Fatigue Management

As with many aspects of the EMS industry, little data exist on the role of fatigue in ambulance accidents or its impact on medical service delivery. The anecdotal accounts of ambulance drivers falling asleep at the wheel and employee complaints about excessive overtime that have appeared in newspapers across the country should serve as a warning to the industry to look at the effects of fatigue on EMS employees' health and safety.1

The National Transportation Safety Board (NTSB) estimates that 100,000 crashes and about 1,500 fatalities annually are caused by driver fatigue, and the development of effective fatigue countermeasures has been on the Board's "Most Wanted" list of safety improvements since the list was developed.2

Fatigue is a shorthand reference to a general state of decreased mental and physical capacity resulting from a lack of sufficient restorative sleep or a disruption of the circadian rhythm-the natural biological clock that drives the body's cycle of sleeping at night and waking at daylight-often exacerbated by on-the-job stress and poor personal habits. Working night shifts, running double shifts and often "sleeping with one eye open" while anticipating the next emergency call are part of the normal work environment of EMS employees. Such conditions place them at high risk for experiencing the detrimental impact of fatigue on their job performance and personal health.

A considerable body of research conducted during the past two decades has led to consensus on the effects of job-related fatigue and offers insights into other measures companies can take to address health and safety issues resulting from shift work.

Studies on strategies for managing fatigue divide actions into two categories: operational countermeasures that require changes in the workplace and preventive strategies or lifestyle changes that employees can adopt to help fight fatigue.

Operational Countermeasures

Education and Training

Education is the first step taken in each program developed to address job-related fatigue. Knowledgeable employees are more likely to embrace change, especially change that affects off-duty behavior, if they understand and appreciate fully the effect of fatigue on their work and in their lives. Training programs are most effective when the countermeasures to be implemented are specifically tailored to the workplace and can be linked to how they will provide relief from specific aspects of fatigue.

Most education programs are mandatory for all employees, including management, and include lectures by experts, brochures and other reference materials, websites, videotapes to disseminate information and an employee hotline.

Managing Shifts

Consider developing rotating shifts to avoid a permanent night shift workforce and provide for adequate recovery time for employees between shift changes. While many workers prefer a fixed shift schedule due to family responsibilities, research indicates that most permanent night shift workers rarely get used to their schedule. Several reasons could account for this. Daytime sleep has been found to be less restorative than nighttime sleep, so regular night shift workers never catch up on deep sleep. In addition, most companies report that their night shift workers say they return to a day schedule on their days off, and their sleep patterns are disrupted again. Rotational shifts have been found helpful in solving the problems caused by permanent shifts if the shifts are rotated forward, from a day to an evening to a night shift.

In order to help maximize the amount of restorative sleep employees can obtain, avoid quick shift changes, long work shifts and overtime, when possible. Keep night shifts to a minimum of two to four consecutive nights. At the end of a night shift, allow at least 24 hours before scheduling employees for their next shift.

Additionally, providing for off-duty shifts of more than eight hours will give employees time to get the full 6-10 hours of sleep they need. The Federal Motor Carrier Safety Administration (FMCSA) standard for long-haul drivers extended off-duty shifts to 10 hours to give operators time to travel to their homes, eat and unwind before bedtime.

Improving the Workplace

Maintaining comfortable temperature, controlling excessive noise and providing well-lit duty areas and dark, quiet sleeping facilities are steps companies have taken to make the workplace more comfortable and reduce employee fatigue. Some companies provide recreational areas with comfortable furniture, television and other leisure pursuits to provide temporary relief to employees. Exercise equipment has been purchased by some companies to encourage a break from work and physical activity on the job, which has been shown to help enhance alertness and efficiency temporarily.

Preventive Strategies

Minimize sleep loss

The only cure for fatigue is sleep. Sleep as much as possible before or between duty days to avoid beginning a shift already tired. Developing a regular sleep routine, going to bed and waking up at the same time each day, has been found to make it easier to fall asleep. Relaxing prior to going to sleep will improve the quality of sleep on a regular basis. Techniques can include reading or taking a warm bath before bedtime and keeping room temperatures cooler in order to promote restful sleep.

Naps can provide a temporary boost to alertness and relief from fatigue but do not compensate for long-term sleep loss, so they are best used in addition to sufficient sleep. Napping longer than 45 minutes allows you to enter a deep sleep that usually results in grogginess and disorientation when interrupted by a duty call and should be avoided. Conversely, two hours of sleep is usually enough to permit one complete cycle through the different stages of sleep and can be beneficial.

Diet

Eating too much, too little or certain kinds of food is likely to interfere with the ability to fall and remain asleep. Caffeine, alcohol and nicotine all stimulate the nervous system and can provide some measure of temporary relief from the effects of fatigue. All of the stimulants also impair the ability to fall asleep and maintain the deep level of sleep necessary to provide restorative benefits, and are best used early in a shift and not at all three hours before bedtime is planned. To avoid headaches, irritability and other symptoms that affect heavy caffeine consumers who try to reduce their intake, begin to cut down on caffeine by one-half or one cup every couple of days.

