Thursday, May 10, 2012
Teresa McCallion, EMT-B
In February, the American College of Occupational and Environmental Medicine’s Presidential Task Force on fatigue risk management published a guidance statement intended to assist in the design and implementation of a fatigue risk-management system (FRMS). Occupational and environmental medicine physicians are often consulted by organizations attempting to address fatigue as a risk factor in the workplace.
According to the guidelines, fatigue is similar to other risk factors that can be managed. The document outlines the features of developing a system to manage risks due to fatigue and provides background and references to help develop, sustain and promote a FRMS.
What is a Fatigue Risk Management System?
FRMS is a subset of a safety-management system. The purpose is to create a safer work environment via a more flexible program than the typical hours-of-service regulations often used by airline pilots and long-haul truck drivers.
The Task Force reports that simply regulating the number of hours a person can work doesn’t ensure employee alertness, which can depend on a variety of factors, such as emotional, physical
or medical issues that might interfere with sleep.
Key features of a FRMS
The physicians in the Task Force say the concepts outlined in the research by Moore-Ede contain the essential elements required for a successful FRMS.1 These include the following:
1. Science based: supported by established peer-reviewed science;
2. Data driven: decisions based on collection and objective analysis of data;
3. Cooperative: designed together by all stakeholders;
4. Fully implemented: system-wide use of tools, systems, policies and procedures;
5. Integrated: built into the corporate safety and health management systems;
6. Continuously improved: progressively reduces risk using feedback, evaluation and modification;
7. Budgeted: justified by an accurate return-on-investment business case; and
8. Owned: responsibility accepted by senior corporate leadership.
A FRMS may include the following:
1. Fatigue management policy;
2. Fatigue risk management, including collecting information on fatigue as a hazard;
3. Analyzing its risk and instigating controls to mitigate that risk;
4. Fatigue reporting system for employees;
5. Fatigue incident investigation;
6. Fatigue management training and education for employees, management (and families);
7. Sleep disorder management; and
8. A process for the internal and external auditing of the FRMS that delivers corrective actions through a continuous improvement process.
To function efficiently, a senior manager must be ultimately accountable for the program. However, the authors note that a FRMS works best if everyone in the organization is actively engaged. A culture of trust between management and employees is critical to the success of the program.
FRMS requires that managers take a proactive approach rather than a reactive approach. Minimizing fatigue by forecasting potential fatigue in advance and taking corrective action is found to be more effective than responding to fatigue-related incidents after they occur.
A good start is to establish a fatigue management steering committee
with representation from various stakeholders. Some organizations may choose to hire third-party experts in
One of the most important root causes of employee fatigue, according to the authors, is not shifts, but staffing levels. Numerous studies have shown that staffing levels have an enormous effect on overtime, time off between shifts, length of shifts, number of hours worked per week and number of consecutive days worked. In EMS, like other services that have 24/7 operations, the number of positions to fill on each shift is fixed.
If the staffing is below optimal levels, the only option is for employees to work additional hours or extra shifts to keep the positions filled. The only possible result is increased overtime.
These studies also found that overtime is rarely evenly distributed among employees. It’s important to monitor those who are piling up the overtime. Excessive levels are linked to increased risk of errors.
The investigation into the British Petroleum (BP) Texas City oil refinery explosion that killed 15 and injured 170 found that the control-room operators on duty at the time of the accident were working their 30th consecutive 12-hour shift.
Hiring more employees isn’t the only answer to staffing issues, according to the authors. A careful workflow analysis can help identify other options, such as adjusting staff to accommodate fluctuations in workload and cross-training employees.
No silver bullet exists regarding shift scheduling. The best way to protect against schedule-induced fatigue risk is to use a combination of three strategies: create a schedule that allows for adequate opportunities to recover from the previous shift, train workers to make maximum use of daytime sleep opportunities (otherwise known as naps), and make environmental adjustments and conduct task engineering that maximize alertness on the job.
Although the research suggests that an associated risk of error exists in shifts exceeding eight hours, the same study indicates that breaks can significantly decrease the risks, even for shifts that last longer than eight hours.2
Often, the issue is that what is scheduled and what an employee actually worked are often two different things. It’s important when investigating ways to mitigate fatigue that the actual shift schedules are examined.
Employee training & education
Employers can make every effort to reduce risk, but without the cooperation of the employees, the efforts will be less than satisfying. To assist employees in understanding their role and the importance of the changes they can make, some form of training is required. Because this includes lifestyle modifications , it’s important for family members to understand the need for the change and the processes involved.
