Strategies to mitigate fatigue in the ICU workforce

In the wake of the COVID apocalypse that flogged the already dead horses of Australian critical care, exhausted CICM examiners (just before dramatically collapsing like Pheidippides) created Question 8 from the first paper of 2022, which asked the candidates to "implement a strategy to mitigate fatigue in the medical workforce". It is the absolute apex of irony that this question was posed to senior ICU trainees who had just experienced two of the most gruelling years of their career, during which many reported no administrative attention whatsoever to their burnout and fatigue, apart from some nauseating cooing sounds made by state politicians. For example, the reader is reminded how, over 2020-2022, the Victorian Health Service declared a "Code Brown" prohibiting healthcare staff from taking leave. Moreover, the question phrasing  ("mitigate fatigue in the medical workforce") neglects the probably more important matter of the nursing workforce, which in the author's experience was the main rate-limiting step in maintaining patient access to critical care services.

Anyway. The question is not "how has the system neglected you", it is "if you were in charge in the last few years, what would you have done in my place", as the reader is also reminded that many of the examiners are senior members of the medical workforce, often directors of Intensive Care units, with influence over rostering and leave allocation.

What follows is a series of attempts to join the fragmented pieces of information on this subject floating around the internet, where they are often present in the form of local policies and guidelines rather than peer-reviewed publications. Probably the most detailed and useful publication available for this topic is the 2020 review by Bywood et al (for the ISCCR), as it seems to cover all the important points, and even though the size (69 pages) might repel some readers, it is well structured and therefore rather easy to follow. Also, an excellent example of a fatigue management system exists in Queensland Health, the AMA has what they consider to be a "minimum standard",  and somebody else's professional college has a good guideline.

Local policy documents and official society statements

Of the CICM documents, none is specifically relevant to this subject. The least irrelevant document is probably IC-5, Statement on the Health and Wellbeing of Fellows and Trainees. There, the onus is squarely upon the Fellows and Trainees, who are instructed to "attend to their own health and wellbeing" and to "develop long-term health and well-being management strategies which reflect the evolving nature of the working life cycle". That's at least better than the Victorian government "WorkSafe" resource website for employers, which at one stage had a page on preventing and managing the risk of employee fatigue during the pandemic, but the URL is dead and the death message is a perfect fitting "Sorry, it looks like something went wrong".  Fatigue management guidelines from 2007 are still available on the NSW Health website, however. Each jurisdiction seems to have its own approach, which is often available as an obsolete PDF on some server somewhere, and the reader is encouraged to find their local version, if only to laugh at it resentfully through their sweaty N95 mask. 

Principles of staff fatigue management

Definition of fatigue in the medical workforce

To define fatigue is usually a good starting point for CICM exam answers. For this, one would require a work-related definition. A good example is this quick from safeworkaustralia.gov.au:

Fatigue is a state of mental and/or physical exhaustion which reduces a person’s ability to perform work safely and effectively

Good, because it focuses on what fatigue does, not on what it is. The decreased function of staff members due to a lack of energy is obviously not something easily defined or measured in a way that would be consistent across different cultures and work environments, so it would probably be better to leave it at this. If one insists on complicating things, Frone & Tidwell (2015) have a whole paper on the measurement and definition of work fatigue, which they divide into physical emotional and mental.

Factors known to contribute to fatigue

At a basic level, fatigue is determined by:

• Hours slept: Less than 10 hours between shifts seems to have an impact on errors, but there does not seem to be much evidence about senior medical staff (most of the data seems to come from nurses).
• Hours worked:  more than 40 hours per week seems to be associated with more medication errors and near misses.
• Shift work, an erratic pattern of irregular work appointment, seems to be a risk factor for fatigue, perhaps partly because it tends to introduce a tiresome disorganization into one's personal life outside the hospital, introducing unpredictable stressors
• Workload, a multidimensional factor which incorporates a whole range of elements, not the least of which are the physical and emotional toll of the work, i.e. the kind of work you do is certainly an influence on how exhausted it leaves you. A whole day of sitting around debating hospital policies over coffee is obviously going to be different to a whole day of back-to-back meetings with angry grieving families. 
• Individual factors, such as seniority, gender, relationship status, existing physical and mental health comorbidities of the staff member, and protective factors ("self-efficacy and resilience; a sense of humour; optimism; engaging in hobbies outside of work; social support") 

Implementation of the fatigue management strategy

This section is modelled on the excellent Queensland Health guidelines:

