Evidence-based recommendations for combatting fatigue in EMS
On June 16, 2017, an EMT was criminally charged for the death of her patient. The EMT was driving an ambulance when she fell asleep at the wheel and crashed into a tree. The 55-year-old male patient died on scene. 1
On May 24, 2017, an ambulance crashed in Duanesburg, N.Y. The 64-year-old patient died on scene. News reports suggest that the driver fell asleep at the wheel just moments before the crash. 2
In another case, on Feb. 14, 2017, a 77-year-old male patient was being transported by ambulance between two facilities. The ambulance crashed around 5:40 p.m. local time and the patient died on scene. The driver informed authorities she fell asleep while operating the ambulance.3
Are these just isolated events or indicators of a more widespread problem? Perhaps it’s the latter. In the 24-day period between July 12 and August 4, 2017, three ambulances in the state of Maine crashed and all three events were believed triggered by the driver falling asleep while driving.4–6
In March 2015, a patient being transported via ambulance died following a crash that was precipitated by the driver falling asleep.7
On March 5, 2013, an ambulance crashed and rolled over around 4:45 a.m. on Interstate 90 in South Dakota. The state police reported that the EMT driver fell asleep. 8
Although we don’t have the details of these events, many of which involved reported sleepiness or fatigue, most of us with any experience in EMS can imagine the sequence of events that led to these outcomes and how fatigue may have played a role.
This article will address fatigue in the EMS setting and discuss factors that may contribute to fatigue and how fatigue affects EMS clinicians.
Statements and stories of clinicians from across the country are included. The identities of those interviewed are kept confidential with the use of aliases. I will present recently released evidence-based guidelines for fatigue risk management in EMS and describe how local administrators can adopt these recommendations to begin to better manage fatigue.
My aims for this article are to emphasize the role that fatigue plays in everyday EMS operations, and to stress the compelling need to manage fatigue guided by the best available evidence.
Fatigue is a complex concept and there are many variables that may contribute to EMS clinicians being impaired by fatigue.
Fatigue refers to “a subjective, unpleasant symptom, which incorporates total body feelings ranging from tiredness to exhaustion creating an unrelenting overall condition which interferes with an individual’s ability to function to their normal capacity.”9
Does EMS have a fatigue problem? According to previous research, more than half of EMS clinicians report severe mental and/or physical fatigue.10–12
If the industry has a fatigue problem, are administrators and individual clinicians prepared to address it? This is unlikely, as there’s no known repository of model fatigue risk management programs for EMS operations. There’s little information about different approaches or best practices pertaining to mitigation of fatigue in EMS. Most administrators and managers aren’t prepared to address fatigue in the workplace.
The National Sleep Foundation (NSF) recommends that adults obtain between seven and nine hours of sleep per 24-hour period. Most adults in the United States report seven hours of sleep per night,13 yet one-third report inadequate sleep in the previous 24 hours.14
Most EMS clinicians don’t meet NSF recommendations for sleep and many report inadequate sleep. Half of EMS personnel sleep only six hours every 24 hours with more than half reporting poor sleep quality,12 and 70% report some problems with sleep.15
Many of us have partners or know of colleagues who regularly report getting little or no sleep between shifts. Nancy is a paramedic in the Northeastern U.S. with 15 years of experience as a paramedic. “I get between five and six hours of sleep per day,” she reports. “I am capable of dealing with little rest during the week, yet when the end of the week comes, I’m a zombie.”
She goes on to say, “There are times that I’m up all night on a 24-hour shift, and that just destroys me.”
Jamie is a paramedic with five years’ experience in a busy urban system in the Northeast. She works a rotation of six days on followed by two days off. “I get as little as three hours of sleep between shifts for six days straight,” she says. “It’s dangerous as hell. It’s horrible. There are times when I dread going to work. The adrenaline kicks in, but at the same time you know you’re not up to standard.”
