Sleep Loss, Fatigue and Medical Training

Sleep Loss, Fatigue and Sleep Loss, Fatigue and Medical TrainingMedical Training

Susan M. Harding, MDSusan M. Harding, MDProfessor of MedicineProfessor of Medicine

Medical Director, Sleep-Wake Disorders CenterMedical Director, Sleep-Wake Disorders CenterUniversity of Alabama at BirminghamUniversity of Alabama at Birmingham

University Hospital Housestaff 1982-83

Learning ObjectivesLearning Objectives

List factors that put you at risk for List factors that put you at risk for sleepiness and fatigue.sleepiness and fatigue.

Describe the impact of sleep loss on Describe the impact of sleep loss on residents’ personal and professional residents’ personal and professional lives.lives.

Recognize signs of sleepiness and Recognize signs of sleepiness and fatigue in yourself and others. Adapt fatigue in yourself and others. Adapt alertness management tools and alertness management tools and strategies for yourself and your program. strategies for yourself and your program.

Residency Training Over Residency Training Over Past 5 DecadesPast 5 Decades

Call every other nightCall every other nightCall every 3Call every 3rdrd night, then every 4 night, then every 4thth night nightWork is more stressfulWork is more stressful““Less sick” patients are out of the hospitalLess sick” patients are out of the hospitalHeightened intensity of patient careHeightened intensity of patient careLower margin for errorLower margin for errorConstant paging interruptions disrupt work Constant paging interruptions disrupt work flowflow

State of Sleepiness Prior to ACGME State of Sleepiness Prior to ACGME Limiting Resident Work HoursLimiting Resident Work Hours

Rosen IM et al. Rosen IM et al. Acad MedAcad Med 2004; 79:407 2004; 79:407

Survey of 79 Internal Medicine residents at the Survey of 79 Internal Medicine residents at the Univ of Pennsylvania, June 2001Univ of Pennsylvania, June 200134% experienced acute sleep deprivation34% experienced acute sleep deprivation64% experienced chronic sleep deprivation64% experienced chronic sleep deprivationDozing while performing work-related tasksDozing while performing work-related tasks– 69% writing notes69% writing notes– 61% reviewing medication lists61% reviewing medication lists– 51% interpreting labs51% interpreting labs– 46% writing orders46% writing orders

ACGME Work Hour RulesACGME Work Hour RulesEffective July 1, 2003Effective July 1, 2003

Restricts work hours to < 80 hrs/week avgRestricts work hours to < 80 hrs/week avg

< 30 hours of continuous coverage at any < 30 hours of continuous coverage at any 1 time1 time

Should have 10 hours off between shiftsShould have 10 hours off between shifts

Stimulus – quality of care, but minimal Stimulus – quality of care, but minimal data was available linking fatigue to errorsdata was available linking fatigue to errors

Different people have different “inflection Different people have different “inflection points” concerning sleep deprivationpoints” concerning sleep deprivation

ACGME Work Hour RulesACGME Work Hour Rules

Made everyone re-examine their Made everyone re-examine their educational programseducational programsProvided impetus to examine ways to Provided impetus to examine ways to improve the systemimprove the systemEmphasizes the need for more effective Emphasizes the need for more effective team workteam workBrought up continuity of care and transfer Brought up continuity of care and transfer of care issues with frequent “hand offs”of care issues with frequent “hand offs”What happens What happens afterafter training? training?

ACGME Work Hour Rules:ACGME Work Hour Rules:Potential StressorsPotential StressorsRyan J. Ryan J. Ann Intern Med 2005; 143:82Ann Intern Med 2005; 143:82

Increased number of patient hand offsIncreased number of patient hand offs

Cross coverageCross coverage

Communication and team workCommunication and team work

Increasing paperworkIncreasing paperwork

Pressure to get done and get outPressure to get done and get out

Rushing from task to task w/out time to think and Rushing from task to task w/out time to think and learnlearn

Resident comraderieResident comraderie

““No, I’ve just come to start my overnight call. Why do you ask?”No, I’ve just come to start my overnight call. Why do you ask?” ACP InternistACP Internist, Jan 2009, Jan 2009

Institute of Medicine’s (IOM) Institute of Medicine’s (IOM) Recommendations (at Congress’ Request)Recommendations (at Congress’ Request)

December 2008December 2008

2003 ACGME2003 ACGME 2008 IOM2008 IOMMax hrs work per Max hrs work per week week

80 hrs, over 4 wks80 hrs, over 4 wks samesame

Max shift lengthMax shift length 30 hrs--24 hrs + 6 30 hrs--24 hrs + 6 hrs for transitional hrs for transitional and education and education activitiesactivities

30 hrs with …30 hrs with …

- 16 hrs admitting, 5 - 16 hrs admitting, 5 hrs protected sleep hrs protected sleep period between 10 period between 10 pm and 8 ampm and 8 am

- 16 hours if no - 16 hours if no protected sleep protected sleep periodperiod

Max in-hospital on-Max in-hospital on-call frequencycall frequency

Every 3Every 3rdrd night, on night, on averageaverage

Every 3Every 3rdrd night, no night, no averagingaveraging

2003 ACGME2003 ACGME 2008 IOM2008 IOM

Minimum time Minimum time off between off between scheduled shiftsscheduled shifts

10 hrs after shift 10 hrs after shift lengthlength

10 hrs after day shift10 hrs after day shift

12 hours after night 12 hours after night shift shift

14 hrs after extended 14 hrs after extended duty of 30 hrs and not duty of 30 hrs and not to return until 6 am of to return until 6 am of the next daythe next day

Max frequency Max frequency of in-hospital of in-hospital night shiftsnight shifts

Not addressedNot addressed 4 nights max; 48 hrs 4 nights max; 48 hrs off after 3 or 4 nights of off after 3 or 4 nights of consecutive dutyconsecutive duty

Mandatory time Mandatory time offoff

4 days off per month4 days off per month

1 day (24 hrs) off per 1 day (24 hrs) off per wk, average over 4 wk, average over 4 wkswks

1 day (24 hrs) off per 1 day (24 hrs) off per wk, no averagingwk, no averaging

5 days off per month5 days off per month

1 (48 hr) off period per 1 (48 hr) off period per monthmonth

2003 ACGME2003 ACGME 2008 IOM2008 IOM

Emergency Rm Emergency Rm limitslimits

12-hr shift limits, with 12-hr shift limits, with at least an equivalent off at least an equivalent off period be tween shiftsperiod be tween shifts

60-hr work wk with 12 60-hr work wk with 12 additional hrs for additional hrs for educationeducation

No changeNo change

Limit on Limit on exemptionsexemptions

88 hrs with a sound 88 hrs with a sound educational rationaleeducational rationale

No changeNo change

MoonlightingMoonlighting Internal moonlighting is Internal moonlighting is counted against 80-hr counted against 80-hr wk limitwk limit

