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EMSFatigueRiskManagementandProjectResearch–What’sNew???
DanielPatterson,PhD,NRP
December1,2020
Outline
• ReviewPhase1–EvidenceBasedGuideline
– TakeQuestions
• DiscussPhase2–ExperimentalStudy
– TakeQuestions
TheFatigueinEMSProject
www.emsfatigue.org
NHTSA DTNH2215R00029
Partnership
NHTSA DTNH2215R00029
Fatigue
...asubjective,unpleasantsymptom,whichincorporatestotalbodyfeelingsrangingfromtirednesstoexhaustioncreatinganunrelentingoverallconditionwhichinterfereswithanindividual’sabilitytofunctiontotheirnormalcapacity.
Ream&Richardson,1996
SignificanceofFatigue
SignificanceofFatigueinEMS
• Placeholderforvideoonfatigue,sleep,etc.
Fatigueisathreat!
FatiguedEMS
Clinician
ClinicianThreatens
PatientThreatens
PublicThreatens
ThreePhasedApproachtoAddressFatigueinEMS
Phase1DevelopanEvidenceBasedGuidelineforFatigueRisk
ManagementinEMS
Phase2ExperimentalStudy
Phase3Freelyavailablebiomathematicalmodeltool
TimelineoftheFatigueinEMSProject
2016 2017 2018 2019 2020
Phase1:Evidence-BasedGuidelineDevelopment
2021
7systematicreviews
SpecialIssueofPEC
ImplementationGuidebook
SupportingDocuments
Phase2:ExperimentalStudy
Phase2:Planning&Approvals
WhatareEvidenceBasedGuidelines?
“….aresystematicallydevelopedstatementsdesignedtohelpadministrators,practitioners,andpatientsmakedecisionsaboutappropriatehealthcareforspecificcircumstances.”
National Academies IOM, 1990, 2001
AGrowingNumberofEMS-focusedEBGs
www.prehospitalguidelines.org
EBGsvs.Consensus
EvidenceBasedGuidelines
• Laborintensive• Comprehensivewithsystematicreviewsandmeta-analyses
• Standardprotocol• Fulltransparency
ConsensusStatements
• Oftenshorttimeframe• Limitedreviewoftheliterature
• Inconsistentprocedures• Lackstransparencyandsubjecttobias
WhydoweneedEBGs?
• Potentialtoreducepracticevariation
• Enhancetranslationofresearchintopractice
• Improvequalityandsafety
National Academies, IOM. Clinical Guidelines We Can Trust. 2011
TheProcess
GradingofRecommendationsAssessment,Development,andEvaluation
www.gradeworkinggroup.org
ReviewingtheEvidence
GradingtheEvidence
TranslatingintoEBGs
STRONGESTEVIDENCE
WEAKESTEVIDENCE
CaseReport,CaseSeries,Opinion
Cross-SectionalStudies
Case-ControlStudies
Cohort|ProspectiveStudies
RandomizedControlledTrials
Meta-AnalysesSystematicReviews
7SystematicReviews
1. Identifyreliableandvalidinstrumentstoassessfatigue.
2. Determinetheimpactofshorterversuslongershiftdurationsonhealth,safety,andperformanceoutcomes.
3. Determinetheimpactofcaffeineonsafetyandperformanceoutcomes.
4. Determinetheimpactofon-dutynapsonsafetyandperformanceoutcomes.
7SystematicReviews
5. Determineimpactofsleephealth/fatigueeducationandtrainingonhealth,safety,andperformanceoutcomes.
6. Determinetheimpactofchangesintaskload/workloadonhealth,safety,andperformanceoutcomes.
7. Determinetheimpactofusingfatiguebiomatheticalmodelsonhealth,safety,andperformanceoutcomes.
Resultsofthe7SystematicReviews
ResearchQuestion
LiteratureScreened/Reviewed
1 1,2572 21,6703 1,4014 4,6565 3,8176 2,7777 3,394
TOTAL 38,972
FiveRecommendations
1. Use(reliable/valid)fatigue/sleepinesssurveyinstrumentstomeasureandmonitorfatigue.
2. EMSpersonnelworkshiftsshorterthan24hoursinduration.
3. EMSpersonnelhaveaccesstocaffeineasafatiguecountermeasure.
4. EMSpersonnelhavetheopportunitytonapwhileonduty.
5. EMSpersonnelreceiveeducationandtrainingtomitigatefatigueandfatigue-relatedrisks.
The2018GuidelineforFatigueRiskManagementinEMS
ReminderThepurposeofEBGs
• Reducepracticevariation• Translateresearchintopractice• Improvequalityandsafety
EBGsare...
