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Fatigue Management


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#1 Merck

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Posted 23 August 2012 - 02:05 AM

Hello all,

An issue we are currently discussing around our workplace is that of crew fatigue. This relates to the fatigue of the Critical Care Paramedics only and not the flight crew as that is handled separately. We work on a 2 days, 2 nights, 4 off patter with shifts of 12 hours. It is not uncommon for us to run into shifts that end up being 16+ hours due to the large geographical area we cover as well as sending facility and other logisitcal issues. A common scenario would be on a first night shift not actually getting off until noon when your next shift is scheduled at 18:30. Currently we have our unwritten rule that you receive 10 hours clear and are expected back at work. This applies no matter the length of the previous shift. As you can likely imagine/relate to falling asleep at 13:00 after an 18 hour shift is not always the easiest thing to do and there can be a large incidence of sick calls afterward.

My question is does anyone have in place a fatigue management plan pertaining specifically to the medical crew that addresses these issues? Things that have been thrown around here are: shift length 12-14 hours (2 hours OT) no change; 14-16 hours, 10 hours clear; 16-18 hours 12 hours clear; 18+ hours, next shift off.

Any thoughts or comments appreciated. It should be noted that these are generally more complicated CCT calls/shifts, not nice sleepy flights :)

Thanks
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#2 Human External Cargo

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Posted 23 August 2012 - 03:06 AM

This would work just fine for me......courtesy of the ORNGE Collective Agreement:

"The company acknowledges the shifts are twelve (12) hours in duration and will endeavour to dispatch accordingly. Any employee who works beyond his/her normal shift duration, then the following will occur:

I. The employee(s) will contact the OCC.

II. An employee(s) who works past their twelve (12) hours until thirteen (13) hours and fifty-nine (59) minutes will not be required to report to their next scheduled shift for twelve (12) hours, regardless of when his/her shift is scheduled to start and will be paid time and one half (1.5) for these hours up to thirteen (13) hours and fifty-nine (59) minutes.

III. If an employee who works greater than fourteen (14) hours past their shift start, he/she will not report for their next shift for an equal amount of hours worked plus they will be paid double time (2x) their rate of pay for all overtime hours worked in that shift in excess of twelve (12) hours.

IV. The hours in Article 56.02 b and c will not be counted towards 26.01(d)(ii), (iii) and (vi).

V. If an employee works greater than seventeen (17) hours past their shift start, they will receive the next consecutive day off with pay and will be paid double time (2.0) their regular rate of pay for all overtime worked in excess of twelve (12) hours.

VI. The seventeen (17) hours will conclude upon the completion of patient care and required documentation and return to base where duty out does not occur.

VII. It is understood that paramedics will clear from a call as quickly as possible.
The employee will be paid from the next scheduled shift start even if the employee is not able to report at the schedule time due to above. When the employee reports to work later then their normal start time due to previous end of shift overrun, their next shift will end at their regular stop time.

(e) When a call is expected to be medically completed past 12 (twelve) hours from shift start, the following is understood:
The call must be deemed emergent by the Transport Physician (TP)
The OCC will confirm that the TP has deemed the call emergent and the confirmation will become part of the OCC record.

All calls that go beyond 12 hours from shift start will be reviewed and audited and presented at a joint Union and Management Shift Overrun/Duty Out Committee on a quarterly basis. All required documentation will be provided at these meetings. After the duty out committee meeting COO of Ornge and the Chairperson will review every call that has exceeded fifteen (15) hours.


ARTICLE 56
DUTY OUT COMPENSATION

56.01 When an employee duties out while working a normal shift, then the employee will get the appropriate overtime rate.

