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Train Driving and Diabetes dr paul grant

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This is a copy of the presentation on the occupational health aspects of Diabetes in the context of train driving in the UK. Comparisons are made with the DVLA and CAA guidance / regulations.

Veröffentlicht in: Gesundheit & Medizin
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Train Driving and Diabetes dr paul grant

  1. 1. Train Driving & Diabetes Dr. Paul Grant
  2. 2. Overview • Diabetes • Medication • Monitoring of capillary blood glucose • Risks of incapacity / hypoglycaemia • The Southern Railway trial • OH guidance
  3. 3. Diabetes Group of metabolic disorders characterised by hyperglycaemia TYPE 1 DIABETES TYPE 2 DIABETES
  4. 4. Diabetes medications
  5. 5. Diabetes & fitness to work Glucose toxicity…..complications Can affect fitness to work gradually or suddenly Health effects can be associated with an increased risk of incapacity Disability issues ‘a physical or mental impairment that has a substantial or long-term effect on a person’s ability to carry out normal day to day activities’ Challenging employers
  6. 6. http://www.medtronicdiabetes.com/LPC https://www.youtube.com/watch?v=-FBpluurLBA <iframe width="560" height="315" src="https://www.youtube.com/embed/-FBpluurLBA" frameborder="0" allowfullscreen></iframe>
  7. 7. Current Regulations Train driving licenses and certificates regulations (TDLCR) “Drivers must not be suffering from any medical conditions or be taking any medication, drugs or substances which are likely to cause; a). a sudden loss of consciousness b). a reduction in attention or concentration c). sudden incapacity d). a loss of balance or co-ordination”
  8. 8. Current regulations Guidance on Medical Fitness for Railway Safety Critical Workers GOGN3655 “Modern treatments and risk assessment methods have enabled some insulin treated individuals to perform safety critical roles just as well as other people” “People with diabetes have successfully challenged employers from their jobs simply because they were Diabetic, rather than assessing them on an individual basis”
  9. 9. How may Diabetes affect fitness for work? Diabetes can affect fitness for work gradually or suddenly. It is the sudden, unexpected or unnoticed impairment that is perhaps the greatest concern for workers in safety critical roles.
  10. 10. Type 1 Diabetes
  11. 11. Case Example 1 36 year old female working as a train conductor Diagnosed with Type 1 Diabetes age 28 Long held ambition to become a train driver Generally good glycaemic control. DAFNE positive
  12. 12. Case Example 1 CBG monitoring appeared stable Pre-meal range 3.7 – 6.8 mmol/l 2 hours post meal 5.2 – 8.5 mmol/l Minimal / nil hypoglycaemia, intact awareness No diabetes complications Keen and determined to pursue her chosen career…………
  13. 13. HYPOGLYCAEMIA The main area of concern that is peculiar to people with Diabetes is the risk of loss of awareness, impaired concentration or loss of consciousness while performing their duties as a consequence of hypoglycaemia. Symptoms of hypoglycaemia are due to the release of adrenaline / autonomic nervous system activation
  14. 14. Whipple’s triad Symptoms known or likely to be caused by hypoglycemia especially after fasting or heavy exercise A low plasma glucose measured at the time of the symptoms Relief of symptoms when the glucose is raised to normal
  15. 15. HYPOGLYCAEMIA Symptomatic hypoglycaemia may be mild and easily rectified by the individual, or more severe ie. requiring 3rd party assistance or causing coma or seizure. Insulin therapy and Sulphonylurea medications can predispose to hypoglycaemia because the treatment action cannot be stopped as the blood glucose level falls. Therefore the individual with diabetes on insulin must learn to balance their food intake against their treatment and exercise levels. Rates of severe hypoglycaemia are high but can be difficult to measure so individual assessment is always required
  16. 16. Consequences of Hypoglycaemia Hypoglycaemia covers a wide spectrum of impairment Confusion / inattention Failure of reaction times Loss of consciousness Aggression Negligence Recklessness Joslin 1930’s “Ketoacidosis may kill a patient, but frequent hypoglycaemic reactions will ruin him.”
