Proposed Performance Measures and Strategies for Implementation of the Fatigue Risk Management Guidelines for Emergency Medical Services

Figures & data

Table 1. Performance measures

Recommendation	Performance Measures
1 – We recommend using fatigue/sleepiness survey instruments to measure and monitor fatigue in EMS personnel (strong recommendation, very low certainty in evidence).	• Performance Measure: Demonstrated use of reliable/valid fatigue and/or sleepiness survey instruments to measure and monitor fatigue in EMS personnel on at least a quarterly basis.
	○ Goal: Assess fatigue/sleepiness of EMS personnel with reliable/valid survey instrument(s) quarterly (4 out of 4 quarters annually).
	○ Numerator: Number of quarters in previous year when reliable/valid fatigue/sleepiness survey instruments was used to assess fatigue/sleepiness.
	○ Denominator: Four quarters over same time period selected for numerator.
	• Notes:
	○ Assessing fatigue/sleepiness for a random sample of scheduled shifts (rather than all shifts) may reduce respondent burden and improve the rate of participation by EMS personnel.
	○ Targeted assessments are recommended. Specifically, the assessment of fatigue/sleepiness is recommended with reliable/valid survey instruments for any shift schedule (pattern/structure) suspected of elevating the risk of fatigue, such as extended duration shifts (e.g., ≥12 hours).
2 – We recommend that EMS personnel work shifts shorter than 24 hours in duration (weak recommendation in favor, very low certainty in effect).	• Performance Measure: Percent of all shifts that are <24 hours in duration.
	○ Goal: 100% of shifts are <24 hours in duration.
	○ Numerator: Number of shifts that are <24 hours in duration.
	○ Denominator: Number of all shifts.
	• Notes:
	○ Shifts performed contiguously should be counted as a single shift period with a total duration (e.g., two 12-hour shifts performed contiguously by a single provider should be counted as a 24-hour shift).
3 – We recommend that EMS workers have access to caffeine as a fatigue countermeasure (weak recommendation in favor, low certainty in effect).	• Performance Measure: Percent of all shifts where EMS personnel have access to caffeine.
	○ Goal: 100% of shifts with access to caffeine.
	○ Numerator: Number of shifts with access to caffeine.
	○ Denominator: Number of all shifts.
	• Notes:
	○ Example of access to caffeine includes availability of caffeinated beverages for free or for purchase while on duty within reasonable access to on-duty EMS personnel.
4 – We recommend that EMS personnel have the opportunity to nap while on duty to mitigate fatigue (weak recommendation in favor, very low certainty in effect).	• Performance Measure: Percent of all shifts where EMS personnel are provided with access to and permission to take a nap while on duty.
	○ Goal: EMS personnel are provided with access to and permission to take a nap while on duty in 100% of extended shifts (e.g., > = 12 hours) and shifts taking place overnight.
	○ Numerator: Number of extended shifts (e.g., ≥12 hours) or shifts taking place overnight where EMS personnel are provided with access to and permission to take a nap while on duty.
	○ Denominator: Number of all shifts ≥12 hours in duration or taking place overnight.
	• Notes:
	○ We define a nap as a short period of sleep (duration is not specified).
	○ The EMS agency that permits EMS personnel the opportunity to nap on duty is best demonstrated with a written policy.
	○ To ensure reasonable access to take a nap while on duty, there should be a scheduled time to take a nap or an unrestricted opportunity to take a nap throughout the shift, and an appropriate place to take an uninterrupted nap.
	○ Agencies may wish to consider the napping strategy regardless of shift duration and include shifts <12 hours as part of the performance measure if personnel work contiguous shifts and/or consecutive shifts with limited recovery between shifts (including combinations of shifts involving different agencies).
5 – We recommend that EMS personnel receive education and training to mitigate fatigue and fatigue-related risks (weak recommendation in favor, low certainty in evidence).	• Performance Measure: Percent of EMS personnel who have: 1) received education and training to mitigate fatigue and fatigue-related risks during new employee orientation/training; and 2) received education and training to mitigate fatigue and fatigue-related risks within the previous 2 years.
	○ Goal(s): 1) 100% of EMS personnel have received fatigue education and training as part of new employee orientation/training; and 2) 100% of EMS personnel have received fatigue education and training within the previous 2 years.
	○ Numerator: Number of EMS personnel who have received fatigue education and training 1) during new employee orientation/training, or 2) within the previous 2 years.
	○ Denominator: All EMS personnel
	• Notes:
	○ Functional memory, knowledge, and skill can decay rapidly after initial education and training. Education and training every 2 years is recommended to address decay in memory, knowledge, and skills in dealing with fatigue in the workplace.