Some in EMS may believe that seven to nine hours of sleep is unnecessary and they can get by with less sleep. This may be true. Every person is different. There’s evidence of individual differences in sleep need and the impact of sleep deprivation on outcomes.16
Nancy describes how people in her organization approach sleep. She says, “People are just different and they need to know their own tolerance levels.” She states that after 15 years, “I’m just now getting to know my own tolerance. I know that I’m getting tired when I start making stupid mistakes or am forgetful, then I know that it’s time when I’m done. When I’m getting short tempered, I know I need to sleep.”
Scott is a paramedic with more than 12 years of experience in EMS and the fire service, most recently as a supervisor in a busy urban EMS system. He believes that most people in EMS would love to sleep if given the opportunity. “We’re not afforded the opportunity to obtain sufficient or adequate sleep. People are just trying to make ends meet. It’s cultural in EMS that sleep deprivation is a part of the job.”
Although many in the profession are severely deprived of adequate sleep, we as a society are just now beginning to appreciate that sleep is vital to health.17 Insufficient sleep has been linked to cardiovascular disease, obesity, metabolic disorder, gastrointestinal conditions, hunger/appetite and changes in emotion.18–23 A single night without sleep can manifest as greater resistance to insulin, which is a key indicator of Type 2 diabetes.22,24 The longer-term impact includes of sleep deprivation includes increased risk of cardiovascular events and other ambulatory sensitive conditions.23
Many EMS clinicians are at increased risk of health problems related to sleep deprivation. More than half report less than six hours of sleep per night.12 Three-quarters of EMS personnel are classified as obese or overweight, and most fail to meet recommendations for exercise and physical activity.25 Half of EMS clinicians report being told by a physician that they have at least one health condition (e.g., hypertension, sleep apnea, breathing problems, diabetes, depression and other conditions).11
Sleep is also important for performance. Hans Van Dongen, an internationally renowned fatigue scientist, led a 14-day experiment with 48 healthy adults to determine the impact of different durations of sleep per night on performance.26 Study participants were stratified into four groups, with Group 1 sleeping eight hours per night, Group 2 sleeping six hours per night, Group 3 sleeping four hours per night, and Group 4 being kept awake for 88 hours straight. The study showed a dose-response pattern, with worsening performance on standardized tests over 14 days. Groups with less sleep showed worse performance than groups with more sleep per night. Notably, the study showed that among participants in the four-hour and six-hour groups, performance over 14 days was equivalent to performance reported in prior studies that tested the effects of just one to two days of total sleep restriction.26
Admittedly, there’s limited research involving EMS clinicians that explore the relationships between sleep, indicators of health and performance. With respect to performance, one study shows that the odds of a medical error or adverse event are twice as high among fatigued EMS clinicians compared to non-fatigued clinicians.11 Most clinicians in this study reported poor sleep, thus the role of sleep hours on performance is unclear.
Thomas is a paramedic with 45 years’ experience in EMS as a clinician, supervisor and educator. When asked if EMS administrators are aware of the issues and importance of sleep deprivation, fatigue, health and performance, he replied, “I think they have no clue and need to be aware of the issues.”
Many would argue that the harder we work, the more fatigued we become. Joe is a paramedic in the Western U.S. He believes fatigue is a problem when “you’re in a system that runs back-to-back calls and have no downtime to complete reports, to just relax, or just get out of the ambulance.”
In general, we have a poor understanding of the relationship between workload and fatigue in EMS.27 Our concept of workload in EMS is fairly simple. Most would operationalize EMS workload as patient call volume. Other tasks may qualify as workload or task load. These might include inspecting, restocking, cleaning, and general maintenance of the ambulance.
Workload may also involve completion of paperwork, such as patient care reports. In some places, such as dual fire/EMS systems, administrators may require multiple tasks be completed during shifts that are integral to the delivery of both the EMS and fire services. Other systems may require a variety of tasks or duties not well described, yet they contribute to a clinician’s workload or shift-related task load. Regardless of how we define workload, the type of work performed by EMS clinicians differs from that of many other shift work occupations and may contribute to feelings of physical and mental fatigue. These feelings may not be comparable to other shift worker groups.
