Statement on peak performance and management of fatigue

The following statement was developed by the American College of Surgeons (ACS) Committee to Enhance Peak Performance in Surgery through Recognition and Mitigation of Fatigue through general consensus. The ACS Board of Regents approved the statement at its June 2014 meeting in Chicago, IL.

The ACS has had a long-standing commitment to defining and promoting excellence in patient care and surgical practice. With greater knowledge and understanding of the impact of fatigue on performance, it is crucial that potential detrimental effects of fatigue be considered and appropriate strategies developed to mitigate them, keeping in mind the distinctive nature of surgical practice and the importance of the continuum of care.

The fundamental characteristics of surgery differentiate it from other disciplines. Surgical proficiency necessitates intellectual, emotional, and physical preparation for all phases of patient care. Surgical practice requires decisive surgical judgment; operative intervention involving mental, physical, and tactile skills; and comprehensive, thoughtful postoperative care. Each part of this process involves sustained attentiveness, vigilance, and commitment to the patient’s care and well-being. Teamwork is an integral component of surgical practice, and the surgeon, as the leader of the team, has the opportunity and privilege to directly affect the patient’s disease process, along with ultimate responsibility for each patient. In 2012, the ACS appointed the Committee to Enhance Peak Performance in Surgery through Recognition and Mitigation of Fatigue, composed of surgeon leaders from various surgical specialties, internationally renowned sleep experts, as well as other national stakeholders, to address this important and complex national issue through far-reaching recommendations and innovative educational resources.

Research related to fatigue has demonstrated the following:

  • Fatigue has significant detrimental effects, including prolonged reaction time, decreased vigilance, impaired decision making, and delayed recognition of critical situations.*
  • Individuals vary in their response to fatigue; an individual’s response may also differ in relation to pre-existing conditions, accompanying stressors, workload, cumulative sleep loss, and the nature of a specific situation.
  • In objective testing, individuals often inaccurately assess their own level of sleepiness.
  • Data concerning surgeons and fatigue are limited and primarily describe physicians in training.
  • Restricted work hours for residents have not been linked to demonstrable improvements in patient safety and better outcomes or improved education of trainees.

While it is important to develop strategies to mitigate the ill effects of fatigue, the ACS believes that the imposition of prescriptive or strict regulation is impractical and potentially detrimental to patient well-being. Loss of continuity of care and the adverse effects of handoffs are two important issues to consider when mitigating fatigue. The ACS supports flexibility in developing these strategies with a strong focus on patient safety in each situation. Concepts that the ACS supports include the following:

  • Commitment to surgical professionalism requires that the surgeon acknowledge the adverse effects of fatigue and be able to recognize and manage them. This may require additional education and support.
  • The surgeon and the institution/organization have a shared responsibility for preventing and addressing fatigue. The individual surgeon is accountable for being physically and mentally prepared but cannot be solely responsible; the institution must establish and support systems to address fatigue issues.
  • Recognizing that fatigue-related incidents represent the consequence of system failures, institutions and departments, with input from surgeons, are responsible for the development of systems to support alertness and peak performance. Each surgeon and each surgical department and organization should develop an educational plan for both the recognition and mitigation of fatigue, as well as practical measures applicable to each situation.* The ACS Division of Education could assume a leadership role in developing and disseminating educational programs on recognition and mitigation of fatigue.
  • The essential principle of any institutional program is that it represents a balance between mitigating the effects of fatigue as much as possible while providing that the patient be cared for by the best surgeon to do so.

Institutional use of fatigue risk-management systems (FRMS) methodology or similar systems may provide guidance for program design. FRMS emphasizes a tiered approach to fatigue, with controls incorporated at each level to prevent fatigue-related errors. Successful systems are characterized by being goal-driven and emphasizing flexibility within the system to optimize patient safety and excellence in care. Characteristics of an FRMS include being evidence-based, data-driven, and cooperative; that is, an FRMS is designed with input from all stakeholders and fully integrated and implemented throughout the system. Additional components include continuous improvement, financial viability, and ownership by corporate leadership.

The ACS has a demonstrated commitment to furthering patient safety, improving quality, and supporting excellence in surgical care. Professionalism in surgery, for both the individual surgeon and the profession as a whole, requires accountability and support systems for identifying, acknowledging, and preventing harmful fatigue. A comprehensive approach to various issues relating to recognition, management, and mitigation of fatigue will be necessary to address a variety of challenges in delivering surgical care of the highest quality.

*Shearburn WE III. Get some rest: Minimizing the effects of sleep deprivation on patient care. Bull Am Coll Surg. 2013;98(12):36-41.

Lerman SE, Eskin E, Flower DJ, et al. American College of Occupational and Environmental Medicine presidential task force on fatigue risk management: Fatigue risk management in the workplace. J Occup Environ Med. 2012;54(2):231-258.



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