1

Learning Objectives

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

2. Describe the impact of sleep loss on residents’ personal and professional lives, and on resident and patient safety.p y

3. Recognize signs of sleepiness and fatigue in yourself and others.

4. Challenge common misconceptions among physicians about sleep and sleep loss.

5. Adapt alertness management tools and strategies for yourself and your program.

2

The Scope of the Problem

“How do you brainwash someone? You sleep deprive them. You feed them bad food and you repeat things over andand you repeat things over and over again. It’s like that kind of

covers residency.”y

Papp et al, Academic Medicine, 2002

3

Sleepiness in Residents

17.50

20.00

Sleepiness in residents is

equivalent to that11.70

14.7015.00S

core

equivalent to that found in patients

with serious sleep disorders. 5.90

10.00

Epw

orth

S

2.20

0.00

5.00

Papp et al, Academic Medicine, 2002Mustafa et al, Sleep and Breathing, 2005

0.00

Normal Insomnia Sleep Apnea Residents Narcolepsy

4

Sleep Loss and Fatigue –Add i th IAddressing the Issue

So why is the problem ofproblem of

sleepiness and fatigue in residency

underestimated?

5

Cultural Norms and Sleep Need

The culture of medicine says:

• Sleep is “optional” (and you’re a wimp if you need it)

• Less sleep = more dedicated doctor

Perception that reducing work hours

• Compromises patient care p p

• Reduces educational opportunity

• Increases “scut” work• Increases scut work

6

What Causes Sleepiness?

7

Physiologic Factors that Cause Sleepiness

Myth: “It’s the really boring f th t tnoon conferences that put me

to sleep.”

F t E i t l f tFact: Environmental factors (passive learning situation, room temperature, low lightroom temperature, low light level, etc) may unmask but DO NOT CAUSE SLEEPINESS.

8

Conceptual Framework (in Residency)

Fragmented Sleep( h ll )

Insufficient Sleep(on call sleep loss; (pager, phone calls)( p ;

inadequate recovery sleep)

EXCESSIVE EXCESSIVE DAYTIME DAYTIME

SLEEPINESSSLEEPINESS

PrimarySleep Disorders

Circadian Rhythm Disruption

(sleep apnea, etc)(night float, rotating shifts)

9

Sleep Needed vs. Sleep Obtained

Myth: “Like a lot of residents, I only need five hours of sleep so none of this applies to us ”sleep, so none of this applies to us.

Fact: Sleep loss is cumulative; getting less than eight hours of sleep starts to create a “sleep debt” which must p pbe paid off.Fact: The effects of sleep loss on attention and working memory become evident when individuals are limited to six hours of sleep per night**Van Dongen et al Sleep 2003Van Dongen et al, Sleep, 2003

10

Sleep Deprivation Decreases Attention16

14total sleep deprivation

4 hours nightly12

10

apse

s

g y

6 hours nightly

8 hours nightly

8

6

Atte

ntio

n l

4

2

0

A

BL 4 8 12

0

6 10 142

Days of sleep deprivation Van Dongen et al, Sleep, 2003

11

Reducing the Impact of Sleep Loss

Avoid starting out with a sleep deficit!g p– Even during light or no call rotations, residents do not

obtain adequate sleep (average 6.38 hrs)*

*Arnedt, JAMA, 2005

12

Adaptation to Sleep Loss

Myth: “I’ve learned not to need as much sleep during my residency.”

Fact: Sleep needs are genetically determined and cannot be changed.

F t H b i d t “ d t” t tti lFact: Human beings do not “adapt” to getting less sleep than they need.*

Fact: Although performance of tasks may improveFact: Although performance of tasks may improve somewhat with effort, optimal performance and consistency of performance do not! (e.g., post-call performance on a neurocognitive battery does not differperformance on a neurocognitive battery does not differ by training year)

*Arnedt JAMA 2005

13

Arnedt, JAMA, 2005

Sleep Fragmentation Affects Sleep Quality

NORMAL SLEEPNORMAL SLEEP

= Paged

ON CALL SLEEPON CALL SLEEP

Morning Rounds

14

How the Circadian Clock Impacts You

Fact: It is easier to stay up l t th t t t f ll llater than to try to fall asleep earlier.

