums of Australasia Dr Stuart Turnbull National Express (Bayside) Dr Anthony Webster Health Services Australia Julie Wills State Rail Authority of NSW Dr Paul Woodhouse Australian Medical Association (Victoria)
Version: Working Draft Status: Industry Review Issue Date: 20 May 2003 Closure Date: 29 August 2003 Authorised: General Manager Safety Foreword I am pleased to release these draft Guidelines for Authorised Health Professionals Conducting Health Assessments for Rail Safety Workers. The document is an Annexe to the draft Code of Practice for Health Assessment and Certification of Rail Safety Workers which outlines the systems underpinning a rigorous approach to monitoring the health and fitness of rail safety workers. These Guidelines contain the medical standards, criteria and tests necessary to perform assessments. Both documents are the result of extensive research and consultation with rail and health industry specialists. They reflect recent advances in medical knowledge, the current rail industry environment and changes in anti-discrimination and privacy legislation. A reference paper entitled Development of Medical Standards for Rail Safety Workers provides background to the development of the Code and the Guidelines and is also attached. The Code of Practice and Guidelines are in working draft form for industry comment. Train and tram organisations accredited to operate in Victoria are invited to trial the draft before its intended adoption on 29 September 2003 as a code of practice under the Transport Act 1983. During this time, comments and feedback are invited from all stakeholders. Refinement will continue, especially in the application of risk analyses and Code requirements to tourist and heritage trains and trams. The closing date for comment is 29 August 2003 and advice for commenting is included with these Guidelines. Comments will be reviewed by the Industry Reference Group that has overseen the development of this package. The legal status of this package once adopted as a code of practice, is explained in the introductory section of the document. A code of practice provides practical guidance for accredited rail organisations to meet the obligations of an Act or regulations. Compliance with a code is not mandatory. An accredited organisation can meet its obligations in another way, provided it fulfils the requirements of the Act or regulations. As a legislative instrument, codes of practice are new to public transport safety, but they have much to offer the industry as a flexible advisory document. Their introduction provides for more informed decisions about safe operations and ensures greater consistency in how industry operators implement safety management systems. Such consistency is vital for rail operations due to track interaction between different operators and other transport modes. The Department has been fortunate therefore that specialist consultant Dr Bruce Hocking and his team have recently reviewed the national medical standards for commercial vehicle drivers for the National Road Transport Commission. This has ensured the medical standards for rail safety workers are consistent and comparable where appropriate. To encourage national adoption of the Code, the Department will liaise closely with State and Territory Rail Safety Regulators, the National Road Transport Commission’s proposed rail reform agenda and other interstate organisations. During this period of trialing and industry comment, accredited rail organisations are encouraged to introduce necessary administrative changes to support the new health assessment system. This would include the authorisation of health professionals under the new system. Where required, rail organisations may call on the Department of Infrastructure Safety Branch for assistance with briefings and information for health professionals to help with this process. I look forward to receiving your support for the successful introduction of this important safety initiative. Yours sincerely
Colin Andrews General Manager Safety 20 May 2003 CONTENTS
INTRODUCTION ...... 7 1. Purpose of the Guidelines ...... 7 2. Users of the Guidelines ...... 7 3. Application andAuthority ...... 7 4. Scope of the Guidelines...... 7 5. How to use the Guidelines...... 8 6. Interface with Other Health and Human Resources Programs...... 8
PART A – HEALTH ASSESSMENT REQUIREMENTS ...... 10 1. Authorisation of Health Professionals Conducting Health Assessments of Rail Safety Workers ...... 10 2. Responsibilities and Relationships ...... 12 3. Workers Who Require a Health Assessment ...... 14 4. Matching the Level of Health Assessments to Each Risk Category ...... 17 5. Types of Health Assessments Required...... 17 6. Procedures for Conducting Health Assessments ...... 22 7. Case Studies...... 29
PART B – RAIL SAFETY WORKER TASKS ...... 34 1. Train Operations...... 34 2. Tram Operations...... 38 3. Tourist and Historical Rail Operations ...... 39
PART C – MEDICAL STANDARDS ...... 41 PART C1 - MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS...... 42 1 ALCOHOL...... 42 2 ANAESTHESIA...... 45 3 CANCER...... 46 4 CARDIOVASCULAR DISEASES ...... 47 5 DIABETES ...... 55 6 DRUGS – ILLICIT ...... 57 7 DRUGS – PRESCRIPTION AND OVER THE COUNTER (OTC) ...... 60 8 EPILEPSY ...... 63 9 GASTROINTESTINAL AND HEPATIC DISORDERS ...... 67 10 HEARING ...... 69 11 HIV / AIDS ...... 71 12 METABOLIC AND ENDOCRINE DISORDERS...... 72 13 MUSCULOSKELETAL DISORDERS ...... 73 14 NEUROLOGICAL DISORDERS...... 75
5 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 15 PREGNANCY ...... 78 16 PSYCHIATRIC DISORDERS ...... 79 17 RENAL FAILURE...... 81 18 RESPIRATORY DISEASES AND SPEECH...... 83 19 SLEEP DISORDERS...... 84 20 SYNCOPE / BLACKOUTS ...... 88 21 VESTIBULAR DISORDERS ...... 89 22 VISION AND EYE DISORDERS ...... 91
PART C2 – MEDICAL CRITERIA FOR TRACK SAFETY ASSESSMENT ...... 95 PART D – MODEL FORMS ...... 98 PART E - APPENDICES...... 121 APPENDIX 1: SCREEN-BASED EQUIPMENT EYE EXAMINATION ...... 122 APPENDIX 2: ALCOHOL AND DRUG CONTROLS ...... 124 COMMENTS AND/OR INQUIRIES ...... 128
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 6 INTRODUCTION
1. Purpose of the Guidelines Outline the criteria by which health professionals are selected as authorised The purpose of the Guidelines for Health providers of health assessment services Professionals conducting Health to accredited rail organisations. Assessments for Rail Safety Workers is to provide the medical criteria, clinical tests and Describe how health assessments practical guidance for authorised health interface with other health, safety and professionals to conduct health assessments human resources initiatives. of current and potential rail safety workers of accredited rail organisations in Victoria. 2. Users of the Guidelines The Guidelines are a companion Annexe to the Code of Practice for Health Assessment The Guidelines are intended for use by a and Certification of Rail Safety Workers. The health professional who has been authorised Code of Practice provides practical guidance by an accredited rail organisation to assess a for accredited rail organisations in Victoria to rail safety worker’s fitness for duty. Criteria monitor the health and fitness of rail safety for the selection and appointment of an workers in performing their duties. This authorised health professional are included in responsibility is an essential part of the safety the Code of Practice and reproduced here. management system for train and tram In most circumstances an authorised health operations aimed at minimising risks to professional must be a medical practitioner, protect the safety of: but for some types of health assessments the public may be a nurse with suitable qualifications. rail safety workers and their fellow In addition, the Guidelines may be used by workers specialist health professionals who may be consulted in relation to a worker’s health the environment. assessment, for example, optometrists, With this aim in mind the Guidelines for psychologists or occupational therapists. Health Professionals Conducting Health Assessments for Rail Safety Workers: 3. Application and Authority Describe in generic terms the system of health assessments applied by accredited These Guidelines accompany the Code of rail organisations, including risk Practice for the Health Assessment and categories of workers and the types and Certification of Rail Safety Workers which frequencies of assessments. applies to all rail organisations accredited under the Transport Act 1983 to operate in Describe the main categories of rail safety Victoria. worker tasks and how the health assessment requirements reflect the risks The Code of Practice together with this of the tasks. Annexe, the Guidelines for Authorised Health Professionals Conducting Health Outline clear medical criteria for rail safety Assessments for Rail Safety Workers are worker capability, based on available approved pursuant to Section 129WA of the evidence and expert medical opinion. Transport Act 1983. Provide general guidelines for managing rail safety workers with respect to their fitness for duty, 4. Scope of the Guidelines The Guidelines are intended for use to Provide guidance with respect to assess the health and fitness for duty of reporting to accredited rail organisations, potential and existing workers to perform rail including model forms. safety workers as defined in the Transport
7 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Act 1983. Their scope is confined to rail Part C1 includes medical criteria for the safety. high risk Safety Critical Workers The Code of Practice and these Guidelines (Categories 1 and 2) do not cover occupational health and safety C2 includes the medical criteria for matters such as for addressing occupational Around the Track Personnel (ATTP) who exposure. The employer must address such work in an Uncontrolled Environment issues and integrate them with the health (Category 3) assessments for occupational exposure as appropriate. The medical criteria in Part C are presented in chapters corresponding to body system or disease categories and are arranged 5. How to use the Guidelines alphabetically. The Guidelines clearly outline the information PART D – Model Forms necessary for conducting health assessments Part D includes the model forms that may be of rail safety workers. They comprise five used for the health assessment system and parts: are the same as those provided to employers PART A – Health Assessment Systems as an appendix to the Code. Part A summarises the management systems PART E - Appendices for health assessments of rail safety workers The Appendices provide some reference contained in the Code of Practice. It material that may be useful to the authorised identifies the categories of rail safety workers health professional. to undergo assessment as well as the nature and frequency of the assessments and the assessment procedures. 6. Interface with Other Health It also outlines the system of authorisation for and Human Resources health professionals conducting health Programs assessments and the roles and Health assessments are one aspect of an responsibilities of the employer, workers and integrated system aimed at achieving safety health professional. on the rail network. The assessments may It is essential that authorised health interface with a range of other health and professionals are familiar with the content of human resources programs, some of which Part A. may have a legislative base. PART B – Rail Safety Worker Task The authorised health professional will need Descriptions to have some understanding of how these Part B is a reference section that describes initiatives interface in practice. It is the the main tasks undertaken by rail safety responsibility of the rail organisation to workers. It is included to provide the ensure the health professional is kept up to authorised health professional with insight date about the organisation’s policies, into the nature of the tasks and associated procedures and programs. risks and therefore the health requirements of The interfaces with relevant programs are the various tasks. illustrated in Diagram 1. PART C – Medical Criteria Part C details the medical criteria for assessing fitness for duty. It comprises two parts:
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 8 Diagram 1. Interfacing Health and Human Resources Programs
Fatigue Psychometric Management testing
Drug and Critical Alcohol Incident Management Health Assessments
Health Promotion Sick Leave policy Employee Assistance OHS Programs Programs
9 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 PART A – HEALTH ASSESSMENT REQUIREMENTS
1. Authorisation of Health Professionals Conducting Health Assessments of Rail Safety Workers The accredited rail organisation is responsible for appointing a suitably qualified and competent health professional to conduct the health assessments for rail safety work (an authorised health professional). The rail organisation should ensure the health professional can meet the selection criteria provided in Table 1 as a basis for appointment. The criteria focus on the health professional’s knowledge and understanding of the rail occupational environment, the risks associated with rail safety work and the corresponding clinical tests to be applied. The rail organisation is not required to assess the health professional’s medical knowledge. The rail organisation may offer assistance to the health professional to meet the criteria for example, by providing a copy of the Guidelines and other relevant information, including briefings or site visits.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 10 TABLE 1 – Criteria for Selection of Authorised Health Professionals
Safety Critical Workers (Categories 1 and 2) Around the Track Personnel (Category 3) health assessments health assessments Qualifications and Experience: The health professional Qualifications and Experience: The health professional must have a qualification in medicine and should have should have a qualification in medicine or a nursing interest or experience in occupational medicine. qualification with a postgraduate qualification in occupational health nursing. For a medical professional, interest and experience in occupational medicine is desirable.
Rail Industry Knowledge: The health professional should Rail Industry Knowledge: The health professional should demonstrate understanding of the rail industry environment demonstrate understanding of the rail industry environment including work performed and risks involved. including work performed and risks involved.
Code of Practice: The health professional should Code of Practice: The health professional should be able demonstrate familiarity with the Code of Practice and a to demonstrate familiarity with the Code of Practice and a working knowledge of the Guidelines for Examining Health working knowledge of the Guidelines for Examining Health Professionals, including: Professionals, including: Appreciation of the role of health assessments in Appreciation of the role of health assessments in rail ensuring rail safety. safety. Familiarity with the risk management approach used Familiarity with the risk management approach used to to identify the level of health assessment required. identify the level of health assessment requirements. Familiarity with the tasks in rail operations and with Familiarity with the tasks in rail operation and major tasks of Safety Critical Workers. experience of major tasks of the Around the Track Personnel. Knowledge of rail safety worker risk categories and the rationale for health assessments applied. Knowledge of rail safety worker categories of and the rationale for health assessments applied. Knowledge of and ability to perform the Safety Critical Worker Health Assessment . Knowledge of and ability to perform the Track Safety Health Assessment. Understanding of requirements and reporting options for fitness for rail safety duty. Understanding of requirements and reporting options for fitness for rail safety duty. Knowledge of the assessment’s administrative requirements, including form completion and record Knowledge of the assessment’s administrative keeping. requirements, including form completion and record keeping. Understanding of ethical and legal obligations and the ability to conduct health assessments accordingly, Understanding of ethical and legal obligations and the including appropriate communication with the worker ability to conduct health assessments accordingly, and the employer. including appropriate communication with the worker and the employer. Understanding of ethical issues in relationships with the treating doctor/GP. Understanding of ethical issues in relationships with the treating doctor/GP.
Interfacing Policies and Programs. The health professional should be able to demonstrate awareness of legislation, policies or programs that might interface with or affect the performance of the health assessment for example, drug and alcohol policy, critical incident management programs, anti-discrimination legislation and privacy legislation.
11 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 rail network and public safety and the 2. Responsibilities and importance of their health and fitness to rail Relationships safety. The successful implementation of health They have a responsibility to notify the assessments for rail safety workers relies on employer of any health condition likely to a clear understanding of the various affect their ability to undertake their work responsibilities as well as effective safely, including impairment from medications communication between the and must also comply with any review individuals/groups involved. The following is requirements of a health assessment. a summary of the responsibilities of the key parties and their interrelationships. 2.4 Health Professionals
2.1 Accredited Rail Organisations Health professionals appointed and authorised by the accredited rail organisation The accredited rail organisation has a legal should have demonstrated that they have responsibility under the Transport Act 1983 to relevant competence and understanding of ensure systems are in place to protect the the rail environment to conduct health safety of the network and public safety. This assessments for rail safety work. includes a responsibility to ensure that the The authorised health professionals should health and fitness of workers is monitored conduct health assessments in line with the and does not jeopardise rail safety. procedures contained in Guidelines for As an employer, the accredited rail Authorised Health Professionals Conducting organisation has a duty of care under Assessments for Rail Safety Workers. occupational health and safety legislation to The relationship between the health the safety of its workers. professional and the worker/patient is Where possible, to meet anti-discrimination governed by the ethics of the relevant health requirements, the employer should profession and by privacy laws. The accommodate the limitations on the worker’s relationship differs from the usual doctor- capabilities due to health issues through patient relationship because of the strategies such as job modifications, involvement of a third party, the employer. alternative or supervised duties as The final decision regarding fitness for duty or appropriate. any restrictions rests with the employer and If employing contractors, the employer is may involve consideration of anti required to inform them of their obligations to discrimination and retraining issues. ensure appropriate health assessment The ongoing treatment and management of systems are in place for their workers. medical conditions should be the responsibility of the worker's general 2.2 Contractors practitioner. Authorised health professionals should communicate and consult with the Contractors have the same responsibilities as general practitioner and other relevant employers in regard to rail safety worker providers to ensure the effective health assessments. management of the worker’s health. Diagram 2 illustrates the relationships and flow of information that should take place in 2.3 Rail Safety Workers conducting rail safety worker health Rail safety workers have a duty of care to assessments. themselves and others. Once employed, they should know their job, its implications for
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 12 Diagram 2. Relationships in the Implementation of Health Assessments for Rail Safety Workers
WORKER/ PATIENT WORKER’S GENERAL PRACTITIONER
AUTHORISED SPECIALISTS & EMPLOYER, OR HEALTH OTHER HEALTH CONTRACTORS PROFESSIONAL PROFESSIONALS
13 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 controls available are both considered in the 3. Workers Who Require a risk assessment. This has led to the Health Assessment establishment of four categories of risk for rail safety work, as described below. Workers who carry out rail safety work for accredited rail organisations in Victoria require a health assessment to determine CATEGORY 1: High Level Safety Critical their health and fitness for duty. Workers Section 93 of the Transport Act 1983 defines These are workers involved in tasks critical to a rail safety worker to include an employee, the safety of the network and whose action or contractor, subcontractor or volunteer inaction or collapse due to ill-health, may lead performing work on a railway or tramway directly to a serious incident affecting the rail system: network and hence public safety. Examples as a driver, second person, trainee driver, are train drivers, flagmen and shunters. guard, conductor, supervisor, observer or CATEGORY 2: Safety Critical Workers authorised officer; These are workers involved in tasks critical to as a signal operator, shunter or person the safety of the network and whose action or who performs other work relating to the inaction due to ill-health, may lead directly to movement of trains or trams; a serious incident affecting the rail network in repairs, maintenance, or upgrade of and hence public safety. For these workers, railway infrastructure, including for rolling the risk of sudden collapse is not critical to stock or associated works or equipment; the safety of the rail network, thus the lower risk rating. in construction or as a look out for construction or maintenance; An example of a safety critical task is signal operation where the system fail-safe any other work that may be included by mechanisms ensure that sudden incapacity regulation. will not affect the safety of the rail network. This includes interstate based workers Thus while signalling is safety critical, it is not required to work on the Victorian rail network safety critical at a high level. and those who do not work on the Victorian CATEGORY 3: Around the Track network but whose actions affect it, for Personnel (ATTP) Who Work in example train controllers. Uncontrolled Environments These are workers whose tasks require them 3.1 Categorisation of Rail Safety to operate around the track, within the Workers According to Risk recognised safety envelope and in an Uncontrolled Environment. An Uncontrolled The requirements for health assessments of Environment is not protected by either rail safety workers are determined by a risk engineering or administrative control management approach. This is to ensure the mechanisms. level of health assessment conducted is commensurate with the risk associated with The health of these workers is unlikely to the tasks performed by the rail safety worker. impact on the safety of the network, however As the work environment significantly it is important that they are able to act to determines the skills required and risk protect their own safety and that of fellow involved, a risk analysis should form the basis workers. Examples of ATTP workers who of all rail safety worker health assessment may be in an Uncontrolled Environment decisions. include cleaners, track auditors and contractors. The key criterion applied in the risk analysis is the extent to which the workers’ health both physical and psychological, may impact on the safety of the rail network and the public. The nature of the task and the engineering
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 14 Where workers may move between CATEGORY 4: Around the Track Controlled and Uncontrolled Environments Personnel (ATTP) Who Work in Controlled the higher level of risk assessment will be Environments applied. All other rail safety workers not covered by Diagram 3 summarises the risk analysis of the above categories fall into Category 4, the rail safety work and the process for lowest risk category from the point of view of determining the type of health assessment the impact of their health on safety. required which is commensurate with the risk. Examples of Category 4 workers include maintenance staff working in sheds protected by alarms and barriers.
15 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Diagram 3. The Risk Analysis of Rail Safety Worker Tasks
Rail Safety Worker Identify the full range of tasks likely to be undertaken by the worker.
For any aspect of the tasks identified, could collapse or loss of vigilance lead to disaster on the rail network? YES NO
SAFETY CRITICAL NON-SAFETY CRITICAL
For any aspect of the tasks identified, could Is the person Around the Track Personnel? ie Is collapse lead to disaster on the rail network? any aspect of the tasks identified undertaken within the recognised safety envelope for railways?
YES NO
Are all aspects of the tasks identified undertaken within a declared Controlled YES Environment? YES NO
NO
CATEGORY 1 CATEGORY 2 CATEGORY 3 CATEGORY 4 High Level Safety Safety Critical ATTP in ATTP in Critical Worker Worker Uncontrolled Controlled (HSCW) (SCW) Environment Environment Health requirements: Health requirements: Health requirements: No rail specific .No risk of sudden .Physical and .Hearing and health requirements. collapse, psychological vision, Assessment may be .Physical and health. .Mobility. necessary to meet psychological OH&S requirements. health. RISK ASSESSMENT
High Level SCW Safety Critical Track Safety No rail safety health Health assessment Worker Health Assessment aims to: assessment required. aims to: assessment aims to: .Assess hearing and . OHS .Identify risk of .Assess overall vision, sudden collapse, physical and .Assess mobility. psychological .Assess overall . OHS physical and health. psychological . OHS health. . OHS HEALTH ASSESSMENT
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 16 task performance, including cardiovascular, 4. Matching the Level of Health neurological, psychological, musculoskeletal Assessments to Each Risk and visual systems. Category The employer is responsible for the risk 4.2 High Level Safety Critical Health analysis and categorisation of their rail safety Assessments (Category 1) workers and will match the worker to the appropriate level of health assessment. In addition to the components of the Safety Critical Worker Health Assessment, a High The risk categories for rail safety work Level Safety Critical Worker must have a described in Section 3 above have been used Cardiac Risk Score assessment to identify to determine minimum requirements for their risk of cardiovascular disease and health assessments of rail safety workers. collapse from heart attack. Tests include: The minimum requirements for the different fasting blood glucose levels are provided in the Parts C1 and C2 of fasting serum cholesterol these Guidelines and should be applied by the authorised health professional. In resting ECG summary, they are: Results are combined with other risk factors such as age, cigarette smoking and blood pressure to calculate a Cardiac Risk Score on 4.1 Safety Critical Health which to base predictions. Assessments (Categories 1 and 2) Safety Critical Workers should undergo a comprehensive physical and psychological 4.3 Track Safety Health Assessments assessment at pre-placement, change of (Category 3) grade and periodically during employment to The Track Safety Health Assessment for detect conditions that may affect safe working ATTP (Category 3) comprises eyesight and ability (for example heart disease, diabetes, hearing tests and an assessment to ensure epilepsy, sleep disorders, alcohol and drug their appropriate mobility around the track. dependence, psychiatric disorders and eye and ear problems). The assessment comprises a questionnaire 5. Types of Health and a clinical examination plus drug Assessments Required screening at pre-placement or change of grade. There are three types of health assessments for rail safety workers which are aimed at Safety Critical Worker Questionnaire satisfying the following criteria: This self-administered questionnaire collects confirming that a rail safety worker a general history and helps identify specific candidate is medically suited to the tasks conditions that might affect rail safety task to be performed performance, including: periodically monitoring the rail safety sleep disorders (Epworth Sleepiness worker’s health during employment to Scale) detect conditions that might affect rail alcohol dependency (AUDIT safety Questionnaire) enabling a timely response to concerns psychological problems (K10 about the worker’s health. Questionnaire) The questionnaire is not diagnostic and no decision should be made regarding fitness for 5.1 Pre-placement or Change of duty before the clinical examination. Grade Health Assessments Clinical Examination Rail safety workers classified in all Categories This assesses the key body systems to 1, 2 and 3 require health assessments at pre- identify conditions that might affect rail safety
17 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 placement and before changing to a higher 5.3 Triggered Health Assessments grade. Triggered Health Assessments are conducted These are aimed at assessing a worker’s in response to incidents or concerns suitability for rail safety duties and should regarding the worker’s ability to perform their match the risk category of the job they are job safely. They are likely to address a entering. particular health issue and include scheduled review assessments for conditional fitness for duty (Fit for Duty Subject to Review). 5.2 Periodic Health Assessments Triggered health assessments aim for early These are conducted to identify health intervention and appropriate management of conditions that may affect safe performance health problems likely to affect safety. They of rail safety work. They should be overlay periodic assessments and help to conducted for Category 1, 2 and 3 rail safety identify and manage illness of unpredictable workers according to the defined frequencies. and rapid onset. Category 1: High Level Safety Critical Psychological conditions, for example anxiety Worker states, are not age dependent and onset At time of commencement then: patterns are not clearly defined. Therefore they may not be readily identified at a 5 yearly to age 55 periodic health assessment. Employers 2 yearly to age 65 should be alert to indicators of ill-health such Yearly thereafter as recurrent absenteeism, repeated incidents and recent traumatic events and discuss Category 2: Safety Critical Worker these with the rail safety worker. This may At time of commencement then: lead to triggered referral for health or 5 yearly to age 55 neuropsychology assessment, retraining in competencies or to the Employee Assistance 2 yearly thereafter Program. Category 3: ATTP in Uncontrolled To ensure appropriate referrals and Environment transparency in decision making, the rail At time of commencement then organisation should develop and distribute at age 40 and 5 yearly thereafter clear referral criteria for triggered health assessments. Examples of trigger situations The frequencies are a minimum requirement include: based on evidence of rate of age-associated degenerative illness, the increased power of Scheduled Review Assessments (Fitness the revised assessment to detect rail safety for Duty Subject to Review) workers at risk and comparison with local and Health assessments scheduled for workers overseas standards. assessed Fit for Duty Subject to Review or Employers may choose to implement more Temporarily Unfit for Duty Subject to Review frequent periodic assessments should the are the most common triggered referrals. need and rationale be identified. They are more frequent than standard periodic reviews to allow closer monitoring of An authorised health professional may also a health condition. Review intervals are recommend more frequent assessments for recommended by the health professional. the purpose of health surveillance, depending on the needs of the individual worker. Sick Leave and Patterns of Absenteeism Ongoing treatment of medical conditions Workers who have been absent from work should continue to be the responsibility of the due to an injury or illness and who have a worker's general practitioner. condition that may adversely affect their The program of comprehensive periodic ability to perform rail safety duties, for health assessments should be maintained example cardiac or neurological problems, even if more frequent triggered assessments high blood pressure or diabetes should be are undertaken for an individual’s particular assessed for fitness for duty before return to condition. work, taking account of their rehabilitation plan.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 18 Recurrent absenteeism may also flag the from medication as required by statutory need for referral for health assessment. Sick drug control provisions. leave review systems should support and validate such referrals. 5.4 Drug Screening Accident/Incident Patterns Pre-placement and/or change of grade health Accident/incident patterns may indicate assessments include a drug screen. While worker difficulties or health issues. The rail screening is not intended at periodic organisation’s incident investigation and assessment, the Guidelines include advice management procedures should consider for applying the drug control procedures potential health (including psychological) where a drug or alcohol impairment is issues and refer for health assessment as suspected at a periodic assessment. required. Diagram 4 shows how the different types of At Worker’s Request health assessments work together to support Workers should report to the employer any the ongoing fitness for duty of rail safety illness or health problem likely to affect their workers ability to work safely, including impairment
Diagram 4. Health Assessments Supporting Fitness for Rail Safety Work
FITNESS FOR DUTY
Pre-employment (Transfer or Upgrade) Health Assessment Aims to Periodic Health Assessments assess initial Fitness for Aims to support initial identification of physical and Duty. (interfaces with psychological health issues likely to impact on preemployment D&A safety. testing, psychometric testing).
Triggered Health Assessment (Fitness for Duty) Aims to achieve early intervention and appropriate management of for health problems likely to impact on safety.
Triggers or red flags may include: prolonged/repetitive sick leave patterns traumatic workplace incidents at worker’s request reports from peers/supervisors accident/incident patterns including SPADS scheduled review assessments (conditional fitness for duty) (Interfaces with triggered referral for D&A testing, psychometric testing)
19 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 TABLE 2 – Summary of Health Assessment Requirements for Rail Safety Workers
CATEGORY 1 - High Level Safety Critical Worker Workers performing tasks critical to rail network safety and whose action, inaction or collapse, due to ill-health, may lead directly to a serious incident affecting the network. Type of Health Assessment Required Frequency Preplacement / Upgrade Health Assessments On commencement and when moving to a higher grade. Safety Critical Worker Health Assessment including: Safety Critical Worker Questionnaire & history Comprehensive physical and psychological assessment Vision and hearing Screen-based equipment (SBE) examination if required Drug Screen plus Cardiac Risk Score Additional health assessments may be implemented to meet OHS requirements Periodic Health Assessments Safety Critical Worker Health Assessment including: 5 yearly to age 55 Safety Critical Worker Questionnaire & history 2 yearly to age 65 Comprehensive physical and psychological assessment Yearly thereafter Vision and hearing Hearing assessment Note: Depending on the needs of the worker, authorised health professionals may also Screen-based equipment (SBE) examination if required plus recommend more frequent assessments for health surveillance. Ongoing treatment and management Cardiac Risk Score of medical conditions should continue to be the Additional health assessments may be implemented to meet OHS responsibility of the worker's General Practitioner. requirements. Triggered Health Assessments As determined by circumstances Nature of health assessment will depend on the triggering circumstances.
CATEGORY 2 - Safety Critical Worker Workers performing tasks critical to rail network safety whose action or inaction, due to ill-health, may lead directly to a serious incident affecting the network. Preplacement / Upgrade Health Assessments On commencement and when moving Safety Critical Worker Health Assessment including: to a higher grade. Safety Critical Worker Questionnaire & history Comprehensive physical and psychological assessment Vision and hearing Screen-based equipment (SBE) examination if required Drug Screen Additional health assessments may be implemented to meet OH&S requirements. Periodic Health Assessments 5 yearly to age 55 Safety Critical Worker Health Assessment including: 2 yearly thereafter Safety Critical Worker Questionnaire & history Comprehensive physical and psychological assessment Note: Depending on the needs of the worker, authorised health professionals may also Vision and hearing recommend more frequent assessments for health surveillance. Ongoing treatment and management Screen-based equipment (SBE) examination if required of medical conditions should continue to be the Additional health assessments may be implemented to meet OH&S responsibility of the worker's General Practitioner. requirements. Triggered Health Assessments As determined by circumstances Nature of health assessment will depend on the triggering circumstances.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 20 CATEGORY 3 - Around the Track Personnel operating in an Uncontrolled Environment Those workers who are required to operate within the recognised safety envelope but without engineering or administrative controls to protect them from moving rolling stock, and whose action or inaction due to ill-health may endanger their safety or those of work colleagues. Type of Health Assessment Required Frequency Preplacement /Upgrade Health Assessments On commencement and when moving Track Safety Health Assessment including: to a higher grade. Vision and hearing Mobility Drug Screen Additional health assessments may be implemented to meet OHS requirements.
Periodic Health Assessments At age 40 and 5 yearly thereafter Track Safety Assessment including: Vision and hearing Note: Depending on the needs of the worker, authorised health professionals may also Mobility recommend more frequent assessments for health surveillance. Ongoing treatment and management Additional health assessments may be implemented to meet OHS of medical conditions should continue to be the requirements. responsibility of the worker's General Practitioner. Triggered Health Assessments As determined by circumstances Nature of health assessment will depend on the triggering circumstances.
CATEGORY 4 Other than those in Categories 1-3 Type of Health Assessment Required Frequency No prescribed health assessment for rail safety purposes. N/A Health assessments may be implemented to meet OHS requirements.
