EMS providers may soon see mandated on-shift napping, sleep hygiene education and shorter shifts if sleep experts have their way.
These are just some of the objectives to emerge from a research project that the National Highway Transportation Safety Administration (NHTSA) began in 2013.
The project—“Developing Evidence-Based Fatigue Risk Management Guidelines for Emergency Medical Services,”—is being led by the expert panel that was formed after the National EMS Advisory Committee (NEMSAC) recommended the EMS community receive evidence-based guidance on how to prevent provider fatigue.
In February 2016, the panel began studying fatigue risk-reduction techniques. Partnering with the National EMS State Officials (NASEMSO), the panel reconvened in February 2017 in Falls Church, VA, to review their findings. They plan to publish by early fall of 2017.
Principal investigator P. Daniel Patterson, PhD, assistant professor of emergency medicine at the University of Pittsburgh, is leading the expert panel in evaluating seven specific research questions about fatigue. The expert panel includes sleep medicine physicians, fatigue scientists, epidemiologists, emergency medicine physicians, EMS clinicians, EMS administrators and consumer representatives. The panel was composed based on recommendations by the Institute of Medicine for the development of evidence-based guidelines.
The group follows a rigorous, scientific process that first screens potentially usable studies (over 30,000 in total), then analyzes them for inclusion in the research. From there, the evidence is considered in concert with other important factors. These other factors include the balance of the intervention’s benefits and harms, the values and preferences of the target population, and the costs (resource needs) associated with a particular intervention. Once this is all reviewed and debated, the panel may issue recommendations to EMS agencies across the country.
The need for this work was clear, according to Patterson, who has studied safety in EMS for over 10 years. “Surprisingly, there have been no prior efforts to develop guidelines for fatigue management based on the evidence,” Patterson says. “While numerous shift worker industries such as aviation, professional truck driving, maritime, nuclear power and manufacturing have shown a concern for safety, to our knowledge this is the first time anyone has attempted to develop evidence-based guidelines for fatigue risk management.”
Certain hurdles exist for employers to control a provider’s sleep. Supervisors cannot ensure that their employees are getting enough sleep while off-duty, the panel acknowledged, so there is a need to implement procedures to guarantee providers are alert and operationally efficient.
Perhaps most interesting to EMS providers is the panel’s finding that mandating naptime during a provider’s shift can alleviate fatigue. The panel discussed the idea that a unit should go out of service for a scheduled time during the shift, and that providers should then be given a dark, quiet space where they can “be horizontal” for a period of 20 minutes to an hour.
Panel member Douglas Kupas, MD, is the Commonwealth EMS Medical Director for the Pennsylvania Department of Health, Bureau of Emergency Medical Services. Diving further into the issue, Kupas noted the importance of giving providers time to recover from this mandated nap: “We probably should not have providers go right back to duty upon waking,” Kupas said.
Indeed, many EMS providers sleep overnight as part of their duty day, and they are often awakened from sleep by 9-1-1 calls. But employer guidelines for mandated napping should take into consideration the dangerous effects of so-called “sleep inertia”: the finding that task performance is negatively affected when workers are asked to perform immediately upon waking.
The panel also recognized that their recommendations may face the obstacles of longstanding fire department traditions and culture, as well as negative public perception. In some agencies, napping on the job is cause for dismissal. And, if the public sees workers sleeping “on the clock,” they may think that providers are lazy and wasting taxpayer dollars.
However, Gerald Krueger, PhD, psychologist with the Transportation Research Board, an attendee at the meeting, thinks a change in culture is achievable. He cited a military study where special forces personnel implemented a nap within their workday.
“If the special forces can take a power nap in the afternoon, having a napping strategy may be a good way to go,” Krueger said.
The panel also analyzed the great variety of shift work schedules across many industries. While the most common EMS schedules tend to be 12- and 24-hour shifts, some are using 48-hour shifts. Patterson and his team found that they can most safely recommend a shift of no more than 24 hours in length. The dangers of shift work are clear: if one cannot achieve a true sleep cycle in a 24-hour period, there are greater risks. Further, shorter shifts have been shown to result in fewer injuries.
According to most surveys, a problematic response to this finding is that the average emergency worker prefers 24-hour shifts, as they are more compatible with their lifestyle. Patterson is aware of this reality, as he is a practicing paramedic in Pennsylvania. His extensive, firsthand knowledge of the realities of EMS are an asset to the panel.
“Shift work in EMS is not like shift work in other settings, because the workload is often unpredictable,” said Patterson. “There are brief moments of high mental and physical stress followed by periods of uncertainty and inactivity. Part of my role in this project is to inform and guide a diverse group of experts and scientists in what is and is not relevant to EMS.”
Other notable findings include the recommendation that caffeine is an acceptable countermeasure for fatigue and that there are benefits to educating providers about healthful sleep. This research topic, led by Laura K. Barger, PhD, an instructor in Medicine in the Division of Sleep Medicine at Harvard Medical School, and an Associate Physiologist in the Division of Sleep and Circadian Disorders at Brigham and Women’s Hospital, uncovered data that showed positive effects of educating providers and their family members on sleep hygiene, exercise, diet and screening for sleep disorders.
Patterson and his team are motivated by the unique opportunity of this project. He believes that all those involved in EMS should be proud of this development.
“This work will reach beyond EMS and guide the fatigue management work of other shift-worker populations,” he said.
Hilary Gates, MEd, NRP, is a paramedic in Alexandria, VA. She is an EMT instructor and teaches in the School of Education at American University. She began her career as a volunteer with the Bethesda-Chevy Chase Rescue Squad. Gates has experience as an EMS educator and symposium presenter, and is involved in quality management and training for the fire department.