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Fatigue, scheduling are critical EMS challenges

EMS Trend Report 2017 findings highlight the importance of fatigue management as a safety issue for both caregivers and patients


Despite the evidence, efforts to move to shorter shifts in EMS continue to face significant resistance.


This feature is part of the 2017 EMS Trend Report, which takes an in-depth look at EMS trends in the United States and sets a foundation for assessing how the EMS profession is changing. Be sure to share this trend report with other EMS leaders and discuss your thoughts on how EMS is changing in the comments.To read all of the articles included in the report, click here.

By Jay Fitch, PhD

Caregiver fatigue and increasing negative performance associated with longer shifts are often the underlying reasons for changing schedules that we hear from clients and colleagues. More than 50 percent of the agencies in the EMS Trend Report Cohort operate with 12-hour shifts, rather than the 16- or 24-hour shifts used in the past and still used by many services.

EMS leaders have been slow to accept the fact that fatigue impacts caregiver performance. According to the Joint Commission, a substantial number of studies indicate that the practice of extended work hours contributes to high levels of worker fatigue and reduced productivity. These studies and others show that fatigue increases the risk of adverse events, compromises patient safety and increases risk to personal safety and well-being [1].

Taking a page from other industries that staff around the clock, health care researchers have been studying the effects of caregiver fatigue as both a patient safety and employee health issue. There is an increase in awareness that fatigue impairs performance. Studies have shown that 17 hours of sustained wakefulness is equivalent to a blood alcohol level of 0.05 percent and that after 24 hours, it is equivalent to 0.10 percent – more than the legal limit for driving [2].

A 2015 study found that EMTs and paramedics who work longer shifts are 60 percent more likely to suffer injury and illness (and to compromise the safety of their patients) than those who work eight- to 12-hour shifts. Researchers looked at three years of shift schedules (totaling almost 1 million shifts and involving more than 4,000 employees) and 950 occupational health records for 14 large EMS agencies in the United States.

Shifts longer than 12 hours were associated with a 50 percent heightened risk of sustaining an injury when compared to shifts of less than 12 hours. This is after taking into account other relevant factors, such as employer type, night or day shift, employment status and how often the EMS crew had previously worked together. The risk associated with shifts lasting 16 to 24 hours was more than double that of shifts up to eight hours [3].

Despite the evidence, efforts to move to shorter shifts in EMS continue to face significant resistance: While 50 percent of this year’s EMS Trend Report respondents use 12-hour shifts, the number of agencies using 24- and 48-hour shifts increased slightly as compared to the 2016 survey.

Patient-, provider-centered solutions

Confronting scheduling preferences is difficult and involves many sensitive issues, including both employee satisfaction and lifestyle. However, in busier systems fatigue management must be considered first and foremost as a caregiver and patient safety issue.

Like so many things in EMS, what works well for one agency or community doesn’t necessarily work for others. In rural systems, working a longer shift with few calls or post moves may not have a significant impact on crew fatigue. However, even in rural systems where EMS workers run fewer calls, they will still occasionally have a shift where they get little rest, increasing the risk of adverse outcomes. This is an issue particularly if caregivers work back-to-back shifts with multiple employers.

Innovative agencies are addressing caregiver fatigue in different ways. For example, Austin-Travis County (Texas) EMS is reducing its longer shifts and tracking paramedic workloads in real time using FirstWatch. Austin-Travis County has added “Safe Sleep Rooms” to stations to give personnel the chance to sleep before driving home after a busy or sleepless shift.

Multnomah County, Oregon, which includes Portland, included a provision in its EMS contract requiring that its contractor maintain an average unit-hour utilization of less than .40 for each unit. This often results in crews being rotated between high-demand and lower call volume stations.

Applying research to improve safety

Other systems are increasing caregiver education to encourage proper rest, exercise and nutrition prior to a long shift. Research has suggested that each of these factors reduces fatigue.

The EMS Trend Report will continue to monitor scheduling and fatigue across the profession. This year, the National Association of State EMS Officials is releasing evidence-based guidelines for managing fatigue in EMS, through an effort funded by the National Highway Traffic Safety Administration and led by EMS researcher Daniel Patterson, Ph.D. Whether the EMS community prioritizes patient and provider safety and begins making changes is up to us.

1. The Joint Commission. (2011) Health care worker fatigue and patient safety. Sentinel Event Alert. 48(14):1-4.

2. Dawson, D., Reid, K. (1997) Fatigue, alcohol and performance impairment. Nature. 388(6639):235-235.

3. Weaver, M.D., Patterson P.D., Fabio A., Moore C.G., Freiberg M.S., Songer T.J. (2015) An observational study of shift length, crew familiarity, and occupational injury and illness in emergency medical services workers. Occup Environ Med. 72(11):798-804.

About the author
Jay Fitch, Ph.D. is a founding partner at Fitch & Associates, which has provided leadership development and consulting for emergency services for more than three decades.

For more than three decades, the Fitch & Associates team of consultants has provided customized solutions to the complex challenges faced by public safety organizations of all types and sizes. From system design and competitive procurements to technology upgrades and comprehensive consulting services, Fitch & Associates helps communities ensure their emergency services are both effective and sustainable. For ideas to help your agency improve performance in the face of rising costs, call 888-431-2600 or visit