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Sleep deprivation in EMS: Causes, consequences and solutions

Posted on 13th December 2016 at 11:48am

Our R&D bloggers look at the issue of sleep deprivation, one of the primary health deficits in emergency medicine, which can have serious physiological, financial and social consequences

(photo: 123rf/ostill)

Man is the only mammal that will willingly delay sleep. Sleep deprivation is defined by the International Classification of Sleep Disorder as a: “Disorder that occurs in an individual who persistently fails to obtain sufficient nocturnal sleep required to support normally alert wakefulness.”

Sleep deprivation is one of the primary health deficits in emergency medicine, which not only affects job performance, but also leads to serious physiological, financial, and social consequences. Recent studies have shown that sleep-deprived individuals are more likely to have suicidal ideations, show impaired procedural performance despite extended practise, and accumulate neurocognitive deficits involving changes to brain structures mediating sensory processing and decision-making.

Impairment of individual cognitive levels can also lead to deleterious financial repercussions; it is estimated that $18 billion is lost on annual productivity in US companies; a total of $43 to $56 billion is estimated to be lost due to human error-related accidents, which could be a result of sleep deprivation (Goel, Namni, et al 2009).

Emergency Medical Service (EMS) providers are at a particular risk of sleep deprivation. While prevalence in the general population is approximated to be around 20 per cent, recent surveys of prehospital providers puts the estimate to up to 59 per cent. The higher incidence of sleep deprivation, along with increased exposure to human disaster, is reflected in elevated rates of PTSD (17 per cent) and depression (22 per cent) relative to the general population, where surveys place the rates of PTSD and depression at as low as 1.9 per cent and 10 per cent, respectively (Carey, Mary G., et al 2011).

Furthermore, a 2011 survey of 112 professional firefighters found correlations between sleep deprivation, binge drinking, nicotine use, depression and poor social bonding, while a 2010 study involving 119 EMS providers found around 45 per cent to be suffering from severe mental and physical fatigue and 60 per cent diagnosed with one or more health conditions such as diabetes. Carey, Mary G., et al also found that a significant portion of the subjects were overweight (41.9 per cent) or obese (42.7 per cent), which corroborates previous studies that have found a correlation between short, low-quality sleep with obesity.

Beyond the immediate effects on the first responders, sleep deprivation also affects job performance such as protocol deviation and quality of patient care. In 2007, Dr William Killgore and colleagues focused on 26 healthy adults, finding that following 53 hours of continuous wakefulness, participants had more difficulty responding to moral dilemmas. The impediment in decision-making corroborates studies that show sleep loss from extended shift work is associated with higher incidences of medical error and attention failures in medical residents and nurses.

In EMS personnel, sleep deprivation has been linked to job-related injuries and medical errors such as protocol deviation, failure in securing an airway, dropping patients, and medication mistakes. Medical errors not only affect the patients physically, but have financial implications, such as malpractice suits, as well. Ultimately, sleep deprivation leads to adverse consequences for both medical personnel, and as for the patients that the sleep deprived provider is taking care of.

Causes of Sleep Deprivation in EMS

The nature of EMS as a continuous service requires providers to work at odd hours of the day, with 24-hour shifts being common. Working multiple shifts is also common, as EMS personnel may work for different agencies simultaneously and have fewer restrictions placed on working hours. Working for long periods or at night can disrupt circadian rhythms and sleep quality, leading to the detrimental physiological consequences as discussed above.

Furthermore, the high-stress environment of EMS may affect sleep quality and duration. A group of EMTs headed by Chad Newland found in a 2015 survey that 37 per cent of a sample of over 4,000 EMS providers had contemplated suicide; meanwhile, firefighter Mark Holland found in 2011 that in 108 fire/EMS personnel, 29 per cent had traumatic stress symptomatology as well as an epidemic of detrimental coping skills.

There is a correlation not only between stress-related disorders and sleep disorders, but also between chronic elevated stress levels, sleep quality and insomnia. The reports are particularly concerning owing to the enduring nature of stress-related disorders and their often-indelible repercussions.

Possible solutions for addressing and combatting sleep deprivation

More research should be carried out to study sources of sleep deprivation in EMS and ways to implement change to prevent the adverse impact that this can cause. On a broad scale, regulation of EMS work hours should be applied and better compensation should be proposed to deter EMS personnel from working for multiple agencies. In particular, policies on resource and personnel distribution should be executed so as to prevent short staffing.

Education on resources for self-care should be implemented, such as therapy programmes and debriefing sessions. The 2015 Newland survey found that support programme such as employee assistance programmes (EAP) and critical incident stress management (CISM) teams were reported to be ‘very helpful’, but found that EMS personnel did not find the support to be accessible. The same survey also found that a positive work environment involving peer encouragement to seek support contributed to voluntarily seeking help, and ultimately increasing the effectiveness of the aforementioned programmes.

At the individual level, EMS personnel must be conscious of making healthy decisions and educate themselves on methods to relax and attenuate sleep disruptions. Working together to minimise sleep deprivation will improve the overall outcome for both the patient and overall quality of life for an EMS provider.

Alexander Koo, Carly Esteves, Kira Saltz, Ian Portelli

Citations

Caldwell, John A.:The impact of fatigue in air medical and other types of operations: a review of fatigue facts and potential countermeasures. Air Medical Journal 20.1 (2001): 25-32.

Carey, Mary G., et al: Sleep problems, depression, substance use, social bonding, and quality of life in professional firefighters. Journal of occupational and environmental medicine/American College of Occupational and Environmental Medicine 53.8 (2011): 928.

Chaput, Jean-Philippe, and Caroline Dutil: Lack of sleep as a contributor to obesity in adolescents: impacts on eating and activity behaviors. International Journal of Behavioral Nutrition and Physical Activity 13.1 (2016): 103.

Furtado, Fabianne, et al: Chronic low quality sleep impairs postural control in healthy adults.PLoS one 11.10 (2016): e0163310.

Goel, Namni, et al: Neurocognitive consequences of sleep deprivation. Seminars in neurology. Vol. 29. No. 04. © Thieme Medical Publishers, 2009.

Holland, Mark: The dangers of detrimental coping in emergency medical services. Prehospital Emergency Care 15.3 (2011): 331-337.

Hublin, Christer, et al: Insufficient sleep--a population-based study in adults. Sleep 24.4 (2001): 392-400.

Itani, Osamu, et al: Short sleep duration and health outcomes: a systematic review, meta-analysis, and meta-regression." Sleep Medicine (2016).

Kurniawan, I. T. et al. Procedural performance following sleep deprivation remains impaired despite extended practice and an afternoon nap. Scientific Reports 6 (2016).

Killgore, William DS, et al: The effects of 53 hours of sleep deprivation on moral judgment. Sleep - New York Then Westchester - 30.3 (2007): 345.

Matsumoto, Yuuki, et al: Day workers suffering from a wider range of sleep problems are more likely to experience suicidality. Sleep and Biological Rhythms 14.4 (2016): 369-376.

Newland, Chad, et al: Critical stress. Survey reveals alarming rates of EMS provider stress and thoughts of suicide. JEMS: a Journal of Emergency Medical Services 40.10 (2015): 30-34.

Patterson, P. Daniel, et al: Sleep quality and fatigue among prehospital providers. Prehospital Emergency Care 14.2 (2010): 187-193.

Patterson, P. Daniel, et al: Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. Prehospital Emergency Care 16.1 (2011): 86-97.

Sofianopoulos, Sarah, Brett Williams, and Frank Archer: Paramedics and the effects of shift work on sleep: a literature review. Emergency Medicine Journal (2010): emj-2010.

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