F t It i i t d t tFact: It is easier to adapt to shifts in forward (clockwise) direction (day ⇒ evening ⇒night).

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

15

Physiologic Determinants of Sleepiness

Normal SleepinessSleep Drive

SLEEPWORKWake Propensity SLEEPWORK

Circadian Drive for Wakefulness

3 pm 9 pm 3 am 9 am

AsleepAwake

9 am

Adapted from: Kryger MH, et al. Principles and

Practices of Sleep Medicine.

16

p2000.

Consequences of Sleep Deprivation

Driving SafetyDriving Safety

Patient Care Patient Care ProfessionalismProfessionalismWorkplaceWorkplace

LearningLearningMood & Mood & PerformancePerformance

Sleep Deprived Sleep Deprived ResidentResident

Health &Health &Family Family

PerformancePerformance

WellWell--beingbeingRelationshipsRelationships

17

Impact on Professionalism

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

between you and a few hours of sleep.”Papp et al, Academic Medicine, 2002

18

Residents Averaging Less Than Five H f Sl Ni htHours of Sleep per Night

W i ifi tl lik l t t Odd R tiWere significantly more likely to report:

1.91Use of medication to stay awake

2.02Involvement in a malpractice suit

Odds Ratio

1 4M ki i di l

1.84Accidents/injuries

1.86Serious conflict with other residents

1.52Increased use of alcohol

1.59Noticeable weight change

1.74Making a serious medical error

Baldwin & Daugherty Sleep 2004

1.47Serious conflict with nursing staff

19

Baldwin & Daugherty, Sleep, 2004

Average Hours of Sleep per Night I t R id E iImpacts Residency Experience

6 3

5

atin

gs

As Nightly Sleep Increases:

• Satisfaction with

4

Res

iden

ts' R

a

2residency increases• Stress rating decreases• Sense of being

3<4 4-5 5-6 6-7 7-8

Average Reported Daily Sleep

1

Sense of being “impaired” decreases• Reports of feeling “belittled or humiliated” decreaseAverage Reported Daily Sleep

Stress Rating Learning Impairment, Self Belittle/Humiliate

decrease

Baldwin & Daugherty, Sleep, 2004

20

Impact on Patient and Personal Health and Safety

21

Resident Performance and Fatigue

• Meta-analysis of 20 studies involving residents– 24 hour sleep deprivation associated with significant24 hour sleep deprivation associated with significant

decline in:• Vigilance

M• Memory• Cognitive performance• Clinical performancep

– Magnitude of performance decline • Almost one SD overall• More than 1 5 SD on clinical tasks• More than 1.5 SD on clinical tasks

Philibert I. Sleep, 2005

22

Resident Self-reported Errors by il f lAverage Daily Hours of Sleep

4545

34.6

26 730

35

40

45

ng E

rror

s ErrorsReported

Adverse26.7

22.4 21

15

20

25

30

ge R

epor

tin Events

10.7

5.7 4.8 3.8 3.7

0

5

10

15

Perc

enta

g

Baldwin & Daugherty Sleep 2004

0Less than 4 4 to 5 5 to 6 6 to 7 7 to 8

Hours of Sleep

23

Baldwin & Daugherty, Sleep, 2004

Sleep Deprivation & Errors in Detection of Cardiac Arrhythmias on ECGCardiac Arrhythmias on ECG

Medical Interns Rested Sleep DeprivedMedical Interns Rested Sleep Deprived

Sleep Amount in Prior 32 h 7.0 h (5.5 – 8.5 h) 1.8 h (0 – 3.8 h)*p ( ) ( )

E ECG S t i dErrors on ECG Sustained Attention Task 5.21 + 0.93 9.64 + 1.41*

*p<.0001Friedman et al., N Engl J Med 1971

24

Impaired Speed and Errors in Performance: Laparoscopic Surgical Performance: Laparoscopic Surgical

SimulatorPre and post 17-hour overnight call duty in a surgical department p g y g p

(median reported sleep time 1.5 h; range 0-3 h)

Grantcharov TP et al, BMJ, 2001

25

Residency Specific Data

• Surgery: 20% more errors and 14% more time required to perform simulated laparoscopy post-callrequired to perform simulated laparoscopy post call (two studies)Taffinder et al, Lancet, 1998; Grantcharov et al, BMJ, 2001

