It’s 4 am. You and your partner are driving back to the station after a call.
You stop at a red light and it appears that he’s falling asleep.
Your partner tells you that he’s been up since 4 am the previous day because he had a sick kid at home. Do you go out of service or just “power through” as your shift is over in four hours?
Like many organizations, Montgomery County Hospital District (MCHD) EMS and Williamson County EMS (WCEMS) systems invest heavily in the safety of our employees. Both agencies are third-service EMS systems located in a suburban environment just outside of major Texas cities. Both enjoy low turnover rates, exceptional safety records, and community support. Both believe that EMS employees deserve a healthy work-life balance that will allow them to remain in the EMS industry over the course of an entire career. Both agencies have been working on ways to balance the safety of our employees with our staff’s preference to maintain some 24-hour shift schedules, in addition to shorter duration shifts which cover the daily “peak” demand times.
Although it’s well established that the leanest of EMS systems don’t need underutilized 24-hour overnight shifts, both MCHD and WCEMS exist in suburban areas where the availability of ambulances located in EMS stations across the county is an expectation of the local citizenry. Collectively, we sought to balance three main factors: 1) adequate resource availability; 2) employee safety; and 3) employee satisfaction. Although each EMS system works to protect our employees in a unique way, we’re proud to have worked collaboratively to improve the safety of our EMS systems using data and objective measurements.
Before MCHD EMS could implement fatigue management guidelines for field providers, they had to develop a better way to monitor when—and for how long—a unit was utilized.
The MCHD Approach: Dashboards & Alerts
In early 2017, MCHD created the Business Analysis Unit (BAU), a department dedicated to organizing and interpreting several internal data sources and work closely with EMS command staff to provide unprecedented insight into the organization. One of the first goals was to develop a way to monitor unit hour utilization for all on-duty ambulances. The purpose was to ensure that field employees were safe, and to establish guidelines and metrics for determining when and where a new ambulance needs to be added to the system to reduce the workload on other units.
The first hurdle was that no retrospective data existed. The system used by the MCHD communications center had no native way to track when—and for how long—a unit was utilized. The first version of the Unit Hour Utilization dashboard used automatic vehicle location tracking data from within the dispatch system, but couldn’t effectively consider when units were utilized for system status management outside their home station coverage area.
The first version of the MCHD unit hour utilization dashboard used incident duration to determine utilization and contained no real-time tracking for crew fatigue level.
It was quickly agreed by the BAU and EMS command staff that units being moved out of their station for system status management coverage need to be considered as utilized, as well as units driving back to their station following a completed transport. Due to the geography of Montgomery County, some units could regularly have at least a 30-minute return trip to their station.
The next steps in the plan were to:
- Figure out how to track utilization in real-time;
- Determine what deemed a unit to be over-utilized/unsafe for the on duty crew; and
- Create guidelines for what to do when a unit/crew reaches that threshold.
Live Fatigue Monitoring
Leveraging previous experience with SQL databases, the BAU developed a real-time monitor that continuously reviewed the EMS system and organized the data into a Tableau dashboard for the communications center and field supervisors to view. This dashboard allowed dispatchers and supervisors to quickly see the status of all 24-hour shift units.
Due to various scheduling options offered at MCHD, fatigue monitoring is currently only implemented on shifts that are 24 hours in length. All 24-hour shift units have a dedicated “home station,” but the shorter “peak” shifts are developed specifically to provide system status coverage throughout the county during hours of high call volume. These shifts vary in length between eight and 14 hours and are mostly scheduled to be active during the daytime.
The new dashboard allows for real-time monitoring of units and employees, and is color-coded to quickly determine personnel utilization and system demand.
The fatigue dashboard is paired with a proprietary alert monitor developed by the MCHD IT department that allows the dispatch center to receive custom alerts not built into the computer-aided dispatch system. This allows the fatigue monitoring system to alert the dispatchers when a unit or employee reaches the over-utilization threshold, instead of relying on the dispatchers to watch the dashboard for changes.
