Sleep Deprivation and Fatigue in Emergency Medical Personnel

 Sleep Deprivation and Fatigue in Emergency Medical Personnel: Causes, Impacts, and Solutions

Abstract

Emergency Medical Personnel typically work shifts that last an extended length of time, typically, 24 hours.  Because of these long work hours Emergency Medical Personnel go long periods of time without sleep or rest.  As a result, sleep deprivation and fatigue quickly set in.  Also, because of the low pay most Emergency Medical Personnel also work at least one additional EMS job which only adds to their fatigue and sleep deprivation.   This level of sleep deprivation becomes a major safety issue especially when the physical fatigue that is incurred from lifting heavy patients and the other physical aspects of the job are factored into the equation.  Research has shown that a vast number of motor vehicle crashes that involve ambulances are a direct result of sleep deprivation and fatigue. There are possible solutions to this safety problem and will be addressed in this study.  The information that will be brought forth has been gathered from professional journals and data that has been gathered from the research that has been gathered by the National Transportation Safety Board and the United States Department of Transportation.

PROBLEM STATEMENT

The Paramedic and Emergency Medical Technicians who work in Emergency Medical Services typically work long periods of time with little to no sleep.  Many EMS Services work a 24 hour on duty 48 hours off duty schedule.  Because of high call volumes EMS personnel do not get the chance to get adequate rest or “downtime” between call.  In addition to the sleep deprivation they are constantly subjected to rises and falls of adrenaline which adds to their fatigue.  Because of the low pay most EMS personnel work an additional job on their off days, usually in EMS.  This means that they potentially may go for days with little to no sleep and must perform their work while being extremely sleep deprives and fatigued.  This bring to the forefront the hazards presented by their sleep deprived and extremely deprived state.  They are much more likely to be in a motor vehicle accident and are a hazard to themselves, their patient, and to the public in general.  They are much more likely to also make an error in administering medications or implementing other treatment that their patient needs.  Emergency medical professionals are routinely expected to rise above and beyond their personal concerns and human weaknesses to deliver excellent, consistent care to their patients, regardless of the circumstances.  It is this ideal that allows the public to trust strangers with their lives and the lives of their family members, but rarely, if ever, does the public stop to consider the personal cost to the medical professional.  Therefore, the paramedic is indirectly taught, through public expectation, to put his or her personal health after the patient’s health.  Also, medical professionals are often expected to place their mental and physical health after the expectations of their family, friends, and even their own employer.

HYPOTHESIS

The personnel who work in Emergency Medical Services must perform their job descriptions while being extremely fatigued and sleep deprived.  This study will investigate and will provide research data that will show how severe the problem is and what possible solutions are that can be implemented to mitigate the hazard and eliminate it altogether to make Emergency Medical Services personnel, their patient, and the public safer.  The effects on the human body will be researched to learn what going for extended periods of time does to the human body from a physical and from a psychological viewpoint.  It has been proven through research that the personnel who work in Emergency Medical Services have a much higher instance of divorce, drug and alcohol abuse and suicide.  How this is related to working extended hours while sleep deprived will be presented.  How sleep deprivation and Post Traumatic Stress Disorder is related will be researched and the data that is discovered will be presented.

Proposal

PO 1- Anticipate, recognize, evaluate, prevent and control workplace safety and occupational health hazards within numerous industries to protect people, property, the environment and organizational operations.

An extensive review of literature will be completed to explore the issues of sleep deprivation and fatigue among Emergency Medical Services Personnel.  The literature review will include detailed information concerning the causes and the results of sleep deprivation and fatigue brought about by the extended workhours and the sometime heavy and chaotic workloads that are a part of Emergency Medical services.

PO 2- Effectively manage the occupational safety and health function within a variety of  

Industries.