• Internal Medicine: efficiency and accuracy of ECG interpretation impaired in sleep-deprived internsLingenfelser et al Med Educ 1994Lingenfelser et al, Med Educ, 1994

• Pediatrics: time required to place an intra-arterial line increased significantly in sleep-deprivedincreased significantly in sleep-deprivedStorer et al, Acad Med, 19891

26

Residency Specific Data

• Emergency Medicine: significant reductions in h i f hi t & h i lcomprehensiveness of history & physical exam

documentation in second-year residents Bertram N Y State J Med 1988

• Family Medicine: scores achieved on the ABFM practice in-training exam negatively correlated with p g g ypre-test sleep amounts Jacques et al J Fam Pract 1990

27

Intern Sleep and Patient Safety Study•Randomized trial comparing interns’ alertness and performance on traditional “q3” schedule with 24-30 hour shifts (ACGME-compliant) vs. 16 hr max schedule

•Results: Twice as many EEG-documented attentional failures at night on

0 7

0.8Traditional

Results: Twice as many EEG documented attentional failures at night on traditional schedule

Between Groups p=0.02

0.4

0.5

0.6

0.7 "q3" 24-30hour shifts

I t tifailu

res

from

H

our o

n D

uty

0.1

0.2

0.3InterventionSchedule -<16 hourscheduledshiftsof

atte

ntio

nal f

m –

7am

per

H

0

Attentional Failures at NightNo.

o11

pm

Lockley et al. N Engl J Med 2004

28

y g

Results: 36% more serious errors on traditional schedule including five times asIntern Sleep and Patient Safety Study

Results: 36% more serious errors on traditional schedule, including five times as many serious diagnostic errors

120

140

160

Traditional "q3"24-30 hour shifts

p < 0.001

p = 0.03

ys

60

80

100

InterventionSchedule - <16hour scheduled0 001er

100

0 pt

da

0

20

40

Serious Serious Serious

hour scheduledshifts

p < 0.001

Err

ors

pe

SeriousMedical Errors

- Total

SeriousMedication

Error

SeriousDiagnostic

Error

Landrigan et al N Engl J Med 2004

29

Landrigan et al. N Engl J Med 2004

Specialties Most Likely to Report Experiences of Sleep DeprivationExperiences of Sleep Deprivation

1 Neurosurgery 4 061. Neurosurgery 4.06 2. General Surgery 3.653 Orthopedic Surgery 3 173. Orthopedic Surgery 3.174. Neurology 3.165 OB/Gyn 3 105. OB/Gyn 3.106. Pediatrics 3.01

Sleep deprivation scale:Sleep deprivation scale: 1=“Never”; 5=“Almost daily”

Baldwin & Daugherty, Sleep, 2004

30

Drowsy Driving: Effects of Sleep Deprivation on Effects of Sleep Deprivation on

Physician Safety

31

Harvard Work Hours, Health, and Safety Study MethodsSafety Study – Methods

• National survey: To objectively quantify the work schedulesNational survey: To objectively quantify the work schedules experienced by house staff, and determine if increased hours are associated with increased risk of house staff injury– Study of a national sample of house staffy p

• 1,417 person-years monthly survey data collected from 2,737 interns nationwide in 2002-2003

– Monthly surveys– Work hours, crashes, and injuries– Correlation of work hours and motor vehicle crashes

Barger, L. K. et al. N Engl J Med 2005

32

g , g

Harvard Work Hours, Health, and Safety Study ResultsSafety Study – Results

• For each extended duration work shift scheduled per month interns had:

8 8 % (3 2% 14 4%) increased monthly risk of any– 8.8 % (3.2%-14.4%) increased monthly risk of any motor vehicle crash

– 16% (7.6%, 24.4%) increased monthly risk of a motor hi l h th t f kvehicle crash on the commute from work

Barger, L. K. et al. N Engl J Med 2005

33

g , g

Harvard Work Hours, Health, and Safety Study:Motor Vehicle Crash Risk in Interns on Commute Motor Vehicle Crash Risk in Interns on Commute

Home from HospitalExtended shifts (>24 hours) Non-extended shfits (<24 hours)