Internal and external Internal and external moonlighting counted moonlighting counted against 80 hr wkly against 80 hr wkly limitlimit

All other duty limits All other duty limits apply in combinationapply in combination

Cost of Implementing IOM’s Cost of Implementing IOM’s RecommendationsRecommendations

1.7 billion per yr (1/4 of cost is bringing non-1.7 billion per yr (1/4 of cost is bringing non-compliant programs into compliance – 8.8% of compliant programs into compliance – 8.8% of programsprogramsCreate and fill fulltime positions for:Create and fill fulltime positions for:– 229 nursing aides229 nursing aides– 45 laboratory technicians45 laboratory technicians– 320 licensed vocational nurses320 licensed vocational nurses– 5984 NPs or PAs5984 NPs or PAs– 5001 attending physicians5001 attending physicians

OR…OR…- 8247 additional residency positions- 8247 additional residency positions

““There are fundamental effects from There are fundamental effects from sleep loss which permeate sleep loss which permeate

performance on virtually all cognitive performance on virtually all cognitive and sustained attention tasks”and sustained attention tasks”

Courtesy of Journal for Respiratory Care Practitioners, Jun/Jul 1998

Regulation of Sleep and Regulation of Sleep and WakefulnessWakefulness

Homeostatic driveHomeostatic drive for sleep (previous for sleep (previous sleep amounts, duration of wakefulness)sleep amounts, duration of wakefulness)Circadian influenceCircadian influence (24 hour clock, (24 hour clock, alertness peaks and troughs)alertness peaks and troughs)Environmental Environmental factors: feedback, factors: feedback, reinforcement, task reinforcement, task nature/length/complexitynature/length/complexityIndividual Individual variables: motivation, emotional variables: motivation, emotional context; physical activity; age, context; physical activity; age, individual individual variation sleep needs and vulnerabilityvariation sleep needs and vulnerability

Effects of Sleep Deprivation: Effects of Sleep Deprivation: Experimental SettingsExperimental Settings

Neurobehavior impairment similar for short-term Neurobehavior impairment similar for short-term (24-48 hrs) (24-48 hrs) total sleep deprivationtotal sleep deprivation and and chronic chronic partial sleep restrictionpartial sleep restriction (<6 hrs/night for > 1 week) (<6 hrs/night for > 1 week)Sleep “debt”:Sleep “debt”: Effects of chronic partial sleep loss Effects of chronic partial sleep loss are are cumulative; not reversed in a cumulative; not reversed in a single nightsingle nightPerception Perception of sleepiness is less affected than of sleepiness is less affected than measuredmeasured sleepiness sleepinessCircadianCircadian influence influence

Effects of Sleep Deprivation: Effects of Sleep Deprivation: Experimental FindingsExperimental Findings

Mood Mood universally affecteduniversally affectedImpairment in Impairment in vigilancevigilance, delayed and , delayed and immediate immediate recallrecallComplexComplex tasks and problem-solving tasks and problem-solving affected; performance deteriorates with affected; performance deteriorates with time-on-task; time-on-task; task duration; task duration; perseveration perseveration and poor prioritization and poor prioritization Maintenance of Maintenance of accuracy accuracy at the expense of at the expense of speedspeed

Effects of Sleep Deprivation: Effects of Sleep Deprivation: Experimental FindingsExperimental Findings

LearningLearning of new tasks compromised of new tasks compromised

Motivation Motivation affectedaffected

““Lapsing”Lapsing”: variability in task performance : variability in task performance related to interruption of sustained related to interruption of sustained attention from “attention from “microsleepsmicrosleeps””VariabilityVariability in performance may be more in performance may be more affected than average qualityaffected than average quality

Factors Increasing FatigueFactors Increasing Fatigue

Prolonged wakefulness (>15 continuous Prolonged wakefulness (>15 continuous hrs)hrs)

Reduced or disrupted sleepReduced or disrupted sleep

Shift variabilityShift variability

Volume and intensity of workVolume and intensity of work

Sleep RestrictionSleep Restriction

Inter-individual differences,Inter-individual differences, BUT… BUT…

Sleepiness – dose response effectSleepiness – dose response effectLapses of attention and vigilance on tasks Lapses of attention and vigilance on tasks More errors on simulated drivingMore errors on simulated drivingResponse slowingResponse slowingSpatial learning problemsSpatial learning problemsDecrease in behavioral alertness with “microsleeps”Decrease in behavioral alertness with “microsleeps”Psychomotor vigilance test performance impairedPsychomotor vigilance test performance impairedWorking memory performance impairedWorking memory performance impairedMood problemsMood problemsCognitive and executive function impairment Cognitive and executive function impairment

Banks S, Dinges DF. J Clin Sleep Med 2007; 3:519


Elevated BPElevated BPReduced glucose toleranceReduced glucose toleranceSympathetic nervous system activationSympathetic nervous system activationReduced leptin levels (appetite)Reduced leptin levels (appetite)Increased inflammatory markers (IL-6, Increased inflammatory markers (IL-6, TNFTNFαα, CRP), CRP)ObesityObesity

Banks S, Dinges DF. J Clin Sleep Med 2007;3:519

Physiological consequences…


ObesityObesity

Insulin resistanceInsulin resistance

Cardiovascular events (epidemiological Cardiovascular events (epidemiological studies)studies)

MortalityMortality

Common cold susceptibility Common cold susceptibility (Cohen S et al. (Cohen S et al. Arch Intern Med Arch Intern Med 2009;169:62)2009;169:62)

Banks S, Dinges DF. J Clin Sleep Med 2007;3:519

Sleep Deprivation: Effects on Sleep Deprivation: Effects on MoodMood

Increased Increased dysphoria/depressiondysphoria/depression anger/hostility; decreased motivationanger/hostility; decreased motivation

Correlation with Correlation with sleep amountssleep amounts Effects last up to Effects last up to 48 hrs post-call48 hrs post-call Independent association with Independent association with night shiftnight shift

Sleep Deprivation –Sleep Deprivation – Socioeconomic Consequences…Socioeconomic Consequences…

More than 1,000,000 motor vehicle accidents More than 1,000,000 motor vehicle accidents annually are sleep-relatedannually are sleep-related

Disasters such as Chernobyl, Three Mile Island, Disasters such as Chernobyl, Three Mile Island, Challenger, Bhopal, and Exxon Valdez were Challenger, Bhopal, and Exxon Valdez were officially attributed to errors in judgment induced officially attributed to errors in judgment induced by sleepiness or fatigueby sleepiness or fatigue

Three Mile Island Three Mile Island and Chernobyl Disasters and Chernobyl Disasters

