What an Evidence-based Guideline for Fatigue Risk Management Means for Us: Statements From Stakeholders

The National Association of EMS Physicians

Many high-risk industries that employ shift workers such as aviation, commercial vehicle operations, rail, maritime, and others are familiar with efforts to mitigate fatigue in the workplace. For many that work in shifts, fatigue mitigation is a natural part of day-to-day operations and tasks. Fatigue mitigation is essentially woven into the fabric of their daily lives. The Emergency Medical Services (EMS) profession will greatly benefit from the development and distribution of guidelines that outline strategies based on a review of the best available evidence (1–10). While these benefits are multi-faceted, a few deserve special mention.

First, acknowledging and mitigating fatigue will improve the health of EMS personnel. Not only does physiologic stress related to sleep deprivation affect individual health, there is also fatigue-related stress associated with vehicle operation, medical decision making, and performance of medical skills that may impair the overall well-being of EMS personnel.

Second, efforts to mitigate fatigue with evidence-based strategies will mitigate the risk to our patients. As EMS care becomes ever more sophisticated, the decisions rendered by EMS personnel have greater and greater impact on patient outcomes. From decisions regarding airway management to hospital destination for time sensitive emergent conditions, our patients will benefit when EMS personnel render care unimpeded by fatigue.

Finally, this will improve the safety of communities. In the absence of fatigue-related stress, operators of emergency vehicles will be less likely to be involved in motor vehicle crashes.

On a daily basis, selfless EMS personnel protect our communities. We owe them the same diligence regarding the stressors associated with shift work. Those who have compiled this excellent group of scientific evaluations are to be commended. Outstanding work has been done, yet there is much more to do. We strongly encourage all EMS organizations to implement the best practices described herein and look forward to ever more robust evidence and guidelines in the future.

Brent Myers, MD, MPH, FACEP, President of the National Association of EMS Physicians (NAEMSP)

The National Association of State EMS Officials

There is growing concern among all involved in EMS that work related fatigue impacts a large number of our nation's EMS personnel and that this fatigue contributes to a growing number of ambulance crashes and may result in harm to patients, personnel, and society. The National Association of State EMS Officials (NASEMSO) is a non-profit, non-governmental national organization comprised of the leaders of State and Territorial EMS agencies that supports an appropriate regulatory environment focusing on patient safety and public protection during the delivery of out-of-hospital care by licensed EMS practitioners.

The NASEMSO supports its members through information and education and encourages visionary leadership in the development and improvement of EMS and emergency care systems. Following the publication of these guidelines, the NASEMSO anticipates a dramatic increase in the national discussion and awareness of work-related fatigue in the EMS environment, as well as an increasing demand to improve safety-related outcomes.

The NASEMSO expects its members will need and demand guidance and assistance with education on sleep and fatigue management tailored to EMS personnel, including resources focused on scheduling decisions. The NASEMSO welcomes these Fatigue Risk Management Guidelines for EMS and their companion measures. They are a call to action for the community of EMS personnel, managers and administrators, physician medical directors, and others in a spirit of collaboration. The message is clear; implement strategies that will improve the safety of personnel, patients, and communities through awareness, education, and sleep health among all EMS personnel and that in turn will support the availability and reliability of our Nation's emergency response system.

R. Keith Wages, President of the National Association of State EMS Officials (NASEMSO)

The National Association of Emergency Medical Technicians

In every community in our nation, EMS is expected to deliver quality care to patients in need of emergent, urgent or preventive medical care. EMS practitioners are expected to work under difficult, unpredictable and rapidly changing circumstances. They may work long hours, in harsh environments, with limited information, assistance, supervision and resources to accomplish their mission. In the course of their work, they may be exposed to risks such as infectious disease, emotional stress, fatigue, physical violence, occupational injury, vehicle crashes, and personal liability (11–18).

