Sleep Loss, Fatigue and Medical Training University Hospital Housestaff 1982-83 Susan M. Harding, MD Professor of Medicine Medical Director, Sleep-Wake Disorders Center University of Alabama at.
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Sleep Loss, Fatigue and Medical Training University Hospital Housestaff 1982-83 Susan M. Harding, MD Professor of Medicine Medical Director, Sleep-Wake Disorders Center University of Alabama at Birmingham Learning Objectives List factors that put you at risk for sleepiness and fatigue. Describe the impact of sleep loss on residents’ personal and professional lives. Recognize signs of sleepiness and fatigue in yourself and others. Adapt alertness management tools and strategies for yourself and your program. Residency Training Over Past 5 Decades Call every other night Call every 3rd night, then every 4th night Work is more stressful “Less sick” patients are out of the hospital Heightened intensity of patient care Lower margin for error Constant paging interruptions disrupt work flow State of Sleepiness Prior to ACGME Limiting Resident Work Hours Rosen IM et al. Acad Med 2004; 79:407 Survey of 79 Internal Medicine residents at the Univ of Pennsylvania, June 2001 34% experienced acute sleep deprivation 64% experienced chronic sleep deprivation Dozing while performing work-related tasks – – – – 69% writing notes 61% reviewing medication lists 51% interpreting labs 46% writing orders ACGME Work Hour Rules Effective July 1, 2003 Restricts work hours to < 80 hrs/week avg < 30 hours of continuous coverage at any 1 time Should have 10 hours off between shifts Stimulus – quality of care, but minimal data was available linking fatigue to errors Different people have different “inflection points” concerning sleep deprivation ACGME Work Hour Rules Made everyone re-examine their educational programs Provided impetus to examine ways to improve the system Emphasizes the need for more effective team work Brought up continuity of care and transfer of care issues with frequent “hand offs” What happens after training? ACGME Work Hour Rules: Potential Stressors Ryan J. Ann Intern Med 2005; 143:82 Increased number of patient hand offs Cross coverage Communication and team work Increasing paperwork Pressure to get done and get out Rushing from task to task w/out time to think and learn Resident comraderie “No, I’ve just come to start my overnight call. Why do you ask?” ACP Internist, Jan 2009 Institute of Medicine’s (IOM) Recommendations (at Congress’ Request) December 2008 2003 ACGME 2008 IOM Max hrs work per week 80 hrs, over 4 wks same Max shift length 30 hrs--24 hrs + 6 hrs 30 hrs with … for transitional and - 16 hrs admitting, 5 education activities hrs protected sleep period between 10 pm and 8 am - 16 hours if no protected sleep period Max in-hospital oncall frequency Every 3rd night, on average Every 3rd night, no averaging 2003 ACGME 2008 IOM Minimum time 10 hrs after shift off between length scheduled shifts 10 hrs after day shift 12 hours after night shift 14 hrs after extended duty of 30 hrs and not to return until 6 am of the next day Max frequency of in-hospital night shifts Not addressed 4 nights max; 48 hrs off after 3 or 4 nights of consecutive duty Mandatory time off 4 days off per month 1 day (24 hrs) off per 1 day (24 hrs) off per wk, no averaging wk, average over 4 5 days off per month wks 1 (48 hr) off period per month 2003 ACGME 2008 IOM Emergency Rm limits 12-hr shift limits, with No change at least an equivalent off period be tween shifts 60-hr work wk with 12 additional hrs for education Limit on exemptions 88 hrs with a sound educational rationale No change Moonlighting Internal moonlighting is counted against 80-hr wk limit Internal and external moonlighting counted against 80 hr wkly limit All other duty limits apply in combination Cost of Implementing IOM’s Recommendations 1.7 billion per yr (1/4 of cost is bringing noncompliant programs into compliance – 8.8% of programs Create and fill fulltime positions for: – – – – – 229 nursing aides 45 laboratory