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Address for correspondence: Howard A. Werman, MD, Professor Emeritus, The Ohio State University, 773 Prior Hall, 376 West 10th Avenue, Columbus, OH 43210.
The purpose of this study was to examine the impact of crew fatigue on the performance of a high-risk clinical skill in a clinical setting.
Methods
This was a retrospective analysis of first-pass intubation success comparing critical care providers with self-reported fatigue and those without fatigue in a transport environment. Results: No statistical difference was found in first-pass intubation between fatigued and nonfatigued practitioners.
Conclusion
Future studies should determine the impact of fatigue on psychomotor and cognitive skills using validated methods of assessing the level of fatigue at the time of skill performance.
Air medical crews are called on to assess and stabilize the most critically ill and injured patients. These health care providers may be called on at a moment's notice to perform skills and make critical decisions. The care provided takes place in a particularly challenging environment because of space limitations, noise, vibration, turbulence, and altitude. Another potential confounder is fatigue, which has been postulated to negatively impact clinical performance.
concluded that air medical crews on 12-hour versus 24-hour shifts showed no difference in intubation success rates or the number of intubation attempts, even when only night hours were compared. However, few studies have examined the impact of air medical crew risk of fatigue on direct clinical skill performance. The purpose of the current investigation was to examine the impact of crew fatigue on the performance of a high-risk clinical skill in a clinical setting.
Methods
Study Setting
MedFlight is a not-for-profit, Commission on Accreditation of Medical Transport Systems–accredited air and ground critical care transportation service based in central Ohio. The service performs over 4,300 air medical transports annually and an additional 2,700 ground critical care transports a year utilizing a nurse paramedic team. Air medical crews worked either 12- or 24-hour shifts, whereas ground crews worked 12-hour shifts only. All medical crewmembers are required to go through simulation labs for procedural (including airway management) proficiency as part of their initial training, which sets a basic standard. Additionally, during annual competency training, there is extensive emphasis on airway management proficiency.
Study Design
A retrospective chart review using data collected from patient charts transported via MedFlight from a period of 4 years (2013-2017) was included in the analysis. All patients who underwent an endotracheal intubation attempt by the MedFlight air or ground critical care crewmembers were eligible for the study. Data were excluded if 1 of the crewmembers had not completed their crew resource management (CRM) risk assessment form or any data were missing from a form. Crewmembers who had not had at least 10 intubations recorded before the data event were excluded from the analysis. No exclusions were made based on whether the procedure was performed midflight or transport or before departure because prior studies in an air medical setting have shown no difference in the success of airway procedures based on the location of the attempt.
The first-attempt success rate as well as the number of attempts were recorded. In addition, the time from dispatch to launch was recorded for each request.
Flight crews completed a CRM risk assessment before beginning their clinical shift (Fig. 1). The risk assessment tool was developed from multiple sources including guidelines provided during the Federal Aviation Administration's Fatigue Management Symposium held in June 2008, and the assessment follows the general Federal Aviation Administration's guidelines for pilots in preflight risk assessment.
Data were analyzed using the chi-square test to determine the odds of failure in fatigued versus nonfatigued crewmembers attempting intubations. Fatigue was defined by CRM scores greater than 8; the scores reflected the summation of team member scores (Fig. 1). Low fatigue risk was defined as a CRM risk assessment as a summation of the 2 crewmember scores of 8 or less. Intubation was dichotomized between those intubations successful on the first attempt and those with more than 1 attempt. Data were also assessed by transport mode to ensure homogeneity of the data. Finally, an analysis of fatigue versus response time was used to determine if there were any differences based on risk assessment.
Results
During the 4-year period of the study, 613 patients underwent an intubation attempt. In 203 cases, either the forms were not completed by 1 crewmember or the information was not complete. The final sample size was 410 events.
Table 1 shows the analysis for the entire cohort. No statistical difference was found between the success rates for those patients who were intubated by fatigued individuals compared with those whose risk scores were not fatigued (P = .6167). Table 2 shows the breakdown comparing air and ground critical care crews. Again, no statistically significant difference was found (P = .5394 for air; P = .9028 for ground).