1

1.2

OR: 2 3 p<0 001

0.6

0.8OR: 2.3, p<0.001

0.2

0.4

0Crashes per 1000 commutes from the hospital

Barger, L. K. et al. N Engl J Med 2005

34

g , g

Driving Simulator

7

8

Lane Variability (ft) Speed Variability (mph)

5

6

7

an

Condition effects:P < 0.001

2

3

4

Mea No effect of sex or

training year

0

1

Light Call Light Call withAl h l

Heavy Call Heavy Call withPl bAlcohol Placebo

Performance Task

Arnedt et al JAMA 2005

35

Arnedt et al. JAMA 2005

Potential Legal Implications for House S ff d H i lStaff and Hospitals

• In New Jersey “driving after having been without sleep for• In New Jersey, driving after having been without sleep for a period in excess of 24 consecutive hours” now explicitly considered reckless

• Laws pending in several other states to make drowsy driving a felonyS l “hi h fil ” i t h it l• Several “high profile” cases in courts accuse hospitals responsible for fatigue-related crashes even after staff have left

36

Recognize Signs of Driving While Drowsy

• Trouble focusing on the roadg• Difficulty keeping your eyes open • Nodding• Yawning repeatedly • Drifting from your lane, missing signs or exits • Not remembering driving the last few miles• Closing your eyes at stoplights

37

Risk Factors for Drowsy Driving• Driving long distances without breaks• Driving alone or on a boring road• Driving at high risk times of day

350400450

s• Driving at high risk times of day

150200250300350

mbe

r of C

rash

e

050

100Num

0:00 3:00 6:00 9:00 12:00 15:00 18:00 21:00Time of DayTime of Day

Driving home post-callPack et al Accid Anal Prev 1995

38

Drowsy Driving: What Does and Does Not WorkWhat Does and Does Not Work

• What works:AVOID driving if drowsy

• What doesn’t work:Turning up the radio– AVOID driving if drowsy.

– If you are really sleepy, get a ride home, take a taxi, or use public transportation.

– Turning up the radio– Opening the car window– Chewing gum

Blowing cold air (water) onp p– Take a 20 minute nap

and/or drink a cup of coffee before going home post-

ll 20 i t

– Blowing cold air (water) on your face

– Slapping (pinching) yourself hardcall 20 minute recovery

time.– Stop driving if you notice

the warning signs of

you se a d– Promising yourself a

reward for staying awake

the warning signs of sleepiness.

– Pull off the road at a safe place, take a short nap.

39

p p

Impact on Medical Education

“We all know that you ystop learning after 12 or 13 or 14 hours. You

don’t learn anythingdon t learn anything except how to cut

corners and how to survive.”

Papp et al, Academic Medicine, 2002

40

pp , ,

Increasing Sleep Time Improves Learning during ResidencyLearning during Residency

A Ni htl Sl IAs Nightly Sleep Increases:

• Satisfaction with learning increases5

6

atin

gs 3

4

• Satisfaction with time with attending increases

• Satisfaction with quality of time with

4

Res

iden

ts' R

a

2

q yattending increases

• Working without adequate supervision decreases

3<4 4-5 5-6 6-7 7-8

Average Reported Daily Sleep

1

Learning Contact w ith Attending

Quality of time w ith Attending W/out adequate Supervision

Baldwin & Daugherty Sleep 2004

41

Baldwin & Daugherty, Sleep, 2004

Impact on Medical Educationp

Myth: “If I’m not on call as much I’ll learnMyth: If I m not on call as much, I ll learn less.”Fact: Study of surgical residents showedFact: Study of surgical residents showed more frequent call is associated with less participation in operative procedures*Fact: Satisfaction with learning in residency is negatively correlated with average hours

*Sawyer et al, Surgery 1999 **Baldwin et al, Soc Sci Med, 1997

of sleep**

42

, ,

Bottom Line

You need to be alert to takeYou need to be alert to takethe best possible care of your patients andy p

yourself.

43

Recognizing Sleepiness in Recognizing Sleepiness in Yourself and Others

44

Estimating Sleepiness

Myth: “I can tell how tired I am and I know when I’m not functioning up to par.”gFact: Almost 50% of the time they had actually fallen asleep, anesthesia residents did not perceive themselves to be asleep*.Fact: The sleepier you are, the less accurateyour perception of degree of impairment. Fact: You can fall asleep briefly (“ i l ”) ith t k i it!(“microsleeps”) without knowing it!