Asynthesisofthebestavailableevidencetohelpguidedecisionmaking.TheyareNOTrules,laws,edicts,or
ordinances.36yearsof
research
1980-2016>38,000piecesof
literature
DespitetheRigor:EBGsdohavelimitationsEvidenceisoftenlimitedorlacking
ResearchQuestion LiteratureScreened/Reviewed[1980-2016]
TotalStudiesRetained
1 1,257 34
2 21,670 100
3 1,401 8
4 4,656 13
5 3,817 18
6 2,777 1
7 3,394 5
LimitationsofEBGsJudgment
Sleep&FatigueScientist
SleepMedicinePhysician
FatigueinPublicSafety
Epidemiologist
EMSMedicalDirector
EmergencyMedicine
PhysicianAir-MedicalDirector
LawyerwithEMSRisk
ManagementExpertise
FireBasedEMS
Front-LineEMS
ParamedicClinician
StateMedicalDirectorExpertise
ConsumerRepresentative
MeetstheIOM
recommendationofdiversityin...
Experience
Expertise
ContentKnowledge
FullTransparency(PMID-29324069):SeeAppendixAforpanelmemberdisclosures
Judgment
BalanceofBenefitsvs.Harms
QualityofEvidence
Values&PreferencesofTargetPopulation
Feasibility,Equity,
AcceptabilityCosts&ResourceNeeds
SeeAppendixBofPMID-29324069–EvidencetoDecisionFramework
Transparentdocumentationofjudgment
Concern,misinformation,andtherealityofthisEBG
Concern/Misinformation• EMScan’tworklongdurationshifts
• Thereisamandatetonotworkcertainshifts
• Theaimistoeliminateshifts
TheReality• Doesnotsayanyofthis• Guidelinesarenotmandates• Manyontheexpertpanel
utilize24hourshiftstoday• Longdurationshiftsare
necessaryinpublicsafety• Shouldbenosurprisethat
evidenceshowslongdurationshiftsarefatiguing
• Iflongdurationshiftsutilized,itisrecommendedthatotherstrategiesbeadopted
Let’sdissectrecommendation#2regardingshiftduration
N=21,674
N=480fulltextarticles
N=100compareddifferentshiftdurations
N=38compared8hrvs.12hrshifts
N=38comparedmultipledurations
N=24comparedtwoshiftdurations:
(n=15~24hrvs.<24hrs)
Acloserlookattheevidence
Whatexactlyisrecommended?
• ThedecisiononshiftdurationshouldNOTbebasedontheevidencealone.
• Itmaynotbepractical,cost-effective,orsafetoeliminateextendedshifts.
• Iflongdurationshiftsmustbeutilized,ensureadequatestaffinganduseofotherfatiguemitigationstrategies.
EBGsareNOTrulesorlaw
RigorousandtransparentassessmentoftheBestAvailable
Evidence
Helpguidedecisionmaking;DONOTdictateit
EBGsareNOT“MagicBullets”forproblems
Needupdatingevery__yearsWoolfetal.,1999:PMID-10024268
TheReality:ShiftWorkinEMSisHeretoStay!
Fatiguecannotbefullyeliminated
Itmustbemanaged
Thereisnogoldstandardfatigueriskmanagement
programinEMS
FatigueRiskManagementProgram
AccesstoCaffeine
Education&Training
Measurement
NappingPolicies
Other
WhyisthisEBGsignificant?