56.02 The employee will be paid overtime starting beyond their twelve (12) hours, to the point where the employee(s) finishes the call. This includes:
a) Bringing back the equipment to the A/C to be secured.

b Traveling to the hotel to check-in.

c) Employee(s) has a meal and then returns to the hotel for mandatory rest.

d) If the employee(s) is on a scheduled day off, then the employee will receive the appropriate rate of pay from the time the prone rest is complete until the employee returns to base and books off shift.

e) Employee(s) will be paid at appropriate overtime rate until commencement of rest period.

f) If an employee(s) is scheduled to work the next shift after a duty out, the employee(s) will receive the appropriate overtime pay rate and rest period in accordance to article 26.01.

g) If an employee(s) is not scheduled to work the next shift after a duty out, the employee(s) will receive appropriate overtime rate from end of prone rest period until the employee(s) returns to their home base and employee books off.

h) It is understood and agreed that all periods of time referred to in clause 56.02 must be reasonable.

56.03 During his/her rest period the employee will be paid at the standby rate as per Article 43.

56.04 If the employee(s) duties out, and are now on scheduled days off and request to return home immediately, the employer will make every effort to immediately get the member back to his/her originating home base. If this does not occur then it is expected that the employer will return the employee(s) to their original base in the most expedient manner possible.

56.05 If an employee incurs a financial loss on scheduled time off due to the duty out then the employer will reimburse the employee for the loss. Reimbursement will be subject to proof that the financial loss was booked prior to the duty out. Financial loss includes:
a) Travel arrangements on scheduled time off.

b Tickets for events on scheduled time off.

c) Additional childcare with receipt.

d) Medical appointment cancellation fee with receipt.

56.06 All necessary expenses and meals will be paid for while duties out. The company will make all hotel and travel arrangements for the employee(s) when he/she is expected to duty out.

56.07 The Company will meet with the Union on a quarterly basis to review the circumstances of all duty outs. All data related to duty outs will be provided at these meetings."
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#3 flightrrt

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Posted 23 August 2012 - 08:37 PM

Merck,

The suggestions that you bring up sound like plausible ideas. However, I could imagine this becoming a scheduling nightmare. Likely, the best solution, if you are running with multiple CCT ground teams, would be to scatter the start times of these different teams. This would provide dispatch with the option of utilizing a team that has a longer duty time than a team that is scheduled to be off in a couple of hours. Otherwise, I could see them trying to scrabble trying to cover a shift for a person who had an extended shift and was scheduled to be back the following shift.
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Aaron J. Lund, JD, LL.M., CHC, CHPC, CHRC, RRT-NPS
Healthcare Corporate Compliance Officer
Former, Flight Respiratory Therapist

#4 Merck

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Posted 24 August 2012 - 12:15 AM

Thanks for the replies.

HEC, I think that the salient points from the ORNGE policies are:

II. An employee(s) who works past their twelve (12) hours until thirteen (13) hours and fifty-nine (59) minutes will not be required to report to their next scheduled shift for twelve (12) hours, regardless of when his/her shift is scheduled to start and will be paid time and one half (1.5) for these hours up to thirteen (13) hours and fifty-nine (59) minutes.

III. If an employee who works greater than fourteen (14) hours past their shift start, he/she will not report for their next shift for an equal amount of hours worked plus they will be paid double time (2x) their rate of pay for all overtime hours worked in that shift in excess of twelve (12) hours.

IV. The hours in Article 56.02 b and c will not be counted towards 26.01(d)(ii), (iii) and (vi).

V. If an employee works greater than seventeen (17) hours past their shift start, they will receive the next consecutive day off with pay and will be paid double time (2.0) their regular rate of pay for all overtime worked in excess of twelve (12) hours.

VI. The seventeen (17) hours will conclude upon the completion of patient care and required documentation and return to base where duty out does not occur.

VII. It is understood that paramedics will clear from a call as quickly as possible.
The employee will be paid from the next scheduled shift start even if the employee is not able to report at the schedule time due to above. When the employee reports to work later then their normal start time due to previous end of shift overrun, their next shift will end at their regular stop time.

These seem to encaspulate what we need to ensure the health of our crews. The pay issues are separate and we have our rates already deteremined by contract so I don't see that changing any time soon. The above points could however be implemented rather easily if we could get management buy in. I'm going to follow up and see what comes of it.