Working in Emergency Medical Services is a dangerous field by nature.  EMS personnel must work in all types of weather, in dangerous situations such as natural disasters, and must perform under intense pressure.  Adding fatigue and sleep deprivation only adds to the dangers of the job.  This section will discuss how certain safety measures could be implemented and followed that would reduce the hazards brought forth by sleep deprivation and fatigue.  These

practices have already been implemented in other areas of the world and have been found to be extremely beneficial and to have reduced the hazards.   Topics that will be addressed will be the definition of sleep deprivation and fatigue, the effect sleep deprivation has on the human body from both a physiological and psychological perspective.  Other topics that will be covered are how to educate the worker to recognize the effects of sleep deprivation and how to mitigate its negative effects.  The safety practices that will be presented will be backed up with data obtained from scholarly works were safety measures have been tested and the results have been positive.

PO3-   Justify occupational safety and health programs, initiatives and control efforts through the use of business and risk management metrics, by maintaining compliance with applicable standards and regulations or through scientific evaluation of outcomes.

The implementation of safety practices that will mitigate or eliminate the hazards brought about by performing while sleep deprived and overly fatigued will be investigated.  The costs of implementing such a program will be researched and a comprehensive study and its results will be revealed.  The results that evidence has shown to occur because of sleep deprivation will be shown.  It will be clearly and concisely shown that implementing a safety program that mitigates the hazards of sleep deprivation and excessive fatigue is extremely cost effective both from a business viewpoint and from a worker safety viewpoint.

PO 4- Effectively communicate and interact with persons at all levels within an organization and externally about occupational safety, health and environmental management.

The ability to communicate health hazards and to educate workers in safe work practices is a skill that all Safety Professionals must possess and must do effectively.  This section will show how an effective safety education program would be put together, implemented, and enforced.  This plan will be explained in detail.  This will be done by showing how other EMS Services in other locations around the globe have implemented these safety practices and have had a marked reduction in hazard occurrences.

PO 5- Practice and perform in an ethical, moral, responsible, and accountable manner in all aspects, but especially in the practice of safety.

One of the main characteristics a Safety professional must possess is the conducting of themselves in an ethical, moral and responsible manner.  They are responsible for the safety of the workers, the public and for the protection of the environment.  There have been instances where EMS personnel have been forced by management to perform while sleep deprived and the results were unfortunate.  This research will show how these unethical practices resulted in the loss of life, damage to property and great financial cost to the ambulance service involved.

PO 6- Identify an occupational safety and health research problem; complete a thorough review of the scholarly literature; formulate hypotheses; collect and appropriately analyze data; and, interpret and report research findings to improve the field of occupational safety and health or to provide solutions to an occupational safety and health problem.

This research project addresses safety and health management of sleep deprivation and fatigue among Emergency Medical Services personnel.  The project includes a thorough review of the literature, especially as it relates to sleep deprivation and fatigue and the causes, hazards, resulting happenings, and the implementing of certain safety policies and practices that act to mitigate the damage incurred by the hazards.  Literature that conveys direction in the implementing of safety policies concerning sleep deprivation will be covered and how to implement these policies will be clearly and concisely covered and explained.

PO 1- Anticipate, recognize, evaluate, prevent and control workplace safety and occupational health hazards within numerous industries to protect people, property, the environment and organizational operations.

The public depends on the quick reactions and educated decisions of every Paramedic and//or Emergency Medical Technician on every call they respond to.  EMS personnel must deal with a plethora of situations such as cardiac arrests, falls, motor vehicle accidents and other traumas, and serious medical conditions on a constant basis.  Emergency Medical Services can be defined as “health care for people with real or perceived emergencies from the onset of emergency dispatch until the care of the patient is turned over to a hospital or other health care facility.  Emergency Medical Services places a multitude of stressors each paramedic and / or EMT.  They are expected to for extended shifts, usually 24 hours, with little to no sleep or rest, are constantly placed in positions where they must lift heavy loads (i.e. people) from awkward positions (i.e. off floor in confined spaces such as bathrooms) and their adrenaline levels are constantly fluctuating.  The constant up and down of the levels of adrenaline in their body only serves to exacerbate their already sleep deprived and fatigued condition.

