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How Do You Measure Fatigue?

More than half of EMS personnel have reported severe mental and/or physical fatigue while on duty, according to recent industry research. Until recent years the extent of the problem generally has not been recognized, and little guidance was available to EMS leaders and personnel to address the issue. Because there is no “one size fits all” approach, many EMS organizations have struggled with fatigue risk management, or the methods, procedures, protocols, and policies used to mitigate the negative effects of fatigue in the workplace.

In February 2018 Prehospital Emergency Care published “Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services.1 The Fatigue in EMS Project, led by Daniel Patterson, PhD, of the University of Pittsburgh Department of Emergency Medicine, aimed to create an evidence-based guideline for fatigue risk management tailored to the EMS industry. VFIS contributed the following comments to the report, emphasizing the risks associated with fatigued EMS personnel:

EMS personnel respond to a variety of incidents and are continuously reviewing ways to improve outcomes for patients and the safety of personnel and providers. VFIS has recognized fatigue as a contributing factor in emergency vehicle accidents, clinical errors, and other incidents caused by human error. The readiness of the responder is a critical factor in operational efficiency and effectiveness.

Evidence-based guidelines contribute to the available research and best practices related to fatigue. VFIS encourages emergency services organizations (ESOs) to consider these sources in determining how to best address fatigue within their organization. Innovative solutions must continue to be sought in order to instill a culture of safety within an organization and the EMS industry. Despite the nationwide scope of fatigue, each ESO may combat fatigue differently based upon the unique characteristics of their EMS system. Identifying and reducing the level of fatigue in the EMS workforce is a priority concern to ensure the safety of patients and personnel.

Fatigue has the potential to impair the cognitive and psychomotor functions of personnel. For decades NIOSH has acknowledged that shift work can be “linked to negative health effects and deficits in performance leading to injury and error.”2 A contributing factor in emergency vehicle crashes, fatigue can diminish driver attentiveness and reaction time.

Fatigue Risk Assessment

The level of fatigue experienced by EMS personnel varies between shifts and from one station to another. Insufficient staffing and unexpected call-offs are ongoing challenges. To effectively manage the risk, an EMS organization must understand the factors that contribute to the fatigue of personnel, including:

  • Number of hours worked consecutively;
  • Number of miles driven;
  • Number of incidents or transports handled;
  • Off-duty activities, personal schedules, and/or working multiple jobs.

But according to an Australian study, 18 hours without sleep can have a comparable effect on driver reaction time as a blood alcohol concentration of 0.05, and with 24 hours of sleeplessness, the effects are similar to a blood alcohol concentration of 0.10.3

The guidelines recommend using fatigue/sleepiness survey instruments to measure and monitor fatigue in EMS personnel, but there is currently no industry-standard unit of measurement or instrument used to assess fatigue. Researchers continue to evaluate the reliability and validity of fatigue-measurement methods in the EMS; however, Patterson, et al. found “limited, though positive evidence supported many of the instruments included” in his study.4 Until a consensus standard is defined within the EMS industry, some EMS organizations have selected methods that best align with their operations, as recommended by National Association of State EMS Officials.5

EMS leaders must make the health, safety, and wellness of their personnel a priority. The consequences of a fatigue-related incident are not in anyone’s best interest. If the risk of fatigue is not managed appropriately, the safety of EMS personnel, patients, and the general public could be in grave danger.


1. Patterson PD, Higgins JS, Van Dongen HPA, et al. Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services. Prehosp Emerg Care, 2018 Feb 15; 22(supp1): 89–101.

2. National Institute for Occupational Safety and Health. Work Schedules: Shift Work and Long Hours,

3. AAA Foundation for Traffic Safety. Acute Sleep Deprivation and Risk of Motor Vehicle Crash Involvement,

4. Patterson PD, Weaver MD, Fabio A, et al. Reliability and Validity of Survey Instruments to Measure Work-Related Fatigue in the Emergency Medical Services Setting: A Systematic Review. Prehosp Emerg Care, 2018 Feb 15; 22(supp1): 17–27.

5. Patterson PD. Evidence-Based Guidelines for Combatting Fatigue in EMS. J Emerg Med Serv, 2018 Feb; 43(2).

Justin Eberly, MPA, CTO, EMT, is an education and training specialist for VFIS, a subsidiary of the Glatfelter Insurance Group, responsible for the national delivery of educational and training programs, curriculum development, and information analysis. He is an active EMT and volunteer firefighter in Cumberland County, Penn.

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