Evidence-Based Guidelines for Fatigue Risk Management in EMS: Formulating Research Questions and Selecting Outcomes

The need for recovery: An investigation into short-term work-related fatigue in veterinary nurses

BACKGROUND

Veterinary nursing is physically and emotionally demanding, putting veterinary nurses at risk of acute work-related fatigue (AWRF). Despite the increased recognition of chronic occupational syndromes such as burnout and compassion fatigue in recent years, few studies have investigated how AWRF impacts individuals and the profession.

METHODS

An anonymous survey open to all UK-based registered veterinary nurses (RVNs) was distributed via email and social media. The survey investigated work patterns, hobbies, opinions about work and intentions to leave the veterinary profession. An English translation of the need for recovery (NFR) scale was used to quantify the AWRF.

RESULTS

The median NFR score from 387 responses was 81.8, indicating high levels of AWRF. Long shifts, sole-charge work and overtime were associated with higher scores, while having support at work and a better work-life balance were associated with lower scores. Higher scores were correlated with intentions to leave the profession.

LIMITATIONS

Although validated as a measure of AWRF, the unidimensional NFR scale oversimplifies the complexities of fatigue. A limited number of RVNs responded to the survey, reducing statistical power.

CONCLUSION

Although there is no single solution to staff turnover, the results from this survey suggest that addressing AWRF may improve retention of RVNs.

Does the evidence support brief (≤30-mins), moderate (31-60-mins), or long duration naps (61+ mins) on the night shift? A systematic review

We performed a systematic review of four databases to determine if the evidence supports a short or long duration nap during night shifts to mitigate fatigue, and/or improve health, safety, or performance for emergency services and public safety personnel (PROSPERO CRD42020156780). We focused on experimental research and evaluated the quality of evidence with the grading of recommendations, assessment, development, and evaluation (GRADE) framework. We used the Cochrane Collaboration's risk of bias tool to assess bias and reported findings using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Our search yielded n = 10,345 records and n = 44 were reviewed in full-text. Inter-rater agreement during screening was substantial (Kappa = 0.66). We retained n = 11 publications, reporting on n = 7 experimental studies with a cumulative sample size of n = 140. We identified wide variation in study design, napping interventions (i.e., timing, placement, and duration), and outcomes. We identified mixed findings comparing brief, moderate, and long duration naps on outcomes of interest. All seven studies presented serious risk of bias and the quality of evidence was rated as low. Based on the best available evidence, decisions regarding nap duration during night shift work should be based on time (post-nap) and outcome.

Evidence-based guidelines for intra-articular injection in knee osteoarthritis: Formulating and evaluating research questions

OBJECTIVE

To formulate and evaluate clinical questions about intra-articular injection for knee osteoarthritis in developing clinical practice guidelines and to introduce a new methodology for framing relevant questions.

METHODS

We framed the clinical questions and evaluated the importance of these questions according to the following four steps: (a) first round questionnaire survey intended to get the clinical questions from doctors; (b) evaluating importance of questions via second round questionnaire survey intended to summarize and rank the clinical questions; (c) consensus conference was conducted by clinical and methodological experts; and (d) confirm the important clinical questions according to PICO (Patients, Intervention, Comparison and Outcomes) principles.

RESULTS

After the first round questionnaire survey, the number of clinical questions was 26. Thirteen of these 26 questions were regarded as important questions by the second questionnaire survey. Ultimately, the 13 important clinical questions were determined in a consensus conference. All included questions were deconstructed by clinical experts and methodologists based on the PICO principles.

CONCLUSION

The present study describes an approach about the selection of clinical questions and importance evaluation. Relevant important clinical questions about intra-articular injection for knee osteoarthritis are determined according to the methodology. It could help other guideline developers to utilize this method to frame clinical questions.

Impact of fatigue and insufficient sleep on physician and patient outcomes: a systematic review

OBJECTIVES

For physicians in independent practice, we synthesised evidence on the (1) impacts of insufficient sleep and fatigue on health and performance, and patient safety and (2) effectiveness of interventions targeting insufficient sleep and fatigue.

DESIGN

We systematically reviewed online literature. After piloting, one reviewer selected studies by title and abstract; full texts were then reviewed in duplicate. One reviewer extracted data; another verified a random 10% sample. Two reviewers assessed risk of bias. We pooled findings via meta-analysis when appropriate or narratively.

