Question all, I recently worked at a agency that was employee driven wanting 24 hr shifts with 72 interem off. What are the national ranking on 24 hr shifts and your personal thoughts on them.
Ben Waller said:
For example, can you show us a study that proves that busy EMS units working 24-hour shifts have a higher vehicle accident rate or medication error rate than an equivalent system that works shorter shifts?
With the volume of literature on medical residents and errors on long shifts, a few studies on residents and MVC rate on the trip home, and even a few studies showing RNs making more errors in hours 12-16 of 16-hour shifts, I'd argue that the burden of proof is on the people who want to continue 24-hour shifts to prove they're safe, not the other way around.
However, I do agree with you that there are plenty of places that are slow enough that 24's are probably OK.
We have a 12 hour duty day with a 14 hour maximum (out at 14 regardless) because it is simply to dangerous for us and our patients to critically think when fatigued. We are busy enough that there really isn't any discussion about changing this, at 14 hours I'm done and want to sleep! If you have a low UHU then perhaps it can still be done, but again if you get your butt kicked all day are you really useful at 3am? That can happen anywhere. I worked 24/48 for years in my youth and loved the time off, but now I can see how foolish and dangerous that really was...
Duncan, I believe that you were actually discussing UHU's instead of FTEs, but understand your point. Actually, both come into play here.
Some additional points that affect this:
1) UHU calculations in most system are estimates, not actual utilization, as they use the "1 call equals 1 hour" math. Unless the agency's CAD is nimble enough to calculate the time on calls as a percentage of the crew's current on-duty time in increments smaller than an hour, the number isn't going to be as accurate as it could. That is especially true early in the shift when a UHU that only recalculates once per hour might be off the mark by up to 59 minutes. A lot of CAD systems I've seen are not that nimble.
2) The more shift changes you have in a 24-hour period, the more overtime you will likely generate per unit, as there will be more late calls that overlap shift change. This is going to generate additional personnel costs. Are those costs higher than paying for a potential increase in vehicle accident rates or for additional medication errors? That's difficult to determine and the answers are not necessarily the same for every EMS system, but those are costs that should be compared.
3) Even if your system drops 24-hour shifts, if you allow shift trades, some employees will do shift trades that put them back on a 24-hour shift schedule. "Mutuals" or "Buddy Swaps" are common in many EMS systems, regardless of the system type. Employees tend to view this as an informal benefit with the perception that it doesn't add any employer salary costs.
4) For fire-based systems, hourly pay rates can be artificially depressed for FF/Medics and FF/EMTs working 24-hour shifts, based on FLSA rules. That rule does not apply to non-fire EMS systems or even to non-firefighter EMS personnel within a fire-based agency unless a union contract or similar agreement changes the rules. That is a powerful incentive for employers to reduce salary costs by using the FLSA exemption for FF/EMS personnel. Also note that this rule doesn't apply just to ambulance personnel, it applies to non-transport units, supervisory units, etc.
5) Working a set 24-hour schedule also lets employees make lifestyle choices that would be impossible with shorter shifts - they can live farther away from work, get more time for family or recreation by taking a single day off, and reduce their transportation costs due to driving (or riding public transportation) to work less frequently. With gasoline costs headed for $4 per gallon, that's a powerful incentive on the side of 24-hour shifts for many employees.
Obviously, the system is going to decide what shifts it works. Just remember that unless you're in an area that is a total sellers market (few EMS systems) a lot of employees may choose to vote with their feet if they perceive their benefits or their travel costs taking a big, unfunded hit. That has the potential to increase system costs by requiring more frequent retraining and it can drop the overall experience level system-wide.
Duncan Hitchcock said:
I do have a bit of advice to all you “consultants” out there. When you figure FTEs, remember the call does not end when the ambulance arrives at its destination or when it comes in-service. There is still a lot of work being done while en-route back to the stations and when the unit finally gets back in quarters. Uninterrupted sleep hours must keep this latter point in mind. Even on cancellations and dry runs. Adrenalin is our savior and our assassin in this crazy world of emergency services.
Thank you, Ben, for your correction of my inadvertent use of the not most appropriate utilization factor. (The curse of being marginally educated and retired. It’s amazing what one’s recall does without that day-to-day stimulation.)
Your points are well received and carry great merit.
Agreed, many CAD systems are still not robust enough to handle the fine details of time. Even programs such IBM Query and Q-Rep Reporting require extensively created formulas to even address the time change associated with the 0800-0800 24 hour shift common in most EMS-based fire services. This holds true, at least in my experiences, with fractionalization of minutes and seconds as recorded in CAD and the conversion back and forth of the standard format of time. It can be done, but its labor intensive.