*Howard et al Academic Med, 2002

45

Microsleeps U i t ti l i d f l t i ll b t• Unintentional episodes of sleep, typically between 5-to-14 seconds in duration

C Sl d bt l d i ti• Cause: Sleep debt, sleep deprivation.

• Behavioral Correlates: Head nods, drooping lideyelids.

• Subjective “unawareness” or “spacing out” tisensation

• Extremely dangerous in situations when continual l t i d d d (d i i ti )alertness is demanded (driving, operating).

Harrison, Y., and Horne, J. A. EEG Clin Neurophysiol, 1996 Risser, M. R., Ware, J. C., and Freeman, F. G. Sleep, 2000

46

, , , , , p,

The Effects of Sleep Loss are Cumulative

Psychomotor vigilance task

(PVT)(PVT) performance

during baseline (B), sleep

restriction (P) and recovery (R)

Dinges et al, SLEEP, 1997

47

Impact of Continued Wakefulness

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

Fact: Performance declines rapidly after about 15-16 hours of continued wakefulness.

Fact: The period of lowest alertness after being up all night is between 6 a m and 11night is between 6 a.m. and 11 a.m. (e.g., morning rounds).

48

Recognize the Warning Signs ofSl iSleepiness

• Falling asleep in conferences or on roundsFalling asleep in conferences or on rounds• Feeling restless and irritable with staff,

colleagues, family, and friends co eagues, a y, a d e ds• Having to check your work repeatedly • Having difficulty focusing on the care of yourHaving difficulty focusing on the care of your

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

49

Alertness Management Strategies

50

Napping Strategies

Myth: “I’d rather just “power through”Myth: I d rather just power through when I’m tired besides, even when I can nap, it just makes me feel worse.”p, jFact: Some sleep is always better than no sleep.pFact: At what time and for how longyou sleep are key to getting the most out of napping.

51

Sleep Inertia

• State of impaired cognition, grogginess,State of impaired cognition, grogginess, disorientation experienced upon waking from sleep– Increased if awakened from slow wave sleep

• Studies suggest severe cognitive impairments lasting up to 10 minutes after awakening*

Worse than performance after 26 hr sleep deprivation– Worse than performance after 26 hr sleep deprivation– Residual effects up to two hours

*Wertz, JAMA, 2006Tassi and Muzet, Sleep Med Rev, 2000

52

Cognitive Performance on Awakening From Sleep Compared with Subsequent Sleep Sleep Compared with Subsequent Sleep

Deprivation

Wertz et al, JAMA, 2006

53

Napping

Pros: Temporarily improve alertness. Types: Preventative (pre-call), operational (on the job)yp (p ), p ( j )Length: Short naps should be no longer than 30 minutes to

avoid sleep inertia*Timing: Take advantage of circadian “windows of

opportunity” (2-5 am and 2-5 pm)

*Note: individuals who are sleep-deprived may go into deep sleep sooner and thus may be more likely to experience sleep inertia

*Tietzel A, Lack L. SLEEP 2001

54

Recovery from Sleep Loss

Myth: “All I need is my usual five to six y yhours the night after call and I’m fine.”Fact: Recovery from on-call sleep loss generally takes at least two nights of extended sleep to restore baseline

l talertness.

55

Recovery Sleep and Attention

Belenky et al, J. Sleep Research, 2003

56

Belenky et al, J. Sleep Research, 2003

Caffeine

• Reduces some sleep-related deficits at doses of 75-150 mg

• Strategic consumption is key• Effects within 15 – 30 minutes; half-life 3 to 7 hours

U f t li f f l i• Use for temporary relief of sleepiness• Cons:

Can disrupt subsequent sleep (more arousals)– Can disrupt subsequent sleep (more arousals)– Tolerance may develop – Diuretic effectsDiuretic effects