It is common practice for paramedics to work 24-hour shifts, not including overtime.  This total to over 2880 hours worked annually.  In most emergency medical services, 24-hour shifts are normal, with forty-eight hours off between shifts to recover.  Unfortunately, many services nationwide are short of paramedics, and the available personnel work an additional twenty-four hours’ overtime with only twenty-four hours off for recovery.  When one includes these added overtime shifts, many EMS professionals may work as many as 4000 hours a year (

The average middle-income employee in the United States works a standard 40-hour work week, which totals 2080 hours worked annually.  Compare this to the normal work year for an average paramedic and one finds that paramedics work an additional 800 hours a year—not including overtime shifts.  This average out to be a base 55-hour work week.  During the 24-hour shift, paramedics may not get the opportunity to sleep more than a few hours, if the opportunity occurs at all.  Or worse, they may get to sleep only to be reawakened several times throughout the night.  All career paramedics will admit that during a busy night it is usually preferable to stay awake all night rather than be reawakened several times, due to the additional stress it creates.  In addition, the awakening is done by loud, obnoxious alarms that instantly activate the sympathetic fight or flight response, which causes an immediate hormone surge in the nervous system.  Yet, through this natural, heightened physical response, the paramedic must be able to think quickly and act to make good, rational decisions because someone’s life may depend upon it.

It has been recommended that healthy adults receive at least six hours of sleep per night.  The effects of sleep deprivation and / or being fatigued has been shown to have a devastating effect on decision making and usage of given information.  Sleep deprivation has been connected to the onset of obesity, diabetes, cardiac disease and the lowering of the immune system.  A literature search indicated little prior research linking sleep-related problems to outcomes specifically for EMS personnel.

As is shown by the above chart from the AAA Foundation for Traffic Safety (2016) drivers who got less than 4 hours of sleep have a 11.5% chance of being in an accident versus the drivers who could get 7 hours of sleep have 1.3 % chance of being in an accident.  Sleep deprivation plays a major role in automobile crashes and represents a major health and safety hazard in the workplace.

Research has shown that in vehicle crashes where the driver had been awake for twenty hours or more without rest their chances of being in an accident were 19.9 percent and where the driver was severely fatigued there was a 17 percent chance of being in an accident.  If the driver had been able to receive 4 hours of sleep or less the night before the chances of them being involved in an accident rose to 22.3 percent.  Obviously, this poses a major safety hazard.  The National Transportation Safety Board has investigated ambulance crashes and has determined that one of the main contributing factors in the causes of the accident has been sleep deprivation and driver fatigue.  They determined that sleep deprivation and fatigue played a major factor 45 percent of the time (Studnek and Fernandez, 2008).

The extended periods of sleep deprivation and the resulting fatigue is exacerbated when the EMS personnel has a chance to get quality restorative sleep.  The bodies circadian rhythm is altered and in many instances the worker is “too tired to sleep” which only brings about more fatigued and the vicious cycle continues.  Using a sample of EMS personnel in the USA (Studnek and Fernandez, 2008) found that 14.9 percent of EMS professionals who reported having sleep problems were involved in an ambulance crash, compared to 7.5 percent of those who did not have sleep problems.

Paramedic and EMT’s also have the additional problem of being awaken from deep sleep to fully awaken at all hours of the night with no warning.  His sudden awakening disrupts the body’s normal circadian rhythm and also cause a spike in blood pressure.  After the call the paramedic or emt has difficulty in going back to sleep which only worsens their already sleep deprived state.  In addition to these sleeping difficulties ,ems workers can also have other safety hazards  brought about by sleep deprivation. For example, one safety hazard brought about by sleep deprivation can be falling asleep during hours when the human body is used to be awake.  Working shifts that last 24 hours has been shown to cause  lead an increase in the ems workers state of being sleepy and fatigues.  Since EMS personnel often have lengthy periods of work with no rest, this may lead to an increase of the hazards brought about by sleep deprivation. The possibility of sleep disturbance and fatigue potentially compromises the role of the paramedic, (Williams, D. M. 2014).  High- speed driving, patient communication and drug administration are routine and has been shown to be a direct factor associated with paramedic caused by sleep deprivation.  Also, associated with issues of sleep deprivation are concerns about depression, the constant rise and fall of the EMS crew’s adrenaline levels coupled with the unfortunate fact  that paramedics are faced with a greater emotional burden as they experience the peaks and valleys  of human emotion on a regular basis, ( Williams, D. M., 2014).

