fatigue implications for the medical profession eleanor m. duduch m.d. program director...

FatigueImplications for the Medical

Profession

Eleanor M. Duduch M.D.

Program Director

Anesthesiology Residency Program

University of Massachusetts Medical School

Why So Much Concern in Medicine About Being Sleepy?

Significant increase in sleep research and

outcome studies in recent years Negative outcomes secondary to fatigue are so well documented that industry has led the way in developing sleep regulations - Military - Maritime - Trucking - Aviation Where’s Medicine?

History of the Problem 1986 Libby Zion vs. New York State

18 yr. old with recent hx cocaine and MAOI use admitted to New York Hospital with agitation and temp 103 medical team consisted of a PGY-1 (18 hrs awake) & PGY-

2 (19 hrs. awake), with little attending involvement rigors treated with 25 mg. Demerol died next a.m. with seizures and temp 108 11 year trial, split verdict (cocaine & negligence both

factors) Jury claimed fatigue, inexperience and lack of supervision

as contributing factors toward claim of negligence

……Rapid Response…..

1987 Bell Commission A blue ribbon panel responsible for work hour recommendations in

New York that eventually became the “405 Regulation”

1989 NY State 405 regulation instituted Largely ignored for first 10 years; financial penalties instituted

and ignored as well

1999 Institute of Medicine published a patient safety report “To Err Is Human: Building a Safer Health System”, revealing that

medical errors contribute to many hospital deaths and adverse events

2000 Presidential Task Force developed to address the issue

….Rapid Response…

2001 OSHA was petitioned by Public Citizen group to implement new regulations on resident work hours This brought the issue to national prominence

2001 Patient and Physician Safety and Protection Act HR3236 was introduced in Congress

2002 ACGME quickly proposed their own standards

2003 Standards approved

July 1, 2003 Compliance required

ACGME STANDARDS

80 hours maximum/week 24 hours max per shift; add’l 6 hours for

education and transfer of care 1 day in 7 free of patient care responsibilities In-house call q 3 nights averaged 10 hour minimum rest period

ACGME STANDARDS

In order to provide high quality education & effective patient care, residency programs must:

Recognize & monitor residents for signs of fatigue

Apply preventive & operational countermeasures

Make clinical assignments that recognize a collective responsibility to patient care

The Extent of the Problem

2002 Multi-center Survey of Medical Residents vs. Patients @ Cleveland VA Sleep Disorders Clinic Self-reporting survey re: likelihood of dozing Results recorded on Epworth Sleepiness Scale 8 items, scored 0-3 scale, with 24 as highest possible score Results: Sleepiness in residents is equivalent to

that found in patients with serious sleep disorders

© American Academy of Sleep Medicine

American Academy of Sleep Medicine

Epworth Sleepiness Scale

Sleepiness in residents is equivalent to that found in patients with serious sleep disorders. Mustafa and Strohl, unpublished data. Papp, 2002

The Potential Impact of Sleep Loss & Fatigue Is Underestimated

In general there is a lack of knowledge about the biology of sleep, particularly by physicians

Signs of sleepiness are often unrecognized by the individuals or observers

There is no drug test to evaluate fatigue level The culture of medicine

“sleep is optional (and you’re a wimp if you need it)” “less sleep = more dedication”

MYTHS ABOUT FATIGUE FALSE: “As long as I’m awake, I’m OK to work”

TRUE: Being “awake” does not mean that your cognitive performance, judgment or reaction time is not affected by lack of sleep. Performance starts to decline after 15-16 hours of continued alertness.

FALSE: “I’m still OK to drive home after 24…30 hours on call”

TRUE: The period of most limited attention span after being awake for 24 hours is between 6 a.m. and 11 a.m.

FALSE: “I can learn to get by on less sleep”

TRUE: You cannot change how much sleep you need. It is a physiologic need, genetically determined

FALSE: “A good nights’ sleep and I’ll be fine”

TRUE: Recovery of sleep debt developed over a 24 hour call period without sleep can take 2 full nights’ sleep to get back to baseline

FALSE “I can tell when I’m too tired to work”

TRUE: Many studies have shown that individuals have little insight into their level of sleepiness. The more tired you are, the less accurate is your perception of how sleepy you really are!

Anesthesia Resident Study Daytime sleepiness was assessed in 11 residents using the

Multiple Sleep Latency Test

Daytime sleepiness was assessed in the baseline, post-24 hour call, and extended sleep (they were allowed to sleep as long as they needed x 4 days) conditions via polysomnography, EEG, EMG,EOG

Results: Residents’ daytime sleepiness in base-line and post-call conditions was near or below levels associated with sleep disorders. Extending sleep time resulted in normal levels of sleepiness.

