Sleepy & ShiftySleepy & ShiftyThe impact of shift The impact of shift

working on training and working on training and healthhealth

Mr Dominic Slade SpR 5Mr Dominic Slade SpR 5

Honorary Secretary ASiTHonorary Secretary ASiT

All round general disliker of All round general disliker of shiftsshifts

No such thing as a good No such thing as a good shift..shift..• Shifts Shifts absenteeism, hypertension, absenteeism, hypertension,

peptic ulceration, depression peptic ulceration, depression 1 1

• 12 hour shifts significantly worse for your 12 hour shifts significantly worse for your health than 8 (alcohol, caffeine and health than 8 (alcohol, caffeine and nicotine dependence) nicotine dependence) 22

• Staying awake at night is unnaturalStaying awake at night is unnatural• 5 shifts to develop alertness or “circadian 5 shifts to develop alertness or “circadian

phase shift” phase shift” 33

• Similar period to readapt to day working Similar period to readapt to day working 1 K Sakate et al 2003 J Occup Envir Med

2 Joi 2001 Ergology

3 “Healthy Nights” Home Office

No such thing as a good No such thing as a good shift..shift..

• Considerable evidence for maximum Considerable evidence for maximum of 4 consecutive duties in task specific of 4 consecutive duties in task specific jobsjobs44

• Physiology prevents quality daytime Physiology prevents quality daytime sleep with reduced REM componentsleep with reduced REM component

• 0300 significant dip in alertness (peak 0300 significant dip in alertness (peak time for car accidents)time for car accidents)

• Irony!Irony! 4 S Folkard 1999 Transport:Rhythm & Blues

Fatigue and Shift WorkFatigue and Shift Work

•3 mile island, 3 mile island, Chernobyl, Exxon Chernobyl, Exxon Valdez, Bhopal & Valdez, Bhopal & Challenger Challenger explosionsexplosions

FatigueFatigue• 17hrs awake=50mg%17hrs awake=50mg%

• 24 hours=100mg%24 hours=100mg%

• Survey of Pilots and DoctorsSurvey of Pilots and Doctors

• ““Even when fatigued I perform effectively Even when fatigued I perform effectively at all times” 26% pilots vs 70% of at all times” 26% pilots vs 70% of surgeons! surgeons! 77

• ECG interpretation errors, tasks take ECG interpretation errors, tasks take longer, diminished intubation skills on longer, diminished intubation skills on night shifts, increased response time to night shifts, increased response time to gas board monitor changesgas board monitor changes

7 RL Helmreich 2000 BMJ

Working the night shift-Royal FreeWorking the night shift-Royal Freewww.rcplondon.ac.uk/news/EWTD_nightshifwww.rcplondon.ac.uk/news/EWTD_nightshift.pdft.pdf

• 13 hour shift, week of nights, 2004 over 8 13 hour shift, week of nights, 2004 over 8 week period-questionnaireweek period-questionnaire

• 39 SpRs (Surg 7, Ortho 7, physicians 25)39 SpRs (Surg 7, Ortho 7, physicians 25)• 30 male:9 female, 9 had one child<6yr30 male:9 female, 9 had one child<6yr• 95% return rate95% return rate• Daytime sleep 4-5hrsDaytime sleep 4-5hrs• Alcohol to help sleep (9), 60% coffee, cigs Alcohol to help sleep (9), 60% coffee, cigs

to stay awake esp day 4 + 5to stay awake esp day 4 + 5• 70% slept during shift, usually at nadir 70% slept during shift, usually at nadir

3am3am

Improved work-life balance?Improved work-life balance?

• 46% seriously affects social/family life46% seriously affects social/family life

• Adverse effects on health in 50%Adverse effects on health in 50%

• Recovery 2-5 days on averageRecovery 2-5 days on average

• 74% worse quality of care at night74% worse quality of care at night

• 89% would rather work on-call89% would rather work on-call

• 50% concerned re negative fx on 50% concerned re negative fx on trainingtraining

Controversies of shift Controversies of shift workwork

• Loss of on call Loss of on call room (4%) –how room (4%) –how pettypetty

• Poor facilitiesPoor facilities

• Cross Cover in Cross Cover in A&E (2 trusts) – A&E (2 trusts) – What about What about training?training?

The Maths of Surgical Training The Maths of Surgical Training & & ShiftsShifts

• 99% SpRs on full shifts99% SpRs on full shifts• 1 week nights1 week nights• 1 week on call1 week on call• Consultant week on Consultant week on

callcall• No relationshipNo relationship• Loss of elective Loss of elective

operating= operating= ¼ or 25% AT LEAST & ¼ or 25% AT LEAST &

DOESN’T INCLUDE 10 DOESN’T INCLUDE 10 WEEKS LEAVE!!!WEEKS LEAVE!!!

Impact on trainingImpact on training

19931993 30,000 hours30,000 hours

20042004 8000 hours8000 hours

Near futureNear future 6000 hours6000 hours

Equates to 25-30% reduction in elective Equates to 25-30% reduction in elective operatingoperating

Improvement in quality of trainingImprovement in quality of training

Reduced standardsReduced standards

US stand:US stand:

The American College of Surgeons The American College of Surgeons published an official statement of its views published an official statement of its views on resident work hours (Public health law: on resident work hours (Public health law: < 80 hours/ week!)< 80 hours/ week!)

““It is illogicalIt is illogical to make specific time-work to make specific time-work recommendations without considering the recommendations without considering the effect on education”effect on education”

Awake & Informed NEJM 2004; Awake & Informed NEJM 2004; 351: 1829-37351: 1829-37

• Brigham & Womens ICUBrigham & Womens ICU• Split shift with 4Split shift with 4thth intern intern• 193 vs 158 serious 193 vs 158 serious

medical errors/1000 pt medical errors/1000 pt daysdays

• 1 serious, preventable 1 serious, preventable event every 3-4 weeksevent every 3-4 weeks

• It is not just about It is not just about reducing hours, you need reducing hours, you need to know your patientsto know your patients

““Decreased total working hours does Decreased total working hours does not equate with decreased fatigue not equate with decreased fatigue

levels and does not improve patient levels and does not improve patient care”care”

• Police & accidents 5

• Pilots and fatigue related entirely to shift design 6

• Shifts should be 8 hours long, flexible, and no more than 4 consecutive duties

• Opt out• Allow non-resident on-call working

5 S.Garbarino 1999 Intl synposium on Night & Shiftwork6 S Bourgeois-Bougrine 1999 “ “ “

LiabilityLiability• Health & Safety legislation makes managers Health & Safety legislation makes managers

personally liable for employees harmed by personally liable for employees harmed by the way they workthe way they work

• In Public sector shifts are often devised by In Public sector shifts are often devised by low level management with NO resource low level management with NO resource management trainingmanagement training

• ““Anyone responsible for resourcing shifts Anyone responsible for resourcing shifts needs to be aware of principles of good needs to be aware of principles of good practice and advances in the field of practice and advances in the field of chronobiology, shift work and fatigue studies” chronobiology, shift work and fatigue studies” 88

8 Fatigue & Anaesthetists www.aagbi.org

Shifts are bad forShifts are bad for

• HealthHealth

• FamilyFamily

• Work-life balanceWork-life balance

• Patient carePatient care

• TRAININGTRAINING

• TRAININGTRAINING

• TRAININGTRAINING