1. US Nuclear Regulatory Commission. Report on the Accident at 1. US Nuclear Regulatory Commission. Report on the Accident at Chernobyl Nuclear Power Station. Washington DC: US Government Chernobyl Nuclear Power Station. Washington DC: US Government Printing Office; 1987. 2. Moss TH, Sills DL. The Three Mile Island Printing Office; 1987. 2. Moss TH, Sills DL. The Three Mile Island nuclear accident: lessons and implications. nuclear accident: lessons and implications. Ann NY Acad SciAnn NY Acad Sci 1981; 1981;

365:1-341365:1-341

Early morning Early morning human errorhuman error

Fatigue-related Fatigue-related accidentsaccidents

Deserted city of Prypiyat with Chernobyl nuclear reactor in the background

Exxon Valdez GroundingExxon Valdez GroundingNTSB. Marine Accident Report – Grounding of the US Tankership NTSB. Marine Accident Report – Grounding of the US Tankership

EXXON VALDEZ on Bligh Reef, Prince William Sound, Near Valdez, EXXON VALDEZ on Bligh Reef, Prince William Sound, Near Valdez, Alaska, March 24Alaska, March 24thth, 1989. Washington DC: NTSB/March-90/04, 1989. Washington DC: NTSB/March-90/04

“…“…probable cause of probable cause of the grounding of the the grounding of the Exxon Valdez was the Exxon Valdez was the failure of the third failure of the third mate to properly mate to properly maneuver the vessel maneuver the vessel because of fatigue because of fatigue and excessive and excessive workload…”workload…”

Epworth Sleepiness ScaleEpworth Sleepiness ScaleJohns MW. Johns MW. Sleep 1994; 17:703-710Sleep 1994; 17:703-710

0 - WOULD NEVER DOZE0 - WOULD NEVER DOZE

1 - SLIGHT CHANCE OF DOZING1 - SLIGHT CHANCE OF DOZING

2 - MODERATE CHANCE OF DOZING2 - MODERATE CHANCE OF DOZING

3 - HIGH CHANCE OF DOZING3 - HIGH CHANCE OF DOZING

Sitting reading (Range 0 – 24)Sitting reading (Range 0 – 24)

Watching TVWatching TV

Sitting inactive in publicSitting inactive in public

Passenger in a car for 1 hourPassenger in a car for 1 hour

Sitting and talkingSitting and talking

Sitting quietly after lunchSitting quietly after lunch

In a car, while stopped for a few minutes in trafficIn a car, while stopped for a few minutes in traffic

Epworth Sleepiness Scale Scores (0-24 range)Epworth Sleepiness Scale Scores (0-24 range) Papp KK, et al. Acad Med 2004; 79:394-402 : :

Sleepiness in residents is equivalent to that found in patients with serious sleep disorders (normal < 10)

Stanford Sleepiness ScaleStanford Sleepiness Scale

Degree of sleepinessDegree of sleepiness Scale Scale RatingRating

Feeling active, vital, alert, or wide awakeFeeling active, vital, alert, or wide awake 11

Functioning at high levels, but not at peak; able to Functioning at high levels, but not at peak; able to concentrateconcentrate

22

Awake, but relaxed; responsive but not fully alertAwake, but relaxed; responsive but not fully alert 33

Somewhat foggy, let downSomewhat foggy, let down 44

Foggy, losing interest in remaining awake, slowed downFoggy, losing interest in remaining awake, slowed down 55

Sleepy, woozy, fighting sleep, prefer to lie downSleepy, woozy, fighting sleep, prefer to lie down 66

No longer fighting sleep, sleep onset soon, having dream-No longer fighting sleep, sleep onset soon, having dream-like thoughtslike thoughts

77

AsleepAsleep XX

An introspective measure of sleepiness – The Stanford An introspective measure of sleepiness – The Stanford Sleepiness Scale (SSS)Sleepiness Scale (SSS)

Despite this, the problem of Despite this, the problem of sleepiness and fatigue in sleepiness and fatigue in

residency is under-estimated.residency is under-estimated.

MYTH:MYTH: “It’s the really boring noon “It’s the really boring noon conferences that put me to sleep.”conferences that put me to sleep.”

FACT:FACT: Environmental factors (passive Environmental factors (passive learning situations, room learning situations, room temperature, low light levels, etc.) temperature, low light levels, etc.) may unmask, but DO NOT CAUSE may unmask, but DO NOT CAUSE SLEEPINESS!SLEEPINESS!

Conceptual FrameworkConceptual Framework((in Residency)in Residency)

Insufficient Sleep (on call sleep loss/

inadequate recovery sleep)

Fragmented Sleep(pager, phone calls)

Excessive Daytime Sleepiness

Circadian RhythmDisruption

(night float, rotating shifts)

Primary Sleep Disorders (sleep apnea, etc)

Sleep Needed Sleep Needed vs Sleep Obtainedvs Sleep Obtained

Myth:Myth: “I’m one of those people who only needs 5 “I’m one of those people who only needs 5 hours of sleep, so none of this applies to me.”hours of sleep, so none of this applies to me.”Fact:Fact: Individuals may vary Individuals may vary somewhat somewhat in their in their tolerance to the effects of sleep loss, but are not tolerance to the effects of sleep loss, but are not able to accurately judge this themselves.able to accurately judge this themselves.Fact:Fact: Human beings need 8 hours of sleep to Human beings need 8 hours of sleep to perform at an perform at an optimal optimal level.level.Fact:Fact: Getting less than 8 hours of sleep starts to Getting less than 8 hours of sleep starts to create a “sleep debt” which must be paid off.create a “sleep debt” which must be paid off.

NORMAL SLEEP

ON CALL SLEEP

= Paged

Sleep Fragmentation Affects Sleep Quality

MORNING ROUNDS

The Circadian Clock Impacts YouThe Circadian Clock Impacts You

It is easier to stay up later than It is easier to stay up later than to try to fall asleep earlier.to try to fall asleep earlier.

It is easier to adapt to shifts in It is easier to adapt to shifts in forward (clockwise) direction. forward (clockwise) direction.

(day evening night)(day evening night)

Night owls may find it easier Night owls may find it easier to adapt to night shifts. to adapt to night shifts.

Interaction of Circadian Interaction of Circadian Rhythms and SleepRhythms and Sleep

Time

9 PM9 AM 9 AM

SleepWake

Sleep Homeostatic drive (Sleep Load)

Circadian alerting signal

Alertness level

3 pm 3 AM

Sleep Disorders: Sleep Disorders: Are you at Risk?Are you at Risk?

Physicians can have sleep disorders too!Physicians can have sleep disorders too!

