BY JAMES L. FLEMING AND SHARON L. BOLLINGER
Firefighting as a profession demands significant physical strength and endurance. To meet these demands, firefighters need to maintain an excellent level of fitness. Also, firefighters are exposed to significant physical, chemical, biological, and psychological hazards, which place significant stressors on them that can impact their overall wellness. This is seen in the high rates of injury, cardiovascular disease, and cancer among firefighters. Maintaining a strong wellness and fitness level can improve a firefighter’s resistance to disease and injury, as well as aid in combating such disease and injury when it occurs.
The International Association of Firefighters (IAFF) and the International Association of Fire Chiefs (IAFC) have developed a wellness and fitness program that provides a model to help firefighters develop and maintain sufficient wellness to meet the demands of their job. In addition, the National Fire Protection Association (NFPA) has developed an industry standard of medical safety for recruits and active firefighters to help protect firefighters and the public. NFPA 1582, Standard On Comprehensive Occupational Medical Program for Fire Departments, includes the provision for a wellness/fitness assessment that is in accord with the IAFF/IAFC Wellness-Fitness Initiative (WFI). Inherent in this program is an in-depth assessment of cardiovascular health, appropriate screening for cancers of risk to firefighters, and self-assessment of overall fitness.
The Phoenix (AZ) Fire Department (PFD) is one of the 10 model programs of the IAFF/IAFC WFI. Our medical surveillance program has monitored the health status of our members and provided medical counseling to improve wellness and fitness for more than 20 years. In cooperation with fire department management and the firefighters’ union, the PFD has developed a program for improved intervention, providing the members with specific goals and recommendations to help maintain appropriate wellness levels. As part of this, we monitor and provide guidance and support on various preventive health issues, including obesity, hypertension, cardiovascular tone, and diabetes.
TIERED MEDICAL PROGRAM
In 2003, we recognized that although firefighters were maintaining an overall excellent level of musculoskeletal fitness, multiple issues in their wellness level continued to be noted in their annual assessments. In collaboration with PFD management and IAFF Local 493, as part of a formal renegotiation by objective (RBO), the PFD Health Center developed a program that would look at specific wellness health parameters, called the Tiered Medical Program. During the assessment phase, we discovered that our members had issues with several preventable health conditions that could be improved with direct intervention.
For this program, we identified four elements to specifically monitor: body fat measure to assess obesity; blood pressure to assess hypertension; metabolic equivalent testing (METs) measured during cardiovascular stress testing, to assess cardiovascular tone; and blood glucose and HbA1C levels to assess diabetes. We used industry standards such as NFPA 1582 as the basis for determining whether a member can safely perform his operational job requirements under this program. When there was no standard available, as in the case of obesity, we used medical consensus to determine appropriate levels. A fifth element was originally identified, pulmonary function changes. However, after three years of evaluation, we found no members who fell into a Tier 3 or 4 level secondary to this element, and it has been dropped from the program.
In 2004, we conducted a yearlong collaborative RBO effort with management and union to develop this program, fostering complete buy-in from both sides. The program was designed as a medical wellness program, and like the WFI, was not meant as a punitive tool. The entire goal of this program was to identify health and wellness issues and assist the firefighter in managing those issues. This program was incorporated in 2005 as part of the firefighters’ annual medical evaluations. In addition, we also informed all firefighters of this program through written and video presentations. The first year was intended to introduce the program to the members. All identified individuals with issues received guidance, but no other actions were taken at that time. Starting in 2006, the program was increased to provide directed intervention for those individuals identified. The Tiered Medical Program has now matured with full awareness among our firefighters, who are able to use their medical evaluations to assess where they stand.
Table 1 describes the elements of the program and the current measurement levels. Firefighters are encouraged to maintain their level of wellness at Tier 1. Tier 2 is designed to act as a buffer to identify members who are below Tier 1 level but do not need medical/wellness intervention other than counseling and guidance. Tier 3 was established to identify members who still meet NFPA 1582 requirements but who are showing health and wellness changes that require intervention. Tier 4 is designed to identify those individuals who have health changes that do not meet current NFPA 1582 criteria. Note: There is currently no NFPA 1582 provision that addresses obesity. Therefore, we only consider a member as Tier 4 for obesity if he also exhibits at least one other comorbid health issue.