The National Association of EMTs (NAEMT) believes that all EMS practitioners should practice within a culture of personal resilience and well-being that allows them to become aware of and learn to adapt to their work and personal life, and cope with significant stressors. Developing and sustaining this culture must be the shared responsibility of agencies, practitioners, and the greater community.

The NAEMT supports efforts to identify ways to protect EMS practitioners from operating in a fatigued state that is past the point of safe practice and is committed to advocating for the safest practices and regulations that protect and promote the health and well-being of EMS practitioners and the patients they serve.

Dennis Rowe, EMT-P, President of the National Association of EMTs (NAEMT)

The National Association of EMS Educators

As the President of the National Association of EMS Educators (NAEMSE) and an educator for 30 years out of my 36 years as a nationally registered paramedic, guidelines for fatigue risk management are more critical now than when I started my career. Early in my EMS career, it was common to deprive yourself of sleep and work long duration shifts. The impact of sleep deprivation on our health and wellness was unknown. The impact of fatigue on patient care was unrecognized. We must address this issue for the health and safety of our EMS personnel and our patients.

The current and future generations of public service leaders in public safety are asked to do more, train harder, educate themselves to a higher level, all while reducing risk in all areas of serving the public. The public demands that we are competent and compassionate in all phases of our care in emergency medicine. Few in EMS and few in the public understand that fatigue increases throughout the long shifts worked by EMS personnel. Care quality and customer service may be negatively impacted by fatigue.

The Fatigue in EMS Project is taking a bold step in identifying and unmasking the evidence concerning the risk that fatigue plays for all of us and what steps can be taken to address fatigue related risks. Many industries have noted that their workers (e.g., pilots, interns, truck drivers, etc.), must maintain work hour and sleep logs, and may not go over an identifiable threshold; public safety deals with life and death issues and yet we have failed to enact similar requirements. We have failed to be watchful of the dangers presented by fatigue. We have failed to monitor our own health and safety with respect to fatigue.

As a representative of our nation's EMS educators, I believe that the need for our EMS educators to help address the fatigue problem through education and training is compelling. We in the EMS education community need to lead our EMS clinicians to be healthier and safer. We in the EMS education community need to lead our EMS personnel to be more productive, healthier, and safer. The next generation of EMS professionals must be informed and educated on all the risks and benefits that this profession poses. I stand by the Fatigue in EMS Project for it is only through research and a healthy debate on this issue that we will improve the care of our fellow professionals while increasing the care of our patients, which must be our goal and it must serve as our legacy for future generations of EMS professionals.

Chris Nollette, EdD, NRP, LP, President of the National Association of EMS Educators (NAEMSE)

The National EMS Management Association

It has been clear for some time that there is a problem in EMS that we know about but struggle with solving; fatigued EMS personnel. As with many problems concerning people and policy, this problem is complex. It cannot be solved with simple solutions but will require concerted efforts to understand that fatigue is not “a problem” but many interrelated system problems. Research into the scope, breadth, and depth, and consequences of fatigue is a critical step toward developing evidence based guidelines, policies, and procedures, and creating an environment where EMS personnel will not have to work when they are fatigued nor will they be considered fit for duty if excessively fatigued.

As leaders, managers, and administrators of EMS organizations, we need to develop an understanding of the physical, emotional, and psychological costs of fatigue in the EMS workplace. We also must attempt to identify the fiscal costs and the liability exposure that fatigue creates. Research into this domain is long overdue. Now, as papers are published, we must be disciplined and critical in our evaluation of the work. We must also be bold and creative in the synthesis of our responses to the studies. In the end, taking action to address the issue of fatigue can lead to healthier, happier, and safer EMS personnel. It may ultimately lead to higher quality of care, reduced costs and healthier communities.

