Fatigue Questions

RocketMedic

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So I've been extended an opportunity to participate in a working group looking at the problem of fatigue, resource management and unit-hour utilization. I'm wanting to compile a good set of ideas to take into this group, and want to bounce ideas and solutions off of y'all, and draw on your opinions and experience.

At present, we're a busy urban/suburban EMS system that operates on 24-hour shifts, in a four-platoon rotation (24 on/72 off). We run P/B, and answer more than 50,000 911 calls annually. Functionally, our service area is pretty busy, with our "slow" stations averaging 6ish calls a day and our "busy" stations averaging 12-14 calls a day, with UHUs ranging from .25 to .75 on average. We've got 15 24-hour trucks, one consistently-operational 12-hour peak truck, and a second occasionally-up peak truck. When levels in one portion of our district are low, or when we are at low levels within our system, we post 24-hour station trucks (this is unpopular). There is no existing fatigue-management policy.

The prevalent EMS culture of Houston is 24-hour shift work, and to my knowledge, no local 911 agency is based in 12-hour shifts. Anecdotally, most of our workforce supports 24-hour shifts because they "get all their hours out of the way at once", have three days off in a row (leaving time for family and supplemental work) and only work 8ish days a month to be full-time. It seems that the 24 is more popular than the 12 in this area, and several local agencies actually work 48/96 shifts.

What are your thoughts?
 

Carlos Danger

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My thoughts are that 24's and even 48's offer real advantages, and are perfectly appropriate providing call volumes and living quarters are such that crews can pretty reliably count on getting a reasonable amount of rest during the shift (preferably at night), AND if a "time out" policy exists where crews who are tired can say uncle and go out of service for a few hours to nap, without repercussion.

If you are working 24's routinely without adequate rest, it will catch up to you personally, one way or another. It factually has a negative impact on patient care decisions and skills performance, and on driving safety. There's lots of research out there on that.

Unless one is prepared to argue that convenience (getting all your hours in with as few workdays as possible) and ease of scheduling (half as many crew changes) is more important than patient and crew safety, there's really no way to justify consistently busy 24's.
 
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RocketMedic

RocketMedic

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@Remi , that's pretty much where we're at now- consistently busy 24s, to the point that management is taking notice.

My proposal is essentially to phase in mandatory "rest periods" of 2-3 hours and drop trucks in series for them overnight, while covering those trucks with a redistributed peak truck and/or neighboring stations.
 

luke_31

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@Remi , that's pretty much where we're at now- consistently busy 24s, to the point that management is taking notice.

My proposal is essentially to phase in mandatory "rest periods" of 2-3 hours and drop trucks in series for them overnight, while covering those trucks with a redistributed peak truck and/or neighboring stations.
That's actually not a bad idea.
 

DrParasite

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At present, we're a busy urban/suburban EMS system that operates on 24-hour shifts, in a four-platoon rotation (24 on/72 off). We run P/B, and answer more than 50,000 911 calls annually. Functionally, our service area is pretty busy, with our "slow" stations averaging 6ish calls a day and our "busy" stations averaging 12-14 calls a day, with UHUs ranging from .25 to .75 on average. We've got 15 24-hour trucks, one consistently-operational 12-hour peak truck, and a second occasionally-up peak truck. When levels in one portion of our district are low, or when we are at low levels within our system, we post 24-hour station trucks (this is unpopular). There is no existing fatigue-management policy.
couple points: unless your math is different than mine, your UHU is off. If your busy trucks average 12 calls a day, their UHU is 0.5. even at 14 or 16 a day, your UHU is 0.58 and 0.67, respectively.

Posting sucks. especially at night. especially when crews are sleeping. especially to a street corner. There is no two ways around that. Street corner posting and SSM are two of the worth ideas to ever come to EMS. Re-locations (the moving of resources to fill a large "hole" in a coverage area) do suck, and should happen, but if you are relocating constantly because holes are developing, than you need to reevaluate your coverage strategy

Which trucks are more in demand? the slow trucks or the busy ones? Would the busy trucks be ok with doing 12 hours in the busy area, and 12 in the slower area? and vice versa?