*Bonnet et al SLEEP 2005

57

Bonnet et al SLEEP 2005

Caffeine Content

Product Serving Size Caffeine (mg)Cola 8 oz 30 45Cola 8 oz 30 -- 45

Tea 8 oz 10 – 70

Orange soda 8 oz 0 – 40gMountain Dew 8 oz 57

Red Bull 330 ml 80

Drip Coffee 7 oz 110 – 175

Starbucks Grande 16 oz 260

No-Doze 1 tab 100No Doze 1 tab 100

Vivarin 1 tab 200

58

Healthy Sleep Habits

• Realize that circadian rhythms and sleep needs are non-negotiableg

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

• Develop a pre-sleep routine.• Use relaxation to help you fall asleep.• Protect your sleep time; enlist your family and

friends!• Get 7 9 hours before anticipated sleep loss• Get 7 - 9 hours before anticipated sleep loss

59

Healthy Sleep Habits

• Sleeping environment: – Cooler temperature– Dark (eye shades, room darkening shades)– Quiet (unplug phone, turn off pager, use ear plugs, white noise

machine))• Avoid going to bed hungry, but no heavy meals within

three hours of sleep. • Get regular exercise but avoid heavy exercise within• Get regular exercise, but avoid heavy exercise within

three hours of sleep.• Avoid using alcohol to help you fall asleep; it induces

sleep onset but disrupts sleep later on

60

Residents Report Using:

Melatonin: minimal effect in ER resident studiesA h t i /MPH* i h tAmphetamines/MPH*: can improve psychomotor performance and promote subjective alertness at 10-20 mg; adverse effects sleep, CV and metabolic/ neuroendocrine p,measures, high abuse potentialModafinil (Provigil)*: Variable improvement performance, l t d t d 100 400 lt ialertness, mood at doses 100-400mg; may result in

subjective “overconfidence,” disrupted sleep

*Bonnet et al SLEEP 2005

61

Operational Measures to Reduce Fatigue

62

ACGME Common Standards for R id D H ( )Resident Duty Hours (2003)

• 80 hour limit/week, averaged over four weeks, g• One day in seven off• Adequate rest (10 hours) between duty periods• In-house call no more than every 3rd night• 24 hour limit on continuous duty (+ up to six hours) for

t f ftransfer of care • Moonlighting must be approved by the program

directordirector

63

Work Hour Limits for Physicians in Other C t iCountries

• European Working Time Directive (law which applies to practicing physicians & residents in all EU countries)

– Maximum of 48-56 hours per week and 13 consecutiveMaximum of 48 56 hours per week and 13 consecutive hours

• New Zealand Employer - Resident Contract– Maximum 72 hours weekly and 16 consecutive hours

64

Work Hour Limits for Other Occupations in the U SOccupations in the U.S.

• Truckers: maximum 11h continuous driving

• Pilots: maximum 8h per 24 flying domestic24 flying domestic routes

• Nuclear Power plant pworkers: maximum 12h shiftT i i• Train engineers: maximum 12h shift

65

Adapting to Night Shifts

Myth: “I get used to night shifts right away; no problem ”problem.Fact: It takes at least a week for circadian rhythms and sleep patterns to adjust.and sleep patterns to adjust.Fact: Adjustment often includes physical and mental symptoms (think jet lag). Fact: Direction of shift rotation affects adaptation (forward/clockwise easier to adapt).

66

How to Survive Night Float

• Protect your sleep.• Nap before work. • Consider “splitting” sleep into two four hour

periodsperiods.• Have as much exposure to bright light as

possible when you need to be alertpossible when you need to be alert.• If you want to go home and sleep, avoid light

exposure in the morning after night shift (be coolexposure in the morning after night shift (be cool and wear dark glasses driving home from work).

67

Morning Shifts

• Reduction in nocturnal sleep by two to four hours

• Anticipation of difficulty in morning waking results in reduced SWSreduced SWS

• Day shifts starting before 7 a.m. more problematic (coincides with circadian nadir of alertness)

68

Aviation Standards to Reduce Shift W k F tiWork Fatigue

• Allow adequate rest time between shifts (not < 12 hrs; f bl > 16 h )preferably > 16 hrs).

• Avoid more than three successive shifts in rotatingAvoid more than three successive shifts in rotating systems, rotate clockwise.

Ni h hif h ld b l d h d f hif l• Night shifts should be placed at the end of a shift cycle; duration not more than eight hours.

• Allow planned “cockpit” nap (30 min) during first night float shift.

69

“The Best Laid Plans…”

Study: Impact of night float coverage (2 a.m. to 6 a.m.))

