It’s estimated that a quarter of North American employees do shift work. Whether it’s manufacturing, hospitality, transportation, public safety or healthcare, shift workers must deal with the unnatural effects of working when their bodies should be sleeping, and managers must consider the safety concerns of workers who are sleep deprived, especially in the life-and-death world of EMS. But do they?
According to the 2011 JEMS EMS Salary and Workplace Survey, barely one-third of all the EMS agencies that responded said they had a formal policy or plan for fatigue management. The majority reported that EMS providers were allowed to work 40 continuous-hour shifts for a maximum of 96 hours, followed by a mandatory four days off.
Although some EMS systems are going to longer shifts—48/92s are being used, particularly in more sparsely populated areas in the western U.S.—others are trying to shorten shifts, with mixed results.
Case study: Austin-Travis County (Texas) EMS
Before 2006, the EMS providers at Austin-Travis County EMS (ATCEMS) all worked the same 24/48 schedule. A third-service system funded by the city and county, ATCEMS covered approximately 1,100 square miles in 12 ambulances a day, including the burgeoning city of Austin. “It was just getting busy,” says ATCEMS EMS Chief of Staff James Shamard. “There was work around the clock.”
The system provided coverage using a combination of dynamically deployed ambulances and some that ran out of stations, adding a demand layer for peak load and an event layer for pre-scheduled events and unscheduled disasters. But the reality was everyone was feeling the strain: Both management and staff became concerned about sleep deprivation.
ATCEMS hired an outside firm, Circadian, to survey the staff’s health, sleep and lifestyles. Some employees kept detailed logs about their activities. Others volunteered to wear activity monitors 24/7 that measured the amount and quality of sleep, including microsleep. Microsleep is a period of sleep that may last for only a fraction of a second or up to 30 seconds. For the sleep deprived, it can occur at any time, typically without substantial warning. It’s extremely dangerous when it occurs in situations that demand one to be especially attentive, such as driving a motor vehicle.
The survey concluded that lack of sleep was beginning to affect many employees’ quality of life. But what really got their attention, says Shamard, was the comparison of fatigue to alcohol intoxication. Studies show that being awake for 18 consecutive hours produces impairment equal to a blood alcohol concentration of 0.05%. Staying awake for 24 hours can cause the same impairments as a person with a blood alcohol concentration of 0.096%.(1) “That was a wake-up call,” he says.
A workforce committee worked with Circadian to develop a new shift plan. “That took [management] out of the crosshairs and allowed us to work side by side with staff,” Shamard says.
Circadian was given a framework based on unit hour utilization. To make sure they were comparing apples to apples, they decided that unit hour utilization would be defined as the percentage of time each ambulance was assigned a task. They also asked for staff suggestions, “and, man, they got millions of them,” Shamard says. Eventually, they landed on a schedule that included four 12-hour shifts over four days, with one day off. “It met our criteria and everybody voted on it,” he says.
Within 60 days, however, the staff wanted to change. The resulting “hybrid schedule” has been working ever since, says Shamard. Each of the busiest units is paired with a low-demand unit. The majority of the staff works two consecutive 12-hour shifts on a busy unit, then a 24-hour shift on the slower unit, followed by four days off. Every week, the schedule steps back a day to rotate employees through weekend shifts. This schedule gave employees a longer period of down time, which they liked. “It’s probably the most equitable shift since 24/48s,” Shamard says.
Although Shamard notes that he “can’t legislate sleep,” he can set limits that manage how much an employee is on the job. The maximum number of hours an employee can work on a busy unit is 14. Once an employee leaves work, he or she can’t come back for eight hours. That includes special event staffing. Regarding shift trades, employees aren’t allowed to work two shifts in a row.
The new schedule distributes the workload fairly and aims to keep employee’s skills from degrading. Employees bid for shifts every six months. Theoretically, employees who work nights would eventually have enough seniority to move to days, if they wish. But with an employee turnover rate of 6.2%, it can be a long wait.
Shamard says they also offer exceptions for special circumstances, such as childcare and school. “The majority use the hybrid system,” he says. To address any issues, the plan is reviewed every two years.
However, Shamard doesn’t recommend having employees rotate between day and night shifts because that doesn’t allow an employee to adjust to either shift. Studies show that the disruption to the body’s natural circadian rhythm is as detrimental as sleep deprivation.