FlightRRT - thanks for the idea. We do have staggered shift times with different crews coming on throughout the day but even at peak time in the afternoon we have only 4 crews. This is in the flight environment, not ground so the calls can get quite long. It doesn't take much to be busy and if that high priority call comes in at 15:00 and you're off at 18:30 you're doing it (as you should). This is common and leads to the long shifts I mentioned. I don't know how much leeway there would be with shift times, especially since again there are some contract issues.

Thanks again for the replies - any others?
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#5 old school

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Posted 24 August 2012 - 12:42 PM

Merck,

The suggestions that you bring up sound like plausible ideas. However, I could imagine this becoming a scheduling nightmare. Likely, the best solution, if you are running with multiple CCT ground teams, would be to scatter the start times of these different teams. This would provide dispatch with the option of utilizing a team that has a longer duty time than a team that is scheduled to be off in a couple of hours. Otherwise, I could see them trying to scrabble trying to cover a shift for a person who had an extended shift and was scheduled to be back the following shift.


This only really works if you have the shifts start far enough apart that there is a really substantial difference between the time that they have left on their duty day. Staggering them by 1 hour, even 2 hours, just isn't enough difference to have much impact if you are talking about potentially LONG (12-16hr) duty days. And if you have the shifts starting at significantly different times (say, 0700, 1000, 1300) then that creates a whole new set of challenges.

We tried this with our helicopters (which were close enough to cover each other's territory in many cases) and it honestly caused more problems than it solved.
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bring it in for the real thing

#6 Macgyver

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Posted 26 August 2012 - 01:48 AM

Good discussion - any other patterns / experiences out there?
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Ken BHSc, RN, REMT-P

#7 Human External Cargo

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Posted 26 August 2012 - 09:14 AM

"HEC, I think that the salient points from the ORNGE policies are:

II. An employee(s) who works past their twelve (12) hours until thirteen (13) hours and fifty-nine (59) minutes will not be required to report to their next scheduled shift for twelve (12) hours, regardless of when his/her shift is scheduled to start and will be paid time and one half (1.5) for these hours up to thirteen (13) hours and fifty-nine (59) minutes.

III. If an employee who works greater than fourteen (14) hours past their shift start, he/she will not report for their next shift for an equal amount of hours worked plus they will be paid double time (2x) their rate of pay for all overtime hours worked in that shift in excess of twelve (12) hours.

V. If an employee works greater than seventeen (17) hours past their shift start, they will receive the next consecutive day off with pay and will be paid double time (2.0) their regular rate of pay for all overtime worked in excess of twelve (12) hours.
"

This stuff is a NO BRAINER for any busy air ambulance system (forget the contractual pay issues of double time, etc included in that language - these points won't be easily negotiated during a current collective agreement, just review the hours of rest included in the clauses). Appropriate rest periods associated with extended shifts should be the standard rather than the exception. Long shifts are part of the game that we play (and I think we all get that and accept that long shifts can and will happen). Having said that, I believe that appropriate rest periods with commensurate pay should be complementary to our extended shift burden reality.

Having worked FAR too many shifts in the 16-23 hour range in recent months, I don't know how it can be reasonably expected that we return to work only 10 hours after our grossly extended shifts. Not only do we feel like DEATH when we return, I frankly believe that we are compromising patient care by doing so.

We would never expect this of our pilots (nor should we), how can we assume it is appropriate for our critical care staff to do so?
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#8 Macgyver

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Posted 26 August 2012 - 07:19 PM

Once again it only points out that 12 hr shifts on sequential days only work with short mission profiles. Anything more than a 4 hr flight (page to cleanup @ home base) should not be considered at 11:59. For most FW programs and RW programs with long legs (like BCAS, STARS and ORNGE), sequential 12's are a problem. They can actually lead to not only more overtime and more uncovered shift starts but also more fatigued providers than 24's with 2 days or more between shifts and a fatigue timeout clause.