Alertness, vigilance, concentration, judgement, mood and performance are all significantly affected by fatigue, with memory impairment, problem- solving and decision-making leading to decreases in work productivity and performance.  Such mental and physical stressors make way for the possibility of increased risk, which could manifest itself in the form of accidents, errors and injuries to individuals or others.  Paramedics are subject to disturbances in sleep and, in prehospital emergency care, fatigue is a growing issue as paramedics are faced with longer working hours and an steadily increasing call volume. . A National Sleep Foundation poll found 20% of Air Ambulance pilots have reported making mistakes due to fatigue, and this percentage doubles in drivers of a ground ambulance. In a study from a recent article from the Association for Psychological Science, “F-117 pilots deprived of one night of sleep were tested on precision instruments.  Not only did pilot errors on those instruments double after one night of sleep loss, pilots reported feeling depressed and confused ”(Wilson, D. 2015, November 06). 

PO 2- Effectively manage the occupational safety and health function within a variety of  

           Industries.

Working in Emergency Medical Services is a dangerous field by nature.  EMS personnel must work in all types of weather, in dangerous situations such as natural disasters, and must perform under intense pressure and do their job accurately and with precision.  Adding fatigue and sleep deprivation only adds to the dangers of the job.  This section will discuss how certain safety measures could be implemented and followed that would reduce the hazards brought forth by sleep deprivation and fatigue.  These practices have already been implemented in other areas of the world and have been found to be extremely beneficial and to have reduced the hazards.   Topics that will be addressed will be the definition of sleep deprivation and fatigue, the effect sleep deprivation has on the human body from both a physiological and psychological perspective.  Other topics that will be covered are how to educate the worker to recognize the effects of sleep deprivation and how to mitigate its negative effects.  The safety practices that will be presented will be backed up with data obtained from scholarly works were safety measures have been tested and the results have been positive.

The risk of negative outcomes for the EMS worker and patient is high and different from risks from within the hospital.  For example, the EMS worker decides to provide medication or other treatment within minutes or even seconds of establishing a general impression of patient and condition.  These decisions are made while in a fast-paced and uncertain environment where the patient and bystanders can be violent, create distractions or disrupt care delivery.  Decisions are based on written protocols and radio-enabled assistance from a medical oversight physician.  Care may be delivered with some assistance from a single partner, an EMT or paramedic.  Most often the paramedic or EMT is in control of patient care alone in the back of an ambulance

EMS workers must be alert and vigilant always to prevent errors in protocol and injury to patients or each other.  Identified errors in EMS care include deviating from protocol, failure to secure a patient’s airway, dropping a patient from a stretcher, and mistakes in administration of medication.  Threats to the EMS worker’s personal safety include violent patients and bystanders, high-speed ground or air-medical transports, lifting and moving patients, and exposure to hazardous materials and contaminated substances and needles. Rates of EMS worker injury and death while on the job exceed that of the public. Many EMS workers hold multiple public safety jobs, routinely working 50 hours or more per week. Unlike resident physicians, the U.S. EMS worker faces few restrictions on hours worked or number of agencies employed.