Avoid using alcoholic drinks to help you unwind after work. While alcohol promotes relaxation and drowsiness, it suppresses the deeper levels of sleep needed to restore your body. It is best to avoid drinking two to three hours before bedtime. Heavy drinking will impair alertness the following day and possibly contribute to long-term health problems.

Physical fitness

A regular exercise routine of about 30 minutes daily helps to maintain health and fight the effects of fatigue. Overall physical fitness helps the body cope with stress and resist illness and disease, and promotes a deeper, more restful sleep. Exercise before the start of a shift, if not overdone, can invigorate you and could provide a healthy way to stimulate yourself for work. Because of this stimulating effect, studies recommend avoiding strenuous exercise three to six hours prior to bedtime.

Components of a Successful Program

Adopting a fatigue countermeasure program will not ensure that employees receive sufficient sleep and develop healthful personal habits. Employees are likely to resent suggestions that affect their off-duty personal time, particularly those who have to juggle family demands while recovering from long shifts. Furthermore, many people suffer from sleep disorders and require individualized interventions to help them avoid sleep disruptions. But all of the successful fatigue countermeasure programs have included similar elements that were found to help most employees.

A commitment from management to address workplace practices that most contribute to fatigue and involving all employees directly in the process of developing strategies and programs were the most frequently cited elements of successful alertness programs. Employees were found to be more supportive of changes in the workplace when a strong fatigue education and training component was included as part of the program, and when employees at all levels within the company participated.

Involving the families of employees in education and training programs on the effects of shift work and fatigue was found to reduce stress within the home and contribute to employees' ability to obtain sufficient uninterrupted sleep while off duty. If family members know what the work and sleep schedule will be, and the importance of sufficient undisturbed sleep, activities and chores can be scheduled accordingly.

Other strategies undertaken to combat fatigue have been more extreme and would require more significant systemic changes within the EMS industry. The New York City Transit Authority, following NTSB recommendations stemming from an investigation into a serious accident, prohibited split-shift and part-time jobs in certain divisions and required selected employees to obtain permission to hold a second job that might interfere with on-the-job performance.

Such restrictions are unlikely to be included in any initial EMS industry effort to develop fatigue management programs, but they may not be far off the mark. The Hartford (CT) Fire Department contract prohibits, by 2008, its active-duty, full-time firefighters from working as firefighters, paid or volunteer, at another company. The department's fire chief told local newspaper reporters that the prohibition was designed to assure the city did not pay benefits to firefighters for injuries incurred at other jobs.3 It is not a stretch to imagine the same restrictions justified on the basis of employee alertness and productivity.

Some EMS agencies have reviewed scheduling policies and made adjustments to work routines they believe will reduce fatigue and improve safety. Boston EMS Deputy Superintendent Kevin Shea says his agency runs three eight-hour shifts worked by 95% of his employees. The others work four 10-hour days. No employee works more than a 16-hour shift. "We're a pretty busy service," says Shea. "We feel that past the 16-hour point there is potential for lapses in judgment and potential for errors in driving."

Will Gluckman, associate EMS medical director at the University of Medicine and Dentistry of New Jersey and the medical director and manager of the New Jersey Urban Search and Rescue Task Force (NJ TF 1), says he has used drills as an opportunity to examine the operational effects of different shift lengths on team members. His team tried shifts of six, eight and 12 hours, and consider 12-hour shifts to be the best compromise between productive work and making sure employees are rested.

It is likely other efforts are underway at individual companies or agencies. In the face of available research and best practices developed in other industries facing similar working conditions, an industry-wide examination of the effects of fatigue on EMS employees would appear to be overdue. As healthcare providers, we cannot ignore decades of research that demonstrates we need to reconsider our attitudes toward shift work, fatigue and the quality of the work experience in the field.

References

1. Zagaroli L, Taylor A. "Ambulance driver fatigue a danger." Detroit News, January 27, 2003, at www.detnews.com/2003/specialreport/0301/27/a01-69705.htm; Collins E. "Paramedics: Long shifts put public at risk." The Capital, June 8, 2003; Antone R. "Ambulance crews piling up overtime." Star Bulletin, July 11, 2001, at https://starbulletin.com/2001/07/11/news/story1.html.
2. Vernon S. Ellingstad, PhD, Director, Office of Research and Engineering, National Transportation Safety Board. "Testimony regarding Fatigue in the Trucking and Rail Industry," September 16, 1998 before the Surface Transportation and Merchant Marine Subcommittee, Senate Commerce Committee, U.S. House of Representatives at www.ntsb.gov/speeches/s980916.htm; Chairman Marion Blakey. "Remarks for the United Transportation Union," Washington, DC, July 30, 2002, at www.bmwe.org/nw/2002/04APR/24.htm; "NTSB Chairman Highlights Fatigue as Major Cause of Transportation Accidents" at www.ntsb.gov/speeches/blakey/mcb020730.htm.
3. Frank AJ. "Two-Hatter Controversy Revisited in Hartford," Best Practices in Emergency Services 6, August 2003, p. 2.