The shift change required that ATCEMS go from a 56-hour work week to a 48-hour week. The agency obtained buy-in from the city and county to maintain the same pay for employees even though they were working fewer hours.
To help with scheduling, ATCEMS uses the automated scheduling software Telestaff. Shamard says they also closely monitor incidents and work-related injuries. He recommends tracking incidents pre- and post-schedule change to note whether changes in work-related injuries and medical errors could be due to the new shift schedule.
The agency also examined other influencing factors from ambulance design modifications to ways to assist employees in addressing lifestyle changes. “We do everything we can to make it easier for them to provide exceptional service to the people of Austin-Travis County,” Shamard says. “We wanted to create a situation where they were as awake and on their game for the first call of the shift as the last call of the shift. That’s our expectation.”
Case Study: District of Columbia Fire & EMS
Attempting to make changes to shift schedules can make a chief unpopular. Just ask District of Columbia Fire and EMS (DC FEMS) Fire Chief Kenneth Ellerbe. His plan to replace 24-hour shifts with a series of 12-hour ones has met with strong opposition.
Ellerbe, who took the position in 2011, cites safety issues during the second half of a 24-hour shift as one reason for shorter shifts. He also says the change will save the city tens of millions of dollars, a figure some firefighters are disputing.
Although there may be some cost savings involved, the real concern, says DC FEMS provider Lt. Robert Alvarado, is the disruption to the employees’ lifestyle. Also at issue is the fact that a certain number of the members live as far away as New Jersey and North Carolina.
Firefighters say that the current schedule for staffing both fire trucks and ambulances, a four-shift system where they work 24 hours and then have 72 hours off, allows them to work fewer days, making long commutes more tolerable and affordable. EMTs and paramedics who aren’t cross-trained as firefighters already work 12-hour shifts that include four days followed by four nights with four days off. All employees work a 42-hour week.
According to news sources, morale in the department is seriously suffering. In January, it was widely reported that more than 100 DC FEMS firefighters turned their backs and walked out on Ellerbe at the end of his “state of the department” speech. Although not all of the firefighters present left, the demonstration was an unmistakable criticism to the Chief’s attempt to make changes to schedules, among other unpopular changes he’s instituted.
Ellerbe outlined his plan for the public in a January 13 op-ed newspaper article. He calls for a three-shift system. All employees will work three consecutive 12-hour day shifts, then three consecutive 12-hour night shifts, followed by three days off. Firefighters would work a 48-hour week, while EMTs and paramedics would continue to work 42 hours. In addition, EMT and paramedic start times would be adjusted in order to provide peak load staffing.
“The result would be more personnel available during each shift, reducing the need to pay overtime to fully staff fire trucks and ambulances during vacations, illnesses and training,” he wrote. “Over several years, the department would be able to reduce staffing through attrition, eventually reaching the optimal number of personnel to meet our service obligations—without closing fire stations or cutting services. “We think the savings from this strategy could exceed $30 million annually by fiscal 2017,” Ellerbe said.
He also notes that the firefighters began working 24-hour shifts starting in 1986. Before that, they worked 12-hour shifts. “There are arguments to [be] made regarding how 24- and 12-hour shifts affect job performance. But working 24 hours straight is too long for employees of the department given our extremely heavy call load,” he writes.
Negotiations are ongoing.
Lessons from Law Enforcement
Many of the same sleep deprivation issues facing EMS providers affect the more than 900,000 sworn law enforcement officers now serving across the U.S. Although law enforcement hasn’t found the answer, it has come a long way in learning what works and what doesn’t, says Bryan Vila, PhD.
Vila is a professor of criminal justice at Washington State University, Spokane, and is director of the Critical Job Tasks Simulation Laboratory in the Sleep and Performance Research Center. He served as a law enforcement officer for 17 years and has authored numerous research articles and four books.
“The police may be seen as a model occupation group for understanding the impact of sleep loss on other first responders, such as firefighters and field emergency medical personnel,” says Vila.
One of the main focuses for law enforcement is traffic crashes. “Slightly more cops die in traffic accidents annually than gun fights and assaults,” Vila says. The key contributor to those crashes, he says, is overtime.
According to the National Law Enforcement Officers Memorial, the primary cause of officers killed in the line of duty in the U.S. for the past 13 years has been traffic-related incidents.2 Vila is currently working on an experimental study, funded by the California Commission on Police Officer Standards and Training and the Office of Naval Research, to examine how sleep deprivation affects officers’ driving performance on the way home after their shift has ended.
