Fatigue, Stress, and their Reduction During Training

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Fatigue, Stress, and their Reduction During
Training
Personal Management Skills in Fellowship Training
July 2011
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Fatigue, Stress, and their Management During
Training

• Case synopsis
• Background
• NEJM study review
• Management suggestions
• Organized discussion

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Background

• ACGME limits resident to 320 hrs/4 weeks
• Does reducing work hours
• Increase duration of sleep?
• Reduce Attentional failures?

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Methods

• 20 interns, two 3-week ICU rotations
• Traditional Q3 call, 30 hr shift, clinic/wk,
  1 day/wk off
• Intervention shifts, max 16 hrs, 1 day/wk off

1.76 hr
Nap
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Methods (cont)

• Sleep/work hour logs recorded
• Attentional failures (AFs) measured by
  continuous electrooculography (EOG)
• Slow, rolling eye movement
• Correlate with psychomotor task performance

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Results
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Results

• 6.60.8 vs. 7.40.9 hrs/day sleep
• Difference of 0.8 hr/day (48 min)
• Loss of 19.2 min sleep per week for each
  additional hour worked

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13/20 subjects decreased AFs
Not shown 1.5 x the number of attentional
failures at night vs. day
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Oct 28, 2004
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Discussion

• Small changes in absolute sleep time (48 min/day)
  major difference AF number
• 1 hr work 20 min less sleep
• More attentional deficits later in day
• Translates into serious medical errors

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Discussion Questions

• How do you recognize your own fatigue and stress
  in the workplace what behaviors, errors?
• What remedial actions do you take to reduce
  fatigue when you have fellowship
  responsibilities?
• Do you notice fatigue in your attending
  physicians, and how do you deal with it?
• What impact has fatigue and stress from the GI
  fellowship program made on your lives?
• Can we do more to reduce these factors in the
  training program?

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THE IMPACT OF SLEEPINESS AND FATIGUE ON PHYSICIAN
PERFORMANCE

• Rebecca P. McAlister, MD
• Washington University School of Medicine

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July 1, 2003

• ACGME Resident Duty Hour Requirements
• No more than 80 hrs/wk averaged over 4 wk
• No more than every third night in house call
• At least 24 hr away every 7 days
• No more than 30 hrs of continuous work
• At least 10 hours off between work shifts

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• Faculty and residents must be educated to
  recognize the signs of fatigue, and adopt and
  apply policies to prevent and counteract its
  potential negative effects.
• ACGME Common Requirements 2004, revised 2011

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NEJM e3 (1-6), 2010
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EDUCATIONAL OBJECTIVES

• The basics of sleep physiology and sleep
  deprivation will be reviewed. The impact of
  sleepiness fatigue on physician performance
  will be examined and suggestions made for
  alertness management.

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INDUSTRY MONTHLY LIMITS

• ACGME 320-352 HRS
• COMM AVIATION 100 HRS
• TRUCKING 260 HRS
• SMALL MARITIME 360 HRS
• RAIL 432 HRS
• UK 224 HRS

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SLEEPINESS AND FATIGUE

• SLEEPINESS
• Acute sleep loss
• Chronic sleep restriction
• Circadian displaced waking (shift work)
• FATIGUE
• Physical/cognitive demands without recovery
• Psychological exhaustion (burnout)

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SLEEPINESS

• SUBJECTIVE MEASUREMENTS
• Epworth Sleepiness Scale
• OBJECTIVE MEASUREMENTS
• Multiple Sleep Latency Test (MSLT)
• EEG Microsleeps

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EPWORTH SLEEPINESS SCALE0 - 3

• How likely are you to doze in these places
• Sitting and reading
• Watching TV
• Sitting inactive in public place
• Passenger in car gt1 hr
• Lying down in afternoon
• Sitting and talking
• Sitting quietly after lunch (w/o ETOH)
• In a car, while stopped in traffic

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EPWORTH SLEEPINESS SCALE

• HIGHEST SCORE POSSIBLE 24
• UPPER NORMAL lt11
• MILD SLEEPINESS 11-13
• MODERATE SLEEPINESS 14-17
• SEVERE SLEEPINESS gt17

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SLEEP HOMEOSTATIC DRIVE (SLEEP LOAD)

• Builds up during wakefulness
• Reaches maximum in late evening
• Determined by the duration and quality of
  previous sleep and time awake since last sleep
• Significant interaction with the circadian rhythm

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SLEEP REQUIREMENTS

• Typically 8 hours per day (6-10)
• Average American approx 7 hrs per day
• Average resident 6 hours per day

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INTERACTION OF CIRCADIAN RHYTHM AND HOMEOSTATIC
DRIVE

• lt5 HRS SLEEP CAUSES INCREASED HOMEOSTATIC DRIVE
• RESIDENTS ROUGHLY EQUIVALENT TO NARCOLEPSY AND
  SLEEP APNEA

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SK Howard, et al, Acad Med 2002
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CONSEQUENCES OF SLEEP DEPRIVATION

• Less than 5 hrs, homeostatic drive rises sharply
• After 4 hrs, can function reasonably well for 2-3
  days
• After one night of no sleep, cognitive
  performance declines 25
• After second missed night, cognitive performance
  declines to 40

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SLEEPY PEOPLE EXHIBIT..

