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modify shift duration, the panel recommends that shifts be less than 24
46 The panel raised concern for shifts worked contiguously and
recommends that administrators consider two 12-hour shifts worked
back-to-back as a 24-hour shift. The goal for any EMS organization that
adopts this recommendation should be 100% of shifts less than 24 hours.
Recommendation #3: The panel recommends that EMS personnel
have access to caffeine as a fatigue countermeasure.
The review of evidence revealed that few studies have evaluated the
impact of caffeine on safety and other outcomes among EMS personnel or similar shift workers.
51 The available evidence showed a positive
impact on performance and other outcomes. The review didn’t identify an optimal dose of caffeine, yet 250 mg per day has been cited as a
low-to-moderate, generally safe dose.
Providing access to caffeine seems intuitive, and many EMS organizations will have no problem meeting this recommendation. However,
creativity and investment will be necessary for others, especially for EMS
organizations that deploy ambulances with system status management
or dynamic deployment.
In these systems, algorithms or various decision guides will often
position or “post” crews on street corners. Clinicians may find it a challenge to access caffeine. Crews may need to prepare coolers of food and
beverages to have available in the event they’re posted in a location with
limited access to a store or facility with caffeinated beverages.
Administrators may need to consider providing access to caffeinated beverages by stocking coolers on ambulances; especially for crews
deployed in remote locations or at night with limited or no access to
stores or other resources.
The panel recommends that the goal for any organization that adopts
this recommendation should be that 100% of all shifts include access
to caffeine. Caffeine should be provided for free or for purchase for all
on-duty EMS personnel.
Recommendation #4: The panel recommends that EMS personnel have the opportunity to nap while on duty to mitigate fatigue.
The review of evidence showed that napping during shifts (i.e., actually sleeping, not just resting) had a positive impact on outcomes.
Many EMS organizations permit crews to sleep or nap during duty;
thus, this recommendation may not be revolutionary for some. However, there are numerous EMS systems that have policies that strictly
prohibit sleeping while on duty. These organizations may require a
substantial change in policy and culture.
For EMS systems adopting this recommendation, the panel proposed that EMS personnel be provided with the access, opportunity
and permission to nap while on duty.
47 The panel emphasized that this
recommendation should be applied to extended shifts and on overnight shifts. A goal for any organization that adopts this recommendation should be permission given to clinicians to nap while on duty
for 100% of extended shifts or overnight shifts.
Recommendation #5: The panel recommends that 100% of EMS
personnel should receive education and training in sleep health and
the dangers of fatigue to mitigate fatigue and fatigue-related risks.
This training should occur as part of new employee orientation (i.e.,
onboarding), and be repeated every two years for all employees.
Findings from a review of diverse education and training programs
that include a sleep health or fatigue component show positive results
in the weeks following education and training.
The panel emphasized the need to re-educate and re-train crews
every two years given that knowledge and skills decay over time. There’s
reason to believe that EMS systems that continuously train and edu-
cate EMS clinicians on the importance of sleep health and the dan-
gers of fatigue will have a positive impact.
The five fatigue mitigation strategies are supported by a review of
the best available evidence interpreted for the purposes of mitigating
fatigue in the EMS setting.
46 There’s no equivalent effort and no other
resource that provides a summary of the evidence germane to multiple
strategies for fatigue mitigation in high-risk environments like EMS.
Administrators, managers and individual clinicians should invest
time in learning more about these recommendations by reading the
publications that will soon appear in a special supplement in the
peer-reviewed journal Prehospital Emergency Care, which provides
more than 1,000 pages of information for the specific purpose of
fatigue mitigation in EMS operations.
27, 48, 51, 53–62
Opinions regarding fatigue mitigation and how to begin, or what to
include in a formal program vary. Nancy believes that a formal fatigue
risk management program should require an avenue for feedback and
communication between the clinician and administrator. “They won’t
say anything if there’s no avenue to provide that feedback,” she says.
Mike, a paramedic in the Northeast, believes programs will differ operationally. “There’s no cut and dry single solution,” he says.