technicians 320 licensed vocational nurses 5984 NPs or PAs 5001 attending physicians OR… - 8247 additional residency positions “There are fundamental effects from sleep loss which permeate performance on virtually all cognitive and sustained attention tasks” Courtesy of Journal for Respiratory Care Practitioners, Jun/Jul 1998 Regulation of Sleep and Wakefulness Homeostatic drive for sleep (previous sleep amounts, duration of wakefulness) Circadian influence (24 hour clock, alertness peaks and troughs) Environmental factors: feedback, reinforcement, task nature/length/complexity Individual variables: motivation, emotional context; physical activity; age, individual variation sleep needs and vulnerability Effects of Sleep Deprivation: Experimental Settings Neurobehavior impairment similar for short-term (24-48 hrs) total sleep deprivation and chronic partial sleep restriction (<6 hrs/night for > 1 week) Sleep “debt”: Effects of chronic partial sleep loss are cumulative; not reversed in a single night Perception of sleepiness is less affected than measured sleepiness Circadian influence Effects of Sleep Deprivation: Experimental Findings Mood universally affected Impairment in vigilance, delayed and immediate recall Complex tasks and problem-solving affected; performance deteriorates with time-on-task; task duration; perseveration and poor prioritization Maintenance of accuracy at the expense of speed Effects of Sleep Deprivation: Experimental Findings Learning of new tasks compromised Motivation affected “Lapsing”: variability in task performance related to interruption of sustained attention from “microsleeps” Variability in performance may be more affected than average quality Factors Increasing Fatigue Prolonged wakefulness (>15 continuous hrs) Reduced or disrupted sleep Shift variability Volume and intensity of work Sleep Restriction Banks S, Dinges DF. J Clin Sleep Med 2007; 3:519 Inter-individual differences, BUT… Sleepiness – dose response effect Lapses of attention and vigilance on tasks More errors on simulated driving Response slowing Spatial learning problems Decrease in behavioral alertness with “microsleeps” Psychomotor vigilance test performance impaired Working memory performance impaired Mood problems Cognitive and executive function impairment Sleep Restriction Banks S, Dinges DF. J Clin Sleep Med 2007;3:519 Physiological consequences… Elevated BP Reduced glucose tolerance Sympathetic nervous system activation Reduced leptin levels (appetite) Increased inflammatory markers (IL-6, TNFα, CRP) Obesity Sleep Restriction Banks S, Dinges DF. J Clin Sleep Med 2007;3:519 Obesity Insulin resistance Cardiovascular events (epidemiological studies) Mortality Common cold susceptibility (Cohen S et al. Arch Intern Med 2009;169:62) Sleep Deprivation: Effects on Mood Increased dysphoria/depression anger/hostility; decreased motivation Correlation with sleep amounts Effects last up to 48 hrs post-call Independent association with night shift Sleep Deprivation – Socioeconomic Consequences… More than 1,000,000 motor vehicle accidents annually are sleep-related Disasters such as Chernobyl, Three Mile Island, Challenger, Bhopal, and Exxon Valdez were officially attributed to errors in judgment induced by sleepiness or fatigue Three Mile Island and Chernobyl Disasters 1. US Nuclear Regulatory Commission. Report on the Accident at Chernobyl Nuclear Power Station. Washington DC: US Government Printing Office; 1987. 