21 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 6. Procedures for Conducting Health Assessments 6.2 Facilities and Equipment The examination room should be well lit, quiet The following is a description of the and offer privacy with a nearby toilet. administrative, clinical and reporting Equipment should include: procedures which (with the exception of making an appointment) should be followed Snellan chart, Ishihara plates, (Maddox by the authorised health professional in wing; 45cm and 70cm tests, or referral to conducting health assessments for rail safety optometrist for SBE testing). workers. Sphygmomanometer. Urine test container and dipsticks. 6.1. Clinical Appointment and Documentation Lap top/PC for recording data and calculating risk score (optional). An appointment for an assessment will be made either by the employer or the employee. 6.3 Orienting the Worker/Patient Prior to the appointment the employer will To orient and inform the worker about the forward to the health professional the health assessment procedure: relevant documentation. The Model Exchange normal greetings and names. Forms for this purpose are included in Part D of the Guidelines and will include: Check the ID photo of the person. - Health Assessment Request and Formally explain to the worker the Report Form which will indicate the purpose of the examination, and that the nature of the worker’s job and the type results will be discussed with them and of health assessment required. provided to management in functional - Supporting documentation including terms in relation to their fitness to perform previous health assessment results, rail safety duties. Specific medical details relevant sick leave record, significant will not be conveyed to the employer. Workcover claims and incident history. Such documentation is required for the periodic assessment of Safety Critical 6.4 Confirmation of Tasks Workers only. It is important to confirm that the worker has - Health Assessment Record to guide the been assigned for a level of health clinical examination. assessment appropriate to the nature of their work and the associated risks. The worker will have been requested to complete the Safety Critical Worker Confirm understanding of the rail safety Questionnaire if appropriate, which tasks undertaken by the worker by he/she will bring to the appointment. referring to Part B of the Guidelines. If an ECG and blood tests are required (for the High Level Safety Critical Worker 6.5 Safety Critical Worker only), they should be completed in Questionnaire advance and the results forwarded to you directly. Review the worker’s responses to the questionnaire. Elicit further information The worker will be asked to bring all as required. medications or a list of their medications to the appointment. Calculate scores for various sections of the questionnaire including: By agreement between the examining health professional and the employer, the - the Epworth Sleepiness Scale worker may have been requested to (Question 4) attend for an audiogram prior to - the alcohol AUDIT questionnaire examination. (Question 5)
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 22 - the K10 questionnaire (Question 7). Neurological/Locomotor Record the results of these scores in the The worker should stand before you. Ask Health Assessment Record. them to: Clarify and discuss aspects of the flex, extend, and rotate head questionnaire as required to establish raise arms above head by swinging them history. outwards Request the person to sign the flex and extend arms, and to grasp your questionnaire as a truthful statement, hands so as to assess full movement and then countersign and date. strength flex trunk to reach about the knees 6.6 Clinical Assessments Relevant to observe gait Worker’s Risk Category Romberg test. When examining a patient to assess their fitness for duty, the functionality of various Chest/lungs and Abdomen body systems is addressed as outlined in Should be examined, but a genital Part C of the Guidelines. The model Health examination is not required. Assessment Record provides a useful guide and template for a general assessment of Vision fitness for rail safety duty. It also provides a Visual acuity is tested with a Snellan chart convenient standardised record for such that includes at least five letters on the 6/12 examinations. line, at a distance of 6m (or scaled to 3m). Additional tests or referral to a specialist may Explain what is required to the person and be required if and when clinical examination ask to read lines near the top to familiarise raises the possibility of potentially significant them with the chart. Visual acuity should be problems. measured one eye at a time (monocularly) without correction in the first place. More The Track Safety Health Assessment than two errors in reading the letters of any (Category 3) requires assessment of vision, line is regarded as a failure to read the line. hearing and mobility only. Fields. Sit about 1m from the person. Ask The Safety Critical Worker Health them to look at your nose. Extent your arms Assessment (Categories 1 and 2) requires to be halfway between you and just in your assessment of all the following areas: own field of vision. Ask the person to tell you Cardiovascular when you move a finger; do this at 180o right and left, and various other points. Any defect Should include: in visual field should lead to referral for Blood pressure - this may be taken sitting detailed assessment. or supine. Colour Vision is screened for using Ishihara Pulse rate plates. Show the person the trial plate and explain the test. Then proceed to show the Heart sounds colour plates with numbers, noting any errors. Peripheral pulses Screen Based Equipment examination Cardiac Risk Score (High Level Safety using the proforma provided Critical Workers only). Note person’s Maddox Wing test age, whether they are a smoker, blood pressure, ECG, fasting cholesterol (total Eye chart at 45 and 70cm. and HDL), and fasting plasma. For Hearing scoring, see Part C1, Cardiovascular Diseases. Conduct audiometry or refer to report. Urinalysis This should be tested for protein and sugar.
23 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Psychological Health Triggered Health Assessment. In these two situations, drug screening may apply to Record K10 score – see Question 7 of the Categories 1, 2 or 3 workers. Screening Safety Critical Workers Health Assessment should be conducted in line with Questionnaire. Australian/New Zealand Standard 4308:2001: Alcohol Procedures for the Collection, Detection and Record Audit Questionnaire score – see Quantification of Drugs of Abuse in Urine. Question 5 of the Safety Critical Workers If during a Periodic Health Assessment, the Health Assessment Questionnaire. examining health professional identifies Sleep impairment which has no apparent medical basis, this should be managed according to Record Epworth Sleepiness Scale score – the specific chapters in Part C addressing see Question 4 of the Safety Critical Workers Alcohol, and Drugs. Diagram 5 summarises Health Assessment Questionnaire. these procedures. Drug Screen Drug screening is required only for Pre- placement/Change of Grade Health Assessments or for a specifically referred
Diagram 5. Drug and Alcohol Impairment Assessment and Management
Is there evidence of impairment? Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, attitude, comprehension). NO YES
Discuss with worker. No further action Is there a medical basis for impairment, ie (continue with health prescription medication /OTC drug taken for a assessment) defined purpose, or an illness.
YES NO
Medical basis If suspect alcohol or illicit drug use: Classify Temporarily Unfit for Duty. Classify Temporarily Unfit for Duty and If appropriate, discuss medication with GP/treating advise on report impairment without clear doctor in order to resolve impact on employment. medical basis. If appropriate, refer to relevant chapter for medical Contact employer regarding impairment conditions. without clear medical basis and await further instructions from employer. Identify review period.
To further assist in assessment there are They should be applied by a psychologist some rail specific resources to be aware of: experienced in their use. Neuropsychological Tests Principal Drivers Neuropsychological tests regarding aptitudes A Principal Driver is a senior driver with wide for drivers of trains have been specifically experience who is often involved in training developed for use in recruitment and other other drivers. Because of their detailed situations. They may be used for knowledge of the skills of driving, a worker assessment of drivers who have had injury or with borderline impairments may be referred illness affecting mental processes to help to a Principal Driver for a practical test. This gauge their recovery and suitability for work. is particularly relevant to musculo-skeletal and neurological impairments.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 24 Such an assessment should be arranged example, drivers are expected to drive any through the worker’s management and could locomotive or tram for which they are trained be in conjunction with a physiotherapist or and hence proposed job modifications may occupational therapist if the opinion of such a require discussion with the worker and professional is also needed. supervisor. Temporarily Unfit for Duty Subject to Review 6.7 Fitness for Duty Classifications This indicates the worker has not met all To assess the fitness for rail safety duty, the criteria in the standard and cannot perform results of the health assessment should be current rail safety duties at present. considered in relation to the specific criteria However, the condition is anticipated to outlined in Part C of these Guidelines. improve with treatment and the worker will be The various levels of fitness for duty are reviewed to determine fitness status. This described below, including reference to the differs from ordinary short term illness requirements for managing the worker. The causing absenteeism. Temporarily Unfit for Case Studies in Section 7 also illustrate how Duty may also be applied in situations where these levels of fitness for duty are applied in a clear diagnosis has not been made in the practice. case of an undifferentiated illness, for example where a worker is being investigated Note that determinations may be combined. for blackouts. Note also that a particular worker may move Permanently Unfit for Duty from one classification to another as you progress through the medical assessment This indicates the worker has not met all and investigation process. criteria in the standard, their condition is permanent and they will not be able to Fit for Duty perform current rail safety duties in the future. This indicates that the person has met all the Normal company policies such as for criteria in the standard and is to be reviewed redeployment may be considered. in line with the normal periodic health Additional considerations assessment schedule. Temporary Illnesses Fit for Duty Subject to Review The Guidelines do not presume to deal with This indicates that the person has not fully the myriad of conditions which may affect met all the criteria in the standard, however health on a short to medium term basis and the condition in question is sufficiently under for which a rail safety worker may be referred control that normal duties may be permitted. for assessment regarding fitness to resume Continuation of normal duties would be duty. Such conditions may include post- conditional on the person being reviewed major surgery, severe migraine, fractures to more frequently than the periodic assessment limbs, or stress. Clinical judgment is usually schedule requires. The review period is required on a case by case basis although specified by the authorised health the text in each chapter gives some advice on professional. the clinical issues to be considered. Fit for Duty Subject to Job Modification Undifferentiated Illness This indicates that the person does not fully meet all the criteria of the standard, but could A rail safety worker may be referred with undertake current rail safety duties if suitable symptoms which could have implications for modifications were made to the job. These their job but the diagnosis is not clear. modifications may include: Referral and investigation of the symptoms will mean that there is a period of uncertainty physical changes to equipment before a definitive diagnosis is made and changes to rosters before the worker and employer can be requirements for the worker to operate confidently advised. Each situation will need under supervision to be assessed individually, with due consideration being given to the probability of Job modifications may not be practicable in a serious disease which will affect rails safety various areas of rail safety work. For work.
25 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Generally, a Safety Critical Worker who nature of his or her condition, the extent to presents with symptoms of a potentially which he or she can maintain control over it, serious nature, for example chest pains, the importance of regular medical review and blackouts, delusional states, dizzy spells and the need for medication where appropriate. the like, should be assessed Temporarily Should the worker be found unfit for duty, the Unfit for Duty until their condition can be health professional should take a conciliatory adequately assessed. However, they may be and supportive role while explaining fully the assessed as fit for alternative duties. risks posed by the worker’s condition with Complex Conditions respect to rail safety work. Where a worker has a systemic disorder of a number of medical conditions, there may be 6.10 Reporting to the Employer additive or cumulative detrimental effects on Should the worker be assessed as Unfit for judgement and overall function. For example, Duty either temporarily or permanently, the there may be a combination of impaired health professional should notify the vision, hearing and locomotor dysfunction or employer immediately by phone to discuss combinations of physical and mental illness the implications of the assessment and to and associated medication. allow the employer to make appropriate Where a clinical condition is not adequately arrangements. covered in Part C, the health professional In all cases the health professional should should consider: complete the report section of the Health the nature of the tasks of the worker Assessment Request and Report Form provided by the employer (refer Model Forms the worker’s capacity to perform the included in Part D). This report should not duties safely including emergency include any clinical information. Only the procedures functional assessment of fitness for duty or whether the condition could cause otherwise, and any recommendations sudden loss of control of the engine/train regarding specialist review or job modifications and the like should be reported whether with a modification of tasks or the environment, the worker’s condition could to the employer. be accommodated without compromising The Questionnaire and Health Assessment their efficiency or the health and safety of Record should not be returned to the others, or incurring unreasonable employer. expense. 6.11 Record Keeping 6.8 Specialist Referral Appropriate records should be maintained by The worker’s condition may warrant referral the authorised health professional including: to a specialist. In such cases the authorised completed Safety Critical Worker Health health professional should explain fully the Questionnaire nature of the rail safety tasks involved and completed Health Assessment Record the concerns regarding health status. The copy of the report form sent to the specialist report should be sent to the employer authorised health professional, not to the employer. copies of relevant support information any additional clinical notes.
6.9 Informing and Counselling the 6.12 Communicating with the Worker’s Worker GP The health professional should advise the The authorised health professional should worker of the results of the assessment and ensure an ethical relationship with the where relevant, about the ways in which their worker’s GP and other treating professionals. condition may impair their ability to conduct Reference to the GP should be made for rail safety work. As part of this process, the ongoing treatment requirements, for worker becomes better informed about the management of lifestyle issues and to
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 26 discuss issues such as medication causing impairment. Diagram 6 provides a summary of the process involved in conducting a health assessment for fitness for rail safety duties and illustrates the roles and responsibilities of the various parties.
27 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Diagram 6. Conducting a Health Assessment for Fitness for Rail Safety Duties EMPLOYER WORKER Requests report on worker’s fitness to undertake rail safety duties. Presents for pathology/ECG tests as required. Provides worker with Health Assessment request & Report Form and identifies the type of health Brings all current medication. assessment to be undertaken (High Level SCW, SWC or ATTP); and the reason for the assessment Brings visual ID. (Preplacement/Change of Grade, Periodic, Triggered). Completes Questionnaire as required (SCW). Provides Worker Questionnaire Form and Clinical Examination Proforma. Provides additional information as required including critical incident & Workcover history.
HEALTH PROFESSIONAL Confirms identification Reviews questionnaire and other information. Undertakes health assessment in accordance with the Guidelines for Examining Health Professionals.
Worker Worker Worker Worker Worker assessed as assessed as assessed as assessed as assessed as
FIT FOR DUTY FIT FOR DUTY SUBJECT TO FIT FOR DUTY SUBJECT TO TEMPORARILY NOT FIT FOR PERMANENTLY NOT FIT Meets all relevant medical REVIEW JOB MODIFICATION DUTY FOR DUTY criteria. Does not meet all medical criteria, but Does not meet all medical criteria, but Does not meet all medical criteria Does not meet the medical could work if condition is sufficiently could work if suitable modifications and cannot work at present, but will criteria and cannot perform the under control and person reviewed. were made to the job. be reviewed to determine status. job in the future.
Practitioner completes Health Assessment Report in accordance with findings indicating: whether fit or otherwise (as above) recommendations regarding frequency of ongoing review as appropriate. recommendations regarding specialist review/referral as appropriate. recommendations regarding practical assessment and job modification as appropriate.
Practitioner also: Advises and counsels employee accordingly. Communicates as appropriate with the employee’s GP. Forwards report to employer by fax, or phone if situation warrants immediate communication. Retains copy of report for file together with original of Employee Questionnaire and Clinical Examination Record.
EMPLOYER WORKER Makes a decision regarding the employee’s fitness for rail safety duties. Attends specialist consultations as required. Advises and implements appropriate practical assessment. Attends follow-up review appointments as required. Advises and implements appropriate job modifications. Advises and implements appropriate medical reviews. DRAFT Advises Guidelines and implements for Authorised re-deployment Health Professionals as required. Co nducting Assessments for Rail Safety Workers 20 May 2003 28 Maintains appropriate records and flags dates for review as appropriate. 7. Case Studies These studies illustrate the application of medical standards and the decision process for assessing rail safety worker fitness for duty. They begin with a typical scenario and then consider the issues arising for the participants.
Case Study 1 Presentation Lou is a 53-year-old train driver who attends for his periodic Safety Critical Worker Health Assessment. His last assessment five years reported him Fit for Rail Safety Duty. He considers himself fit and well, does not regularly attend the family doctor and takes no medication. Assessment At the routine health assessment the authorised health professional notes that Lou smokes 30 cigarettes per day, has a family history of heart disease (his father died at 56 from a heart attack) and is overweight. He gives no history of chest pain or shortness of breath. He admits he does not exercise regularly any more and that he has gained quite a bit of weight in the past year since his wife left him. Upon examination it is noted that he has a resting blood pressure of 180/110mmHg, his total cholesterol is 7.0 and HDL 0.91, his resting ECG is normal and he has no diabetes. The cardiac risk score is calculated to be 30, which is above the cut-off score of 22. Action Authorised Health Professional The authorised health professional diagnoses a raised cardiac risk score that requires referral to a cardiologist for detailed assessment (for example, treadmill, thallium scan). Since Lou is asymptomatic and the cardiac score is less than 32 he may continue to drive but should be seen soon after the cardiologist’s report is received. The authorised health professional advises Lou’s GP of his findings and alerts him to the need for risk factor modification. The authorised health professional discusses the findings with Lou, explaining the possible concern about his heart and the need for prompt referral for more tests and attention to his lifestyle. Lou is told that the health professional will recommend he is Fit for Duty Subject to Review but if Lou experiences chest pains he must stop driving immediately, see his GP and tell his supervisor. The authorised health professional completes the report to the employer, indicating Fit for Duty Subject to Review and noting that referral to a specialist has been made. The authorised health professional indicates that Lou should be seen at the practice within the next month. Employer On receipt of the report, the employer enters Lou’s details into the rail organisation’s recall system and flags him for review in a month. One Month Later Authorised Health Professional The cardiologist advises that Lou has a positive exercise test and that a thallium scan has revealed significant reversible myocardial ischaemia. Lou has been advised by the cardiologist that he will require an angiogram and cardiac surgery (either a stent or coronary artery bypass grafting). The authorised health professional tells Lou he will be unfit to drive trains for at least three months after the cardiac procedure and that he may not be able to return to driving duties in the long term. He emphasises the need to address lifestyle issues with support from his GP. The authorised health professional advises the employer that Lou is Temporarily Unfit for Duty as a loco driver. Lou is however fit for alternate duties.
29 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Employer On receipt of the final report, the employer discusses employment options with Lou. There is a vacancy due to maternity leave at the local station. As he remains well, Lou is happy to fill this position in preference to staying at home on sick leave.
Case Study 2 Presentation Serge is a 45-year-old train driver who attends the rail organisation’s authorised health professional for his periodic Safety Critical Worker (Category 1) Health Assessment. His last assessment was five years ago and reported him Fit for Rail Safety Duty. He smokes 40 cigarettes a day and is overweight. The attendance records supplied by the employer show that Serge has taken twenty sick days in the past six months - all of one to two days’ duration. Some were accompanied by a doctor’s certificate for a medical condition. Assessment On review of Serge’s Safety Critical Worker Questionnaire, the authorised health professional finds the K10 questionnaire gives a score of 35. On further questioning, Serge reports having problems at home. His wife has a gambling problem, their financial situation is poor and their fifteen-year-old son has been in trouble with the police. His wife is worried by the fact that he appears to stop breathing during the night. He is constantly tired, has no energy and admits that on a couple occasions recently he nearly missed a couple of red signals while driving freight trains at night. His Epworth Sleepiness Scale (ESS) (in the Safety Critical Worker Questionnaire) score is 16/24.He is due to drive that evening. Action Authorised Health Professional The authorised health professional diagnoses significant anxiety, mild depression (history and raised K10) and probable sleep apnoea (history and ESS score). These conditions, undiagnosed and untreated, are incompatible with operating a train safely. Serge is referred for a sleep study and his GP is contacted to arrange management of his anxiety and depression. The authorised health professional discusses with Serge that he has an anxiety state that requires referral to his GP and a probable sleep disorder that requires urgent investigation. The authorised health professional counsels Serge that he is Temporarily Unfit for Duty as a driver and is to be reviewed again in one month after the results are to hand and the anxiety state is treated. He advises Serge that his employer provides a free Employee Assistance Program to workers and their families and that this might help him with his family difficulties. The authorised health professional contacts Serge’s crew manager immediately by phone as Serge was scheduled to drive an interstate freight train later that evening. He advises that Serge is Temporarily Unfit for Duty. He does not provide detail of Serge’s medical condition but indicates that Serge will be referred to a specialist and to his GP. The authorised health professional completes the report and indicates that he will review Serge in a month’s time. Employer The manager makes immediate changes to the driving roster and arranges to see Serge to discuss alternative duties. He enters Serge’s details into the rail organisation’s recall system and flags him for review within a month’s time. One Month Later Authorised Health Professional At review in one month the sleep specialist report advises that Serge has confirmed sleep apnoea and has had a good response to treatment.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 30 The psychologist’s report indicates that Serge is making good progress, his wife is attending Gamblers Anonymous and that Serge’s anxiety is receding without the need for medication. As a result, Serge is considered Fit to Return to Work with Job Modification, Subject to Review. Serge can drive two person-operated trains with a review in three months. If he continues to do well, return to single-operator trains may be considered. Employer The employer notes the report results and flags Serge for triggered assessment in three months’ time. Modifications are made to the roster to accommodate Serge’s requirements and a Principal Driver is allocated to monitor Serge’s capabilities.
Case Study 3 Presentation Jack is a 48-year-old signaller who attends for his periodic Safety Critical Worker (Category 2) Health Assessment. His last assessment five years ago under the new standard reported him fit for rail safety duty. He considers himself fit and well. He does not regularly attend the family doctor and takes no medications. Assessment At the routine health assessment the authorised health professional notes that Jack smokes, is obese and he has glycosuria +++ on urine testing. He has no history of diabetes but advises that his father is a non insulin dependent diabetic. He has no ocular, cardiac or peripheral vascular symptoms associated with diabetes. Action Authorised Health Professional The authorised health professional diagnoses that Jack probably has diabetes, though without complications at present. He refers him to his GP for fasting blood glucose and other tests to confirm a diagnosis of diabetes. He alerts the GP to the fact that Jack works shifts and this should be considered when discussing his diet. Close liaison with the GP is required. If he is treated by diet and exercise alone he is not at risk of hypoglycaemia and may work, but if oral hypoglycaemics or insulin are begun his stability of control should be assessed by a specialist before resuming normal duties. The authorised health professional discusses the finding of probable diabetes with Jack and the need to see his GP soon and to comply with treatment to help ensure his continuing employment. He advises Jack that he is being assessed as Fit for Duty Subject to Review and that he will be in touch with his GP. If Jack begins oral hypoglycaemics or insulin he will be Temporarily Unfit for Duty until control is established. The authorised health professional completes the report form advising the employer that Jack is Fit for Duty Subject to Review. He should be reviewed in one month’s time to determine the outcome of his investigations with his local doctor. Employer The employer records the details of the recommendations and arranges a review assessment with the authorised health professional. General Practitioner and Specialist Jack is examined by his GP who finds he has a fasting blood sugar of 24mmol per litre. The GP provides the employer with a doctor’s certificate indicating Jack is not currently fit for safety critical work. He refers Jack to an endocrinologist and a dietician and reports these actions to the authorised health professional. The authorised health professional follows up the endocrinologist, providing background on Jack’s job requirements as a Safety Critical Worker and alerting the endocrinologist to the medical standards for rail safety workers.
31 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Employer On receipt of the GP report, the employer discusses the situation with Jack. He is able to provide alternative duties. Jack is advised to remain in alternative duties until the authorised health professional reviews the endocrinologists report. One Month Later Authorised Health Professional The authorised health professional reviews the specialist reports. Jack has been commenced on an oral hypoglycaemic agent and dietary modifications. His blood sugar over the past week has been 8-10mmol per litre indicating good control. The specialist has advised that Jack’s condition is well controlled and that he is fit for Safety Critical Work. The authorised health professional advises the employer by telephone and faxes a completed report form. A recommendation for review one month after resuming his usual duties is made. If meals and shift work hours are a problem the possibility of alteration of hours may be raised (Fit for Duty Subject to Job Modification). Jack however does not have problems with adjusting to shift work with his meals and his diabetic control is good. Following review assessment the authorised health professional recommends that Jack is Fit for Duty Subject to Review. He recommends review every twelve months. This final medical recommendation is completed and sent to the employer. The employer records that Jack is to have annual triggered review. Jack is reviewed in twelve months. His diabetic control continues to be satisfactory as evidenced by his diabetic record booklet and history provided. He does not have problems with his medication, meals or shift work. He is considered to have stable diabetes under control, he requires ongoing annual review rather than every five years. The employer is advised of this and records that annual review is required.
Case Study 4 Presentation Sam is a 35-year-old flagman who has been referred for a triggered assessment due to a funny turn at work. Sam had his last periodic Safety Critical Worker (Category 1) Health Assessment three years ago at which he was reported Fit for Duty. Assessment Sam advises the authorised health professional that he has had three funny turns over the past two years (not while at work). He has not been investigated or treated for these episodes. He states he gets no warning and cannot recall what happens. He thinks he is out for a few minutes, he cannot recall any injury such as bitten tongue or incontinence and he is just a bit sore generally. He had a head injury five years ago with a fractured skull from a motor bike riding incident. He has no neurological or cardiac symptoms. His cardiac risk score was acceptable and the ECG normal and the AUDIT score was low. Clinical examination is essentially normal. Action Authorised Health Professional Sam has an undiagnosed disorder (undifferentiated illness) that is predisposing him to sudden loss of awareness and this is not compatible with Safety Critical Work. The authorised health professional considers a wide range of disorders that may cause funny turns including drug or alcohol abuse. If drug abuse is suspected the health professional may contact the employer and advise that Sam has an impairment for which a medical basis is not apparent. Then the employer may request Sam to have a urine test for drugs. Otherwise Sam would be referred to GP for investigation and the safety critical nature of his job emphasised to the GP or any specialist subsequently involved. The authorised health professional considers a medical cause is likely and discusses his concerns with Sam and the need to see his GP. He advises Sam that Sam is assessed as Temporarily Unfit for Duty and will see him after results of investigations
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 32 are to hand. The health professional may also ask if any of Sam’s workmates saw his turns and whether they can give any more information. The authorised health professional completes the report form and faxes it immediately to the employer, advising that Sam is Temporarily Unfit for Duty but may perform non- Safety Critical Work (where he can be seen by others if he becomes unwell). If no cause of the turns is found or they cannot be treated adequately then Sam would be Permanently Unfit for Duty as a Safety Critical Worker and alternative duties would need to be considered for him. Employer The manager records Sam’s work restrictions and is able to provide him with temporary alternative employment working in a Controlled Environment. General Practitioner Sam attends his GP and undergoes some initial blood tests and resting ECG. Because of his past head injury a possible neurological cause of the condition needs to be excluded. He is referred to a specialist neurologist by his GP. Unfortunately results from EEG and MRI of the brain indicate that Sam has epilepsy and medication is prescribed. This information is sent to the authorised health professional. Authorised Health Professional On review of the specialist report the authorised health professional finds Sam is Unfit to resume Safety Critical Work. His employer is advised this is a long term restriction. Sam should not be performing Flagman duties. Sam can work in a gang repairing rail tracks provided it is a Controlled Environment and that he is accompanied by others while working on the track. Employer His manager is to record this information and ensure Sam is not placed in Safety Critical Work. Sam is no longer a SCW or an ATTP who works in an Uncontrolled Environment and is not scheduled for any regular reviews in future. If Sam’s epilepsy is stabilised over the next few years his job restrictions may be reviewed in conjunction with a specialist.
33 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 PART B – RAIL SAFETY WORKER TASKS
Outlined in the following pages are descriptions of the main types of task categories in the rail industry and the relevance to the health assessments. Knowledge of the task is important in order to enable the health professional to conduct the assessment. A more detailed description of the risk assessment of rail safety tasks is provided in Appendix 2 of the Code of Practice. 1. Train Operations confined space, wash the driving window, and 1.1 Train Driving change points and (Category 1 - High Level SCW) d) in emergency situations the driver must be The train driver usually operates alone; cabs able to exit the cab to the ground in usually have a vigilance control (deadman’s unpredictable conditions such as after an handle) which the driver needs to continually accident or incident. activate or the brakes will automatically operate. The train driver’s job involves a mixture of tasks If the driver of a country train were to collapse which include: when driving there may be a 55 second delay in the vigilance system before activation of the a) continuous skilled driving to meet a timetable, brakes, during which time about 2km could be which involves sitting for long periods while covered at speeds of over 100km/h with attendant reading instruments, communicating by radio risks. These include no whistle at unprotected to a central control, operating handles to level crossings, speeding on restricted curves and brake and accelerate the train, scanning the through stations, accelerating on down hill track ahead and by use of side mirrors, and gradients, and hence jeopardising safety of the b) being constantly vigilant to detect rail network. red/yellow/green signals or unexpected New technology may require good eyesight to events and respond appropriately, and read flat screen/SBE in multicolour to monitor the c) the driver may be expected to perform tasks train. outside the cab including checking the integrity of the train, coupling carriages in a
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 34 individuals and help coordinate the overall 1.2 Signalling, Controlling and response. In an emergency normal safety Gatekeeping controls may be overridden which could lead to (Category 2 - Safety Critical Worker) errors affecting safety of the rail network. A The point of entry for signalling and controlling is magenta colour is used on the screen to identify a the signaller job and therefore all requirements route which has been cancelled by manual must be met for a signaller in the first place. intervention. The open plan system lends to good peer support and communication in times of crisis. Signalling Controllers are safety critical but not at a high Signallers are responsible for the control of trains level because: through a section of track. They monitor the Collapse on duty will not jeopardise safety of the progress of the train from a large display board rail system because of the fail-safe engineering of set at a distance above them, and activate points the signal system and others are present who can and signals by switches or by pulling/releasing identify the collapse. levers. The action of pulling levers may be repeated up to 1-2 times a minute at peak hours and requires appreciable strength of arms, back and legs. In an emergency the signaller may need to access the track to give a written ‘rail pass’ to a driver. In the event of a signal failure they may need to access the track and quickly and correctly identify red/yellow/green colours from a single lens signal. Signallers are safety critical but not at a high level because: Collapse while on duty will not jeopardise safety of the rail system because of the fail-safe engineering of the signaling system. Gatekeeping The gatekeeper closes the gates some minutes before setting the signal to GO to permit the train to pass through the gates. The gatekeeper works in isolation. If the gatekeeper collapses after closing the gates but before changing the signal the safety of the rail network is not in jeopardy.
Controlling Operators in the Metrol room set and monitor the progress of suburban trains. They receive information about problems arising from passengers, track or the train and make any necessary routing decisions. They are in voice communication with drivers and others; monitor progress of trains on banks of screens, work in an open plan area, and have shift rosters that include night shifts. There is always a minimum of eight persons in the room. The work may be routine but can be stressful, for example if a storm causes signal faults or trees across lines. In emergency situations experienced supervisors lend support to
35 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 1.3 Infrastructure Flagman Duties Infrastructure workers are responsible for many (Category 1 - High level SCW) aspects of track maintenance. The flagman’s job is safety critical at a high level because: Driving of Hi-rail Vehicles (Category 2 - Safety Critical Worker) constant vigilance is required to protect safety of the network and the gang; These vehicles are used by track inspectors, signal maintainers and others. They travel long the flagman must be able to move quickly to distances in a hi-rail vehicle, typically a land set detonators; cruiser with extra wheels suitable for driving on if the flagman collapses and there is failure to alert rails, and then dismounting onto road as required. train drivers this may lead to a train entering the Trains are usually but not always excluded from work area jeopardising safety of the rail network the section of track under inspection. The worker and lives of track workers. may be solo. In Victoria these vehicles move at up to 80km/h with a flashing warning light and have a vigilance system (but not in SA). Therefore, in the event of collapse the vehicle will stop, but remain on the track. In the event of collapse the vehicle may enter a level crossing before braking but the likelihood is considered remote and in addition they have warning lights flashing.