• Fatigue Lack of initiative
• Lack of energy Indifference
• Apathy Irritability
• Inattention Ptosis/eye irritation
• Difficulty concentrating Slow reaction time
• Poor communication Poor decision making

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SLEEPINESS ERODES PERFORMANCE

• Pediatric sleepiness scale ratings are inversely
  related to middle school grades
• Performance error peaks reflect circadian troughs
• Fatigue related accidents peak at 6AM and 2 PM
• Rested night shift workers have lower performance
  than day shift

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The Far Side, G Larson
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Grantcharov TP, et al, BMJ 2001
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STUDIES ON RESIDENTS

• Rarely or never controlled for stimulant use,
  chronic sleep deprivation, circadian rhythm
  during testing, level of training
• Small study size and significant drop out
• Self selection of work hours / tolerance
• Applicability of test to actual practice
• Effect of practice

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STUDIES ON RESIDENTS

• Perceived vs. objective sleepiness
• Diminished mood, increased depression
• Increased anger, frustration, dysphoria
• Decreased satisfaction with training
• Subnormal serum testosterone levels
• Singer F, Zumoff B, Steroids 1992

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• No evidence that 80wk will reduce MD fatigue or
  its consequences
• 24 hr continuous duty limit well beyond the 16-18
  hr increased risk rate for wakefulness
• Sleep loss / fatigue can be recognized and
  managed but not eliminated

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ALTERTNESS MANAGEMENT

• SIGNS AND SYMPTOMS OF SLEEP LOSS AND FATIGUE
• INTERVENTION STRATEGIES

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SIGNS AND SYMPTOMS

• Falling asleep while sedentary
• Irritability
• Repeatedly checks work
• Difficulty focusing / concentrating
• Apathy or indifference

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Symptoms of Drowsy Driving

• Long blinks
• Head nodding
• Difficulty focusing on road
• Missing exits / forgetting drive
• Drifting from lane
• Closing eyes at light
• Slowed reaction time

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NAPPING

• PROPHYLACTIC
• Brief naps prior to 24 hr loss
• THERAPEUTIC
• Q 2-3 hrs X 15 min
• MAINTENANCE
• 2-8 hour nap prior to 24 hr loss

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NAPPING

• Sleep inertia
• Avoid deep sleep arousals
• Limit nap to 40 min
• Circadian nadir 2am 9am
• Most resistant to counter measures

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RECOVERY FROM SLEEP LOSS

• TWO DAYS TO REPLACE CHRONIC LOSS
• MSLT NO CHANGE PRE AND POST CALL UNTIL 4 DAYS OF
  NORMALIZED SLEEP

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SHIFT STRATEGIES

• 1 WK ADAPTATION (W/O RETURN TO DAY/NIGHT ON DAYS
  OFF)
• MINIMIZE INTERRUPTIONS TO SLEEP
• PROPHYLACTIC NAPS
• SPLIT SLEEPS
• EFFECT OF BRIGHT LIGHT

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DROWSY DRIVING

• 100,000 drowsy driving crashes / yr
• 37 driving population have nodded off
• Population at highest risk
• Male 2X
• Ages 16 29yo
• Shift worker, esp rotating shifts and post call
• Untreated sleep disorders
• NHTSA

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www.nhtsa.dot.gov/people/injury/drowsy_driving
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DROWSY DRIVING

• CIRCADIAN RHYTYM
• Use it, dont fight it
• NAPS/CABS
• DEATH MORE LIKELY THAN WITH ETOH

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MEDICATIONS

• EXOGENOUS MELATONIN
• HIGH DOSE TARGETED CAFFIENE
• D-AMPHETAMINES
• MODAFINIL (PROVIGIL)
• SHORT TERM SHORT ACTING HYPNOTICS (ZOLPIDEM,
  ZALEPHLON)
• ALCOHOL

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The Far Side, G Larson
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MULTIPLE SLEEP LATENCY TEST

• Series of five 20 minute nap opportunities in
  which the time to onset of EEG documented sleep
  is measured

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MICROSLEEPS

• Brief intrusions of EEG indications of sleep into
  the awake state

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REGULATION OF SLEEP AND WAKEFULNESS

• HOMEOSTATIC SLEEP DRIVE
• Sleep dependent process
• CIRCADIAN ALERTNESS RHYTHM
• Sleep independent process