Residents did not perceive themselves to be asleep 49% of the time there was physiologic sleep identified by EEG

Residents were wrong 76% of the time when they reported having stayed awake

Howard et al, Acad Med 2002; 77(10):1019-1025

SO HOW DO I KNOW WHEN I’M NOT GETTING ENOUGH SLEEP??

You and/or others notice your work performance is not up to your previous standards

You find yourself “nodding off” to sleep during lectures, breaks, lunch etc.

You become less efficient in your work routine, taking longer to accomplish the same tasks

You have trouble focusing It is difficult to become motivated You became more impatient with patients, friends, family

members and colleagues

Wakefulness and Sleep

The key determinant that underlies fatigue is the interaction of sleep homeostasis and circadian rhythm

Homeostatic sleep drive regulates the length and depth of sleep

Endogenous circadian rhythms influence timing and duration of daily sleep/wake cycles

Influence of external and internal stimuli Workload, stress, boredom, motivation, environment all effect

sleep. It is important to note that environmental factors can unmask fatigue (a warm/dark room, boring lecture, uninteresting topic), but do not cause sleepiness.

Optimal performance = adequate sleep + circadian wakefulness

In Other Words…..Sleep Is Not Negotiable!

It is a physiologic drive…….

Q. What is “Adequate” Sleep?

Balance between

sleep quantity

and

sleep quality

HOW MUCH SLEEP IS ENOUGH??

MYTH

“I’m one of those people who don’t need much sleep”

FACTS Avg. sleep need for optimal performance is 8hrs.14min Individual variance is from 6-10 hours Individuals have varying tolerance to effects of sleep loss….BUT

self-assessment of sleepiness has been proven to be inaccurate Acute sleep deprivation: 0-4 hrs sleep in 24 hours Chronic sleep deprivation: repetitive sleep cycles of <7-8 hrs./day. <5 hrs of sleep increases sleep drive and propensity to sleep, with

associated decline in cognitive performance. Creation of “sleep debt”

SLEEP DEBT

Definition: The accumulation of ‘lost sleep’ ‘Lost sleep’ averages 1-1.5hrs/night for most individuals Sleep debt is not repaid hour for hour

Example: 1.5 hrs. less sleep/night x 5 nights=

7.5 hrs. of sleep debt requiring (2) 8hr sleep

periods

WHAT MAKES A GOOD NIGHT’S SLEEP??

Non-REM sleep (75-80%) (low brain activity) Stage 1 @ sleep-wake transition “light” Stage 2 “true” sleep Stages 3 & 4 “deep” or “delta” sleep

• Highest arousal threshold-most difficult to awaken

• Most restorative

REM sleep (20-25%;4-6 episodes/night) Nearly absent muscle tone except respiration High levels of cortical activity- dreaming, irregular respiratory

and heart rates

FRAGMENTED SLEEP Interferes with a good night’s sleep Most common in those age > 50 years Sleep Disorders

Obstructive sleep apnea Restless leg syndrome Insomnia

• Learned/conditioned• Medication induced

Alcohol REM suppressant first half of night Rebound REM as ETOH concentration decreases, with

increased awakenings & decrease in total sleep time External stimuli – pagers, phone call, anticipation,

etc.



Sleep Fragmentation

= Paged

NORMAL SLEEP

ON CALL SLEEP

MORNING ROUNDS

The Circadian Factor Suprachiasmatic nucleus (SCN) of hypothalamus

Sets the biological clock to 24.18 hours• Easier to stay up late than go to sleep early

Controls body temperature cycles ↑ during day, ↓ at night Uses light as synchronizer via retino-hypothalamic pathway Melatonin as complementary synchronizer of SCN

• Secreted at night by pineal gland• Suppressed by light

Controls physiologic, behavioral & mood functions• 24 hr. sleep-wake pattern• Daily digestive activity, BP changes, renal function• Hormone secretion – prolactin, testosterone, GH

The Circadian FactorCircadian nadir

Lowest levels of alertness, activity & performance Greatest vulnerability to errors and accidents Increased sleepiness from 3-6 a.m. and 2-5 p.m.

• Peak in fatigue-related MVA between 6-9 a.m.

Circadian peak Maximal alertness from 9-11 a.m. and 9-11 p.m.

