The understanding that sustainable staffing and systems of work are keys to success in
the implementation of alertness management policies is paramount.
Workload management strategies observed though gameplay that seem to limit fatigue as
much as is reasonably possible appear to include:
Optimal staffing according to S19 standards,
The employment of Educators to maximise skill mix
Proactive adherence to all ACORN standards across the board
Minimising on-call recall by managing out-of hours surgery
Rostering evening and night duty staffing to levels consistent with ACORN standards
should be undertaken to maximise effectiveness, not cost effectiveness
The Sample Game:
The game was played in Recovery with Anaesthetic and Recovery staff, 2 of whom were
full-time (76 hours per fort), and one part time (66 hours per fort).
Identifying key times for pro-active workload management measures was enlightening,
because the game made visible for us times when transitions to lesser resources
Players verbalised that these transition times were most likely to result in resource overextension
(to the point of being chronic in terms of systems of work), and observed that if
those times were not managed firmly, they resulted in the biggest risk for fatigue.
For example, when theatres finished at the end of the day (17:30), if too many theatres
over-ran because we tried to 'sneak in' extra cases, then not only would the evening
emergency theatre be delayed, but recovery staff had to stay back because they were
unable to hand off patients.
The other key time, and probably the most important time of the 24 hour period seemed to
at 22:30, when resources transitioned from 2 theatres and theatre teams down to just the 1
theatre (rarely staffed with a full complement of staff).
If we were unable to have the second theatre closed and the patient into recovery by
22:30, it was stated that it was highly likely that staff would have to stay back, and/or that
some on-call staff had to be called back in.
Players verbalised that the impact was that it resulted in fatigue, both for the 'lates' who
were 'expected' to stay back (and whom stated that they often 'felt' they had 'no choice',
and the fact they had to get up to small children the next day was not allowed to factor into
the equation) and the on-calls (who were recalled to catch the overflow from the unfinished
evening workload), who resulted in being on downtime thus creating staffing shortages the
next day, which meant that everyone had to pick up where staffing shortages left gaps,
similarly resulting in fatigue.
When everything went perfectly according to plan, players reminisced of times when that
happened, and commented on how 'great' they felt when it happened (less tired, less
wind-down time, greater work reward, coping and satisfaction).
The finding of 'Sample Solutions':
When we tried to overlay fatigue management strategies such as 12 hour caps to working
days and 17 hours of wakefulness, solutions became complex to the point of impossible.
On-call became 'unable to respond' and 12 hour caps became 'too many people on downtime'
Thus solutions seemed to include:
1) Fully staff night duty to ACORN Standards
2) Manage workload at key transition times, so that the day work could be done during the
day, and the more urgent emergency work had more likelihood of being completed during
the evening rather than not starting until after 7 PM and then needing to continue well into
the early hours of the morning.
3) Possibly engaging on-call expert clinicians on 'on-call contracts', possibly one person for
scrub and one for anaesthetics. Whilst you could still need day staff on call, this would
minimise the occasions on which they were called in.
Incidentally, the game revealed that evening work starting late was more likely to result in
poor transition at 11 PM, because it was too tempting for the surgeons, the anaesthetist
and the in-charge nurse to do 'that one little emergency case that has been waiting all
So the simple answer to the fatigue question is that it is, in all probability, simpler, more
effective, and perhaps most cost neutral to:
employ practical workload management measures and have a review process to explore
times where fatigue mitigation failed due to excessive workload;
minimise recall, possibly by having two people, (one anaesthetics, one scrub) on on-call
contracts, perhaps from Monday to Friday; than it is to otherwise try to deal with fatigue by
attempting to implement 'after-the-fact' fatigue restitution strategies.
These observations apply only to our own operating theatre complex, of course, and so
different game outcomes would possibly (and hopefully!) be discovered which are more
appropriate to individual circumstances when it is played at different institutions.
Probably, the best solutions haven't been invented yet.