Table 1Chi-Square Analysis of All First-Attempt Success Versus Crew Resource Management (CRM) Risk Assessment
Table 3 shows the liftoff times for air crews based on their fatigue status. Of note, data were incomplete for 30 cases. Although not statistically significant, there appeared to be a trend suggesting that fatigued individuals were less likely to achieve a liftoff of less than 7 minutes (P = .0741).
Table 3Chi-Square Analysis of Time to Liftoff Versus Crew Resource Management (CRM) Risk Assessment
CRM, previously known as cockpit resource management, evolved in the aviation industry secondary to some serious and fatal aircraft mishaps. CRM over the years has evolved to include various areas of focus, such as human error, company safety culture, communication, coordination, automation issues, and many others. A specific area of concern that is also included is stress, stress management, and fatigue of the crew.
Multiple factors can play into crew development of stress and fatigue, including but not limited to poor sleep hygiene, disturbances in circadian rhythm, work schedules, and outside personal and environmental influences.
Given the importance that CRM can have in recognizing potential hazards in aviation, these concepts have been applied in health care wehre teamwork and cooperation are involved. An article out of the United Kingdom demonstrated how the aviation industry, with its method of reducing errors in the field, could be applied in the health care field.
One can argue about the further importance of CRM when one speaks of flight or transport crews working with health care workers to transport patients.
Statistics from 2008 showed that there were about 400,000 rotor wing transports annually, with another 150,000 patients flown by fixed wing aircraft each year.
This number has likely increased because the number of rotator wing aircraft alone providing medical care has grown from around 800 to over 1,000 as of September 2016 according to the Atlas and Database of Air Medical Services.
showed that nearly 50% of air medical crews have shift lengths greater than 16 hours and that one third of programs do not provide for crew rest.
Certainly, in addition to aviation safety, the factors cited previously can have an impact on skill performance, with airway management being among the most critical skills used by air medical crewmembers. Few studies have been conducted in the air medical environment. Indeed, Myers et al
showed that nontechnical skills such as teamwork and situational awareness that accompany skill performance are impacted by fatigue. However, our study results failed to demonstrate a difference in first-time intubation success among crewmembers with high CRM risk scores indicating a high likelihood of fatigue compared with those at low risk. Our findings are similar to Allen et al,
who used shift length as a surrogate measure of fatigue and were unable to demonstrate a difference in intubation success.
Limitations
Our study results had several limitations. First, although our CRM risk assessment instrument was based on similar tools used in the aviation industry, it has not been validated for use by air medical crewmembers. An additional limitation was that compliance with completion of the instrument was uniform, leading the authors to discard approximately one third of the eligible cases. Although it is possible that those who did not complete the risk assessment were well rested and felt no need to complete the form, it is equally likely that some crews were concerned that their higher scores might preclude them from being assigned a mission and thus did not comply with the requirement to complete the assessment. An additional concern with the CRM risk assessment was that it was only required at the beginning of the shift and may not reflect the fatigue status of the crew at the time of the actual transport. Finally, it is also possible that our study may have been underpowered to detect small differences in intubation success rate.
Since the time of this study, several changes may have impacted our findings. In conjunction with our participation in the Ground and Air Quality in Transport initiative, our program has focused on first-attempt intubation success and is now achieving > 90% success. Additionally, the crews have moved to a newer risk assessment tool that is used after every transport.
Conclusion
No differences were found in air medical crewmembers’ risk assessment and their ability to successfully complete endotracheal intubations on the first attempt. It is possible that there are nontechnical elements of transport that are adversely affected by fatigue. Given the limitations of our study, future prospective studies should evaluate whether fatigue affects the performance of critical skills as well as the impact of mitigating strategies on performance.
References
Frakes MA
Kelly JG.
Shift length and on-duty rest patterns in rotor-wing air medical programs.
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