Fatigue Prevention in EMS

On October 3, 2013, the Strategy for a National EMS Safety Culture was released following a 2009 recommendation by the National Emergency Medical Services Advisory Council (NEMSAC) for NHTSA to create a strategy for building a culture of safety in EMS.

In an attempt to begin the process of molding the culture of ground EMS to this strategy, HealthNet Aeromedical embarked on a journey to answer a complicated question: How do we take these recommendations and combine them with what we have been doing as an organization for the past 30 years in the aeromedical environment to make a ground transport service as safe and efficient as we can?

We began the implementation of the Just Culture process three years prior to the introduction of our ground service. The first decision made was to keep the structure of the air and ground side consistent. Each applicant that is called experiences a unique interview process. They are given a written knowledge, medication calculation and protocol exam, followed by a medical physical agility exam (MPAT) and an interview by the hiring committee.

The unique training area for our new employees is our fatigue management system. We have transitioned our aeromedical FAA requirements into our ground operation in an attempt to align with the National recommendations. We require each employee to have been off from any employment for a minimum of 10 hours prior to their current shift. Upon arriving for duty, they complete a daily fatigue risk assessment. If the assessment is a high value indicating a high risk (between 7 and 11), the employee must contact the supervisor on call to develop a mitigation plan prior to the truck going into service for the shift. The daily fatigue risk assessment consists of four questions:

Criteria 1

What was your schedule the day before the start of current shift?

• Employee was off work = 1
• Employee worked 12 hours or less = 2
• Employee worked more than 12 hours = 3

Criteria 2

How many total run hours did you have in the past 24 hours?

• Less than six = 1
• Six to 12 = 2
• Greater than 12 = 3

Criteria 3

How many hours of uninterrupted rest did you receive in the past 24 hours?

• Eight or more = 0
• Five to seven = 1
• Less than five hours = 2

Criteria 4

How many consecutive days in a row have you worked (including other employers) prior to this shift?

• Zero to four = 1
• Five to eight = 2
• Greater than eight = 3

Each crew works a traditional 24-hour shift, increasing their fatigue level throughout the shift. With this in mind, we have allowed our crews to use our time-out policy. If a crew reaches a point where one or both crew members feels they are too fatigued to continue, they will call our communications center and put themselves on a safety time out. A safety time out is two hours of complete, uninterrupted downtime allowing the crews to rest. If at the end of the initial two hours the crews need more time, they get an additional two once approved by the supervisor. If the crews feel a total of four hours is not enough time to be safe, they are instructed to clock out and are sent home to rest with the truck being taken out of service.

Our units are dedicated for interfacility transfers only. We are not on the 9-1-1 system. The local area for our units is a 30 mile radius from the base. However, many of our transports are outside the local area into high-traffic, large cities. We also ask our crews to complete a seven-question transport risk assessment prior to any transport outside of the 30-mile local area.

The following questions are what must be completed:

Question 1 - Transport Crew / Driver Fatigue (hours on shift)

• Greater than 36 hours = 5
• Less than 36, but more than 24 = 3
• Less than 24, but more than 12 = 1
• Less than 12 = 0

Question 2 - Severe Weather (all seasons)

• Regional State of Emergency = 30
• Regional watches for duration of transport = 5
• Regional advisories for duration of transport = 3
• None = 0

Question 3 - Distance (round trip)

• Greater than 700 miles = 3
• Greater than 350 miles, less than 700 miles = 2
• Greater than 150 miles, less than 350 miles = 1
• Less than 150 miles = 0

Question 4 - Time spent on transports during current shifts

Includes flight crew transports and other ground transports, but does not include time spent at base doing paperwork.

• More than five hours = 4
• Four to five hours = 3
• Three to four hours = 2
• Less than three hours = 1

Question 5 - Road Conditions

• Impassible/fully snow or ice covered = 30
• Difficult/partially ice or snow covered = 15
• Fair/slippery or snow covered stretches = 10
• Wet/heavy rain/standing water = 5
• Normal/good = 0

Question 6 - Road types experienced during entire route of transport

• Two-lane roads= 4
• Mix of two- and four-lane roads = 3
• Four-lane roads = 0

Question 7 - Medical Crew Fatigue

• Trip extends greater than four hours past shift and/or more than two trips over three hours each this shift = 4
• Trip extends less than four hours past shift and/or less than two trips this shift = 3
• Trip extends beyond regular shift and/or less than two other trips equal to or less than three hours each this shift = 2
• Trip extends beyond 12th hour of 24-hour shift and/or less than two other short trips this shift = 1
• Well rested/early in shift and/or had rest period before transport request = 0

If the assessment score is 30 or above, the crew must contact the supervisor on duty to establish a mitigation plan for the transport. If no plan can be developed, the transport is denied.

When we implemented this program and began to teach around the state what we were doing, more than once we heard: “Wow, you will never do a transport.” Truthfully, we had no idea how this system was going to work. It was completely new for ground EMS in our area. Our first full quarter of operation, we were requested a total of 808 times and completed 404 of those transports with two trucks. Of the 404 missed transports, 0.25% (two transports) were missed due to a high risk assessment and 1.25% (13 transports) were missed due to a safety time out. The rest were missed due to the two trucks already being on transports.

Ultimately, ground EMS transport can be done safely, and we can change the culture of the industry if we put appropriate programs in place and support crews making safe decisions. At this point, it is stated that EMS is 2.5 times more dangerous than general industry, and we have to begin the process of change.

Jeff White, MS, MTSP-C, NREMT-P, FP-C, began his career in 1996 in Fayette County, WV. Jeff spent nine years as a volunteer firefighter and EMT in Fayette County while working full time as an environmental design engineer in the coal mining industry. After reaching the rank of captain and medical training officer Jeff began a career as a professional firefighter with the Charleston (WV) Fire Department where he was a member of the dive rescue team and WV Regional Response Team. During this time Jeff completed his paramedic certification training. Jeff currently serves as the director of safety for HealthNet Aeromedical Services, Inc. in Charleston WV, after serving as a flight paramedic. Jeff recently completed his Master’s in Safety from Marshall University and is a graduate of the Safety Management Training Academy hosted by AAMS. In his spare time he teaches for Spec Rescue International and is a hazardous materials specialist for Ohio Task Force One.