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EMS Fatigue is a Serious Problem. Better Education Can Solve It.

by  Bob Elling     Jul 10, 2023
fatigue_driver_ems

Headlines in local news, TV or social media are an opportunity to hook the reader to invest some of their valuable time to read the story. Often people see a headline on their phone and just keep scrolling.

Having a personal interest in the factors leading to ambulance crashes for five decades now, I usually take the time to read more than the headline, follow-up articles, and sometimes review after-action reports or detailed investigations as they become available.

However, I realize that the public and frankly most responders do not take that level of interest. I recently decided to review most of the headlines for ambulance crashes throughout the U.S. for the past six years. Simply looking at what the public in your community’s perceptions or point of view can be framed by. Here are just five of the crashes from the month of June 2023, as reported by EMS1, the popular news site for the emergency medical services industry:

I did make a few initial impressions from reading the headlines. For starters, I was surprised to see so many “stolen and then crashed” ambulances. Perhaps the vehicles should be locked before walking away from them.

There were lots of “car or truck runs into the ambulance.” Guess that is just more of a reminder of the need for Traffic Incident Management (TIM) training in every community.

There were many “flipped or rolled over ambulances.” Just another reminder that ambulances have a high center of gravity and everyone should always be belted in at all times. And, yes, there were some headlines noting the operator of the ambulance was charged with a crime.

These headlines brough to mind quite a few headlines from 2017 involving an ambulance operator/driver who was asleep at the wheel. There has been a lot of effort to educate response agencies about fatigue and its dangerous effects. Has this problem been eliminated? Absolutely not. But we may be making some headway, which, hopefully, has not been set back by the pandemic and employee retention and turnover issues.

Let’s take a closer look at the fatigue issue.

Background on EMS Fatigue

The National Institutes of Health describes fatigue is described as “a subjective, unpleasant symptom that incorporates total body feelings ranging from tiredness to exhaustion, creating an unrelenting overall condition that interferes with a person’s ability to function to normal capacity.”

Studies show work-related fatigue has affected greater than half the EMS personnel. Reports of fatigue-related events that involved ambulance crashes, personnel and patient injury and death were on the rise pre-2018. This has a danger impact on the safety of patients and providers. The odds of injury, medical error, patient adverse events, and safety-compromising behavior are higher among fatigued EMS providers than non-fatigued providers.

Recognizing the dangers of this safety issue, in January 2013 the National EMS Advisory Council issued an advisory recommending the National Highway Traffic Safety Administration (NHTSA) and federal partners examine fatigue in EMS and disseminate evidence for fatigue mitigation. A contract was issued in 2015 to develop evidence-based guidelines (EBGs) for fatigue risk management focused on EMS responders.

In August 2019 the NHTSA report entitled Fatigue in Emergency Medical Services was issued. The expert panel analyzed over 38,000 pieces of literature and used a rigorous EBG development process based on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. They were able to arrive at consensus on the following five recommendations:

  • Use reliable and/or valid fatigue/sleepiness instruments to measure and monitor fatigue in EMS personnel. (Strong recommendation, very low certainty in evidence).
  • EMS personnel work shifts should be shorter than 24 hours long. (Weak recommendation in favor, very low certainty in effect).
  • EMS personnel have access to caffeine as a fatigue countermeasure. (Weak recommendation in favor, low certainty in effect).
  • EMS personnel have opportunities to nap while on duty to mitigate fatigue. (Weak recommendation in favor, very low certainty in effect).
  • EMS personnel receive education and training to mitigate fatigue and fatigue-related risks. (Weak recommendation in favor, low certainty in evidence).

To complement the five EBGs, goals and performance measures were developed for each recommendation. The performance measures assist the EMS administrators (stakeholders) in implementation and evaluation of the EBGs for fatigue risk measures. The panel developed a checklist for implementation of fatigue in EMS evidence-based guidelines as a resource for agencies that chose to implement the EBGs.