Unfortunately, no easy answer exists. “There is no magic shift,” Vila says. “Each shift brings its own set of problems.” He says the better question is: “What is the best way to manage shift work, stay healthy and maintain high performance in our organization?
“It’s not natural to work through the night, like many public responders do,” he says. “What we can do is set a schedule that is as sleep-friendly as possible and manages the risk.” Over the long term, substantial evidence shows medical problems among people who don’t get enough sleep. “It’s like putting the wrong fuel in your gas tank,” Vila says. “The less healthy you are, the less likely you are to get good sleep when you do get a chance to sleep. It’s a vicious cycle.”
Other industries, such as trucking and aviation, have developed computer models to determine shift schedules by predicting fatigue as it relates to impairment. “That’s a good first step,” Vila says. However, there are differences in individual vulnerabilities to shift work. How well someone bounces back from a night shift is different from how well another person bounces back. Further, how well that same person bounces back is different now from 20 years ago.
Sleep quality plays a big role as well. Once the industry began to study police officers, Vila says, it found that more than 40% of employees have sleep disorders. “Even when they were getting sufficient time to sleep, they were not getting enough sleep,” he says. Four different studies are currently underway to understand this phenomenon.
Vila thought he would get more of a push back from the officers once he began presenting his findings and addressing shift work. “Police overtime is a big deal,” he says. Some officers are routinely working more than 100 hours of overtime each month. Part of the hurdle is getting the employees to understand the problem and what can be done to mitigate it. “Everybody knows this is a problem. They know it’s not safe. They know it hurts them,” he says.
For EMS agencies considering changes, Vila recommends conducting some sort of objective measurement. Many law enforcement departments and the Navy SEALs use individual sleep tracking devices, called actigraphs, which employees wear on their arm like a wrist watch for a set period of time. The results are uploaded to the Internet to produce a sleep report that displays an individual’s risk based on the amount of sleep he or she received. “When you make them aware of it, they can be safer, healthier, stronger and a better team member,” he says.
Interestingly, Vila says, the impetus for change may come from outside pressure. Some insurance companies for municipal agencies are starting to offer better rates based on healthy shift management practices. “If that doesn’t do it, the trial lawyers will,” he says. He’d rather see individual agencies regulate themselves, but it will take management and staff working together. “It’s an issue that affects every aspect of a person’s life. It’s got to be a cooperative effort to manage properly,” he says.
Clearly, sleep deprivation is dangerous, but more research is needed to determine which shift schedules provide the best possible solution. Sleep deprivation is on the radar for the National EMS Culture of Safety. “The point of the project is to reframe how we think of things in EMS,” says Sabina Braithwaite, MD, MPH, medical director for Sedgwick County (Kan.) Braithwaite is the EMS committee chair for the American College of Emergency Physicians (ACEP) and chair of the steering committee for the Culture of Safety project. “When providers don’t get any sleep, it not only affects their safety, it affects patient safety,” she says.
The project, a three-year cooperative agreement between the National Highway Traffic Safety Administration (NHTSA), with support from the Health Resources and Services Administration’s (HRSA) EMS for Children (EMSC) Program and the American College of Emergency Physicians (ACEP), brings together an 18-member steering committee representing a variety of national EMS and fire organizations to help develop a national EMS safety strategy. Although the issue was only briefly mentioned in version 2.1, Braithwaite says it has a place in the next iteration, due out in May.
Patrick R. Elmes, EMT-P (ret.), manager of the EMS and disaster preparedness department at the American College of Emergency Physicians and a point of contact for the project, says that the resulting document will not be a manual for safety. “[It] is being developed at the 30,000-foot level,” he says. The idea is to allow the industry to build best practices based on evidence.
More about this issue, including links to resources and a sleep deprivation quiz, is available online at JEMS.com.
1. Falleti MG, Maruff P, Collie A, et al. Qualitative similarities in cognitive impairment associated with 24 h of sustained wakefulness and a blood alcohol concentration of 0.05%. J Sleep Res. 2003;12(4):265–274.
2. National Law Enforcement Officers Memorial Fund press release. Law Enforcement Fatalities Rise Sharply for Second Straight Year
68 officers killed by gunfire in 2011—near decade high.
December 28, 2011. Online at www.nleomf.org/newsroom/law-enforcement-fatalities.html.