When calculating UHU, are you including postings and relocations? for UHU, do you consider a call to be door to door (from the moment you get dispatched until you are back in quarters), or from dispatch until you clear the ER and are available for the next assignment?
The prevalent EMS culture of Houston is 24-hour shift work, and to my knowledge, no local 911 agency is based in 12-hour shifts. Anecdotally, most of our workforce supports 24-hour shifts because they "get all their hours out of the way at once", have three days off in a row (leaving time for family and supplemental work) and only work 8ish days a month to be full-time. It seems that the 24 is more popular than the 12 in this area, and several local agencies actually work 48/96 shifts.
24/72s are awesome, and the best way to do 24 hour shifts. I wish more places who did 24s around here did them. Especially when you have enough downtime to get some ZZZs. Then you might need a nap, but afterwards you have two days to do what you want.
Let me play devils advocate, pretending to me a mean nasty management (I don't know what yours is like, but lets say worst case scenario):
so you want me to pay you guys to sleep? At $25 an hour, for 3 hours, for two people. So nap time costs me $150. time 15, for each 24 hour truck...so it's costing me $2,250 a day (that's $821,250) a year to cover your naptime, which is all time when you won't be making me money, because I can't send you on a call that would result in you making me money. another way you are costing me money while not making me money.

Why don't you simply sleep during your downtime? your UHU is 0.75; that means during a 24 hour shift, you should have at least 6 hours when you aren't on calls, and that is only on the busiest truck in the fleet. Why aren't you getting your rest during those 6 hours? So if you haven't had a run for 4 hours, you expect me to give you another 3 hours of no runs? that's 7 hours where you cost me money, but didn't generate anything.

If your too tired from working or too busy, lets do this: lets switch all of you to 12 hour shifts. we can do it with the same amount of personnel as a 24/72; you need a day 12, and a night 12, and two opposite tours to cover the entire week. you don't need to worry about rest time, since you should be able to function for 12 hours without sleep, provided you reported to work fit for duty.

Mr. Paramedic, since we implemented your 3 hour down time, it has been interesting. The mayor's mother is in your first due, and suffered a heart attack. Because you were in your downtime, we had to send an ambulance from further away, while the fire department (who also works 24s, and doesn't get a paid rest periods) was only able to give oxygen and tell the further away ambulance to hurry up, despite seeing the truck parked right down the block at the EMS station. Suffice it to say, he's looking into exploring other providers, because your naptime is having a negative impact on his residents.

Think any of the above situations can't happen? or are unrealistic?

I'm not saying your idea isn't a good one, but it will be an uphill battle, especially if you have less than supportive management. 24/72 is great if your slow (with slow often being a relative term), and the same goes for 48/144. But they end up sucking if you are busy. And as much as you might not want to hear this, we are paid to work, not to sleep. very few jobs will pay you to sleep.

But if you can get upper management buyin, especially by showing them a financial reason why they should do this, than you will be golden.
 

Tigger

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Could you go to a three platoon schedule and increase the number of ambulances on the street, therefore lowering the UHU or finding staff to staff the peak trucks? My AMR op used to do sleep time for the 48 hour calls as they would get slammed regularly (eventually that schedule had to be done away with). A city car would come cover them for a bit, which in turn just made the other city cars busier which didn't do a lot for morale.
 
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RocketMedic

RocketMedic

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@Tigger I don't think a return to the three-platoon system would work; people built their lives around 24/72s and the majority of our people cherish the status quo.

To me, the 'easiest' (and operationally "cheapest" over the long term) would be to transition to a 12-hour, SSM-type system. This seems to me to be a non-starter, because it would effectively destroy the corporate culture and alienate a lot of employees. This would be the functional equivalent of letting AMR or Acadian in to take over the contract, and I think that this will keep that from being a viable fix. At a minimum, it would provoke some serious retention challenges and Houston actually seems to be pretty paramedic-poor in terms of finding lots of people willing to work 12s, if the recruiting challenges Acadian and AMR have here are reasonable guides. Granted, we're a 'better' 911 service, but still, I don't think it would reek of popularity. At a minimum, going to 12s would seem to require a significant across-the-board pay raise, particularly with our EMTs, many of whom work side jobs to make ends meet. Taking twice as many of their days per month to work would nuke a lot of part-time jobs.