Track Inspection (Category 2 – Safety Critical Worker – See also Hi-rail Driver) Track inspectors check safety of track, level Other Track maintenance crossings and bridges. To do this they travel long (Category 3 – ATTP) distances in a hi-rail vehicle, typically a land Other Track maintenance staff are not safety cruiser with extra wheels suitable for driving on critical but should have a Track Safety Health rails, and then dismounting onto road as required. Assessment to ensure safety when walking to and Trains are usually but not always excluded from from the site, noting that while at the work site no the section of track under inspection. Track assumptions should be made regarding their sight inspectors may be solo. In Victoria these vehicles or hearing. have a deadman’s handle vigilance system (but not in SA). Therefore, in the event of collapse the Electrical Systems Maintenance vehicle will stop, but remain on the track. (Signals and Traction) Track Machine Operation (Category 3 – ATTP) (Category 2 – Safety Critical Worker) Electrical systems maintenance workers repair a. Track Machine Operators who drive signal systems and overhead wiring systems machinery classified as a locomotive should across the rail network. They may work solo or as be examined as for a driver (High Level part of a team using tools and equipment that SCW). varies in size from hand tools to large machinery. Other workers drive equipment which is not When working solo within the rail safety envelope, classified as a locomotive (SCW). Some track they are often responsible for their ‘own workers are responsible for tamping ballast using protection’ but when in groups, lookouts may be a track tamper machine. This is driven at low used to see or hear trains at a distance. When speed on rails to the site of work usually by two using hand tools they will not jeopardise safety of men. Driving requires pressure on a throttle and the rail network. However when undertaking any in the event of collapse release of pressure will type of work that involves obstructing the track, bring the machine to a halt. During work the the relevant Train Control/Signaller is normally machine is given exclusive track occupancy. notified and protection put in place in accordance with the safe working rules. Signal systems maintenance workers need to recognise red/green/purple at a distance from a single lens signal to check correctness of their
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 36 repairs and to ensure safety of the network. couple air compression lines which requires However they are generally not under time bending in confined spaces, pressure to read the signal and there is often redundant information regarding the signal colour board/alight from trucks and carriages which available in the control enclosure. They may also requires agility and sound arms and legs. be required to distinguish between red, yellow and blue colours on plans and drawings used when commissioning systems. However cross check processes by another person are used to detect any colour identification errors made during commissioning. Signal systems maintenance workers are therefore only required to have Colour Defective Safe vision (similar to shunting). 1.4 Train Examination (Category 2 – Safety Critical Worker) Train Examiners inspect a train for its integrity prior to dispatch from rail yards and are the quality control point for the mechanical safety of a train which has implications for safety of the network. They work in isolation and under time pressure so vigilance is important. They lock off the train when examining it and then they check it by 1.6 Freight Yard Operations walking along the ballast and bending to check (Category 3 or 4 – ATTP – depending couplings, bogies and protrusions. They then on Controlled Environment) issue a Permit to Work to clear a train; hence a collapse will not jeopardise safety of the network. Freight yard workers unload pallets or containers They communicate by radio. of goods (including Dangerous Goods) from wagons often using fork lifts. Their activities are 1.5 Shunting not safety critical because the safety of the rail (Category 1 – High Level Safety network will not be jeopardised by their activities Critical Worker) or by them incurring a collapse at work. They are within the safety envelope and their job needs to Shunting work occurs mainly in freight rail yards be assessed to determine if they are in a and involves marshalling the trucks or carriages Controlled Environment, or if they require a Track that make up a train. A rake of trucks may be Safety Health Assessment. hundreds of metres long and may contain dangerous goods. 1.7 Train Maintaining The shunter works as a team with the driver of the (Categories 3 or 4 - ATTP – engine and sometimes a signaller using radio depending on Controlled communication. The shunter acts as the eyes of Environment) the train-driver and controls precise shunting. The Maintainers of rolling stock are typically fitters and main lines are protected from the marshalling turners and their assistants, or other tradesmen. yards by roll out protection which would derail any They perform the full range of engineering runaway trucks, in addition to which loose required to maintain chassis, engines, bogies and shunting is not permitted. However an error or a seating. Their activities are not safety critical collapse may result in an accident and derailed because the safety of the rail network will not be trucks fouling the mainline or a possible explosion jeopardised by their activities or by them incurring occurring. a collapse at work. They usually work in large The shunter also needs to: workshops with rails entering the ‘shops to bring in rolling stock. Also, they may leave the ‘shops walk extensively over uneven ballast, to perform other tasks (for example, brake open or close coupling mechanisms, blocking, washing carriages, fuelling engines). They are within the safety envelope and their job apply or release brakes to carriages and needs to be assessed to determine if they are in a trucks which requires forceful action of the Controlled Environment, or if they require Track arms, Safety Health Assessment.
37 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 2. Tram Operations 2.1 Tram Driving (Category 2 - Safety Critical Worker) 2.2 Recovery and Infrastructure The driver is required to only drive the tram. (Category 3 – ATTP in Uncontrolled (Tickets are dispensed by machine; there are no Environment or Category 2 - Safety conductors.) Drivers drive several types of trams Critical Worker) that have differing types of controls and vigilance systems. The driver usually controls the tram by Infrastructure generally work on tramlines is using a console of buttons and switches, plus usually at night after the service has ceased or on hand levers and foot pedals. There are also side protected (closed) track. The hazard to mirrors and an internal video to view the tram. infrastructure staff is therefore usually from road traffic rather than trams. The standard safety The vigilance systems on Class A, B and Z trams procedures for traffic management as required by are sensitive foot pedals that will activate the VicRoads are enforced to protect these workers. brakes immediately if the foot pressure lessens. The workers may be wearing face shields when The new Citidas class trams have a sliding hand - welding or wearing ear muffs when using controlled combined accelerator and vigilance pneumatic drills and therefore should be regarded system which is responsive to hand pressure and as functionally blind and deaf, and their safety movement. If the pressure is suddenly reduced ensured by lookouts as well as barriers, signs and (as in a collapse) the device recoils and begins warning lights. They are then assessed as applying the brakes, and if not activated in three working in a Controlled Environment. seconds it sounds an alert and in another two seconds activates the emergency brakes. This is Electrical workers usually work in a tower above a a sophisticated vigilance system. truck with the driver responsible for traffic safety All the W class trams used on the City Circle have Recovery workers go to the scene of a breakdown been modified to include a vigilance system and or accident involving a tram. They may be travel at less then 30km/h. In addition, the driver required to drive a tram on the mainline. is in radio contact with central control. The main All recovery staff required to drive trams on main stress on the driver is the need to drive lines should be examined as for a Tram Driver defensively regarding traffic on the road because (Category 2, Safety Critical Worker). a tram can only brake; it is not possible to make avoidance. 2.3 Tram Maintaining Red-green perception is not regarded as essential (Category 4 – ATTP in Controlled for tram drivers. They are analogous to Environment or Category 2 – Safety commercial vehicle drivers who do not require red Critical Worker or) vision because red traffic lights give positional Maintainers generally work in sheds and are cues. Also trams are usually on well-lit roads responsible for all aspects of maintenance of which enables detection of emergency signs. trams including bogies, chassis, electrical and fittings. Trams are slowly brought into sheds by the maintainers themselves. Maintainers work in a Controlled Environment. All maintainers required to test drive trams on main lines need to be examined as for drivers (Category 2, Safety Critical Worker).
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 38 3. Tourist and Historical Rail Operations
3.1 Tourist Trains Signalling systems are predominately simple The operations of tourist trains have with a single signal to control entry to the important differences from commercial rail stations. operations. These are identified by asking Shunting operations are within simple yard the question: layouts, involve only a small number of For any aspect of the tasks vehicles, and do not involve dangerous goods. Signals are exchanged predominantly identified is continual vigilance and by sight, with hand signals used directly situational awareness important to between staff involved with shunting. the operational safety of the rail Operations often use more than person network? involved in shunting, the use of two person The differences vary between tourist operations crews on locomotives, and are not in close but often include the following: proximity to the commercial rail networks. Many tasks that require vigilance and Tourist rail lines are typically 10-15km long, and points of entry to the network are well awareness of the tasks are of short duration defined as they have only one or two defined at the time, and may happen only infrequently stations on the network where trains can during the shift of duty. originate or arrive. Train operations are of low Workers on Tourist Railways predominately density and frequency. This enables do not attend to duties on a daily basis and knowledge about traffic movements and work may undertake the tasks with many weeks sites to be communicated to those concerned. between duties. Trains travel slowly so passengers can enjoy Tourist Railway rules for track work require the scenery, with speeds typically 40km/h up protection for work sites at distance of 200 to a maximum of 60km/h. Within station limits metres. Due to reduced speed they can speeds are limited to a maximum by the utilise fixed stop boards in-lieu of flagman. Tourist Railway Rules to a maximum of Due to reduced distances track maintenance 24km/h (15mph). workers are in close visual and audio communication. A look-out person is required Locomotives always have two persons in the cab or a deadman’s handle system, as well as who controls the flagmen. Track gangs are a guard or conductor who can brake the train. usually small in number (<10 persons) and work in very short distance sections at a time. Tourist rail lines use a Staff and Ticket safety Tourist railways often do not operate every day system to control train movements. This and hence have the opportunity for total protection system would require two persons to make on days for track work (apart from a special work errors to cause an accident. train), which lessens risks to the track workers.
39 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Driving of Tourist Trains Diagram 7. Risk Assessment for Driving of Tourist Trains The driving operation of tourist trains varies considerably. One driver drives the train and the other Does the train (fireman) fuels it. Both can operate the brakes so if run on a one collapses the other may operate the brakes (as mainline? well as a guard who has a brake). The diversity of operation influences the risk analysis as shown in Diagram 7. YES NO Members of tourist rail societies may visit and work at other societies with different locomotives and rolling stock. Therefore medical standards need to be High Is there a deadman’s sufficient so as to be portable, or a restriction may be NO level handle system or are applied to working on a specific railway or locomotive. SCW two persons able to drive always present?
YES
SCW
3.2 Driving of Historical Trams Diagram 8. Risk Assessment for Driving of The operation of historical trams varies and this may Historical Trams affect the risk assessment. Does the tram go on a In some cases the tram route is along main roads public roadway? but others are on private land and the public may not have access. No Yes Members of historical tram societies may visit and work at other societies with different routes and Is there a deadman’s rolling stock. handle fitted? Therefore medical standards need to be sufficient so as to be portable, or a restriction may be applied to working on a specific tramway or type of tram. Yes No Drivers are solo in the cab; sometimes there may be a conductor on the tram. The tram is operated by moving the controller handle for power, as well as a brake handle. Trams may move up to 50km/h along Is a second person present who main streets with traffic and pedestrians. Some trams is competent to drive, able to have no deadman’s handle/pedal or other vigilance observe the driver, and able to system. In the event of collapse the tram would accessYes the cab? No continue at the speed set by the controller till the end of the line. Therefore, the job is safety critical at a high level to protect the safety of the tram network.
Safety Critical Worker High Level Safety (Category 2) Critical Worker (Category 1)
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 40 PART C – MEDICAL STANDARDS Recent advances in the diagnosis and treatment Sections on Alcohol and Drugs-Illicit and of various illnesses combined with engineering Prescription in these medical standards are developments and the introduction of anti- included to reflect statutory drug controls. discrimination and privacy legislation, has meant the medical standards for rail safety workers in the Because of the potential for catastrophic rail industry required substantial revision. impacts, that can result from a rail incident certain rail industry work is assessed as In the following pages, the medical standards are safety critical at a higher level than for truck shown by body system / disease. For each driving and additional tests have been standard the opening text provides some general included for these categories. information about the condition and its effects on safety, and then provides advice about the The risk of a worker having a heart attack is a medical assessment of the condition. The table in major consideration for the health assessment of each standard sets out the criteria that need to be workers in safety critical jobs, such as train met for unrestricted fitness for duty and the criteria drivers. Risk tables based epidemiological that need to be met for Fitness for Duty Subject to studies enable a reasonably accurate forecast for Review or other restrictions. five years of the risk of a fatal coronary event and stroke by integrating a number of measures. The main focus of the criteria is on serious conditions that would impact on the ability to These medical standards have adopted the perform rail safety work. The criteria emphasise Cardiac Risk Score based on data from the function in relation to the job rather than being American Heart Association (April 2002) and developed by Civil Aviation Safety Authority based on diagnosis or impairment. Specialist 1 advice may be useful regarding assessment of (CASA) . It calculates a risk score using data on: Safety Critical Workers. Age & sex Levels of Evidence systolic blood pressure HDL cholesterol For each of the standards, the level of evidence for that standard are noted according to the cigarette smoking NHMRC requirements (NHRMC. How to Use the diabetes and left ventricular hypertrophy (as Evidence: Assessment and Application of shown on ECG). Scientific Evidence. 2000.
psychiatric health. The importance of this has 1 been recognised and included in the rail A risk calculator based on Australian data is standard. being developed at Dept of Epidemiology and Preventive Medicine, Monash University and should be available late 2003. Its use will then be considered
41 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 PART C1 - MEDICAL CRITERIA FOR SAFETY CRITICAL WORKERS
1 ALCOHOL (see Drug and Alcohol Controls Appendix 2) practitioner must take appropriate steps to 1.1 RELEVANCE TO SAFETY CRITICAL restrict involvement in safety critical work while WORK on medication, for example, reporting worker as Alcohol is well known for the effects it has on Temporarily Unfit for Duty while on the vigilance and reaction times, and hence medication. increased risk of an error and accident occurring. The Transport Act 1983 contains stringent 1.3 ALCOHOL AND ILLICIT DRUGS provisions for alcohol control and all rail companies’ alcohol control policies in Victoria The use of alcohol in association with a number require a zero blood-alcohol concentration while of ‘recreational’ drugs such as marijuana undertaking rail safety work. A rail company can exacerbates their effect and significantly require a rail safety worker to submit to an increases the risk of an error. Therefore where alcohol breath test or blood test if alcohol alcohol is thought to be a problem, consideration impairment is suspected while undertaking rail should also be given to illicit drug use and safety work or within three hours of undertaking appropriate steps taken. rail safety work.
1.4 MEDICAL STANDARDS FOR SAFETY 1.2 EFFECT OF HABITUAL INTOXICATION CRITICAL WORKERS ON OTHER DISEASES Medical criteria for fitness for duty are outlined in Alcohol dependent drivers and workers are a the table overleaf. particular concern and are disproportionately The AUDIT questionnaire should be applied as represented in (road vehicle) crashes. shown in Section 5 of the Safety Critical Worker Prolonged alcohol abuse leads to effects on end Questionnaire (Part D) and scored as follows: organs such as the brain or peripheral nerves or liver, which may lead to further impairment of Questions 5.1 – 5.8, scores are 0,1,2,3,4, from safety. Persons who are frequently intoxicated left to right. and who also suffer from certain other medical conditions are often unable to give their other Questions 5.9 and 5.10, scores 0,2,4, from left medical problems the careful attention required. to right. Alcohol and Epilepsy Thus total maximum score is 40. Many patients with epilepsy are quite likely to A score of eight or more indicates a strong have a seizure if they miss their prescribed likelihood of hazardous or harmful alcohol medication even for a day or two, particularly consumption. Referral to a specialist in alcohol when this omission is combined with inadequate should be considered. Workers with alcohol rest, emotional turmoil, irregular meals and problems who are not truthful may score lower alcohol. Patients under treatment for any kind of on their questionnaire than should be the case. epilepsy are unfit for safety critical work if they Alcohol Dependence: Alcohol dependence is a are frequently intoxicated. syndrome the key elements of which are: Alcohol and Diabetes Narrowing of the drinking repertoire (every Patients with diabetes and on insulin have a days drinking is similar to the day before). special problem when they are frequently Salience of drinking (priority given to intoxicated. Not only may they forget to inject maintaining alcohol intake and neglect of their insulin at the proper time and in the proper previously important work and social quantity, but also their food intake can get out of activities). balance with the insulin dosage. This may result in a hypoglycaemic reaction or the slow onset of Increased tolerance to alcohol. diabetic coma. Such persons should not perform safety critical work until they no longer drink to Withdrawal symptoms on stopping drinking. excess. Relief or avoidance of withdrawal symptoms Alcohol and Medication by further drinking. Some medications are incompatible with Subjective awareness of compulsion to drink ingestion of alcohol (for example some (impaired control, urges or cravings). sedatives). Where alcohol is thought to be a Reinstatement of drinking after abstinence. problem, medical practitioners should advise the patient accordingly and consider alternative Three or more of the above fit the International medication where available. If the medication is Classification of Diseases (ICD) criteria for likely to cause any level of impairment, the dependence.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 42 Binge Drinking: Binge drinking has been alcohol abuse may be conducted if referred for a defined as the intermittent consumption of triggered assessment or clinically indicated. alcohol to intoxication in short periods of time (six standard drinks for a male and four for a female). In the event of a person presenting for During binges persons may exhibit behaviour examination with evidence of impairment, an similar to that of problem drinkers and should be assessment of the impairment should be done considered unfit for rail safety work. and then the person managed as shown in Diagram 9. Tests of blood alcohol are not routinely required at periodic examination, but biochemical tests for
Diagram 9. Management of Impairment Assessment relevant to usage of Alcohol and Drugs (Illicit and Prescription/OTC)
Is there evidence of impairment? Preliminary Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, YES attitude, comprehension). NO
Discuss with worker. No further action Is there a medical basis for impairment, ie (continue with health prescription medication /OTC drug taken for assessment) a defined purpose, or an illness. YES NO
Medical basis If suspect alcohol or illicit drug use: Classify Temporarily Unfit for Duty. Classify Temporarily Unfit for Duty If appropriate, discuss medication and advise on report impairment with GP/treating doctor in order to without clear medical basis. resolve impact on employment. Contact employer regarding If appropriate, refer to relevant impairment without clear medical chapter for medical conditions. basis and await further instructions from employer. Identify review period.
43 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – ALCOHOL CONDITION STANDARDS Alcohol The criteria for Fit for Duty are not met: Impairment If the worker is impaired by alcohol Refer to Diagram 9 for management Alcohol The criteria for Fit For Duty are not met: Dependency there is alcohol dependency. If the worker has a strong history of alcohol abuse and clinical evidence of abuse is limited to biochemical findings without clinical signs. Fitness for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist, and the nature of the work: If the worker has stopped drinking for a substantial period; and Demonstrates good evidence of insight into the problem; and Is compliant with treatments; and Shows no evidence of end organ damage relevant to safety critical work as specified elsewhere in these Guidelines.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which the Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further reading Arnedt, J.T., et al, Simulated driving performance following Liguori, A.D., et al, Alcohol effects on mood, equilibrium, and prolonged wakefulness and alcohol consumption: separate and simulated driving, Alcoholism, Clinical and Experimental Research, combined contributions to impairment, Journal of Sleep Research, 23(5), 815-821, 1999. 9(3), 233-241, 2000.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 44 2 ANAESTHESIA
2.1 RELEVANCE TO SAFETY CRITICAL 2.2 GENERAL MANAGEMENT GUIDELINES WORK (Including Temporary Conditions) Anaesthesia may affect the ability to perform In cases of post-operative recovery following safety critical work. Post anaesthesia, both surgery or procedures under general or local physical and mental capacity may be impaired anaesthesia, it is the responsibility of the for some time thus affecting a worker’s ability to surgeon and anaesthetist to advise patients drive and work safely. This is applicable to both about the potential effects of the anaesthesia general and local anaesthesia. The effects of and the need to allow for an appropriate period general anaesthesia will depend on factors such of physical and mental recovery before resuming as the duration of anaesthesia, the drugs safety critical work. administered, and the surgery performed. The degree of effect of local anaesthesia on the Following minor procedures under local ability to perform safety critical work is anaesthesia without sedation (for example, dependent on dosage and region of dental block), return to work may be acceptable administration. A further factor to consider is the immediately following the procedure. effects of analgesics and sedatives (refer Drugs Following brief surgery or procedures with short – Prescription and OTC). acting anaesthetic drugs, the patient may be fit for duty after a normal night's sleep. After longer surgery or procedures requiring anaesthesia, it may not be safe to perform safety critical work for 24 hours or more. Decisions should be made on a case-by-case basis.
Reference: Lichtor, J., Alessl, R., Lane, B. Sleep tendency as a measure of recovery after drugs used for ambulatory surgery. Anesthesiology 2002;96:878- 883
45 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 3 CANCER
effects. This will also involve assessing the 3.1 RELEVANCE TO SAFETY CRITICAL patient’s functional capacity and what medication WORK the patient is taking. Patients should be advised Cancer may affect the ability to perform safety accordingly and employers advised. critical work. The site and degree of If the tumour involves the brain the patient advancement of the cancer is a prime should not undertake safety critical work, subject consideration as to whether a worker remains fit to a health assessment (refer standards below). for safety critical work because the cancer may affect various body functions. This is particularly Palliative Care: Patients with cancer are often important for cerebral tumours. Refer elsewhere prescribed opioids, particularly for palliative care. in these Guidelines for advice regarding other Safety Critical Workers will require careful specific organ involvement, for example, liver individual assessment. (Refer also Drugs – metastases. Prescription and OTC). Cancers requiring intervention with opioids, chemotherapy or radiotherapy may prove 3.3 MEDICAL STANDARDS FOR SAFETY deleterious to the ability to perform safety critical work if such treatment presents side effects CRITICAL WORKERS which interfere with an individual’s functional Medical criteria for fitness for duty are outlined in capacity. the following table. Neuropsychological assessment may be helpful 3.2 GENERAL MANAGEMENT GUIDELINES regarding recovery from a brain tumour and in the case of a driver, an assessment by a Cases should be assessed on an individual basis Principal Driver may also be useful. regarding the site of the cancer, the response to chemotherapy and radiotherapy and any side
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – CANCER CONDITION STANDARDS Cancer The effects at the primary site or of metastases are mainly covered by criteria given elsewhere. Intracranial The criteria for Fit for Duty are not met: tumours If the person has evidence of primary or secondary cancer within the brain. Fit for Duty Subject to Periodic Review may be recommended, taking into account the opinion of an appropriate specialist and the nature of the work: Three months after successful treatment of tumour; and If the person is likely to remain stable and physical and mental abilities are judged by treating specialist to be adequate for safe working. Neuropsychologist and Principal Driver assessment may be helpful.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which the Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 46 4 CARDIOVASCULAR DISEASES
some cases this is curative of the underlying 4.1 RELEVANCE TO SAFETY CRITICAL disorder and so will not impact on fitness for duty WORK as shown in Table 3 on Non-working Periods. In Cardiovascular disease may affect the ability to other cases the condition may not be stabilised perform safety critical work due to sudden and hence needs to be individually assessed. All incapacity such as from a heart attack or an cardiac surgery patients should be advised arrhythmia. Evidence suggests that people who regarding returning to safety critical work in the develop severe and even fatal coronary attacks short-term as for any other post-surgery patient while doing safety critical work such as driving and may be classed as Temporarily Unfit for may have sufficient warning to slow down or stop Duty. before losing consciousness, since less than half Deep venous thrombosis may occur in result in property damage and injury. However, association with surgery or from clotting sometimes no warning occurs or a warning sign disorders. A risk to safety critical work occurs if is misinterpreted or ignored, and this may result a pulmonary embolus arises. DVT need to be in severe injury or death to the Safety Critical assessed with regard to the likelihood of Worker and others. recurrence over a long period to gauge the Collapse from ischaemic heart disease (non-fatal impact on fitness for duty. A DVT arising in the and fatal) appears to account for around 15% of course of surgery is unlikely to have impact on sudden illness road crashes, which in turn fitness for duty, because it is self-limiting. account for about one in 1,000 reportable Treatment often involves anti-coagulants and this crashes. Thus ischaemic heart disease poses a section in the standard should also be referred relatively small but increased risk. to. Anti-coagulant therapy may be used for disorders of cardiac rhythm, following valve 4.2 GENERAL MANAGEMENT GUIDELINES replacement or for deep venous thrombosis to lessen the risk of emboli. However, if not Although the medical and surgical treatment of adequately controlled there is a risk of bleeding ischaemic heart disease may lead to alleviation which in the case of an intracranial bleed may of symptoms and improve life expectancy, acutely affect safety critical work. Such workers coronary arteriosclerosis tends to be a may only work if well controlled and subject to progressive process and the risk of heart attack, review. collapse and sudden loss of consciousness is greater than in healthy populations. When Effects of Safety Critical Work on the Heart A assessing a patient with cardiovascular disease, further problem in those who have established the health professional should consider any ischaemic heart disease is that safety critical symptoms of sufficient severity to be a risk while work such as driving causes occasional performing safety critical work. emotional and sensorimotor arousal leading to a faster heart rate and fluctuation in blood Patient examination will find some people with pressure. Such workers may need to respond to established heart disease. These people clearly emergency which theoretically could trigger have increased risk over the general population. angina, or even infarction. A stress ECG should be performed if clinically indicated. NonSsafety-Critical-Work Periods. A number of cardiovascular incidents and procedures may Suspected Angina Pectoris Where chest pains impact on short term safety critical work capacity of uncertain origin are reported, every attempt as well as long term fitness for duty, for example, should be made to reach a positive diagnosis AMI or aneurysm repair. Such situations present and the patient counselled in the meantime to an obvious risk. The patient should be classified restrict his or her safety critical work. If the tests as Temporarily Unfit for Duty and should not are positive or the person remains symptomatic undertake safety critical work for the appropriate and requires anti-angina medication for the period, as laid out in the following table. The control of symptoms, the criteria listed for proven recommendations regarding fitness for duty angina pectoris apply. should be considered once the condition has Cardiac surgery may be performed for various stabilised and work capacity can be assessed reasons including valve replacement, excision of per the standards outlined in this chapter. atrial myxoma or correction of septal defects. In
47 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Table 3. Suggested Non-working Periods Post Cardiovascular Events or Procedures
Event / Procedure Minimum non- working period for Safety Critical Workers Acute Myocardial Infarction 3 months Aneurysm Repair 3 months Angioplasty 4 weeks Cardiac Arrest As determined by treating specialist Cardiac Defibrillator N/A Cardiac Pacemaker Insertion 1 month Coronary Artery By-pass Grafts 3 months Deep Vein Thrombosis As determined by treating specialist Heart/ Lung Transplant 3 months Pulmonary Embolism As determined by treating specialist Syncope 3 months
4.3 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS 3. Stratification and Risk Management. Medical criteria for fitness for duty are outlined in The risk score is set at 22 (risk >2%pa). In the the table overleaf. event of a risk score exceeding 22 and less than Standards for chronic disorders are made with 32 and the Safety Critical Worker is the presumption that the disorder is stable and asymptomatic, the worker is not stood down but well controlled. If this is not the case, a specialist referred for prompt medical investigation. consultation should be conducted. Fitness for If the worker is symptomatic, or the risk score is Duty Subject to Review may be recommended 32 (when the probability of a fatal coronary in after initial assessment by an appropriate five years is near 25%, that is, 5% pa), the specialist. worker should be classed Temporarily Unfit for Cardiac Risk Score (Only High Level Safety safety critical work. Critical Workers) Referral to a cardiologist will usually involve Some groups of Safety Critical Workers (train stepwise investigations: drivers, flagman and shunters) have duties with i) Stress ECG; if negative review in five years; high levels of risk on assessment. They are if positive proceed to perfusion scan; required to have their Cardiac Risk Scores evaluated as follows. ii) Thallium or equivalent perfusion scan; if negative review in five years; 1. Data iii) If scan is positive the worker is not suitable Obtain the information for the Cardiac Risk for safety critical work unless an angiogram Score calculator as follows: is negative. Age The cardiologist may advise more frequent Cigarette smoking review than the above times. Blood pressure as measured supine; 4. Health Promotion ECG - report specifically requiring The worker should be advised of the life style information re presence of left ventricular factors that influence the risk score (smoking, hypertrophy; diet/overweight, exercise) and advised how to maintain good health. Fasting blood for Total and HDL cholesterol; Fasting plasma glucose test (level over 7mmol/L is diabetic). 2. Calculation Calculate the score using Table 4: Coronary Heart Disease Risk Factor Prediction Chart on the following page.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 48 Table 4. Coronary Heart Disease Risk Factor Prediction Chart (Civil Aviation Safety Authority)
1. Find Points For Each Risk Factor Age (If Female) Age (If Male) HDL- Cholesterol Total-Cholesterol Systolic Blood Pressure Other Pts Age Pts Age Pts Age Pts Age Pts HDL-C Pts Total-C SBP Pts 30 -12 47-48 5 30 -2 57-59 13 0.65-0.67 7 3.60-3.91 -3 98-104 -2 Cigarettes 4 31 -11 49-50 6 31 -1 60-61 14 0.70-0.75 6 3.94-4.30 -2 105-112 -1 Diabetic-male 3 32 -9 51-52 7 32-33 0 62-64 15 0.78-0.83 5 4.33-4.72 -1 113-120 0 Diabetic-female 6 33 -8 53-55 8 34 1 65-67 16 0.85-0.91 4 4.74-5.16 0 121-129 1 ECG-LVH 9 34 -6 56-60 9 35-36 2 68-70 17 0.93-0.98 3 5.18-5.67 1 130-139 2 35 -5 61-67 10 37-38 3 71-73 18 1.01-1.09 2 5.70-6.19 2 140-149 3 36 -4 68-74 11 39 4 74 19 1.11-1.19 1 6.22-6.79 3 150-160 4 0 pts for each NO 37 -3 40-41 5 1.22-1.30 0 6.81-7.46 4 161-172 5 38 -2 42-43 6 1.32-1.42 -1 7.49-816 5 173-185 6 39 -1 44-45 7 1.45-1.55 -2 8.19-8.55 6 40 0 46-47 8 1.58-1.71 -3 41 1 48-49 9 1.74-1.89 -4 42-43 2 50-51 10 1.92-2.07 -5 44 3 52-54 11 2.10-2.25 -6 45-46 4 55-56 12 2.28-2.49 -7
2. Sum Points For All Risk Factors Age ( ) + HDL-C ( ) + Total C ( ) + SBP ( ) + Smoker ( ) + Diabetes ( ) + ECG-LVH ( ) = Point Total ( NOTE: Minus Points Subtract from Total
3. Look Up Risk Corresponding to Point Total 4. Compare to Average 10 Year Risk Probability Probability Probability Probability Probability Pts 5Yr. 10Yr. Pts 5Yr. 10Yr. Pts 5Yr. 10Yr Pts 5Yr. 10Yr Age Women Men < 1 <1% <2% 10 2% 6% 19 8% 16% 28 19% 33% 30-34 <1% 3% 2 1% 2% 11 3% 6% 20 8% 18% 29 20% 36% 35-39 <1% 5% 3 1% 2% 12 3% 7% 21 9% 19% 30 22% 38% 40-44 2% 6% 4 1% 2% 13 3% 8% 22 11% 21% 31 24% 40% 45-49 5% 10% 5 1% 3% 14 4% 9% 23 12% 23% 32 25% 42% 50-54 8% 14% 6 1% 3% 15 5% 10% 24 13% 25% 55-59 12% 16% 7 1% 4% 16 5% 12% 25 14% 27% 60-64 13% 21% 8 2% 4% 17 6% 13% 26 16% 29% 65-69 9% 30% 9 2% 5% 18 7% 14% 27 17% 31% 70-74 12% 24% Chart by The American Heart Association
49 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES CONDITION STANDARDS Acute The person should not drive/perform safety critical work for at least three months after an AMI. Myocardial The criteria for Fit for Duty are not met: Infarct If the person has had an acute myocardial infarction. See also Angioplasty Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: See also Coronary Artery If the clinical history is one of minimal symptoms; and Bypass Grafting There is an exercise tolerance of greater than nine minutes (men) and six minutes (women) on (CABG) the Bruce Treadmill Test (or equivalent protocol); and There is no evidence of severe ischaemia, that is, less than 2mm ST segment depression on an exercise ECG and absence of a large defect on a stress perfusion scan; and There is an ejection fraction of 40% or over. The presence of other risk factors should also be considered. Aneurysms The person should not drive/perform safety critical work for at least three months post repair. Abdominal & The criteria for Fit for Duty are not met: Thoracic If the person has aortic aneurysm, thoracic or abdominal. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: If the condition is minor; or If the condition has been adequately treated. Angina The criteria for Fit for Duty are not met: If the person is subject to angina pectoris. Fit for Duty Subject to Periodic Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work, in the following circumstances: 1. If a Bruce Treadmill Test (or equivalent protocol) of greater than nine minutes (men) and six minutes (women) and thallium or sestamibi scan show no evidence of myocardial ischaemia. 2. If myocardial ischaemia is demonstrated a coronary angiogram may be offered. If that shows lumen diameter reduction of less than 70% in a major coronary branch, and less than 50% in the left main coronary artery, the person may drive, subject to annual review. 3. If the result of the angiogram shows a lumen diameter reduction of equal to or greater than 70% in a major coronary branch and less than 50% in the left main coronary artery (or if an angiogram is not conducted), and: The clinical history is one of minimal symptoms; and There is an exercise tolerance of greater than nine minutes (men) and six minutes (women) on the Bruce Treadmill Test (or equivalent protocol); and There is no evidence of severe ischaemia, that is, less than 2mm ST segment depression on an exercise ECG and absence of a large defect on a stress perfusion scan; and There is an ejection fraction of 40% or over. The presence of other risk factors should also be considered. Where surgery or angioplasty is undertaken to relieve the angina, the criteria listed in the table below apply. Angioplasty The person should not drive/perform safety critical work for at least four weeks after the angioplasty. The criteria for Fit for Duty are not met: If the person has had coronary angioplasty.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 50 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES CONDITION STANDARDS Angioplasty Fit for Duty Subject to Periodic Review may be recommended, taking into account the opinion of a cardiologist and the nature of the work: (continued) If the clinical history is one of minimal symptoms; and There is an exercise tolerance of greater than nine minutes (men) and six minutes (women) on the Bruce Treadmill Test (or equivalent protocol); and There is no evidence of severe ischaemia, that is, less than 2mm ST segment depression on an exercise ECG and absence of a large defect on a stress perfusion scan; and There is an ejection fraction of 40% or over. Anti-coagulant The criteria for Fit for Duty are not met: therapy If the person is on anti-coagulant therapy. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist or haematologist, and the nature of the work: If the therapy is satisfactory. Arrhythmia The criteria for Fit for Duty are not met: If the person has a history of recurrent or persistent arrhythmia, which may result in syncope or incapacitating symptoms. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: If the condition has been cured surgically (for example, Wolf-Parkinson White syndrome); or If the person is taking anti-coagulants refer to anti-coagulants therapy above; or If the condition has been successfully treated medically for at least three months. Cardiac The person should not drive/perform safety critical work for at least one month after insertion of Pacemaker pacemaker. The criteria for Fit for Duty are not met: If a cardiac pacemaker is required. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist with expertise in electrophysiology, and the nature of the work: After consideration of the relative risks of pacemaker dysfunction (see also Cardiac Defibrillator). Cardiac The criteria for Fit for Duty are not met: Defibrillator If the person has a cardiac-defibrillator implanted for ventricular arrhythmias. (AICD) Cardiac Arrest The non-working period following a cardiac arrest should be determined by the treating specialist. The criteria for Fit for Duty are not met: If the person has suffered a cardiac arrest. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: After consideration of the cause of the cardiac arrest; and Response to treatment. Congenital The criteria for Fit for Duty are not met: Disorders If the person has a complicated congenital heart disorder. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: If there is a minor congenital heart disorder such as pulmonary stenosis, atrial septal defect, small ventricular septal defect, bicuspid aortic valve, patent ductus arteriosus or mild coarctation of the aorta; and There are no other disqualifying conditions.