  17. 17. https://www.youtube.com/watch? v=Qz-Zk8l9tK0 <iframe width="640" height="360" src="https://www.youtube.com/embed/Qz-Zk8l9tK0" frameborder="0" allowfullscreen></iframe>
  18. 18. The impact of hypoglycaemia Quality of life Time off work Falls risk Seizure risk Accidents Weight gain Medication adherence
  19. 19. Recognition, treatment and prevention of hypoglycaemia Regular monitoring of capillary blood glucose levels Clear and retained signs and symptoms of hypoglycaemia Who is at particular risk? Those with recurrent hypo’s Poor symptom awareness Variable eating or exercise patterns Older people Alcohol related problems Incorrect use of DM meds DM complications – renal, ANS Poor diet, variable intake
  20. 20. Avoiding Hypoglycaemia PATIENT Situational awareness Eat regularly Understand early signs and appropriate treatment Readily available Rx Carry ID / Medic-alert DOCTOR Education / reinforcing information Check correct insulin Advise patient to carry glucometer with them at all times and to check regularly 5.0 to drive Review and assessment of CBG records in a meter with a 3 month memory Interventions to help reduce hypo frequency and severity
  21. 21. TYPE 2 DIABETES
  22. 22. General effects Characterised by insulin resistance and caused by multiple factors and strongly associated with cardiovascular disease Can be associated with a deterioration in health due to long term complications such as angina, visual impairment or renal failure Natural history of T2DM is that of progressive decline, so those initially managed with diet / lifestyle and OHA’s may eventually progress to requiring insulin treatment By the time a patient is started on insulin, they have on average, experienced; 5 years of HbA1c > 8.0%, 10 yrs of HbA1c > 7.0% (Brown JP. et al. Diab Care 2004;27 1535-40)
  23. 23. OH Concerns OH Physicians are having to deal with an ageing cohort of unfit railway workers and drivers Having to manage the physical demands of work and highly variable working hours Development of Diabetes and progression of glucose lowering therapies lead to challenges of returning drivers to work Difficult to get a handle on their fitness, especially if they are not encouraged / allowed to self monitor their CBG values Concerns over the time required, the need for education and detailed advice Support is needed from specialist units and this is not always forthcoming
  24. 24. Case Example 2 50 year old man. Train driver for 15 years, diagnosed with T2DM 8 yrs ago Lifestyle & OHA combination not working ‘advised to commence injectable therapy with basal insulin’ S/B OH – only drives a short route < 2.5 hrs twice per day, with some rest at turnaround time but variable start and end times Asked to monitor CBG levels closely, including 2hrs post prandially to assess for hyperglycaemia Deemed not fit to drive at that stage
  25. 25. Case Example 2 Reviewed 3 months later Basal insulin requirements had increased from 10 to 40 units Monitored CBG’s twice daily with a downloadable glucose meter Return to work outline plan; - Not for night shift working - To shadow another driver for several weeks and closely monitor CBG’s to assess and understand profile - To attempt to maintain normoglycaemia
  26. 26. Case Example 2 Further review 2 months later Improved HbA1c 7.1% (previously 8.8%) Better glycaemic control and denies any hypoglycaemia CBG range 4.3 – 13.1 mmol/l Plan is to start retraining / route refresh / clarify rules and competencies with supervised driving only for 4 weeks
  27. 27. Case Example 2 3 months later C/O Peripheral neuropathic type symptoms HbA1c continues to be good 7.3%. Small weight gain Further 3 month review Continuing to monitor as instructed, no hypoglycaemia, working day shifts only, still driving under supervision Produces download of 3 months of data, 5-6 measurements per day, 7-8 pages of information to look through
  28. 28. Case Example 2 Eventually started to drive solo 5 months in had 1 concerning incident, passing a yellow signal and overshooting a red signal by one train length Several months worth of CBG scrutinised On the day of the incident; - Pre-lunch CBG = 9.0, ate a normal lunch - Next CBG test at 16.00 = 15. - Incident occurred at 14.30
  29. 29. Case Example 2 Human factors – driver felt well at the time of the incident - set up for expectation of alternating yellow signals - denies other stressors or inter-current illness - felt that he was able to interpret and respond to glucose values adequately Advised to strictly monitor post lunch, changed lunch routine slightly and intensify monitoring overall Returned to driving