A unit is considered “Busy” if assigned to a response, assigned to cover a station or post other than the home station, or outside a geofenced area near the home station. This means units returning from the hospital, and assigned to return home, will still be considered utilized until reaching the home area. The colors on the utilization dashboard progress from yellow to red, based on the length of utilization. EMS command staff and the BAU established five hours as the threshold for over-utilization.
A unit is considered “Resting” if not assigned to a response, and within a specific geofenced area around their station or placed out of service for downtime anywhere. As a unit returns to resting status, the busy timer doesn’t reset to zero until being in resting status for at least 45 minutes. This accounts for time to restock the ambulance, finish patient reports, and attend to other duties that need to be completed when returning to the station.
In its current form, the system only allows for downtime for over-utilization to be taken while at a hospital following the completed transport of a patient. This gives the crew time to catch up on patient reports, eat food without interruption, and/or take some time to rest before returning in service. The obvious limitations to this are when a unit is eligible for downtime in the early morning hours, when the options for food at the hospital are typically limited or non-existent, and sleep is the highest priority.
Future plans for the fatigue monitoring system include dynamic downtime availability changing based on the time of day, and utilization of the downtime while at station to give the crews time to sleep.
System Demand Monitoring
The United States Census Bureau lists Montgomery County, Texas, as one of the fastest growing counties in the country, and the call volume trends for EMS reflect this growth. MCHD EMS command staff and the field crew-driven deployment committee meet quarterly to review call volume and response trends and make decisions on where to place new units, and what shift hours would make the biggest impact on the system.
With the addition of the fatigue monitoring system, the deployment committee could now see utilization of units and determine which were at the biggest risk of errors due to continuous high overnight demand. The deployment committee and EMS command staff established a goal of at least 6.5 hours of rest for a particular unit, averaged monthly. When a unit failed to meet this target, the BAU investigates the specifics of their responses during that time period, and the deployment committee makes a determination if an additional unit is necessary.
After the fatigue monitoring system was developed and live for EMS command staff and the dispatch center to review, guidelines had to be developed for procedures to follow for over-utilization alerts generated by the new fatigue monitoring system, as well as empowering the crews to know they have options when they don’t feel safe, and what to look for in their partners. The process for developing and implementing the new guidelines was a coordinated effort between EMS command staff and vetted by a number of field employees. The MCHD guidelines are included at the end of this article. (Click here to jump to the guidelines.)
The WCEMS Approach: Training, Assessing and Scoring
Leadership at WCEMS wanted to look at ways to assess and manage fatigue so that our caregivers are safe while providing care and going home. Just like MCHD EMS, we’re committed to raising awareness of fatigue, helping our caregivers know how to measure their own fatigue levels, and providing them with skills and strategies to manage fatigue.
Unfortunately, until recently there wasn’t much information on fatigue and EMS. Most fatigue information was related to other industries. Although this is helpful, EMS is somewhat unique in that many organizations have 24-hour shifts, but it’s not realistic to expect caregivers to be up and working for 24 hours. As leaders in EMS we need to plan for our caregivers to have downtime to rest and sleep.
We took an approach that measures prior sleep-wake cycles. Lack of sleep, or slept debt, occurs when a caregiver doesn’t achieve adequate sleep. This debt can result in impaired performance, reduced alertness and higher levels of fatigue. Sleep debt can only be corrected with sleep. The South Australian (SA) Ambulance Service and Government of South Australia have done an excellent job of developing a comprehensive fatigue risk management system that’s based on the available science. We modeled and adapted our system using their best practices. We also looked to information and research done by Circadian, a leader in fatigue risk management.
We took a holistic approach with our fatigue risk management system. We looked at different areas that affect sleep and alertness, not just focusing on a policy. This brought up some important questions:
- Do we have sufficient staffing levels?
- Are we asking our caregivers to work excessive amounts of overtime to keep ambulances in service?
- Do we provide our caregivers sufficient sleep opportunities while on-duty?
- We need to ensure our caregivers have ample time between shifts to rest; we need to control the number of hours they are at work.
- Have we provided training to our caregivers and their families on the lifestyle of shift work?