14- and 16-hour shifts at the stations have been proposed, but I'm not sure how that would work. The 'busy' trucks already have a $1.00/hour stipend, but that's not curing fatigue or even really making up for sleepless nights (and it's not exactly fair when trucks that weren't historically busy when that stipend was developed are now just as busy- or worse- than the stipend trucks). The hybrid 12/24 system makes sense, but to me, the big problem that pops up is Hall Syndrome (@VentMonkey ) where a 24-hour truck gets sucked into the 'busy' core and the perceived benefits of the 'slow' truck are destroyed. Given that our entire district is only 177 square miles, or about 18 x 10 miles long x wide, that leaves essentially no meaningful geographic distance between the 'slow' and 'busy'. Adding to this is the demographics of the 'slow' areas...they're greying fast and they're not going to be 'slow' in a hurry. Even in my limited time here, I've noticed a trend- when I started last year, we were brisk, now it's EMSA-level busy. We just don't stop for a meaningful length of time most days, and I really think my peak truck assignment is generally easier because I don't have the normal expectation of rest.

@DrParasite , those are essentially the concerns that I reckon are out there (and pretty much how they'll be brought up). The problem with our operation is that the standard problem of EMS applies- people aren't machines and don't do well with non-cumulative and erratic rest periods, and fatigue is not equal in its effects. As for the UHUs, it is difficult to say, except that the 'average' call at most of our stations is anecdotally closer to 90 minutes than 60 and can easily stretch to overall mission times of 2-3 hours with even a modestly out-of-area transport (for example, to the Woodlands or The Land That Knows No Time, aka Ben Taub). We're not yet at SoCal-level bed delays, but it is a problem. I don't have the numbers, so this is all from observation. That's the hard UHU. If we include time spent posting for the 24-hour trucks, it gets demoralizing fast.

The eventual answer to this seems to be 'more' of everything: more trucks, more people, etc, but that means more money, and that's not a popular thing.
 

DrParasite

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The problem with our operation is that the standard problem of EMS applies- people aren't machines and don't do well with non-cumulative and erratic rest periods, and fatigue is not equal in its effects.
I am going to say something you don't want to hear: No one thinks people in EMS are machines (we are all human), however during the time you are at work, you are expected to be working. That's one of the basic rules of business. It might not be popular to say, but it's the truth. Also, you can't have it both ways: you can't say you want 24/72s, and then complain when you have to work for 24 straight hours (see earlier statement). I agree there are issues (exactly the ones you are citing) but if the vast majority of employees are ok with the "conditions" and will fight any change, why should management?
As for the UHUs, it is difficult to say, except that the 'average' call at most of our stations is anecdotally closer to 90 minutes than 60 and can easily stretch to overall mission times of 2-3 hours with even a modestly out-of-area transport (for example, to the Woodlands or The Land That Knows No Time, aka Ben Taub). We're not yet at SoCal-level bed delays, but it is a problem. I don't have the numbers, so this is all from observation. That's the hard UHU. If we include time spent posting for the 24-hour trucks, it gets demoralizing fast.
UHU is one of those funny statistics, because it can sometimes be calculated in a way that doesn't show the actual utilization.

What is supposed to happen is the "utilization" is the time from dispatch until you are either back in the station or assigned the next call (if you get dispatched one on the way back to station). We all know some EMS people tend to like being away from their station, especially on a nice day, so some can be found outside of quarters during the day time (shopping, enjoying a park, getting food, etc), especially when you transport to a hospital that has awesome food outside your primary area. So getting a truly accurate UHU gets tough. But all those things (bed delays/holding the wall, transports to far away hospitals and the return trips, relocations/postings) need to be considered when looking at UHU, and all too often they aren't, making your UHU appear lower than it really is.
The eventual answer to this seems to be 'more' of everything: more trucks, more people, etc, but that means more money, and that's not a popular thing.
Raleigh NC's Fire Department had one engine that was chronically one of the busiest engines in the city. Engine 1 was located downtown (which was the most densely populated part of the city), which generated the most EMS first responder calls, as well as fire related calls. So 60 years ago, when they were building a new station 1, some forward thinking individual decided to build a station with 3 bays: for an engine, ladder, and the arson investigation and chief's vehicles. with an increase in run volume, the chief was moved out, and a second engine was put in that third bay. Engine 1 covered everything north of the firehouse, and engine 13 south. and if a major fire occurred in either first due, both engines would go.