The implementation of a Safety Management System is one method that could be implemented to help mitigate the hazards of sleep deprivation and fatigue that are present in Emergency Medical Services.  One model that has been implemented and has shown to be beneficial and plausible is one that has been implemented for Emergency Medical Services personnel is a model that was first devised and implemented by the Emergency Medical Services that are in Japan.  The Emergency Medical Services have implemented several safety practices regarding sleep deprivation and fatigue.  The normal shift within Emergency Medical Services usually starts at either 7 a.m. or 8 a.m. and lasts for 24 hours.  The Japanese have discovered that by staggering the starting times of ambulance crews there has been a reduction in accidents.  By staggering the starting times a “fresher” crew is available.  They have also implemented the mandatory practice of 3 to 4 safety naps lasting thirty minutes spaced out during the twenty-four-hour shift.  Because the starting time of shifts is staggered a more rested ambulance crew is always available.  The workers diet is also carefully controlled while they are on duty.  Snack machines which contain sugary, high calorie foods and drink machines containing high caloric and carbonated drinks have been taken out of the EMS stations.  This is because high sugar, high carbohydrate foods tend to increase an already sleep deprived state.  Mandatory exercise has also been implemented.  Exercise has been shown to help advert the signs of sleep deprivation and fatigue.  There has also been a policy of “no-fault” sleep deprivation recognition among the ambulance crews.  Should a member of an ambulance crew recognize the onset of severe fatigue their ambulance is rerouted by dispatch to a nearby ambulance post and they must take a “safety nap’.  They may do this without any reprisal by management.  The attitude of the ambulance crew’s safety comes first is constantly shown and reinforced.  Of course, this practice may be abused so a comprehensive and detailed records of when and how often an ambulance crew pleads “fatigued”.  The results of the implementing of these sleep deprivation and fatigue mitigation practices have been phenomenal.  Since the implementation of the safety practices there has been a thirty-five percent reduction in ambulance crashes.  Employee job retention has improved by fifteen percent and the amount of worker sick time that has been utilized has decreased by eighteen percent.  The annual savings of the new safety practices has been estimated to be over eighty-five thousand dollars.

PO3–   Justify occupational safety and health programs, initiatives and control efforts through the use of business and risk management metrics, by maintaining compliance with applicable standards and regulations or through scientific evaluation of outcomes.

The implementation of safety practices that will mitigate or eliminate the hazards brought about by performing while sleep deprived and overly fatigued will be investigated.  The costs of implementing such a program will be researched and a comprehensive study and its results will be revealed.  The results that evidence has shown to occur because of sleep deprivation will be shown.  It will be clearly and concisely shown that implementing a safety program that mitigates the hazards of sleep deprivation and excessive fatigue is extremely cost effective both from a business viewpoint and from a worker safety viewpoint.  The tried and true metrics of safety measure the number and severity of accidents, how often the hazard happens and finally what is the overall dollar amount that the hazard occurrence winds up costing the business.  These metrics can be readily applied to the hazard of sleep deprivation in Emergency Medical Services.  Between 1990-2009 there were a total of 84,814 ambulance crashes.  Of these crashes, there were 17,889 injuries and 743 fatalities.  Of these accidents sleep deprivation and severe fatigue was named as a major contributing factor in eighty-five percent of ambulance crashes, (Studnek, J. and Fernandez, A., 2008).  These crashes incurred a damage amount of $1.1 million in damages.

One method that the occurrence of sleep deprivation is the implementation of safety activities.  These activities would include extensive training in the recognition of debilitating sleep deprivation and severe fatigue.  The theory is that if the worker can recognize when they are becoming severely sleep deprived they can take measures that would mitigate the hazard.  These methods may include exercise, the ingestion of caffeine, and mandatory safety “naps”.  Because participation in safety meetings and thus safety practices can play a major impact in the final results regarding the implementation of safety practices, the results can be accurately measured.  The perception of safety within the workplace must be changed so that the attitude of safety is foremost on the worker’s mind and shown in their actions.  The worker should be shown that safety practices do work and play a major role in keeping them, their partner, and their patient safer.  The implementation of safer work practices can change the perceptions that workers have.  It has been shown the one of the major impacts on behavior is perception and that improved behavior has a direct impact on accident reduction.  Behavior can be measured by observing the actions of the safety practices that are implemented.  Accident data can be measured as a percentage of safe behavior versus what is termed to be at risk behavior.

PO 4- Effectively communicate and interact with persons at all levels within an organization and externally about occupational safety, health and environmental management.

