“Two roads diverged in a wood, and I—I took the one less traveled by, and that has made all the difference.”
The immortal words by Robert Frost are an important reminder that we’re often faced with choosing a path in life—and in leadership. Sometimes when we look back on our choices we don’t like the path we’ve walked, but if we look forward we have a choice: the path others have taken or forging our own path.
In terms of addressing the critical issue of EMS worker fatigue and resiliency, Austin-Travis County EMS (ATCEMS) has chosen to chart its own course in regard to the alarming numbers of mental health issues, accidents, suicides, and loss of medics through separations. A sweeping new set of initiatives are underway, developed through coordinated efforts between EMS administration, the ATCEMS Association, city administration and mental health professionals.
The new initiatives start with a transition from a 48-hour to a 42-hour workweek. This transitions the vast majority of regular unit shifts from a 24 on/48 off for a total of 92 hours per pay period to a 24 on/72 off for a total of 84 hours every two weeks. The schedule was designed after hearing concerns from staff that part of the contributor to fatigue was the fact that when they were off work, they were either recovering from the prior shift or preparing for the next shift. The 72-hour period is more conducive to rest and recovery and should lessen the impact on the circadian rhythm.
Although the shorter workweek seems like a move in the right direction, I was concerned about the concept of continuing a 24-hour shift. A medical workforce study showed that shift lengths in interns and residents of over 16 hours resulted in significant cognitive impairments. The impairment peaked at shift lengths of 24 hours, which showed impairments equivalent to a blood alcohol level of 0.1.1 ATCEMS has addressed this issue by allowing the providers to be immediately placed out of service to allow a period of recovery when they express they feel fatigued. This is an essential safety net to avoid the potential of dangerous fatigue with the new workweek schedule. Currently, there are no “hard stops” built into the safety net; instead, there are surveillance systems that have been developed to help detect fatigue.
The first system was developed in-house by determining workload in real time by tracking unit hour utilization (UHU) live via FirstWatch. This system can be used to determine a correlation between individual UHUs and fatigue. Similar to other benchmarks, a threshold alert can be triggered to indicate a unit has surpassed the threshold and, in the future, may require a programmed break for rest.
On the clinical side, the Office of the Medical Director is utilizing standardized scoring on two different measures. The first is a Standard of Care Index that measures individual charts on compliance with the standard of care, using a 1 through 5 score. This scoring system is similar to models used in hospital-based peer-review systems. The other is a Documentation Index that assesses the thoroughness of the patient care report. These measures will be tracked by individual providers and can be utilized to assess the effect of fatigue on the clinical mission.
ATCEMS is also instituting several physical and mental health initiatives to aid in the battle against fatigue. One year ago, they initiated a peer support program to help providers recover from the emotional aftereffects of tough calls, including post-traumatic stress. They also developed a psychology and chaplain program that helps to provide a menu of options for staff who want to reach out for help from workplace stress that suits their personal needs.
ATCEMS, despite having limited traditional options with proven benefit, has chosen to move forward on an unclear path. This charging forward with the knowledge that the system may be imperfect is what leadership looks like. It displays a commitment to take the issues affecting our workforce seriously, and should serve as a model for the industry to try other techniques, study them, and share the information with the rest of the profession. We’ve seen many great advances in EMS medicine over the past few decades; now it’s time to make advances in how we better care for our workforce! jems
1. Dawson D, Reid K. Fatigue, alcohol, and performance impairment. Nature. 1997;388(6639):235.