Emergency Medical Services has often been described as a safety net for the health care system. That description refers to the fact that no matter the time, the day, or the location – if a patient needs emergency medical help, a single call to 9-1-1 activates a response.
The paradox is that this safety net for patients is also one of the most hazardous workplaces for employees.
According to data collected by the US Department of Labor Bureau of Labor Statistics, EMS is one of the most dangerous jobs in the country, with an injury rate about three times the national average for all occupations. (Maguire & Smith, 2013)
There are many factors that affect workplace injuries in EMS. The workplace is mobile, responds to emergency situations at all hours, in all weather conditions, at all types of locations, and provides treatment in the back of a moving vehicle. The vehicles are often highly customized by the buyer and regulations regarding ambulance standards vary greatly.
EMS personnel have a wide range of training, experience, and understanding about workplace safety, including operating a large motor vehicle in emergency mode and often work long shifts. Fatigue is a leading factor in injuries and treatment errors.
Treat before Street
Many EMS providers still remember the days when treatment for a cardiac arrest meant holding on to the IV rail with one hand while doing chest compressions with the other hand, heading to the hospital with lights flashing and sirens wailing. Law enforcement were called to clear intersections so the ambulance could proceed quickly to the hospital where a patient was frequently declared dead shortly after arrival. Fast forward to the 21st century and a growing number of EMS protocols direct that care is provided on the scene instead of in the back of a moving ambulance. The result is a better outcome for more patients and a much safer environment for the provider.
Another adage has been about caring for a patient while seated and restrained. As a result of research conducted by the National Institute for Occupational Safety and Health (NIOSH) and the National Institute of Standards and Technology (NIST), ambulance interior designs are able to address this challenge. Changes in training and protocols also help educate providers that treatment and safety go together. However, all of these changes will only be successful as the culture of EMS changes.
Culture of Safety
The American College of Emergency Physicians (ACEP) under a cooperative agreement with several federal partners developed and published a National EMS Culture of Safety Strategy.
The Strategy, which can be downloaded at www.emscultureofsafety.org/, includes sections on: EMS Personnel Safety, Patient Safety, and Community Safety. The Strategy also discusses the elements of a National EMS Culture of Safety including: Just Culture; Coordinated Support and Resources; EMS Safety Data Systems; EMS Educational Initiatives; EMS Safety Standards; and Requirements for Reporting and Investigation.
Red Lights and Sirens
For decades, providers and the public have associated emergency response and transport with red lights and sirens; and some new ambulances seem to have been designed with a “more is better” theme. But are these devices really helping – or are they actually making EMS response more dangerous for providers and the public?
In this paper, Dr. Douglas Kupas presents considerable information that uses data to dispel the dogma: Lights and Siren Use by EMS: Above All, Do No Harm
Fatigue in EMS
Fatigue in the workplace is not unique to EMS. It has been reported across all occupations by 33% of adult workers, including 36% of hospital based nurses, 40% of truck drivers, and 75% of small-airline commercial pilots. (Ricci et al, 2007; Geiger-Brown et al, 2012; Arnold et al, 1997; Jackson & Earl, 2006)
Shiftwork is a key factor associated with fatigue in EMS. Over half of EMS personnel work more than 45 hours/week. Most EMS personnel work extended shifts (12 or 24 hours) and in some locations, 80% of EMS personnel work at multiple jobs; some with excessive overtime hours. (Patterson et al, 2014; Patterson et al, 2012; Patterson et al, 2010, Van Der Ploeg et al, 2003; Brown et al 2002; Frakes & Kelly, 2007; Bauder 2012)
Fatigue in EMS results in: 1.9 greater odds of an injury; 2.2 greater odds of a medical error or adverse event; and 3.6 greater odds of a safety compromising behavior (Patterson et all, 2012)
In 2016, the National Highway Traffic Safety Administration (NHTSA) entered into a new initiative with the National Association of State EMS Officials (NASEMSO) to develop evidence based guidelines for fatigue risk management. The principal investigator, Dr. Daniel Patterson, University of Pittsburgh Department of Emergency Medicine will be working with a team of content experts. This initiative includes having draft guidelines available in mid-2017 and conducting an experimental study before the end of the project in June 2018.
Considerable information and links to presentations, podcasts, and related articles is available at: https://www.nasemso.org/Projects/Fatigue-in-EMS/Fatigue-in-EMS-Resources.asp
Separating Hype from Facts
With so much information available with a few keystrokes, it can be challenging to know where to turn for accurate and reliable information. The organizations and documents reference throughout this site have been reviewed by leading EMS professionals and are known to be credible.
NSC and BWH Offers New Fatigue Cost Calculator
According to the National Safety Council (NSC) and the Brigham and Women’s Hospital (BWH), “Sleep deficiency is a hidden cost of our technology-driven, 24/7 society. Approximately 70% of Americans report that they routinely get insufficient sleep. The issue is pervasive in the workforce, with 30% of U.S. workers and 44% of night shift workers reporting less than six hours of sleep on average. In addition, undiagnosed and untreated sleep disorders are common.
The Institute of Medicine estimates that 50-70 million people in the U.S. are living with a sleep disorder.
The Brigham and Women’s Hospital Sleep Matters Initiative and the National Safety Council have developed an online fatigue cost calculator that estimates the cost of sleep deficiency for individual businesses. The cost calculator asks users to enter their workforce size, industry and location. This information is used to predict the prevalence of sleep deficiency and common sleep disorders among employees. The calculator draws from peer-reviewed scientific literature to further estimate costs associated with these conditions. Costs of sleep health education and sleep disorder screening programs are factored in to estimate the economic impact of improving employees¹ sleep health. Read the methodology at http://www.nsc.org/Fatigue%20Documents/Methodology.pdf. Access the NSC Fatigue Cost Calculator at https://forms.nsc.org/real-costs-of-fatigue-calculator/index.aspx.