51 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES CONDITION STANDARDS Coronary Artery The person should not drive/perform safety critical work for at least three months after CABG. Bypass Grafting The criteria for Fit for Duty are not met: (CABG) Following CABG. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: If the clinical history is one of minimal symptoms; and There is an exercise tolerance of greater than nine minutes (men) and six minutes (women) on the Bruce Treadmill Test (or equivalent protocol); and There is no evidence of severe ischaemia, that is, less than 2mm ST segment depression on an exercise ECG and absence of a large defect on a stress perfusion scan; and There is an ejection fraction of 40% or over; and There is minimal residual musculoskeletal pain after the chest surgery. The presence of other risk factors should also be considered. Deep Vein The non-working period following DVT should be determined by the treating specialist. Thrombosis The criteria for Fit for Duty are not met: (DVT) If the person suffers deep vein thrombosis which is liable to recurrence or embolus. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist, and the nature of the work: Depending on the cause of the thrombosis and the response to treatment. Dilated The criteria for Fit for Duty are not met: Cardiomyopathy If the person has a dilated cardiomyopathy. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: If the ejection fraction is greater than 40%. ECG Changes: An ECG is only required if clinically indicated. Strain Patterns, The criteria for Fit for Duty are not met: Bundle Branch If the person has an electrocardiographic abnormality. Blocks or Heart Fit for Duty Subject to Review may be recommended, taking into account the opinion of a Block cardiologist, and the nature of the work: If the ECG shows left or right bundle branch block, pre-excitation or changes suggestive of myocardial ischaemia or previous myocardial infarction; and An exercise test performed by a cardiologist or specialist physician or referral made to an approved specialist is negative; and There are no other disqualifying conditions. Heart Failure The criteria for Fit for Duty are not met: If the person has heart failure. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: If there is an exercise tolerance of greater than nine minutes (men) and six minutes (women) on the Bruce Treadmill Test (or equivalent protocol); and There is an ejection fraction of 40% or over; and There is a satisfactory response to treatment; and The underlying cause of the heart failure is considered.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 52 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES (CONT) CONDITION STANDARDS Heart Transplant The person should not drive/perform safety critical work for at least three months post-transplant. The criteria for Fit for Duty are not met: If the person has had a heart or heart/lung transplant. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a transplant cardiologist, and the nature of the work. Hypertension The criteria for Fit for Duty are not met: (continued) If the person’s sitting blood pressure is consistently 200/110 or greater (treated or untreated); or If there is end organ damage (cardiac, cerebral, or retinal) which will impair safe working; or If treatment results in marked postural hypotension or impaired alertness. The presence of other factors should also be considered. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: If the person is treated with anti-hypertensive drug therapy and effective control of hypertension is achieved (ideal blood pressure less than 140/90 but no greater than 150/95) without appreciable side effects over a four week follow-up period; and If there is no evidence of damage to target organs relevant to safety critical work, or associated ischaemia, or other forms of heart disease; and If causative factors have been treated. Hypertrophic The criteria for Fit for Duty are not met: Cardiomyopathy If the person has HCM. (HCM) Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work: If the person is asymptomatic; and The left ventricular ejection fraction is >40; and The person is able to complete nine minutes (men) and six minutes (women) of the Bruce Treadmill Test (or equivalent ) without significant cardiac symptoms or significant ST segment ( >2mm) shift; and An absence of severe LV hypertrophy, a family history of sudden death, or ventricular arrhythmia on Holter testing. Pulmonary The non-working period following pulmonary embolism should be determined by the treating Embolism specialist. The criteria for Fit for Duty are not met: If the person has suffered a pulmonary embolism. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist, and the nature of the work: Depending on the cause of the embolus and response to treatment. Strokes See Neurological Disorders. Syncope due to The person should not drive/perform safety critical work for at least three months after syncope. Hypotension The criteria for Fit for Duty are not met:
(Vasovagal and If the condition is severe enough to cause episodes of loss of consciousness without warning. autonomic dysfunction) Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist, and the nature of the work depending on:
Identification of the underlying cause; and/or
The institution of satisfactory treatment.
53 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – CARDIOVASCULAR DISEASES (CONT) CONDITION STANDARDS Valvular Heart The criteria for Fit for Duty are not met: Disease If the person has any history or evidence of valve disease, with or without surgical repair or replacement, association with symptoms or a history of, embolism, arrhythmia, cardiac enlargement (on chest X-ray greater than 16cm), abnormal ECG, high blood pressure; or If the person is taking anti-coagulants. Fit for Duty Subject to Review may be recommended noting the criteria specified above in relation to anti-coagulant therapy; or If mitral stenosis is present with echocardiograph evidence of moderate (valve area <1.5cm2) or severe stenosis. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a cardiologist, and the nature of the work:
If the person’s cardiological assessment shows mild valvular disease of no haemodynamic significance, and there is no other cardiac condition per these Guidelines which would render the person unfit to drive/perform safety critical work; or
Three months following successful surgery and there is no other cardiac condition per these Guidelines which would render the person unfit to drive/perform safety critical work.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further Reading Akiyama, T., et al, Resumption of driving after life-threatening Lurie, K.G., et al, Resumption of motor vehicle operation in vasovagal ventricular tachyarrhythmia, New England Journal of Medicine, 345(6), fainters, The American Journal of Cardiology, 83(4), 604-606, 1999. 391-397, 2001. Petch, M.C., Driving and heart disease, European Heart Journal, Cardiovascular Disease and Driving www.csanz.edu.au 19(8), 1165-77, 1998. Li, H., et al, Potential risk of vasovagal syncope for motor vehicle driving, The American Journal of Cardiology, 85(2), 184-186, 2000.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 54 5 DIABETES
consciousness and judgment may develop 5.1 RELEVANCE TO SAFETY CRITICAL rapidly and result in the loss of control of a WORK vehicle or train or tram. Hypoglycaemic Diabetes may affect a person’s ability to perform awareness is an important consideration. safety critical work, either through loss of The worker should be classified as Temporarily consciousness in a hypoglycaemic episode or Unfit for Duty and should not perform safety from end organ effects on relevant functions, critical work after a defined hypoglycaemic including effects on vision, the heart, the episode or after a hypoglycaemic episode peripheral nerves and vasculature of the experienced whilst working until they have been extremities particularly the feet. The main cleared by the specialist. hazard in people with insulin requiring diabetes is the unexpected occurrence of hypoglycaemia. The worker should also be advised to take appropriate precautionary steps to avoid hypoglycaemic episodes, for example: 5.2 HYPOGLYCAEMIA self monitoring of blood glucose levels; A defined hypoglycaemic event relevant to safety carrying of glucose in the vehicle; critical work is one of sufficient severity to cause compliance with specified review periods impairment of perception or of motor skills, (GP or specialist); and abnormal behaviour or impairment of cessation of safety critical work should a consciousness. It is to be distinguished from hypoglycaemic episode occur. mild hypoglycaemic symptoms such as sweating, tremulousness, hunger and tingling around the mouth which are common occurrences in the life of a person with diabetes treated with insulin and 5.3 MEDICAL STANDARDS FOR SAFETY some hypoglycaemic agents. CRITICAL WORKERS Hypoglycaemia may be caused by many factors Medical criteria for fitness for duty are outlined in including non-compliance or alteration to the following table. medication, unexpected exertion or irregular For diabetes-related end organ damage, for meals. Irregular meals may be an important example diabetic retinopathy, see the Vision and consideration with long distance driving or those Eye Disorder chapter. operating on shifts. Impairment of
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – DIABETES CONDITION STANDARDS Diabetes A person with Diabetes controlled by diet alone may perform safety critical work. They should be controlled by reviewed periodically regarding progression of the illness. diet alone Non-Insulin The criteria for Fit for Duty are not met: Requiring If the person has Non-Insulin Requiring Diabetes Mellitus on oral hypoglycaemic agents. Type 2 Diabetes Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in Mellitus Diabetes or Endocrinology, and the nature of the work: If the condition is well controlled and the patient compliant with treatment; and There is an absence of defined hypoglycaemic episodes as assessed by the specialist, the patient has awareness (sensation) of hypoglycaemia, and the patient is taking agents that provide the minimum risk of hypoglycaemia; and There is an absence of end organ effects which may effect working per these Guidelines.
55 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – DIABETES (CONT) CONDITION STANDARDS Insulin- The criteria for Fit for Duty are not met: Requiring If the person has Insulin Requiring Diabetes Mellitus. Diabetes Mellitus (both Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in Types 1 and 2) Diabetes or Endocrinology, and the nature of the work: If the condition is well controlled and the patient compliant with treatment; and
There is an absence of defined hypoglycaemic episodes as assessed by the specialist, the patient has awareness (sensation) of hypoglycaemia, and the patient is taking agents that provide the minimum risk of hypoglycaemia; and
There is an absence of end organ effects which may effect working per these Guidelines. In the event of a defined hypoglycaemic episode occurring in a previously well-controlled person they should not drive/perform safety critical work for a period determined by a specialist.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References
NHMRC, Diabetes and driving, Canberra, 1992
Further reading Cox, D.J., et al, Progressive hypoglycemia’s impact on driving Laberge-Nadeau, C., et al, Impact of diabetes on crash risks of truck- simulation performance. Occurrence, awareness and correction, permit holders and commercial drivers, Diabetes Care, 23(5), 612- Diabetes Care, 23(2), 163-170, 2000. 617, 2000. Qualifying individuals with insulin-treated diabetes to operate MacLeod, K.M., Diabetes and driving: towards equitable, evidence- commercial motor vehicles, Federal Motor Carrier Safety based decision-making, Diabetic Medicine, 16(4), 282-290, 1999 Administration, Washington DC, November 2001. Weinger, K., et al, The perception of safe driving ability during hypoglycemia in patients with type 1 diabetes mellitus, The American Journal of Medicine, 107(3), 246-253, 1999.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 56 6 DRUGS – ILLICIT (see Drug and Alcohol Controls Appendix 2)
observed when the effect of the drug wears off 6.1 RELEVANCE TO SAFETY CRITICAL and is associated with profound sleepiness, WORK which can result in a driver suddenly falling asleep at the wheel, with obvious consequent Legislative Requirements risk of accident. In June 2002 the Transport Act 1983 was amended to provide for controls over the use of There is little information about safety critical drugs by rail safety workers. The new laws are work such as driving and the short or long-term in addition to existing laws for alcohol control and effects of drugs such as LSD, heroin and rail organisation’s policies which necessitate a designer drugs (for example, Ecstasy, Angel zero blood-alcohol concentration. They make it Dust), and no information specifically relevant to an offence to undertake rail safety work while rail safety. However, the known clinical effects of impaired by any type of drug. these drugs indicate that they have adverse effects on driving skills and judgment. Given The Act defines a drug broadly as: their significant affect on mood and behaviour, their use is clearly not compatible with safety any substance - - - that may temporarily critical work. or permanently deprive a person of any of his or her normal mental or physical Cannabis can impair psychomotor functions faculties. It may be a substance in any related to safety critical skills and has been form, whether gaseous, liquid, solid or shown to have adverse effects on driving skills other and includes material, preparation, and judgment. However, there is still debate extract and admixture. about the duration of impairment outside laboratory experiments. Illicit drugs of concern are those prohibited by the Drugs, Poisons and Controlled Substances Act Methadone abuse is not compatible with safety 1981. These include cannabis in its various critical work. However, it is recognised that forms, non-prescribed opiates, such as heroin, Methadone may be prescribed for narcotic non-prescribed amphetamines or speed, and addiction and in some circumstances such designer drugs such as ecstasy and cocaine. persons may be recommended Fit for Duty Subject to Review. Effect of Drugs on Rail Safety Work The combination of alcohol with illicit drugs is especially dangerous. Many of the physiological effects of illicit drugs are similar to both alcohol and psychoactive prescription drugs. Their usage is therefore likely to cause a significant safety hazard. This 6.2 GENERAL MANAGEMENT GUIDELINES is particularly so where illicit drugs are used in Careful individual assessment must be made of combination with prescription drugs or alcohol. workers using illicit psychoactive drugs. Illicit drugs are by their nature psychoactive (or Additional advice from those involved in psychotropic). This means their detrimental specialised treatment centres will frequently be effects in safety terms are not limited to their necessary and ongoing assessment is likely to demonstrated physiological effects on the be crucial, including blood tests. Patients with workers physical skills, but extend to their ‘dual diagnosis’ in particular may require psychological, or behavioural effects. Those specialist assessment regarding working. under the influence of these drugs have a higher Users of illicit drugs are unlikely to volunteer propensity to behave in a manner incompatible information about their condition. This creates a with safe working. This may involve but not be problem in identifying cases of illicit drug use. limited to, risk taking, aggression, feelings of vulnerability, narrowed attention and poor The habitual use of illicit drugs is not tolerated in judgement. rail safety work. Occasional use of these drugs requires very careful assessment. Some Information regarding effects of stimulants on companies may have a policy of counselling or risk of accidents mainly comes from road crash disciplining the worker who is found to have an data. Stimulant drugs such as amphetamines isolated case of drug use. The health and cocaine, which produce a heightened sense professional should be aware of the of well being, uninhibited behaviour, increased organisation’s policy in this regard. aggression and risk taking behaviours obviously have a potential for causing accidents. These drugs have been used to combat fatigue and while they may initially increase alertness and 6.3 MEDICAL STANDARDS FOR SAFETY efficiency, their effect is notoriously unpredictable CRITICAL WORKERS and may be accompanied by marked changes in Screening for illicit drugs is routinely required for mood and behaviour. The use of illicit (and licit) Pre-placement (Transfer or Change of Grade) stimulants to counteract the effects of fatigue Health Assessments. carries with it the risk of fatigue rebound. This is
57 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Screening for illicit drugs is not routinely intended satisfactory medical basis for impairment is at the periodic examination, but may be required established, (that is, a prescription medication or by management at a Triggered Assessment. OTC drug taken for a defined purpose, or a Consistent with the procedures for Preliminary medical condition) the worker should be Impairment Assessment adopted under the new classified as Temporarily Unfit for Duty Subject drug control laws, a reasonable belief that the to Review. Management should be contacted worker may be impaired by a drug may be based and advised that the person has impairment for on observation of abnormal or uncharacteristic which no medical basis could be found. signs in relation to speech, eyes, breathing, skin, Management will then direct the steps to be actions, movement, balance, attitude and taken. This is illustrated in Diagram 10. comprehension. Medical criteria for fitness for duty are outlined in If the Health Professional has a reasonable belief the table opposite.. that the worker may be impaired by a drug, this should be discussed with the worker. Where no
Diagram 10. Drug and Alcohol Impairment Assessment and Management
Is there evidence of impairment? Preliminary Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, YES attitude, comprehension). NO
Discuss with worker. No further action Is there a medical basis for impairment, ie (continue with health prescription medication /OTC drug taken for assessment) a defined purpose, or an illness. YES NO
Medical basis If alcohol or illicit drug use suspected: Classify Temporarily Unfit for Duty. Classify Temporarily Unfit for Duty If appropriate, discuss medication and advise on report impairment with GP/treating doctor in order to without clear medical basis. resolve impact on employment. Contact employer regarding If appropriate, refer to relevant impairment without clear medical chapter for medical conditions. basis and await further instructions from employer. Identify review period.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 58 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – DRUGS – ILLICIT CONDITION STANDARDS Impairment The criteria for Fit for Duty are not met: due to illicit If the worker is impaired by illicit drug/s drugs Refer to flow chart for management. Illicit drugs The criteria for Fit for Duty are not met: Narcotics, If there is evidence of illicit drug use or dependence. Analgesic abuse, Fit for Duty Subject to Review may be recommended taking into account the opinion of an appropriate Methadone (illicit specialist, and the nature of the work: use), and other illicit drug use for persons who are compliant with treatment for illicit drug addiction (including methadone or buprenorphine medication); and
the severity of the addiction(s), the response to treatment and the working requirements are taken into account. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist, and the nature of the work where amphetamines/stimulants are prescribed for a medical condition, for example, ADHD.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further reading Liguori, A., Gatto, C.P., Robinson, J.H., Effects of marijuana on equilibrium, psychomotor performance, and simulated driving, Behavioral Pharmacology, 9(7), 599-609, 1998.
59 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 7 DRUGS – PRESCRIPTION AND OVER THE COUNTER (OTC) (see Drug and Alcohol Controls Appendix 2)
7.1 RELEVANCE TO SAFETY CRITICAL 7.2 GENERAL MANAGEMENT GUIDELINES WORK In all cases when health professionals are Studies show that common medications, prescribing or dispensing medications (including prescribed for a number of illnesses, including OTC and alternative medications), they should anxiety and depression, can affect work consider any possible effects on safe working performance and increase the likelihood of a rail skills and advise the worker on what they should incident. do to avoid impairment. Failure to do so may have medico-legal consequences for the health In June 2002 the Transport Act 1983 was professional in the event of a rail incident amended to provide for controls over the use of involving the patient. drugs by rail safety workers. The new laws are in addition to existing laws for alcohol control and When prescribing or dispensing of any drug for rail oranisation’s policies which necessitate a the first time should be accompanied by a zero blood-alcohol concentration. They make it general warning to the patient to be vigilant for an offence to undertake rail safety work while responses that may affect ordinary activities impaired by any type of drug. including safety critical work. A similar warning should accompany changes in dose, or the The Act defines a drug broadly as: addition of other drug treatment. any substance - - - that may temporarily Problems affecting fitness for rail safety work or permanently deprive a person of any may arise with short term use of drugs when the of his or her normal mental or physical condition being treated does not itself preclude faculties. It may be a substance in any working, for example, drowsiness due to (older form, whether gaseous, liquid, solid or generation) antihistamines for hay-fever. The other and includes material, preparation, subjective effects of the drug should be extract and admixture. determined by a test dose before working is The Minister for Transport has declared certain attempted. substances to be a drug for the purposes of the Legitimate long-term medication for therapy or Act and has published a list of drugs in the prophylaxis should not automatically preclude Government Gazette. (See Appendix 2). fitness for duty. But many drugs can diminish The list does not contain banned substances. the capacity for rail safety work safely in addition Rather, it includes drugs that have been proven to any such effects of the disorder being treated. to show that given particular circumstances, Successful treatment will often increase safety impairment may be caused. Its primary purpose by control of the disorder, for example, effective is to provide prima facie evidence in a Court of prevention of seizures. Issues relating to drug Law in proving that a particular drug has the treatment of chronic disorders such as epilepsy, ability to cause impairment. Drugs included on psychiatric conditions and diabetes are dealt with the scheduled list are: in the relevant sections devoted to these diseases. Drugs of dependence as defined in Section 4 of the Drugs, Poisons and Controlled Workers receiving continuing long term drug Substances Act (1981) and listed in treatment should be evaluated for their reliability Schedule 11 of that Act. in taking the drugs according to directions and their understanding of the possibility that the Drugs listed in Schedule K of the Standard Uniform Schedule for Drugs and Poisons. effect of the drug may be unexpectedly affected These are incorporated into the Drugs, by factors such as drug interactions. They Poisons and Controlled Substances Act should also be assessed for their acceptance (1981) by reference as the 'Commonwealth that their medicines can have undesired Standard' and are substances which require consequences that may affect their ability to a warning as to their potential to cause work safely. drowsiness and possible effects on driving Combined effects of prescribed and OTC or operating machinery. medications should also be considered. When Deleterious substances are included by such medicine is prescribed or dispensed reference to Section 57 of the Drugs, adequate counselling should be provided and Poisons and Controlled Substances Act labelling requirements complied with. (1981). This includes methanol, methylated There are many useful community information spirits and inhaled solvents, resulting from resources for patients, including the Australian glue and petrol sniffing. Drug Foundation website www.adf.org.au/dd/index.htm.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 60 actions, movement, balance, attitude and 7.3 MEDICAL STANDARDS FOR SAFETY comprehension. CRITICAL WORKERS Where impairment is suspected, the results Safety Critical Workers are required to take all should be discussed with the worker. If a current medication or a list to the health medical basis for possible impairment is assessment appointment for the purposes of established (that is, a prescription medication or identifying any potential impact on rail safety OTC drug is being taken for a defined purpose, work. or a medical condition), the health professional Drug screening is not intended to be a routine should classify the worker as Temporarily Unfit part of the Periodic Health Assessment of rail for Duty Subject to Review and identify a review safety workers. Drug screening is routinely date. Where appropriate, the worker’s GP may required for Pre-placement or Change of Grade be contacted to discuss the impact of their Health Assessments and may be required at a current treatment on their fitness for duty. Triggered Health Assessment. Where there is not a satisfactory a medical basis If during a Periodic Health Assessment, the for impairment, (that is, a prescription medication health professional has a reasonable belief that or OTC drug taken for a defined purpose, or a the worker may be impaired by a drug medical condition), the worker should be (prescribed or illicit), this should be assessed classified as Temporarily Unfit for Duty Subject consistent with the procedures for Preliminary to Review. The employer should be contacted Impairment Assessment adopted under the drug and advised that the person has impairment for control laws. A reasonable belief that the worker which no medical basis could be found. The may be impaired by a drug may be based on employer will then direct the steps to be taken as observation of abnormal or uncharacteristic signs shown in Diagram 11). in relation to speech, eyes, breathing, skin,
Diagram 11. Drug and Alcohol Impairment Assessment and Management
Is there evidence of impairment? Preliminary Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, YES attitude, comprehension). NO
Discuss with worker. No further action Is there a medical basis for impairment, ie (continue with health prescription medication /OTC drug taken for assessment) a defined purpose, or an illness. YES NO
Medical basis If alcohol or illicit drug use suspected: Classify Temporarily Unfit for Duty. Classify Temporarily Unfit for Duty If appropriate, discuss medication and advise on report impairment with GP/treating doctor in order to without clear medical basis. resolve impact on employment. Contact employer regarding If appropriate, refer to relevant impairment without clear medical chapter for medical conditions. basis and await further instructions from employer. Identify review period.
61 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – DRUGS – PRESCIPTION & OTC CONDITION STANDARDS Impairment The criteria for Fit for Duty are not met: due to If the person is impaired due to the effects of prescription or OTC drugs. prescription or OTC drugs Refer to Diagram 11 for management.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, patients presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References 1. Classification of medicines according to their influence on driving ability. Grenez, M. V. et al. Acta Clin Belg Suppl; 1999; 1; 82-8. 2. Relations among chronic medical conditions, medications, and automobile crashes in the elderly: a population-based case-control study. McGwin, G. Jr et al. Am J Epidemiol; 2000; 152; 424-31.
3. Driving ability in cancer patients receiving long-term morphine analgesia. Vainio, A. et al. Lancet; 1995; 346; 652-3.
Further Reading / Reference Material Austroads report Drugs and Driving in Australia, 1999. British Medical Association website on Driving under the influence of drugs (via www.bma.org.uk) Ogden, E., and Brous, D., Medicines and Driving – A Code of Practice for Health Care Professionals, Report No GR/99-7, 2000. Victorian Parliamentary Road Safety Committee Report, Effects of Drugs (Other than Alcohol) on Road Safety in Victoria 1996.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 62 8 EPILEPSY
8.1 RELEVANCE TO SAFETY CRITICAL 8.2 GENERAL MANAGEMENT GUIDELINES WORK Responsible individuals with well managed Epilepsy may affect the ability to perform safety epilepsy (as demonstrated by an appropriate critical work due to sudden loss of concentration seizure-free period) may be assessed as Fit for and loss of ability to control machinery. Duty Subject to Review. Individual responsibility on the patient’s behalf means personal Epilepsy is a common disorder with a cumulative accountability for management of their condition incidence of 2% of the population, with 0.5% 5 in conjunction with the support of a medical affected and taking medication at any one time . practitioner. Fortunately, the majority of cases respond well to treatment with a terminal remission rate of 80% It is extremely important that the worker’s or more5-11. The majority suffer few seizures in a specific epilepsy syndrome and seizure types are lifetime and about half will have no further identified so that an adequate evaluation of the seizures in the first one or two years after person’s safety can be undertaken (including the starting treatment8-10. Some cases may risk of further seizures) and the appropriate eventually cease medication and in other therapy instituted. Thus any Safety Critical selected cases surgery has proven beneficial. Worker experiencing a seizure or recurrent seizures should be referred to an appropriate Seizures vary considerably, some being purely consultant for detailed evaluation. subjective experiences, for example, some simple partial seizures but the majority involve It is crucial that in the assessment of worker some impairment of consciousness (for example, fitness, disease management takes into account absence and complex partial seizures) or loss of that the worker: control (for example, focal motor, simple or must have been free of seizures for the complex partial or myoclonic seizures). specified period (see medical standards Convulsive (tonic-clonic) seizures may be below) generalised from onset or secondarily generalised with partial onset. Seizures must continue to take anti-epileptic associated with loss of awareness, even if brief medication regularly when and as or subtle, or loss of motor control have the prescribed potential to impair the ability to perform safety critical work12,13. should ensure adequate sleep and not drive/work if sleep deprived. Information regarding risk of accidents due to epilepsy mainly comes from road crash data. should avoid other circumstances or the use Estimates of the relative casualty crash risk of of substances that are known to increase drivers with epilepsy compared with other drivers the risk of seizures. has varied from 1.0 to 1.95 14-16, (and in one All Safety Critical Workers who need active exceptional study 7.0 17). Around 11% of management of epilepsy should be under review, crashes of drivers with epilepsy are felt to be including where necessary, at least annual seizure-related14. Reported estimates of the specialist appraisal. prevalence of epilepsy-related crashes vary between 0.01% and 0.3% of all crashes2, 18, 22. Complex partial seizures without aura, 8.3 MEDICAL STANDARDS FOR SAFETY secondarily generalised seizures and CRITICAL WORKERS generalised tonic-clonic seizures are the types most implicated in road crashes. Simple partial Medical standards for Safety Critical Workers seizures, complex partial seizures with aura and and the requirements for Fit for Duty Subject to absence seizures are less frequently, and Review are outlined in the Standards Table myoclonic seizures are rarely implicated23. Other overleaf. A confirmed diagnosis of epilepsy will examples include seizures that have occurred mean that the criteria for Fit for Duty are not met. only during sleep, some, but not all, simple The table recommends seizure-free periods after partial seizures ('auras'), and seizures that are which resumption of work may be permitted on consistently preceded by a prolonged warning or the advice of a suitably qualified consultant. In premonition (provided that full control is retained considering the recommended seizure-free during the period of such premonitory 13 period, generally apply the longer period, but a symptoms) . There are also examples where shorter period may be accepted on the seizures only occur at a particular time of day, recommendation of a consultant experienced in especially in the first hour after awakening. the management of epilepsy. Relevant Safety critical work in the rail industry exposes considerations will include response to the worker and the public to a relatively greater treatment, previous seizure frequency, the nature risk than driving on roads. For this reason, the of seizures, the syndromic diagnosis and the acceptable risk of an illness-related accident for patient’s reliability and compliance with performing safety critical work is much less, the treatment. Further considerations are the duties criteria applied are much stricter than on roads. to be performed and the hours to be worked.
63 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 The Initial or Isolated Seizure: The occurrence of a seizure in a Safety Critical Worker warrants consultant review should be obtained. A consultant assessment. The assessment may recurring seizure in a Safety Critical Worker will reveal that the seizure was likely to have been require immediate suspension from safety critical an isolated event, or alternatively a diagnosis of work. epilepsy may be made. The worker should be Medication Non-compliance: Where non- classified Temporarily Unfit for Duty until the compliance with medication is suspected, drug diagnosis and response to treatment is monitoring may be required where appropriate. determined and a decision can be made regarding their fitness for duty. Medication Withdrawal: In workers stabilised on medication over a suitable period, the Where seizures occur only at a particular time of consultant may attempt a withdrawal of day (for example, in the first hour after medication. The worker should not drive/perform awakening) a recommendation may be made safety critical work for the full period of regarding Fit for Duty Subject to Job withdrawal and for three months thereafter Modification, limiting working to certain hours or unless withdrawal is advised by an experienced circumstances. Workers experiencing such safe consultant on the basis that the risk of seizure- or possibly safe seizures must be the subject of recurrence is low. However, withdrawal of consultant review and their assessment must medication is not compatible with continued includes appropriate documentation of the safety critical work (unless advised by a factors that are important to their safety, and the consultant). corroboration of eye witnesses whenever possible. Concurrent Conditions: Where epilepsy is associated with other impairments or conditions, Recurrent Seizure. In the event of a recurrent the relevant sections covering those disorders seizure in a person previously seizure-free and should also be consulted. classed Fit for Duty Subject to Review, a
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – EPILEPSY CONDITION STANDARDS Initial or The criteria for Fit for Duty are not met: Isolated If the person has had a seizure due to any cause. Seizures Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist (an isolated in epilepsy, and the nature of the work: seizure is not synonymous If the person has had a single provoked seizure event, and with Epilepsy) Provocative factors can be avoided reliably, and Has been seizure free for one year, and Takes no anti-epileptic medication, and The EEG shows no epileptiform activity Epilepsy The criteria for Fit for Duty are not met: - general If the person has epilepsy. requirements Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in epilepsy (who may recommend variation of the seizure-free periods in exceptional circumstances), and the nature of the work: If the person has a past history of febrile seizures or of benign childhood epilepsy; and Does not take anti-epileptic medication; and The EEG shows no epileptiform activity or If the person has a past history of a single seizure event; or of seizures occurring only under provocative circumstances that can be avoided reliably; and Has been seizure free for five years; and Takes no anti-epileptic medication; and The EEG shows no epileptiform activity. (continued overleaf)
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 64 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – EPILEPSY (CONT) CONDITION STANDARDS Epilepsy or - general If the person has epilepsy and is taking anti-epileptic medication; and requirements Maintains at least annual review and compliance; and (continued) Has been seizure free for five years; and Has had no more than three seizures in the preceding ten years; and The EEG shows no epileptiform activity. or If the person has epilepsy and has had surgical treatment; and Maintains at least annual review; and Has been seizure free for five years; and The EEG shows no epileptiform activity. or Taking into account the duties to be performed and the hours to be worked (with conditions including limited and/or restricted duties). If the person has epilepsy and is taking anti-epileptic medication; and Maintains periodic review and compliance; and Has been seizure free for five years; and The EEG shows no epileptiform activity. or Taking into account the duties to be performed and the hours to be worked (with conditions including limited and/or restricted duties). If the person has had a single provoked seizure event; and Provocative factors can be avoided reliably; and Has been seizure free for one year; and Takes no anti-epileptic medication; and The EEG shows no epileptiform activity. Epilepsy- Recurrent seizure Special Recurrence of seizure in a Safety Critical Worker requires immediate suspension from safety critical situations work. Withdrawal of Medication Withdrawal of medication is not compatible with continued safety critical work (unless advised by a consultant).
