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The Importance of Nurses for Fatigue Risk Management

It is no secret that fatigue in healthcare professionals constitutes a safety risk both to the caregiver and the patient. Healthcare professionals with limited experience, such as medical residents, may be particularly prone to performance impairment under these circumstances. Inexperienced residents rely on guidance from attending physicians and also from experienced non-physician providers like nurses. Nurses are known to be the backbone of healthcare, so it was so cool when IBR’s SAFTE-FAST software recently captured the impact of nurses on fatigue risk during an unrelated study of medical residents.

The IBR science team have been investigating fatigue risk mitigation strategies that could be applied to surgical resident scheduling practices to avoid periods of high fatigue risk over the past several years in collaboration with a consortium of D.C. area hospitals. We first analyzed the actual worked hours for rotating residents during the 2018-2019 academic year using IBR’s fatigue modeling software SAFTE-FAST to estimate performance as a function of work schedules and sleep opportunities. Shift start times, average shift length, and average rotation length were consistently found to be related to fatigue risk across all service lines, such as trauma, pediatric, emergency, plastic, or general surgery. Next, we ranked the service lines as having minimal, low, medium, or high fatigue risk based on schedule features that SAFTE-FAST routinely picked out as fatiguing. Long hours, overnight work, and early start times were some of the features that regularly triggered a fatigue risk. After we developed the method of ranking with the schedules from 2018-19, we re-ran the analysis using actual worked data from academic year 2020-21 to see if the method would generalize to other years.

Fatigue ranking of service lines from the 2020 resident work schedules were largely similar to the results of the 2018 analysis with one notable exception—Trauma. Residents rotating in the Trauma Unit in a major D.C. area hospital had lower fatigue risk during the 2020 academic year compared to 2018. We were puzzled as to why this would be until our hospital collaborator told us that the Trauma Unit had a hiring push to increase the number of nurses, or advanced practice providers (APPs) on staff at the beginning of 2020. While we were looking at medical resident fatigue, it looks like we accidentally captured the impact of having more available nurses!

We checked the role of APPs by using the hire date of the APPs to estimate how many would be on staff during a given rotation month/year. In 2018 and 2019, there were 4 APPs on staff in the Trauma Unite during the rotation year. There were 6 APPs on staff from March 2020 until January 2021; 8 APPs on staff between January and April 2021, and 7 APPs for the remainder of the academic year. Resident working hours and variability in working hours were apparently shorter with the hiring of each additional APP, as shown below. Residents in 2020/21 worked less overtime than their counterparts in 2018/19, which had a protective effect on fatigue risk. There was not enough power to say that these differences are statistically significant, but these data provide a clear anecdotal picture of the importance of nurses to the healthcare ecosystem



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