– Obstructive sleep apneaObstructive sleep apnea

– Restless legs syndromeRestless legs syndrome

– Periodic limb movement disorderPeriodic limb movement disorder

– Learned or “conditioned” insomniaLearned or “conditioned” insomnia

– Medication-induced insomniaMedication-induced insomnia

Adaptation to Sleep LossAdaptation to Sleep Loss

MythMyth:: “I’ve learned not to need as much “I’ve learned not to need as much sleep during my residency.”sleep during my residency.”FactFact:: Sleep needs are genetically Sleep needs are genetically determined and cannot be changed.determined and cannot be changed.Fact: Fact: Human beings do not “adapt” to Human beings do not “adapt” to getting less sleep than they need.getting less sleep than they need.Fact: Fact: Although performance of tasks may Although performance of tasks may improve somewhat with effort, improve somewhat with effort, optimal optimal performance and performance and consistencyconsistency of of performanceperformance do not! do not!

Consequences of Chronic Sleep Consequences of Chronic Sleep DeprivationDeprivation

Sleep is a vital and necessary function, and sleep needs (like hunger and thirst) must be met

Learning

DrivingSafety

Health&

Well-Being

Family Relationships

Patient CareProfessionalism

MoodAnd

Performance

Workplace

Sleep DeprivedSleep DeprivedResidentResident

Impairment Impairment Across SpecialtiesAcross Specialties

Surgery:Surgery: 20% more errors and 14% more time 20% more errors and 14% more time requiredrequired to perform simulated laparoscopy post-call to perform simulated laparoscopy post-call (two studies) (two studies) Taffinder NJ et al, Taffinder NJ et al, Lancet Lancet 1998; 352:1191; 1998; 352:1191; Grantcharov TP et al.Grantcharov TP et al. BMJ BMJ 2001; 323:1222 2001; 323:1222

Internal Medicine:Internal Medicine: efficiency and accuracy efficiency and accuracy of of ECG interpretation impaired in sleep-deprived ECG interpretation impaired in sleep-deprived interns interns Lingenfelser T et al. Lingenfelser T et al. Med EducationMed Education 1994;28:566 1994;28:566

Pediatrics:Pediatrics: time requiredtime required to place an intra-arterial to place an intra-arterial line increased significantly in sleep-deprived line increased significantly in sleep-deprived residents residents Storer JS et al, Storer JS et al, Acad MedAcad Med 1989; 64:291989 1989; 64:291989

Surgery Residents:Surgery Residents:Laparoscopic Skills Suffer on the First Laparoscopic Skills Suffer on the First

Night ShiftNight Shift

Technical skills assessed on 2 tasksTechnical skills assessed on 2 tasks

Took longer (Took longer (p=p=.002) and made more errors (.002) and made more errors (pp=.025) on =.025) on their first night shifttheir first night shift

Were less economical with movements on the first night Were less economical with movements on the first night shiftshift

Some improvement noted during subsequent shiftsSome improvement noted during subsequent shifts

Lesson: Prepare for night shift, realize your Lesson: Prepare for night shift, realize your limitations limitations

21 residents trained on a virtual reality surgical simulator:

Leff DR et al. Leff DR et al. Ann SurgAnn Surg 2008;247:530 2008;247:530

Across TasksAcross Tasks

Emergency Medicine:Emergency Medicine: significant significant reductions in comprehensivenessreductions in comprehensiveness of of history & physical exam documentation in history & physical exam documentation in second-year residents second-year residents Bertram DA. Bertram DA. NY State J MedNY State J Med 1998; 88:10-151998; 88:10-15

Family Medicine:Family Medicine: scores achieved on the scores achieved on the ABFM practice in-training examABFM practice in-training exam negatively negatively correlated with pre-test sleep amounts correlated with pre-test sleep amounts Jacques CJ et al. Jacques CJ et al. J Fam PractJ Fam Pract 1990; 30:223-229 1990; 30:223-229

Impact on ProfessionalismImpact on Professionalism

““Your own patients have become the Your own patients have become the enemy…because they are the one thing enemy…because they are the one thing

that stands between you and a few that stands between you and a few hours of sleep.”hours of sleep.”

Work Hours, Medical Errors, and Work Hours, Medical Errors, and Workplace Conflicts by Average Workplace Conflicts by Average

Daily Hours of Sleep*Daily Hours of Sleep*

0102030

405060708090

100

< 4 hrs 5-6 hrs > 7 hrs

Work Hrs/wk

% Reporting MedErrors

% Reporting StaffConflicts

* Baldwin DJr et al. Acad Med 2003;78:1154Hours of Sleep

Per

cent

%

Limiting Resident Work Hours:Limiting Resident Work Hours:Impact on Patient SafetyImpact on Patient SafetyFletcher KE, et al. Fletcher KE, et al. Ann Intern MedAnn Intern Med 2004:141 2004:141

Insufficient evidenceInsufficient evidence

7 studies had an intervention to reduce 7 studies had an intervention to reduce work hours and assessed patient safety work hours and assessed patient safety outcomes (4 retrospective, 3 prospective outcomes (4 retrospective, 3 prospective studies)studies)

Limitations on study design, diversity of Limitations on study design, diversity of interventions and possibly publication biasinterventions and possibly publication bias

Do ACGME Duty Hour Rules Do ACGME Duty Hour Rules Impact Hospital Mortality? No?Impact Hospital Mortality? No?

Compared mortality rates for all Medicare pt Compared mortality rates for all Medicare pt admissions to teaching hospitals from 2000-admissions to teaching hospitals from 2000-2003 (pre duty hours reform) to 2003-2005 (after 2003 (pre duty hours reform) to 2003-2005 (after duty hour reform)duty hour reform)

ACGME duty hours reform was not associated ACGME duty hours reform was not associated with either worsening or improvement in with either worsening or improvement in mortality during the first 2 years after mortality during the first 2 years after implementationimplementation

Volpp KG et al. JAMA 2007;298:975

Do ACGME Duty Hour Rules Do ACGME Duty Hour Rules Impact Hospital Mortality? Yes?Impact Hospital Mortality? Yes?

Compared mortality rates for all VA Compared mortality rates for all VA Hospitals from 2000-2003 and 2003-2005Hospitals from 2000-2003 and 2003-2005

Duty hour rules were associated with Duty hour rules were associated with improvement in mortality for 4 common improvement in mortality for 4 common medical conditions (AMI, CVA, GI bleed, medical conditions (AMI, CVA, GI bleed, CHF)—but not for surgical conditionsCHF)—but not for surgical conditions

Volpp KG et al. JAMA 2007; 298:984

Serious Medical Errors in the ICUSerious Medical Errors in the ICULandrigan CP et al. Landrigan CP et al. N Engl J MedN Engl J Med 2004; 351:1838 2004; 351:1838

Prospective randomized trial of internsProspective randomized trial of interns

Traditional schedule with an extended (> 24 hr) Traditional schedule with an extended (> 24 hr) work shift every 3work shift every 3rdrd night (3 interns) night (3 interns)– 77 to 81 hrs/wk up to 34 hrs of continous work77 to 81 hrs/wk up to 34 hrs of continous work