You might be saying to yourself, “With all those weak recommendations and low certainty in evidence why should our service change our SOPs?”

These recommendations were not released as mandates. As services become more aware of the fatigue safety issue there is a need for more research to narrow down the best solutions.

The expert panel suggested that testing of fatigue and sleepiness survey instruments should be a priority for future research. They also understood that changing the length of shifts is a complex decision since most EMS personnel (>80 in some areas) report working multiple jobs. It is not merely reducing the shifts to less than 24 hours but also dealing with the provider who works for one employer then another and then another (or back to the first employer) without adequate time for quality sleep between the shifts.

Relevant Education for EMS Leaders

In regard to the recommendation for education and training in fatigue and sleep health, the panel felt that the training should be a key component of each agency’s comprehensive strategy to mitigate the effects of fatigue related to EMS shift work. They felt that further research was needed to investigate the following:

  • Content of training that has meaningful impact on outcomes.
  • Effectiveness of diverse methods of educating and training personnel.
  • Costs of the education and training.
  • Impact of the education and training on the behavior(s) of EMS personnel.

In 2017, the National Highway Traffic Safety Administration released a report on drowsy driving crashes from 2011 to 2015. During this period, there were approximately 29 million total motor vehicle crashes. Of these, 396,000  involved drowsy driving. Of these, 3,662 resulted in fatalities

In January 2023, NHTSA released the document, The Emergency Medical Services Sleep Health Study, citing that the Fatigue Risk Management in EMS Education Program, developed specifically for the study to measure the effectiveness of such an educational tool, may be a useful resource for EMS administrators that aim to fulfill the 2018 EBG recommendation of educating and training EMS workers on the importance of sleep health and fatigue mitigation.

In this study the research team created a 10-module education program based on recommendations from the American College of Occupational Environmental Medicine (ACOEM) Task Force on Fatigue Risk Management. The ten online modules, each 10-15 minutes long consists of a summary of published evidence, quiz questions about the evidence presented, and video recordings of interviews with experts in sleep medicine, EMS administrators, and EMS clinicians.

The specific topics of the training included:

  • Hazards of fatigue,
  • Sleep physiology,
  • Sleep health,
  • Work-related stress,
  • Sleep disorders,
  • Fatigue recognition,
  • Adequate sleep,
  • Diet and exercise,
  • Alertness strategies, and
  • Managing fatigue.

The details on the study background, methods, results and conclusions, as well as statistical information on the participants and agencies, is presented in the journal Sleep Health 9 (2023) 64-76. If you are trying to deal with fatigue issues for your response agency or simply want to learn more about the topic, I suggest you read it.

Other useful resources to learn more about the topic of fatigue, and drowsy driving include: CDC, NHTSA, NAEMT’s EMS Safety 3rd Edition and the soon to be published EMS Vehicle Operator Safety (EVOS) 2nd Edition.

You can also consider downloading a free digital review copy for EMS Vehicle Operator Safety, First Edition, available now.

Download Your Review Copy

Related Content:

About the Author:

Bob Elling, MPA, Paramedic (retired) – has been a career paramedic, educator, author, and EMS advocate since 1975. He was a paramedic with the Town of Colonie EMS Department, Albany Times Union Center, and Whiteface Mountain Medical Services. He was also an Albany Medical Center Clinical Instructor assigned to the Hudson Valley Community College Paramedic Program. Bob has served as National/Regional Faculty for the AHA and involved in many successful life-saving legislative campaigns with the You’re the Cure Network. He also served as paramedic and lieutenant for New York City EMS, a paramedic program director, and the associate director of New York State EMS Bureau. He has authored hundreds of articles, videos, and textbooks to prepare EMS providers for their career. Bob is the ECSI Medical Editor for the CPR and First Aid Series and Co-Lead Editor of Nancy Caroline’s Emergency Care in the Streets.