The reason I bring that up is because no agency should be doing standup 24s (or even standup 12s) on a regular basis. I've done it, and I have done it after spending all day at my other job. it sucks. And if your management is allowing it, than something should be reviewed (with sources of funding being considered to add additional units). The reason I say this is if you are running for your entire shift, than you have 0 surge ability. What happens when all your units are tied up? Your taxing your crews with the routine call volume, what happens when the bus accident occurs? or the house fire with people trapped? Yes, your making money for your agency (because an ambulance not on a run isn't making money, and assuming you for a for profit, this is important) when all your rigs are on assignments, but what happens when the local nursing home loses power on a hot summer day? or a cold winter night? or the flu season hits?

If you need a selling point to management, that's what I would focus on. You might be good right now, but how much surge capacity is built in? How much happier will the public be with quicker response times? When we need a second EMS unit, how much easier will it be for the unit to be closer? How much less will we need to rely on mutual aid, and still maintain a level of service that our tax payers expect (which is often how the FDs sell their staffing levels to the bean counters).

It might be an uphill battle, especially without buy-in from the field staff or management. But good luck.
 

VentMonkey

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The eventual answer to this seems to be 'more' of everything: more trucks, more people, etc, but that means more money, and that's not a popular thing.
I am still convinced public education needs to be factored into a larger part of this equation than is (generally) emphasized with most EMS management courses—even now—that I am familiar with, and know of.

Re: The “Hall Syndrome”—
That’s a cultural problem more than a specific service problem. I realize you know this Rocket, and were merely inviting me into this conversation.

But again, if instead of, say, always trying to “beef up” our deployment models, and simply reaching out to the public, involving them, educating them, and generally including them in part of the service that many of the well-to-do citizens seem ill-informed about when it comes to utilizing [their respective service]
so frivolously I don’t see how this is not A) more universally adopted, and B) much cheaper than any other exhausting and costly measure endlessly offered by managers nationwide.
 

Tigger

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Also of note: Everyone calculates UHU differently. Transports/Hours in Service is one way. Calls/Hours in Service is another. AMR uses an entirely different metric. Hours on call/Hours In Service. Hours on a call is measured from dispatch to time at hospital, the unit is considered available at all other times to include hospital time and SSM moves. Which of course pushes down the UHU artificially...
 
OP
RocketMedic

RocketMedic

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When my dad was at Hall, he often worked a 24 hour truck, but would get sucked into the urban Bakersfield system, for many hours. It sounded terrible.
 

chriscemt

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...AMR uses an entirely different metric. Hours on call/Hours In Service...Which of course pushes down the UHU artificially...

Or, in some cases, units are taken Out Of Service For Admin, inflating UHU artificially...
 

DrParasite

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Also of note: Everyone calculates UHU differently. Transports/Hours in Service is one way. Calls/Hours in Service is another. AMR uses an entirely different metric. Hours on call/Hours In Service. Hours on a call is measured from dispatch to time at hospital, the unit is considered available at all other times to include hospital time and SSM moves. Which of course pushes down the UHU artificially...
I could swear someone already said that.... oh wait....
UHU is one of those funny statistics, because it can sometimes be calculated in a way that doesn't show the actual utilization.

What is supposed to happen is the "utilization" is the time from dispatch until you are either back in the station or assigned the next call (if you get dispatched one on the way back to station). We all know some EMS people tend to like being away from their station, especially on a nice day, so some can be found outside of quarters during the day time (shopping, enjoying a park, getting food, etc), especially when you transport to a hospital that has awesome food outside your primary area. So getting a truly accurate UHU gets tough. But all those things (bed delays/holding the wall, transports to far away hospitals and the return trips, relocations/postings) need to be considered when looking at UHU, and all too often they aren't, making your UHU appear lower than it really is.
;)
Or, in some cases, units are taken Out Of Service For Admin, inflating UHU artificially...
not necessarily... if you are taken OOS because you are doing assignments for administration, or meeting people, or doing stuff, while it isn't an actual run, it is an assignment, and should be included, because you are being utilized for a management purpose.

Now if you are taken OOS because your truck broke down, your partner didn't show up, or your missing critical equipment and don't want to be assigned a job, that's a different story.
 

chriscemt

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not necessarily... if you are taken OOS because you are doing assignments for administration, or meeting people, or doing stuff, while it isn't an actual run, it is an assignment, and should be included, because you are being utilized for a management purpose..

Theoretically, your statement is true, but only if various operations didn't calculate UHU differently. In my operation, we have a unit that is routinely taking itself OOS for "admin" when they are posted. While they may be performing various "admin" duties, it's not as though those duties couldn't be otherwise completed. Their UHU is always the highest, since they're only in service when a call is available for them to take...