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
65 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 References 1. Sonnen A. Epilepsy and driving: a European view. 13. Berkovic S.F. Epilepsy Syndromes: Effects on Cognition, International Bureau for Epilepsy, Haarlem, (1997) Performance and Driving ability. Med Law 19:757-761 (2000) 2. Fisher R.S. et al. Epilepsy and driving: an international 14. Waller J.A. Chronic medical conditions and traffic safety. N perspective, Epilepsia 35: 675-684 (1994) Engl J Med 273:1413-1420 (1965) 3. Black A. in Bladin P.F. et al. Driving and Epilepsy. ESA, 15. Hansotia P & Broste S.K. The effects of epilepsy or diabetes Melbourne (1988) mellitus on the risk of automobile accidents. N Engl J Med 324:22-26 (1991) 4. Chivell W.C. (Coroner, South Australia) Finding of Inquest 5th October (2001) 16. Taylor J & Chadwick D. Risk of accidents in drivers with epilepsy. J Neurol Neurosurg Psychiat 60:621-627 (1996) 5. Goodridge G.M. & Shorvon S.D. Epileptic seizures in a population of 6000. Br Med J 287:645-647. 17. Lings S. Increased driving accident frequency in Danish patients with epilepsy. Neurology 57:435-439 (2001) 6. Shorvon S.D. & Reynolds E.H. Early prognosis of epilepsy. Br Med J 285:1699-1701 (1983). 18. Herner B et al. Sudden illness as a cause of motor vehicle accidents. Br J Ind Med 23:37-41 (1966) 7. Elwes R.D. et al. The prognosis for seizure control in newly diagnosed epilepsy. N Engl J Med 311:944-947 (1984) 18. Vander Lugt P.J.M. Traffic accidents and epilepsy. Epilepsia 16:747-751 (1975) 8. Beghi E. & Tognoni G. Prognosis of epilepsy in newly referred patients, Epilepsia 29: 236-243 (1988) 20. Millingen K. Epilepsy and Driving. Proc Aust Assoc of Neurologists 13:67-72 (1976) 9. Mattson R.H. et al. A comparison of Valproate with Carbamazepine. N Engl J Med 327:765-771 (1992) 21 Krumholz A. et al. Driving and Epilepsy. A Review and Re- appraisal. JAMA 365:622-626 (1991) 10. Mattson R.H. et al. Prognosis for total control of complex partial and secondarily generalised tonic clonic seizures. 22. Black A.B. & Lai N.Y. Epilepsy and Driving in South Australia Neurology 47:68-76 (1996) – an assessment of compulsory notification. Med Law 16:253-267 (1997) 11. Cockerell O.C. et al. Prognosis of epilepsy. Epilepsia 38:31-46 (1997) 23. Gastaut H and Zifkin B.G. The risk of automobile accidents with seizures occurring while driving. Neurology 37: 1613- 12. Kastelijnij-Nolst Trenite N.G.A. et al. On-line detection of 1616 (1987) transient neuropsychological disturbances during EEG discharges in children with epilepsy. Dev Med Child Neurol 24. Chadwick D in Taylor J.F. Medical Aspects of fitness to 32:46-50 (1990) drive. The Medical Commission on Accident Prevention, London (1995). 25. Somerville, E and ESA Driving Sub-Committee. Consideration of Australian Accident statistics from ABS, FORS and Austroads Websites. Fremantle October 2001.
Further Reading Black A.B. Epilepsy and driving: The Pperspective of an Australian Krauss, G.L., et al, Individual state driving restrictions for people with Neurologist, Med Law 20: 553-568, 2001. epilepsy in the US, Neurology, 57, 1780-1782, 2001. Berger J.T. et al. Reporting by physicians of impaired drivers and Lawden, M., Epilepsy surgery, visual fields, and driving, Journal of potentially impaired drivers, J Gen Int Med, 15: 667-672, 2000. Neurology, Neurosurgery and Psychiatry, 68(1), 6, 2000. Chadwick D.W. Driving restrictions and people with epilepsy, Manji, H., and Plant, G.T., Epilepsy surgery, visual fields, and driving: Neurology, 57: 1749-1750, 2001. a study of the visual field criteria for driving in patients after temporal lobe epilepsy surgery with a comparison of Goldmann and Esterman perimetry, Journal of Neurology, Neurosurgery and Psychiatry, 68(1), 80-82, 2000.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 66 9 GASTROINTESTINAL AND HEPATIC DISORDERS
9.1 RELEVANCE TO SAFETY CRITICAL questionable. In a second study of real life WORK driving conditions in Chicago the results in those patients studied were not different from healthy Gastrointestinal and hepatic disorders may affect controls. the ability to perform safety critical work due to metabolic disturbances affecting mental function. However, there is only limited data to support the 9.2 GENERAL MANAGEMENT GUIDELINES assumption of a higher crash rate as a result of gastrointestinal and hepatic disorders. As a general rule, gastrointestinal disorders should not interfere with a patient’s ability to Hepatic Encephalopathy drive/perform safety critical work. Acute Hepatic encephalopathy describes the spectrum conditions require appropriate advice regarding of potentially reversible neuro-psychiatric working but have no impact on overall fitness for abnormalities seen in patients with liver duty. dysfunction after other neurological causes or The diagnostic pointers to the presence of metabolic causes are excluded. The vast chronic liver disease include peripheral signs majority of patients have established chronic liver such as muscle wasting, spider telangiectasis disease with signs of chronic liver disease and and palma erythema. Signs of hepatic sometimes those of encephalopathy such as decompensation will include jaundice, ascites asterixis and the fetor hepaticus. oedema as well as the above, while signs of Working ability will be impaired firstly because of hepatic encephalopathy will include altered the disturbed diurnal sleep pattern (insomnia and mentation, fetor hepaticus and asterixis. hypersomnia) but further by impaired Not to be ignored are the potentially subtle consciousness with levels of consciousness disturbances of mentation that can occur in the potentially fluctuating, and also by focal absence of overt liver failure. An indication that neurological signs which occasional develop in hepatic encephalopathy is developing might such patients. include a disturbed sleep pattern. Patients may Treatment of hepatic encephalopathy is the also develop fleeting neurological signs such as treatment of the underlying liver disease and hemiplegia. reversing of factors that can precipitate Assessment of workers with chronic liver disease encephalopathy. for Fit for Duty will require referral to a specialist There is dispute regarding the cognitive function whose predominant interest is liver disease. of patients with chronic liver disease and portal hypertension without signs of porta systemic encephalopathy. Two studies have addressed 9.3 MEDICAL STANDARDS FOR SAFETY driving motor vehicles in this group of patients CRITICAL WORKERS and in one study 60% of patients were considered unfit to drive and 25% considered Medical criteria for Fit for Duty are outlined in the following table.
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – GASTROINTESTINAL DISORDERS CONDITION STANDARDS Hepatic Failure The criteria for Fit for Duty are not met: If the person has chronic liver disease and clinical evidence of hepatic encephalopathy. If the person has chronic liver disease and no overt evidence of hepatic encephalopathy they may still have impaired cognitive and motor skills and will need to be assessed on an individual basis by their hepatologist. Liver The criteria for Fit for Duty are not met: Transplants After a liver transplant. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist, and the nature of the work: Noting the reason for the transplant; and
Taking into account the stability of the transplant and the biochemical and haemodynamic response.
67 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workerspresenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Consensus statements on the definition of Hepatic Encephalopathy Srivastava, A et al. Fitness to drive in patients with cirrhosis and by the International Working Party at the 11th World Congress of portal systemic shunting. A pilot study evaluating driving Gastroenterology (Vienna 1998). performance. J Hepatol 1994;21:1023. Quero, JC, et al. The diagnosis of subclinical hepatic Schomerus, H, et al. Latent portasystemic encephalopathy. I. encephalopathy in patients with cirrhosis using neuropsychological Nature of cerebral tests and automated electroencephalogram analysis. Hepatology 1996; 24:556. Cadranel, JF et al, Focal neurological signs in hepatic encephalopathy in cirrhotic patients; An underestimated entity? Am J Gastroenterol 2001; 96:515.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 68 10 HEARING
10.1 RELEVANCE TO SAFETY CRITICAL For tram drivers, the main safety requirement to WORK hear other traffic on the road. Mild to moderate hearing loss does not appear to affect a person’s Substantial hearing loss may affect the ability to ability to drive/work safely. It may be that a loss perform safety critical work due to failure to hear of hearing is well compensated for since most sounds indicating a hazard or equipment failure people who are hard of hearing are aware of as well as the ability to communicate. their disability and therefore tend to be more For trains, the main requirement for hearing cautious and to rely more on visual cues. While regarding safety critical work is the ability to use driving ability per se might not be affected by a radio-communication devices in a variety of hearing deficiency, responsiveness to critical settings. events is an important safety consideration for drivers/Safety Critical Workers. These workers Train drivers and track workers such as flagmen therefore require to a reasonable level of hearing and shunters need to communicate via two-way in order to ensure their awareness of changes in radio or mobile phone against a noisy engine or other noises which may signal background. Most radios in engine cabs can be developing problems or in the case of tram amplified to help hearing against background drivers hearing emergency vehicles or other noise. In addition, they need reasonable hearing warning horns, bells, sirens. to sense an oncoming train if walking about yards. Safety critical work ability per se might not be 10.2 MEDICAL STANDARDS FOR SAFETY affected by a hearing deficiency. However, CRITICAL WORKERS responsiveness to critical events is an important Medical criteria for fitness for duty are outlined in safety consideration for such workers which the following table. could be impaired. These workers therefore require a reasonable level of hearing to ensure Compliance with the standard should be initially they are aware of changes in engine or other assessed by audiometry and if the standard is noises which may indicate potential risks. not met a practical test should be arranged. For example, a practical test for a driver could Train signallers and controllers need to involve sitting in the cab of a locomotive with communicate via radio or mobile phone in a quiet engine running and the person communicating background. by radio to a Principle Driver to assess ability to clearly understand driving instructions. A similar test may be devised for a signaller or controller.
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – HEARING CONDITION STANDARDS Hearing Compliance with the standard should be initially assessed by audiometry. The criteria for Fit for Duty are not met: If the person has an unaided average hearing threshold level of equal to or greater than 40dB in the better ear. (Average hearing threshold is the simple average of pure tone air conduction thresholds at 500, 1000, 2000 and 3000 Hz). Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ENT specialist, and the nature of the work: If the standard is met with a hearing aid. A practical assessment may be conducted of ability to hear communication devices relevant to the job such as mobile phones, walkie-talkie and radio-communication against a noisy background in the case of drivers or other track workers, or a quiet background in the case of signallers or controllers.
69 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References ‘Hearing Disorders and commercial motor vehicle drivers' compiled Edwards FC, McCallum RI, Taylor PJ 'Fitness for work: The Medical by the University of Pittsburgh, March 1993. Aspects' Joint Report of the Royal College of Physicians and the Faculty of Occupational Medicine, Oxford University Press, 1988 Expert opinion
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 70 11 HIV / AIDS
risks when performing safety critical work are 11.1 RELEVANCE TO SAFETY CRITICAL greatly reduced. WORK If the disease progresses to AIDS then various HIV/AIDS may affect the ability to perform safety organs relevant to working may be affected, such critical work due to impairment of mental function as the eyes. or other affects on the body. The human immunodeficiency virus (HIV) is highly neurotropic and may cause neurological effects which impact on safety critical work ability. 11.2 MEDICAL STANDARDS FOR SAFETY However the advent in recent years of highly CRITICAL WORKERS active antiretroviral therapy (HAART) for patients Safety Critical Workers who are HIV positive or has had a significant impact on their prognosis have AIDS and are under treatment may be and their well-being. As a result, there has been recommended for Fit for Duty Subject to Review, a substantial reduction in neurological sequelae providing they meet the criteria set out in these particularly AIDS dementia and progressive Guidelines for end organ damage which may multifocal leukoencephalopathy (PML) so the arise as a complication of the disease, for example, vision.
References Dore, G.J., et al., Changes to AIDS dementia complex in the era of highly active antiretroviral therapy, AIDS, 13, 1249 1253, 1999. Gendelman, H.E., et al., Suppression of inflammatory neurotoxins by highly active antiretroviral therapy in human immunodeficiency virus- associated dementia, Journal of Infectious Disease, 178, 1000-1007, 1998. Li, T.S., et al., Long lasting recovery in CD4 T cell function and viral loading reduction after highly active antiretroviral therapy in advanced HIV-1 disease, Lancet, 351, 1682-1686, 1998. Montaner, J.S.G., Hogg, R.S., and O’Shaughnessy, M.V., Emerging international consensus for use of antiretroviral therapy, Lancet, 341, 1042, 1997.
71 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 12 METABOLIC AND ENDOCRINE DISORDERS (Excluding Diabetes)
12.1 RELEVANCE TO SAFETY CRITICAL 12.3 MEDICAL STANDARDS FOR SAFETY WORK CRITICAL WORKERS Metabolic and endocrine disorders may affect There are no specific criteria regarding Fit for the ability to perform safety critical work due to Duty for metabolic and endocrine diseases. effect on mental function or other organs of the Because of the diverse manifestation of these body. Metabolic or endocrine disorders conditions, each person will require individual (Addison’s Disease, Adrenal or Cushing’s assessment. Disease, Hyperthyroidism, Hypothyroidism, Parathyroid Disease, Phaeochromocytoma, If there is a real risk of acute loss of control then Pituitary Disorders, Insulinoma) can cause many the criteria would not be met; a recommendation symptoms ranging from generalised asthenia, may be made for Fit for Duty Subject to Review localised muscle weakness, spasm to tetany, dependent on stability of control of the condition sudden episodes of dizziness or and an appropriate specialists opinion obtained. unconsciousness. Specific defects which may be associated with Unless controlled by adequate treatment, an endocrine disorder may also need evaluation, workers so afflicted may pose an increased for example, effects on visual field from pituitary safety risk. tumours or exophthalmos in hyperthyroidism.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 72 13 MUSCULOSKELETAL DISORDERS
13.1 RELEVANCE TO SAFETY CRITICAL Disability of Cervical Region: Good head WORK movement is important to support good fields of vision. Workers with severe neck pain and very Substantial musculoskeletal disorders may affect reduced mobility including that arising from the ability to perform safety critical work due to wearing soft collars or braces should be inability to adequately control machinery and classified as Temporarily Unfit for Duty and perform bodily movements as required. should not perform safety critical work for the duration of their treatment. Some loss of neck Train drivers require good musculoskeletal movement is allowable if the cab is fitted with capacities to: adequate outside mirrors. In the case of - sit and drive the train using arms and permanent disability, the criteria may not be met. legs; Disability of Thoracolumbar Region: Workers - walk about the train on uneven track; with severe pain and reduced mobility of the - join heavy couplings, bend and check thoracolumbar region, including those required to bogies; wear a brace or body cast that severely limits mobility, should be classified as Temporarily - enter and exit the cab to/from the Unfit for Duty and should not perform safety ground in emergency. critical work for the duration of their treatment. In Flagmen require good musculoskeletal the case of permanent disability, the criteria may capacities to: not be met. - move quickly over uneven track Arthritis: Painful joints may arise due to inflammatory or degenerative arthritis. Workers - place detonators quickly and accurately who have persistent pain and marked reduction on the track in range of movement in shoulders, elbows, - signal to trains. wrists, hands, hips, knees, ankles or feet may not meet the criteria. A driver may be usefully Shunter requires good musculoskeletal assessed by a Principal Driver. capacities to: Post Surgery Including Joint Replacement: - move over uneven track Workers should generally not perform safety - board/alight slowly moving trucks or critical work for six weeks post major orthopaedic carriages surgery. A Principal Driver’s opinion may be obtained where appropriate if there is ongoing - open or close coupling mechanisms. limitation of function.
13.2 GENERAL ASSESSMENT AND 13.3 MEDICAL STANDARDS FOR SAFETY MANAGEMENT GUIDELINES CRITICAL WORKERS (Including Temporary Conditions) Medical criteria for fitness for duty are outlined in The aim of a health assessment is to detect the following table. those Safety Critical Workers who have difficulty in performing their duties, and to identify those The driver should wear any prosthesis workers who would benefit from job modification. prescribed during an assessment by a Principal However, modification to cabs and other Driver. equipment is usually difficult because drivers need to rotate between locomotives. Agility of movement requires good balance (refer Vestibular Disorders chapter). In many cases a functional assessment of a driver by a Principal Driver (in conjunction with OT if necessary) may be helpful.
73 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – MUSCULOSKELETAL DISORDERS CONDITION STANDARDS Musculoskeletal The criteria for Fit for Duty are not met: Disorders a) Driver If there is amputation or congenital absence of a limb (whole or part) required to operate a hand or foot control; or If the thumbs are missing from both hands; or If rotation of the cervical spine is chronically restricted to less than 45° to the left or right; or If chronic pain and restriction of joint movement interferes with the relevant movements or concentration such that a train cannot be operated safely; or If there is ankylosis or chronic loss of joint movement of sufficient severity that control of train is not safe; or If there is limitation of movement such that the person cannot enter and exit the cab from the track; or If there is limitation of gait such that the person cannot move rapidly about the track in the event of emergency. b) Flagman If there is limitation of gait such that the person cannot move rapidly about the track; or If there is limitation of arm movement which impairs ability to clearly signal or use radio communication device. c) Shunter If there is impairment of arms and legs which affects the ability to board/alight slowly moving trucks or carriages; or If there is limitation of gait such that the person cannot move rapidly about the track; or If there is impairment of back movement that will affect ability to open or close coupling mechanisms for Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist or therapist and/or Principal Driver, and the nature of the work. A practical assessment may be helpful.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 74 14 NEUROLOGICAL DISORDERS (Excluding Epilepsy and Syncope)
evaluation by a Principal Driver. A visual field 14.1 RELEVANCE TO SAFETY CRITICAL defect will usually exclude a person from safety WORK critical work as will all but minor residual defects Neurological disorders may affect the ability to in accordance with these standards. perform safety critical work due to affect on Transient Ischaemic Attacks: TIA may recur or mental function or the loss of control of other be harbingers of a full stroke. Safety Critical parts of the body. At present only limited Workers who have had only one transient evidence can be cited about the incidence of ischaemic episode should be referred to an accidents across a given population of Safety appropriate specialist to determine their fitness Critical Workers such as drivers suffering from a for duty. If an underlying cardiac pathology for neurological disorder. However, it is very likely such episodes is identified any recommendation that symptoms which are common to many for Fit for Duty Subject to Review, would be neurological conditions, such as potential based upon the prognosis of that condition, and spontaneous loss of consciousness, confusional the likelihood of continued recurrence. states, impairment of muscular power and coordination are deleterious to safety critical Multiple Sclerosis: Multiple Sclerosis may work. progress to cause poor coordination, weakness, vertigo, memory loss, significant cognitive impairment, or visual impairment, any of which may impair capacity to work safely. 14.2 GENERAL MANAGEMENT GUIDELINES Peripheral Neuropathy: Peripheral neuropathy The worker with a neurological disorder must be may impair working due to difficulties with assessed to determine whether the sum of sensation (particularly proprioception) or severe symptoms and signs, being physical, mental and weakness developing. behavioural is compatible with safety critical work. Limb Control: A loss of control of a limb due to paralysis, paresis or other neurological Any impairment of consciousness or awareness, conditions needs to have the severity assessed or the presence of confusion or loss of visual on an individual basis. Where appropriate fields or vertigo, is usually incompatible with assessment by a Principal Driver may be helpful. safety critical work. Muscular power and coordination should be adequate to undertake Intracranial Surgery: In the event of work safely. intracranial surgery the worker should not perform safety critical work until cleared by a If the health professional is concerned about a relevant specialist (neurosurgeon/neurologist). worker’s ability to work safely, the opinion of a (See also Epilepsy – surgery). Principal Driver where appropriate or Neuropsychologist may be helpful. Head Injury: A person who recovers from a loss of consciousness of less than 24 hours with no Dementia and Other Cognitive Impairments: complications does not present any special risk. The person should not perform safety critical Similarly, immediate seizures which occur within work if there is significant impairment of memory, 24 hours of a head injury are not considered to visuospatial skills, insight or judgement or if be epilepsy, but part of the acute process. problematic hallucinations or delusions. Baseline and periodic review are required as Workers who have had minor head injuries most forms of cognitive impairment and should not perform safety critical work dementia are progressive. If unsure in the case immediately afterwards. The occurrence of of a driver, refer to a Principle Driver for further persisting functional disturbances requires assessment. Referral to a Neuropsychologist careful assessment to determine fitness for duty. may be helpful in cases of cognitive impairment. This may include neuropsychological testing and assessment where appropriate by a Principal Intellectual Impairment: Persons with Driver as well as referral to a neurologist. intellectual impairment are not suitable for safety critical work. Persons with minor degrees of Migraine and Recurrent Headache: Attacks of impairment should be identified by selection migraine and recurrent headache are common (neuropsychological) tests at time of recruitment. and may impair a persons ability to concentrate Usually this is not a medical or health and to work safely. Workers who suffer migraine assessment matter. and recurrent headaches should have their symptoms and treatment reviewed. A plan of Stroke: In the event of a stroke the worker management if an attack occurs at work should should not perform safety critical work for a be discussed and agreed with their supervisor as minimum of one month post event (3 months for necessary. Provoking factors such as shift work, subarachnoid haemorrhage) if there is significant lighting and noise may need attention. In severe neurological, perceptual or cognitive deficit. cases Fit for Duty Subject to Review may be Return to safety critical work depends upon recommended. physician assessment and where appropriate,
75 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 14.3 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS Medical criteria for Fit for Duty are outlined in the following table.
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – NEUROLOGICAL DISORDERS CONDITION STANDARDS Berry The criteria for Fit for Duty are not met: Aneurysms & If the person has a Berry Aneurysm or other vascular malformation. other vascular malformations Fit for Duty Subject to Review may be recommended, taking into account the opinion of an of the brain appropriate specialist, and the nature of the work: After consideration of the risk and the benefits of any treatments.
Cerebral Palsy The criteria for Fit for Duty are not met: (See also If the capacity to control a vehicle is impaired due to musculoskeletal or cognitive or neurological Neuromuscular causes. and/or Cognitive Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist, and the nature of the work, and: Disorders) The severity of the disabilities; The interaction between multiple disabilities; The response to treatments; and Suitable vehicle modifications. An assessment where appropriate by a Principal Driver may be helpful. Dementia and The criteria for Fit for Duty are not met: other cognitive If the person’s dementia or cognitive impairment is confirmed. impairments Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist, and the nature of the work, and: The cause of the condition and likely response to treatment; and Any appropriate neuropsychological tests; and The result of an assessment by a Principal Driver. Head injury The criteria for Fit for Duty are not met: (Acquired brain If the person has had head injury causing chronic functional disturbances. injury) Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist, and the nature of the work, and: The result of neuropsychological testing; and The result of an assessment by a Principal Driver (see also Cognitive Impairment); and Other disabilities which may impair safety critical work per these Guidelines. Migraine See text. Neglects (While The criteria for Fit for Duty are not met: patient perceives, If there are neglects present. does not respond appropriately) Neuromuscular The criteria for Fit for Duty are not met: conditions (MS, If the person has Parkinsonism, multiple sclerosis, degenerative peripheral neuropathy, Parkinson’s progressive muscular dystrophy or any other severe neuromuscular disorder. Disease, Peripheral Fit for Duty Subject to Review may be recommended, if the disability is limited to minor effects on Neuropathy) safety critical work, taking into account the opinion of a neurologist or rehabilitation specialist, and the nature of the work, and: The response to treatments; and The result of an assessment by a Principal Driver; and Modifications to the job, where practical.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 76 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – NEUROLOGICAL DISORDERS (CONT) CONDITION STANDARDS Strokes The criteria for Fit for Duty are not met: If the person has had a stroke. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist, and the nature of the work: If the stroke was caused by a condition which has now been satisfactorily treated. A satisfactory recovery from the stroke, including perceptual deficits, must also be demonstrated. Cases of berry aneurysm should be referred to an appropriate specialist.
Transient The criteria for Fit for Duty are not met: Ischaemic If the person has had two or more transient ischaemic attacks. Attacks Fit for Duty Subject to Review may be recommended, taking into account the opinion of an appropriate specialist, and the nature of the work: If the aetiology of the attacks has been identified, the underlying cause removed, and the person has had a six-month period free of attacks.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further reading Bonn, D., Patients with mild Alzheimer’s disease should not drive, Hawley, C.A., Return to driving after head injury, Journal of The Lancet, 356, 49, 2000 Neurology, Neurosurgery and Psychiatry, 70(6), 761-766, 2001. Cox, D.J., et al, Evaluating driving performance of outpatients with Heikkila, V.M., et al, Decreased driving ability in people with Alzheimer’s disease, The Journal of the American Board of Family Parkinson’s disease, Journal of Neurology, Neurosurgery and Practice, 11(4), 264-271, 1998. Psychiatry, 64(3), 325-330, 1998. Drachman, D.A., and Swearer, J.M., Driving and Alzheimer’s Lachenmayer, L., Parkinson’s disease and the ability to drive, disease: the risk of crashes, Neurology, 43(12), 2448-2456, 1993. Journal of Neurology, 247(Suppl 4), 28-30, 2000. Foley, D.J., et al, Driving cessation in older men with incident Lipski, P.S., Driving and dementia: a cause for concern, Medical dementia, Journal of the American Geriatrics Society, 48(8), 928- Journal of Australia, 167(8), 453-454, 1997. 930, 2000. Schultheis, M.T., Garay, E., DeLuca, J., The influence of cognitive Fox, G.K., and Bashford, G.M., Driving and dementia: balancing impairment on driving performance in multiple sclerosis, Neurology, personal independence and public safety, Medical Journal of 56(8), 1089-1094, 2001. Australia, 167(8), 406-407, 1997.
77 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 15 PREGNANCY
15.1 RELEVANCE TO SAFETY CRITICAL 15.2 GENERAL MANAGEMENT GUIDELINES WORK Gestational Diabetes: If the diabetes occurs In normal circumstances, pregnancy should not only in pregnancy, it should not impact on fitness be considered a barrier to safety critical work. for duty. However, conditions that may be associated with Post natal Depression: A Safety Critical some pregnancies should be considered Worker with post natal depression will require regarding their effect on safety critical work. individual assessment regarding the severity of These include: the condition in relationship to the job. (Refer fainting or light-headedness; also to Psychiatric Disorders) hyperemesis gravidarum; hypertension in pregnancy; and 15.3 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS post caesarean section. There are no medical standards which impact on A caution regarding performing safety critical fitness for duty because pregnancy is a work may be required depending on the severity temporary condition. of the symptoms and the expected effects of medication.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 78 16 PSYCHIATRIC DISORDERS See also Neurological Disorders, Alcohol and Drugs - Illicit.