[email protected]

CONSEQUENCES OF SLEEP DEPRIVATION

Safety Issues Performance Issues Medical Errors Health Correlates Medical Education Professionalism Personal and Family Life

…..Consequences

Skills that are especially vulnerable to fatigue and sleep loss are uniquely human:

Motivation Creativity Judgment Decision-making Interpersonal happiness

Safety Risks of FatigueSOCIETAL Three Mile Island and Chernobyl nuclear accidents

Circadian factors NASA Challenger

Flawed decision making from poor work-rest patterns of managers

Exxon Valdez marine grounding Alcohol and fatigue

PERSONAL Increase in blood-borne pathogen exposure incidents

Risk is 50% greater at night Motor vehicle collisions: 100,000 crashes, 76,000 injuries &

1,550 fatalities annually NTSB 2001 poll “1:2 drivers report driving while drowsy; 1:5

report “nodding off” while driving”

4 SECONDS CAN END YOUR LIFE

All it takes is a brief 4 second break in your attention to cause a fatigue related

crash

RECOGNIZE THE SIGNS OF DROWSY DRIVING

Getting home and not remembering driving past the usual landmarks i.e. not remembering driving the last few miles

Difficulty focusing on road Wanting to “rest your eyes” for just a second or two Drifting across lanes Missing exits Closing your eyes whenever you have a chance i.e.

at stoplights, crosswalks etc. Be aware of microsleep

MICROSLEEP

Brief, uncontrolled and spontaneous episodes of physiologic sleep

Significant performance reductions sufficient to create safety risks before & after a microsleep

Usually no subjective awareness

FATIGUE RELATED CRASHES <5 hours sleep increases risk of involvement in sleep-related vs. non

sleep-related crash by 4.5 times

Greater likelihood of serious injury

Usually a single occupant off-road accident

Risk increases with certain conditions Alcohol - it doesn’t have to be a lot! Medical conditions including sleep apnea Medications Solo driving Driving for long stretches or along roads with little visual stimulus

Often dependent on time of day – most occur between 6 a.m. and 9 a.m.

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Time of Day

Accidents vs. Time of Day

DROWSY DRIVING: WHAT DOESN’T WORK!!

Turning up the radio Opening the car window and letting the cold air

blow on your face Singing/talking to yourself Eating/chewing gum/drinking fluids

DROWSY DRIVING: WHAT DOES WORK

If you are really tired, don’t try to drive home. Thinking “it’s just a short drive…I’m fine” is dangerous. Get someone to drive you home, take a taxicab or a bus.

Take a nap before driving home. Although a short 30 minute snooze will help, a 2 hour nap is best (allow sleep inertia to pass before getting into a car)

If you notice any of the warning signs of drowsiness, don’t ignore them. Get off the highway/road, pull into a safe area

(parking lot etc.), lock your car and take a nap.

Automobile Accidents and EM Residents & Faculty

Prevalence rates for: Collisions up to 8% (74% post night shift) Near misses up to 58% (80% post night shift) Correlated with:

# of night shifts worked Resident’s self-reported tolerance of shift work Self-reported adaptation to drowsiness

Steele MT, The occupational risk of motor vehicle collisions for emergency medicine residents. Acad Emer Med 1999;6:1050

Automobile Accidents and Pediatric Residents & Faculty

Prevalence Rates for: Falling asleep at the wheel:

Residents 49% Faculty 13%

Motor Vehicle Accidents• Residents 20 • Faculty 11

Traffic citations Residents 25% Faculty 18%

Marcus CL. Effects of sleep deprivation on driving safety in house staff. Sleep 1996, 19:763

PERFORMANCE ISSUES

Reduced vigilance, impaired memory & decision-making, prolonged reaction time

Increased risk for errors and critical incidents Increased performance variability – consistency in knowledge,

judgment and actions diminishes Speed-accuracy trade-off i.e. in order to maintain same level of

accuracy in decision-making, it takes more time to think through the situation

Impairment from 24 hr. sustained wakefulness is equivalent to 0.1% blood alcohol level

Effects of Sleep Deprivation on Functioning

Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997;388(6639):235.

