Sleep Apnea and Driver Wellness

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Sleep Apnea and Driver Wellness

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• This webcast will cover ...
• Regulatory and Legal Overview,
• Walmarts Sleep Apnea Program,
• Screening, Diagnosis and Treatment of Sleep
  Apnea, and
• Question Answer
• Moderator
• Dr. Gary Petty, President CEO, National Private
  Truck Council
• Panelists
• Bob Rose, Editor Transportation Management, J.
  J. Keller Associates, Inc.
• Tom Moore, Vice President of Education, National
  Private Truck Council
• Rick Foster, Senior Director-Fleet Safety,
  Walmart Transportation LLC

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• Dr. Gary Petty
• President CEO
• National Private Truck Council

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Introduction

• Regulatory and Legal Overview Bob Rose
• Screening, Diagnosis and Treatment of Sleep Apnea
  Tom Moore
• Walmarts Sleep Apnea Program Rick Foster
• Housekeeping issues
• You will be muted during the event.
• Please use the Question feature to text questions
  to the QA Panelist. Well try to answer them
  during the QA period if they are not covered in
  the presentation.
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Gary Petty National Private Truck Council
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Disclaimers

• The content in this webcast is intended for
  information purposes only and should not be
  construed as providing legal or medical advice.
• This is an introductory course and is intended
  to highlight critical safety and compliance
  topics. Time constraints limit our ability to go
  in depth.
• We invite you to ask questions. We will answer
  them throughout todays webcast.

Gary Petty National Private Truck Council
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• Bob Rose
• Editor, Transportation Management
• J. J. Keller Associates, Inc.

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What is Obstructive Sleep Apnea (OSA)

• Apnea is an episode of not breathing
• Causes
• Blocked or narrowed airways in your nose, mouth,
  or throat
• Large tonsils or adenoids or a large uvula
• Overweight, use of certain medicines or alcohol
  before bed, or sleeping on back
• AHI can be used to classify the severity of
  disease
• Mild 5-15 events per hour of sleep
• Moderate 15-30 events per hour of sleep
• Severe greater than 30 events per hour of sleep
• OSA afflicts at least 15 million in the USover
  90 remain undiagnosed FMCSA study indicated
  26 of drivers have OSA

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FMCSRs Driver Qualifications

• 391.41(b) A person is physically qualified to
  drive a commercial motor vehicle if that person
• (5) Has no established medical history or
  clinical diagnosis of a respiratory dysfunction
  likely to interfere with his/her ability to
  control and drive a commercial motor vehicle
  safely
• FMCSA Medical Examination Report for Commercial
  Driver Fitness Determination contains a
  questionSleep disorders, pauses in
  breathingwhile asleep, daytime sleepiness, loud
  snoring

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FMCSA FAQs -- Medical

• Drivers should be disqualified until the
  diagnosis of sleep apnea has been ruled out or
  has been treated successfully. As a condition of
  continuing qualification, it is recommended that
  a CMV driver agree to continue uninterrupted
  therapy (e.g., C-PAP), monitoring and undergo
  objective testing as required.
• A driver with a diagnosis of (probable) sleep
  apnea or a driver who has Excessive Daytime
  Somnolence (EDS) should be temporarily
  disqualified until the condition is either ruled
  out by objective testing or successfully treated.

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FMCSA OSA Activity

• 1988, 1991, and 2008 FMCSA convened Medical
  Expert Panels (MEP) to provide recommendations
  on revising the Medical Examiners Guidelines
  for OSA
• 2009 FMCSAs Medical Review Board essentially
  adopted the recommendations of the 2008 MEP and
  included screening at a BMI of 30
• June 30 - Medical Review Board held public
  meeting updating industry on sleep apnea
• August 29 FMCSA scheduled to meet with Medical
  Review Board and the Motor Carrier Safety
  Advisory Committee to discuss options for
  regulating OSA

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2008 Medical Expert Panel Recommendations

• OSA at certain levels should be a disqualifying
  condition
• Screen at 33 BMI (a BMI of 30 was discussed but
  that would cover 42 of commercial drivers),
  high risk result on Berlin Questionnaire, or high
  risk based on clinical evaluation
• 1-month, 3-month and 1-year conditional medical
  certifications depending on severity of OSA and
  contingent on compliance with treatment program
• Symptoms chronic loud snoring, witnessed apneas,
  daytime sleepiness
• Risk factors advancing age, BMI 28, small jaw,
  large neck ( 17/15.5), small airway, family
  history

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2008 Medical Expert Panel Recommendations (cont.)

