that their accident/event occurred when working their second or third
job—or maybe even their fourth job.
Median pay for EMTs and paramedics in 2016 was $15.71 per
hour, according to the U.S. Department of Labor’s Bureau of Labor
39 That means half of paid EMS personnel make less than
$15.71 per hour. Many in EMS might argue that low pay contributes
to their decision to work multiple shifts or excessive overtime; which
can contribute to fatigue.
There are numerous factors that may lead to fatigue in the EMS
workplace. I don’t provide an exhaustive review of these factors, nor
do I provide a breakdown of the complex relationships between each.
My hope is to awaken those in EMS ignoring the issue and the
related risks, deliberately or unintentionally. Poor sleep health and
fatigue threaten our clinicians, our patients and the public.
Most administrators and managers aren’t adequately prepared to
address fatigue in the workplace. This is evidenced by the news reports
cited earlier, the referenced research, and by the comments from numerous EMS clinicians interviewed for this article. There’s credible evidence
from studies that shiftwork, workload and other factors contribute to
fatigue and fatigue-related outcomes.
Shiftwork isn’t going away.
40, 41 The burden on EMS administrators,
managers and individual EMS clinicians is how to effectively manage
shiftwork to protect personnel, patients and the public. Clinicians and
employers must work together; after all, fatigue risk management is a
shared responsibility between the employer and employee.
FATIGUE MITIGATION STRATEGIES
Attention to fatigue and the negative impacts of fatigue have increased
in recent years. In 2017, a panel of experts reviewed the evidence germane to multiple fatigue mitigation strategies and formulated five recommendations tailored to EMS operations. The effort originated in
2013, when the National EMS Advisory Council (NEMSAC) issued
an advisory that recommended the National Highway Traffic Safety
Administration (NH TSA) and federal partners examine the evidence
germane to fatigue mitigation.
In 2015, NHTSA solicited applications for a funding opportunity
that would create evidence-based guidelines for fatigue risk manage-
ment in EMS. After a competitive process, the National Association
of State EMS Officials (NASEMSO) was awarded the contract.
Together with my colleagues at the University of Pittsburgh Depart-
ment of Emergency Medicine, we collaborated with NASEMSO and
led a research team of more than two-dozen investigators and staff in
a detailed review of more than 38,000 pieces of literature.
We evaluated the quality of the evidence linked to multiple fatigue
mitigation strategies and led a panel of experts through a rigorous protocol for evidence-based guidelines development. The panel of experts
was formed based on recommendations from the Institute of Medicine (now referred to as the National Academy of Medicine), and
included individuals with expertise in sleep medicine, fatigue science,
epidemiology, public safety, risk management, administration, emergency medicine and EMS.
We adhered to the grading of recommendations assessment, development and evaluation (GRADE) methodology, an emerging standard for evidence-based guideline development.
The expert panel reached consensus on recommendations that
addressed five areas: 1) shift duration; 2) access to caffeine; 3) use of
napping during shift work; 4) education and training; and 5) use of
reliable/valid instruments to diagnose fatigue in the field.
Recommendation #1: The panel recommended that EMS organizations use fatigue/sleepiness survey instruments to measure and monitor
fatigue in EMS personnel; specifically, use survey instruments discovered in a recent systematic review that show evidence of reliability and/
Not all instruments are created equal, and not all assess fatigue or
sleepiness in the same way. Some instruments ask about fatigue in
general, whereas other instruments ask about fatigue in reference to
the previous month.
Administrators who adopt this recommendation will need to decide
which instrument to use. The panel recommended that regardless of
the instrument selected, assessments should occur quarterly.
Assessments should target shifts that administrators believe con-
tribute to fatigued clinicians. These may include extended duration
shifts (e.g., > 12 hours) or night shifts. Many administrators may need
to test or experiment with different survey tools before settling on the
one that works best in their organization with their fatigue mitiga-
tion program. Individual clinicians should be prepared to contribute
by answering the survey tools completely and truthfully.
Recommendation #2: The panel recommends that EMS personnel work shifts that are shorter than 24 hours in duration.
review of evidence showed that shifts 24 hours in duration or longer
are unfavorable in terms of fatigue and related outcomes.
48 The pattern of favorability toward shorter-duration shifts wasn’t observed in
the evidence review when comparing shifts of other durations (e.g.,
eight-hour vs. 12-hour shifts).
The panel acknowledged the contentious nature of dealing with
shift duration and recognized that, in certain circumstances or in certain locations, longer shifts are necessary.
The panel also noted that fatigue mitigation shouldn’t begin and
end with targeting shift duration. Modification of shift duration as the
lone solution or strategy for fatigue mitigation is considered a “20th
49, 50 Modern-day fatigue risk management incorporates
multiple components and is tailored to local needs.
Shift duration should be part of the conversation, yet it shouldn’t be
the sole focus. For EMS organizations and employees that choose to
EMS personnel should be provided with the access, opportunity and permission to
nap while on duty, especially while on extended or overnight shifts.