09 Sep Original Article: It’s Time to Address Shift Length, Fatigue, & EMS Workforce Safety
© 2014 MedicHealth.com
In recent years, focus on medic safety has received increasing attention. Maguire et al. reported in 2002 that EMS providers had a rate of occupational fatalities due to transportation incidents of 9.6 per 100,000; a third higher than firefighters (6.3), twice that of police (4.5), and more than 4 times the general public.  The authors described it as a hidden crisis.
One of the contributing factors in paramedic safety and patient safety is the role of fatigue. Fatigue is a feeling of tiredness that has a gradual onset but can affect mental and physical abilities. In the EMS work environment, fatigue can result from extended work hours without rest and may contribute to injury, vehicular accidents, and medical errors.
Articles & Papers
The first reference to EMS provider fatigue found in a PubMed search is from a 1991 JEMS article by McCallion and Fazackerly called Burning the EMS candle. EMS shifts and worker fatigue.  Since 1991, there have been more than 20 papers on the topic of EMS fatigue and shift work. Nearly half printed in peer-reviewed journals; including several by Daniel Patterson, Ph.D. at the University of Pittsburgh. EMS World published the most in a non-peer reviewed publication.
Case Study – Austin, Texas
In 2007, former Austin-Travis County Medical Director Ed Racht, MD (now Chief Medical Officer at American Medical Response) presented the results of a study commissioned by the EMS department as they considered transitioning from an all 24 hour shift system to shorter shifts in the urban EMS system. The consulting firm – CIRCADIAN – found:
- Two-thirds of the staff reported they felt they where working too much and nearly one third worked in access of 72 hours per week.
- Fifty-seven percent had worked more than 48 consecutive hours in the past two weeks.
- Nearly half reported having a second job where as many as 13% worked more than 20 additional hours.
When they looked at EMS provider sleep, only 61% reported getting 7 hours or more sleep before coming into work and, once on shift, the amount of sleep possible varied by station call volume density. Less than 30% receiving 7 or more hours sleep in a 24 hour period. What did EMS providers say was the effect of sleep deprivation due to long shifts: drowsiness while responding to calls 70%, nodding off while driving, 52%, making mistakes 13%, and falling a sleep at the wheel 5%. In addition, EMS providers admitted resulting fatigue and stress impacted quality of care and customer service. 
Absence of EMS Industry Position
With the attention on EMS safety and extended work hour related fatigue, one would expect to find an industry position statement on shift length and off duty rest. A search of professional organization position statements (e.g. NAEMT, AAA, NAMESP, etc.) found none and there was no recommendation in the recent National EMS Culture of Safety strategy document.  The International Association of Fire Chiefs produced a report on the effects of sleep deprivation on EMS providers and firefighters in June of 2007, that includes a comprehensive review of the literature, recent cases, and how this may be considered, but it makes no recommendation for how leaders or regulators should change todays practice.  Also, the National EMS Advisory Council published an official advisory on Fatigue in Emergency Medical Services in 2013 that defines the issue and makes three recommendations for the NHTSA to further study the issue and share information. [Updated 9/11/14]. The industry has no published position standards to date.
Recommendations – What you need to do
The literature specific to EMS fatigue and shift work hours is light. This is not dissimilar to other problems in the EMS literature (e.g., deployment). There is guidance found in transportation industries like rail, air, and sea or nuclear power plant workers, or something more similar like doctors in training that can act as a reasonable benchmark. See table below.
Table. Work Hour Requirement Comparisons
|Industry||Allowable Shift Length||Off-Duty Rest||Sleep|
|Airline Pilots||8-9 hours||10 hours||8 hours|
|Truck Drivers||11-14 hours||10 hours||8 hours|
|Rail Operators||12-16 hours||8 hours|
|Nuclear Power Plant Operators||16 Hours|
|Doctors in Traing||12-16 hours (12 in Emergency Department)||10 Hours|
|Paramedics||No Standard||No Standard||No Standard|
Absence of robust EMS industry specific evidence to support change is not a responsible excuse for inaction when there is significant evidence in other industries to guide. Other resistance may come from administrators’ challenged with the complexity and expense of shorter shift schedules and with providers who have longer commutes, responsibilities in addition to their primary employer, and reliance on overtime income. These are all very real and important to appreciate and incorporate when making any change.
In a 2013 interview in EMS World, CIRCADIAN Vice President of Operations Bill Davis suggested the following guideline considerations:
- Limit the number of hours in a shift to 12 hours.
- Limit the number of consecutive days on—generally about seven 8-hour shifts in a row, or no more than 4–5 12-hour shifts in a row.
- The schedule has to provide sufficient rest and recovery time. Allow a couple of full days off per week to burn off sleep debt 
One addition I would add, borrowing from the transportation industries, is that shifts should be separated by 10 hours of off time with 8 of those hours for sleep.
The safety of our communities, our medics, and our patients should be a key tenant of every EMS system. It’s time for frontline providers and professional organizations to step up and establish industry guidelines for shift work hours that reduce risk and fatigue. There may not be a one size fits all, but there is plenty of guidance from other industries to support a start and protect the majority. It’s time for action.
David M. Williams, Ph.D. is a researcher, consultant, & chief executive of the international consulting firm Medic Health. He is also an improvement advisor and faculty for the Institute for Healthcare Improvement. Contact him at www.medichealth.com.