Mitigating Risk From Fatigue in EMS

When a person decides a career in EMS is the right choice, they have to accept a few things: Most of your meals will be cold, you will spend approximately one third of your life at work and you will spend the biggest part of your life functioning in a fatigued state. We have accepted these things for so many years, it is now the norm, but we probably shouldn’t be so accepting poor nutrition, long hours and especially fatigue.

Since the invention of electricity, the human race has been in a constant conflict with our internal circadian rhythm. The circadian rhythm is the body’s internal clock that goes through physical, mental and behavioral changes that follow a roughly 24-hour cycle based on cues from its environment. We work longer hours, stay up later at night and do not have the best sleep environments. Even if you have dark curtains and try to block out as much as you can, there are street lights, traffic and noise from the neighbors that all lead to distracted sleep. One item of interest here is that EMS as an industry has had little national regulation in all aspects of the industry.

A 2013 release of the National Strategy for an EMS Safety culture states EMS providers are two-and-a-half times more likely to be killed on the job than the average American worker.¹ To put that into perspective, the Occupational Safety and health Administration (OSHA) has been in place since 1970 in an industry with thousands of regulations, and on average there are still approximately 10 deaths per week.

A 2011 NFPA report documents that from 1990-2009 there were 85,000 ambulance crashes with 29,000 injuries and 509 fatalities, compared to 310 accidents with 302 fatalities in aeromedical from 1972-2013.

Thus, even when regulated, there will be accidents. You cannot eliminate all human error, ours or others. The best strategy is risk mitigation. My services has taken the mentality of the aeromedical industry and applied these techniques to our newly formed ground service. For us, it was an easy transition because we have been doing it for thirty years. The challenge has been getting facilities and other agencies to grasp the concept, because it is just not how EMS as an industry usually operates.

For the ground transport arena, we begin with a comprehensive hiring process which includes a physical agility test. We hire in groups and each group is put through an academy-type process where each recruit receives threat and error management training, fatigue recognition and management training, stress recognition and management training and training on our internal safety management system (SMS). Each ground academy recruit is required to take the NAEMT EMS Safety course.

Once working, the ground and aeromedical crews’ first step of each day is to complete a four-question daily fatigue assessment. The fatigues assessment consists of four scientifically supported criteria questions that are answered by each crew member.

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

If a crew member scores below seven, it is deemed safe. If a crew member scores between seven and 11, the crew member must contact their supervisor to work out a mitigation strategy and document that strategy prior to submitting the form. Since our ground crews are on 24-hour shifts, we allow them to use the timeout policy that has been in place for the aeromedical side since inception. If during a transport a crew feels they are too fatigued to take another transport, they are to contact the communication center upon finishing their current call and advise the center they are taking a safety timeout. Once that notification is made, the crew is then taken out of service for two hours. If at the end of two hours they feel they need more time, they can contact an immediate supervisor and get approval for one additional hour. If they feel they need more than that, the supervisor will advise them to mark out of service, take PTO and go home for the rest of the shift. The thought behind that is not punitive, but that if three hours is not enough rest you are too fatigued to complete the shift.

We also monitor the fatigue levels of the ground agencies we contract with to transport our flight crews if down for weather. The first question of the ground transport risk assessment completed internally is completed once the contract company arrives to transport us. The question asks how many hours the contractor has been on shift:

Transport crew / driver fatigue (hours on shift)

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

If either or both of the contract crew members score a three or five, the flight team leader is to be contacted. The flight team leader then contacts the contracted agency and requests a new crew who is less fatigued. If that cannot be provided, we go to an alternate service or turn down the transport.

Fatigue in EMS will be a challenging risk item to mitigate due to the complexities of emergency responses as compared to non-emergent transports and reimbursement. We have to realize that while supporting the organization is important, the safety of our crews and patients should hold a higher value in the grand scheme of things. Great discussion has been had, but we are really in the infancy of EMS safety and I am excited to see of the great thing to come in the EMS safety arena.

Jeff White, MS, MTSP-C, NREMT-P, FP-C, began his career in 1996 in Fayette County, W. Va. 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 (W. Va.) Fire Department where he was a member of the dive rescue team and W. Va. 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 W. Va., 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.

References

1. Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical services: A hidden crisis. Ann Emerg Med, 2002, 40(6):625-632