antipsychotics) may improve compliance and 16.1 RELEVANCE TO SAFETY CRITICAL therefore reduce symptoms. WORK Persons with personality disorders often show Psychiatric disorders may affect the ability to disregard for social values and rules. They are perform safety critical work due to effects on unsuitable for safety critical work. Persons with mental function. Safety critical work is a unsuitable personality traits/attitudes should be complicated psychomotor performance which identified by selection (neuropsychological) tests depends on fine coordination between the at time of recruitment. Usually this is not a sensory and motor systems. It is influenced by medical or health assessment matter. factors such as arousal, perception, learning, memory, attention, concentration, emotion, reflex Specialist advice should be sought regarding speed, time estimation, auditory and visual Safety Critical Workers who have complex functions, decision making and personality. conditions such as ADHD or Tourette’s Complex feedback systems interact to produce Syndrome. the appropriate coordinated behavioural Where a mental health condition is associated response. Anything that interferes with any of with epilepsy or illicit drug use, the relevant these factors to a significant degree may impair section should also be referred to. safety critical work ability. Information regarding risk of accidents due to psychiatric disorders mainly comes from road 16.3 MEDICAL STANDARDS FOR SAFETY crash data. There is little empirical evidence in CRITICAL WORKERS relation to the precise effect of alterations in mental state on safety critical work such as Medical criteria for fitness for duty are outlined in the driving ability. It has been reported that more following table. than 50% of fatally injured road drivers had Use of the K 10 Questionnaire The K 10 experienced interpersonal or vocational stresses questionnaire for anxiety and depression is included in during the twelve months preceding their the Safety Critical Worker Health Assessment crashes, compared with 18% of a control group. Questionnaire. It should be applied as follows: In a study of schizophrenic and manic depressive individuals (bipolar disorder), it was 1. Each question is scored as follows : reported that the motor vehicle crash rate was All of the time 5 twice that among mentally ill drivers when compared to an age-adjusted sample. Most of the time 4 Some of the time 3 16.2 GENERAL MANAGEMENT GUIDELINES A little of the time 2 Persons with any substantial mental illnesses None of the time 1 (whether acute or chronic) should not perform safety critical work, although recommendation of Fit for Duty Subject to Review may be 2. The values are then summed. If the total is considered in some circumstances on the nineteen or greater the worker should be further recommendation of a treating psychiatrist. assessed and referred as appropriate. This may involve discussing the result of the K 10 with the An acute episode of mental illness (for example, worker and gauging the cause of an abnormal psychosis, acute mania or panic attack) poses a score. For example, a domestic situation may be substantial risk. Such an episode in a Safety self-explanatory. Critical Worker would mean the criteria for fitness for duty are not met. 3. Referral to a GP or psychiatrist, clinical psychologist, financial, or marital counsellor may Evidence indicates that safety is adversely then be appropriately made. affected when the worker is in a state of stress or anxiety. It is therefore recommended that such 4. A decision as to whether or not a Safety Critical people be individually assessed regarding their Worker, particularly a high level one, should be safety critical work until the anxiety state is placed on alternative duties while being further resolved. Use of the K 10 to assess anxiety is assessed will need to be made on a case-by-case explained below. basis. Some medications for mental illness may affect The K 10 is used by kind permission of Professor Gavin Safety Critical Worker alertness and Andrews of the Clinical Research Unit for Anxiety & coordination. However, the use of more modern Depression of the University of New South Wales. drugs with less side-effects (especially Further information about the K 10 is available at www.crufad.unsw.edu.au
79 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – PSYCHIATRIC DISORDERS CONDITION STANDARDS Psychiatric The criteria for Fit for Duty are not met: disorders If the person has an acute or chronic psychosis, whether schizophrenic, bipolar (manic or depressive phase) or other depressive psychosis; or If the person has a personality or psychiatric disorder with features such as aggression or violence which are hazardous to safety critical work; or If the person is taking psychoactive drugs which will impair safety critical work performance on a long term basis; or If the person’s judgement or perceptual, cognitive or motor function is affected by mental disorder (for example, ADHD); or If the examining doctor believes that there is a significant risk of previous psychotic condition relapsing. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a psychiatrist, and the nature of the work: If the condition is well controlled and the person is compliant with treatment over a substantial period; and The person is taking medication that minimises the risk of cognitive or other side effects that might effect safety critical work.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
Further reading Hollister, L.E., Automobile driving by psychiatric patients, American Wylie, K.R., Thompson, D.J., Wildgust, H.J., Effects of depot Journal of Psychiatry, 149(2), 274, 1992. neuroleptics on driving performance in chronic schizophrenic patients, Journal of Neurology, Neurosurgery, and Psychiatry, 56(8), 910-913, 1993.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 80 17 RENAL FAILURE
relevant to the task, and (after the initial post 17.1 RELEVANCE TO SAFETY CRITICAL operative recovery) persons with kidney WORK transplants who have good renal function are not Renal failure may affect the ability to perform regarded as impaired from a Fit for Duty point of safety critical work due to metabolic disturbances view. affecting mental function. The initiation of dialysis treatment is associated Chronic Renal Failure: Potential impact from with some metabolic and cardiovascular chronic renal failure on the performance of safety adjustment and may be associated with critical work can result from: increased functional impairment. It is considered prudent to avoid performing safety critical work The metabolic consequences of uraemia itself; for the first few treatments or weeks of treatment, The risks associated with the secondary but after this individually variable period, most complications of chronic renal disease and its patients achieve a reasonable symptomatic or treatment, in particular cardiovascular functional state, which is maintained by ongoing problems, labile hypertension, post dialysis dialysis treatment. hypotension, cramp, volume overload, The combination of the subtle cognitive congestive cardiac failure, and accelerated impairment, probably present in most patients atherosclerosis; or with advanced chronic renal failure, together with co-morbidities associated with renal failure and The underlying cause of the chronic renal dialysis, suggests a conservative, or restrictive failure (eg: 25% of dialysis patients have approach in the high-risk situation of safety diabetes mellitus, a disease with its own risks critical work. of impairing safety critical work including retinopathy which is commonly associated with Proteinuria is a reliable marker for chronic renal diabetic nephropathy). disease. In an elderly population, the cause of proteinuric renal disease (eg: diabetes or There are described abnormalities in ischaemic vascular disease) may be the more psychophysical ability in stable dialysis patients relevant factor in impairment. which may be relevant to working safely. Dialysis treatment has improved significantly in Acute Renal Conditions and Recurrent Acute the twenty years since the only relevant literature Conditions: Glomerular disease in the absence was published, and erythropoietin therapy has of severe renal failure or hypertension, and resulted in the disappearance of anaemia. There recurrent urinary tract infection do not have any is no detailed recent literature on the functional associated risk. ability of chronic renal failure/dialysis patients in relation to working safely, and no firm evidence Renal Calculus Disease, with Renal Colic: is a based recommendations can be made. condition that can cause acute severe pain, which could, in some instances severely impair safety critical work. After a first stone episode, the risk of recurrence is only 14% at one year 17.2 GENERAL MANAGEMENT GUIDELINES and 35% at five years6. Most episodes of colic The renal condition most commonly relevant to a will commence with some milder prodromal fitness for duty assessment is chronic renal symptoms, sufficient to allow a train driver to failure. Chronic renal failure may be 'end stage' stop or a flagman to radio for help, and there are requiring treatment by dialysis or kidney no published data supporting a risk for safety transplantation, or less severe renal failure, critical work such as driving from calculus which has not yet progressed to end stage. disease. The risk from recurrent calculi is, therefore, considered to be remote and differs While mild chronic renal failure is not usually from the situation with aeroplane pilots, for whom associated with significant symptomatic or the option of immediately landing is not available. functional impairment, late stage chronic renal failure (Glomerular Filtration Rate (GFR) approximately <20% of normal), although not 17.3 MEDICAL STANDARDS FOR SAFETY 'end-stage', may have some of the clinical impairments seen in dialysis treated end stage CRITICAL WORKERS renal failure patients. Medical criteria for Fit for Duty are outlined in the Successful kidney transplantation reverses most following table. of the metabolic or functional impairment of chronic renal failure, including those likely to be
81 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – RENAL FAILURE CONDITION STANDARDS Renal Failure The criteria for Fit for Duty are not met: If the person has end-stage renal failure (requiring dialysis) or advanced predialysis renal failure (GFR <20% of normal). Fit for Duty Subject to Review may be recommended, taking into account the opinion of a renal specialist, and the nature of the work: If the patient’s condition is stable with limited co-morbidities per these Guidelines.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generallyworkers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Schewe G, Eisenhauer T, Leber H, Lindner U, Ludwig O, Shcuster R Stewart RB, Moore MT, Marks RG, May FE, Hale WE. Driving [Studies on psychophysical ability of kidney transplant receivers with accidents in the elderly: an analysis of symptoms, diseases and regard to the question of driving aptitude] [German] Bietrage zur medications. J. Geriatric Drug Therapy. 1993:8:31-44. Gerichtlichen Medizin. 1982;40:265-273. Lyman JM, McGwin G, Sims RV. Factors related to driving difficulty Schewe G, Broens R, Dietz B, Lange H, Ludwig O, Schuster R and habits in older drivers. Accident Analysis and Prevention, [Studies on psychophysical ability of dialysis patients with regard to 2001:31:413-421 the question of driving aptitude] [German] Bietrage zur Gerichtlichen Medizin. 1982;40:249-264. Uribarri J, Oh MS, Carroll HJ. The first kidney stone. Ann. Int. Med. 1989;111:1006-1009. Fraser CL, Arieff AI. Nervous system complications in uraemia. Ann. Int. Med. 1988;109:143-153.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 82 18 RESPIRATORY DISEASES AND SPEECH
with unpredictable circumstances. Flagman 18.1 RELEVANCE TO SAFETY CRITICAL must be able to move quickly along the track. WORK Portable oxygen is impractical in these jobs. Respiratory disease and speech disorders may Post Thoracotomy: Post thoracotomy patients affect the ability to perform safety critical work. generally should not perform safety critical work This is partly because considerable exertion may for four weeks unless cleared by a specialist. be required to work safely and in other Lung transplant patients should be managed circumstances normal blood gases are required similarly as with heart transplant (see to enable vigilance to be maintained and Cardiovascular). appropriate decisions made. Clear speech is required for communication particularly by radio- Laryngectomy and Tracheostomy Persons communication systems regarding normal with a tracheostomy or laryngectomy need to be operating as well as emergency situations. assessed regarding their ability to speak clearly including radio-communications. Both hands are usually needed in safety critical work, so one 18.2 GENERAL MANAGEMENT GUIDELINES hand is not available to close a stoma for (Including Temporary Conditions) speech. Severe Chronic Asthma: Careful assessment Tuberculosis: Workers with tuberculosis may of the ability to perform safety critical work is perform safety critical work providing they meet warranted in severe chronic asthma. Workers criteria in these Guidelines. (Public health should not perform safety critical work for two aspects may need to be considered in tram weeks following admission to an ICU or following drivers). loss of consciousness, unless otherwise cleared by a specialist. 18.3 MEDICAL STANDARDS FOR SAFETY Severe respiratory disease is not compatible with CRITICAL WORKERS safety critical work. A driver’s duties requires not only sitting in a cab, but also ability to walk along Medical criteria for Fit for Duty are outlined in the the train and inspect couplings and in an following table. emergency the ability to exit the cab and deal
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – RESPIRATORY DISEASES CONDITION STANDARDS Respiratory The criteria for Fit for Duty are not met: Failure If the person has severe respiratory failure. Fit for Duty Subject to Review may be recommended, taking into account the opinion of a respiratory physician, and the nature of the work: After consideration of the severity of the person’s condition and the likelihood of control of the failure. Long – term The criteria for Fit for Duty are not met: Oxygen If the person has unstable disease requiring oxygen therapy. therapy
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect Safety Critical Worker. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Crockett AJ, Moss JR, Cranston JM, Alpers JH. Domiciliary Hjalmarsen A, Waterloo K, Dahl A, Hjorde R, Viitanen M. Effect of long- oxygen for chronic obstructive pulmonary disease. Cochrane term oxygen therapy on cognitive and neurological dysfunction in Database Syst Rev 2000; CD 001744. chronic obstructive pulmonary disease. Eur Neurol 1999; 42: 27-35.
83 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 19 SLEEP DISORDERS
asleep. Many chronic illnesses cause fatigue 19.1 RELEVANCE TO SAFETY CRITICAL without increased sleepiness. WORK Increased sleepiness during the daytime in Sleep disorders may affect the ability to perform otherwise normal people may be due to: safety critical work due to sleepiness per se and/or altered blood gases and hypoxia affecting prior sleep deprivation (restricting the time mental function. for sleep) Information about risk of accidents due to sleep poor sleep hygiene habits disorders mainly comes from road crash data. irregular sleep wake schedules Studies have shown an increased rate of motor vehicle accidents two to seven times that of influence of sedative medications including 9--13 control subjects in those with sleep apnoea . alcohol. Studies have also demonstrated increased Insufficient sleep (less than five hours) prior to objectively measured sleepiness while driving 10 (electro-encephalography and eye closure driving is strongly related to accident risk . measurements) and impaired driving simulator Excessive daytime sleepiness may also result performance in sleep apnoea patients3, 14, 15. from a number of medical sleep disorders This performance impairment is similar to that including the sleep apnoea syndromes seen due to illegal alcohol impairment or sleep (obstructive sleep apnoea, central sleep apnoea deprivation16. Drivers with severe sleep and nocturnal hypoventilation), periodic limb disordered breathing (respiratory disturbance movement disorder, circadian rhythm index greater than 34) may have a much higher disturbances (for example, advanced or delayed rate of accidents than those with a less severe sleep phase syndrome), some forms of insomnia sleep disorder26. (LOE-III-2) and narcolepsy. Fatigue is a major cause of road accidents. Sleep Apnoea Definitions and Prevalence. Sleep apnoea is present on overnight monitoring Sleepiness and sleep disorders are one 4, 5 important aspect of managing the risks of in 9% of adult women and 24% of adult men . fatigue1. Sleep apnoea syndrome (excessive sleepiness in combination with sleep apnoea on overnight Safety Critical Workers who are exposed to monitoring) is present in 2% of women and 4% of periods of sleep deprivation, may increase the men. Some studies have suggested a higher severity of sleep disorders and result in more prevalence in (transport) drivers6, 7. (LOE-III-2) severe sleepiness in workers with sleep disorders26. Obstructive sleep apnoea involves repetitive obstruction to the upper airway during sleep, Treatment of obstructive sleep apnoea with nasal precipitated by relaxation of the dilator muscles continuous positive airways pressure (CPAP) of the pharynx and tongue, and/or narrowing of has been shown to reduce daytime sleepiness the upper airway, and resulting in cessation and reduce the risk of accidents back to control (apnoea) or reduction (hypopnoea) of breathing. levels 8, 10, 18, 19. CPAP has also been shown to improve driving simulator performance to Central sleep apnoea refers to a similar pattern control levels 20. Mandibular advancement of cyclic apnoea or hypopnoeas caused by splints have also been used to treat obstructive oscillating instability of respiratory neural drive, sleep apnoea. While they reduce daytime and not due to upper airways factors. This sleepiness and improve vigilance, studies have condition is less common than obstructive sleep not been performed to assess whether they apnoea and is associated with cardiac or reduce motor vehicle accident rates22- 24. (LOE- neurological conditions or may be idiopathic. III-2) Hypoventilation associated with chronic obstructive pulmonary disease or chronic Those with narcolepsy perform worse on neuromuscular conditions may also interfere with simulated driving tasks and are more likely to sleep quality causing excessive sleepiness. have accidents than control subjects28, 29. (LOE- III-2) Sleep Apnoea Assessment: Common indicators of the possibility of sleep apnoea include habitual snoring during sleep, witnessed 19.2 GENERAL MANAGEMENT GUIDELINES apnoeic events, falling asleep inappropriately (particularly during non-stimulating activities) and 8 Excessive sleepiness during the day, which feeling tired despite adequate time in bed . Poor manifests itself as a tendency to doze at memory and concentration, morning headaches inappropriate times when intending to stay and insomnia may also be presenting features. awake, can arise from many causes and is The condition is more common in men and with associated with an increased risk of accidents. It increasing age. is important to distinguish sleepiness (the Physical features commonly found in those with tendency to fall asleep) from fatigue or tiredness sleep apnoea include obesity, a thick neck and a which is not associated with a tendency to fall narrow oedematous (‘crowded’) oropharynx. Sleep apnoea may be present without these
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 84 features however. Specific questioning in sleep disorders in a clinic setting. Their efficacy relation to each of the clinical disorders, for for screening large general populations remains example, snoring, witnessed apnoeas, limb under evaluation7, 17, 18. jerking, or cataplexy will focus on the likelihood of a specific sleep disorder. Use of the Epworth Sleepiness Scale (ESS): The ESS is scored by summing the numeric Workers in whom sleep apnoea is suspected, values in the boxes in the questionnaire; the chronic excessive sleepiness or another medical maximum possible is 8 x 3 = 24. sleep disorder should be referred to a specialist medical sleep physician for further investigation A score of 0 to 10 is within the normal range. with overnight polysomnography and Mild to moderate self reported sleepiness management. (Epworth Sleepiness Scale score of 11 to 15) Narcolepsy: Narcolepsy is present in 0.05% of may be associated with a significant sleep the population and usually starts in the second or disorder, although the degree of increased risk of third decade of life27. Sufferers present with sleepiness-related (motor vehicle) accidents is excessive sleepiness and can have periods of unknown. sleep with little or no warning of sleep onset. Scores of 16 to 24 are consistent with moderate Other symptoms include cataplexy, sleep to severe sleepiness and are associated with an 28, paralysis and vivid hypnogogic hallucinations increased risk of sleepiness related motor 29. The majority of sufferers are HLA-DR2 vehicle accidents (odds ratio 15.2) 1. (LOE-III-2) positive. There is a sub-group of individuals who are excessively sleepy, but do not have all the Modified or alternate ‘driver-specific’ sleepiness diagnostic features of narcolepsy. Inadequate questionnaires are yet to be widely accepted. warning of oncoming sleep, and cataplexy, put General Recommendations for Sleep Apnoea, Safety Critical Workers at high risk. Narcolepsy or Other Sleep Disorder: Any Diagnosis of narcolepsy is made on the worker with unexplained daytime sleepiness combination of clinical features, HLA typing and while working or having a motor vehicle accident multiple sleep latency test (MSLT) with a potentially caused by sleepiness should be diagnostic sleep study on the prior night to considered for referral to a sleep disorders exclude other sleep disorders and aid specialist for assessment. 39, 31 interpretation of the MSLT . High-risk workers include those with severe Subjects suspected of having narcolepsy should daytime sleepiness, a history of frequent self- be referred to a sleep physician or neurologist for reported sleepiness while working, (off duty) assessment (including a multiple sleep latency motor vehicle crashes caused by inattention or test) and management. They should have a sleepiness, or an ESS Score of 16 to 24 review at least annually by their specialist. (consistent with moderate to severe sleepiness). Sleepiness in narcolepsy may be managed Workers with high risk features have a effectively with scheduled naps and stimulant significantly increased risk of sleepiness-related medication32-34. Tricyclic antidepressants and accidents (odds ratio 15.2) 1. (LOE-III-2) These MAO inhibitors are used to treat cataplexy35. patients should be referred to a sleep disorders (LOE-II) specialist, particularly in the case of Safety Critical Workers. They should be classified as Temporarily Unfit for Duty should be immediately 19.3 MEDICAL STANDARDS FOR SAFETY removed from safety critical duties. CRITICAL WORKERS All workers suspected of having sleep apnoea or other sleep disorders should be warned about Determining sleepiness is a clinical decision. potential impact on safety critical work. General Subjective measures include tools such as the advice should include: Epworth Sleepiness Scale*2. minimising unnecessary working at times Objective measures of sleepiness include the when normally asleep maintenance of wakefulness test (MWT) and multiple sleep latency test (MSLT). Excessive allowing adequate time for sleep sleepiness on the maintenance of wakefulness test is related to impaired driving performance 2. avoiding working after having missed a large portion of their normal sleep Screening tools, which combine questions and physical measurements (for example, The avoiding alcohol and sedative medications, Multivariate Apnoea Prediction Questionnaire), resting if sleepy. have been evaluated for screening patients for The Safety Critical Worker is responsible to: avoid working if they are sleepy 2 The Epworth Sleepiness Scale is under copyright to comply with treatment including management Dr Murray Johns 1991-1997. It may be used by of lifestyle factors individual doctors without permission, but use on a commercial basis must be negotiated. It is included in maintain their treatment device the Safety Critical Worker Health Assessment Questionnaire. attend review appointments and
85 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 honestly report their condition to their treating to allow objective assessment and recording of physician treatment compliance 35. Assessment of sleepiness should be made and objective Safety Critical Workers who are diagnosed with measurement of sleepiness should be obstructive sleep apnoea syndrome and require considered (maintenance of wakefulness test treatment are advised to have annual review by and/or or multiple sleep latency test), particularly a sleep specialist to ensure that adequate if there is concern regarding persisting treatment is maintained. For workers who are sleepiness or treatment compliance. treated with CPAP it is recommended that they should use CPAP machines with a usage meter
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – SLEEP DISORDERS CONDITION STANDARDS Sleep Apnoea The criteria for Fit for Duty are not met: If the person has established sleep apnoea syndrome (sleep apnoea on a diagnostic sleep study and excessive daytime sleepiness), with moderate to severe sleepiness, until treatment is effective. If there is a history suggestive of sleep apnoea in association with severe daytime sleepiness, until investigated and treated. Severe sleepiness is indicated by frequent self reported sleepiness while working, motor vehicle crashes caused by inattention or sleepiness or an Epworth Sleepiness Scale Score of 16 to 24 2, 37, 38. (LOE-III-2) Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in sleep disorders, and the nature of the work: For those with established sleep apnoea syndrome (sleep apnoea on a diagnostic sleep study and excessive daytime sleepiness) who are on satisfactory treatment 10. (LOE-IV) Consideration should be given to how long-distance drivers will comply with treatment such as CPAP 11, 13. (LOE-III-2) Narcolepsy The criteria for Fit for Duty are not met: If narcolepsy is confirmed 27, 28. (LOE-III-3) Fit for Duty Subject to Review may be recommended, taking into account the opinion of a specialist in sleep disorders, and the nature of the work, after the following requirements are met: A clinical assessment has been made by a sleep physician; and Cataplexy has not been a feature in the past; and Medication is taken regularly; and There has been an absence of symptoms for six months; and Normal sleep latency present on MWT (on or off medication). (Expert Opinion)
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 86 References
20. George, C.F., A.C. Boudreau, and A. Smiley, Effects of nasal 1. Fatigue Expert Group Options for Regulatory Approach to CPAP on simulated driving performance in patients with Fatigue in Drivers of Heavy Vehicles in Australia and New obstructive sleep apnoea. Thorax, 1997. 52(7): p. 648-53. Zealand, February 2001, NRTC. 21. Bloch, K.E., et al., A randomized, controlled crossover trial of 2. Stutts, J.C., J.W. Wilkins, and B.V. Vaughn, Why Do People two oral appliances for sleep apnea treatment. American Have Drowsy Driver Crashes?, . 1999, AAA Foundation for Journal of Respiratory & Critical Care Medicine, 2000. 162(1): Traffic Safety: Washington. p. 1-85. p. 246-51. 3. Hakkanen, H., et al., Blink duration as an indicator of driver 22. Mehta, A., et al., A randomized, controlled study of a sleepiness in professional bus drivers. Sleep, 1999. 22(6): p. mandibular advancement splint for obstructive sleep apnea. 798-802. American Journal of Respiratory & Critical Care Medicine, 4. Bearpark, H., et al., Snoring and sleep apnea. A population study 2001. 163(6): p. 1457-61. in Australian men. Am J Respir Crit Care Med, 1995. 151(5): p. 23. Pancer, J., et al., Evaluation of variable mandibular 1459-65. advancement appliance for treatment of snoring and sleep 5. Young, T., et al., The occurrence of sleep-disordered breathing apnea. Chest, 1999. 116(6): p. 1511-8. among middle-aged adults [see comments]. N Engl J Med, 1993. 24. Ferguson, E., et al., Road Crash Costs in Australia, . 2000, 328(17): p. 1230-5. Bureau of Transport Economics: Canberra. p. 102. 6. Stoohs, R.A., et al., Sleep and sleep-disordered breathing in 25. O'Donnell, C.P., et al., Effect of sleep deprivation on responses commercial long-haul truck drivers. Chest, 1995. 107(5): p. 1275- to airway obstruction in the sleeping dog. J Appl Physiol, 1994. 82. 77(4): p. 1811-8. 7. Howard, M., et al., Seep Disordered Breathing In Victorian 26. Hublin, C., et al., Epidemiology of narcolepsy. Sleep, 1994. Transport Drivers. AJRCCM, 2001. 163(5): p. A933. 17(8 Suppl): p. S7-12. 8. Maislin, G., et al., Apnoea risk as determined by a short self- 27. Overeem, S., et al., Narcolepsy: clinical features, new administered assessment tool is associated with crash rates in a pathophysiologic insights, and future perspectives. J Clin population of commercial motor vehicle operators. Sleep Neurophysiol, 2001. 18(2): p. 78-105. Research, 1997. 26: p. 421. 28. Bassetti, C., Narcolepsy. Curr Treat Options Neurol, 1999. 1(4): 9. Horstmann, S., et al., Sleepiness-related accidents in sleep p. 291-298. apnea patients. Sleep, 2000. 23(3): p. 383-9. 29. Aldrich, M.S., Diagnostic aspects of narcolepsy. Neurology, 10. Connor, J., et al., The role of driver sleepiness in car crashes: a 1998. 50(2 Suppl 1): p. S2-7. systematic review of epidemiological studies. Accident Analysis 30. Aldrich, M.S., R.D. Chervin, and B.A. Malow, Value of the & Prevention, 2001. 33(1): p. 31-41. multiple sleep latency test (MSLT) for the diagnosis of 11. George, C.F., Reduction in motor vehicle collisions following narcolepsy. Sleep, 1997. 20(8): p. 620-9. treatment of sleep apnoea with nasal CPAP. Thorax, 2001. 31. Broughton, R.J., et al., Randomized, double-blind, placebo- 56(7): p. 508-12. controlled crossover trial of modafinil in the treatment of 12. Teran-Santos, J., A. Jimenez-Gomez, and J. Cordero-Guevara, excessive daytime sleepiness in narcolepsy. Neurology, 1997. The association between sleep apnea and the risk of traffic 49(2): p. 444-51. accidents. Cooperative Group Burgos-Santander [see 32. Fry, J.M., Treatment modalities for narcolepsy. Neurology, comments]. N Engl J Med, 1999. 340(11): p. 847-51. 1998. 50(2 Suppl 1): p. S43-8. 13. Young, T., et al., Sleep-disordered breathing and motor vehicle 33. Helmus, T., et al., The alerting effects of short and long naps in accidents in a population- based sample of employed adults. narcoleptic, sleep deprived, and alert individuals. Sleep, 1997. Sleep, 1997. 20(8): p. 608-13. 20(4): p. 251-7. 14. Findley, L.J., et al., Driving simulator performance in patients 34. Brooks, S.N. and C. Guilleminault, New insights into the with sleep apnea. Am Rev Respir Dis, 1989. 140(2): p. 529-30. pathogenesis and treatment of narcolepsy. Curr Opin Pulm 15. Risser, M.R., J.C. Ware, and F.G. Freeman, Driving simulation Med, 2001. 7(6): p. 407-10. with EEG monitoring in normal and obstructive sleep apnea 35. Douglas, N.J. and H.M. Engleman, Effects of CPAP on patients. Sleep, 2000. 23(3): p. 393-8. vigilance and related functions in patients with the sleep 16. Turkington, P.M., et al., Relationship between obstructive sleep apnea/hypopnea syndrome. Sleep, 2000. 23(Suppl 4): p. S147- apnoea, driving simulator performance, and risk of road traffic 9. accidents. Thorax, 2001. 56(10): p. 800-5. 36. Masa, J.F., M. Rubio, and L.J. Findley, Habitually sleepy 17. Maislin, G., et al., A survey screen for prediction of apnea. Sleep, drivers have a high frequency of automobile crashes 1995. 18(3): p. 158-66. associated with respiratory disorders during sleep. American 18. Gurubhagavatula, I., G. Maislin, and A.I. Pack, An Algorithm to Journal of Respiratory & Critical Care Medicine, 2000. 162(4 Pt Stratify Sleep Apnea Risk in a Sleep Disorders Clinic Population. 1): p. 1407-12. Am J Respir Crit Care Med, 2001. 164(10): p. 1904-1909. 37. Lloberes, P., et al., Self-reported sleepiness while driving as a 19. Cassel, W., et al., Risk of traffic accidents in patients with sleep- risk factor for traffic accidents in patients with obstructive sleep disordered breathing: reduction with nasal CPAP. Eur Respir J, apnoea syndrome and in non-apnoeic snorers. Respiratory 1996. 9(12): p. 2606-11. Medicine, 2000. 94(10): p. 971-6. 20. Krieger, J., et al., Accidents in obstructive sleep apnea patients 38. Mitler, M.M., et al., Sleep latency on the maintenance of treated with nasal continuous positive airway pressure: a wakefulness test (MWT) for 530 patients with narcolepsy while prospective study. The Working Group ANTADIR, Paris and free of psychoactive drugs. Electroencephalography & Clinical CRESGE, Lille, France. Association Nationale de Traitement a Neurophysiology, 1998. 107(1): p. 33-8 Domicile des Insuffisants Respiratoires. Chest, 1997. 112(6): p. 1561-6.
Further reading
Fairclough, S.H., and Graham, R., Impairment of driving Hack, M.A., et al, Comparison of the effects of sleep deprivation, performance caused by sleep deprivation or alcohol: a comparative alcohol and obstructive sleep apnoea (OSA) on simulated steering study, Human Factors, 41(1), 118-128, 1999. performance, Respiratory Medicine, 95(7), 594-601, 2001.
87 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 20 SYNCOPE / BLACKOUTS
20.1 RELEVANCE TO SAFETY CRITICAL 20.2 GENERAL MANAGEMENT GUIDELINES WORK Some of these conditions are temporary (for Unpredictable, spontaneous loss of example, fainting in hot weather) and do not consciousness is incompatible with safety critical impact on fitness for duty. However, in the event work. Syncopal/blackout episodes may arise of an unexplained episode of syncope/blackouts from various causes including: consideration must be given to discontinuation of performing safety critical work until the cause is cardiac (for example, arrhythmias, flow ascertained and treated. obstruction);
hypotension due to inappropriate vasodilation (for example, vaso-vagal faints, autonomic 20.3 MEDICAL STANDARDS FOR SAFETY system disorder); CRITICAL WORKERS neurogenic (for example, epilepsy, transient Where a firm diagnosis has been made, the ischaemic attacks); standard appropriate to the condition should be referred to in the Guideline. For recurrent metabolic (for example, hypoglycaemia); or syncope/blackouts which is not covered psychiatric (for example, hyperventilation, elsewhere in these Guidelines refer to the table psychosomatic states). below. Determination of the cause of syncope/blackout may be difficult and require extensive investigations and referral to several specialists.
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – SYNCOPE/BLACKOUTS CONDITION STANDARDS Syncope The worker should not perform safety critical work for six months following syncope/blackouts The criteria for Fit for Duty are not met:
If the person suffers from unheralded recurrent syncope/blackouts which does not respond to treatment.
Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Workermay be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 88 21 VESTIBULAR DISORDERS
21.1 RELEVANCE TO SAFETY CRITICAL In cases of acute neurolabyrinthitis (syn. WORK vestibular neuronitis, viral infection of the vestibular nerve) which causes nystagmus and Vestibular disorders may affect the ability to vertigo, recurrence of symptoms can present for perform safety critical work due to their affect on many years despite treatment. This makes it balance. Safety critical work ability is dependent quite difficult to isolate a given phase of the on the normal functioning of the vestibular condition where symptoms deleterious to an mechanism to sense movement and position and individual’s fitness for duty may be present. may be impaired by defects in balance. In confirmed Meniere’s disease vestibular Vestibular malfunction can occur suddenly and malfunction and nystagmus can occur despite with sufficient severity to make safe driving or treatment. The natural history is of progression other safety critical work impossible. It is often in the affected ear associated with increasing accompanied by nystagmus, which compounds hearing loss until in the extreme total loss of the disability. In addition, drivers need to be able vestibular function and partial loss of cochlear to enter and exit the cab to and from the ground function in the affected ear. in emergency situations and require balance to do so. All Safety Critical Workers need to walk Benign paroxysmal positional vertigo and in emergency to run, along ballast and other (BPPV): Generally patients with BPPV will not uneven surfaces and require good balance. have symptoms in the upright position. However, workers with BPPV and symptoms in the upright position should not perform safety 21.2 GENERAL MANAGEMENT GUIDELINES critical work while symptoms persist in the upright position. (Including Temporary Conditions) The ability to perform rail safety work may be 21.3 MEDICAL STANDARDS FOR SAFETY affected by unheralded attacks of vertigo which are associated with many vestibular disorders. CRITICAL WORKERS Vestibular disorders may vary between Medical criteria for fitness for duty are outlined in symptomatic and asymptomatic with little the following table. warning. Generally, those who suffer from unheralded Subsequent to an initial attack of vertigo due to attacks of vertigo are Unfit for Duty. Vestibular acute labyrinthitis (deafness and vertigo), there function should be assessed by using a simple may be further recurrence of vertigo for up to Romberg test, which is also required for twelve months. Given that there are no neurological function. A pass requires the ability peremptory symptoms, a sudden inability to work to maintain balance while standing with shoes safely may eventuate. The person should not off, feet together side by side, eyes closed and perform safety critical work while symptoms arms by sides, for thirty seconds. persist. The opinion of an otorhinolaryngologist may be sought.
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – VESTIBULAR DISORDERS CONDITION STANDARDS Vestibular The criteria for Fit for Duty are not met: Function If the person has, or has had in the previous twelve months, any condition of recurrent vertigo. This includes confirmed Meniere's disease, recurrent unheralded vertigo and/or benign paroxysmal positional vertigo, with or without treatment, or any other type of vertigo. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ENT specialist, and the nature of the work: For persons who have had vertigo caused by Meniere's condition, or recurring unheralded attacks of vertigo, after at least twelve months free of vertigo; For persons who have had one episode of vertigo caused by acute labyrinthitis (deafness and vertigo), acute neurolabyrinthitis (vestibular neuronitis), or any other type of vertigo, after at least six months free of vertigo; For persons who have had BPPV only, after at least two months free of symptoms and signs of BPPV. The ENT Specialist is to have regard to: The nature of the condition and response to treatment; and The functional ability to perform safety critical work such as drivers entering/exiting the cab in an emergency.