2. Moss TH, Sills DL. The Three Mile Island nuclear accident: lessons and implications. Ann NY Acad Sci 1981; 365:1-341 Early morning human error Fatigue-related accidents Deserted city of Prypiyat with Chernobyl nuclear reactor in the background Exxon Valdez Grounding NTSB. Marine Accident Report – Grounding of the US Tankership EXXON VALDEZ on Bligh Reef, Prince William Sound, Near Valdez, Alaska, March 24th, 1989. Washington DC: NTSB/March-90/04 “…probable cause of the grounding of the Exxon Valdez was the failure of the third mate to properly maneuver the vessel because of fatigue and excessive workload…” Epworth Sleepiness Scale Johns MW. Sleep 1994; 17:703-710 0 - WOULD NEVER DOZE 1 - SLIGHT CHANCE OF DOZING 2 - MODERATE CHANCE OF DOZING 3 - HIGH CHANCE OF DOZING Sitting reading (Range 0 – 24) Watching TV Sitting inactive in public Passenger in a car for 1 hour Sitting and talking Sitting quietly after lunch In a car, while stopped for a few minutes in traffic 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) 20 Narcolepsy Residents 15 Sleep Apnea 10 Norm al 5 Insomnia 0 Mean Normal Insomnia Sleep Apnea Residents Narcoleps y 5.90 2.20 11.70 14.70 17.50 Stanford Sleepiness Scale An introspective measure of sleepiness – The Stanford Sleepiness Scale (SSS) Degree of sleepiness Scale Rating Feeling active, vital, alert, or wide awake 1 Functioning at high levels, but not at peak; able to concentrate 2 Awake, but relaxed; responsive but not fully alert 3 Somewhat foggy, let down 4 Foggy, losing interest in remaining awake, slowed down 5 Sleepy, woozy, fighting sleep, prefer to lie down 6 No longer fighting sleep, sleep onset soon, having dreamlike thoughts 7 Asleep X Despite this, the problem of sleepiness and fatigue in residency is under-estimated. MYTH: “It’s the really boring noon conferences that put me to sleep.” FACT: Environmental factors (passive learning situations, room temperature, low light levels, etc.) may unmask, but DO NOT CAUSE SLEEPINESS! Conceptual Framework (in Residency) Insufficient Sleep (on call sleep loss/ inadequate recovery sleep) Fragmented Sleep (pager, phone calls) Excessive Daytime Sleepiness Circadian Rhythm Disruption (night float, rotating shifts) Primary Sleep Disorders (sleep apnea, etc) Sleep Needed vs Sleep Obtained Myth: “I’m one of those people who only needs 5 hours of sleep, so none of this applies to me.” Fact: Individuals may vary somewhat in their tolerance to the effects of sleep loss, but are not able to accurately judge this themselves. Fact: Human beings need 8 hours of sleep to perform at an optimal level. Fact: Getting less than 8 hours of sleep starts to create a “sleep debt” which must be paid off. Sleep Fragmentation Affects Sleep Quality NORMAL SLEEP = Paged MORNING ROUNDS ON CALL SLEEP The Circadian Clock Impacts You It is easier to stay up later than to try to fall asleep earlier. It is easier to adapt to shifts in forward (clockwise) direction. (day evening night) Night owls may find it easier to adapt to night shifts. Interaction of Circadian Rhythms and Sleep Sleep Homeostatic drive (Sleep Load) Wake Sleep Alertness level Circadian alerting signal 9 AM 3 pm 9 PM Time 3 AM 9 AM Sleep Disorders: Are you at Risk? Physicians can have sleep disorders too! – Obstructive sleep apnea – Restless legs syndrome – Periodic limb movement disorder – Learned or “conditioned” insomnia – Medication-induced insomnia 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. Fact: Human beings do not “adapt” to getting less sleep than they need. Fact: Although performance of tasks may improve somewhat with effort, optimal performance and consistency of performance do not! Consequences of Chronic Sleep Deprivation Sleep is a vital and necessary function, and sleep needs (like hunger and thirst) must be met Workplace Mood And Performance Learning Driving Safety Sleep Deprived Resident Patient Care Professionalism Health & Well-Being Family Relationships Impairment Across Specialties Surgery: 20% more errors and 14% more time required to perform simulated laparoscopy post-call (two studies) Taffinder NJ et al, Lancet 1998; 352:1191; Grantcharov TP et al. BMJ 2001; 323:1222 Internal Medicine: efficiency and accuracy of ECG interpretation impaired in sleep-deprived interns Lingenfelser T et al. Med Education 1994;28:566 Pediatrics: time required to place an intra-arterial line increased significantly in sleep-deprived residents Storer JS et al, Acad Med 1989; 64:291989 Surgery Residents: Laparoscopic Skills Suffer on the First Night Shift Leff DR et al. Ann Surg 2008;247:530 21 residents trained on a virtual reality surgical simulator: Technical skills assessed