DATA SOURCES

We searched Medline, Embase, PsycINFO, CINAHL and PubMed for published studies in April 2016; Medline was updated in November 2017. We searched Embase for conference proceedings, and hand-searched meeting abstracts, association and foundation websites.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

English or French language primary research studies published from 2000 to 2017 examining the effect of fatigue-related or sleep-related exposures or interventions on any outcome among physicians in independent practice and their patients.

RESULTS

Of 16 154 records identified, we included 47 quantitative studies of variable quality. 28 studies showed associations between fatigue or insufficient sleep and physician health and well-being outcomes. 21 studies showed no association with surgical performance, and mixed findings for psychomotor performance, work performance and medical errors. We pooled data from six cohort studies for patient outcomes. For sleep deprived versus non-sleep deprived surgeons, we found no difference in patient mortality (n=60 436, relative risk (RR) 0.98, 95% CI 0.84 to 1.15, I²=0% (p=0.87)) nor postoperative complications (n=60 201, RR 0.99, 95% CI 0.95 to 1.03, I²=0% (p=0.45)). The findings for intraoperative complications and length of stay were considerably heterogeneous.

CONCLUSIONS

Fatigue and insufficient sleep may be associated with negative physician health outcomes. Current evidence is inadequate to inform practice recommendations.

Systematic Review Methodology for the Fatigue in Emergency Medical Services Project

BACKGROUND

Guidance for managing fatigue in the Emergency Medical Services (EMS) setting is limited. The Fatigue in EMS Project sought to complete multiple systematic reviews guided by seven explicit research questions, assemble the best available evidence, and rate the quality of that evidence for purposes of producing an Evidence Based Guideline (EBG) for fatigue risk management in EMS operations.

METHODS

We completed seven systematic reviews that involved searches of six databases for literature relevant to seven research questions. These questions were developed a priori by an expert panel and framed in the Population, Intervention, Comparison, and Outcome (PICO) format and pre-registered with PROSPERO. Our target population was defined as persons 18 years of age and older classified as EMS personnel or similar shift worker groups. A panel of experts selected outcomes for each PICO question as prescribed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We pooled findings, stratified by study design (experimental vs. observational) and presented results of each systematic review in narrative and quantitative form. We used meta-analyses of select outcomes to generate pooled effects. We used the GRADE methodology and the GRADEpro software to designate a quality of evidence rating for each outcome.

RESULTS

We present the results for each systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). More than 38,000 records were screened across seven systematic reviews. The median, minimum, and maximum inter-rater agreements (Kappa) between screeners for our seven systematic reviews were 0.66, 0.49, and 0.88, respectively. The median, minimum, and maximum number of records retained for the seven systematic reviews was 13, 1, and 100, respectively. We present key findings in GRADE Evidence Profile Tables in separate publications for each systematic review.

CONCLUSIONS

We describe a protocol for conducting multiple, simultaneous systematic reviews connected to fatigue with the goal of creating an EBG for fatigue risk management in the EMS setting. Our approach may be informative to others challenged with the creation of EBGs that address multiple, inter-related systematic reviews with overlapping outcomes.

Systematic Review and Meta-analysis of the Effects of Caffeine in Fatigued Shift Workers: Implications for Emergency Medical Services Personnel

BACKGROUND

Emergency Medical Services (EMS) workers may experience fatigue as a consequence of shift work. We reviewed the literature to determine the impact of caffeine as a countermeasure to fatigue in EMS personnel and related shift workers.

METHODS

We employed the GRADE methodology to perform a systematic literature review and search multiple databases for research that examined the impact of caffeine on outcomes of interest, such as patient and EMS personnel safety. For selected outcomes, we performed a meta-analysis of pooled data and reported the pooled effect in the form of a Standardized Mean Difference (SMD) with corresponding 95% confidence intervals.

RESULTS

There are no studies that investigate caffeine use and its effects on EMS workers or on patient safety. Four of 8 studies in shift workers showed that caffeine improved psychomotor vigilance, which is important for performance. Caffeine decreased the number of lapses on a standardized test of performance [SMD = 0.75 (95% CI: 0.30 to 1.19), p = 0.001], and lessened the slowing of reaction time at the end of shifts [SMD = 0.52 (95% CI: 0.19 to 0.85); p = 0.002]. Finally, 2 studies reported that caffeine reduced sleep quality and sleep duration.