Interventional schedule where one intern worked Interventional schedule where one intern worked 7 am to 10 pm on call and another worked 9 pm 7 am to 10 pm on call and another worked 9 pm to 1 pm (4 interns)to 1 pm (4 interns)– 60 to 63 hrs/wk with up to 16 continous working hours60 to 63 hrs/wk with up to 16 continous working hours

Examined incidence of serious medical errorsExamined incidence of serious medical errors

Serious Medical Errors in the ICUSerious Medical Errors in the ICULandrigan CP et al. Landrigan CP et al. N Engl J MedN Engl J Med 2004; 351:1838 2004; 351:1838

Interns on the traditional scheduleInterns on the traditional schedule– Made 36% more serious medical errorsMade 36% more serious medical errors– Made 21% more serious medication errorsMade 21% more serious medication errors– Made 5.6 times as many serious diagnostic Made 5.6 times as many serious diagnostic

errorserrors

Eliminating extended work shift and Eliminating extended work shift and reducing the number of work hours per reducing the number of work hours per week can reduce serious medication week can reduce serious medication errors in the ICUerrors in the ICU

Bottom Line:Bottom Line:You need to be alert You need to be alert

to take the best possible care to take the best possible care of your patients...of your patients...

…and yourself!

Adverse Health Consequences Adverse Health Consequences by Average Daily Hours of Sleep*by Average Daily Hours of Sleep*

0

10

20

30

40

50

60

<4 hrs 5-6hrs >7 hrs

% Reporting SignifWgt Change

% Reporting Med Useto Stay Awake

% ReportingIncreased AlcoholUse

Hours of Sleep

Baldwin DC Jr, et al. Baldwin DC Jr, et al. Acad MedAcad Med 2003; 78:1154 2003; 78:1154

Sleep Loss and Fatigue: Sleep Loss and Fatigue: Safety IssuesSafety Issues

58%58% of emergency medicine residents reported of emergency medicine residents reported near-crashes near-crashes – 80%80% post night-shiftpost night-shift– Increased with number night shifts/monthIncreased with number night shifts/month

Steele MT et al, Steele MT et al, Acad Emerg Med Acad Emerg Med 1999; 6:10501999; 6:1050

50%50% greater risk of blood-borne pathogen greater risk of blood-borne pathogen exposure incidents (needlestick, laceration, etc) in exposure incidents (needlestick, laceration, etc) in residents between 10 pm and 6 amresidents between 10 pm and 6 am

Parks DK et al, Parks DK et al, Chronobiology Intl Chronobiology Intl 2000; 17:61 2000; 17:61

MICU Resident Sleepiness Post CallMICU Resident Sleepiness Post CallReddy R et al. Reddy R et al. ChestChest 2009; 135:81 2009; 135:81

Monitored sleep times with diaries and actigraphsMonitored sleep times with diaries and actigraphs

Stanford Sleepiness Scale (SSS) and MSLT performed Stanford Sleepiness Scale (SSS) and MSLT performed day of and day after call (2 nap sessions)day of and day after call (2 nap sessions)

Sleep time prior to call day: 7.15 Sleep time prior to call day: 7.15 ± 1 hr± 1 hr

Sleep time on call: 2.5 ± 1.4 hrSleep time on call: 2.5 ± 1.4 hr

On CallOn Call Post CallPost Call

SSS 1.5 ± 0.6SSS 1.5 ± 0.6 3.15 ± 13.15 ± 1

MSLT 9 ± 4.4 minMSLT 9 ± 4.4 min 4.8 ± 4.1 min 4.8 ± 4.1 min

20 residents on call every 4th night, home after call at/or before noon:

MICU Resident Sleepiness MICU Resident Sleepiness Post CallPost Call

Severity of sleepiness post-call Severity of sleepiness post-call approximates someone with narcolepsyapproximates someone with narcolepsy

Residents are often sleepy during on-call Residents are often sleepy during on-call and post-call days even while and post-call days even while implementing the ACGME guidelinesimplementing the ACGME guidelines

Implications for patient and resident safetyImplications for patient and resident safety

The High Price of Sleep Deprivation…

Courtesy of Advance for Managers of Respiratory Care, Apr 2000

Sleep Loss and Fatigue: Sleep Loss and Fatigue: Driving Driving

Marcus CL et al. Marcus CL et al. SleepSleep 1996; 19:763 1996; 19:763

Retrospective survey of 85 pediatric residents and 85 faculty:

2.7 hrs avg sleep on-call; 7.2 hrs avg off-call2.7 hrs avg sleep on-call; 7.2 hrs avg off-call

23% had fallen asleep while driving (vs 8%)23% had fallen asleep while driving (vs 8%)

44% had fallen asleep at traffic light (vs 12.5%)44% had fallen asleep at traffic light (vs 12.5%)

Total 49% had fallen asleep at the wheel; 90% Total 49% had fallen asleep at the wheel; 90% of incidents post-callof incidents post-call

25 traffic citations (vs 15), 20 MVAs (vs 11)25 traffic citations (vs 15), 20 MVAs (vs 11)

Risk of MVA Crashes Risk of MVA Crashes Among InternsAmong Interns

Barger LK et al. Barger LK et al. N Engl J MedN Engl J Med 2005; 352:125 2005; 352:125

Web-based survey of 2737 interns examining work hrs, Web-based survey of 2737 interns examining work hrs, shifts, crashes, and near miss incidents (July 2002 - May shifts, crashes, and near miss incidents (July 2002 - May 2003)2003)Extended work shift increased the monthly risk of an Extended work shift increased the monthly risk of an MVA by 9.1%, and the risk during the commute from MVA by 9.1%, and the risk during the commute from work by 16.2%work by 16.2%In months where interns had > 5 extended shifts, the risk In months where interns had > 5 extended shifts, the risk of falling asleep while driving increased (OR 2.39) as did of falling asleep while driving increased (OR 2.39) as did the risk for falling asleep in traffic (OR 3.69)the risk for falling asleep in traffic (OR 3.69)Extended work hour shifts pose a driving safety hazard.Extended work hour shifts pose a driving safety hazard.