on 2 tasks Took longer (p=.002) and made more errors (p=.025) on their first night shift Were less economical with movements on the first night shift Some improvement noted during subsequent shifts Lesson: Prepare for night shift, realize your limitations Across Tasks Emergency Medicine: significant reductions in comprehensiveness of history & physical exam documentation in second-year residents Bertram DA. NY State J Med 1998; 88:10-15 Family Medicine: scores achieved on the ABFM practice in-training exam negatively correlated with pre-test sleep amounts Jacques CJ et al. J Fam Pract 1990; 30:223-229 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.” Work Hours, Medical Errors, and Workplace Conflicts by Average Daily Hours of Sleep* 100 90 80 70 60 50 40 30 20 10 0 Work Hrs/wk % Reporting Med Errors % Reporting Staff Conflicts < 4 hrs 5-6 hrs Hours of > 7 hrs * Baldwin DJr et al. Acad Med Sleep 2003;78:1154 Limiting Resident Work Hours: Impact on Patient Safety Fletcher KE, et al. Ann Intern Med 2004:141 Insufficient evidence 7 studies had an intervention to reduce work hours and assessed patient safety outcomes (4 retrospective, 3 prospective studies) Limitations on study design, diversity of interventions and possibly publication bias Do ACGME Duty Hour Rules Impact Hospital Mortality? No? Volpp KG et al. JAMA 2007;298:975 Compared mortality rates for all Medicare pt admissions to teaching hospitals from 20002003 (pre duty hours reform) to 2003-2005 (after duty hour reform) ACGME duty hours reform was not associated with either worsening or improvement in mortality during the first 2 years after implementation Do ACGME Duty Hour Rules Impact Hospital Mortality? Yes? Volpp KG et al. JAMA 2007; 298:984 Compared mortality rates for all VA Hospitals from 2000-2003 and 2003-2005 Duty hour rules were associated with improvement in mortality for 4 common medical conditions (AMI, CVA, GI bleed, CHF)—but not for surgical conditions Serious Medical Errors in the ICU Landrigan CP et al. N Engl J Med 2004; 351:1838 Prospective randomized trial of interns Traditional schedule with an extended (> 24 hr) work shift every 3rd night (3 interns) – 77 to 81 hrs/wk up to 34 hrs of continous work Interventional schedule where one intern worked 7 am to 10 pm on call and another worked 9 pm to 1 pm (4 interns) – 60 to 63 hrs/wk with up to 16 continous working hours Examined incidence of serious medical errors Serious Medical Errors in the ICU Landrigan CP et al. N Engl J Med 2004; 351:1838 Interns on the traditional schedule – Made 36% more serious medical errors – Made 21% more serious medication errors – Made 5.6 times as many serious diagnostic errors Eliminating extended work shift and reducing the number of work hours per week can reduce serious medication errors in the ICU Bottom Line: You need to be alert to take the best possible care of your patients... …and yourself! Adverse Health Consequences by Average Daily Hours of Sleep* Baldwin DC Jr, et al. Acad Med 2003; 78:1154 60 50 % Reporting Signif Wgt Change 40 % Reporting Med Use to Stay Awake 30 20 % Reporting Increased Alcohol Use 10 0 <4 hrs 5-6hrs Hours of Sleep >7 hrs Sleep Loss and Fatigue: Safety Issues 58% of emergency medicine residents reported near-crashes – 80% post night-shift – Increased with number night shifts/month Steele MT et al, Acad Emerg Med 1999; 6:1050 50% greater risk of blood-borne pathogen exposure incidents (needlestick, laceration, etc) in residents between 10 pm and 6 am Parks DK et al, Chronobiology Intl 2000; 17:61 MICU Resident Sleepiness Post Call Reddy R et al. Chest 2009; 135:81 20 residents on call every 4th night, home after call at/or before noon: Monitored sleep times with diaries and actigraphs Stanford Sleepiness Scale (SSS) and MSLT performed day of and day after call (2 nap sessions) Sleep time prior to call day: 7.15 ± 1 hr Sleep time on call: 2.5 ± 1.4 hr On Call SSS 1.5 ± 0.6 MSLT 9 ± 4.4 min Post Call 3.15 ± 1 4.8 ± 4.1 min MICU Resident Sleepiness Post Call Severity of sleepiness post-call approximates someone