MARCO ISLAND, Fla. — Though fatigue has been discussed in healthcare for years, what have we done to address it in emergency services? A session at Pinnacle 2024 addressed how organizations are combating fatigue, and strategies to reduce the cost of fatigue, while making your workforce safer and healthier.
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The panel included:
- Joe Coons, director of safety and Communications Center manager, LifeFlight Eagle
- Thomas Moore, junior partner, Fitch & Associates
- Ed Racht, MD, chief medical officer, Global Medical Response (GMR)
Results from the EMS Trend Survey
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Memorable quotes
- “EMS is an on-demand job and sleep disruption is built into it.” — Joe Coons
- “We’ve culturally reinforced that sometimes we’ve got to work when we’re exhausted.” — Ed Racht, MD
- “Similar to having alcoholic beverages, one of the first skills we lose when we are fatigued is self-awareness.” — Joe Coons
- “We have to figure out our shifts – we have to figure out how to do it more effectively.” — Ed Racht, MD
- “Scheduling is the low-hanging fruit, but you have to fund it … and you have to have people to hire.” — Joe Coons
- “We have an obsession with productivity and output.” — Thomas Moore
Top takeaways
Following are top takeaways from the discussion.
1. Fatigue is not mere sleepiness
Fatigue is unpleasant, like an ache or a pain, dramatically different from being sleepy or tired, Dr. Racht stressed. “Sleepiness isn’t fatigue. Tiredness is normal … the difference is fatigue is constant and limiting,” he said.
While sleepiness is addressable by getting a good night’s sleep, fatigue is not. Moreover, fatigue has lasting impacts on:
- Cognitive function (memory, concentration, learning and problem solving)
- The immune system becomes sluggish
- Appetite & metabolism – less appetite but for the wrong things
- Skin – accelerated signs of aging
- Mood (fatigue goes hand-in-hand with depression)
- Heart health
- Cancer risk
Dr. Racht shared there are 3 different kinds of fatigue:
- Transient fatigue: brought on by extreme sleep restriction for 1-2 days
- Cumulative fatigue: repeated mild sleep restriction over extended hours or series of days
- Circadian fatigue: reduced performance during nighttime hours (night shift)
Fatigue is measurable
Coons shared how LifeFlight Eagle has implemented fatigue measurements to identify when providers and pilots are too fatigued to function safely and effectively.
First, pilots at LifeFlight Eagle take a psychomotor vigilance test before every flight – a test that measures response time to clicking on a computer, to ID red flags.
Clinical staff complete a detailed fatigue matrix for each shift, including:
- Experience with the organization (with higher scores for those with few or many years of experience – it’s more fatiguing to be the new employee, Coons pointed out, or to be older)
- Hours of sleep prior to the shift
- Awake hours during the shift
- Illness and stress (to document feeling unwell or coming off a tough shift)
- Temperature feels like (measuring extreme hot and cold)
- Transport time
When providers exceed the pre-determined fatigue score, they are pulled off shift.
Cultural shifts begin with leadership support
Coons shared how the cultural shift to prioritize sleep requires leadership support. This looks like:
- Providing the resources and support clinical staff need to get adequate rest. LifeFlight Eagle provides sleep rooms for staff who need to rest after a shift, and overtime for providers who need to complete their charting after shift so they can rest when needed during the shift.
- Taking action when a peer reports a problem, like an EMT falling asleep at the wheel. These concerns must be addressed and not swept under the rug, Coons stressed.
- Communicating with staff. Coons shares fatigue education and sleep hygiene tips with providers, and communicates when red flags (like high fatigue scores, or a medical error) are raised.
Coons shared an interaction he had with a medic after a medication error occurred. When Coons initiated the conversation, the employee reported difficulty sleeping, noting his wife was sleeping in a different room due to his snoring. Coons encouraged a sleep study, and the provider discovered he suffered from sleep apnea and was able to get treatment.
Addressing fatigue in the future of EMS
There are no one-size-fits all approaches to managing fatigue, or to time management, Moore noted, amongst providers or leaders. He offered the following tips:
- Embrace the power of waiting (patience!)
- Practice the art of stopping (set a task time limit)
- Stop trying to clear the deck (you set yourself up for failure with a too-long to-do list)
- Do one thing at a time
- Realize the value of leisure
- Remember to focus on what matters
Complex problems require complex solutions. Racht noted it may be time to question the current model of EMS, and to consider a future in which staffing includes a vehicle operator and one clinician, who could be supported by telemedicine. “We need to get to the patient safely, we need to care for them on the way, but maybe it’s not two clinicians. Is it time to rethink some of the staffing models?,” he asked.
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