CONCLUSIONS

Although the quality of evidence was judged to be low to moderate, when taken together, these studies demonstrate that caffeine can improve psychomotor performance and vigilance. However, caffeine negatively affects sleep quality and sleep duration. More systematic, randomized studies need to be conducted in EMS workers in order to address the critical outcomes of health and safety of EMS personnel and patients. The risk/benefit ratio of chronic caffeine use in shift workers is currently unknown.

Effects of Napping During Shift Work on Sleepiness and Performance in Emergency Medical Services Personnel and Similar Shift Workers: A Systematic Review and Meta-Analysis

BACKGROUND

Scheduled napping during work shifts may be an effective way to mitigate fatigue-related risk. This study aimed to critically review and synthesize existing literature on the impact of scheduled naps on fatigue-related outcomes for EMS personnel and similar shift worker groups.

METHODS

A systematic literature review was performed of the impact of a scheduled nap during shift work on EMS personnel or similar shift workers. The primary (critical) outcome of interest was EMS personnel safety. Secondary (important) outcomes were patient safety; personnel performance; acute states of fatigue, alertness, and sleepiness; indicators of sleep duration and/or quality; employee retention/turnover; indicators of long-term health; and cost to the system. Meta-analyses were performed to evaluate the impact of napping on a measure of personnel performance (the psychomotor vigilance test [PVT]) and measures of acute fatigue.

RESULTS

Of 4,660 unique records identified, 13 experimental studies were determined relevant and summarized. The effect of napping on reaction time measured at the end of shift was small and non-significant (SMD 0.12, 95% CI -0.13 to 0.36; p = 0.34). Napping during work did not change reaction time from the beginning to the end of the shift (SMD -0.01, 95% CI -25.0 to 0.24; p = 0.96). Naps had a moderate, significant effect on sleepiness measured at the end of shift (SMD 0.40, 95% CI 0.09 to 0.72; p = 0.01). The difference in sleepiness from the start to the end of shift was moderate and statistically significant (SMD 0.41, 95% CI 0.09 to 0.72; p = 0.01).

CONCLUSIONS

Reviewed literature indicated that scheduled naps at work improved performance and decreased fatigue in shift workers. Further research is required to identify the optimal timing and duration of scheduled naps to maximize the beneficial outcomes.

Shorter Versus Longer Shift Durations to Mitigate Fatigue and Fatigue-Related Risks in Emergency Medical Services Personnel and Related Shift Workers: A Systematic Review

BACKGROUND

This study comprehensively reviewed the literature on the impact of shorter versus longer shifts on critical and important outcomes for Emergency Medical Services (EMS) personnel and related shift worker groups.

METHODS

Six databases (e.g., PubMed/MEDLINE) were searched, including one website. This search was guided by a research question developed by an expert panel a priori and registered with the PROSPERO database of systematic reviews (2016:CRD42016040099). The critical outcomes of interest were patient safety and personnel safety. The important outcomes of interest were personnel performance, acute fatigue, sleep and sleep quality, retention/turnover, long-term health, burnout/stress, and cost to system. Screeners worked independently and full-text articles were assessed for relevance. Data abstracted from the retained literature were categorized as favorable, unfavorable, mixed/inconclusive, or no impact toward the shorter shift duration. This research characterized the evidence as very low, low, moderate, or high quality according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

The searched yielded n = 21,674 records. Of the 480 full-text articles reviewed, 100 reported comparisons of outcomes of interest by shift duration. We identified 24 different shift duration comparisons, most commonly 8 hours versus 12 hours. No one study reported findings for all 9 outcomes. Two studies reported findings linked to both critical outcomes of patient and personnel safety, 34 reported findings for one of two critical outcomes, and 64 did not report findings for critical outcomes. Fifteen studies were grouped to compare shifts <24 hours versus shifts ≥24 hours. None of the findings for the critical outcomes of patient and personnel safety were categorized as unfavorable toward shorter duration shifts (<24 hours). Nine studies were favorable toward shifts <24 hours for at least one of the 7 important outcomes, while findings from one study were categorized as unfavorable. Evidence quality was low or very low.

CONCLUSIONS

The quality of existing evidence on the impact of shift duration on fatigue and fatigue-related risks is low or very low. Despite these limitations, this systematic review suggests that for outcomes considered critical or important to EMS personnel, shifts <24 hours in duration are more favorable than shifts ≥24 hours.