89 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Mckiernan D, Jonathon D 'Driving and Vertigo' Clinical Edwards FC, McCallum RI, Taylor PJ 'Fitness for work: The Otolaryngology, 2001, 26, 1-2. medical aspects' Joint Report of the Royal College of Physicians and the Faculty of Occupational Medicine, Oxford University Press, 1988.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 90 22 VISION AND EYE DISORDERS
not met then Goldman or Esterman perimetry 22.1 RELEVANCE TO SAFETY CRITICAL should be performed. WORK Colour vision: The following applies to Good vision is essential to safety critical work as differenct Safety Critical Workers. visual information is crucial to operating machinery and walking about as required by Train drivers require good red and green colour work. Any marked loss of visual acuity or visual vision. Positional cues are not always available field will diminish an individual’s ability to work as red-green lights may operate from a single safely. A worker with a significant visual defect lens signal; lights from a signal may have no may fail to detect another train or member of the background or illumination at night to help their public and will take appreciably longer to identification; there may be dazzle from a low perceive and react to a potentially hazardous sun behind the signal; and red lights may be situation. shone from a lantern in emergency situations requiring rapid reaction. Combinations of red/yellow/green signals are used to inform the 22.2 GENERAL MANAGEMENT GUIDELINES train driver of a safe speed and routing. Signallers may be required to rapidly and The two most important aspects of vision in accurately identify all signal lights in the event of relation to safety critical work are: signal failure occurring. Shunters need to visual acuity identify all colours including purple but the train is moving slowly. visual fields Flagman need to identify red/yellow/green flags Visual acuity: For the purposes of these and be able to interpret signal lights as warning Guidelines, visual acuity may simply be defined of an oncoming train. Signal repairers need to as the best obtainable vision with or without recognise red/green at a distance from a single glasses or contact lenses. Visual acuity should lens signal to check correctness of their repairs be measured with one eye occluded and without and to ensure safety of the network. However correction. If correction is normally used when they are not under time pressure to read the working then vision should be retested with signal and there is redundant information corrective lenses and the corresponding results regarding the signal colour in the electronics in recorded. Acuity should be tested using a the control box. standard visual acuity chart (Snellen chart or equivalent). Alternative charts (for example, Colour vision should be screened using Ishihara Landolt Ring, tumbling E) may be used for plates; more than one error/12 plates is a fail. persons who cannot read English characters. Drivers and signallers who fail do not meet the Visual fields: Adequate visual fields are criteria, but may be further assessed for important for safety critical work and peripheral confirmation at a colour vision clinic because vision is particularly important in certain common there is a small false positive rate. driving tasks, such as use of side mirrors (which Shunters, flagman and signal repairers who fail are important for monitoring the integrity of the should be tested by Medmont C100. Those who train). Visual fields may be reduced as a result are protans are Unfit for Duty, those who are of head trauma, brain tumour, stroke or cerebral deutans should be tested with Farnsworth infection. Lantern and those who pass are Fit for Duty Visual field losses also occur in eye diseases (colour defective safe). such as retinitis pigmentosa, a not uncommon Train controllers who work with multicolour inherited degeneration of the retina that causes screen-based equipment need to distinguish red significant visual field loss by the age of 30. and magenta as well as green. They should be Conditions such as glaucoma, optic atrophy, screened with Ishihara plates; one or more retinal detachment and localised retinal or errors/12 plates is a fail. Workers who fail should choroidal infection can also reduce visual fields. be further tested with Farnsworth D15 test three Good rotation of the neck is also necessary to times on separate days. A pass is two or more ensure adequate overall fields of vision. (Refer correct trials. An incorrect trial is two or more to Musculoskeletal Disorders.) crossings on the test. Visual fields may be initially screened by Heritage and Tourist train drivers who are not on confrontation. Any person who has or is a main line usually have a semaphore arm on a suspected of having a visual field defect should signal which gives a positional cue as well as a be referred for expert assessment by an red/green light. They should be screened with optometrist or ophthalmologist. Visual fields Ishihara plates; one or more errors/12 plates is a should be measured using an automated static fail. Workers who fail should be tested by perimeter (Humphrey Field Analyser, Medmont Medmont C100 and those who are protans are M700, Octopus). If the automated perimetry Unfit for Duty, those who are deutans should be suggests that the criteria for fitness for duty are tested with Farnsworth Lantern and those who
91 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 pass are fit for duty. (All drivers on main lines regularly. Because persons with cataract suffer are required to be colour vision normal). loss of contrast sensitivity and greater sensitivity to glare, they may have more difficulty seeing ATTP do not require colour vision testing. when working than is indicated by their visual Tram drivers do not require red and green colour acuity. vision. This is consistent with the latest Short-term Eye Conditions and Eye Austroads standard for commercial vehicle Treatments: Persons whose vision is drivers1-13. Tram driving is comparable to bus temporarily disturbed by a short term eye driving in terms of risk and similar standards condition or an eye treatment should be should be applied. counselled not to perform safety critical work for There may be a degree of flexibility allowed at a specified time or to limit their work during this the optometrist's or ophthalmologist's discretion time. This includes temporary patching of any for individuals who barely meet visual standards eye, the use of mydriatics or drug known to affect but who are otherwise alert, have normal vision, and after eye surgery. reaction times and good muscular coordination. Congenital and Acquired Nystagmus: The Dark Adaptation: Health professionals may criteria for visual acuity must be met and any wish to recommend restrictions on workers who underlying condition fully assessed. appear to meet the visual criteria in the clinical Diplopi:. Workers suffering from all but minor setting but may, in certain environments have forms of diplopia generally are unsafe to drive. extreme difficulty. Examples of such restrictions Any person who reports or is suspected of might be daylight driving only, where certain experiencing diplopia should be referred for disorders or diseases such as retinitis expert assessment by an optometrist or pigmentosa can cause poor night vision, or ophthalmologist. distance and/or speed restrictions. Progressive Eye Conditions: Workers with a progressive eye condition such as cataract, 22.3 MEDICAL STANDARDS FOR SAFETY glaucoma, diabetic retinopathy, optic neuropathy CRITICAL WORKERS and retinitis pigmentosa should be counselled that their eye condition will or may progress to a Medical criteria for fitness for duty are outlined in stage where they are no longer able to work. the following table. They should be encouraged to consider making It is not required that workers carry spare sets of lifestyle changes in anticipation of not being able glasses at work. to work. Their vision should be monitored
MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – VISION & EYE DISORDERS CONDITION STANDARDS Acuity and Visual acuity should be measured one eye at a time (monocularly), without correction in the first place. Monocularity Acuity should be tested using a standard visual acuity chart (Snellen chart or equivalent) that includes at least five letters on the 6/9 and 6/18 lines. Alternative charts (for example, Landolt Ring, tumbling E) may be used for persons who cannot read the alphabet. More than two errors in reading the letters of any line is regarded as a failure to read the line. The criteria for Fit for Duty are not met: If the person's visual acuity is worse than 6/9 in the better eye; or If the person's visual acuity is worse than 6/18 in either eye. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ophthalmologist or optometrist or GP, and the nature of the work: If the standard is met with corrective lenses; and After consideration of the nature of any underlying disorder. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ophthalmologist or optometrist, and the nature of the work: If the person's vision is worse than 6/18 in the worse eye, provided that the visual acuity in the better eye is 6/9 or better; and After consideration of the nature of any underlying disorder. In cases of latent nystagmus made manifest by the occlusion of one eye for the purpose of testing, a binocular visual acuity of 6/9 is acceptable if the visual acuity of the better eye is below 6/9 with occlusion of the fellow eye. The same minimum standard of vision in the worse eye applies.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 92 MEDICAL STANDARDS FOR SAFETY CRITICAL WORKERS – VISION & EYE DISORDERS (CONT) CONDITION STANDARDS Colour vision Drivers and signallers: Colour vision should be screened using Ishihara plates; more than one error/12 plates is a fail. The criteria for Fit for Duty for drivers and signallers are not met: If the person is not Colour Vision Normal, that is, does not pass the Ishihara test. Drivers and signallers who fail the Ishihara test do not meet the criteria, but may be further assessed for confirmation at a colour vision clinic. Flagman, shunters and signal repairers: Colour vision should be screened using Ishihara plates; more than one error/12 plates is a fail. Shunters, flagman and signal repairers who fail the Ishihara test should be tested by Medmont C100 and those who are protans are not fit for duty, those who are deutans should be tested with Farnsworth Lantern and those who pass are fit for duty. The criteria for Fit for Duty for flagman, shunters and signal repairers are not met: If the person is not Colour Vision Normal, or is not Colour Defective Safe, that is, a protan or deutan as determined by the Farnsworth Lantern test. Train controllers: Colour vision should be screened using Ishihara plates; more than one error/12 plates is a fail. They should be further tested using Farnsworth D15 test. The criteria for Fit for Duty for a train controller are not met: If the person is a protan as determined by the Farnsworth D15 test. Heritage and Tourist train drivers: Colour vision should be screened using Ishihara plates; more than one error/12 plates is a fail. Historical train drivers who fail the Ishihara test should be tested by Medmont C100 and those who are protans are not fit for duty, those who are deutans should be tested with Farnsworth Lantern and those who pass are fit for duty. The criteria for Fit for Duty for historical train drivers are not met: If the person is not Colour Defective Safe, that is, a protan or deutan as determined by the Farnsworth Lantern test. Diplopia The criteria for Fit for Duty are not met: If the person experiences any diplopia (other than physiological diplopia) when fixating objects within 20o of the primary direction of gaze. Night No specific standard. Refer general management guidelines in text (Paragraph 23.2.6). blindness (Dark adaptation) Visual Fields Visual fields may be initially screened by confrontation. Any person who has or is suspected of having a visual field defect should be referred for expert assessment by an optometrist or ophthalmologist. Visual fields should be measured using an automated static perimeter (Humphrey Field Analyser, Medmont M700, Octopus.). If the automated perimetry suggests that The criteria for fitness for duty are not met then Goldman or Esterman perimetry should be performed. The criteria for Fit for Duty are not met: If the person has any visual field defect. Fit for Duty Subject to Review may be recommended, taking into account the opinion of an ophthalmologist or optometrist, and the nature of the work: o o If the binocular visual field has an extent of at least 140 within 10 above and below the horizontal midline; and If the person has no significant visual field loss (scotoma, hemianopia, quadrantanopia) that is likely to impede work performance; and After consideration of the nature of any underlying disorder.
93 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
References Colour Vision 9. Hager, G., Das Sehorgen und das Unfallgeschehen im Strassenverkehr. Klin. Mbl. Augenheilk 142:427-433 1963 1. Vision and Driving. Department of the Environment, Transport and the Regions 12/12/2001 10. Cole, BL and Brown, B (1966) Optimum intensity of red road-traffic signals lights for normal and protanopic 2. Council Directive of 29 July 1991 on driving licences observers. J. Opt Soc Amer 56: 516-522 (91/439/EEC) The Council of the European Communities. 11. Cole, BL and Vingrys, AJ (1983b) Do protanomals have 3. Pape vs CAA 1985, Denison vs CAA 1989 Administrative difficulty seeing red lights? Proc CIE 20th Session, Appeals Tribunal Amsterdam, 1983. Guideline 56, E04, CIE Paris, 1-3 4. Vingrys A.J., Cole B.L., Are colour vision standards 12. Nathan, J, Henry, GH and Cole, BL (1964) Recognition of justified for the transport industry? Ophthal. Physiol. coloured road traffic light signals by normal and color- Opt.,1988, Vol.8,July vision-defective observers. J Opt Soc Amer 54: 1041- 5. Owsley C., Vision impairment and driving Survey 1045 Ophthal.43,6 May Jun 1999 13 Favilla I.,Visual Requirements for drivers licences RACO 6. Norman L.G., Medical aspects of road safety. Lancet 1, 14. Hovis and Oliphant (2000) A lantern colour vision test for the 989-994 1960 rail industry. Am J Ind Med, 38 (6); 681-96) 7. Verriest et al.: New investigations concerning the 15. CIE Technical Report: recommendations for colour vision relationships between congenital colour defects and road requirements for transport. CIE 143-2001 traffic security. Int. Ophthal. 2: 87-9 8. Cole B.L., Vingrys A.J.:Reply to the report 'Review of the research basis for the current medical standards for colour vision (Protan deficits)' Soames Job, R.F.
Visual Fields 6. Lovsund P and Hedin A. Effects on driving performance of visual field defects. In: Gale AG et al, editors. Vision in 1. See Charman WN. Vision and driving – a literature review Vehicles. Amsterdam: Elsevier; 1986: 323-329. and commentary Ophthal Physiol Optics 1997; 17: 371- 391, and North RV. The relationship between the extent of 7. Keeney JL. The relationship between ocular pathology and visual field and driving performance – a review Ophthal driving impairment Am J Ophthalmol 1976; 82: 799-801. Phyiol Optics 1985; 5: 205-210. 8. Liesmaa M. The influence of drivers vision in relation to his 2. Johnson CA and Kelttner JL. Incidence of visual field loss driving ability Optician; 1973: 166, 10-13. in 20,000 eyes and its relationship to driving performance Arch Ophthalmol 1983; 101: 371-375. 9. Edwards MG and Schachat AP. Impact of enucleation for choroidal melonoma on the performance of vision 3. Fishman GA, Anderson RJ, Stinson L and Haque A. Driver dependent activities Arch Ophthalmol 1991; 109: 519-521. performance of retinitis pigmentosa patients Brit J Ophthalmol 1981; 65: 122-126. 10. McKnight AJ, Shinar D and Hilburn B. The visual and driving performance of monocular and binocular heavy 4. Elkington AR and MacKean JM. Glaucoma and driving Brit truck drivers Accid Anal Prev 1991; 23: 225-237. Med J 1982; 285: 777-778. 11. Ivers RQ, Mitchell P, Cumming RG. Sensory Impairment 5. Wood JM and Troutbeck R. Effect of restriction of binocular and Driving: the Blue Mountain Study. Am J Public Health visual field on driving performance Ophthal Physiol Optics 1999; 89: 85-87. 1992; 12: 291-298.
Further reading Higgins, K.E., Wood, J., Tait, A., Vision and driving: selective effect of Steward, J.M., and Cole, B.L., What do colour vision defectives optical blur on different driving tasks, Human Factors, 40(2), 224-232, say about everyday tasks? Optometry and Vision Science, 1998. 66(5), 288-295, 1989. Soames Job, R.F., Review of the research basis for the current medical Westlake, W., Another look at visual standards and driving, standards on colour vision (Protan deficits), Report to Licensing and BMJ, 321, 972-973, 2000. Policy Projects, Roads and Traffic Authority of NSW, June 2001.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 94 PART C2 – Medical Criteria for Track Safety Assessment Rail safety workers who are within the safety envelope but not in a Controlled Environment require examination. There are appreciable risks from moving trains which can be surprisingly quiet even at high speed. Full visual fields and good acuity and hearing are important to sense an oncoming train. There must be sufficient soundness of limb to permit rapid movement away from a train. Workers who access the track receive Track Safety Awareness training on a regular basis. Frequency of Assessment: This Track Safety Health Assessment for Category 3 (ATTP not in a Controlled Environment assessment should be conducted at: time of commencement and change of grade age 40 and five yearly thereafter. It is assumed that workers who incur serious injury or illness to their eyes or hearing or limbs or will report to their supervisor for a Triggered Assessment.
MEDICAL STANDARDS FOR TRACK SAFETY HEALTH ASSESSMENT CONDITION STANDARDS Vision Visual acuity should be measured one eye at a time (monocularly), without correction in the first place. Acuity should be tested using a standard visual acuity chart (Snellen chart or equivalent) that includes at Acuity and least five letters on the 6/9 and 6/18 lines. Alternative charts (for example, Landolt Ring, tumbling E) may Monocularity be used for persons who cannot read the alphabet. More than two errors in reading the letters of any line is regarded as a failure to read the line. The criteria for Fit for Duty are not met: If the person's visual acuity is worse than 6/9 in the better eye; or If the person's visual acuity is worse than 6/18 in either eye. Fit for Duty Subject to Review may be recommended if: The standard is met with corrective lenses; and After consideration of the nature of any underlying disorder. Fit for Duty Subject to Review may be recommended if: The person's vision is worse than 6/18 in the worse eye, provided that the visual acuity in the better eye is 6/9 or better; and After consideration of the nature of any underlying disorder. In cases of latent nystagmus made manifest by the occlusion of one eye for the purpose of testing, a binocular visual acuity of 6/9 is acceptable if the visual acuity of the better eye is below 6/9 with occlusion of the fellow eye. The same minimum standard of vision in the worse eye applies. Fit for Duty Subject to Job Modification may be considered, for example if the worker is to be escorted at all times when around the track. Vision Visual fields may be initially screened by confrontation. Any worker who has or is suspected of having a visual field defect should be referred for expert assessment by an optometrist or ophthalmologist. Visual Visual Fields fields should be measured using an automated static perimeter (Humphrey Field Analyser, Medmont M700, Octopus). If the automated perimetry suggests that the criteria for Fit for Duty are not met then Goldman or Esterman perimetry should be performed. The criteria for Fit for Duty are not met: If the person has any visual field defect. Fit for Duty Subject to Review may be recommended: If the binocular visual field has an extent of at least 140o within 10o above and below the horizontal midline; and If the person has no significant visual field loss (scotoma, hemianopia, quadrantanopia) that is likely to impede work performance; and After consideration of the nature of any underlying disorder. Fit for Duty Subject to Job Modification may be considered, for example if the person is to be accompanied at all times when around the track.
95 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 MEDICAL STANDARDS FOR TRACK SAFETY HEALTH ASSESSMENT - CONDITION STANDARDS Hearing Compliance with the standard should be assessed by conducting audiometry. The criteria for Fit for Duty are not met: If the worker has an unaided average hearing threshold level of equal to or greater than 40dB in the better ear. (Average hearing threshold is the simple average of pure tone air conduction thresholds at 500, 1000, 2000 and 3000 Hz). Fit for Duty Subject to Review may be recommended: For workers who use hearing aids and have sufficient corrected hearing to meet the criteria (above). Fit for Duty Subject to Job Modification may be considered, for example if the worker is to be escorted at all times when around the track.
Musculoskeletal The criteria for Fit for Duty are not met: Disorders If chronic pain or restriction of joint movement or amputation of the lower limbs interferes with the ability to rapidly move from an oncoming train: Fitness for Duty Subject to Periodic Review may be recommended, taking into account the opinion of a specialist, and the nature of the work: If the condition is under adequate treatment. Fitness for Duty Subject to Job Modification may be considered, for example if the person is to be accompanied at all times when around the track.
Alcohol, Drugs If at time of examination a person appears to be mentally impaired they should be assessed per the procedures for Drug and Alcohol impairment (refer to Diagram 12).
Diagram 12. Management of Impairment Assessment Relevant to Usage of Alcohol and Drugs: Illicit and Prescription/OTC
Is there evidence of impairment? Preliminary Impairment Assessment (speech, eyes, breathing, skin, actions, movements, balance, attitude. YES NO
Discuss with worker. No further action Is there a medical basis for impairment, ie continue with health prescription medication /OTC drug taken for a assessment defined purpose, or an illness. YES NO
Medical basis If suspect alcohol or illicit drug use: Classify Temporarily Unfit for Duty. Classify Temporarily Unfit for Duty and If appropriate, discuss medication with advise on report “impairment without GP/treating doctor in order to resolve clear medical basis”. impact on employment. Contact employer regarding “impairment If appropriate, refer to relevant chapter without clear medical basis” and await for medical conditions. further instructions from employer. Identify review period.
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 96 Temporary Illnesses. The Guidelines do not presume to deal with the myriad of conditions which may affect health on a short to medium term basis and for which a Safety Critical Worker may be referred for assessment regarding fitness to resume duty. Clinical judgement is usually required on a case by case basis although the text in each chapter gives some advice on the clinical issues to be considered. Undifferentiated Illness. A Safety Critical Worker may be referred with symptoms which could have implications for their job but the diagnosis is not clear. Referral and investigation of the symptoms will mean that there is a period of uncertainty before a definitive diagnosis is made and before the worker and employer can be confidently advised. Each situation will need to be assessed individually, with due consideration being given to the probability of a serious disease which will affect safety critical work. Generally, workers presenting with symptoms of a potentially serious nature should be classified Temporarily Unfit for Duty until their condition can be adequately assessed. However, they may be suitable for alternative duties.
97 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 PART D – MODEL FORMS
DRAFT Safety Critical Worker Request & Report Form 20 May 2003 98 1. Safety Critical Worker Health Assessment
1.1 Safety Critical Worker Request and Report Form This form’s format allows for increased confidentiality and for inclusion of additional supporting information to be provided to the authorised health professional, for example, previous health assessment, Workcover and critical incident reports. The form is used as follows. 1. Part A: Employer completes Part A, encloses copies of relevant supporting information and a copy of the Health Assessment Record and forwards them to the examining health professional. 2. Part B: Health professional upon completion of the assessment, completes Part B of the form, retains a copy and returns the original form to the employer. 3. Part C: Employer completes Part C of the form.
99 DRAFT Safety Critical Worker Request & Report Form 20 May 2003 CONFIDENTIAL
Safety Critical Worker Request & Report Form
IMPORTANT INFORMATION To the Employer Please complete all relevant details in PART A of the form including: Personal details of the worker. Appointment details if appropriate. A description of the rail safety duties to be performed by the worker. The category of risk determined by the tasks and therefore the level of assessment (Category 1 or 2). The type of assessment requested (eg. Pre-placement, periodic, triggered) The pathology tests required (High Level Safety Critical Worker only) Audiometry requirements.
Additional forms and information to be issued with this request include: Safety Critical Worker Health Assessment Record to be completed and retained by the examining health professional. Screen–based equipment Request and Report Form and Assessment Record. Any additional information for effective worker assessment including copies of previous health assessment report, relevant Workcover reports, critical incident history and sick leave record. Pathology request forms if required.
On receipt of the completed Health Assessment Report, please complete Part C and take action as appropriate. To the Health Professional You are requested to conduct a health assessment to assess the worker’s fitness for rail safety duties according to the details provided in PART A of this form and according to the Guidelines for Health Professionals Conducting Assessments for Rail Safety Workers.
Please undertake the assessment, complete PART B of this form and return to worker’s employer according to the instructions noted in PART A.
Category 1 High Level Safety Critical Workers are required to present for fasting cholesterol, fasting glucose and an ECG for preplacement and periodic assessments. This will have been arranged before the appointment with you and results will be forwarded to you directly.
Both Category 1 and Category 2 Safety Critical Workers are required to undertake audiometry for preplacement, change of grade and periodic assessments. This will be arranged separately if audiometry facilities are not available at your practice.
Should the worker be assessed Unfit for Duty please contact the employer immediately so that appropriate rostering changes may be made.
Details of the examination should be recorded on the enclosed Safety Critical Worker Health Assessment Record form. This record is confidential and should be retained by you, not returned to the employer. The employer’s chief medical officer may contact you for more information regarding the worker’s condition.
For more detailed information about the conduct of health assessments for rail safety workers see Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers.
DRAFT Safety Critical Worker Request & Report Form 20 May 2003 Page 1 of 3 PART A – Employer to complete 1. Worker Details Family Name: First Names: Company: Location: Employee No: Date: Supervisor: Phone: Facsimile: Account and report to be sent to Supervisor at the following address (Please insert postal address or fax number):
2. Medical Appointment Details: Doctor: Address: Date: Time:
3. Description of Duties
4. Risk Category/Level of Assessment (tick appropriate box)
Category 1 (High Level Safety Category 2 (Safety Critical Worker) Critical Worker)
5. Type of Assessment requested: Preplacement/change of grade Health Assessment Periodic Health Assessment Triggered Health Assessment (specify reason): ______Drug Screen Screen Based Equipment Examination Other (specify): ______
5. Tests ordered: Pathology (Category 1 only) Audiometry (Category 1 and 2) Fasting Cholesterol Audiometry ordered from: Fasting Glucose ______Resting ECG
Pathology ordered from: ______
6. Supporting information provided (include photocopies only, original documents should remain on file): Previous health assessment report Sick leave record Relevant Workcover history Relevant Critical Incident episodes Positive Drug and Alcohol Assessment Reports Record of involvement in notifiable occurrence under Transport (Rail) Safety Regulation 1198 and/or SPAD Other (specify): ______
DRAFT Safety Critical Worker Request & Report Form 20 May 2003 Page 2 of 3 PART B – Health Professional to complete
I have sighted the worker’s photo ID I certify that I have examined the worker named in accordance with the Rail Medical Standards contained in the “Guidelines for Health Professionals Conducting Assessments for Rail Safety Workers” and in my opinion they are (tick appropriate box):
Fit for Duty – Meets all relevant medical criteria. Local doctor referral
Fit for Duty Subject to Review – Does not meet I recommend: all medical criteria, but could undertake rail safety Review at this practice work if the condition is sufficiently under control and worker is more frequently reviewed than DATE: prescribed under periodic review. Specialist referral Local doctor referral CMO referral Laboratory tests
This certificate is valid to:
Fit for Duty subject to Job Modification – Does I recommend the following job modifications: not meet all medical criteria, but could undertake ______rail safety work if suitable modifications were made to the duties. ______
Temporarily Unfit for Duty Subject to Review – I recommend the following in terms of management and Does not meet all medical criteria and cannot review: undertake current rail safety tasks. May return to ______duty pending improvement in condition, response to treatment, confirmed diagnosis of ______undifferentiated illness. ______
Permanently Unfit forDuty – Does not meet the I recommend the following in terms of management and medical criteria and cannot perform the job in the review: future. ______
Health Professional Details Name Phone: Facsimile: Practice address Signature: Date::
PART C – Employer to complete on receipt of Assessment Report
Action taken as a result of Health Assessment: Job modification (details):______Triggered review (indicate period): ______Full periodic health assessment (details): ______Redeployment (details): ______Drug Assessment (details): ______
DRAFT Safety Critical Worker Health Assessment Record 20 May 2003 Page 3 of 3 1.2 Safety Critical Worker Health Assessment Record The model Health Assessment Record is a tool for health professionals designed to help guide the health assessment process. It provides a standard format for recording the results of the assessment which should then be filed by the examining health professional in the worker/patient’s medical history.
The form is used as follows. 1. Part A: Employer completes PART A, and includes the form with the Request and Report Form and forwards to the health professional. 2. Part B: Health professional records the results of the clinical examination in PART B and retains the form in the worker’s medical record. 3. The completed Health Assessment Record is not to be forwarded to the employer for reasons of privacy. The Health professional should summarise the result in terms of fitness for duty on the Request and Report Form.
103 DRAFT Safety Critical Worker Health Assessment Record 20 May 2003 CONFIDENTIAL Safety Critical Worker Health Assessment Record
PART A Worker Details – Employer to complete Family Name: First Names: Company: Location: Employee No: Date:
PART B Clinical Findings – Health Professional to complete and retain
1. Cardiovascular System: 2. Neurological/Locomotor:
1.1 Blood Pressure 2.1 Cervical spine rotation
Systolic mm Hg Normal Abnormal Diastolic mm Hg 2.2 Back movement
1.2 Pulse Rate: Normal Abnormal Regular Irregular 2.3 Upper Limbs 1.3 Heart Sounds: a) Appearance: Normal Abnormal Normal Abnormal b) Joint movements: Normal Abnormal 1.4 Peripheral Pulses: Normal Abnormal 2.4 Lower Limbs ______a) Appearance: Normal Abnormal 1.5 Calculation of Cardiac Risk Score (High level SCW examination only). See b) Joint movements: Normal Abnormal Cardiovascular chapter for scoring.
Age/sex 2.5 Gait Normal Abnormal Smoker: No Yes 2.6 Romberg’s sign (A pass requires the ability to Blood Pressure (see above) maintain balance while standing with shoes off, ECG (left ventricular feet together side by side, eyes closed and arms by hypertrophy) sides, for thirty seconds): Fasting cholesterol – TOTAL Normal Abnormal – HDL Fasting plasma glucose (diabetes) 3. Chest/Lungs: Normal Abnormal SCORE
DRAFT Safety Critical Worker Health Assessment Record 20 May 2003 Page 1 of 2 4. Abdomen (liver): Normal Abnormal 9. Alcohol: Audit Questionnaire Score: ______
5. Hearing (Audiometry results): 10. Sleep: Epworth Sleepiness Scale Score:
______0.5 kHz 1.0 kHz 2.0 kHz 3.0 kHz Right Left 11. Drug Screen (pre-placement or change of grade only): ______
6. Vision: RELEVANT CLINICAL FINDINGS 6.1 Visual Acuity & ACTION Note Comments on any relevant findings detected in Uncorrected Corrected the questionnaire or examination, making reference to the requirements of the standard. RLRL 6/ 6/ 6/ 6/
Are contact lenses worn? No Yes
6.2 Visual Fields (Confrontation to each eye): Normal Abnormal
6.3 Colour vision (Ishihara plates) Normal Abnormal
7. Urinalysis 7.1 Protein: Normal Abnormal 7.2 Glucose: Normal Abnormal
8. Psychological Health:
8.1 K 10 Score: ______
8.2 Is attitude, speech and behaviour appropriate? No Yes
IMPORTANT: For privacy reasons, the completed Health Assessment Record must not be returned to the employer. Please retain in the worker’s health records file.
DRAFT Safety Critical Worker Health Assessment Record 20 May 2003 Page 2 of 2 1.3 Safety Critical Worker Health Assessment Notification and Questionnaire
This contains the Safety Critical Worker Health Assessment Notification Form and Safety Critical Worker Health Questionnaire as well as instructions for the worker.
The self-administered questionnaire has been designed as a screening tool to help identify conditions that might affect the performance of safety critical work. The questionnaire is not a diagnostic tool and no decision can be made regarding the worker’s fitness for duty until the full clinical examination is undertaken. The health professional may need to guide or assist with completion of the questionnaire if literacy or cultural background presents a barrier to self-administration by the worker. The health professional will also need to review the answers with the worker to ascertain relevant detail. Dishonest completion of the questionnaire may be an issue. Workers are required to sign the completed questionnaire in the presence of the examining health professional and the health professional should countersign.
The form is used as follows. 1. Part A: Employer completes PART A and provides all of the form to the worker. 2. Part B: Worker completes PART B and presents to the health professional. The worker signs the form as a true statement and the health professional countersigns. 3. The employer discusses the results with the worker. The form is retained by the health professional and filed in the workers medical record.
DRAFT Safety Critical Worker Model Notification & Health Questionnaire 20 May 2003 106 CONFIDENTIAL
Safety Critical Worker Notification and Health Questionnaire
IMPORTANT INFORMATION
To the Worker You are required to attend a health assessment as a condition of your employment, to assess your fitness for undertaking rail safety work.
The health assessment must be completed by ______to ensure that you are able to carry out normal duties.
Before attending your health assessment, please:
Complete the enclosed questionnaire BEFORE ATTENDING THE APPOINTMENT and provide it to the examining health professional
Take glasses, hearing aid or any other aids required for safety critical work to the appointment
Take all medication that you are currently taking to the appointment or a list of such medications.
Take photo identification with you to the appointment.
Should blood tests or other tests be required before you attend for the assessment, your supervisor will advise you. The details of your health assessment will remain confidential and will only be reported to your employer in terms of your fitness for duty. The examining health professional may ask your permission to speak to your GP
DRAFT Safety Critical Worker Model Notification & Health Questionnaire 20 May 2003 Page 1 of 4 PART A – Employer to complete 1. Worker Details Family Name: First Names: Company: Location: Employee No: Date: Supervisor: Phone: Facsimile: Account and report to be sent to Supervisor at the following address (Please insert postal address or fax number):
2. Medical Appointment Details: Doctor: Address: Date: Time:
3. Tests ordered: Pathology (Category 1 only) Fasting Cholesterol Fasting Glucose Resting ECG
Instructions to workers: ______
Audiometry (Category 1 and 2)
Instructions to worker ______
DRAFT Safety Critical Worker Model Notification & Health Questionnaire 20 May 2003 Page 2 of 4 PART B - SAFETY CRITICAL WORKER HEALTH QUESTIONNAIRE– Worker to complete
This questionnaire must be completed in order to help assess your fitness for safety critical work. Please answer the questions by ticking the correct box or circling the appropriate response. If you are not sure, leave question blank and ask the examining health professional what it means. The health professional will ask you more questions during the assessment.
No Yes No Yes 1. Are you currently being treated by a doctor 4. Please tick the box ‘No’ or ‘Yes’ in response to the for any illness or injury? following:
2. Are you receiving any medical treatment or 4.1 Have you ever had, or been told by a taking any medication (either prescribed doctor that you had a sleep disorder, or otherwise) sleep apnoea, or narcolepsy? (Please take any medications with you to show the doctor) Please note brief details: 4.2 Has anyone noticed that your breathing ______stops or is disrupted by episodes of ______choking during your sleep? ______
3. Have you ever had, or been told by a doctor that you had 4.3 How likely are you to doze off or fall asleep in the any of the following? following situations, in contrast to feeling just tired? 3.1 High blood pressure This refers to your usual way of life in recent times. Even if you haven’t done some of these things 3.2 Heart disease recently try to work out how they would have affected 3.3 Chest pain, angina you. 3.4 Any condition requiring heart surgery Use the following scale to choose the most appropriate 3.5 Palpitations/irregular heartbeat number for each situation: 3.6 Abnormal shortness of breath 0 = would never doze off 3.7 Head injury, spinal injury 1 = slight chance of dozing 2 = moderate chance of dozing 3.8 Seizures, fits, convulsions, 3 = high chance of dozing epilepsy 3.9 Blackouts or fainting Situation Chance of dozing (0-3) 3.10 Migraine 1 2 3 4 3.11 Stroke 3.12 Dizziness, vertigo, problems with Sitting and reading balance Watching TV 3.13 Double vision, difficulty seeing 3.14 Colour blindness Sitting, inactive in a public place (eg. a theatre or meeting) 3.15 Kidney disease 3.16 Diabetes As a passenger in a car for an hour without a break 3.17 Neck, back or limb disorders 3.18 Hearing loss or deafness or had an ear Lying down to rest in the operation or use a hearing aid afternoon when 3.19 Do you have difficulty hearing people on circumstances permit the telephone (including use of hearing Sitting andtalking to aid if worn)? someone 3.20 Have you ever had, or been told by a doctor that you had a psychiatric illness, Sitting quietly after a lunch or nervous disorder without alcohol 3.21 Have you ever had any other serious In a car, while stopped for injury, illness, operation, or been in a few minutes in the traffic hospital for any reason?
