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Studying sleep health and fatigue in EMS

Explore the evidence about poor sleep health and work-related fatigue


Good sleep health is characterized by appropriate timing, adequate duration, high efficiency and sustained alertness

Photo/Federal Occupational Health

Updated Aug. 2, 2017

By Daniel Patterson, Matthew Weaver and Francis X. Guyette

There is growing evidence that most EMS clinicians suffer from poor sleep quality, mental fatigue, and physical fatigue while at work.[1-5]

Definition of fatigue

Fatigue refers to “a subjective, unpleasant symptom, which incorporates total body feelings ranging from tiredness to exhaustion creating an unrelenting overall condition which interferes with an individual’s ability to function to their normal capacity."[6] Half of EMS clinicians report work-related fatigue.[1, 2, 3] In comparison, one-third of all U.S. workers report fatigue.[7]

Impacts of fatigue

Fatigue limits physical strength, erodes reaction time, impacts decision-making, and may result in riskier behavior.[8. 9, 10] Fatigue can lead to poor safety outcomes for patients and EMS clinicians.[2] Odds of injury are 1.9 times greater among fatigued EMS clinicians than those that do not report fatigue.[2]

The odds of making an error or suffering a patient-related adverse event are 2.2 times greater among fatigued clinicians, and odds of safety-compromising behaviors (e.g., driving at excessive speeds) are 3.6 times greater among fatigued EMS clinicians than those that do not report fatigue.[2]

Fatigue is tied to sleep health.[1] Good sleep health is characterized by subjective satisfaction, appropriate timing, adequate duration, high efficiency (percentage of time in bed spent sleeping), and sustained alertness during waking hours.[11]

Adequate sleep

Adequate sleep is important, but many in the EMS occupation do not get the sleep they need. With data from prior studies, including data from the EMS Agency Research Network (, we determined that half of EMS clinicians get less than six hours of sleep per day/night.[1, 2, 12] In comparison, only 30 percent of all U.S. adults get less than six hours of sleep per day/night.[13]

Getting sleep of adequate duration and of good quality is a challenge for EMS clinicians. Most work outside the parameters of a normal work day (e.g., 9-to-5), and many work extended shifts (e.g., 24-hours).[1, 2, 3, 4, 5] Shift work can wreak havoc on one’s ability to obtain adequate sleep and feel rested. Recovering physically and mentally between shifts is a challenge for shift workers, and some of our recent research shows many EMS clinicians report low recovery between shifts.[4]

Managing fatigued clinicians

EMS clinicians and employers are familiar with these challenges. Despite awareness, most EMS organizations under-manage or fail to manage fatigued EMS clinicians. It is likely that most EMS agencies do not have a formal or evidence-based process to:

  • Comprehensively evaluate an EMS clinician’s sleep health
  • Identify fatigued EMS clinicians in a reliable and valid way
  • Address clinician sleep health and fatigue appropriately and in accordance with recommendations from leading authorities such as the American College of Occupational Environmental Medicine (ACOEM).[14]

This lack of programs or action may be associated with a general lack of fatigue-related research involving EMS clinicians.[5] Few studies have sought to quantify the magnitude of the poor sleep and fatigue problems in EMS. Few studies have identified the most likely sources of poor sleep and fatigue amongst diverse EMS clinicians working across diverse EMS settings. Even fewer studies have tested novel approaches to fatigue risk management in the EMS environment.

Recently, we performed a pilot test of a novel use of mobile phone text-messaging. We used a text-message dialogue with EMS clinicians located all over the U.S. These messages were sent while clinicians were on duty and designed to assess and intervene on fatigued and sleepy EMS clinicians in real time.[15,16]

The preliminary findings, presented at the annual meeting of the National Association of EMS Physicians (NAEMSP), are promising and show EMS clinicians are willing to engage and discuss the topic of fatigue, sleep, and shift work. Novel and effective solutions to the sleep/fatigue problem seem possible. However, the research is limited and we cannot begin to fix a problem we have not adequately defined.

Support for fatigue research

We – as in the entire EMS community – should support more observational and experimental research of clinician sleep health and fatigue. You – as in the front line clinicians and agency administrators – should engage in research projects that address these issues internally or in collaboration with other organizations with a shared interest in sleep and fatigue. We need this research – and need it published. Without it, our base of knowledge on the issues will remain limited.

We need creative thinking and an open dialogue between front-line EMS clinicians and administrators to address these issues and their potential impact on safety.[5, 17] The duration of shifts should be part of the conversation, yet it should not be the sole topic or sole target of intervention.[17]

There are numerous factors linked to sleep health and fatigue, including:

  • Employment at multiple organizations
  • Overtime elective and mandated
  • Income needs
  • Workload (patient volume)
  • Utilization and deployment
  • Scheduled rest or sleep while on duty
  • Recovery between shifts

In addition, numerous other factors play a role.[18, 19, 20]

We must consider all factors when conducting research and designing solutions. A one-size-fits-all approach to mitigating fatigue-related risk in EMS will not exist. By opening the conversation on this issue we hope to better understand the perspective and needs of all stakeholders. We can work together to identify strategies to keep our workers and communities safe, while being mindful of preferences, constraints, and realities of this unique occupational setting.