And yes, I'm using the quotations around "admin" in it's strictest sense - they are often just posted, and I'm speaking to something I witness directly.
 

SpecialK

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Since the 1970s the fire brigade roster of 2 x 12 hr days then 2 x 12 hr nights has been used; this is fine for the fireys who can get two days training, watching telly and reading the paper, then two nights watching telly, eating and sleeping in. Ambulance is not so fortunate.

12 hour shifts, even with the two mandatory 30 minute breaks are too long. The DDNN pattern is also horrible.

For ages it's been bantered around changing to 8 or 10 hour shifts and doing, for example, a block of days, a block of lates, and a block of nights then resetting.

That would be much better. It's pretty rare to get more than a few hours kip on a night shift anymore, gone are the days when you only got woken a little.

Day shifts are horrible; it's basically show up and work constantly. You're absolutely shattered at the end and only 12 hours inbetween a shift means say 30 minutes getting home, having to go straight to bed pretty much, sleep, get up, have an hour or so before you have to go back to work, then going back to work; there's no down time.

If the shifts were say 8 or 10 hrs long that's more time to be a person and mentally decompress before you have to go back!
 

DrParasite

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12 hour shifts, even with the two mandatory 30 minute breaks are too long.
why? yes, it's a long 12 hours, but assuming you work a 40 hour work week, you are only working 3 days a week. however
The DDNN pattern is also horrible.
this is probably your biggest killer. days to nights kills your circadian rhytyhm. FD can do it because they can usually sleep at night, or sleep for part of the night.
For ages it's been bantered around changing to 8 or 10 hour shifts and doing, for example, a block of days, a block of lates, and a block of nights then resetting.

That would be much better. It's pretty rare to get more than a few hours kip on a night shift anymore, gone are the days when you only got woken a little.
8 or 10 hour shifts wouldn't help: but doing a month of nights followed by a month of days would be even better. the change over week would suck, but it's better than giving yourself 24 hours off to change from working days to working nights
Day shifts are horrible; it's basically show up and work constantly. You're absolutely shattered at the end and only 12 hours inbetween a shift means say 30 minutes getting home, having to go straight to bed pretty much, sleep, get up, have an hour or so before you have to go back to work, then going back to work; there's no down time.

If the shifts were say 8 or 10 hrs long that's more time to be a person and mentally decompress before you have to go back!
I could be mistaken here, but didn't you say previously that you always got a 1 hour uninterrupted meal break, and two 15 minute breaks during your shift?

and I don't think it's too unreasonable for management to expect you to work for the full 12 hours of your shift. yeah you go home tired, and that day to night switch sucks, but you are doing your job that you are being paid for.

Scheduling is always tough in a 24/7 environment (not simply EMS or public safety), because you need nights and weekends, which many people don't want to do. but it still needs to be done, so many places try to share the misery equally (hence the day to night switch).

Bottom line is, you aren't paid to sleep, and if you are working 12s, you shouldn't expect to.(because you can sleep when your off shift)
 

MMohler

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Well got off a 48 and got a total of 7 hours of sleep between the 2 nights. Got off and went straight to the part time job. I signed up for this and do not regret it but being that I work for a smaller 911 company in SoCal we do not have the resources to give guys solid sleep. Just part of the business.
 
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RocketMedic

RocketMedic

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Well got off a 48 and got a total of 7 hours of sleep between the 2 nights. Got off and went straight to the part time job. I signed up for this and do not regret it but being that I work for a smaller 911 company in SoCal we do not have the resources to give guys solid sleep. Just part of the business.

Until you bork a call or introduce your truck to a motorist, guardrail or curve due to fatigue..
 

MMohler

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Until you bork a call or introduce your truck to a motorist, guardrail or curve due to fatigue..

If it is that bad we as in me and my partner will switch or vise versa. When I was on a 24 ift/911 car it was mostly one sleep on the way there and other sleep on the way back. An actual emergent call also wakes you up pretty quickly...
 
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RocketMedic

RocketMedic

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Well got off a 48 and got a total of 7 hours of sleep between the 2 nights. Got off and went straight to the part time job. I signed up for this and do not regret it but being that I work for a smaller 911 company in SoCal we do not have the resources to give guys solid sleep. Just part of the business.

Until you bork a call or introduce your truck to a motorist, guardrail or curve due to fatigue..
 

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