The move from 24's to 12's often seems to the beancounters like it will ensure more rested providers and reduce overtime but time and time again it ends up being exactly the opposite. UNLESS you have a lot of part-time staff or (as mentioned) redundant, staggered or overlapping coverage. Just as 24's in programs with call volumes that get too high are a problem, simply changing the pattern to 12's is a bandaid that is used at the expense of the providers quality of life and total work/rest -vs- off duty hours. The solution is more staff/units in addition to redesigning the schedule.

What should be added to any fatigue policy aside from a "call-out" clause for rest is some form of calculation of accumulated sleep debt. Much work needs to be done in this area but it likely will prove a better predictor of fatigue than how many hrs on that particular shift or even how many rest hrs prior to the next one.

Keep an eye on the CAMTS standards in the next few years for those who follow them....
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Ken BHSc, RN, REMT-P

#9 SerendepitySaki

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Posted 26 August 2012 - 08:30 PM

if i am not mistaken, revision is wrapping up as we speak.... B)
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LET THE WILD RUMPUS BEGIN !!!!!!
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#10 MSDeltaFlt

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Posted 27 August 2012 - 10:12 PM

Though the shift lengths mentioned sound plausible, there is another thing not mentioned: rotations. Being on night for only 2 days then off 2 then back on 2, you never get your biological clock switched over adequately resulting in built up fatigue. That leads to dangerous situations and flying tired.
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#11 Macgyver

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Posted 28 August 2012 - 09:23 PM

Great article on accumulated sleep debt on pages 11-14, applies just as much to Air Medical crew as it does to maintainers...

Cumulative Sleep Debt / fatigue
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Ken BHSc, RN, REMT-P

#12 Macgyver

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Posted 28 August 2012 - 09:25 PM

Though the shift lengths mentioned sound plausible, there is another thing not mentioned: rotations. Being on night for only 2 days then off 2 then back on 2, you never get your biological clock switched over adequately resulting in built up fatigue. That leads to dangerous situations and flying tired.


Worse is the day/night switch (2x10-11 hrs day shift/2x14-13 hrs night shift, 4 calendar days off, repeat)
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Ken BHSc, RN, REMT-P

#13 Merck

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Posted 29 August 2012 - 03:19 PM

That's us. 2 12 hour days, 2 12 hour nights, 4 off. That's why the management of this is so important. Especially for the first 3 shifts. If it's on the last one, well, you're just screwed. But I've been doing these shifts for so long I don't notice - and I do like having the 24 hours off after my second day shift. I usually stay up late and sleep in on the day before my first night shift to try and adjust.
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#14 onearmwonder

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Posted 30 August 2012 - 05:21 PM

Hey Merck is there an option to, with a safe application of course, to switch to 24 hour shifts? Say 24 on 24 off 24 on and how ever many days off depending on what ever schedule...

Matt
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#15 Merck

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Posted 30 August 2012 - 08:59 PM

I don't think there's any way we could pull 24 hour shifts. There's little chance of downtime and I'm not as young as I used to be. We also run into issues with aircraft having to drop us and fly back to change pilots etc as our calls can last quite a long time, especially with winter coming.
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#16 Macgyver

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Posted 31 August 2012 - 12:11 AM

I think, knowing your area etc, the best compromise woud be a combined flight / medical crew that stayed together the whole shift. IE if the pilots have to time out or RTB to swap - you do as well. And if they can't accept a flight due to duty time - you shouldn't either. Especially with the 17 hr max TC allows under certain conditions!
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Ken BHSc, RN, REMT-P

#17 Human External Cargo

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Posted 31 August 2012 - 07:41 AM

That was the way it USED to work Mac.......not perfect by any means but MUCH better than the offset of shift times with pilots that we currently endure (e.g the critical care crews going off shift at 1830 along with the rotary and turbo prop pilots but having the jet pilots working until 2100 - every now and then, this works out well for Dispatch scheduling. Most times however, not so much......). This set up often only serves to create scheduling grief, extended duty hours (for both pilots and critical care crews), and operational crew resource inefficiencies, in my opinion. Crew and/or aircraft stranding are much more likely with this configuration, not to mention extended duty times that push operational limits for the flight crews.

