Fighting Fatigue in EMS

NHTSA, NASEMSO kick off effort to make recommendations for mitigating the impact of fatigue on patient and provider safety

Likely every member of the EMS profession knows the impact fatigue can have on performance and safety. Whether it’s driving an ambulance at the end of a long shift or calculating a drug dose after a sleepless night, the effect that fatigue has on EMS providers is clear.

What isn’t as easy to determine, however, is what to do about the problem. While EMS has largely embraced evidence-based medicine and protocols for treating patients, the profession has not yet developed many evidence-based practices for reducing fatigue.

A new project aims to do just that. Sponsored by the National Highway Traffic Safety Administration (NHTSA) Office of Behavioral Safety Research, the Fatigue in EMS initiative launched in February with a meeting in Washington, DC. The goal of the project is to develop evidence-based recommendations that can help EMS agencies and practitioners mitigate the impact that fatigue has on the health and safety of patients and providers.

"I think it’s great that EMS is going to address fatigue," said NHTSA Administrator Mark Rosekind, PhD, an expert on human fatigue. "This is not going to be easy — nobody has a magic bullet."

The lead investigator of the effort, paramedic and researcher Daniel Patterson, PhD, explained the process that will be used to develop evidence-based guidelines agencies can use to limit the impact of fatigue.

"We still have a limited understanding" of the role fatigue plays, he acknowledged, "but that doesn’t mean there is an absence of evidence."

Research shows that anywhere from half to 85% of U.S. EMS workers report feeling fatigued while at work. Some of the factors that characterize EMS professionals who have a higher risk of fatigue, Patterson said, include poor health, lack of quality sleep, and full-time (versus part-time) employment in EMS.

Fatigue has significant impact on the health and well-being of both the EMS providers and the patients they treat. In a study co-authored by Patterson and published in Prehospital Emergency Care in 2011, self-reported fatigue was associated with higher rates of work-related injuries, medical errors or adverse events, and safety-compromising behavior.

The research team will cull the scientific literature to answer questions proposed by an expert panel, which includes EMS field providers and agency leaders, EMS physicians, and sleep specialists.

Patterson explained that in addition to available EMS and fatigue research, the expert panel will review related studies, such as those on fatigue in other industries or in the general population. While the number of studies about fatigue in EMS is limited, research on fatigue and its impact on healthcare providers or members of other high-risk occupations, such as pilots or truck drivers, may still provide insights that can be applied to the project.

Using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, a systematic way of evaluating the research, the panel will then develop recommendations and tools that could be used at the local level to measure and mitigate the risk of fatigue.

"The intent of this project is creating voluntary guidelines," not laws and regulations, said Kathy Robinson, a project manager with the National Association of State EMS Officials (NASEMSO), which is coordinating the effort along with NHTSA and the University of Pittsburgh Department of Emergency Medicine, where Patterson is an Assistant Professor.

The Institutes for Behavior Resources, a nonprofit research organization in Baltimore, is also assisting with the project by developing a biomathematical model of EMS fatigue and a personnel scheduling tool for agency use.

Receiving input from the public is a top priority of project leaders, several people involved in the project said. The first opportunity for comment came during the kickoff meeting, as several sleep researchers and representatives of EMS organizations spoke in support of the initiative and provided advice to the panel members in the room.

"We have learned a lot about developing [evidence-based] guidelines," said Cathy Gotschall, senior health scientist with the NHTSA Office of EMS, "including the crucial, critical importance of stakeholder input."

"Tell us your stories," she said.

"We’re very serious about involving the community in every way we can," added Steven Higgins, a research psychologist and project manager with the NHTSA Office of Behavioral Safety Research.

Higgins encouraged members of the public and the EMS community to visit the project website,, for more information and to contact him or other members of the project team with comments or questions. PowerPoint presentations from the kickoff meeting are also available online.

The first meeting of the project’s expert panel, which is open to the public, is scheduled for April 26 and 27 at the U.S. Department of Transportation headquarters in Washington, DC. Register for the meeting here or visit