• Governance includes putting somebody in a position of authority over fatigue management, and to give them the resources necessary to carry out their duties. 
  • This would include the authority to amend the roster or grant emergency leave to at-risk individuals
• Integration with patient safety and quality improvement services could be used to pool resources with this already well-developed system
• Local representatives or "champions" can be supported to establish a culture that promotes self-care and self-assessment of fatigue risk
• Auditable criteria such as the mandatory maximum working hours, break times, staffing numbers, availability of leave or hours between shifts can be imposed and regularly tested
• Monitoring of these criteria, as well as monitoring of fatigue-related accidents
• Regular staff interviews or forums to gauge the subjective effect of these changes would need to be integrated into the process of auditing the overall strategy

Practical recommendations for staff fatigue management

Protective institutional responses

The following organisation-level changes can be made to minimise the risk factors for the development of fatigue:

• Protective rostering: manage the shifts of shift-workers to reduce the number of consecutive hours worked, and introduce mandatory rest periods between shifts
• Change work conditions: reduce workload by reallocating more staff to the roles where the workload is greatest, eg. shifting more staff to the night shift if that is where all your admissions seem to be happening
• Change the environment: allow rest periods to be genuinely restful by providing spaces for staff to have breaks away from the clinical environment, including private spaces where they can sleep.
• Automation wherever possible to minimise the exposure of staff to monotonous tasks

Ameliorative strategies at an organisation level

This is where, faced with the realities of some sort of Desperate Times, the institution is forced to conclude that the workload is what it is, there's no funding to fix the leaky environment, and the roster is borked beyond all recognition. In short, fatigue will happen. The only thing you can do now is ameliorate its effects. Unfortunately, these strategies are not especially evidence-based. Bywood et al lists the following:

• Resiliency and coping skills training;
• Support for workers (clinical supervision, mentoring)
• Relaxation and lifestyle courses, such as mindfulness, meditation, yoga and exercise. 
• Caffeine, unbelievably, has some of the best evidence behind it, even though Temple et al (2018) do admit that it decreases sleep quality. The mutiny-inducing effect of suggesting to fatigued workers that they simply increase their caffeine intake also needs to be taken into account. Hilariously, and totally on-brand, the ANZCA document on fatigue management even incorporates a recommendation on the dose of caffeine required to treat fatigue (they give a range of 100-600mg).

Individual fatigue management

The Canadian Royal Colleges, in their 2013 statement, suggested that fatigue management is something that should be individualised, rather than being imposed from above in the shape of mandatory maximum working hours or holiday leave. The risk of fatigue varies among individuals. Personalised assessment of risk from fatigue should be undertaken. Unfortunately, the Canadian recommendations stopped short of spelling out exactly how to do this, and so the details of the implementation are left to the imagination of the reader. Still, a few indivdual-level interventions could be helpful:

• Sleep health and fatigue education: training the staff to recognise fatigue and teaching them the basics of sleep hygiene may be helpful, according to several data points. For example, a meta-analysis by Barger et al (2018) concluded that it reduces stress and burnout in shift workers. Unfortunately, it is also true that individuals under the effects of fatigue are rather likely to underestimate their impairments, and to minimise the problem.
• Scheduled napping or other forms of scheduled breaks could counteract this failure to detect one's own level of tiredness by imposing a regular routine of rest periods. A "nap", to be effective, probably needs to be at least 30-45 minutes.
• Reducing workload would be the most effective method of preventing fatigue, but is at the same time a largely unrealistic expectation, partly because workload is not always controlled by the individual, and partly because of the terrible workplace culture in medicine, where being stoic about your burnout is viewed as 我慢.

Culture management:

Fatigue in other industries (transportation, aviation) is seen as an occupational hazard and is discussed in those terms, in the same way as one might discuss a frayed electrical cable or a gas leak. Instead, for some reason in medicine fatigue is instead seen as some sort of personal challenge to be overcome. Taylor et al (2016), exploring this topic with medical and surgical residents, found that it was conceptualised as inescapable, manageable, surmountable and even necessary for future practice. The authors were forced to conclude that any fatigue management programs that treat workforce fatigue as a hazard would come up against this barrier, i.e. the medical workforce would still perceive being overworked as some kind of a virtue, a part of professional self-discipline. Look at how hard we work to patch the holes in this broken system, we would say, congratulating ourselves over tens of cups of poverty-brand instant coffee, as our personal lives disintegrate. Obviously, medical readers, we are all of us responsible for this, and to change this would require for us to individually change, including the author himself.