  30. 30. Case Example 2 Continued to drive, no further incidents, good glycaemic control and no hypoglycaemia Seen in secondary care by DSN and advised splitting of basal insulin to help with CBG’s. Information not passed to OH Informed by DSN re: Freestyle Libre Currently working and well
  31. 31. The Southern Railway Trial
  32. 32. What’s the best way to assess train drivers? 18 drivers at Southern, 3 with T2DM, 1 individual with T1DM who wants to become a train driver 3 months of intensive CBG monitoring whilst on and off duty to identify patterns and any evidence of hypoglycaemia Clear criteria about stability of glucose readings – aiming for 90% of values in the range of 5-10 mmol/l. 5.0 to drive. Any hypoglycaemia leading to reduced level of consciousness, impaired cognitive function or seizure leads to immediately being unfit to drive
  33. 33. Overview of results – Subject A Train Driver age 51. T2DM HbA1c 11.4% - commenced on insulin April 2014 Metformin 1g bd, Gliclazide 160mg od, LANTUS 14 units od HbA1c improved significantly to 6.5% CBG monitoring: few intermittent hypo’s, lowest 4.3, very few higher readings. 15 episodes of hypoglycaemia out of 388 readings over 5 months = 3.8% Would deem acceptable because of the gross stability and no hypo’s whilst at work.
  34. 34. Subject B Train Driver aged 51, T2DM, HTN, Hyperlipidaemia HbA1c 11.1%, commenced on insulin March 2014 Improved to 8.0% on a combination of Liraglutide, Lantus 44 units nocte, Metformin 1g bd, Perindopril, Atorvastatin. Good improvement in CBG values; 7 mild hypoglycaemic episodes, lowest = 4.3, but one marked hypo of 1.9 on a non work day. 19 hypo’s out of 180 readings over 4/12 = 10.5% Too great a burden of hypoglycaemia and the 1.9 needs to be explained…
  35. 35. Subject C 33 yr old shunter driver T2DM and Dyslipidaemia High HbA1c 11.5%, started on insulin, came down to 7.4% Meds: Lantus 74 units, Novorapid – variable doses, Metformin 1g bd, Pioglitazone 30mg od, Sildenafil 50mg, Atorvastatin Quite a large insulin dose, very variable CBG readings with lots of hypoglycaemia 2.3 – 4.1 mmol/l Unacceptable Is he getting the CHO counting and dose adjustment right? Are the injection sites okay? Needs DSN review…. Plus associated factors – not fit for role
  36. 36. Subject D 35 year old female train conductor T1DM, insulin Rx Last HbA1c 6.7% Meds: Lantus 22 units, Apidra 10-15 units with meals, Metformin 750 mg tds Good glycaemic control and CBG monitoring, vast majority of readings 5 – 9 mmol/l, few readings of 4.5 – 4.9 whilst off work. Full awareness. 7 episodes of blood glucose <5mmol/L out of 252 readings over 4 months = 2.7 %
  37. 37. Outcome ? Elsewhere there are few, sporadic examples of individuals with type 1 and 2 diabetes being allowed to drive trains No consensus amongst train operating companies It’s likely that more people will want to pursue this Increased burden on Diabetes specialists, OH clinicians, line managers and TOC’s. Supporting the individual / avoiding discrimination / wider safety concerns / train company operational and reputational costs
  38. 38. Comparison with the CAA Increasing number of Pilots with DM on insulin were keen for clarity Specific issues; long distance flights, scheduled periods of duty and rest, changing time zones, safety critical work These can be accommodated for with modern treatment regimes Medical assessment of pilots is based on agreed standards of recognised diabetes management, glycaemic control and the presence / absence of complications of diabetes
  39. 39. Comparison with the CAA Potential hypoglycaemia risk is carefully scrutinised and any episodes of severe hypoglycaemia or significantly impaired awareness will be considered as rendering them medically unfit to fly. Six monthly review assessments include a supportive report from the Pilot’s Diabetes Consultant and retinal screening data Particular attention is paid to serial glucose measurements, looking at variability and stability, plus inspection of operational glucose data in the pilot’s log book. Clear operational protocol with regards to CBG levels