• Condition associations Hypertension, Type 2
  Diabetes, Hypothyroidism
• Preferred diagnosis Overnight Polysomnography
• Preferred treatment Positive Airway Pressure
  (PAP)
• Certify after 1 week of use, 4 hours per night,
  70 of nights -- MINIMUM STANDARD
• Alternative treatment Surgery
• Certify after post-op confirmation of success
• Alternative treatment Dental Appliance
• Not acceptable due to lack of compliance
  verification

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• Tom Moore, CTP
• Vice President of Education
• National Private Truck Council

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Health Risks of OSA

• Risks of untreated, sleep apnea
• High blood pressure (2-3x incidence of Non-OSA)
• Heart failure (30 higher risk versus Non-OSA)
• Stroke
• Obesity and Diabetes (negatively impacts leptin
  and grehlin levels)
• Mental Health
• Other
• Versus people without OSA, those with untreated
  OSA have health care costs 2x or 1,336 more and
  their risk of death is 3x greater

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Crash Risks of OSA

• Fatigue-induced motor vehicle crashes occur at a
  rate of 2 to 7x that of those without OSA
• Drivers with severe sleep apnea were 4.6x more
  likely to be involved in a severe crash
• 800,000 drivers were involved in OSA-related
  car crashes in 2000, costing more than 15.9
  billion in damage and claiming 1,400 lives
• CPAP treatment can reduce collision cost by
  11.1 billion per year

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Sleep Apnea-Related Crash Litigation

• Plaintiffs lawyers
• Know the disqualifying nature of sleep apnea
  and the gray area of the regulations
• Will tell a jury that a driver with OSA is
  disqualified and should not have been driving a
  CMV and the carrier was negligent in allowing
  them to drive
• Will make it sound like the driver was asleep at
  the wheel
• Cases
• DOT Physicals can be a shield
• No - Achey v. Crete Carrier Corp
• Yes - U.S. Xpress, Inc. v. Am. Field Serv. Corp
• Sudden-medical-emergency defense can be used if
  sleep apnea isnt diagnosed before accident
• No - Dunlap v. W.L. Logan Trucking Company
• Yes - Slone v. Ibert
• People v. Wilson untreated OSA risks finding of
  criminal reckless homicide

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Financial Impact of Untreated OSA

• 2,727 reduction in health insurance claims per
  treated driver in first year after treatment
• 3,086 reduction per driver in second year
• 528 reduction per treated driver in 2 years of
  short-term disability claims after treatment
• 6.9 day reduction in lost work days per treated
  driver over 2 year period post treatment

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Findings of Key Study on OSA in Trucking

• Findings
• 36 of accidents were fatigue-related (gross
  under-reporting of fatigue on police reports)
• 28 of drivers have OSA but only 15 diagnosed
• 18 of drivers with OSA have a BMI under 30
  (screen all drivers)
• 82 accuracy in online pre-screen questionnaire
• Program
• Pre-screen with online questionnaire, screen all
  drivers, cover all costs, monitor treatment
  compliance real-time for first 30 days and every
  90 days thereafter
• Outcomes
• 12 reduction in preventable accidents
• 63 reduction in the median cost of crashes
• 539 monthly savings per driver in the 12 months
  after being diagnosed
• 60 improvement in driver retention

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So What Do You Do?

• FMCSA has not indicated that it will issue a
  specific regulation on sleep apnea, although it
  is under consideration by the agency
• Standard of Care means models of managing the
  issue have been developed by the industry
• Best approach is to have a company policy that
  addresses the screening, diagnosis, treatment and
  management of sleep apnea in drivers

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• Rick Foster
• Senior Director-Fleet Safety Walmart
  Transportation LLC

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Walmart Fleet Operations

• Fleet stats
• 6,399 Power Units
• 55,000 Trailers
• 7,515 CDL Drivers
• Walmart serves customers and members more than
  208 million times per week at more than 8,600
  retail units under 59 different banners in 15
  countries. With fiscal year 2010 sales of 405
  billion, Walmart employs more than 2 million
  associates worldwide.