- Have we provided training to our caregivers on sleep disorders, and how to obtain sufficient sleep?
- Are sleeping quarters at the station conducive to sleep?
- Do we have a system in place that empowers peers to call out fatigue?
- Do we have a system in place that allows caregivers to measure their fatigue?
- Most importantly, do we have a culture that supports all these initiatives?
First, we had to dig into the data: How many hours a year do we need to cover? Do we have enough extra staff to cover this time off or are we depending on overtime to cover this time off?
The typical field provider at WCEMS utilizes 370 hours of time off in a year. This includes vacation, sick time, jury duty, FMLA and bereavement leave. We took 370 and multiplied it by the number of field providers. This gave us the number of hours that we needed to cover. We utilize float paramedics and extra overtime to cover time off. It’s important to make sure to not rely solely on overtime to cover time off, otherwise you will create fatigue issues. We discovered that when fully staffed, we have a sufficient number of float medics. Because of this, we demonstrated that we weren’t asking caregivers to work excessive amounts of overtime to keep ambulances in service.
In our calculation for adequate sleep opportunity we define “adequate” as eight hours of sleep. As many agencies do, we encourage our staff to nap, so these eight hours can be accumulated at any time during the entire 24-hour shift. Looking at our call data volume data, we had 2-3 ambulances that were at or approaching the threshold, but we were still able to provide sufficient sleep opportunity.
Where we were failing was on the training component. We had never provided training to our staff about sleep-related issues. This is a key component of a fatigue risk management system. We wouldn’t expect our caregivers to provide a high-risk medical procedure without training, however we were expecting them to function on a 24-hour shift without education.
We developed education and implemented training based on best practices. Our education covered how our human body normally operates, the health effects of working during nontraditional hours, as well as understanding fatigue: what causes it, sleep disorders resulting from fatigue, how to monitor for fatigue, and understanding sleep stages, napping, diet, nutrition, family and social issues caused by shiftwork, alertness factors, and our specific fatigue risk management system. Training was broken into three different modules and delivered over three months. We provided the training via distributive education.
In addition to educating providers on best practices to manage fatigue, Williamson County EMS also provides training to the families of caregivers.
The other aspect was educating the families of our caregivers. We often hire caregivers who are new to shift work, and so their families aren’t accustomed to shiftwork. We’ve started to provide some brief education to family members during our new member orientation to help with this issue.
We continue to make necessary changes in stations to make sure bedrooms are conducive to sleep. This is a slow process—you can’t just change the structure of a building. We’ve taken some small steps such as purchasing blackout blinds for bedrooms. This is an ongoing process and will take time to get where we want to be on making the station environment more conducive to promoting healthy sleep.
Fatigue Assessment Tool/Score
Our biggest challenge was developing an objective tool to measure fatigue, and then what to do with the objective score. We quickly discovered there was no standard tool to utilize. Luckily the SA Ambulance Service had developed a fatigue assessment tool. This became the backbone for our tool.
With a tool that provides a score in place, we then had to make decisions on what to do with the score. Again, we turned to the SA Ambulance Service as a model. You will see in our guideline the different levels and actions we take for each level.
As with any new initiative we’re constantly monitoring the fatigue assessment tool to make sure it’s effective and being utilized. This is a huge culture shift in our organization, so it will take time for all caregivers to feel comfortable utilizing the assessment tool. It’s been utilized successfully several times.
Think back to the scenario at the beginning of this article. What if we changed it to, “your partner showed up to work and told you that he just drank four beers in the past hour, would you let him work?” Twenty-four hours of sleep deprivation is equivalent to the same level of impairment after drinking four beers.
As leaders, we need to recognize the risk that fatigue presents to our patients, caregivers and citizens. We need to take steps to ensure our caregivers are safe to operate while on duty and make it back home to their families at the end of their shift. As caregivers, we need to speak up when we are fatigued. The most important thing is that we must address fatigue industrywide and work together collaboratively to solve the problem.
Although not a suitable replacement for rest, consumption of caffeine-based drinks can help to mitigate the risks of provider fatigue.