The ability to communicate health hazards and to educate workers in safe work practices is a skill that all Safety Professionals must possess and must do effectively.  This section will show how an effective safety education program would be put together, implemented, and enforced.  This plan will be explained in detail.  This will be done by showing how other EMS Services in other locations around the globe have implemented these safety practices and have had a marked reduction in hazard occurrences.

Paramedics and Emergency Medical Technicians depend on communication to perform their jobs effectively and to keep their selves and their partner safe.  Safety, especially scene safety, is taught and reinforced repeatedly from the first day of training.  Ironically, the hazard of performing their jobs while severely sleep deprived is briefly covered, if it is covered at all.  Therefore, the vicious circle of personnel going for days with little to no sleep continues.  It is the Safety Professionals duty to convey this information.  This can be done by implementing mandatory training on recognizing   the signs and symptoms of sleep deprivation and how to lessen the impact it has on their work performance.  The severity of sleep deprivation and how serious a safety hazard it is can be taught.  One method that a safety professional could convince upper level management is by showing them the cost of allowing EMS personnel to work while sleep deprived versus the benefits reaped for implementing a sleep deprivation prevention program.  When the cost of replacing or repairing an ambulance is added to the cost of workers compensation insurance claims, the cost of training a new worker, the liability assumed by allowing workers to work while sleep deprived, and the cost of possibly injury or loss of life, is compared to the cost of instituting a sleep deprivation prevention program, it becomes apparent quickly that a sleep deprivation program is much less costly.  The cost of one lawsuit would very possibly place the controlling body, ( county or city government, or private company), in financial ruins should they be sued for knowingly allowing a worker to perform their  duties while sleep deprived or severely fatigued.   A sleep deprivation avoidance program would only cost money in the purchasing of education materials and would cost in time the implementing of the new safety policies and education the workforce.   Given the fact that to replace a new ambulance cost upwards of two hundred thousand dollars, the cost of a sleep deprivation avoidance program is a bargain.  One key to being successful in the implementing of a sleep deprivation avoidance program is to change to the mindset of EMS workers regarding working while sleep deprived. Sleep deprivation in the world of EMS is accepted as something that is innate within EMS.  The workers in EMS know that working while sleep deprived is harmful to their bodies and unsafe but due to the low pay they have to work a secong EMS job.  Should the pay for EMS personnel be raised so that working a second EMS job is a choice and not a necessity, the instances of working while severly sleep deprived and fatigued would be avoided.  The safety professional should be able to show upper level management that even the cost of increasing the cost of payroll is much cheaper than the cost and added liability  of allowing workers to work while sleep deprived and unsafe.

PO 5- Practice and perform in an ethical, moral, responsible, and accountable manner in all aspects, but especially in the practice of safety.

One of the main characteristics a Safety professional must possess is the conducting of themselves in an ethical, moral and responsible manner.  They are responsible for the safety of the workers, the public and for the protection of the environment.  There have been instances where EMS personnel have been forced by management to perform while sleep deprived and the results were unfortunate.  This research will show how these unethical practices resulted in the loss of life, damage to property and great financial cost to the ambulance service involved.

Education on healthy sleep is a key component of sleep education.   Although the use of online learning is becoming increasingly popular it has been shown that a presentation from an expert who has been educated in sleep deprivation and fatigue brought forth more participation in the sleep disorders education subject matter than did the online education.    An interactive, multimedia training tool improved knowledge transfer and retention compared with traditional classroom learning

The workers involved in Emergency Medical Services have a responsibility to themselves and their patients to ensure they have adequate sleep.  Working long shifts and rotating shifts, as well as taking mandatory or voluntary overtime contribute to medication errors and ambulance crashes.  Supervisors and the Directors of the service are responsible for the implementation and making sure that the safety policies are followed without exception.   The EMS culture promotes overtime despite the major hazards that it presents.  Because of the lower than average pay overtime is coveted despite the safety hazards that it brings with it.  There is very little education presented to ems personnel on sleep deprivation and fatigue.  Implementing this training is the responsibility of the services Training Officer, Shift Supervisors, and Service Director.  Once the education has been completed and the workers are able to recognize the onset of sleep deprivation, they can be mandated to follow policy.