Rick FosterWalmart
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Why is Walmart Establishing an OSA Policy

• It is the right thing to do for our drivers.
• Improve overall health of drivers
• Improve alertness while driving / improve safety
• Compliance
• Our belief is that we will get more regulation
  around sleep apnea and we want to be ahead of the
  game.
• We have always tried to be in the forefront of
  compliance issues (i.e. Hours of Service).
• Better selection of suppliers
• Once the rulemaking begins, companies will
  scramble to contract with a supplier and may
  struggle to get the services they need.

Rick FosterWalmart
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Policy/Program Considerations

• Who pays? Company? Driver? Shared?
• Driver wellness program enhancements
• Communication and education of policy,
  expectations, etc. to drivers and applicants
• What type of monitoring program will we have?
• Do we use a national health care provider to
  ensure consistency in our program?
• Does our truck equipment spec have the means to
  support needed medical equipment?
• Will program require more frequent physicalswith
  added costs?

Rick FosterWalmart
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Funding Considerations

• Current program
• Driver covers screening, diagnosis and treatment
  through
• company medical plan which includes
  deductible and co-pay.
• Future plan
• Our benefits group is considering a program
  outside our company funded benefits plan that
  will pay 100 of cost of the program for DOT
  drivers.

Rick FosterWalmart
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Driver Communication Plan

• Roll Out / Communication Plan
• Select pilot location
• Communicate the program to drivers through depart
  group
• meetings, recorded messages delivered over
  the OBC to each driver, and written communication
  to each driver
• Invite sleep center personnel to driver meetings
  to answer technical questions and explain the
  process
• Make the process as convenient as possible for
  the driver
• Remove fear of the process
• Explain the benefit coverage
• Reduce downtime
• Reassure driver of continued certification

Rick FosterWalmart
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Screening for OSA

• Currently relying on DOT examiner to evaluate and
  recommend screening
• Future program will utilize the following
• Utilize questionnaire (Berlin or equivalent) to
  determine immediate testing needs
• Provide ambulatory testing that can be done at
  drivers home or in cab
• Follow up with full PSG, if indicated, to
  determine appropriate treatment protocol
• Central apneas
• Borderline cases
• Goal is to get driver back in the truck as soon
  as possible

Rick FosterWalmart
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Diagnosing OSA

• Screening will identify drivers that should have
  further testing.
• Utilize ambulatory test equipment that allows the
  driver to be tested at home or in cab
• Perform full Polysomnogram if indicated by
  initial testing
• Remove time constraints
• Screen and perform ambulatory test same or next
  day
• Send test results to sleep specialist and receive
  diagnosis and treatment protocol the same day the
  results are downloaded
• Provide treatment equipment and training that day
• Return driver to work with electronic monitoring

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Diagnosing OSA

• Polysomnogram (aka sleep study)
• Brain activity
• Eye movement and other muscle activity
• Breathing, heart rate, and blood pressure
• How much air moves in and out of your lungs
  while you're sleeping
• The amount of oxygen in your blood
• Two methods
• Sleep Centers
• In-home equipment

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Treating OSA

• Select a provider
• Select a provider who is willing to customize a
  program that meets your operational needs and
  offers sufficient coverage to serve all your
  driver domicile locations
• Treatment Program
• Full service - provider supplies screening,
  testing, equipment and monitoring of compliance
• Local provider network - sometimes an option
  based on insurance requirements
• Equipment CPAP, APAP or Bi-PAP
• Utilize auto-set device with 12 volt operating
  system
• Adjusts to patients needs automatically
• Easy implementation in sleeper berth operations

Rick FosterWalmart
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Walmart OSA Results

• Number of drivers currently treated
• Approximately 10-11 of our driver group based on
  a physical survey early last year
• We have had our DOT medical examiners evaluating
  drivers at recertification for 3 years.
• Expected number when program has been fully
  implemented
• We expect to be between 30 and 40 when fully
  implemented due to our job requirements. We are
  mostly drop and hook and drivers normally do not
  load or unload freight.

Rick FosterWalmart
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Question Answer

• Please submit questions to QA
• using the QA tool

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Closing Remarks

• Checkout the archive of past topics at
  http//www.jjkeller.com/nptcinfo
• PowerPoint slides up in 1-2 days
• Recording up in 1 week
• Topics for 2011
• October 12 Driver Discipline and Coaching

Gary Petty National Private Truck Council