Shifts include: 1) scheduled and unscheduled work periods; 2) all work periods performed by EMS personnel, regardless of patient care responsibilities. Performance Measures 1–4 should each be measured over a one-year period.

Table 2. Checklist for the implementation of fatigue in EMS evidence-based guidelines^*

PICO 1 – Diagnostic

1. Select use of a fatigue and/or sleepiness survey instrument (refer to Online Supplemental Material in a separate publication).^†

2. Distribute survey at least quarterly to EMS personnel across shifts.

a. Random or targeted sampling of EMS personnel is recommended, such as during extended duration (≥12 hours) shifts, overnight shifts, or during work periods of high task load.

b. Paper or electronic surveys.

3. Review results of completed surveys on at least a quarterly basis.

4. Develop a plan to address shifts that are associated with excess fatigue and/or sleepiness, and then repeat measures to determine if there was a change.

PICO 2 – Scheduling

1. Determine the percent of all EMS personnel shifts that are:

a. <24 hours:     N = ____ per month (____ %)

b. ≥24 hours:     N = ____ per month (____ %)

2. If there are shifts that are ≥24 hours:

a. Evaluate ability to decrease the number of shifts that are ≥24 hours and decrease or eliminate if possible.

b. If unable to eliminate shifts that are ≥24 hours, ensure maximal use of all other fatigue mitigation recommendations provided in this guideline

3. Consider implementation of a policy for EMS personnel to have the right to call “time out” and be granted a reasonable rest period if the individual determines that he or she is unfit or unsafe to continue duty, without adverse personal action or undue pressure to continue in this circumstance. Policy should include management monitoring use of the “time out” policy.

PICO 3 – Caffeine

1. Determine the number of shifts where EMS personnel have access to caffeine:

a. List all shifts (scheduled and unscheduled): N = ____

b. Identify during which shifts EMS personnel have access to caffeine: N = ____ (____ %)

2. If EMS personnel do not have access to caffeine for 100% of shifts, identify ways to increase the availability of caffeine on the remaining shifts (e.g., availability of caffeinated beverages for free or for purchase while on duty).

3. Identifying the type, length, and location of shifts without access to caffeine can assist in identifying ways to increase the availability of caffeine.

PICO 4 – Napping

1. Establish a policy that allows for napping by EMS personnel while on duty.

a. Policy should identify a scheduled time to take a nap by shift or an unrestricted opportunity to take a nap throughout a shift.

b. Policy should focus particularly on extended duration (≥24 hours) or overnight shifts.

c. Policy may include all shifts, especially where EMS personnel may work contiguous shifts and/or consecutive shifts with limited recovery between shifts (including combinations of shifts involving different agencies).

2. Establish access to a location where EMS personnel can have reasonable access to take a nap (defined as a period of sleep).

3. Consider and mitigate potential risks associated with sleep inertia (transient performance impairment immediately after awakening from a nap).

a. Consider staggering naps among members of the same duty crew.

b. Consider use of caffeine to minimize the effects of sleep inertia.

PICO 5 – Education and Training

1. Establish an educational and training program on fatigue risk management to be delivered to all EMS personnel during new employee orientation/training and every 2 years.

2. Develop a tracking mechanism for this training for all EMS personnel in the agency.

3. Audit the rate of delivery of this education:

a. New orientees in prior year (total): N = ____ New orientees that received fatigue education/training: N = ____ (____ %)

b. All EMS personnel: N = ____ All EMS personnel who received fatigue education/training in prior 2 years: N = ____ (____ %)

4. If either percentage is <100%, determine ways to improve completion of this training.

^* Fulfillment of each evidence-based recommendation should be reassessed on an annual basis to better incorporate the recommendations into practice and ensure their ongoing use.

^† Patterson PD, Weaver MD, Fabio A, et al. Reliability and validity of survey instruments to measure work-related fatigue in the Emergency Medical Services setting: A systematic review. Prehosp Emerg Care. 2018;22(S1):17–27.