DRAFT Safety Critical Worker Model Notification & Health Questionnaire 20 May 2003 Page 3 of 4 5. Please circle the answer that is correct for you: 7. Please circle the answer that is correct for you:
5.1 How often do you have a drink containing alcohol? 7.1 In the past 4 weeks, about how often did you feel tired Never Monthly Two or four Two to three Four or more out for no good reason? or less times a month times a week times a week All of Most of Some of A litt le of None of 5.2 How many drinks containing alcohol do you have on a the time the time the time the time the time typical day when you are drinking? 7.2 In the past 4 weeks, about how often did you feel 1 or 2 3 to 5 5 to 6 7 to 9 10 or more nervous? 5.3 How often do you have six or more drinks on one occasion? All of Most of Some of A litt le of None of Never Monthly Two or four Two to three Four or more the time the time the time the time the time or less times a month times a week times a week 7.3 In the past 4 weeks, about how often did you feel so 5.4 How often during the last year have you found that you nervous that nothing could calm you down? were not able to stop drinking once you had started? All of Most of Some of A litt le of None of Never Monthly Two or four Two to three Four or more the time the time the time the time the time or less times a month times a week times a week 7.4 In the past 4 weeks, about how often did you feel 5.5 How often during the last year have you failed to do what hopeless? was normally expected from you because of drinking? Never Monthly Two or four Two to three Four or more All of Most of Some of A litt le of None of or less times a month times a week times a week the time the time the time the time the time
5.6 How often during the last year have you needed a first 7.5 In the past 4 weeks, about how often did you feel drink in the morning to get yourself going after a heavy restless or fidgety? drinking session? Never Monthly Two or four Two to three Four or more All of Most of Some of A litt le of None of or less times a month times a week times a week the time the time the time the time the time
5.7 How often during the last year have you had a feeling a 7.6 In the past 4 weeks, about how often did you feel so guilt or remorse after drinking? restless you could not sit still? Never Monthly Two or four Two to three Four or more All of Most of Some of A litt le of None of or less times a month times a week times a week the time the time the time the time the time
5.8 How often during the last year have you been unable to 7.7 In the past 4 weeks, about how often did you feel remember what happened the night before because you depressed? had been drinking? Never Monthly Two or four Two to three Four or more All of Most of Some of A litt le of None of or less times a month times a week times a week the time the time the time the time the time
5.9 Have you or someone else been injured as a result of your 7.8 In the past 4 weeks, about how often did you feel that drinking? everything was an effort? No Yes, but not in the last year Yes, during the last year All of Most of Some of A litt le of None of the time the time the time the time the time 5.10 Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut 7.9 In the past 4 weeks, about how often did you feel so down? sad that nothing could cheer you up? No Yes, but not in the last year Yes, during the last year All of Most of Some of A litt le of None of the time the time the time the time the time
No Yes 7.10 In the past 4 weeks, about how often did you feel 6. Do you use illicit drugs? worthless? All of Most of Some of A litt le of None of the time the time the time the time the time
Worker’s Declaration (in presence of health professional):
I, ______(Print Name) - certify that to the best of my knowledge the above information supplied by me is true and correct
Signature: ______Signature of health professional:______
Date: _____/_____/_____
IMPORTANT For privacy reasons, the completed Questionnaire must not be returned to the employer.
DRAFT Safety Critical Worker Model Notification & Health Questionnaire 20 May 2003 Page 4 of 4 1.4 Screen-Based Equipment (SBE) Examination Request & Report Form Some Safety Critical Workers may perform duties which require them to undertake a Screen-Based Equipment (SBE) Examination. This model form is designed for this purpose.
The form is used as follows. 1. Part A: Employer completes PART A and forwards to health professional together with the SBE Examination Record (See Model Form 1.5). Note: Health professional retains the Examination Record and does not return it to the employer. 2. Part B: Health professional summarises the results of the examination from the Examination Record in PART B and includes recommendations for corrective lenses. The Report Form is then sent to the employer. 3. Part C: Worker has the prescription filled and signs the declaration in PART C, should corrective lenses be prescribed specifically for SBE work.
111 DRAFT Screen Based Equipment Examination Request & Report Form 20 May 2003 CONFIDENTIAL
Screen-Based Equipment Examination Request & Report Form
PART A - Worker Details – Employer to complete Family Name: First Names: Company: Location: Employee No: Supervisor: Phone: Facsimile: Account and report to be sent to (Please insert postal address or fax number):
PART B - Examination Report – Health Professional to complete and retuen to employer
Fit SBE work / does not require visual correction.
Fit SBE work / with current prescription.
Current prescription is not suitable for SBE work, therefore there is a need for lenses prescribed specifically for SBE work.
The person requires glasses prescribed specifically for SBE work, because of a visual problem that only arises with SBE work.
I certify I have prescribed glasses that only need to be used for SBE work, as this employee does not need to use glasses for other visual tasks.
Provider Name:
Provider No: Phone:
Provider Signature: Date:
The above section must be completed by the Optometrist prior to employee re-imbursement
PART C – Worker Declaration – Worker to complete I have obtained glasses specifically for SBE work as prescribed by this provider. Attached are:
(a) The original itemised receipt
(b) Health Benefit refund towards cost of glasses (if applicable)
Signature: Date:
DRAFT Screen Based Equipment Examination Request & Report Form 20 May 2003 Page 1 of 1 1.5 Screen-Based Equipment Eye Examination Record for Health Professional
This form guides the health professional in undertaking the SBE examination. The form should not be returned to the employer. The results should be summarised on the Request and Report form (Form 1.4).
113 DRAFT Screen Based Equipment Eye Examination Record for Health Professional 20 May 2003 CONFIDENTIAL
Screen-Based Equipment Eye Examination Record for Health Professional
PART A – Worker Details – Employer to complete Family Name: First Names: Company: Location: Employee No: Date: Is a multi coloured screens used for SCW?
PART B – Examination Report – Health Professional to complete and retain
No Yes 1. Does the worker wear glasses or contact lenses? Specify ______
2. Is there a history of eye disorders? Specify ______
3. External eye examination normal? Specify ______
4. Distance Visual Acuity (Snellen chart) normal? - Right (Fail is 2 or more errors in 6/9 line) - Left Specify ______
5. Acuity at 45cm and 70cm (Times Roman Chart or equivalent) normal? - Right (Fail is 2 or more errors of 20 words of N6 or N12 respectively) - Left Specify ______
6. Oculomotor Coordination (Maddox Wing) Horizontal normal? (fail is >12 prism dioptres of exophoria and >5 prism dioptres of esophoria) Vertical normal? (fail is >1.5 prism dioptres phoria)
7. Colour vision (where multi-coloured screens are used for safety critical work) normal? Ishihara test (fail is 3 or more errors)
If abnormal conduct Farnsworth D15 – Normal? Specify ______
8. For OHN use: Pass Refer
9. Clinical Notes: (In the event of an abnormality being found which requires optical correction, please consider all other optical requirements of the job to be included in the lens prescription). ______Ref: Eyesight testing of users of screen-based equipment. NOHSC 1992
DRAFT Screen Based Equipment Eye Examination Record for Health Professional 20 May 2003 Page 1 of 1 2. Track Safety Health Assessment
2.1 Track Safety Health Assessment Request & Report Form The model Request and Report Form for the Track Safety Health Assessment allows for a greater confidentiality in handling health assessment reports.
The form as follows: 1. Part A: Employer completes PART A, encloses a copy of the Health Assessment Record and forwards to the examining health professional. 2. Part B: Health professional upon completion of the assessment, completes PART B of the form, retains a copy and returns the original form to the employer. Health professional also completes the Health Assessment Record (Form 2.2) and retains it. 3. Part C: Employer completes PART C of the form.
115 DRAFT Track Safety Health Assessment Model Request & Report Form 20 May 2003 CONFIDENTIAL
Track Safety Health Assessment Request and Report Form
DRAFT Track Safety Health Assessment Model Request & Report Form 20 May 2003 Page 1 of 3 IMPORTANT INFORMATION To the Employer
Please complete all relevant details in PART A of the form including: Personal details of the worker Appointment details if appropriate Description of the rail safety duties to be undertaken by the worker Type of assessment requested.
Upon receipt of the Health Assessment Report, please complete Section C indicating the action taken. To the Worker You are required to attend a health assessment as a condition of your employment, to assess your fitness for undertaking rail safety work. The health assessment must be completed by ______in order to ensure that you are able to carry out normal duties. Before attending the health assessment, please: Before attending your health assessment, please:
Take glasses, hearing aid or any other aids required for rail safety work to the appointment
Take all medication that you are currently taking to the appointment or a list of such medications.
Take photo identification with you to the appointment.
The details of your health assessment will remain confidential and will only be reported to your employer in terms of your fitness for duty. The examining health professional may ask your permission to speak to your GP. To the Health Professional You are requested to conduct a health assessment to assess the worker’s fitness for rail safety work in accordance with the details provided in PART A of this form and in accordance with the Guidelines for Authorised Health Professionals Conducting Health Assessments for Rail Safety Workers. Please undertake the assessment, complete PART B of this form and return to worker’s supervisor according to the instructions in PART A. Should the worker be assessed Unfit for Duty please contact the employer immediately so that appropriate rostering changes may be made. Details of the assessment should be recorded on the enclosed Track Safety Health Record form. This record is confidential and should be retained by you, not returned to the employer. The employer’s chief medical officer may contact you for more information regarding the worker’s condition. For more detailed information about the conduct of health assessments for rail safety workers see Guidelines for Health Professionals Conducting Health Assessments for Rail Safety Workers.
DRAFT Track Safety Health Assessment Model Request & Report Form 20 May 2003 Page 2 of 3 PART A – Worker Details – Employer to complete Family Name: First Names: Company: Employee No: Location: Supervisor: Phone: Facsimile: Account and report to be sent to Supervisor at the following address (Please insert postal address or fax number):
Description of Duties Type of Assessment requested: Preplacemnt/\Change of Grade Health Assessment Periodic Health Assessment Triggered Health Assessment (provide reason): ______Drug Screen (pre-placement or change of grade only) Other (specify): ______
PART B – Health Professional to complete I have sighted the worker’s photo ID I certify that I have examined the worker named in accordance with the Medical Standards contained in the Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers and in my opinion they are (tick appropriate box):
Fit for Duty – Meets all relevant medical criteria. Local doctor referral
Fit for Duty Subject to Review – Does not meet all I recommend: medical criteria, but could undertake rail safety work Review at this practice DATE if the condition is sufficiently under control and worker is more frequently reviewed than prescribed Specialist referral under periodic review. Local doctor referral CMO referral Laboratory tests
This certificate is valid to: I recommend the following job modifications: Fit for Duty Subject to Job Modification – Does not meet all medical criteria, but could undertake rail ______safety work if suitable modifications were made to the duties. ______I recommend the following in terms of management and review: Temporarily unfit for Duty Subject to Review – Does not meet all medical criteria and cannot ______undertake current rail safety duties. May return to duty pending improvement in condition, response to ______treatment, confirmed diagnosis of undifferentiated ______illness. I recommend the following in terms of management and review: Permanently Unfit for Duty – Does not meet the medical criteria and cannot perform rail safety work ______in the future. ______
Health Professional Details Name Date: Time: Practice address Phone: Facsimile: Signature: Date:
PART C – Employer to complete on receipt of Assessment Report Action taken as a result of Health Assessment: Job modification (details):______Triggered review (indicate period): ______Next full periodic health assessment (details): ______Redeployment (details): ______Drug Assessment (details): ______
DRAFT Track Safety Health Assessment Model Request & Report Form 20 May 2003 Page 3 of 3 2.2 Track Safety Health Assessment Record The model Track Safety Health Assessment Record is a tool designed to help guide authorised health professionals with the health assessment process. It provides a standard format for recording the results of the health assessment which should then be filed in the worker’s medical history. The completed Health Assessment Record is not to be forwarded to the employer for reasons of privacy. The completed Health Assessment Record is not to be forwarded to the employer for reasons of privacy. The Health professional should summarise the result in terms of fitness for duty on the Request and Report Form
119 DRAFT Track Safety Health Record for Health Professional 20 May 2003 CONFIDENTIAL Track Safety Health Assessment Record
PART A – Worker Details – Employer to complete Family Name: First Name: Company: Location: Employee No: Date:
PART B – Examination Report – Health Professional to complete and retain
1. Medical History (tick appropriate box) 4. Hearing (Audiometry results): No Yes 1.1 Do you have any serious illnesses? 0.5 kHz 1.0 kHz 2.0 kHz 3.0 kHz 1.2 Do you have any difficulty of vision? Right 1.3 Do you have any difficulty of hearing? Left 1.4 Do you have any difficulty walking?
5. Drug Screen (pre-placement or change of grades 2. Neurological/Locomotor: only): ______2.1 Cervical spine rotation Normal Abnormal Comment on any relevant findings detected in the 2.2 Back movement Health Assessment, making reference to the Normal Abnormal requirements of the standard. 2.3 Upper Limbs c) Appearance: Normal Abnormal d) Joint movements: Normal Abnormal 2.4 Lower Limbs a) Appearance: Normal Abnormal b) Joint movements: Normal Abnormal 2.5 Gait Normal Abnormal 2.6 Romberg’s sign (A pass requires the ability to maintain balance while standing with shoes off, feet together side by side, eyes closed and arms by sides, for thirty seconds): Normal Abnormal
3. Vision:
3.1 Visual Acuity Uncorrected Corrected RLRL 6/ 6/ 6/ 6/ IMPORTANT: For privacy reasons, the completed Health Assessment Record Are contact lenses worn? No Yes must not be returned to the employer. It 3.2 Visual Fields (Confrontation to each eye): should be retained in the patient record. Normal Abnormal
DRAFT Track Safety Health Record for Health Professional 20 May 2003 Page 1 of 1 PART E - APPENDICES
121 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Appendix 1: Screen-based Equipment Eye Examination Based on Technical Report of The Study Group on Eyesight Testing of Users of Screen-Based Equipment, National Occupational Heath and Safety Commission, Worksafe Australia, Canberra: AGPS. - v, 8 p., table, 1992, [NOHSC:1004(1992)]
the case of a subject who wears multifocals, care 1. Tests should be taken that the card is viewed through The four eyesight screening tests are: the reading or intermediate segment (as appropriate to the test distance) for the lenses. distance visual acuity; The test should be carried out with the subject near visual acuity; using both eyes. It is desirable that the oculomotor coordination; and illuminance on the test card be 250±50 lux. colour vision. With the Times Roman chart, the subject should be directed to read the N6 block of print at a test distance of between 300 and 450mm, or the N12 2. Distance Visual Acuity block of print at a test distance between 450 and 700mm. If the subject has to see clearly at more Testing for Distance Visual Acuity than one test distance, the test should be carried Using a Snellen letter chart at a distance of 6m out at each test distance. The number of words from the subject. read incorrectly should be counted ignoring mispronunciations. An error is the omission of a If the subject usually wears an optical correction, it word, the substitution of a different word or the should be worn during the test. More than two misreading of any syllable within a word. Two or errors with either eye in the 6/9 line indicates the more errors in a string of twenty consecutive need for a further assessment of the person's words indicates the need for further assessment. visual fitness. The Times Roman test may not be suitable for persons whose native language is not English.
3. Near Visual Acuity With a reduced LogMAR or a reduced Snellen chart the subject should be directed to read a line Testing of Near Visual Acuity of letters depending on the test distance as shown in the table below. The test should be carried out Using either a Times Roman nearpoint chart or a at more than one test distance if the subject reduced LogMAR or Snellen chart at each of the carries out SBE work at several working working distances that are required of the distances. More than two errors in the designated operator. line at any of the test distances indicates the need If the subject normally wears glasses for near for further assessment. work, these should be worn during the test and, in
If the distance (cm) the test and the line of letters from the eyes to the distance (cm) that should be read is work-plane is between: should be: (LogMAR units): 90 to 112 100 0.4 70 to 89 80 0.3 57 to 69 63 0.2 45 to 56 50 0.1 36 to 44 40 0 28 to 35 32 -0.1
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 122 Persons who make one or more errors/12 plates 4. Oculomotor Coordination with the Ishihara test should be further tested with Testing of Oculomotor Coordination Farnsworth D15 test three times on separate days. A pass is two or more correct trials. An Use a Maddox Wing test or its equivalent. incorrect trial is two or more diametrical crossings Any optical correction normally used for near work on the test. should be worn during the test. Persons who pass the Farnsworth D15 test will There is a need for further assessment if: most likely perform satisfactorily with colour coded SBE units. horizontal heterophoria is more than twelve prism diopters of exophoria or five prism diopters of esophoria; and 6. Workers to be tested vertical heterophoria is more than 1.5 prism All persons who work 25% or more of their time diopters. on SBE should be routinely tested: Testing for Sufficiency of Convergence pre-commencement on SBE; Using a near fixation target which is steadily every two years over the age of 40 years, and approached towards the subject's eyes: whenever symptoms indicate a problem may The subject is directed to look at the near exist. fixation target with both eyes.
The tester observes the subject's eyes and 7. Management of Workers Who Do Not notes the point when one eye diverges outwards. Pass the Tests: Those who fail to meet any one of the above If the distance between the target and the standards should be assessed with a view of eyes is greater than 15cm when one eye either bringing them up to the required standard diverges, this indicates the need for further (for example, by optical correction) or obtaining an assessment. appropriate certification that they have adequate vision to meet the standards required for the SBE task. 5. Colour Vision A failure to meet the requirements set out in the Testing for Colour Vision foregoing sections must not be interpreted as Use the Ishihara colour vision test or an meaning that the person is visually unfit for SBE equivalent test. work, but should be regarded simply as an indication of the need for further more Colour vision should be checked where the SBE comprehensive assessment. display is colour coded, and the coding is essential to the carrying out of the SBE task such Referral to an optometrist or ophthalmologist may as use of magenta as well as red and green. be helpful.
123 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Appendix 2: Alcohol and Drug Controls In June 2002 the Transport Act 1983 was Case Study 1: Self Disclosure amended to provide for controls over the use of A rail safety worker advises a supervisor drugs by rail safety workers. The new laws are in before commencing or during a shift that addition to existing laws for alcohol control and rail he/she may be impaired by a drug. oranisation’s policies which necessitate a zero blood-alcohol concentration. They make it an The worker does not start, or immediately discontinues rail safety work and offence to undertake rail safety work while contingency arrangements should be made impaired by any type of drug. by management. All rail safety workers are covered by the alcohol The worker is advised to consult their own and drug controls whether an employee, doctor or the authorised health professional contractor, subcontractor or volunteer. to certify whether they are fit or unfit to perform rail safety work. Company Drug and Alcohol Control Procedures The authorised health professional believes the worker is impaired by a drug, indicates All accredited rail organisations are required to the worker is Temporarily Unfit for Duty and have an adequate safety management system identifies a review date. which includes a drug and alcohol control Management explores available sick leave or program. This should include provisions for alternative duties options for the rail safety conducting preliminary breath tests and worker. preliminary impairment assessments on a rail Case Study 2: Show Cause safety worker where there are reasonable grounds to believe they may have alcohol present A supervisor/manager has a reasonable in the system or be impaired by a drug. belief that a rail safety worker may be impaired by drugs. A protocol describing an approved framework for The worker is required to undertake a rail organisations to develop consistent drug preliminary impairment assessment (PIA) to assessment processes for rail safety work was establish the reasonable belief. Reasonable published in the Government Gazette in June belief is based on a worker’s behaviour or 2002. appearance such as poor mental alertness, poor physical coordination, or unusual The focus of the drug assessment is not on the behaviour. drug itself, as medications and drugs affect people in different ways. Rather, the focus should be on The PIA conducted by the organisation’s the on the impairment and the at risk behaviour of trained authorised officer and provides a show cause assessment. It comprises an the rail safety worker. alcohol breath test and a standardised Each rail organisation should ensure that the procedure for observing behaviour and authorised medical officer is made aware of their appearance and recording results. procedures for assessment and counselling The PIA establishes the basis for a and/or disciplining workers found in breach of the reasonable belief the worker is impaired and policies. the worker is referred to the authorised health professional for an alcohol and drug The main aim of the drug control laws is to raise screen. This may constitute a Triggered awareness within the industry about the risks of Assessment. drugs and some medications for rail safety work. The authorised medical officer classifies the However penalties for non compliance can apply. worker as Temporarily Unfit for Duty pending Failure to do so can attract a maximum penalty of the results of the screening test. $200,000 for a rail organisation. The screening test performed by the authorised A maximum penalty of $1,200 for rail safety health professional in line with the organisation’s workers may occur if they are found to carry out procedures, should be done to the Australian safety work while impaired by alcohol or drugs, Standard, AS 308:2001 Procedures for the refuse to be assessed for drug impairment or Collection, Detection and Quantitation of Drugs of refuse to provide blood or urine for an impairment Abuse in Urine. The test does not need to be assessment. conducted to the evidentiary standard described In most cases, it is expected that drug impairment below and prescribed in the Transport Act 1983. issues will be resolved by internal company Circumstances Involving a Formal Drug processes. Impairment Assessment In exceptional circumstances the rail safety worker may be required to undergo a formal drug
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 124 impairment assessment as outlined in the Act and has published a list of drugs in the Transport Act 1983. This is undertaken as a Government Gazette. result of a serious matter such as in the event of a The list does not contain banned substances. notifiable rail occurrence (for example, collision or Rather, it includes drugs that have been proven to derailment) and where the PIA indicates likely show that given particular circumstances, impairment. impairment may be caused. Its primary purpose The drug impairment assessment is undertaken is in the event of a prosecution, to provide prima by a specially trained Police Officer at a police facie evidence in a Court of Law in proving that a station for the purposes of possible prosecution. particular drug has the ability to cause The worker may be referred to the police by the impairment. Drugs included on the scheduled list organisation’s management, or may be taken into are: custody for an assessment by a police officer attending at the scene of a rail incident. drugs of dependence as defined in Section 4 of the Drugs, Poisons and Controlled The drug impairment assessment comprises Substances Act (1981) and listed in Schedule behavioural tests and usually a clinical screening 11 of that Act test. The police can require the worker to provide blood or urine samples to a registered medical drugs listed in Schedule K of the Standard practitioner or health professional for the purposes Uniform Schedule for Drugs and Poisons. of alcohol and/or drug screening. These are incorporated into the Drugs, Poisons and Controlled Substances Act The results of these tests will not be accepted by (1981) by reference as the Commonwealth a Court of Law unless they have been video taped Standard and are substances which require a and supervised respectively. This is an warning as to their potential to cause evidentiary standard. drowsiness and possible effects on driving or Drugs Declared Under the Transport Act 1983 operating machinery The Act defines a drug broadly as: deleterious substances are included by reference to Section 57 of the Drugs, Poisons any substance - - - that may temporarily and Controlled Substances Act (1981). This or permanently deprive a person of any includes methanol, methylated spirits and of his or her normal mental or physical inhaled solvents, resulting from glue and petrol faculties. It may be a substance in any sniffing. form, whether gaseous, liquid, solid or other and includes material, preparation, This list is of likely interest to an authorised extract and admixture. medical officer and is therefore reproduced below. Further general information about the drug The Minister for Transport has declared certain controls may be found on the Department of substances to be a drug for the purposes of the Infrastructure website at: www.doi.vic.gov.au/publictransportsafety
125 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 Transport Act 1983 ORDER AS TO DECLARED DRUGS I, Peter Batchelor, acting under Section 93(1AA) of the Transport Act 1983, by this Order - (a) declare - (i) each of the substances specified in the Schedule to this Order; and (ii) any natural principle, any natural or synthetic derivative, any salt and any compound of those substances; and (iii) any preparation or admixture of those substances, active principles, salts or compounds; and (iv) any substance included in a class of drug specified in the Schedule to this Order; and (v) any deleterious substance as defined by Section 57 of the Drugs, Poisons and Controlled Substances Act 1981 to be a drug for the purposes of that Act.
The Schedule Acetorphine Cyclohexanone (Ketamine) Dioxaphetyl Butyrate N-Acetylamphetamine 1-Chloro-1-Phenyl-2-Methylamino- Diphenhydramine Acetyldihydrocodeine Propane Diphenoxylate Acetylmethadol Chlorpromazine Diphenyl Pyraline N-Acetylmethylamphetamine Clemastine Dothiepin 6-Acetylmorphine Clobazam Doxepin Alprazolam Clomipramine Doxylamine Amitriptyline Clonazepam Dronabinol (delta-9- Amylobarbitone Clonidine Tetrahydrocannabinol) Amphetamine Clonitazene Droperidol Anileridine Clorazepate Dipipanone Azatadine Cocaine Ecgonine Baclofen Codeine Ephedrine Barbiturates Codeine N-Oxide Ethylmorphine 1,4-Benzodiazepines Codoxime N-Ethyl-1-Phenylcyclohexylamine Benzoxazocines Cyclizine Etonitazene Benzethidine Cyclobarbitone Etorphine Benztropine Cycloserine Etoxeridine Benzylmorphine Cyproheptadine Fenfluramine Bezitramide Cysteamine Fentanyl Bromazepam Dantrolene Flunitrazepam 4-Bromo-2,5- Desipramine Fluphenazine Dimethoxyamphetamine Desomorphine Flurazepam 4-Bromo-2,5- Dexchlorpheniramine N-Formylamphetamine Dimethoxymethylamphetamine Dextromoramide N-Formylmethylamphetamine 4-Bromo-2,5- Dextropropoxyphene Furethidine Dimethoxyphenethylamine Diacetylmorphine (Heroin) Gabapentin (Nexus) Diampromide Gemcitabine Brompheniramine Diazepam Glutethimide Buclizine Diethylpropion Haloperidol Buprenorphine N, N-Diethyltryptamine Harmaline Bufotenine Difenoxin Harmine Butobarbitone Dihydrocodeine Hydrocodone Butorphanol Dihydrohydroxymorphine Hydromorphone Cetirizine Dihydromorphine Hydroxyamphetamine Chloral Hydrate Dimenhydrinate 4-Hydroxybutanoic Acid (GHB) Chlordiazepoxide Dimenoxadol N-Hydroxy-3, 4- Chlormethiazole Dimepheptanol Methylenedioxyamphetamine Chlorpheniramine Dimethindene Hydroxyzine 1-Chloro-1-Phenyl-2-Aminopropane 2,5-Dimethoxy-4- Imipramine 2-(2-Chlorophenyl)-2- Methylamphetamine Ketobemidone (Methylamino)- N, N-Dimethyltryptamine Lamotrigine
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 126 Levocabastine Metopon Phenylpropanolamine Lorazepam Mianserin Phenyl-2-Propanone Lysergamide Mirtazapine Phenyl-2-Propanone Oxime Lysergic Acid Monoacetylmorphine Phenyltoloxamine Lysergic Acid Diethylamide Moramide Pholcodine Mazindole Morpheridine Pimozide Mebhydrolin Morphinan Piminodine Meclozine Morphine Piperidine Derivatives Including- Mecloqualone Morphine N-Oxide Allylprodine, Meprodine, Medazepam Morphinone Phenoperidine and Prodine Meprobamate Myrophine Piritramide Mepyramine Nalbuphine Pizotifen Mescaline Nicocodine Prazepam Metazocine Nicodicodine Prochlorperazine Methadone Nicomorphine Proheptazine Methaqualone Nitrazepam Promazine Methdilazine 7-Nitro-1,4-Benzodiazepines Promethazine Methocarbamol Noracymethadol Protriptyline Methorphan Norcodeine Properidine 4-Methoxyamphetamine Normethadone Propiram 4-Methoxymethylamphetamine Normorphine Propoxyphene 5-Methoxy- N, N-Diethyltryptamine Norpipanone Pseudoephedrine 5-Methoxy- N, N- Nortriptyline Psilocin Dimethyltryptamine Olanzapine Psilocybin Methoxyamphetamines Opium Quinalbarbitone 2-Methylamino-Propiophenone Oxazepam Risperidone (Methcathinone) OxycodoneOxymorphone Secbutobarbitone Methylamphetamine Papaveretum Temazepam Methyldesorphine Pentazocine Tetrahydrocannabinol Methyldihydromorphine Pentobarbitone Thebacon Methylenedioxy-Amphetamines Pericyazine Thebaine 3,4-Methylenedioxy-Amphetamine Perphenazine Thenyldiamine (MDA) Pethidine Thiambutene 3,4-Methylenedioxy-N- Phenelzine Thiethylperazine Ethylamphetamine Pheniramine Thiopropazate 3,4-Methylenedioxy-N- Phenylacylmorphan Thioridazine Methylamphetamine Phenadoxone Thiothixene (MDMA) Phenampromide Tramadol (3,4-Methylenedioxyphenyl)-2- Phenazocine Tranylcypromine Bromopropane Phencyclidine 1-[1-(2-Thienyl) Cyclohexyl] N-Methyl-1-(3,4- Phendimetrazine Piperidine Methylenedioxyphenyl)-2- Phenmetrazine Trifluoperazine Butanamine (MBDB) Phenobarbitone Trimeperidine 1-(3,4-Methylenedioxyphenyl)-3- Phenomorphan Trimeprazine Bromopropane Phenoperidine Trimipramine (3,4-Methylenedioxyphenyl)-2- Phentermine Triprolidine Propanone 1-Phenyl-2-Chloropropane Zolpidem Methylphenidate 1-(1-Phenylcyclohexyl) Pyrrolidine Zopiclone Methylphenobarbitone 1-Phenyl-2-Nitropropene
127 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 COMMENTS AND/OR INQUIRIES
The Department of Infrastructure Safety Branch invites comments on and/or and inquires about the Guidelines for Authorised Health Professionals Conducting Health Assessments for Rail Safety Workers. Comments from health professionals are especially welcome and may address any of the relevant matters, especially the accessibility and usefulness of the Guidelines Use of the attached pro-forma is encouraged to aid the consideration and collation of responses. It provides a list of subject headings derived from the contents of the Guidelines. Respondents may choose to comment in relation to any subject or number of the subjects, but as far as possible, are asked to assign the comments to these headings. The closing date for comment is 29 August 2003. Comments and/or inquiries should be directed to the address shown below.
General Manager Safety Safety Branch Department of Infrastructure Level 6, 80 Collins Street Melbourne, VIC 3000
ATTENTION: Review of Health Assessment Standard
Telephone: 03-9655-6235 Fax: 03-9655-8929 Email: [email protected]
DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003 128 GUIDELINES FOR AUTHORISED HEALTH PROFESSIONALS CONDUCTING ASSESSMENTS FOR RAIL SAFETY WORKERS Stakeholder and Industry Comment
Respondent’s Name & Title
Name of Practice or Rail Organisation
Address
Respondent’s Contact Details Phone: Mobile: Email: Date of Submission
Please provide comments where relevant using the following subject headings 1. Health Assessment Requirements Part A 1.1 Summary of the system of health assessments provisions contained in Code. 1.2 System for selecting and authorising health professionals to conduct health assessments 1.3 Roles and responsibilities of the employers, workers and health professionals. 2. Health Assessment Requirements Part B 2.1 Workers who require a health assessment 2.2 Matching the level of health assessment to each risk category 2.3 Types of health assessments 2.4 Case Studies 3. Rail Safety Worker Task Descriptions: 3.1 Reference section that describes the main tasks undertaken by rail safety workers. 4. Medical Criteria 4.1 Part C1: medical criteria for the High Risk Safety Critical Workers (Categories 1 and 2). 4.2 Part C2: medical criteria for ATTP who work in an Uncontrolled Environment (Category 3). 5. Model Forms 6. Appendices: Further Reference Material
129 DRAFT Guidelines for Authorised Health Professionals Conducting Assessments for Rail Safety Workers 20 May 2003