Sleep Deprivation & Equivalent Sleep Deprivation & Equivalent ETOH LevelsETOH Levels

WakefulnessWakefulness Equivalent ETOH LevelEquivalent ETOH Level 17 hours17 hours . . . . . . . . . . .. . . . . . . . . . . 0.05% 0.05% 21 hours21 hours . . . . . . . . . . .. . . . . . . . . . . 0.08% 0.08% 24 hours24 hours . . . . . . . . . . .. . . . . . . . . . . 0.1% 0.1%

Legally drunk level = 0.08% ETOHLegally drunk level = 0.08% ETOH US Legal limit ETOH level for commercial drivers = US Legal limit ETOH level for commercial drivers =

0.04%0.04% Maggie’s Law (New Jersey) – a sleep-deprived driver (no Maggie’s Law (New Jersey) – a sleep-deprived driver (no

sleep > 24 hrs) can be convicted of vehicular homicidesleep > 24 hrs) can be convicted of vehicular homicide In almost all states, people can be charged under In almost all states, people can be charged under

existing laws if they fall asleep at the wheelexisting laws if they fall asleep at the wheel

ACGME Duty Hour Limits: ACGME Duty Hour Limits: Effects on Safety, Sleep and Work HoursEffects on Safety, Sleep and Work Hours

220 residents, prospective cohort study, 220 residents, prospective cohort study, evaluated the spring before and the spring after evaluated the spring before and the spring after implementation of ACGME duty hour standardsimplementation of ACGME duty hour standardsNo change in total work or sleep hours, No change in total work or sleep hours, medication errors, MVAs, occupational medication errors, MVAs, occupational exposures, or depressionexposures, or depressionMean length of on call shifts decreased 2.7% to Mean length of on call shifts decreased 2.7% to 28.5 hours (28.5 hours (pp = .001) = .001)Resident burnout decreased from 75.4% to Resident burnout decreased from 75.4% to 57.0% (57.0% (p p = .007) = .007)

Landrigan CP et al. Pediatrics 2008; 122:250

Landrigan CP et al. Pediatrics 2008;122:250-258

Outcomes Before and After ACGME Duty Hour Standards

““We all know that you stop learning after We all know that you stop learning after 12 or 13 or 14 hours. You don’t learn 12 or 13 or 14 hours. You don’t learn

anything except how to cut corners and anything except how to cut corners and how to survive.”how to survive.”

Impact on Medical Education

Recognizing Sleepiness in Recognizing Sleepiness in Yourself and OthersYourself and Others

Myth:Myth: “If I can just get through the night (on “If I can just get through the night (on call), I’m fine in the morning.”call), I’m fine in the morning.”

Fact:Fact: A decline in performance starts after A decline in performance starts after about 15-16 hours of continued about 15-16 hours of continued wakefulness.wakefulness.

Fact:Fact: The period of lowest alertness after The period of lowest alertness after being up all night is between 6 am and being up all night is between 6 am and 11am (morning rounds).11am (morning rounds).

Estimating Sleepiness Estimating Sleepiness

Myth: Myth: “I can tell how tired I am and I know “I can tell how tired I am and I know when I’m not functioning up to par.”when I’m not functioning up to par.”Fact:Fact: Studies show that sleepy people Studies show that sleepy people underestimate underestimate their level of sleepiness their level of sleepiness and and overestimateoverestimate their alertness. their alertness.Fact:Fact: The sleepier you are, the The sleepier you are, the less less accurateaccurate your perception of degree of your perception of degree of impairment. impairment. Fact:Fact: You can fall asleep briefly You can fall asleep briefly (“microsleeps”) without knowing it!(“microsleeps”) without knowing it!

Perceived Impact of Sleep Perceived Impact of Sleep DeprivationDeprivation

Surgery residents are less likely to Surgery residents are less likely to perceive the potential impact of sleep perceive the potential impact of sleep deprivation on their own performancedeprivation on their own performance

Could it be due to optimism bias?Could it be due to optimism bias?

Be aware!Be aware!

Surgical vs Non-Surgical ResidentsSurgical vs Non-Surgical Residents

SurgicalSurgical Non-SurgicalNon-Surgical PP

Work hrs per weekWork hrs per week 8383 62.562.5 < .01< .01

Epworth Sleepiness ScaleEpworth Sleepiness Scale 12.812.8 9.29.2 < .01< .01

Sleep Deprivation Impact ScoreSleep Deprivation Impact Score 45.245.2 51.551.5 < .01< .01

Woodrow SI et al. Medical Education 2008; 42:459

Attention Failures on Different Work Attention Failures on Different Work HoursHours

Lockley SW et al. Lockley SW et al. N Engl J MedN Engl J Med 2004; 351:1829 2004; 351:1829

20 interns on 2 different 3 wk ICU rotations20 interns on 2 different 3 wk ICU rotations

Traditional and intervention work hoursTraditional and intervention work hours

Continuous ambulatory polysomnographyContinuous ambulatory polysomnography

Attentional failures identified by slow-Attentional failures identified by slow-rolling eye movements into confined rolling eye movements into confined wakefulness during work hourswakefulness during work hours

Attentional Failure: Example

Attentional Failures on Different Attentional Failures on Different Work HoursWork Hours


On the intervention work hour shift On the intervention work hour shift schedule:schedule:– Interns worked 19.5 hrs/wk lessInterns worked 19.5 hrs/wk less– Slept moreSlept more– Had less than half of the rate of attentional Had less than half of the rate of attentional

failures while working during on-call nightsfailures while working during on-call nights

Mean Number of Attentional Mean Number of Attentional Failures Failures


Neurocognitive Effects of Sleep Neurocognitive Effects of Sleep Deprivation in ResidentsDeprivation in Residents

Arnedt JT, et al. Arnedt JT, et al. JAMAJAMA 2005; 294-1025 2005; 294-1025

Prospective 2 session within-subject study Prospective 2 session within-subject study of 34 pediatric residentsof 34 pediatric residentsCompared post-call performance to non Compared post-call performance to non post-call performance with and w/out a post-call performance with and w/out a blood alcohol level of 0.04 – 0.05 g %blood alcohol level of 0.04 – 0.05 g %– Sustained attentionSustained attention– VigilanceVigilance– Simulated drivingSimulated driving


Arnedt JT, et al. Arnedt JT, et al. JAMAJAMA 2005; 294:1-1025 2005; 294:1-1025

Light call rotation – 4Light call rotation – 4thth week of 44 hr week of 44 hr work weekwork week– Testing before and after alcohol ingestionTesting before and after alcohol ingestion

Heavy call rotation – 4Heavy call rotation – 4thth week of 80 hr week of 80 hr work weekwork week– Testing before and after placebo ingestionTesting before and after placebo ingestion



Heavy call:Heavy call:– Reaction times 7% slowerReaction times 7% slower– Commission errors 40% higherCommission errors 40% higher– Simulated driving lane variability 27% greaterSimulated driving lane variability 27% greater– Simulated driving speed variability 71% Simulated driving speed variability 71%

greatergreater– Results similar to light call results with a 0.04 Results similar to light call results with a 0.04

to 0.05 g % blood alcohol levelto 0.05 g % blood alcohol level

Residents could not judge this impairment



Post-call performance impairment is presentPost-call performance impairment is present

Impairment is comparable to drinking 3 to 4 Impairment is comparable to drinking 3 to 4 alcoholic drinksalcoholic drinks

Residents have limited ability to recognize their Residents have limited ability to recognize their degree of impairment degree of impairment

Potential risk to personal and patient safetyPotential risk to personal and patient safety