Caring for patients can be fatiguing mentally and physically. Patient care is unpredictable and stressful. The care needs and demands vary dramatically from one patient to the next. An interfacility transport with a patient that requires oxygen and cardiac monitoring isn’t the same workload as an acutely ill patient with multi-system trauma that needs a patent airway, multiple IVs, cardiac monitoring, splinting, bandaging, full immobilization, prolonged extrication and other interventions. The environment, time pressures and other factors create stress. Stress and anxiety can lead to mental fatigue and disrupted sleep.28,29
The nature of EMS work is complex, and the workload is often not easy to describe to others not familiar with EMS. Most would agree that the job of an EMS clinician is stressful and shifts are often filled with anxiety, regardless of call volume. Heightened arousal/awareness during both low- and high-workload periods is common.30
It’s plausible that the ambulance accidents described at the beginning of this article were precipitated by excessive workload, which may have caused fatigue.
Shift duration feels like the elephant in the room when discussing fatigue mitigation in EMS. Extended shifts (e.g., 12-hour and 24-hour shifts) are common.11,31
The industry appears to have three camps of people on this issue. The first camp includes those who are unapologetic about how much they work. They’ll do everything in their power to defend working as much as they want; continuously and without much rest, if necessary.
The second camp includes those who feel they work too much and welcome restrictions on shift duration to ensure adequate rest and recovery, time with family, adequate leisure time, etc.
The third camp might easily be comprised of individuals who really don’t care. They work a regular shift schedule, and if necessary, will work overtime or additional hours to fill in for voids in the schedule, or simply to make some extra income.
The clinicians interviewed for this article differ in their opinions on this issue. Joe from the Western U.S. reports that he’s worked every shift duration imaginable and believes that there’s a strong correlation between shift duration and fatigue.
However, Joe doesn’t believe that limiting shift duration will have a positive impact on fatigue in EMS. “Crews would supplement the lost time with second or third jobs,” he says.
Nancy shares Joe’s opinion. “You can make eight-hour shifts, yet that doesn’t mean you will work less,” she says. “Even though the shifts are shorter, you’ll work more days per week. In EMS, we have late calls and you often have to work beyond the end of your shift. An eight-hour shift isn’t always an eight-hour shift.”
Mike, a paramedic in the Northeast U.S. who describes working more than 48 hours in a row says, “I used to work a 56-hour shift. I would work Tuesday and Wednesday as 24s back-to-back, and then I would work Thursday daylight. I can tell you it was a bad idea. It doesn’t work out well. It’s too long. Between those two 24-hour shifts, if you didn’t have any calls, you were fine; but if you were out on calls half the night, you started the next 24-hour shift with no sleep. It just seemed like a domino effect.”
When asked about the impact of longer shifts on health and safety in EMS, Scott, a supervisor, says, “I would advocate moving away from 24-hour shifts. It throws off your internal clock and really impacts your eating habits. Your mental sharpness definitely fades after so many hours on the truck. Even if you do get sleep during shifts, it’s not battery-charging sleep. If you’re working a 24-hour shift, it’s like working a 32 because you have to recover the next day. These longer-duration shifts and working too much has a tremendous impact on your life.”
Despite the concerns, Scott believes that 24-hour and longer-duration shifts can be beneficial. “It does provide a better living for folks.” Scott advocates for a potential threshold on shift duration. “My push would be to move away from 24s, and go with 16s as the longest shift that people would work. Many people don’t want to work five days a week. The happy medium would be 10-, 12- and 16-hour shifts.”
Others interviewed for this article share Scott’s view that longer-duration shifts are dangerous, yet offer a better lifestyle. Bob, a paramedic from the Midwest, works 24 hours on, followed by 48 hours off. “Your time at home feels vastly more improved [with 24-hour shifts]. Your interaction with family is a lot better. It’s much more enjoyable.”
The details of shift schedules and patterns of those involved in the events described earlier aren’t clear. It’s possible that some may have been working on longer-duration shifts, on back-to-back shifts, or some other pattern of shiftwork. It’s possible that shift scheduling contributed to their reported feelings of fatigue or sleepiness, and preceded the poor outcomes.
