Fatigue Risk Management in High-Risk Environments: A Call to Action

Our society depends on 24/7 operations for everything from transporting passengers and goods, manufacturing products, to providing emergency services. Around-the-clock operations require millions of individuals to work non-traditional schedules that shorten sleep opportunities and disrupt natural sleep patterns (1). These shift workers are susceptible to work-related fatigue and fatigue-related risks such as injury, error, and poor performance (2). Unfortunately, many employers of shift workers, including Emergency Medical Services (EMS), lack guidance on evidence-based strategies for managing fatigue in the workplace (3). Recommendations and solutions for fatigue management based on systematic reviews and synthesis of the evidence are long overdue.

Fatigue and shift work are crosscutting safety risks that are not unique to any one industry or occupation (4–7). As a physiological issue, fatigue — the overwhelming feeling of tiredness and exhaustion—affects all types of workers (8). The outcomes of fatigue-related events are much greater in safety critical jobs where lives are on the line. Safety critical jobs can include transporting passengers, operating heavy machinery, providing medical care, or doing a task that place the worker's life or the lives of others at risk.

Fatigue-related events are common (9). The National Transportation Safety Board (NTSB) has investigated thousands of accidents and identified fatigue as a contributing factor in aviation, highway, marine, pipeline, and rail operations. The NTSB has issued over 200 recommendations focused on mitigating fatigue in high-risk industries with worker education, use of medical screenings for sleep disorders, scheduling practices, and other solutions (10). In 2011, the Federal Aviation Administration promulgated new flight and rest requirements for commercial pilots that take into consideration factors such as the time of day for their first flight, the number of time zones they cross, and the number of flight legs in a given day. In the last decade, the Federal Motor Carrier Safety Administration issued guidance to clinicians that perform employee medical exams and directed them to screen commercial vehicle drivers for sleep apnea and also identified how drivers may return to work with effective treatment (11). In addition, both the aviation and trucking industries have addressed risks by going beyond regulations through fatigue risk management programs tailored to operational demands. Not all industries have these regulations but all organizations, especially those with safety critical jobs, should address fatigue as a component of a comprehensive safety management system.

The need for fatigue risk management in the EMS setting is compelling. Any industry with 24/7 operations involving safety critical tasks will have contributing factors that are numerous, complex, and undeniably difficult to address. Previous research suggests that large numbers of EMS personnel suffer from work-related fatigue, sleep deprivation, inadequate recovery between scheduled shifts, and fatigue-related risks such as injury and error (12–14). Adoption of recommendations to manage fatigue, supported by the evidence, and tailored to the EMS setting may lead to significant improvements in safety and enhance the health status of EMS personnel.

All employers should learn about fatigue in the workplace, its costs, its causes and how fatigue can lead to a higher rate of safety-related incidents. While shiftwork and fatigue will never be eliminated in the workplace, it can be managed (15). Science-based fatigue risk management systems (FRMS) include policies, programs, and procedures to manage fatigue risk in the workplace with the goal of a safer and healthier workforce and community in which they live (16). An effective FRMS will identify fatigue risk and include effective countermeasures, such as a well-designed shift schedule that can improve the wellbeing, productivity, health, and safety of workers (16). As part of a FRMS, employers should be encouraged to provide sleep health education and sleep disorder assessment and treatment to improve employee well-being and reduce operational risks. Fatigue can impact every aspect of life including job and safety performance, family relationships and health (17). Incorporating fatigue risk management into existing safety management systems is vital for preventing injuries and fatalities and improving the well-being of employees or workers.