The authors suggest that instructor-led training can be more motivational than computer-based training or written materials. Working in teams has also been found to be effective.
Periodic reinforcement is also critical. A regular newsletter, safety meetings or computer-based training can be used, although the authors suggest that handouts that can be taken home to the rest of the family are particularly helpful. Some companies choose to invite family members to the periodic training sessions.
Sleep disorder management
According to the authors, it’s estimated that approximately 38% of the U.S. workforce is fatigued. “Which is consistent with prevalence estimates from many community studies,” the report states. A major cause is sleep disorders. More than 40 million Americans suffer from one of the approximately 85 different sleep disorders.3 The most common disorders are sleep apnea, acute/chronic insomnia, restless leg syndrome and narcolepsy. Interestingly, among those who have been diagnosed, only a small fraction receives treatment.
Part of an effective FRMS is implementing a workplace sleep-disorder management program. This doesn’t need to be extensive. A screening component with a follow-up by a personal physician is adequate. Screening can be done via something as simple as a questionnaire. An examination by a physician is required to make a diagnosis, however. Treatment may include behavior modification, continuous positive airway pressure equipment or medication. Like other diagnoses, compliance is the key to successful treatment.
A sleep disorder management program may seem extreme, but it can be cost-effective. The authors cite transportation companies that have seen a 30% reduction in accidents and an average of $538 per driver per month in healthcare savings during a 12-month period, compared with the previous 12-month period. Retention rates reportedly doubled for the same period.4
The authors recommend a number of environmental changes to the workplace to promote alertness. However, given the type of work conducted by EMS providers, many of the recommendations
There may be little a manager can do to control the amount of light, temperature, ventilation, humidity and noise level within an EMT or paramedic’s normal work environment, but there’s one area that can be considered—ergonomics. Some EMS agencies have found that simply installing arm rests for the front seat occupants of the ambulance can prevent stress on the body, which reduces fatigue.
Allowing for short, but frequent work breaks, can also have an effect on alertness during the course of a shift. Sleep-deprivation experiments have found that physical activity is the most effective method of fighting fatigue. Isometric exercises or stretches are often all that are required to get the blood circulating.
Frequently, the sleep-deprived turn to food for comfort and to remain alert. The authors note that it’s important to eat the right kind of food and maintain a regular schedule. The parent of any 2-year old can tell you the value of a nap. A study of paramedics found that naps work wonders for them as well.5
Researchers reported that naps resulted in “decreased subjective fatigue and improved physiologic function.” To be effective, naps should be brief: 20–60 minutes is all that’s needed.
Individual risk assessment & mitigation
Managers or supervisors must learn to recognize signs of fatigue among employees. To put the responsibility on the employees and avoid what may be seen as a punitive system, some organizations use peer-to-peer safety observation programs. Either way, training is required to help recognize excessive fatigue. Objective assessment tools are available. The organization must also develop a plan for what to do when an employee is too tired to work.
FRMS isn’t simply a set of rules and regulations; it’s a living process. It requires a strong understanding of the shared sense of responsibility—and ultimately benefit—for both the organization and the individuals who work for it. The organization must use data to develop shift schedules that provide adequate opportunities for rest and training. The employees must understand their responsibility to use off-time to rest so they can respond fit for duty.
1. Moore-Ede M. (n.d.). Evolution of fatigue risk-management systems: The “Tipping Point” of Employee Fatigue Mitigation. CIRCADIAN White Papers. In Circadian 24/7 Workforce Solutions. Retrieved April 15, 2012 from www.circadian.com/pages/157 white papers.cfm.
2. Folkard S, Lombardi D, Tucker P. Shift work, safety and productivity. Ind Health. 2005;43(1):20–23.
3. Thorpy M. Classification of sleep disorders. In: Meir H, Kryger M, Roth T, et al., eds. Principles and Practice of Sleep Medicine, 5th ed.
Elsevier (Saunders): St Louis, Mo., 680–693, 2010.
4. Berger MB, Sullivan W, Owen R. A corporate driven sleep apnea detection and treatment program. Chest. 2006;130(suppl):157S.
5. Takeyama H. Effects of a modified ambulance night shift system on fatigue and physiological function among ambulance paramedics.
J Occup Health. 2009;51(3)204–209.
To download the Guidelines, click here.