Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario

Your team has been working under tense conditions for days: you are all sleep-deprived and are making errors that put patients at risk. There is no back-fill support available. As a team leader, what is your duty of care to protect your team and yourself?

• List the Issues that arise from the scenario

Prioritisng patient safety and taking care of the team

• Identify Critical Information required and Assumptions to be made

Step 2 – ANALYSE

Patient: What are the views of the Patient? (and ‘patient group’)? How do 4 principles of : Autonomy, Beneficence, Non-maleficence and Justice apply? Other perspectives?

‘Minimize harm to patients by addressing sleep-deprived errors through enforced rest and prioritization of critical tasks. Use triage systems to manage care for the most vulnerable patients effectively’.

https://healthcareindanger.org/wp-content/uploads/2021/03/4504_002-ebook.pdf

Prioritize Patient Care:

o A triage system could be used to rank patient according to the severity of their condition (critical, urgent or stable groups).

o The most rested and competent team members could be assigned to patients ranked as ‘critical’ condition.

o Allocate another team member (a leader for that specific rank of patient group or could be yourself in this scenario as you are the general team leader) to check decisions that are being made for ‘critical’ patients.

Stop Non-Essential Duties:

o Stop routine administration tasks to allow healthcare workers to concentrate tasks that are more urgent. For example, writing an overly extensive handover note when a concise summary would suffice.

o Delegate non-clinical tasks (e.g., stocking supplies) to non-medical personnel or volunteers if available.

Continuity of Care:

o If patient load is overwhelming, consider temporary referral or diversion of stable cases to other nearby facilities such as a clinic or a hospital where there are not a lot of patients under their care.

Compassionate Communication:

o Have a designated spokesperson such as a team leader or senior nurse to explain delays and errors to patients with honesty and reassurance to maintain trust.

o Provide patients with realistic timelines and manage expectations to reduce tension and complaints. This is only possible if the team is organised in other aspects that have been outlined and are yet to be discussed.

Clinical: What are the clinical diagnosis, prognosis, treatment options? Is this scenario covered by professional regulation or guidance? What are the views of individual members of the clinical team? Other perspectives?

Fatigue Management:

o Allow say 15 to 20 minute naps for exhausted staff where feasible. There are studies to show that short rests can significantly improve alertness.

o Rotate shifts to ensure staff who are extremely fatigued are assigned lower-intensity tasks, such as observing stable patients, rather than performing complex procedures.

o Have recovery areas in the workplace where staff can relax briefly (for example a quiet room separate to wards with seating and hydration stations).

Communication and Morale:

o Have regular check ins to assess morale and fatigue levels and use these moments to address team frustrations or identify individuals who need breaks.

o Build a sense of teamwork by encouraging team members to look out for one another’s well-being. For example, a nurse can alert the team leader if they notice a colleague struggling with decision-making.

Access to Resources:

o Set up easily accessible snack and hydration stations to provide quick energy boosts for the team.

o Ensure everyone takes hydration breaks, even during critical shifts.

Balancing Duty and Ethics:

o Reassure the team that prioritizing their health is part of delivering ethical care.

Legal: Is scenario covered by IHL, Geneva Conventions, military law, other law? Other perspectives?

Healthcare in Danger discusses the need to uphold international healthcare laws and ethical guidelines

Document Challenges and Decisions:

o Keep track of medical errors alongside the reason for why those errors occurred (for example fatigue). This can help gain clarity on what mistakes and why they are happening to help find solutions forward.

o Include this documentation when escalating resource needs to higher authorities, such as boards responsible for quality of military healthcare.

Avoiding Malpractice Risks:

o Before a high risk-procedure, check that the staff believe that they are able to proceed safely. Consider post-poning high-risk procedures until staff feel more competent, and are also more competent and not making as many errors.

Societal/Military: Is there a military necessity? Is this scenario covered by military regulation or military perspective? Is this scenario covered by public health or societal ethics? Other perspectives?

Impact on Society:

o Give public updates about healthcare system constraints (contact hospital spokespeople or local government) to help public understand the reality of the situation, which may hep with international aid.

Engagement with Military:

o If military personnel are involved, coordinate with their leadership to address challenges like securing safe transport of patients or managing surges in casualties.

o Request military assistance when feasible, but ensure such arrangements comply with international humanitarian guidelines to avoid perceptions of bias.

Long-Term Resource Advocacy:

o Escalate written documentation of your team’s struggles and needs to decision-makers, such as hospital administrators, government bodies, or military commanders.

o Suggest post-crisis debriefing sessions to analyze systemic failures and propose long-term solutions, such as increased staffing reserves or stress-management training.

Step 3 – FUSE

· Summarise conclusions

· Insert citations to key reference sources for your analysis

· Determine the exact Decision(s) to be made

To manage overwhelming healthcare scenarios, prioritize patient care by using a triage system to assign team members based on patient severity. Stop non-essential duties, delegate administrative tasks, and consider diverting stable patients to other facilities. Maintain compassionate communication by designating a spokesperson to manage patient expectations. Document errors to improve care and manage malpractice risks. Address staff fatigue with rest periods, shift rotations, and morale-building activities. Ensure access to resources like snacks and hydration. Keep the public informed and collaborate with military personnel as needed. Advocate for long-term resource solutions and debrief post-crisis to improve future responses.

Key References:

Ethical Principles of Health care in times of armed conflict and other emergencies

Ethical Principles: WMA Statement on Medical Ethics in the Event of Disasters

Step 4 – DECIDE

In high-pressure healthcare situations, prioritize critical patients, delegate non-essential tasks, and manage staff fatigue with rest breaks. Ensure compassionate communication with patients, document errors, and address malpractice risks. Collaborate with military and public authorities, advocate for long-term resources, and debrief post-crisis to improve future healthcare responses.

Reviewed and formatted by: Yvonne Zhou MBBS Year 3 King’s College London Dec 2024

Amy B. Adler, PhD, Amanda L. Adrian, PhD, Marla Hemphill, MC USA, Nicole H. Scaro, MSC USA, Maurice L. Sipos, MSC USA, Jeffrey L. Thomas, MSC USA, Professional Stress and Burnout in U.S. Military Medical Personnel Deployed to Afghanistan, Military Medicine, Volume 182, Issue 3-4, March-April 2017, Pages e1669–e1676, https://doi.org/10.7205/MILMED-D-16-00154

Gabel S. (2011). Ethics and values in clinical practice: whom do they help?. Mayo Clinic proceedings, 86(5), 421–424. https://doi.org/10.4065/mcp.2010.0781

Paul Sargent, MD, Jeffrey Millegan, MD MPH, Eileen Delaney, PhD, Scott Roesch, PhD, Martha Sanders, MA, Heather Mak, MD, Leonard Mallahan, BA, Stephanie Raducha, BA, Jennifer Webb-Murphy, PhD, Health Care Provider Burnout in a United States Military Medical Center During a Period of War, Military Medicine, Volume 181, Issue 2, February 2016, Pages 136–142, https://doi.org/10.7205/MILMED-D-14-00449

Alhaffar, B.A., Abbas, G. & Alhaffar, A.A. The prevalence of burnout syndrome among resident physicians in Syria. J Occup Med Toxicol 14, 31 (2019). https://doi.org/10.1186/s12995-019-0250-0