Consider interventions to minimize impactConsider interventions to minimize impact

Recognize The Recognize The Warning Signs of SleepinessWarning Signs of Sleepiness

Falling asleep in conferences or on roundsFalling asleep in conferences or on rounds

Feeling restless and irritable with staff, Feeling restless and irritable with staff, colleagues, family, and friendscolleagues, family, and friends

Having to check your work repeatedlyHaving to check your work repeatedly

Having difficulty focusing on the care of Having difficulty focusing on the care of your patientsyour patients

Feeling like you really just don’t careFeeling like you really just don’t care

Be Aware of Sleep InertiaBe Aware of Sleep Inertia

Clouded sensorium when arousing from sleepClouded sensorium when arousing from sleepConfusion, slowed speech, repeating phrases or Confusion, slowed speech, repeating phrases or questionsquestionsVulnerable time: answering a beeper or phone Vulnerable time: answering a beeper or phone call when asleepcall when asleepCan’t retain informationCan’t retain informationWe may not recognize our own sleep inertiaWe may not recognize our own sleep inertiaReversible with < 10 minutes of stimulation like Reversible with < 10 minutes of stimulation like movement and caffeinemovement and caffeineManage it before making important medical Manage it before making important medical decisiondecision

If you don’t recognize that If you don’t recognize that you’re sleepy,you’re sleepy,

you’re not likely to do you’re not likely to do anything about it.anything about it.

Alertness Management Alertness Management StrategiesStrategies

Myth:Myth: “I’d rather just “power through” “I’d rather just “power through” when I’m tired; besides, even when I when I’m tired; besides, even when I can nap, it just makes me feel worse.”can nap, it just makes me feel worse.”

Fact:Fact: Some sleep is always better than Some sleep is always better than no sleep.no sleep.

Fact:Fact: At At what timewhat time and for and for how longhow long you you sleep are key to getting the most out of sleep are key to getting the most out of napping.napping.

Napping Napping

Pros:Pros: naps temporarily improve naps temporarily improve alertnessalertness

Types:Types:– Preventative (pre-call)Preventative (pre-call)– Operational (on the job)Operational (on the job)Length:Length:– Short naps:Short naps: no longer than 30 minutes to avoid no longer than 30 minutes to avoid

the grogginess (“sleep inertia”) that occurs when the grogginess (“sleep inertia”) that occurs when you’re awakened from deep sleepyou’re awakened from deep sleep

– Long naps:Long naps: 2 hours (range 30 to 180 minutes) 2 hours (range 30 to 180 minutes)

NappingNappingTiming:Timing: – if possible, take advantage of circadian if possible, take advantage of circadian

“windows of opportunity” (2 to 5 am/2 to “windows of opportunity” (2 to 5 am/2 to 5 pm)5 pm)

– but if not, nap whenever you can!but if not, nap whenever you can!Cons: Cons: sleep inertia; allow adequate sleep inertia; allow adequate recovery time (15-30 minutes)recovery time (15-30 minutes)Bottom line:Bottom line: naps take the edge off but naps take the edge off but do do not replacenot replace adequate sleep. adequate sleep.

Healthy Sleep HabitsHealthy Sleep Habits

Get adequate (7 to 9 hours) sleep Get adequate (7 to 9 hours) sleep beforebefore anticipated sleep loss.anticipated sleep loss.

Avoid Avoid starting outstarting out with with a sleep deficit! a sleep deficit!

MythMyth:: “All I need is my usual 5 to 6 “All I need is my usual 5 to 6 hours the night after call and I’m fine.”hours the night after call and I’m fine.”

Fact:Fact: Recovery from on-call sleep loss Recovery from on-call sleep loss generally takes 2 nights of extended generally takes 2 nights of extended sleep to restore baseline alertness.sleep to restore baseline alertness.

Fact:Fact: Recovery sleep generally has a Recovery sleep generally has a higher percentage of deep sleep, which higher percentage of deep sleep, which is needed to counteract the effects of is needed to counteract the effects of sleep loss.sleep loss.

Recovery from Sleep LossRecovery from Sleep Loss

Healthy Sleep Healthy Sleep HabitsHabits

Go to bed and get up at about Go to bed and get up at about the same time every day the same time every day

Develop a pre-sleep routineDevelop a pre-sleep routine

Use relaxation to help you fall asleepUse relaxation to help you fall asleep

Protect your sleep time; enlist your Protect your sleep time; enlist your family and friends!family and friends!

Healthy Sleep HabitsHealthy Sleep Habits

Sleeping environment:Sleeping environment:– No animals!No animals! – Cooler temperatureCooler temperature– Dark (eye shades, room darkening shades)Dark (eye shades, room darkening shades)– Quiet (unplug phone, turn off pager, use Quiet (unplug phone, turn off pager, use

ear plugs, white noise machine)ear plugs, white noise machine)

Avoid going to bed hungry, but no heavy Avoid going to bed hungry, but no heavy meals within 3 hours of sleep. meals within 3 hours of sleep.

Get regular exercise but avoid heavy exercise Get regular exercise but avoid heavy exercise within 3 hours of sleep.within 3 hours of sleep.

Recognize Signs of DWD*Recognize Signs of DWD*

Trouble focusing on the roadTrouble focusing on the roadDifficulty keeping your eyes openDifficulty keeping your eyes openNoddingNoddingYawning repeatedlyYawning repeatedlyDrifting from your lane, missing signs or Drifting from your lane, missing signs or exitsexitsNot remembering driving the last few milesNot remembering driving the last few milesClosing your eyes at stoplightsClosing your eyes at stoplights

* Driving While Drowsy

Risk Factors for Drowsy DrivingRisk Factors for Drowsy Driving

• Taking any sedating medicationsTaking any sedating medications• Drinking even small amounts of alcoholDrinking even small amounts of alcohol• Having a sleep disorder (sleep apnea)Having a sleep disorder (sleep apnea)• Driving long distances without breaksDriving long distances without breaks• Driving alone or on a boring roadDriving alone or on a boring road

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Driving home post-call

Pack A et al. Anal Prev 1995; 27:769

Drowsy Driving:Drowsy Driving:What DOES NOT WorkWhat DOES NOT Work

Turning up the radioTurning up the radio

Opening the car windowOpening the car window

Chewing gumChewing gum

Blowing cold air (water) on your faceBlowing cold air (water) on your face

Slapping (pinching) yourself hardSlapping (pinching) yourself hard

Promising yourself a reward for staying Promising yourself a reward for staying awakeawake

It takes only a 4 second lapse It takes only a 4 second lapse in attention to have a drowsy in attention to have a drowsy

driving crash.driving crash.

Post-call MVA Driving Home Post-call MVA Driving Home Who’s Liable?Who’s Liable?