IMPACT ON PERFORMANCE Surgery

24% more errors & 14% more time to perform simulated laparoscopy post-call

Taffinder et al, Lancet.1998; 352

2-fold increase in errors & 38% increase in time required for same task

Grantcharov et al, BMJ. 2001; 323

Internal Medicine Efficiency & accuracy on simulated ECG interpretation deteriorated

Lingenfelser et al, Med Educ. 1994; 28

Pediatrics Efficiency on task performances decreased significantly at 24 hours of

wakefulness

Storer et al, Acad Medicine; 64

MEDICAL ERRORS Surveys: 60% U.S. anesthesiologists & 90 % Australian

anesthesiologists report making fatigue-related errors Gravenstein et al, Anes. 1990;72 Gander et al,Anaesth Intensive Care 2000;28

IM residents- 41% their “most significant medical mistake” was secondary to fatigue Wu et al, JAMA 1991;265(16)

Case reviews of fatigue-related complications: 3% of 5600 reported anesthesia incidents/10 years Morris et al, Anaesth Intensive Care2000;28

5% of “preventable incidents” & 10% of drug errors Williamson et al, Anaesth Intensive Care 1993;21

Post-op surgical complication rates 45% higher when resident post-call

Haynes et al,S.Med J. 1995



0

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< 4 hrs 5-6 hrs > 7 hrs

Hours of Sleep

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rs/w

k

0

20

40

60

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Percent

Work Hrs/wk

% ReportingSerious MedicalErrors

% ReportingSerious StaffConflicts

*Baldwin and Daugherty,1998-9 Survey of 3604 PGY1,2 Residents

Work Hours, Medical Errors, and Workplace Conflicts by Average Daily Hours of Sleep*

HEALTH CORRELATES

Physiologic alterations Depression of immune function CHO metabolism & endocrine dysfunction

Abnormal glucose tolerance Decreased thyrotropin concentrations Increased SNS activity

Cerebral metabolic & cognitive function Decreased CMR in thalamus, frontal & parietal cortices

Adverse pregnancy outcomes Independent risk factor for CV and GI disease



Adverse Health Consequences by Average Daily Hours of Sleep*

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<4 hrs 5-6hrs >7 hrs

Hours of Sleep

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% Reporting SignifWt Change

% Reporting MedUse to Stay Awake

% ReportingIncreased AlcoholUse

*Baldwin and Daugherty,1998-9 Survey of 3604 PGY1,2

Residents

IMPACT ON PROFESSIONALISM

Negative change in attitude toward patients Conflicts with staff and colleagues Loss of empathy/compassion Role resistance Resentment and disenchantment with

profession

Negative Effects of Sleep Deprivation on Professionalism

Decreased Motivation:

“I keep thinking he’s blue enough to go the ICU. I keep hoping he’s too blue to go anywhere. Probably a nice man with a loving wife and concerned children, but I don’t want the SOB to make it because I’ve got one patient who is going to keep me up two more hours…I don’t want the asthmatic SOB to live if it means I don’t sleep. I don’t want the patient to live if it means I don’t sleep. I just want to sleep.”1

1. Excerpt from trainee diary: L C Groopman. Medical internship as moral education: an essay on the system of training physicians. Cult Med Psychiatry 1987; 11: 207–27.

IMPACT ON PERSONAL AND FAMILY LIFE

Mood disturbances Increased stress/anxiety Potential for alcohol and substance abuse Negative effect on motivation

HOW TO STAY ALERT

NapsCNS Stimulants

Caffeine Medications

MelatoninBetter schedulingSleep!

NAPSTemporarily improve alertness but do not replace a

good night’s sleep!! Types

Preventative (pre-call) Operational (on the job)

Length Short naps < 30 min. helps avoid grogginess known as “sleep inertia” Long naps 30-240 min.

Timing Take advantage of circadian windows (2-5 am & 2-5 pm)

SLEEP INERTIAWHAT IS IT? Grogginess or incomplete arousal from sleep Most likely to occur after 3-4 hours sleep

WHAT ARE ITS EFFECTS? Slowed speech Poor memory Performance deficits Impaired decision making May take up to 1 hour to clear

CAFFEINE Key is strategic consumption during periods of vulnerability Effects noted within 15-30 minutes, lasting 3-6 hours Significant response from 200mg

Be aware of the negative effects: Tolerance may develop Diuretic effects Disruption of subsequent sleep Dose-related tremors & palpitations

MEDICATIONS Melatonin

Promotes sleep at 0.3-80 mg doses Circadian phase-shifting effects Food supplement, no FDA involvement Insufficient evidence that it eases adaptation to changing

workshifts

Modafinil, Methylphenidate, Dextroamphetamine Avoid using stimulants

Alcohol Alcohol may make you sleepy initially, but it will disrupt a full night’s sleep as the night progresses

Take home message!

Sleep, sleepiness and performance are inextricably bound with each other

Know your limitsAppreciate the subtle but destructive &

catastrophic effects of sleep deprivationRealize that the need for sleep is not

negotiable

[email protected]

fatigue implications for the medical profession eleanor m. duduch m.d. program director...

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