Fatigue, Risk and Excellence:  Towards a Pan-Canadian Consensus on Resident Duty Hours

Towards a Pan-Canadian Consensus 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

Collaboration Across Canadian Health Care 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

Project Phases The project was divided into three key phases, which together spanned the period from March 2012-May 2013. Phase 1 (March 2012-August 2012) Preliminary research and report development Phase 2 (June 2012-January 2013) Analysis and consultations with Expert Working Groups Phase 3 (January 2013-May 2013) Consensus Conference Final Report

Project Methodology 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 Canada Key Findings + 5 Central Principles + 5 Recommendations to Move Forward

Considering the Context of Duty Hour Regulations in Canada 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.

Key Findings Statements on the Impact of Resident Duty Hours and Resident Duty Hour Regulations Traditional duty periods present risks to the physical, mental, and occupational health of residents. Fatigue impairs cognitive and behavioural performance. A tired doctor is not necessarily an unsafe doctor. There is no conclusive data to show that restrictions on consecutive resident duty hours are necessary for patient safety. Successful efforts to improve patient safety and resident fatigue will need to be comprehensive, involving not only the regulation of resident duty hours alone.

Key Findings Statements on the Impact of Resident Duty Hours and Resident Duty Hour Regulations 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.

5 Principles for a Collective, Pan-Canadian Response Residents have inter-related roles as learners and care providers. Residents are vital providers in a health care system that is collectively responsible for 24/7 patient care coverage Duty periods of twenty-four or more consecutive hours without restorative sleep should be avoided. Efforts to minimize risk and enhance safety are necessary and cannot be undertaken by addressing resident duty hours alone. 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.

Recommendations to Move Canada Forward

Recommendation #1 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

Recommendation #2 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

Recommendation #3 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

Recommendation #4 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.

Recommendation #5 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: Create and coordinate dissemination of national toolbox of resources Support the process of Fatigue Risk Management Plan creation/implementation Undertake science and evidence-based research on resident duty hours Knowledge translation and dissemination of scholarly evidence

Download the Final Report 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

Download the full report at www. residentdutyhours. ca Questions Download the full report at www.residentdutyhours.ca Questions? Contact the Project Secretariat at  RDH-HTR@royalcollege.ca