Purpose: To ensure a safe and well-rested workforce are providing optimal clinical and operational service to the citizens served by MCHD EMS; provide employees optimal duty/rest cycles; reduce unnecessary overtime costs.
Guideline: Live Fatigue Monitoring
Excessive Unit Demand
MCHD shall continuously monitor rest opportunity for each unit in the EMS system. Units that reach five hours of consecutive demand will be offered a 30-minute break after completing their assigned response either at or immediately nearby the destination of their last transport. If the crew chooses to take their 30-minute break at a location not at the hospital, they will be effectively in “first available” status and will be dispatched to any ECHO level response that they’re closer to than the next due unit. Alarm shall contact the crew via radio and offer the 30-minute break, assuming the EMS system is not at or below critical levels as outlined in the comprehensive response plan.
Excessive Individual Demand
MCHD shall also continuously monitor the hours worked and demand of each individual employee in the EMS system. Employees working greater than one shift may be required to have a rest period before being allowed to work overtime or additional shifts, based on the fatigue risk management dashboard. Employees requesting overtime hours in exception to the established maximum hours worked must not be listed on the excessive individual demand dashboard in order to be allowed to work additional hours.
Nighttime Fatigue Monitoring
Given that the majority of sleep-related errors and vehicle crashes occur between the hours of 2300 and 0700, MCHD’s deployment committee shall review on a quarterly basis the overnight rest opportunity trends for all 24-hour shifts. The goal shall be to allow an average of 6.5 hours of rest opportunity for each 24-hour unit. This shall be measured as the amount of time each unit spends at their home station between the hours of 2200‐0700 hours each night, and will begin counting 45 minutes after returning to quarters to allow for response related duties such as restocking and completion of patient care records. Units with less than 6.5 hours of rest opportunity will be considered at risk, which will prompt the addition of more 24-hour or nighttime Peak ambulances to ensure staff are allowed ample rest opportunity to perform their duties safely.
As noted in FOG 07‐04.02, employees are encouraged to take naps while on duty after morning unit and station duties are completed, particularly in the afternoon hours. Further, employees are encouraged to watch out for one another and identify instances where they or their partner needs a break or a nap.
Recognizing & Reporting Fatigue
If at any time in a shift an employee feels they or their partner need a nap, they should immediately contact their supervisor to request a safety nap at their own station or a Safe Sleep Room, whichever is closer. If an employee needs to take a nap at the end of their shift, they may either do so at their assigned station or at a safe sleep room, with notification of their District Supervisor.
Individual Fatigue Symptoms that should trigger a fatigue mitigation strategy
- Desire to sleep;
- Involuntary napping and micro-naps;
- Abnormal driving behavior/performance;
- Reduced vigilance;
- Delayed reaction time;
- Drowsy/decreased alertness;
- Poor judgement;
- Decreased motor skills;
- Reduced visual perception;
- Difficulty focusing;
- Headache; and
- Short-term forgetfulness.
Safe Sleep Rooms
Each MCHD regional station (10, 20, 30 and 40) and the Alarm center have one room designated and outfitted as a “Safe Sleep Room.” These rooms are designed for crews to use during or after shifts or when the need for rest is identified via self or peer fatigue recognition. Employees who are fatigued are encouraged to utilize safe sleep rooms before driving home if they weren’t able to rest during their shift. Safe sleep rooms shall be equipped with blackout panels/curtains, white noise machines, and will have the ability to disable any station alerting (e.g., tones, lights, etc.) equipment for that room using the U.S. Digital Room Remote.
Mitigating Fatigue in EMS
- In situations when napping isn’t possible due to low levels, long-distance transports, etc., the following should be considered:
- Consumption of caffeine-based drinks;
- Switching drivers with partner;
- 20-minute nap at destination;
- Cold pack use;
- Alternating A/C with heat, opening windows.
- HR Policy #25-201: Hours of Work and Pays
- National Association of EMS Officials. (2018) Fatigue in EMS documents and resources. Retrieved May 6, 2019, from www.nasemso.org/projects/fatigue-in-ems/.
- Williamson County EMS Fatigue Risk Management System.