American Medical NewsAmerican Medical News, October 31, 2005, October 31, 2005

In July 1997, an intern at Rush University Medical Center In July 1997, an intern at Rush University Medical Center had an MVA while driving home after being on call for 36 had an MVA while driving home after being on call for 36 hourshoursA 23 year-old woman sustained a head injury which has A 23 year-old woman sustained a head injury which has left her totally disabledleft her totally disabledHer family is suing the intern and the teaching hospital Her family is suing the intern and the teaching hospital because the hospital enforced a work schedule resulting because the hospital enforced a work schedule resulting in sleep deprivationin sleep deprivationHospital not responsibleHospital not responsibleUnder appeal/no further action as of February 2009Under appeal/no further action as of February 2009

Drugs Drugs

AVOIDAVOID using stimulants (methylphenidate, using stimulants (methylphenidate, dextroamphetamine) to stay awakedextroamphetamine) to stay awake

AVOIDAVOID using alcohol to help you fall asleep; it using alcohol to help you fall asleep; it induces sleep onset but disrupts sleep later on.induces sleep onset but disrupts sleep later on.

Modafinil:Modafinil: little data little data

MelatoninMelatonin: little data in residents: little data in residents

HypnoticsHypnotics: may be helpful in : may be helpful in specificspecific situations (eg, situations (eg, persistent insomnia)persistent insomnia)

CaffeineCaffeine

StrategicStrategic consumption is key consumption is key

Effects within 15 – 30 minutes; Effects within 15 – 30 minutes; half-life 3 to 7 hours half-life 3 to 7 hours

Use for temporary relief of sleepiness Use for temporary relief of sleepiness

Cons: Cons: – disrupts subsequent sleep (more arousals)disrupts subsequent sleep (more arousals)– tolerance may developtolerance may develop– diuretic effects diuretic effects

Myth:Myth: “I get used to night shifts right “I get used to night shifts right away; no problem.”away; no problem.”

Fact:Fact: It takes at least a week for circadian It takes at least a week for circadian rhythms and sleep patterns to adjust. rhythms and sleep patterns to adjust.

Fact:Fact: Adjustment often includesAdjustment often includes physical physical and mentaland mental symptoms (think jet lag). symptoms (think jet lag).

Fact:Fact: Direction of shift rotation affects Direction of shift rotation affects adaptation (forward/clockwise easier to adaptation (forward/clockwise easier to adapt).adapt).

Adapting to Night Shifts Adapting to Night Shifts

How to Survive Night FloatHow to Survive Night FloatProtect your sleepProtect your sleepNap before work Nap before work Consider “splitting” sleep into two 4 hour periodsConsider “splitting” sleep into two 4 hour periods

Have as much exposure to bright light as Have as much exposure to bright light as possible when you need to be alertpossible when you need to be alert

Avoid light exposure in the Avoid light exposure in the morning after night shift morning after night shift (wear dark glasses (wear dark glasses

driving home from work)driving home from work)

Alertness StrategiesAlertness Strategies

There is no “magic bullet” There is no “magic bullet”

Know your own vulnerability to Know your own vulnerability to sleep loss sleep loss

Learn what works for you from a range Learn what works for you from a range of strategies of strategies

There needs to be a shared There needs to be a shared responsibility for fatigue management responsibility for fatigue management and a “culture of support” in the and a “culture of support” in the training programtraining program

Effects of Work Hour Reduction on Effects of Work Hour Reduction on Residents’ LivesResidents’ Lives

Fletcher KE, et al. Fletcher KE, et al. JAMAJAMA 2005; 294:1088 2005; 294:1088

12 studies -- performed on Internal 12 studies -- performed on Internal Medicine residentsMedicine residentsNurse perceptions -- residents made fewer Nurse perceptions -- residents made fewer mistakes and they were easier to work mistakes and they were easier to work withwithFaculty perceptions -- residents learned Faculty perceptions -- residents learned less and developed a shift-work mentalityless and developed a shift-work mentalityProgram Directors perceptions -- 81% Program Directors perceptions -- 81% agreed that resident morale improved agreed that resident morale improved when night float system used when night float system used

Effects of Work Hour Reduction on Effects of Work Hour Reduction on Residents’ LivesResidents’ Lives

Fletcher KE, et al. Fletcher KE, et al. JAMAJAMA 2005; 294:1088 2005; 294:1088

Resident perceptions:Resident perceptions:– Decreased work hoursDecreased work hours– Increased sleep timeIncreased sleep time– Fewer attention failuresFewer attention failures– More time with familyMore time with family– Less impact of fatigue on learningLess impact of fatigue on learning– No difference in moodNo difference in mood

Resident Attitudes About ACGME Resident Attitudes About ACGME Duty Hour RegulationsDuty Hour Regulations

Surveyed 200 residents trained both before and Surveyed 200 residents trained both before and after implementation at 6 residency pgms (3 IM, after implementation at 6 residency pgms (3 IM, 3 GS) 2 yrs after implementation3 GS) 2 yrs after implementation

Fatigue-related errors decreased slightlyFatigue-related errors decreased slightly

Errors related to continuity of care significantly Errors related to continuity of care significantly increasedincreased

Opportunities for formal education, bedside Opportunities for formal education, bedside learning and procedures decreasedlearning and procedures decreased

Quality of life improved and burnout decreasedQuality of life improved and burnout decreased

Myers JS et al. Acad Med 2006; 81:1052

In Summary...In Summary...

Fatigue is an impairment—like alcohol or drugsFatigue is an impairment—like alcohol or drugs

Drowsiness, sleepiness, and fatigue cannot be Drowsiness, sleepiness, and fatigue cannot be eliminated in residency, but can be managedeliminated in residency, but can be managed

Recognition of sleepiness and fatigue and use of Recognition of sleepiness and fatigue and use of alertness management strategies are simple alertness management strategies are simple ways to help combat sleepiness in residencyways to help combat sleepiness in residency

When sleepiness interferes with your When sleepiness interferes with your performance or health, talk to your supervisors performance or health, talk to your supervisors and program directorand program director

International Medical News, Sep 1, 2005

Sleepy DrivingFrom Sleep Review, Mar-Apr 2005, pg 38

Sleepy Driver Crash VideoSleepy Driver Crash VideoCComputer must be connected to the internet. omputer must be connected to the internet.

Open your browser: Go to the Open your browser: Go to the YouTubeYouTube website: (website: (www.youtube.comwww.youtube.com) )

Search for: “Sleepy Driver Crash” video clip,Search for: “Sleepy Driver Crash” video clip,or click or click

http://www.youtube.com/watch?v=s-jkbhO8I2Ihttp://www.youtube.com/watch?v=s-jkbhO8I2I

then then minimizeminimize it. When you are ready to it. When you are ready to view the video, double-click on the URL at the view the video, double-click on the URL at the

bottom of the screen.bottom of the screen.

Sleep Loss, Fatigue and Medical Training

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