Seeking Shift Work Solutions

• Performance insight involves the ability to self-monitor one’s performance level and fatigue, and recognize its impact on memory, spatial ability, comprehension, motor function and reaction times.

• Controlling emotion. Paramedics are often in emotion-provoking situations, which can negatively influence decision-making.

Legal Implications

The U.S. Department of Transportation identifies fatigue as the No. 1 safety problem in transportation operations, with a cost of more than $12 billion per year, and NHTSA estimates drowsiness is the primary causal factor in more than 100,000 police-reported motor vehicle crashes each year, resulting in 76,000 injuries and 1,500 deaths.6 As a result many states are establishing laws pertaining to driving while distracted, including driving while drowsy. New Jersey now has what is known as Maggie’s Law, which specifically provides that a “knowingly fatigued” driver who causes a fatal accident can be convicted of vehicular homicide. Fatigue in this instance is defined as having been without sleep for a period in excess of 24 consecutive hours. Even in states without specific laws, criminal negligence charges may be levied against drivers who operate while drowsy. One case recently occurred in Georgia when an ambulance operator was charged with reckless driving after he fell asleep while transporting a patient. Witnesses said the ambulance was across the center line for more than 1.5 miles prior to a head-on crash that injured five.7

In addition to criminal penalties, fatigued employees may be held liable for injuries they cause under civil law. Additionally, employers can be held liable in civil suits as well under the doctrine of respondeat superior, and could be liable to the public for damages caused by their employees. Additionally, if an employer has knowledge of an employee’s fatigued status, the employer may also be at risk for negligently allowing its fatigued employee to cause an accident or injury to a patient.

A Shared Governance

Employees sometimes place the burden of fatigue on management, which controls shift schedules, duration and frequency. Conversely, employers tend to believe employees work too much and overextend themselves by skirting rules on part-time employment and off-duty activities. Both are right in that properly addressing issues of shift work, fatigue and risk takes a cooperative effort.

What can employers do to manage fatigue?

• Identify at-risk workers—Sleep apnea is associated with increased daytime sleepiness, and there are a host of other health conditions that can interrupt employee sleep patterns.

In general, the ability to adjust to night shift work and extended shifts diminishes with age. Conversely, as studied in the trucking industry, there appears to be greater risk associated with younger drivers than older ones. Older drivers are more likely to limit their exposure to risky driving situations, whereas younger drivers are more prone to risky behavior when operating vehicles in sleep-deprived states. This issue can be particularly concerning for EMS organizations, since, for many reasons, the youngest and most inexperienced employees tend to migrate to night shifts.

• Commuting issues—The most common times of day for drowsiness-related crashes are in the morning and mid-afternoon. This also often coincides with healthcare shift work. The safest approach to this issue is simply not to drive drowsy. Employers can take an active role in this issue by educating staff about the dangers and providing alternative means of transportation for tired staff members or allowing them to take naps before driving home after shifts.

• Structuring work hours—Shift duration, patterns and sequencing unfortunately have yet to be comprehensively studied in the EMS setting; thus the industry tends to look at other facets of healthcare and other industries for information on structuring work hours. Due to the wide variation in current EMS work structures and staffing patterns, it is difficult to make specific recommendations regarding ideal shift structures. However, principles from other healthcare disciplines and industries may be applicable when examining our industry’s shift structures.