We know sleep is important, so why do we often find ourselves getting too little of it?
Fatigue is not a new problem for EMS providers, but there’s a big difference between feeling worn out after a particularly busy shift and actual fatigue caused by sleep deprivation. And managing fatigue is the responsibility of both the provider and the agency they work for.
Maybe you’re saying, “Sure, I could stand to get a few more hours of shut-eye every night, but I’m still able to perform my duties just fine, even if I am a little tired.” Or, “I can function fine on just a few hours of sleep every night.” Well, perhaps you can. But a functional alcoholic is still an alcoholic. Just because you’re managing the day-to-day right now doesn’t mean there’s not a greater underlying problem.
“Any industry or entity that has to work in a 24/7 world is going to face fatigue,” says Bill Davis, vice president of operations for CIRCADIAN, a global leader in providing 24/7 workforce performance and safety solutions for businesses that operate around the clock. “Our bodies were designed to be awake during the day and find the safety of the cave at night so we could recharge our batteries. From the time humans have existed on the face of the earth, we naturally got up with the sun, did what we needed to do during the day, and when it got dark outside, there wasn’t anything else we could do. It’s only been a little over 100 years since we found an effective way to produce artificial light, and now there are more than 24 million Americans working either shift work or straight nights. That just hasn’t been long enough for us to break our genetic code. Even though we have people who work nights, night hours do not equal day hours.”
CIRCADIAN works with a number of industries that deal with fatigue, including EMS, but it was the transportation industry that really was the pioneer in finding ways to combat fatigue, Davis says. For industries like trucking, the U.S. Department of Transportation implemented hours-of-service (HOS) regulations. The intent behind those regulations is good, according to Davis, but sometimes the models themselves are too simplistic.
“The more you work or the longer you’re awake, the more fatigued you become,” Davis explains, “and then the longer you’re at rest—and particularly at sleep—the more you’re able to burn off that fatigue. That does make some sense. It’s kind of an hourglass design. As you’re awake the sands go from the top to the bottom. You deplete your body, you start to increase your fatigue, and then when you get to that point, you turn the hourglass over, and now you’re getting your rest again.”
But HOS regulations don’t account for the circadian factor, which goes back to not all hours of the day being equal when it comes to fatigue. Davis says studies show there’s a specific period of time, for most people around 2 a.m. to 6 a.m., where our ability to respond is decreased. It’s called the window of circadian low, or WOCL. And the studies indicate when talking about fatigue in 24/7 operations, it’s important to be very mindful of the time of day, as well as the number of hours of service.
Davis notes the second thing HOS regulations don’t adequately cover is schedule regularity—or, more simply, if the hours spent working plus the hours of time off don’t equal 24. An example would be with passenger carrier drivers. Under DOT regulations, they can drive a maximum of 10 hours after having eight hours off duty. On the first day a driver starts at 8 a.m., works for 10 hours and gets off at 6 p.m. After taking the minimum eight hours of rest, the driver can start to drive again at 2 a.m.
“What we normally find is that schedules that cause you to start your next day earlier than you started today—called a backward rotating schedule—are more fatiguing,” explains Davis.
Among the EMS agencies CIRCADIAN has worked with is Austin-Travis County EMS in Texas. Davis says one of the things they found was that in Austin-Travis’ heavy metropolitan districts, a 24-hour schedule was too fatiguing because it meant providers could be awake for 24 hours straight or longer. However, in a rural part of the county, a 24-hour shift might be more acceptable because providers would have time to rest.
Davis believes, in most cases, shifts shouldn’t last longer than 12 hours, because of the physiological toll a longer shift has on the body. He points to research that shows a person who’s been awake for 24 hours has the same detriment in speed and accuracy of response as a person who has a blood alcohol content of 0.10—legally drunk in all 50 states. “So while we would never allow EMS personnel to be on duty under the influence of alcohol, what do we do to make sure they’re not equally under the influence of fatigue?”
Davis says there are a few steps EMS agencies can take to proactively combat provider fatigue. First, take a scientific approach to fatigue management, which has to start with educating providers and management about circadian rhythms, how the body functions and what its limits are. Second, use that information as part of a three-step process to design schedules that will provide adequate coverage while minimizing fatigue:
• The schedule must satisfy demand and operational requirements.
• The schedule must match physiological criteria.
• The schedule must satisfy provider expectations.
Individual agencies should already have a good grasp on the level of demand and operational requirements in their service areas. Physiological requirements should shape the schedule in the following ways:
• Limit the number of hours in a shift to 12.
• 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.
• Then the schedule has to provide sufficient rest and recovery time. “People tend to get less sleep when they work than on days when they’re off,” says Davis, “and we find people who work night shifts sleep less than people who work during the day.” Because people build up a sleep debt on days they work, the schedule has to allow a sufficient amount of time to burn off that sleep debt before they go back to work. According to Davis, two full sleep episodes can burn off the sleep debt most people generate over a 7–10-day period.
It’s also important to speak with providers and find out what they actually want to see from schedules. “We often find employees like longer shifts because they provide longer breaks,” Davis says. Employees often prefer having full weekends off—including Fridays, if they can get them—and like schedules that periodically provide anywhere from 4–7 days off in a row.
Unfortunately, there is no one-size-fits-all schedule. Demand is not the same every hour of the day and every day of the week. There are peaks and valleys. But, Davis says, if you study the trends long enough, history can help determine when you need certain staffing levels and ensure, as much as possible, the right number of people are scheduled per hour each day. As a result, an agency might require a variety of schedules that are overlaid to match the demand of its service area and the desires of its providers.