Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services: A Significant Step Forward and a Model for Other High-Risk Industries

In 24/7 operations, including Emergency Medical Services (EMS) and a wide variety of other industries, fatigue is unavoidable. The primary reason is that night and shift work schedules, which are needed for such operations, cause misalignment of the timing of wake and work periods with respect to biological processes that promote wakefulness and alertness during the day and sleep at night (1). People involved in shift work (whether through night, early morning, split, or rotating shifts) therefore experience sleep restriction, typically to less than 6 hours of sleep per day, as well as increased levels of sleepiness and fatigue while on shift (2).

This situation puts the schedules found in around-the-clock operations at odds with guidelines from sleep and health scientists, who recommend at least 7 hours of sleep, per night, with regularity (3). While these guidelines serve to promote safety, health, and well-being for the general public, they provide minimal guidance for 24/7 operations—and may even discourage shift workers from obtaining catch-up sleep when needed, despite evidence of beneficial effects thereof (4,5). As such, in many operational settings, fatigue is taken for granted, regarded simply as a cost of doing business around the clock. But the productivity, safety, and health consequences of fatigue are substantial and involve a significant economic burden to society (6,7).

In EMS operations, fatigue is a threat to safety for both personnel and patients (8). Fatigue-related risks to safety in EMS stem primarily from the increased probability of motor vehicle accidents associated with fatigued drivers (9) and the increased likelihood of medical errors associated with fatigued health care providers (10). Managing fatigue risks in EMS, therefore, is of considerable importance, just as in other high-risk settings such as aviation (11), railroad transportation (12), and maritime operations (13). News stories of EMS personnel falling asleep at the wheel, crashing ambulances and killing patients (14–17), underline the urgency of addressing fatigue risks in EMS operations.

Best practices for fatigue risk management are a topic of ongoing research (18–20). In U.S. commercial motor vehicle driving and various other transportation, energy production, and manufacturing industries, federal hours-of-service regulations are the prevailing method for curbing fatigue risks, even though this approach is known to be suboptimal outside of normal daytime work hours (21). In contrast, in U.S. commercial aviation, advanced systems for fatigue risk management involving predictive, proactive, and reactive mitigation of fatigue risks have been implemented (22). In the military, efforts have focused on measuring and prioritizing sleep (23) and predicting fatigue using mathematical models (24). In air traffic control (25), hospitals (26), and assorted other settings with extended work hours (27), the benefits and feasibility of workplace napping have been widely debated; implementation of this fatigue countermeasure remains sporadic. Additionally, in various other industries, a diversity of policy-based and informal approaches to fatigue proofing can be found (28–30). These fatigue risk management strategies tend to be highly industry-specific, vary widely in their operational effectiveness, and often lack published evidence.

Faced with the paucity of previously developed, suitable options, Patterson and colleagues set out to develop an evidence base for fatigue risk management in EMS. In a comprehensive set of journal articles (31–38), they presented the results of a painstaking effort to systematically review the available literature pertaining to specific research questions, framed in the Population, Intervention, Comparison, Outcome (PICO) framework by an expert panel (39). The expert panel reviewed summaries of the evidence drawn from the literature using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. The GRADE methodology was particularly suitable for this effort as it allowed the expert panel to formulate recommendations based on published evidence evaluated within the context of EMS operations. They were thus able to formulate recommendations that are not only supported by science but can also be plausibly implemented in the EMS setting (40).

The evidence-based guidelines for EMS operations provided by Patterson and colleagues (40) appear to be the first, for any 24/7 industry, that are based on systematic review of the literature. These guidelines are also grounded in EMS experience and common sense, readily actionable, and achievable while maintaining operational integrity and productivity. Although implementation of the recommendations will not counteract the risks associated with fatigue completely — as such risks are inevitable in around-the-clock operations — we may expect to see a marked improvement over the status quo.

The evidence-based approach to the development of fatigue risk management strategies presented by Patterson and colleagues (40) will need to be assessed and validated in practice. To this end, the research team also provided evidence-based performance measures (41) which can be used to evaluate the effectiveness of the evidence-based guidelines. It should be recognized that improvements may still be possible, either because the recommendations are not yet formulated optimally, or because their effectiveness leads to systematic changes in EMS that then create new opportunities for further fatigue risk mitigation. Such contingencies are formally recognized in fatigue risk management systems currently in use in commercial aviation, which have embedded procedures for continuous system evaluation and improvement. The availability of evidence-based performance measures (41) provides a stepping-stone for the development of similar procedures for EMS operations.

In conclusion, the work by Patterson and colleagues for the EMS industry represents a meaningful step toward improving the safety of personnel, patients, and the public at large. It may also serve as a blueprint for how other high-risk industries may go about developing their own evidence-based guidelines for fatigue risk management.