Results: “protected” interns slept less than controls; used time to catch up on work, not sleep; thus there was no improvement in

fperformance

B tt li Sl h !Bottom line: Sleep when you can!

Richardson et al, SLEEP, 1996

70

, ,

Schedule Design Principles

Provide relief for residents: • Reduce hours and/or workload

– Limit consecutive work hours to < 16 when possible• Minimize risk-prone situations

M i t i t iti f d ti• Maintain opportunities for education • Support resident well-being• Create shared responsibility for fatigue managementCreate shared responsibility for fatigue management

and a “culture of support” in the training program.• Focus on making things better rather than amplifying

past problemspast problems.

71

Reducing Hours or Workload -ExamplesExamples

• Floats: not limited to nighttime; should include explicit educational componenteducational component

• Shifts: can stagger team or team member start times or admission times; can provide for designated sleep breaksbreaks

• Caps: call in float when it appears recommended cap will be exceededPh i i t d d th kl d t i t i• Physician extenders: spread the workload to maintain resident education and morale and provide sleep breaks

• Rethinking the care of the patient: not “my patient” or “your patient,” but the team’s patients. Integrating all of the work, learning, and caring minimizes the impact of any one resident’s day off

72

y y

Some Potential Pitfalls Regarding Mi t k Ed ti d M lMistakes, Education, and Morale

Common Sensible Solutions Overall BenefitsComplaints Sensible Solutions Overall Benefits

Hand-offs lead to mistakes; cross-coverage means no

Improve communication •More minds understand patient’s problems•All hand-offs and coverage will improve, a needed skill for practiceone knows the

patientneeded skill for practice

Night shifts have no educational value

Attending can round one on one with the night float before the rest of the team; night float

•Float gets individualized educational opportunity•Float gets to know a team’s patients in depth, aiding with future cross coverage; g

can be structured to allow float to stay for rounds with one team and conferences at least every other day

aiding with future cross-coverage•Float has social interaction with other residents on team and in conferences

Night float causes Structure floats so that people •Float time may increase overall (e g q2 scheduleNight float causes poor morale

Structure floats so that people can see their families and friends

•Float time may increase overall (e.g. q2 schedule for two weeks instead of q1 for one week) but be more pleasant, especially when combined with greater education opportunity (just remember to maintain a consistent sleep routine)

73

Minimizing Risk-prone Situations

• High-risk procedures (e.g. central lines): g p ( g )Done by incoming team. Residents’ procedure logs should fill at same rate over the course of the rotationthe course of the rotation

• Drowsy driving: Provide cab vouchers orDrowsy driving: Provide cab vouchers or reimbursements

74

Maintaining Opportunities for Education Education

• Conferences:Schedule at times where floats can attend also– Schedule at times where floats can attend also

– Videotape so residents can watch when more alert– Distribute handouts; reinforce messages on rounds

• Achieving competency: education is about learning how to do• Achieving competency: education is about learning how to do something right; not the number of times it is done.– Maintain a curriculum to ensure all material is covered and available in

multiple learning formats (formal didactic conferences, rounds, journal p g ( jreading, etc.)

– Use simulators and computerized resources• Attending time:

– Incorporate into every rotation, including floats– Provide advisors as resource to oversee resident progress and facilitate

getting any needed experiences

75

Supporting Resident Well-being

• Schedule rotations so that residents have adequate time to sleep and see family/friends

• Check-in with residents through advisors, surveys, and attending interaction to assess adequacy of schedules and any associations with mood and morale

• Monitor depression and burnout rates– Resident depression has been associated with chronic sleep

deprivation and increased from 4% to 30% over one year (Rosen, p y (et al, Acad Med, 2006)

– Up to ¾ of residents report burnout symptoms, with positive associations with increased workload and work hours (Thomas, JAMA 2004)JAMA, 2004)

76

In Summary…

• Fatigue is an impairment like alcohol or drugs.

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

• Recognition of sleepiness and fatigue and use of alertness management strategies are simple ways to g g p yhelp combat sleepiness in residency.

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

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“P ti t h i ht t t “Patients have a right to expect a healthy, alert, responsible, and y, , p ,

responsive physician.”

January 1994 statement by American College of Surgeons Re-approved and re-issued June 2002pp

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American Academy of Sleep Medicine

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