In the first year (2006), we identified 86 individuals who fell into Tier 4 and another 235 individuals who were at Tier 3. The majority of these individuals had issues either with their cardiovascular tone or their level of body fat. This represents overall about 20 percent of our workforce. Most individuals (about 70 percent), after becoming aware of their issues, were able to improve their Tier status by at least one level within three months.
By 2008, the overall rate for Tier 3/4 dropped to 10 percent. In 2009, the rate was less than three percent, with only 22 members in Tier 4 and 26 in Tier 3. This shows a significant improvement for all of our fire members. Figure 1 shows the progression from 2006 through 2009.
|Figure 1. Tiered Medical Program: Percentage of Personnel in Each Tier by Year|
|Source: Tiered Medical Program, Phoenix (AZ) Fire Department Health Center|
We feel this program has shown that close attention to health and wellness parameters, along with timely intervention and positive motivation, dramatically improves firefighter health. The marked decrease in the percentage of members in Tiers 3 and 4, along with the improvement of members into more healthful patterns within reasonable time frames, clearly shows the benefits of this program. We again emphasize that this program is in no way punitive. It identifies health and wellness issues and assists members in finding ways to improve.
The program has not matured without issues. The biggest issue is maintaining this as a wellness program, designed to identify and assist those with problems. There has been a strong push in some areas to make this a fitness program, which we do not support. There is a strong fitness component necessary to maintain true wellness, but our goal remains to help firefighters individually maintain improved wellness.
Also, there is small number of our members who have developed morbid conditions that are not likely to improve. However, we continue to work with these members to maintain good control of their disease issues, maximizing their overall function.
Our program still needs improvements. A large number of our members show blood pressure values (when they come in for annual assessment) that place them in a prehypertensive region. A recent review showed that about 39 percent of our members had at least one blood pressure reading of 135/85 or greater. We are looking to adjust the values of our Tier program to better identify and help members monitor their blood pressure.
Also, we have noted through the WFI annual assessments that a large number of members have elevated lipids. We know this increases their risk for developing cardiovascular disease, and we do counsel on ways to help manage this issue. However, placing measurement of lipids into the formal Tier program may help increase awareness and support better management of control by members. This will be part of the next suggestion to the management/union RBO committee to improve our program. Like the issue with obesity, there will be no Tier 4 level unless there are also other significant comorbid conditions.
JAMES L. FLEMING, D.O., MPH, has been the medical director of the Phoenix (AZ) Fire Department Health Center since 2001. He received his osteopathic doctorate from the College of Osteopathic Medicine and Surgery and master of public health degree and a fellowship in occupational medicine from Johns Hopkins University. Fleming is a member of the American Osteopathic Board of Preventive Medicine in Occupational and Environmental Medicine, from which he received his Board Certification in 1986. Fleming served as the United States Army Surgeon General’s consultant in occupational medicine until his retirement in 1998. From 1998 to 2001, he was assistant professor and director of occupational medicine at the Des Moines University-Osteopathic Medical Center. He is a member of the National Fire Protection Association 1581, 1582, and 1584 Task Groups and the IAFF/IAFC Wellness-Fitness Initiative Technical Committee.
SHARON L. BOLLINGER, RN, has been clinical nurse manager since 2007 for the Phoenix (AZ) Fire Department Health Center, where she began work as an occupational health nurse in 1998. She received an associate degree in nursing from Parkersburg (WV) Community College and her bachelor’s degree in nursing from Florida State University. Previously, she worked as a staff nurse on a medical/surgical floor and as a cardiovascular intensive care charge nurse for more than 15 years. Bollinger is a member of the Arizona Valle del Sol Association of Occupational Health Nurses.
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