Thursday, September 6, 2007
Fire Fighter Medical Standards for Diabetes
Fire Fighter Medical Standards for Diabetes
Toni McGarrah, MSN, NP-C
The National Fire Protection Association (NFPA) develops codes, standards, recommended practices and guides through a consensus standards development process which then gets approved by the American National Standards Institute (ANSI). The initial mandatory medical requirements for candidates for fire fighter were in the 1974 edition of NFPA 1001, Standards on Professional Qualifications for Fire Fighter. In 1987 NFPA 1500 addressed Standards on Fire Department Occupational Safety and Health Program which involved standards for members, as well as, candidates.
In the late 1980s, members from both committees which worked on NFPA 1001 and 1500 came together to develop the first edition of NFPA 1582. This first edition was issued in 1992 and there were subsequent edition in 1997 and 2000. In the subsequent edition, the standards provided an increasing amount of guidance to persons serving as fire department physicians. The 2003 edition further delineated between medical issues of the person seeking to become a firefighter (candidate) and those currently performing the tasks of firefighting (incumbents/members).
The most recent 2007 edition of the standards includes requirements which were added addressing medical evaluation of candidates and members to allow persons with diabetes to enter the fire service or continue to perform essential job tasks if they meet defined criteria. This discussion will be limited to the differences in the qualifications for specific to fire fighter candidates with diabetes.
The NFPA delineates its Medical Condition Classifications into Category A and Category B medical conditions. Category A is defined as “a medical condition that would preclude a person from performing as a member in a training or emergency operational environment by presenting a significant risk to the safety and health of the person or others". Category B is defined as "a medical condition that, based on its severity or degree, could preclude a person from performing as a member in a training or emergency operational environment by presenting a significant risk to the safety and health of the person or others." (NFPA 1582, 2007) In other words, category A is disqualifying and category B might be disqualifying depending on the severity of the condition.
NFPA 1582 2003
In the NFPA 1582 2003 edition the difference between Category A and B Diabetic conditions was simple. Insulin dependent diabetes was a category A disqualifying condition. Also, diabetes not treated by insulin which is not controlled, based on a Hemoglobin A1c (HbA1c) measurement, was also disqualifying. The exact measurement of an acceptable HbA1c value for qualification, however, was not specified.
Category B diabetes mellitus was defined as being “well controlled on diet, exercise, and/or oral hypoglycemic agents”. There was no specification regarding the values that would be used to define the control other than the HbA1c which was mentioned in category A but not defined. As you can see, in the 2003 edition, it was simple but poorly defined. The 2007 edition attempts to clarify the issue.
NFPA 1582 2007
In the most recent edition of the NFPA standards, the information addressing qualifications related to diabetes went from being two paragraphs in 2003 to being two pages in 2007. It begins by discussing the different types of diabetes. Category A includes Type I and insulin-requiring Type II diabetes, as disqualifying unless they meet several criteria. Category B is defined the same as the 2003 edition, as well controlled on diet and exercise and/or oral hypoglycemics, but now includes the detailed criteria used to determine fitness. Although these criteria are listed separately under each category and condition in the 2007 document, they are actually quite similar so we will discuss them together as a comparison.
Type I diabetics need to have shown a one year history of being able to manage their diabetes, including HbA1c level less than 8 when monitored at least twice in the last year. Insulin-requiring Type II diabetics only require a three month history of management but require HbA1c less than 8 twice in the last year. Category B diabetics who don’t require insulin must have a three month history of management and one HbA1c less than 8 during the last three month period.
All three designations (category A Type I, Insulin-requiring Type II, and category B managed without the use of insulin) share the rest of the criteria. They must have a dilated retinal exam that shows no higher grade of diabetic retinopathy than microaneurysm, as indicated on the standard severity scale. Normal renal function based on a calculated creatinine clearance greater than 60ml/min and the absence of proteinuria on 24 hr or random collection. The absence of autonomic and peripheral neuropathy is also required. Both measurements are defined in the document. Last, they must demonstrate normal cardiac function without evidence of ischemia on cardiac stress testing (to at least 12 mets) by ECG and cardiac imaging.
Category A diabetics, both types, must have a signed statement that the candidate meets the criteria. This signed statement must be by an endocrinologist knowledgeable, not only in diabetes, but also knowledgeable of the essential job tasks and hazards of firefighting.
In conclusion, the 2007 edition of NFPA 1582 Standard on Comprehensive Occupational Medical Program for Fire Departments does an exceptional job of clarifying the criteria for qualification when a candidate has diabetes. Medical providers who evaluate firefighters now have an excellent tool to assist in having due diligence in protecting the safety and health of the member and others when determining fitness. These criteria, although written specifically for fire fighters, may serve as excellent guidance for all workers in physically demanding, safety sensitive jobs.
National Fire Protection Association (2007). Standard on Comprehensive Occupational Medical Program for Fire Departments. Retrieved from F:\Medical Resources\Fire Fighter Standards - NFPA\2007 NFPA1582 medical standards-click open document link\Free Access Document.htm
Toni McGarrah, MSN, NP-C
Toni received a Bachelor of Science in Nursing from Rutgers University. She completed her Master of Science Degree in Nursing at the University of Tampa as a family nurse practitioner. Toni is board certified in Family Practice by the American Nurses Credentialing Center.
Toni worked in the emergency room transitioning through her training from an emergency room technician to a nurse practitioner. She spent close to a year in family practice as a nurse practitioner before joining Lakeside. Toni is the primary treating provider for Lakeside’s Tampa office proving a full array of occupational health services for private, municipal and federal businesses. She has developed expertise in knowledge of the fire fighter standards based on her experience with local municipal and county fire departments.
Toni is an active member of both the American Association of Nurse Practitioners and the American Association of Occupational Health Nurses.
For additional resources, visit www.lakesideoccmed.com