A culture of safety should be implemented and become the rule instead of the exception.  Safety Officers and Shift Supervisors and began to implement this safety culture by enforcing the policy of ems personnel taking short naps at different intervals during their 24-hour shift.  This can be accomplished by locating and relocating emergency units is high call areas and allowing the designated unit to return to post and take their naps and get necessary down time.  Service Directors can help to implement a safer work environment by making sure that all unnecessary overtime is picked up by part time personnel.  By doing this the practice of working several 24 hour shifts back to back can be avoided and give full time personnel a chance to get sleep and some down time.  This will affect the payroll without any doubt.  However, the service director can show and hopefully convince the governing authorities that the increase in payroll is much less costly that the cost of a medication error or ambulance crash and the oncoming lawsuit.  A safety environment can be better maintained by the keeping of concise and accurate work records of all personnel.  There can be a limit placed on the amount of overtime and number of consecutive 24-hour shifts that are worked.  When a worker reaches the maximum number of hours worked they would not be allowed to work until they have had adequate number of days to rest and recoup.  The number of days or hours worked consecutively should not be contained within an individual service but should instead be dependent on the number of hours or consecutive days that a worker has personally worked within that time.  Should a Shift Supervisor suspect or discover that a worker is reaching the unsafe limit of sleep deprivation it is their responsibility and duty to take that worker off the ambulance crew until such time they can get some sleep.  Not doing this presents a major safety hazard, and is one that is avoidable.  Failure to follow this safety policy is follow could result in mandatory shifts taken off and should the policies continue to be circumvented job termination should be possible.  Should Shift Supervisors fail to make sure that the safety policies are followed than they could be penalized by the loss of their Shift Supervisor position, mandatory days of and job termination.   Should an accident occur than the first question that should be asked is, “Was sleep deprivation or fatigue a contributing factor, and if so, why was that worker allowed to be on duty and part of an ambulance crew?”  The responsibility of answering these questions rests on the Shift Supervisor and Upper Management.

The literature specific to EMS fatigue and shift work hours is light.  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.

TABLE.  WORK HOUR REQUIREMENT COMPARISONS

*Note: These work hour requirements are pulled from multiple, publicly available sources and presented in a simplified format for comparison.  Some standards include additional considerations like cumulative hours in specific time periods (Williams, D. M. ,2014).
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—about seven 8-hour shifts in a row, or no more than 4–5 12-hour shifts in a row.
• The schedule must 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 is 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 is time for action.

PO 6– Identify an occupational safety and health research problem; complete a thorough review of the scholarly literature; formulate hypotheses; collect and appropriately analyze data; and, interpret and report research findings to improve the field of occupational safety and health or to provide solutions to an occupational safety and health problem.

This research project addresses safety and health management of sleep deprivation and fatigue among Emergency Medical Services personnel.  The project includes a thorough review of the literature, especially as it relates to sleep deprivation and fatigue and the causes, hazards, resulting happenings, and the implementing of certain safety policies and practices that act to mitigate the damage incurred by the hazards.  Literature that conveys direction in the implementing of safety policies concerning sleep deprivation will be covered and how to implement these policies will be clearly and concisely covered and explained.

Research done by Drew Dawson and Kathryn Rein entitled, “Fatigue, Alcohol, and Performance” and found in the journal Nature, has determined that twenty-four hours of sleep deprivation is equivalent to a blood alcohol content of .12 %.  This level is the definition of a person being legally intoxicated in most states. This is shown by the chart below.  Both sleep deprivation of 24 hours and a blood alcohol content of 0.12 result in the same amount of impairment.  Obviously, this is a major safety hazard, especially when operating an ambulance at high speeds or making life or death decisions when dealing with patients.