  40. 40. Comparison with the CAA Presently 50 airline pilots, most with type 1 diabetes have been assessed, with the majority (84%) certified as being medically fit to fly All have been on modern, flexible insulins regimes (MDI) or insulin pump therapy Most have now been assessed several times, evaluating flying experience and glucose monitoring data during operational procedure All pilots so far proving highly motivated and disciplined
  41. 41. Suggested OH Guidance 2015
  42. 42. Stage 1 Prior to consideration, following information is necessary; - Type 1 Diabetes – must have been stable for 6 months - Type 2 Diabetes switched to Insulin – stable regimen for 3/12 - Any change in regime / insulin type or new OHA should trigger a further period of observation - A Consultant Diabetologist’s report should be available covering the last 3 years - Record of regular CBG checking (90% values 5-10 mmol/l) - Confirm hypo awareness (? <3.5 mmol/l without symptoms) - Any severe hypoglycaemia in the past year automatically disqualifies
  43. 43. Stage 2 Commencement of train driving can only be undertaken with compliance to the following conditions - The employee should take their CBG at the start of the shift and then every 2 hours (glucometer with non-deletable memory) - It’s the responsibility of the line manager to always check and establish if a blood glucose monitor is being maintained or if there is any other cause for concern. - If there is any lack of clarity, employee is restricted from driving pending an OH assessment
  44. 44. Stage 2 On commencing a shift, the employee should inform the line manager if they are unfit to undertake train driving If at any time during the shift the employee feels hypoglycaemic or the CBG is < 5.0 mmol/l, they should stop driving and inform the line manager Following the above – driving should not take place for 45 minutes after taking hypo Rx (approx. 15g CHO) and a normal CBG > 5.0 mmol/l has been recorded For such a situation, every employee should have an emergency supply of fasting acting glucose readily available
  45. 45. Stage 2 Alcohol should be avoided for the 24 hours before a shift Changes in insulin regime or introduction of a new OHA, the employee should be restricted from driving until review in OH – potentially 2-3 months Should an employee experience a hypoglycaemic episode requiring third party assistance they will cease driving pending a review in OH
  46. 46. Recommendations There should be close collaboration between OH, the TOC, the line manager and HR so the the following responsibilities are clear; - The employee is responsible for their own health, CBG monitoring and reporting to their line manager - A signed agreement with each driver to ensure they understand the significant commitment they will have to make - The line manager is responsible for checking the CBG diary and facilitating the requirements of monitoring from an operational perspective
  47. 47. Recommendations HR and senior management should be aware of the potential impact of having train drivers on insulin on operational capacity It’s also necessary to obtain the commitment of senior management in the organisation prior to the introduction of such an approach for drivers on insulin
  48. 48. Summary Traditionally Diabetes was seen as a barrier to multiple safety critical occupations mainly as due to the risks of hypoglycaemia However, within a relatively short period of time, a significant change in attitude and improved risk assessment – driven by individual determination, enlighted OH and the DDA 2010 – have led to a more flexible and sensible approach to the employment of insulin treated individuals in certain occupations.
  49. 49. With regards to train drivers….. The situation is complex Well controlled patient with T1DM / T2DM on insulin should be allowed to drive This needs to balanced against the operational implications of having a train driver on insulin (eg. arrangements for regular glucose monitoring) Furthermore, the business needs to be able to cope with the rare situation of a driver being temporarily removed from driving duties at short notice.
  50. 50. Worse case scenario Risk of a driver having a hypoglycaemic episode on the mainline
  51. 51. Best fit The optimal soultion would be for any decision to allow train driving on insulin to be taken jointly by all TOC’s, with the support of the Railway Safety and Standards Board and the Office of Rail Regulation.
  52. 52. Many thanks Acknowledgements to; Professor Ken Shaw, Harry Phoolchund, Megan Taylor, Beatrice Cooper, Rupert Hall-Smith, Josie Wilson, Sara Moore & Andy Smith