Michael Touchstone, BS, EMT-P, FACPE, Immediate Past President of the National EMS Management Association (NEMSMA)

The International Association of Fire Chiefs

The International Association of Fire Chiefs (IAFC) is pleased to support efforts from the National Highway Traffic Safety Administration (NHTSA) and other industry associations to develop evidence-based guidelines for fatigue risk management. Firefighters and EMS personnel actively respond to a large variety of emergencies in their communities at all hours of the day and night. Given the incredibly taxing physical and mental demands of emergency response work, fatigue management is an issue to which fire departments must pay close attention.

Effectively managing fatigue is important to ensure firefighters and EMS personnel are able to continue providing effective medical care, fire suppression, disaster response and mitigation, and many of the other critical services that firefighters and EMS personnel provide. The IAFC looks forward to working with numerous partners to identify options for fire departments to consider when working to effectively manage fatigue in their personnel.

Chief John Sinclair, NREMT-P(Ret), President and Chair of the Board of the International Association of Fire Chiefs (IAFC)

The National Volunteer Fire Council

This research project will provide needed data and information about the impact of fatigue on EMS responders to agencies that lack the resources to undertake such an investigation on their own. The National Volunteer Fire Council (NVFC) believes that it is important to have members of small and rural volunteer and combination systems included in the study. Volunteer emergency services leaders need to understand how fatigue affects volunteers running calls outside regular work hours so they can put protections in place to effectively manage risk. Additionally, because so many volunteer emergency personnel work other jobs, including for a different public safety agency in a paid capacity, understanding how off-duty activities and rest can impact on-duty performance is also critical.

The NVFC believes that strategies to mitigate fatigue supported by evidence, as shown in the research published in this special issue of Prehospital Emergency Care, will help volunteer agencies develop programs tailored to their needs with confidence that the strategy is supported by evidence. We also look forward to having input into the development of an EMS-tailored biomathematical model to help inform agency-staffing practices.

Edward L. Mund, Director-at-Large of the EMS/Rescue Section of the National Volunteer Fire Council (NVFC)

The Volunteer Firemen's Insurance Services Incorporated

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 Organization's (ESO) 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.

Justin M. Eberly, BS, EMT of the Volunteer Firemen's Insurance Services (VFIS)

The National Fire Protection Association

The National Fire Protection Association (NFPA) is the leading global advocate for the elimination of death, injury, property, and economic loss due to fire, electrical, or related hazards. As part of this mission, the Fatigue in EMS Project is of great interest to the efforts of our organization.

In order to achieve our mission, the NFPA develops accredited national codes and standards to make the missions, tools, training, and equipment of first responders safer for them and the public. The Fatigue in EMS Project will provide valuable data, tools, and resources that could influence the revisions of those standards for years to come. This includes standards for health, safety, and wellness and organizational deployment.

John Montes of the National Fire Protection Association (NFPA)

The Association of Air Medical Services

The air medical and critical care ground medical transport community requires that emergency care be available 24-hours a day. Shift work in our operating environment requires personnel to deviate from normal circadian sleep cycles, yet remain vigilant and fully prepared to treat the most ill or injured patients when the pressure to sleep may be the highest. Given that the relationships between shift duration, sleep, fatigue, and performance are so multifaceted, the need for evidence-based guidelines to mitigate the risk posed by personnel fatigue is evident.

Organized into three phases, the Fatigue in EMS Project is clearly the most comprehensive research undertaken to date. The Association of Air Medical Services (AAMS) looks forward to the results of the study, most notably a set of fatigue risk management guidelines, which will be vital to better work place environments, the safety of our industry's professionals, and the safety of the patients we serve. AAMS believes these guidelines will help optimize the levels of patient care provided across spectrum of healthcare, especially in the EMS setting.