Agreed, the nature and randomness of calls wreaks havoc on even the morning shift change.
Agreed, “swap time” is a great employee benefit. I used it a lot while on-shift and going to nursing school and taking other college classes.
I read your item 4 several times. I guess your employer and my previous employer had different reads on FLSA as it applies to Fire Rescue personnel assigned to 24 hour shifts regardless of the seat or the type of apparatus assigned. The only difference that we recognized was a contractual agreement for an increased percentage based on the individual’s base salary for 24 hour assignments on the ambulance. After all, our statistics clearly demonstrated that the folks in the ambulance run most of the calls and are on assignments much longer than the Engine crew.
Agreed, the 24 hour shift does offer a nice perk for doing things on your days off. Take off one vacation day and you’re off for 5 days in a row. (Especially since vacation time is ‘sweat time’ for calculating overtime.) But it also contributes to the missed holidays, birthdays and extracurricular activities that our children, families and friends are involved.
Agreed, systems and agencies will decide the staffing formats that best meet their needs and abilities.
The safety issue of fatigue on a 24 hour shift appears obvious but anecdotal. Agreed, I have not seen any studies based in the EMS environment that would prove or disprove this observation. Dr.X does refer to studies in the environments of the medical residency programs and in nursing. While EMS is not medical residency or nursing, it is my opinion that a concern can be inferred from these studies. It is my opinion is that the best way to address the matter of fatigue is through evidence based studies conducted within the EMS environment.
With the results of such studies, system directors will be better prepared to insure that the primary objective of their service is being met.
Oh, and my advice to you consultants still stands. Just change around them darn FTEs and UHUs things.
Duncan, the difference on #4 is that my state is a right-to-work state and we do not have collective bargaining or contractual agreements with employee representation groups. In South Carolina, tose are illegal.
Your point is well taken - there will be state or local differences in that regard.
I am from canada and currently working on hours of work for EMS can you point me to where I can find this European working time directive, as I would love to have the background information for our service.
Neil White said:
European working time directive. A piece of law that had a massive impact on healthcare working, no more junior doctors doing 60+ hours a week. All healthcare staff can only be "forced" to work 37.5 hours per week averaged out across 13 week cycles. A maximum of 16 hours per day only.
All staff must have 11 hours rest before their next shift so if a crew on a 7am-7pm get a late Job and ends up finishing at 11pm the crew cannot report until 10am following day.
Resource nightmare but patient safe
There's nothing anecdotal about the impact of fatigue on performance - you just have to go out there and look at the data. No, I'm not going to provide the citations - if you care enough you can do the research yourself.
It's not the 24 hour shift, per se, that is the problem. If the employee can get 5 consecutive hours of uninterrupted sleep (which correlates with VERY low demand patterns after 2200 or so) in that shift, fine. That is a big "if" as that is NOT what occurs in most places. After the 19th hour without sleep, the performance degradation is the same as a blood alcohol of 0.100. Using the "my mom" test, I would not want someone with a BAC of 0.10 working on my mom, therefore I should not ethically inflict that on the community that I serve.
The truth is that the 24 hour shift is about the medic and lifestyle, not about what's best for the patient - and that should be the deciding factor. There may be a small economic component, but people outside the fire and EMS community HATE the notion that people get paid to sleep - every city manager, county manager, and most of the elected officials (not financed by labor unions) I've crossed paths with are willing to pay more to end 24 hour shifts.
We keep talking about being a profession - a profession puts the interests of the client first. Until we do that - we are not. The rest of the world works 4 or 5 days per week - what makes us so special that we think we are entitled to work only 8-10 days per month, in what often is a performance-degraded position? And I don't want to hear that "I need to work two jobs" either. If the salary is too low, don't take the job! If enough people do that, the salaries will rise. And don't forget the impact of "free" workers on that salary. Docs, nurses, even truck drivers have safety driven work limit. Why do we think we should be the exception?
PS - I really dislike the intellectual dishonesty that says "if it hasn't been studied in EMS it must not be so." It is perfectly logical and appropriate to infer conclusions from data developed in other disciplines.
Think about it - how much research can you do in a community that is made up principally of 10-employee (or no employee) organizations? If we approached medicine that way, we wouldn't rely on any drug, device, or procedure that wasn't developed in the EMS environment. Back to the stone ages!
Skip Kirkwood said:
"There's nothing anecdotal about the impact of fatigue on performance - you just have to go out there and look at the data."