Working multiple jobs
The U.S. Bureau of Labor Statistics defines full-time workers as “persons who work 35 hours or more per week.”32 Large numbers of EMS personnel work more than 35 hours per week, and many work 45 hours or more each week.31
Working multiple jobs is common in EMS. The 2016 JEMS salary survey reported that more than half of EMS personnel have a second job to supplement income.33 One study of 119 EMS clinicians in Western Pennsylvania reported that 34% work more than one job.10 A separate study of 511 clinicians from across the U.S. also showed that 34% work multiple jobs.11 Another study of 450 clinicians from across the U.S. showed that 46% work more than one job.34 And yet another study shows that more than 80% of air-medical clinicians have outside employment, and that many start a shift within eight hours of leaving their other job.35
Some in EMS may not work multiple jobs, yet they work multiple shifts back-to-back with limited time off or take advantage of overtime.36–38
“There’s an addictive, compulsive behavior about overtime,” says George, a paramedic in the Northeast with six years’ experience as a clinician.
As a supervisor in a busy urban system, Scott believes that when his crews work too much, it’s detrimental to their physical and mental health. “You don’t get downtime to recover and decompress. This is where burnout originates in EMS. For those who work more than 80 hours a week, it’s almost guaranteed they’ll have a safety event or get sick. I get worried about my crews when they work long-duration shifts; but unfortunately, with the turnover rate and call-offs, it’s a necessary evil.”
Nancy from the Northeast recalls, “I tried to work multiple jobs for a few years, but it didn’t work for me. I just wasn’t able to meet the needs and demands of my different employers.”
It’s plausible that those involved in the tragic events described in the introduction to this article worked multiple jobs. It’s plausible that their accident/event occurred when working their second or third job—or maybe even their fourth job.
Median pay for EMTs and paramedics in 2016 was $15.71 per hour, according to the U.S. Department of Labor’s Bureau of Labor Statistics.39 That means half of paid EMS personnel make less than $15.71 per hour. Many in EMS might argue that low pay contributes to their decision to work multiple shifts or excessive overtime; which can contribute to fatigue.
There are numerous factors that may lead to fatigue in the EMS workplace. I don’t provide an exhaustive review of these factors, nor do I provide a breakdown of the complex relationships between each.
My hope is to awaken those in EMS ignoring the issue and the related risks, deliberately or unintentionally. Poor sleep health and fatigue threaten our clinicians, our patients and the public.
Most administrators and managers aren’t adequately prepared to address fatigue in the workplace. This is evidenced by the news reports cited earlier, the referenced research, and by the comments from numerous EMS clinicians interviewed for this article. There’s credible evidence from studies that shiftwork, workload and other factors contribute to fatigue and fatigue-related outcomes.
Shiftwork isn’t going away.40,41 The burden on EMS administrators, managers and individual EMS clinicians is how to effectively manage shiftwork to protect personnel, patients and the public. Clinicians and employers must work together; after all, fatigue risk management is a shared responsibility between the employer and employee.42
Fatigue Mitigation Strategies
Attention to fatigue and the negative impacts of fatigue have increased in recent years. In 2017, a panel of experts reviewed the evidence germane to multiple fatigue mitigation strategies and formulated five recommendations tailored to EMS operations. The effort originated in 2013, when the National EMS Advisory Council (NEMSAC) issued an advisory that recommended the National Highway Traffic Safety Administration (NHTSA) and federal partners examine the evidence germane to fatigue mitigation.
In 2015, NHTSA solicited applications for a funding opportunity that would create evidence-based guidelines for fatigue risk management in EMS. After a competitive process, the National Association of State EMS Officials (NASEMSO) was awarded the contract. Together with my colleagues at the University of Pittsburgh Department of Emergency Medicine, we collaborated with NASEMSO and led a research team of more than two-dozen investigators and staff in a detailed review of more than 38,000 pieces of literature.