I go back to the ORNGE contract language - this seems to be a reasonable approach to an unreasonable and yet unavoidable set of circumstances that inexorably leads to extended duty hours in our unique work environment. The calls will still come in regardless of how well we pre-plan. The irregular nature of these calls also dictate the length of our shifts and are often well out of our control and careful forward planning. The high acuity calls just happen and we have to do them......regardless of the plans that we might have with our family or friends "after" work. I think we all get that fact and understood it clearly when we signed on for the job.

The reality is that we are often going to be tasked with work that will lead to absurd shift extensions due to the large area that we serve and the amazing complexities of transport that we all face. We need a simple, respectful, and APPROPRIATE way of remunerating our staff for extended duty days. We clearly need to ensure the safety of our staff and patients, to promote a work environment that is SUPPORTIVE of health and wellness, and to create a professional environment that is sustainable for all of our crew members in the long term.

Not doing so condemns us to an unhealthy, unsustainable, and inefficient system that is unresponsive to both patient and crew needs.
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#18 Macgyver

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Posted 31 August 2012 - 09:40 PM

Are ORNGE or BCAS CAMTS members? I think STARS is (although none of the FW contractors in AB are IIRC) Their current standards limit duty time for med crewws to 16 hrs and require 8 hrs rest prior to the start of a shift... And I think EURAMI is on the same page.

A "fatigue call out" policy should be included - while I know the pain of an 11:45 call for a flight that will last 8+ hours, I think it is more than reasonable to allow med crew the ability to call off for fatigue. Where I work now we have a very good fatigue call out culture - as long as you call out BEFORE dispatch accepts a flight. (Still working on that - their role should be to facilitate not command - with med crews just as for flight crews)

After work plans nonwithstanding, a response that extends up to 16 hours should be tolerated and planned for by all concerened - and if a request comes in (no matter how "critical", 'cause we all know how often they really are) that will last longer than that (back to base and post-flight duties) it should be deferred to the next crew.

If a truly critical pt flight request comes in that will be possible to release pt care by 16 hrs it could be CONSIDERED by the crews involved - with the understanding that they will be timed out at the destination until rested. But not assigned without consent - not only of the crews but also Med Control ie: is the Medical Director willing to accept the liability of a fatigued crew error or would they rather have the pt remain in the ER or ICU for a short while longer until the relief crew can get there)

In fact my opinion is that ANY flight that requires medical decision making after the 12 hour point should be signed off on by the Med Dir (after reviewing their duty time and recent flight acuity/intensity and the pt's acuity/prognosis/current location and resources there). And that Dispatch should NOT have operational control over either flight or medical crews but be a collector and diseminator/facilitator of flight requests and available resources.

If the Med Control MD constatntly had to specifically authorise these holdover flights and if all such flight PCR's/charts had to be QA'd and reviewed not only for appropriate/timely/correct care, but also flight appropriateness -vs- wait for next available crew, a LOT fewer such flights would ever be dispatched...

All of this is with the understanding that we are primarily taking about secondary response flights, ie: IFT's (from a nursing station / clinic / hospital etc or anywhere that has an EQUAL or higher level of medical care available) (yeah yeah - I know all about Scene Calls With Walls / Well Lit Scene Calls and Rescue IFT's...) A holdover scene call by RW that can be finished within 2-4 hrs should be expected by everyone.
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Ken BHSc, RN, REMT-P

#19 Macgyver

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Posted 31 August 2012 - 09:43 PM

And I wonder if a punative pay scale (ie a minimum of quintuple time rates after 12 hrs) would magically reduce the number of late flights... :P
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Ken BHSc, RN, REMT-P