Nootherresourcelikethis
2020CriticalAppraisalofEBGs
Appraisedfor...• Scope/Purpose• Stakeholderinvolvement• RigorofDevelopment• Clarity• Applicability• Editorialindependence
Findings...• 71EBGs• 96%clinicallyfocused• Ranked2nd
Turneretal.,2020PMID-32286899
QuestionsaboutPhase1?
UpdateonPhase2
2016 2017 2018 2019 2020
Phase1:Evidence-BasedGuidelineDevelopment
2021
7systematicreviews
SpecialIssueofPEC
ImplementationGuidebook
SupportingDocuments
Phase2:ExperimentalStudy
Phase2:Planning&Approvals
TestingImpactofRecommendation#5
EMSpersonnelreceiveeducationandtrainingtomitigatefatigueandfatigue-relatedrisks.
DevelopedProgramTailoredtoEMS
18monthstodevelop
10BriefEducationModules
HazardsofFatigue
SleepPhysiology
Work-RelatedStress
SleepHealth
Diet&Exercise
AdequateSleep
SleepDisorders
FatigueRecognition
AlertnessStrategies
FatigueManagedNOTEliminated
10EducationModules
• Placeholderforvideoonmodules
ApprovedCon-EdCredits
Approvedfor2.25hoursofcontinuing
educationcredits
CommentsfromParticipants
Greatcourse!woulddoitagain...lookingforwardtofindingouttheresults!
Wellorganizedcourse.
Greatinformation
CommentsfromParticipants
SinceIenrolledinthis… ihavebeendoingbetteronmysleeprestcycles,Ihavebeendieting,andihavelost30lbsin8weeks.IamverythankfulforyouguysinsavingmylifeandgettingmeoutofarutIwasinandhopetohavemanyyearsinthisfieldsinceIlovedoingthis.Thankssomuch.
Greatcourse.Wellputtogether.Greatjob.Youshouldtrytogetiton_____websiteforotherstoview.Goodjob.
Greatjob.Excellentmaterialandjusttherightlengthtokeepmyattentionwhileachievingtheeducationalobjectives!Kudos.
StudyDesign
InterventionGroup(immediateaccesstoeducationmodules)
Wait-ListControlGroup(accesstoeducationmodulesat3months)
Accesstoeducation
modulesat3months
3-monthfollow-up
6-monthfollow-up
Baselineassessment
A“Wait-ListControlStudyDesign”
Everyonewillgetaccesstotheinterventionmaterials
EligibleAgencies
1. ProvideEMSserviceinU.S.2. Ground-based(orair/groundmixed).3. Employ50ormorepaidpersonnel.4. Limitedrestrictionsonuseofmobilephones.
IndividualParticipation
1. Full-timeorpart-timeateligibleagency.2. 18yrsorolder.3. CertifiedFF,EMT,etc.atanylevel.4. Currentlyworkinginshifts.5. Workatleast1shiftperweek.6. Haveacell/smartphonethatcansendtexts.7. Willingtoparticipatefor6months.
Remuneration?
Eligibleparticipantswillreceive• $5dollarsatenrollment• $5everymonthfor6months• Totalremunerationworth$35
AccesstoEducationModules
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GGGGGGGGGG G G G G
GGGGGGGGGGGGGG G
Example Graph
Agency ID## Progress
Date
Num
ber
of p
artic
ipan
ts
Goal Enrollment (n=50)G
Goal n=50
Agency-ID ## (Enrolled)
30dayopenenrollmentperiod
UpdateonPhase3
Biomathematicalmodel
Modelfatigueasitrelatestoscheduling.Softwareprogram.Inputs:Scheduling,Rest,WorkHours.Outputs:Riskoffatiguebasedoninputs
HowtoParticipate
1. Needagencyleaderstoagreetoparticipate.2. Setadatetostartrecruitmentwithinagency.3. Helpcirculaterecruitmentinfoinagency.4. Promoteparticipationfordurationofstudy.
DEADLINEforagencies=December15th2020
www.emssleephealth.pitt.edu
Clarification
• EMSSleepHealthStudy– www.emssleephealth.pitt.edu
• SleepandTeamworkinEMSStudy– www.saftie.pitt.edu
• EMSShiftWorkProject– www.emsshiftwork.org