with narcolepsy Residents are often sleepy during on-call and post-call days even while implementing the ACGME guidelines Implications 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: Driving Marcus CL et al. Sleep 1996; 19:763 Retrospective survey of 85 pediatric residents and 85 faculty: 2.7 hrs avg sleep on-call; 7.2 hrs avg off-call 23% had fallen asleep while driving (vs 8%) 44% had fallen asleep at traffic light (vs 12.5%) Total 49% had fallen asleep at the wheel; 90% of incidents post-call 25 traffic citations (vs 15), 20 MVAs (vs 11) Risk of MVA Crashes Among Interns Barger LK et al. N Engl J Med 2005; 352:125 Web-based survey of 2737 interns examining work hrs, shifts, crashes, and near miss incidents (July 2002 - May 2003) Extended work shift increased the monthly risk of an MVA by 9.1%, and the risk during the commute from work by 16.2% In months where interns had > 5 extended shifts, the risk of falling asleep while driving increased (OR 2.39) as did the risk for falling asleep in traffic (OR 3.69) Extended work hour shifts pose a driving safety hazard. Sleep Deprivation & Equivalent ETOH Levels Wakefulness Equivalent ETOH Level 17 hours . . . . . . . . . . . 0.05% 21 hours . . . . . . . . . . . 0.08% 24 hours . . . . . . . . . . . 0.1% Legally drunk level = 0.08% ETOH US Legal limit ETOH level for commercial drivers = 0.04% Maggie’s Law (New Jersey) – a sleep-deprived driver (no sleep > 24 hrs) can be convicted of vehicular homicide In almost all states, people can be charged under existing laws if they fall asleep at the wheel ACGME Duty Hour Limits: Effects on Safety, Sleep and Work Hours Landrigan CP et al. Pediatrics 2008; 122:250 220 residents, prospective cohort study, evaluated the spring before and the spring after implementation of ACGME duty hour standards No change in total work or sleep hours, medication errors, MVAs, occupational exposures, or depression Mean length of on call shifts decreased 2.7% to 28.5 hours (p = .001) Resident burnout decreased from 75.4% to 57.0% (p = .007) Outcomes Before and After ACGME Duty Hour Standards Landrigan CP et al. Pediatrics 2008;122:250-258 Impact on Medical Education “We all know that you stop learning after 12 or 13 or 14 hours. You don’t learn anything except how to cut corners and how to survive.” Recognizing Sleepiness in Yourself and Others Myth: “If I can just get through the night (on call), I’m fine in the morning.” Fact: A decline in performance starts after about 15-16 hours of continued wakefulness. Fact: The period of lowest alertness after being up all night is between 6 am and 11am (morning rounds). Estimating Sleepiness Myth: “I can tell how tired I am and I know when I’m not functioning up to par.” Fact: Studies show that sleepy people underestimate their level of sleepiness and overestimate their alertness. Fact: The sleepier you are, the less accurate your perception of degree of impairment. Fact: You can fall asleep briefly (“microsleeps”) without knowing it! Perceived Impact of Sleep Deprivation Surgical vs Non-Surgical Residents Woodrow SI et al. Medical Education 2008; 42:459 Surgical Non-Surgical P Work hrs per week 83 62.5 < .01 Epworth Sleepiness Scale 12.8 9.2 < .01 Sleep Deprivation Impact Score 45.2 51.5 < .01 Surgery residents are less likely to perceive the potential impact of sleep deprivation on their own performance Could it be due to optimism bias? Be aware! Attention Failures on Different Work Hours Lockley SW et al. N Engl J Med 2004; 351:1829 20 interns on 2 different 3 wk ICU rotations Traditional and intervention work hours Continuous ambulatory polysomnography Attentional failures identified by slowrolling eye movements into confined wakefulness during work hours Attentional Failure: Example Attentional Failures on Different Work Hours Lockley SW et al. N Engl J Med 2004; 351:1832 On the intervention work hour shift schedule: – Interns worked 19.5 hrs/wk less – Slept more – Had less than half of the rate of attentional failures while working during on-call nights Mean Number of Attentional Failures