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EMS Fatigue is a Serious Problem. Better Education Can Solve It.

by  Bob Elling     Jul 10, 2023
fatigue_driver_ems

Headlines in local news, TV or social media are an opportunity to hook the reader to invest some of their valuable time to read the story. Often people see a headline on their phone and just keep scrolling.

Having a personal interest in the factors leading to ambulance crashes for five decades now, I usually take the time to read more than the headline, follow-up articles, and sometimes review after-action reports or detailed investigations as they become available.

However, I realize that the public and frankly most responders do not take that level of interest. I recently decided to review most of the headlines for ambulance crashes throughout the U.S. for the past six years. Simply looking at what the public in your community’s perceptions or point of view can be framed by. Here are just five of the crashes from the month of June 2023, as reported by EMS1, the popular news site for the emergency medical services industry:

I did make a few initial impressions from reading the headlines. For starters, I was surprised to see so many “stolen and then crashed” ambulances. Perhaps the vehicles should be locked before walking away from them.

There were lots of “car or truck runs into the ambulance.” Guess that is just more of a reminder of the need for Traffic Incident Management (TIM) training in every community.

There were many “flipped or rolled over ambulances.” Just another reminder that ambulances have a high center of gravity and everyone should always be belted in at all times. And, yes, there were some headlines noting the operator of the ambulance was charged with a crime.

These headlines brough to mind quite a few headlines from 2017 involving an ambulance operator/driver who was asleep at the wheel. There has been a lot of effort to educate response agencies about fatigue and its dangerous effects. Has this problem been eliminated? Absolutely not. But we may be making some headway, which, hopefully, has not been set back by the pandemic and employee retention and turnover issues.

Let’s take a closer look at the fatigue issue.

Background on EMS Fatigue

The National Institutes of Health describes fatigue is described as “a subjective, unpleasant symptom that incorporates total body feelings ranging from tiredness to exhaustion, creating an unrelenting overall condition that interferes with a person’s ability to function to normal capacity.”

Studies show work-related fatigue has affected greater than half the EMS personnel. Reports of fatigue-related events that involved ambulance crashes, personnel and patient injury and death were on the rise pre-2018. This has a danger impact on the safety of patients and providers. The odds of injury, medical error, patient adverse events, and safety-compromising behavior are higher among fatigued EMS providers than non-fatigued providers.

Recognizing the dangers of this safety issue, in January 2013 the National EMS Advisory Council issued an advisory recommending the National Highway Traffic Safety Administration (NHTSA) and federal partners examine fatigue in EMS and disseminate evidence for fatigue mitigation. A contract was issued in 2015 to develop evidence-based guidelines (EBGs) for fatigue risk management focused on EMS responders.

In August 2019 the NHTSA report entitled Fatigue in Emergency Medical Services was issued. The expert panel analyzed over 38,000 pieces of literature and used a rigorous EBG development process based on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. They were able to arrive at consensus on the following five recommendations:

  • Use reliable and/or valid fatigue/sleepiness instruments to measure and monitor fatigue in EMS personnel. (Strong recommendation, very low certainty in evidence).
  • EMS personnel work shifts should be shorter than 24 hours long. (Weak recommendation in favor, very low certainty in effect).
  • EMS personnel have access to caffeine as a fatigue countermeasure. (Weak recommendation in favor, low certainty in effect).
  • EMS personnel have opportunities to nap while on duty to mitigate fatigue. (Weak recommendation in favor, very low certainty in effect).
  • EMS personnel receive education and training to mitigate fatigue and fatigue-related risks. (Weak recommendation in favor, low certainty in evidence).

To complement the five EBGs, goals and performance measures were developed for each recommendation. The performance measures assist the EMS administrators (stakeholders) in implementation and evaluation of the EBGs for fatigue risk measures. The panel developed a checklist for implementation of fatigue in EMS evidence-based guidelines as a resource for agencies that chose to implement the EBGs.