Richard J. Sherlock, President and CEO of the Association of Air Medical Services (AAMS)

The Sleep Research Society

The nature of EMS requires coverage 24-hours/day, 7 days/week, and 365 days/year creating demanding work schedules for EMS clinicians. Typical EMS workers have 12- or 24-hour shifts with half working more than 45-hours per week and many working more than one job (19). Poor sleep and fatigue are common in EMS personnel and associated with increased risk of injury, medical errors, adverse events, and safety compromising behavior (20). Fatigue management guidelines to improve sleep and reduce fatigue in EMS personnel are important for the health and safety of the workers and the public that they serve. The long road to creating guidelines relies on the full spectrum of research, from basic laboratory experimental designs to simulation studies, through to field-based research, where the feasibility, acceptability, and effectiveness can be evaluated in the operational environment. The work of the Fatigue in EMS Project is invaluable in completing this process.

The Fatigue in EMS Project has developed these guidelines with rigorous methods that infuse the highest scientific quality into their recommendations. They first undertook a comprehensive review of the literature addressing specifically what countermeasures and policies may be helpful to EMS personnel. Project leadership then assembled a group of researchers who not only have the scientific expertise, but who also have relevant operational experience that provided unique insight into the specific challenges and needs of this occupational group. The diversity in background and expertise this group brought to the process allowed them to develop guidelines that will be well received and applicable to the end user. These evidence-based guidelines, and the process by which they were developed, should set the standard in translating sleep and circadian rhythm research into operational application in such a way as to influence policy and promote safety and better health outcomes.

There is also significant value in these guidelines for an academic organization such as the Sleep Research Society (SRS), as well as, we believe, sister organizations focused on similar scientific areas. In our efforts to advance the sleep and circadian field, the SRS has a strong focus on promoting the generation of science and translating that science into operational settings. We also advocate directly with government agencies in favor of evidence-based policy. These rigorous guidelines will make that work more effective.

In short, this project was done the right way and will have clear benefits for the scientific field, as well as EMS personnel and the public.

Laura K. Barger, PhD, and Sean P. A. Drummond, PhD, of the Sleep Research Society (SRS)

The American Academy of Sleep Medicine

We commend Dr. Patterson and his group for their work, “Evidence-based guidelines for fatigue risk management in Emergency Medical Services.”

From the viewpoint of the American Academy of Sleep Medicine (AASM), sleep medicine health professionals, EMS personnel, and their employers should partner to ensure that important downstream effects of fatigue are mitigated. Attention should be placed on the following goals:

•	educate key stakeholders, including EMS personnel, employers, safety personnel, and health benefits managers regarding common sleep disorders, their risks to the individual, and the benefits of identifying and treating them;
•	encourage the use of simple screening tools for fatigue and common sleep disorders that may impact job performance, including obstructive sleep apnea;
•	encourage health care delivery teams to develop diagnostic and treatment strategies for sleep disorders;
•	implement fatigue management programs that are accessible, convenient and affordable to EMS personnel, minimizing disruption on work schedules; and
•	encourage employers to reduce barriers to care, including out-of-pocket costs and penalties for time lost.

Some employers have already implemented systemic responses to the issue of workplace fatigue. Namely, the Accreditation Council for Graduate Medical Education (ACGME) has outlined ways that hospitals can address fatigue in medical house staff (21). Existing strategies include duty hour restrictions; adequate staffing to allow for nap opportunities during overnight shifts, to reduce medical errors; limiting invasive procedures after working extended hours, to reduce the risk of medical errors and needle-stick injuries; ride-sharing after extended shifts to reduce the rate of crashes; and implementing forward-rotating schedules to facilitate acclimatization to changing work shifts. In the trucking industry, Schneider incorporated a program to screen, diagnose and treat all commercial truck drivers for obstructive sleep apnea (22). Union Pacific implemented a system-wide program to educate rail operators about obstructive sleep apnea, to encourage testing and treatment (23).

These templates are not only helpful, but point to tangible ways in which employers can protect workers from the serious consequences of workplace fatigue on the employee and the people they service.  We laud the authors for doing this important work, and we are grateful for this opportunity to comment.

Indira Gurubhagavatula, MD, MPH, Chair of the Occupational Sleep Wellness Presidential Committee of the American Academy of Sleep Medicine (AASM)