Lockley SW et al. N Engl J Med 2004; 351:1835 Neurocognitive Effects of Sleep Deprivation in Residents Arnedt JT, et al. JAMA 2005; 294-1025 Prospective 2 session within-subject study of 34 pediatric residents Compared post-call performance to non post-call performance with and w/out a blood alcohol level of 0.04 – 0.05 g % – Sustained attention – Vigilance – Simulated driving Neurocognitive Effects of Sleep Deprivation in Residents Arnedt JT, et al. JAMA 2005; 294:1-1025 Light call rotation – 4th week of 44 hr work week – Testing before and after alcohol ingestion Heavy call rotation – 4th week of 80 hr work week – Testing before and after placebo ingestion Neurocognitive Effects of Sleep Deprivation in Residents Arnedt JT, et al. JAMA 2005; 294:1-1025 Heavy call: – Reaction times 7% slower – Commission errors 40% higher – Simulated driving lane variability 27% greater – Simulated driving speed variability 71% greater – Results similar to light call results with a 0.04 to 0.05 g % blood alcohol level Residents could not judge this impairment Neurocognitive Effects of Sleep Deprivation in Residents Arnedt JT, et al. JAMA 2005; 294:1-1025 Post-call performance impairment is present Impairment is comparable to drinking 3 to 4 alcoholic drinks Residents have limited ability to recognize their degree of impairment Potential risk to personal and patient safety Consider interventions to minimize impact Recognize The Warning Signs of Sleepiness Falling asleep in conferences or on rounds Feeling restless and irritable with staff, colleagues, family, and friends Having to check your work repeatedly Having difficulty focusing on the care of your patients Feeling like you really just don’t care Be Aware of Sleep Inertia Clouded sensorium when arousing from sleep Confusion, slowed speech, repeating phrases or questions Vulnerable time: answering a beeper or phone call when asleep Can’t retain information We may not recognize our own sleep inertia Reversible with < 10 minutes of stimulation like movement and caffeine Manage it before making important medical decision If you don’t recognize that you’re sleepy, you’re not likely to do anything about it. Alertness Management Strategies Myth: “I’d rather just “power through” when I’m tired; besides, even when I can nap, it just makes me feel worse.” Fact: Some sleep is always better than no sleep. Fact: At what time and for how long you sleep are key to getting the most out of napping. Napping Pros: naps temporarily improve alertness Types: – Preventative (pre-call) – Operational (on the job) Length: – Short naps: no longer than 30 minutes to avoid the grogginess (“sleep inertia”) that occurs when you’re awakened from deep sleep – Long naps: 2 hours (range 30 to 180 minutes) Napping Timing: – if possible, take advantage of circadian “windows of opportunity” (2 to 5 am/2 to 5 pm) – but if not, nap whenever you can! Cons: sleep inertia; allow adequate recovery time (15-30 minutes) Bottom line: naps take the edge off but do not replace adequate sleep. Healthy Sleep Habits Get adequate (7 to 9 hours) sleep before anticipated sleep loss. Avoid starting out with a sleep deficit! Recovery from Sleep Loss Myth: “All I need is my usual 5 to 6 hours the night after call and I’m fine.” Fact: Recovery from on-call sleep loss generally takes 2 nights of extended sleep to restore baseline alertness. Fact: Recovery sleep generally has a higher percentage of deep sleep, which is needed to counteract the effects of sleep loss. Healthy Sleep Habits 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! Healthy Sleep Habits Sleeping environment: – No animals! – 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 3 hours of sleep. Get regular exercise but avoid heavy exercise within 3 hours of sleep. Recognize Signs of DWD* Trouble focusing on the road 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 * Driving While Drowsy Risk Factors for Drowsy Driving Pack A et al. Anal Prev 1995; 27:769 Taking any sedating medications Drinking even small amounts of alcohol Having a sleep disorder (sleep apnea) Driving long distances without breaks Driving alone or on a boring road 450 400 350 300 250 200 150 100 50 0 of Number Number of Crashes Crashes • • • • • Time of Day 0:00 3:00 6:00 9:00 12:00 Time of Day 15:00 18:00 21:00 Driving home post-call Drowsy Driving: What DOES NOT Work Turning up the radio Opening the car window Chewing gum Blowing cold air (water) on your face Slapping (pinching) yourself hard Promising yourself a reward for staying awake It takes only a 4 second lapse in attention to have a drowsy driving crash. Post-call MVA Driving Home Who’s Liable? American Medical News, October 31, 2005 In July 1997, an intern at Rush University Medical Center had an MVA while driving home after being on call for 36 hours A 23 year-old woman sustained a head injury which has left her totally disabled Her family is suing the intern and the teaching hospital because the hospital enforced a work schedule resulting in sleep deprivation Hospital not responsible Under appeal/no further action as of February 2009 Drugs AVOID using stimulants (methylphenidate, dextroamphetamine) to stay awake AVOID using alcohol to help you fall asleep; it induces sleep onset but disrupts sleep later on. Modafinil: little data Melatonin: little data in residents Hypnotics: may be helpful in specific situations (eg, persistent insomnia) Caffeine Strategic consumption is key Effects within 15 – 30 minutes; half-life 3 to 7 hours Use for temporary relief of sleepiness Cons: – disrupts subsequent sleep (more arousals) – tolerance may develop – diuretic effects Adapting to Night Shifts Myth: “I get used to night shifts right away; no problem.” Fact: It takes at least a week for circadian rhythms 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). How to Survive Night Float Protect your sleep Nap before work Consider “splitting” sleep into two 4 hour periods Have as much exposure to bright light as possible when you need to be alert Avoid light exposure in the morning after night shift (wear dark glasses driving home from work) Alertness Strategies There is no “magic bullet” Know your own vulnerability to sleep loss Learn what works for you from a range of strategies There needs to be a shared responsibility for fatigue management and a “culture of support” in the training program Effects of Work Hour Reduction on Residents’ Lives Fletcher KE, et al. JAMA 2005; 294:1088 12 studies -- performed on Internal Medicine residents Nurse perceptions -- residents made fewer mistakes and they were easier to work with Faculty perceptions -- residents learned less and developed a shift-work mentality Program Directors perceptions -- 81% agreed that resident morale improved when night float system used Effects of Work Hour Reduction on Residents’ Lives Fletcher KE, et al. JAMA 2005; 294:1088 Resident perceptions: – Decreased work hours – Increased sleep time – Fewer attention failures – More time with family – Less impact of fatigue on learning – No difference in mood Resident Attitudes About ACGME Duty Hour Regulations Myers JS et al. Acad Med 2006; 81:1052 Surveyed 200 residents trained both before and after implementation at 6 residency pgms (3 IM, 3 GS) 2 yrs after implementation Fatigue-related errors decreased slightly Errors related to continuity of care significantly increased Opportunities for formal education, bedside learning and procedures decreased Quality of life improved and burnout decreased 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 help combat sleepiness in residency When sleepiness interferes with your performance or health, talk to your supervisors and program director International Medical News, Sep 1, 2005 Sleepy Driving From Sleep Review, Mar-Apr 2005, pg 38 Sleepy Driver Crash Video Computer must be connected to the internet. Open your browser: Go to the YouTube website: (www.youtube.com) Search for: “Sleepy Driver Crash” video clip, or click http://www.youtube.com/watch?v=sjkbhO8I2I then minimize it. When you are ready to view the video, double-click on the URL at the bottom of the screen.