As shown in the above graph which can be found in the article entitled, “Sleep Alertness and Fatigue in Residency”, found in the 2006 American Academy of Sleep Medicine’s article after being sleep deprived for eighteen hours or greater cognitive performance decreases sharply.  This is a major safety hazard and is one that a safety professional should be concerned with and work to implement measures to mitigate or eliminate the dangers presented within the hazard.

As shown from the above chart when ambulance crashes were researched of the accidents where the ambulance crew had been awake for twenty hours or greater prior to the accident taking place 19.9 percent of the accidents were directing related to sleep deprivation and 17 percent could be connected to operating the ambulance while fatigued.   When the ambulance crews involved in the accidents were questioned 22.3 percent of the crew members had gotten less than four hours of sleep and 12.8 percent stated they were fatigued in the twenty-four-hour timeframe leading up to the accident.  Additionally, 31.5 percent had gotten between four to six hours of sleep in the twenty-four hours leading up to the accident.  Sleep deprivation was a contributing factor in the cause of the accidents.  Judgement and mental clarity has been found to be directly proportional to the amount of sleep and rest received in the twenty-four to forty-eight hours prior to an event.

As shown in the graph of the crashes whose drivers were age 18 or more, eighty-five percent of the drivers were sleep deprived, having six hours of sleep or less.  Unfortunately, these statistics have become commonplace rather than a rarity.

  SUMMARY AND IMPLICATIONS

Working in Emergency Medical Services while sleep deprived and severely fatigued is, unfortunately, the norm rather than the exception.  Because of the low salary, many Paramedics and Emergency Medical Technicians must work another job.  This job is usually also in Emergency Medical Services.  This means that the worker goes to their second job already sleep deprived and unsafe.  As stated, studies have shown that a loss of sleep over 24 hours equates to the same mental alertness and performance level of having a blood alcohol content of .12 percent.  This presents an extreme safety issue.  The sleep deprived state most Emergency Medical Personnel perform under much of the time places them, their partner, the patient and the public in grave danger.  Sleep deprivation also has a negative impact on the health and well-being of Emergency Medical Personnel. Sleep deprivation has been proven to cause cardiac problems, hypertension, obesity, and contribute to the onset of diabetes.

CONCLUSIONS

Sleep deprivation and fatigue in Emergency Medical Services is and has been a ongoing hazard since the birth of EMS in the early 1970’s.  It puts the ambulance crew, the paitent, and the public at great risk for injury or death.  Part of the blame can be laid on the low salaries that EMS personnel earn which requires them to work a second EMS job. This only adds to their already sleep deprived state.  Another problem is that there, up to the present, has been very little emphasis placed on the hazard of sleep deprivation and the hazards it brings with it in the form of education.  Sleep deprivation and working numerous twenty- four hour shifts in a row is worn as a badge of accomplishment.  Working sleep deprived and fatigued is just accepted as the norm.  The hazard of sleep deprivation is just coming to the forefront and gaining interest in the EMS community.  This is a positive thing.  It is the Safety Professional, ( Safety Officer), responsibility to mitigate the dangers imposed by sleep deprivation by first, educating the workers , and then implementing safer work practices such as imposing mandatory naps throughout the shift, exercise, limiting dependence on caffeine, staggering start times of shifts, and promoting an “no fault” work environment where, should the worker feel like they are not safe they can be allowed to get needed sleep without reprisal from upper level management or their shift supervisors. There are methods that can alleviate or at least mitigate this hazard.  These come in the form of (1) education of workers concerning the dangers of sleep deprivation, how to recognize it, and what actions to take should it occur (2) staggering the start of shifts, (3) mandatory safety naps during the day, and (4) implementing a “no fault” policy that empowers the ambulance crew to report that they are fatigued and need rest with no worry of reprisal by upper level management.  It is the safety professional that must take the hazard and implement policies and practices that mitigate the hazard.  The problem  of sleep deprivation is solvable.  It is the safety professional job and his / her duty to make sure this is accomplished.

                                                     References

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Wilson, D. (2015, November 06). An EMS Emergency : Sleep Deprivation and Fatigue. EMS World.