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SLEEP STAGES

• NON-REM SLEEP
• STAGE 1 (2-5)
• STAGE 2 (45-55)
• STAGES 3 AND 4 (3-23) SLOW WAVE
• REM SLEEP
• 20-25 4-6 EPISODES PER NIGHT
• ABSENT MUSCLE TONE
• DREAMING / BURST OF EYE MOVEMENTS

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SLEEP INERTIA

• Cognitive performance impairment, grogginess,
  amnesia and tendency to return to sleep
  immediately after awakening
• Time course
• Experimentally 1-4 hours
• Practically 30-60 minutes
• Decreased decision making performance
• After 3 min, 51 of optimum
• After 30 min, 20 below optimum

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PHYSIOLOGIC EFFECTS OF SLEEP DEPRIVATION

• Hypoxemia
• Insulin resistance
• Elevated sympathetic activity
• Blunted arousal response

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NEUROBEHAVIORAL EFFECTS OF SLEEP DEPRIVATION

• Voluntary / involuntary MSLT shorten
• Microsleeps intrude (state instability)
• Behavioral lapses (error of omission)
• False response (error of commission)
• Time on task decrements (fatigue)
• Cognitive speed/accuracy trade off
• Learning and recall deficits
• Working memory etc decline

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ADAPTATION TO SLEEP LOSS

• EFFECTS OF CIRCADIAN RHYTYM
• ON SHIFT WORK
• LEARNING TO FUNCTION

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MASKING EXCESSIVE SLEEPINESS

• Motivation
• Emotion
• Environment
• Posture
• Activity
• Light
• Food intake

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CHRONOBIOLOGY

• Examines the timing of biologic processes and the
  effect of time on function
• Studies dysharmonies between circadian rhythms
  and sleep wake cycle
• Applies principles to designing work to maximize
  function over 24 hr day

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• Grounding of the Exxon Valdez
• Three Mile Island
• Erroneous launch of the Challenger
• Transportation accidents

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IMPACT ON MD/PT SAFETY

• BSE
• MEDICAL ERRORS
• SURGICAL COMPLICATIONS
• DROWSY DRIVING

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EXTENDED SHIFTS MVAs

• Barger et al. NEJM Jan 05
• 2737 interns , 17,003 monthly reports
• OR after extended shift
• MVA 2.3
• Near miss 5.9
• OR with 5 or more extended shifts in mo
• Fall asleep driving 2.39
• Fall asleep at light 3.69

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BSE EXPOSURES / TIME OF DAY

• Average 40 accidents per hour per 1000 MDs in
  training 6AM-6PM
• Average 60 accidents per hour per 1000 MDs in
  training 6PM-6AM
• RR 1.5 for BSE on nights, esp junior HO
• Parks et al, Chronobiol Int 2000

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SURGICAL COMPLICATIONS

• 6371 resident surgical cases 1/85 4/88
• Analyzed complications by call status of
  residents who took q 4th night call
• When occurred on a non call day, complication
  rate was 45 higher post call
• Analyzed emergent vs. scheduled cases and no
  statistically significant difference
• Haynes, Southern Medical Journal, 1995

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STUDIES ON RESIDENTS

• Surgical residents
• Increase in time to complete gt accuracy
• Decreased performance on in training exam
• Decreased participation in OR
• Non surgical residents
• Some studies show higher error in procedures and
  interpretation of data

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MEDICAL ERRORS

• NO study conclusively demonstrates direct causal
  relationship between fatigue/medical error
• 41 residents cited fatigue as cause of most
  serious medical error
• Wu, JAMA 1991
• 10 anesthesia errors found fatigue as factor
• Morris, Anaesth Intensive Care, 2000

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• Harvard ICU/CCU intern study, 2004
• 3 intern traditional vs. 4 intern intervention
• 35.9 more serious errors
• 20.8 more serious medication errors
• 5.6 X more serious diagnostic errors
• Landrigan, et al NEJM 2004

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EFFECT OF PROTECTED SLEEP TIME

• Provision of night float for 4 hr protected sleep
• Did not change total sleep time
• Sleep efficiency improved
• Alertness and performance unchanged
• Richardson GS et al, Sleep 1996

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CAN WE MAKE IT WORK?

• 6 ED attendings in RCT crossover active
  placebo
• Chronobiologic principles
• Education, altered shifts, active placebo,
  experimental intervention
• Smith Coggins R et al, Acad Emerg Med,1997

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• No change in sleep time or quality
• No change in performance measures
• Subjectively, interventions gt placebo gt
  baseline
• Small sample size, complex scheduling
• Smith-Coggins, et al, 1997

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NHTSA survey
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Hours slept night before most recent nod off
while driving
NHTSA survey