The Cole County Ambulance Service is testing a new 48-hour shift schedule that has seen mixed reviews among other ambulance services as well as the emergency medical services community nationwide.
At the beginning of January, the service opted to try 48-hour shifts, which means the paramedic and emergency medical technician work two back-to-back 24-hour shifts, followed by four days off before returning to work.
Cole County Presiding Commissioner Sam Bushman said early reports seem to show it is working well, although the effect these shifts would have on overtime and holiday schedules has yet to be seen.
"We're fully staffed now, so I think it's worth looking at," Bushman said. "No one has quit, and it does give more time off. We'll just have to see where we are in the next few weeks."
Ambulance Chief Matt Lindewirth said the service will try the new model for three month then vote on whether to continue it.
"If I feel it's becoming unsafe or the staff feels that way, then we'll stop immediately," Lindewirth said. "This is a schedule that's being done at many ambulance services, including in Miller and Osage counties."
The only ones involved in the 48-hour trial, he said, are assigned to non-peak trucks, which means they are in areas that don't historically have high call volumes.
For about a year, the commission used 12-hour paramedic shifts based on safety concerns, with the belief that having staff work 12 hours rather than 24 would keep them fresher.
However, some of the paramedics who were let go or resigned voiced concerns about doing away with 24-hour shifts as the main reason the service was struggling to attract employees, as they said 24-hour shifts give employees more schedule flexibility.
So the staff began working 24-hour shifts in August.
When the staff suggested trying 48-hour shifts in late 2018, Lindewirth consented to a three-month trial of the approach.
To make sure staff of the 48-hour shift stays as fresh as possible while on the job, Lindewirth said, the battalion chiefs go through a protocol of checks every morning to gauge fatigue levels. The fatigue of a crew member is assessed by calculating the amount of time they are assigned to a task compared to the amount of down time that they have. The formula helps to determine fatigue, Lindewirth said.
"Say a crew has worked at a high call volume location like the ambulance based at the county jail: we can transfer them to a lower call volume location to allow them to get rest. And we've told them there won't be any reprimands if they feel they need a break," Lindewirth said. "So far, we haven't had any safety concerns."
"I'm not a fan of these shifts, but the staff wanted to explore them," he said. "We've heard positives, but some negatives. We haven't had an overwhelming response either way. We're taking an open approach to see if it works."
To the south of the Cole County district, the 48-hour approach has been used for several years.
Miller County Ambulance Director Ron Schlicht said the 48-hour shift seems to be working fairly well for his department.
"Just like Cole County, we have people who come from long distances to work on our service," Schlicht said. "We've got people coming from Boonville and St. Louis, and they prefer to work the 48-hour shift.
"We give them a choice of 24 or 48. It's not mandatory. Some of the staff know their limitations, and they don't work 48," he said. "It's been done for several years, and I don't see it going away."
But other area services have decided not to schedule 48-hour shifts due to safety concerns.
"I just don't think it's safe," said Lee Kempf, director administrator of Mid-MO Ambulance Service, which operates in Moniteau and Morgan counties. "What happens when a person works 39 hours, they have no sleep and have to go to St. Louis? I've been doing this for a long time, and I don't have the stats to back me up, but it seems the 24-hour shift is where you need to be.
"Occasionally, we'll have them go 36 (hours), and the staff has the ability to take out so they can get rest if needed. I've worked all over state, and I've seen anywhere from 8- to 48-hour shifts used. I can tell you my folks are exhausted at 24 (hours). We have long transport times. We average an hour going one way to our destinations. Maybe in urban areas a 48-hour shift may not be as much of a problem since your transport times are shorter."
The success of the approach may in part depend upon the family status of the EMS worker, says the director of the Callaway Ambulance Service.
"We've heard mixed reviews, and our staff has been against doing them," said Charles Anderson, Callaway County Ambulance Service director. "We do 24-hour shifts and could do some overtime, but it's not approaching the 48 hours. We also do 72 hours off following a 24-hour shift.
"From what I can tell, you end up at work more hours so unless you make an adjustment in the pay scale, I don't think our people would go for it (the 48-hour shift). It seems a better system for single staff members than those with families," he said.
From a medical standpoint, research seems to show that shifts of 24 hours or longer do produce unfavorable results due to fatigue and related outcomes.
The National Sleep Foundation recommends adults get between seven and nine hours of sleep per 24-hour period. Most ambulance staff don't meet NSF recommendations for sleep, with national reports indicating more than half only getting six hours every 24 hours.
Daniel Patterson, assistant professor of emergency medicine and the primary investigator for the EMS (Emergency Medical Services) Agency Research Network at the University of Pittsburgh, studies safety in emergency care settings and published a report in February 2018 that looked at ways to combat fatigue at ambulance services.
His report drew from a 2015 study where he and his colleagues at the Pitt Department of Emergency Medicine collaborated with the National Association of State EMS Officials to create evidence-based guidelines for fatigue-risk management at ambulance services.
The panel came up with several recommendations:
- EMS personnel should work shifts that are shorter than 24 hours long. Shifts of 24 hours or longer are unfavorable in terms of fatigue and related outcomes.
The panel acknowledged the contentious nature of dealing with shift duration and recognized that, in certain circumstances or in certain locations, longer shifts are necessary.
The panel also noted fatigue mitigation shouldn't begin and end with targeting shift duration. Fatigue-risk management incorporates multiple components and is tailored to local needs.
Shift duration should be part of the conversation, yet it shouldn't be the sole focus. For EMS organizations and employees who choose to modify shift duration, the panel recommended administrators consider two 12-hour shifts worked back-to-back as a 24-hour shift.
- EMS organizations should use fatigue/sleepiness survey instruments to measure and monitor fatigue in EMS personnel.
The panel said it is up to administrators to decide which test or gauge to use. They also said assessments should be done quarterly and should target shifts that administrators believe contribute to fatigued staff, such as those longer than 12 hours.
- EMS personnel should have access to caffeine as a fatigue countermeasure.
- EMS personnel should have the opportunity to nap while on duty to mitigate fatigue.
- EMS personnel should receive education and training in sleep health and the dangers of fatigue to mitigate fatigue and fatigue-related risks. This training should occur as part of new employee orientation and be repeated every two years for all employees.
In the report, Patterson said these guidelines don't prescribe a specific approach to fatigue mitigation, and administrators shouldn't perceive the guideline is prescriptive or restrictive.
"There's tremendous flexibility in how systems may apply the recommendations and strategies studied," Patterson wrote. "The burden on administrators is high. If fatigue is as widespread a problem in EMS as we perceive it to be, then we must act. Fatigue in the EMS workplace can't be ignored."