About the Authors

Daniel Patterson, PhD, NRP, is a nationally registered paramedic and senior scientist in the Department of Emergency Medicine at Carolinas HealthCare System Medical Center in Charlotte, N.C. His research focuses on fatigue, sleep, and other factors that affect the health, safety, and well-being of EMS clinicians and their patients.

Matthew Weaver, PhD, EMT-P, is a paramedic and epidemiologist at the University of Pittsburgh, Department of Emergency Medicine. His research focuses on the health and safety of the EMS workforce and the patients they treat.

Francis Guyette, MD, MS is an associate professor at the University of Pittsburgh, Department of Emergency Medicine and medical director of STAT MedEvac air-medical system. His research focuses on treatment of the acutely ill and injured in the prehospital setting and health and safety of EMS professionals.


1. Patterson PD, Suffoletto BP, Kupas DF, Weaver MD, Hostler D. Sleep quality and fatigue among prehospital providers. Prehosp Emerg Care. 2010;14(2):187-193.

2. Patterson PD, Weaver MD, Frank RC, et al. Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. Prehosp Emerg Care. 2012;16(1):86-97.

3. Patterson PD, Buysse DJ, Weaver MD, et al. Emergency healthcare worker Sleep, Fatigue, and Alertness Behavior survey (SFAB): Development and content validation of a survey tool. Accid Anal Prev. 2014;73C:399-411.

4. Patterson PD, Buysse DJ, Weaver MD, Callaway CW, Yealy DM. Recovery between work shifts among Emergency Medical Services clinicians. Prehosp Emerg Care. 2015;00(00):000-000.

5. Patterson PD, Weaver MD, Hostler D, Guyette FX, Callaway CW, Yealy DM. The shift length, fatigue, and safety conundrum in EMS. Prehosp Emerg Care. 2012;16(4):572-576.

6. Ream E, Richardson A. Fatigue: a concept analysis. Int J Nurs Stud. 1996;33(5):519-529.

7. Ricci JA, Chee E, Lorandeau AL, Berger J. Fatigue in the U.S. workforce: prevalence and implications for lost productive work time. J Occup Environ Med. 2007;49(1):1-10.

8. Barker LM, Nussbaum MA. Fatigue, performance and the work environment: a survey of registered nurses. J Adv Nurs. 2011;67(6):1370-1382.

9. Lim J, Dinges DF. Sleep deprivation and vigilant attention. Ann N Y Acad Sci. 2008;1129:305-322.

10. Killgore WD, Grugle NL, Balkin TJ. Gambling when sleep deprived: don’t bet on stimulants. Chronobiol Int. 2012;29(1):43-54.

11. Buysse DJ. Sleep health: can we define it? Does it matter? Sleep. 2014;37(1):9-17.

12. Patterson PD, Weaver MD, Hostler D. EMS provider wellness. In: Cone D, Brice JH, Delbridge T, Myers B, eds. mergency Medical Services: Clinical Practice and Systems Oversight. Vol 2. Chichester, West Sussex; Hoboken: John Wiley & Sons, Inc.; 2015:211-216.

13. CDC. Short sleep duration among workers --United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61(16):281-285.

14. Lerman SE, Eskin E, Flower DJ, et al. Fatigue risk management in the workplace. J Occup Environ Med. 2012;54(2):231-258.

15. Patterson PD, Buysse DJ, Weaver MD, et al. [ABSTRACT #9] Real-Time Fatigue Reduction in Emergency Care Clinicians: The SleepTrackTXT Trial. Prehosp Emerg Care. 2015;19(1):142.

16. Patterson PD, Moore CG, Weaver MD, et al. Mobile phone text messaging intervention to improve alertness and reduce sleepiness and fatigue during shiftwork among emergency medicine clinicians: Study protocol for the SleepTrackTXT pilot randomized controlled trial. Trials. 2014;15(1):244.

17. Dawson D, Chapman J, Thomas MJ. Fatigue-proofing: a new approach to reducing fatigue-related risk using the principles of error management. Sleep Med Rev. 2012;16(2):167-175.

18. Caruso CC. Negative impacts of shiftwork and long work hours. Rehabil Nurs. 2014;39(1):16-25.

19. Williamson A, Lombardi DA, Folkard S, Stutts J, Courtney TK, Connor JL. The link between fatigue and safety. Accid Anal Prev. 2011;43(2):498-515.

20. Lockley SW, Barger LK, Ayas NT, et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(11 Suppl):7-18.

The National Association of EMS Physicians (NAEMSP) is an organization of physicians and other professionals partnering to provide leadership and foster excellence in the subspecialty of EMS medicine. The NAEMSP promotes meetings, publications and products that connect, serve and educate its members, and acts as an advocate of EMS-related decisions in cooperation with organizations throughout the country.