Fatigue, Risk and Excellence: 

Towards a Pan-Canadian Consensus on Resident Duty

Hours

Funded in part by Health Canada, the project ran from March 2012 – May 2013; Public report released on June 27

•Two central goals:To assemble the available evidence on the issue of resident duty hours in Canada and similar international contexts (or duty hours at large)

To facilitate a national consensus-building process to come to pan-Canadian statements on issues, directions, and best practices

The final report was developed by the National Steering Committee on Resident Duty Hours, a diverse group of medical educators, residents and experts from across Canada, including nine health care organizations

The project was divided into three key phases, which together spanned the period from March 2012-May 2013.

A mixed-method, multi-phased approach was developed to guide research and analysis throughout the project, including

– Interviews with National Steering Committee members, – National Survey of Residents, Postgraduate Deans, Program ,

Directors, and a Sample of Hospital Administrators, – Analysis of Current and Historic Collective Agreements, – Literature Review, – Jurisdictional Review outside Canada, – Six Expert Working Group Commentary Papers, and– Canadian Consensus Conference on Resident Duty Hours.

A Way Forward for CanadaA Way Forward for Canada

Key Findings + Key Findings +

5 Central Principles +5 Central Principles +

5 Recommendations 5 Recommendations

to Move Forwardto Move Forward

•Canada has a unique landscape as pertains to resident duty hour regulations.

•The environment in Canada is marked by tremendous historical and geographic variability in the working environments faced by residents.

1. Traditional duty periods present risks to the physical, mental, and occupational health of residents.

2. Fatigue impairs cognitive and behavioural performance.3. A tired doctor is not necessarily an unsafe doctor.4. There is no conclusive data to show that restrictions on

consecutive resident duty hours are necessary for patient safety.

5. Successful efforts to improve patient safety and resident fatigue will need to be comprehensive, involving not only the regulation of resident duty hours alone.

6. There is no clear evidence that resident duty hour regulations have had a significant positive or negative impact on academic performance.7. There is evidence suggesting suboptimal patient care and

educational outcomes in surgery resulting from the restriction of resident duty hours. 8. Resident duty hour regulations necessitate reorganization of health human resources deployment and care delivery models. These changes have the potential for impact on the health care system.

1. Residents have inter-related roles as learners and care providers.2. Residents are vital providers in a health care system that is

collectively responsible for 24/7 patient care coverage3. Duty periods of twenty-four or more consecutive hours without

restorative sleep should be avoided.4. Efforts to minimize risk and enhance safety are necessary and

cannot be undertaken by addressing resident duty hours alone.5. Given the substantial variation in resident training needs, a

tailored and rigorous model for resident duty hours and the provision of after-hour care is needed.

Recognizing that there are many factors that contribute to resident fatigue, a comprehensive approach to minimize fatigue and fatigue-related risks should be developed and implemented in residency training in all jurisdictions in Canada.

• Residency education programs to develop fatigue risk management plans

• Create monitoring and enforcement mechanisms at a local level• Develop a national tool-box of fatigue mitigation strategies and

techniques

Educational approaches should be redesigned to leverage innovations and new approaches, to ensure appropriate training and acquisition of competencies in an era of increasing resident duty hour regulations.

• Encourage and catalogue pilot projects for a range of educational tools and innovative scheduling systems

• Re-design residency education to maximize teaching and learning opportunities, and minimize excessive service obligations

• Incorporate simulation experiences into programs as teaching tools• Curricula to include self-assessment, fatigue management, and handover

skills• The Three sister colleges to review specialty training requirements to

allow flexibility in training

Accreditation standards must be adapted to support planned modifications of the content and duration of resident duty, through the enforcement of fatigue risk management activities.

• Standards to specify that individual institutions must develop, and keep up to date, fatigue risk management plans (FRMPs)

• Standards should require education in effective self-awareness, handover and communication skills

An inventory of alternate models of scheduling and after-hours care provision should be created and disseminated to provide alternatives and benchmarks of scheduling and service delivery.

•A national evaluation framework to monitor the impact of changes to resident duty hours should be created.

An independent, pan-Canadian consortium devoted to the evaluation of resident duty hours in Canada should be created. •Enable local decision-making through the provision of resources and measurement related to resident duty hours

Consortium would have four key roles:1.Create and coordinate dissemination of national toolbox of resources2.Support the process of Fatigue Risk Management Plan creation/implementation3.Undertake science and evidence-based research on resident duty hours4.Knowledge translation and dissemination of scholarly evidence

View the complete report to learn more about•Project timelines and activities•Project methodology•A glossary of resident duty hours terminology•Key research themes and findings•Pan-Canadian principles•Recommendations