We evaluated the quality of the evidence linked to multiple fatigue mitigation strategies and led a panel of experts through a rigorous protocol for evidence-based guidelines development. The panel of experts was formed based on recommendations from the Institute of Medicine (now referred to as the National Academy of Medicine), and included individuals with expertise in sleep medicine, fatigue science, epidemiology, public safety, risk management, administration, emergency medicine and EMS.43,44
We adhered to the grading of recommendations assessment, development and evaluation (GRADE) methodology, an emerging standard for evidence-based guideline development.45
The expert panel reached consensus on recommendations that addressed five areas: 1) shift duration; 2) access to caffeine; 3) use of napping during shift work; 4) education and training; and 5) use of reliable/valid instruments to diagnose fatigue in the field.
Recommendation #1: The panel recommended that EMS organizations use fatigue/sleepiness survey instruments to measure and monitor fatigue in EMS personnel; specifically, use survey instruments discovered in a recent systematic review that show evidence of reliability and/or validity.46
Not all instruments are created equal, and not all assess fatigue or sleepiness in the same way. Some instruments ask about fatigue in general, whereas other instruments ask about fatigue in reference to the previous month.
Administrators who adopt this recommendation will need to decide which instrument to use. The panel recommended that regardless of the instrument selected, assessments should occur quarterly.47
Assessments should target shifts that administrators believe contribute to fatigued clinicians. These may include extended duration shifts (e.g., > 12 hours) or night shifts. Many administrators may need to test or experiment with different survey tools before settling on the one that works best in their organization with their fatigue mitigation program. Individual clinicians should be prepared to contribute by answering the survey tools completely and truthfully.
Recommendation #2: The panel recommends that EMS personnel work shifts that are shorter than 24 hours in duration.46 The review of evidence showed that shifts 24 hours in duration or longer are unfavorable in terms of fatigue and related outcomes.48 The pattern of favorability toward shorter-duration shifts wasn’t observed in the evidence review when comparing shifts of other durations (e.g., eight-hour vs. 12-hour shifts).48
The panel acknowledged the contentious nature of dealing with shift duration and recognized that, in certain circumstances or in certain locations, longer shifts are necessary.46
The panel also noted that fatigue mitigation shouldn’t begin and end with targeting shift duration. Modification of shift duration as the lone solution or strategy for fatigue mitigation is considered a “20th century tactic.”49,50 Modern-day fatigue risk management incorporates multiple components and is tailored to local needs.42
Shift duration should be part of the conversation, yet it shouldn’t be the sole focus. For EMS organizations and employees that choose to modify shift duration, the panel recommends that shifts be less than 24 hours.46 The panel raised concern for shifts worked contiguously and recommends that administrators consider two 12-hour shifts worked back-to-back as a 24-hour shift. The goal for any EMS organization that adopts this recommendation should be 100% of shifts less than 24 hours.
Recommendation #3: The panel recommends that EMS personnel have access to caffeine as a fatigue countermeasure.46
The review of evidence revealed that few studies have evaluated the impact of caffeine on safety and other outcomes among EMS personnel or similar shift workers.51 The available evidence showed a positive impact on performance and other outcomes. The review didn’t identify an optimal dose of caffeine, yet 250 mg per day has been cited as a low-to-moderate, generally safe dose.52
Providing access to caffeine seems intuitive, and many EMS organizations will have no problem meeting this recommendation. However, creativity and investment will be necessary for others, especially for EMS organizations that deploy ambulances with system status management or dynamic deployment.
In these systems, algorithms or various decision guides will often position or “post” crews on street corners. Clinicians may find it a challenge to access caffeine. Crews may need to prepare coolers of food and beverages to have available in the event they’re posted in a location with limited access to a store or facility with caffeinated beverages.
Administrators may need to consider providing access to caffeinated beverages by stocking coolers on ambulances; especially for crews deployed in remote locations or at night with limited or no access to stores or other resources.
The panel recommends that the goal for any organization that adopts this recommendation should be that 100% of all shifts include access to caffeine. Caffeine should be provided for free or for purchase for all on-duty EMS personnel.
Recommendation #4: The panel recommends that EMS personnel have the opportunity to nap while on duty to mitigate fatigue.46 The review of evidence showed that napping during shifts (i.e., actually sleeping, not just resting) had a positive impact on outcomes.53
Many EMS organizations permit crews to sleep or nap during duty; thus, this recommendation may not be revolutionary for some. However, there are numerous EMS systems that have policies that strictly prohibit sleeping while on duty. These organizations may require a substantial change in policy and culture.