Granted, but given that data comes from jobs like truck driving and nursing where the UHU's closely approach 1.0, are we SURE how that correlates to 24-hour shifts, and if so, at what point?
"It's not the 24 hour shift, per se, that is the problem. If the employee can get 5 consecutive hours of uninterrupted sleep (which correlates with VERY low demand patterns after 2200 or so) in that shift, fine. That is a big "if" as that is NOT what occurs in most places. After the 19th hour without sleep, the performance degradation is the same."
What are "most places"? Large, urban "most places", or the much more numerous, smaller, suburban and rural places that don't run much in the last 1/3 of the shift - or at all?
"...every city manager, county manager, and most of the elected officials (not financed by labor unions) I've crossed paths with are willing to pay more to end 24 hour shifts."
Most of those same people I've run across don't like it either...until they realize that if it's connected to a combination fire/EMS system that it will cost them anywhere from 20% to 30% more in recurrent costs to move away from 24-hour shifts, then suddenly the costs revert to being the most important factor.
"We keep talking about being a profession - a profession puts the interests of the client first. Until we do that - we are not. " and "PS - I really dislike the intellectual dishonesty that says "if it hasn't been studied in EMS it must not be so." It is perfectly logical and appropriate to infer conclusions from data developed in other disciplines."
One of the key components of a profession is that it requires mastery of a specialized body of knowledge. That knowledge comes from research based in that profession. It's difficult to claim that EMS is (or is going to be) an actual profession when we say that we have a specialized body of knowledge, based in our own research...until we don't have research for a specific topic, so some us decide to use some other group's research that we think applies, despite variables that apply to us but that weren't even considered for the original research population. One of those differences is the VERY high UHUs experienced by truck drivers (behind the wheel for their entire driving shift) or for nursing (doing patient care or charting for essentially their entire shift) vs. EMS systems that have some downtime during a shift.
You're also painting this as two extremes, (10 employees???) which looks a lot like a false dilemma. What about suburban or rural places that have, say, 40 to 120 employees in the organization? It might take longer to get a large enough data set to meet the same level of reliability as an urban system with a larger EMS population, call volume, etc.
Is sleep deprivation bad for you - sure. Can anyone factually defend a statement like "24 hour shifts are just fire department B.S." as made by another poster? No way.
I'm certainly not defending sleep deprivation, but to be a real profession, we need to have our own research-based body of knowledge with OUR variables controlled instead of an assumption that someone else's study always applies to us. Wanting the essentials of true professionalism for EMS include wanting our OWN body of knowledge. Otherwise, forget that "profession" dream.
I agree with you 100% sleep deprivation is just that regardless of the profession, There has recently been a couple of studies out there one in paticuliar from the university of Pittsburg I believe that was on EMS practioneers and the effects along with some smaller ones, My service has been very heavily involved in research as we are very much evidence based. The data shows that with increased shift times ie 24 hours etc there is a corelation to increased possiblity of adverse patient events, like medication errors, increased potentilal for MVCs, and paramedic injuries like back and muscle fatigue, most of the studies show that after 16 hours these incidents are more likely to occur. The was no correlation to when a paramedic had to perform a crtical skill ie an intubation or chest decompression etc as that is when the adrenal kicks in and we are able to focus. What it did show was the things that we do routinely were affected, needle stick, poor lifting techniques, driver inattention was the types of things to watch out for.
In our system we have roughly 140 units and 1000 paramedics, we have been staedily reducing the 24 hour shifts over the last 2 years to 12 hr rotations ie the power shift 4 on two days/2 nights 4 off but I am not convinced this is the right shift either as it does throw your rythm for sleep etc off. One thing I can tell you is that a lot of the paramedics have said they cannot believe how tired they were on the 24/72 rotation now that they do the 12s.
This is a very interesting topic and I like tforward to see more direct research and correlation to EMS our system has palaced a huge emphasis on paramedic and patient safety and we are looking to find new ways of achieving this on a regular basis.
Keep the info coming thanks
That assumes high UHUs correlate to 24 hour shifts. That is not always the case. That's whe we need to get better research that gives us a better idea of what kind of call volume and call patterns correlate to "sleep deprivation", not just shift length, the amount of time off between shifts, and how shift rotations affect circadian rhythms and in turn how altering circadian rhythms affects performance, error rates, and accident rates.
Tim Bayers said:
I agree with you 100% sleep deprivation is just that regardless of the profession,
Another point on studying small groups - like an EMS system with only 10 employees. There is always the ability to study several small groups at a time to create an adequate study population, as well as to lengthen the study time.
Just another way to give us the ability to conduct our own research and to do it for more than just the urban EMS providers...