You might be saying to yourself, “With all those weak recommendations and low certainty in evidence why should our service change our SOPs?”

These recommendations were not released as mandates. As services become more aware of the fatigue safety issue there is a need for more research to narrow down the best solutions.

The expert panel suggested that testing of fatigue and sleepiness survey instruments should be a priority for future research. They also understood that changing the length of shifts is a complex decision since most EMS personnel (>80 in some areas) report working multiple jobs. It is not merely reducing the shifts to less than 24 hours but also dealing with the provider who works for one employer then another and then another (or back to the first employer) without adequate time for quality sleep between the shifts.

Relevant Education for EMS Leaders

In regard to the recommendation for education and training in fatigue and sleep health, the panel felt that the training should be a key component of each agency’s comprehensive strategy to mitigate the effects of fatigue related to EMS shift work. They felt that further research was needed to investigate the following:

  • Content of training that has meaningful impact on outcomes.
  • Effectiveness of diverse methods of educating and training personnel.
  • Costs of the education and training.
  • Impact of the education and training on the behavior(s) of EMS personnel.

In 2017, the National Highway Traffic Safety Administration released a report on drowsy driving crashes from 2011 to 2015. During this period, there were approximately 29 million total motor vehicle crashes. Of these, 396,000  involved drowsy driving. Of these, 3,662 resulted in fatalities

In January 2023, NHTSA released the document, The Emergency Medical Services Sleep Health Study, citing that the Fatigue Risk Management in EMS Education Program, developed specifically for the study to measure the effectiveness of such an educational tool, may be a useful resource for EMS administrators that aim to fulfill the 2018 EBG recommendation of educating and training EMS workers on the importance of sleep health and fatigue mitigation.

In this study the research team created a 10-module education program based on recommendations from the American College of Occupational Environmental Medicine (ACOEM) Task Force on Fatigue Risk Management. The ten online modules, each 10-15 minutes long consists of a summary of published evidence, quiz questions about the evidence presented, and video recordings of interviews with experts in sleep medicine, EMS administrators, and EMS clinicians.

The specific topics of the training included:

  • Hazards of fatigue,
  • Sleep physiology,
  • Sleep health,
  • Work-related stress,
  • Sleep disorders,
  • Fatigue recognition,
  • Adequate sleep,
  • Diet and exercise,
  • Alertness strategies, and
  • Managing fatigue.

The details on the study background, methods, results and conclusions, as well as statistical information on the participants and agencies, is presented in the journal Sleep Health 9 (2023) 64-76. If you are trying to deal with fatigue issues for your response agency or simply want to learn more about the topic, I suggest you read it.

Other useful resources to learn more about the topic of fatigue, and drowsy driving include: CDC, NHTSA, NAEMT’s EMS Safety 3rd Edition and the soon to be published EMS Vehicle Operator Safety (EVOS) 2nd Edition.

You can also consider downloading a free digital review copy for EMS Vehicle Operator Safety, First Edition, available now.

Download Your Review Copy

Related Content:

About the Author:

Bob Elling, MPA, Paramedic (retired) – has been a career paramedic, educator, author, and EMS advocate since 1975. He was a paramedic with the Town of Colonie EMS Department, Albany Times Union Center, and Whiteface Mountain Medical Services. He was also an Albany Medical Center Clinical Instructor assigned to the Hudson Valley Community College Paramedic Program. Bob has served as National/Regional Faculty for the AHA and involved in many successful life-saving legislative campaigns with the You’re the Cure Network. He also served as paramedic and lieutenant for New York City EMS, a paramedic program director, and the associate director of New York State EMS Bureau. He has authored hundreds of articles, videos, and textbooks to prepare EMS providers for their career. Bob is the ECSI Medical Editor for the CPR and First Aid Series and Co-Lead Editor of Nancy Caroline’s Emergency Care in the Streets.

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