For EMS systems adopting this recommendation, the panel proposed that EMS personnel be provided with the access, opportunity and permission to nap while on duty.47 The panel emphasized that this recommendation should be applied to extended shifts and on overnight shifts. A goal for any organization that adopts this recommendation should be permission given to clinicians to nap while on duty for 100% of extended shifts or overnight shifts.
Recommendation #5: The panel recommends that 100% of EMS personnel should receive education and training in sleep health and the dangers of fatigue to mitigate fatigue and fatigue-related risks.46 This training should occur as part of new employee orientation (i.e., onboarding), and be repeated every two years for all employees.
Findings from a review of diverse education and training programs that include a sleep health or fatigue component show positive results in the weeks following education and training.54
The panel emphasized the need to re-educate and re-train crews every two years given that knowledge and skills decay over time. There’s reason to believe that EMS systems that continuously train and educate EMS clinicians on the importance of sleep health and the dangers of fatigue will have a positive impact.54
The five fatigue mitigation strategies are supported by a review of the best available evidence interpreted for the purposes of mitigating fatigue in the EMS setting.46 There’s no equivalent effort and no other resource that provides a summary of the evidence germane to multiple strategies for fatigue mitigation in high-risk environments like EMS.
Administrators, managers and individual clinicians should invest time in learning more about these recommendations by reading the publications that will soon appear in a special supplement in the peer-reviewed journal Prehospital Emergency Care, which provides more than 1,000 pages of information for the specific purpose of fatigue mitigation in EMS operations.27,48,51,53–62
Opinions regarding fatigue mitigation and how to begin, or what to include in a formal program vary. Nancy believes that a formal fatigue risk management program should require an avenue for feedback and communication between the clinician and administrator. “They won’t say anything if there’s no avenue to provide that feedback,” she says.
Mike, a paramedic in the Northeast, believes programs will differ operationally. “There’s no cut and dry single solution,” he says.
Scott, the paramedic supervisor, believes that more personnel are needed for his program to work effectively. “Put more people on the trucks,” he suggests. “My goal is to get folks to have the luxury to work just one job at 40 hours a week. That’s my dream. Obviously this is impacted by reimbursement and turnover. We need this not only for physical health, but also for mental health.”
George, a paramedic with five years’ experience in a busy urban system, advocates a focus on shift scheduling as part of a comprehensive fatigue risk management program. “The big killers are transitions/rotations in shift schedules in a short window of time. This can impact alertness and fatigue. The rotation is tough for a lot of clinicians. Trying to build in consistency as much as possible.”
Thomas, the clinician, supervisor and educator with 45 years of experience in EMS believes that rest during shifts should be priority. “We’ve created this monster that sleep deprivation in EMS is acceptable.” He recommends, “We create a policy that a truck could be off for an hour during the shift to clean up or even take a break, rest, catch up on charts, etc. We need to schedule ‘regeneration’ time.”
The journey from not having a fatigue risk management program to one that’s woven into the fabric of the organization won’t be easy. The evidence-based guidelines prepared for EMS with support from NHTSA and in coordination with the NASEMSO can aid administrators in their decisions regarding creating new fatigue risk management programs or modifying existing programs and guidelines.
For the first time, administrators can make decisions regarding specific strategies and feel confident that their decisions are informed by a synthesis of the best available evidence. Individual clinicians may also use these materials to question their organization’s approach to fatigue mitigation.
The guidelines for fatigue risk management in EMS doesn’t prescribe a specific approach to fatigue mitigation, and administrators shouldn’t perceive that the guideline is prescriptive or restrictive. It’s not.
There’s tremendous flexibility in how systems may apply the five recommendations and strategies studied. The burden on administrators and individual clinicians is high.
If fatigue is as widespread a problem in EMS as we all perceive it to be, then we must act. Fatigue in the EMS workplace can’t be ignored.
Patients and the public call upon EMS in their moment of greatest need. In those moments, they deserve us at our best, not when we’re “dead tired” and unable to perform optimally.
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