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Barbara Phillips, MD, MSPH, FCCP

Sleep and Sleep Loss: What Physicians in Training Need to Know. Barbara Phillips, MD, MSPH, FCCP. Objectives. 1. to understand who is at risk when a surgeon is sleep-deprived 2. to describe the greatest risk of sleep deprivation 3. to discuss two countermeasures to sleep loss. Overview.

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Barbara Phillips, MD, MSPH, FCCP

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  1. Sleep and Sleep Loss: What Physicians in Training Need to Know Barbara Phillips, MD, MSPH, FCCP

  2. Objectives 1. to understand who is at risk when a surgeon is sleep-deprived 2. to describe the greatest risk of sleep deprivation 3. to discuss two countermeasures to sleep loss.

  3. Overview • Why are we having this talk? A Little History • What is the evidence to support these policies? • How is sleepiness measured? • Who is at risk? • What is the risk? • How to protect yourself

  4. Correlates of Reduced Sleep Duration:Residents • Residents averaging ≤ 5 hours sleep/night were more likely to report: serious accidents or injuries OR = 1.84 (1.23 – 2.74) conflict with other professional staff OR = 1.41 (1.08 – 1.84) use of medications to stay awake OR = 1.91 (1.39 – 2.62) working in an “impaired condition” OR = 2.19 (1.79 – 2.68) making significant medical errors OR = 1.74 (1.47 – 2.06) being named in malpractice suit OR = 2.02 (1.17 – 3.47) Baldwin & Daugherty, SLEEP 2004

  5. Impact on Performance • Surgery: • 20% more errors and 14% more time required to perform simulated laparascopy post-call (two studies) (Taffinder et al, 1998; Grantcharov et al, 2001) • Emergency Medicine: • Significant reductions in comprehensiveness of history & physical exam documentation in second year residents(Bertram 1988) • Longer intubation time required after call (Smith-Coggins, 1994) • Internal Medicine: • Efficiency and accuracy of ECG interpretation impaired in sleep-deprived interns (Lingenfelser et al, 1994) • Family Medicine: • Scores achieved on the ABFM practice in-training exam negatively correlated with pre-test sleep amounts(Jacques et al 1990) • Pediatrics: • Time required to place an intra-arterial line increased significantly in sleep-deprived(Storer et al, 1989)

  6. Impact on Performance • Surveys: more than 60% of anesthesiologists report making fatigue-related errors. Gravenstein 1990 • Case Reviews: - 3% of anesthesia incidents Morris 2000 - 5% “preventable incidents” “fatigue-related” - 10% drug errors Williamson 1993 - Post-op surgical complication rates 45%, higher if resident was post-call Haynes et al 1995

  7. Impact of Extended Duration Shifts on Medical Errors and Adverse Events • 1 of every 5 interns admitted to making a fatigue-related mistake that injured a patient ( 700% when interns worked >24 consecutive hours) • 1 of every 200 interns admitted to a fatigue-related mistake that resulted in the death of a patient ( 300% in months interns worked five >24-hour shifts) Barger LK et al. PLoS Medicine. 2006;3:2440-2448.

  8. Professionalism “Your own patients have become the enemy…because they are the one thing that stands between you and a few hours of sleep.” Surgical resident, Time Magazine, March 2001

  9. Resident Learning • Residents working longer hours report decreased satisfaction with learning environment and decreased motivation to learn. Baldwin et al 1997 • Study of surgical residents showed less operative participation associated with more frequent call. Sawyer et al 1999

  10. Impact on Personal Health *Baldwin and Daugherty, 1998-9 Survey of 3604 PGY1,2 Residents

  11. Resident Safety • 50% greater risk of blood-borne pathogen exposure incidents (needlestick, laceration, etc) in residents between 10pm and 6am. Parks 2000 • 58% of emergency medicine residents reported near-crashes driving. • 80% post night-shift • Increased with number of night shifts/month Steele 1999

  12. A Little History • The Accreditation Council for Graduate Medical Education (ACGME) established common duty hour requirements in 2003. • This increased workload in many instances, because fiscal constraints forced many institutions to continue a heavy reliance on residents clinical contributions.

  13. Limitation of Duty Hours (to 24) and rate of Medical Errors, Occupational Exposure and Motor Vehicle Crash Pre-implementation Post-implementation P =0.37 50 45 40 35 30 25 20 15 10 5 0 P =0.88 P >0.99 Percent of respondents P =0.22 Self-reported Occupational Near-miss MVC medical error exposure MVC Landrigan CP et al. Pediatrics. 2008;122:250-258.

  14. Work Hour Restriction PolicyPros and Cons • Effects of work-hour restriction on residents’ lives: review of 54 studies (Fletcher et al. JAMA. 2005;294:1104-1106.) • Restricted work hours improve resident’s quality of life • Mixed results with regards to educational quality

  15. Work Hour Restriction PolicyPros and Cons • Effects on resident well-being, patient care, and education [survey of IM] (Goitein L et al. Arch Intern Med. 2005;165:2561-2562.) • Improved career satisfaction • Decreased emotional exhaustion • Overall approval by residents of work hour restriction • Patient care: negative (37%); neutral (34%); positive (29%) • Education: negative (47%); neutral (21%); positive (32%) • Work hour limitation in isolation is not the solution, and work hour limitation to 24 hours may not be not substantial enough.

  16. Consequences of Long Resident Work Hours Summary • 109% more attentional failures at night working >16 hours1 • 36% more serious medical errors working 30-hour shifts2 • 464% more serious diagnostic errors in the ICU2 • 168% more car crashes commuting after >24-h3 shifts • 468% more near-miss car crashes3 • 73% greater risk of needle stick or scalpel lacerations after >20 consecutive hours at work4 Lockley SW et al. N Engl J Med. 2004;351:1829-1837. 2. Landrigan CP et al. N Engl J Med. 2004;351:1838-1848. 3. Barger LK et al. N Engl J Med. 2005;352:125-134. 4. Ayas NT et al. JAMA. 2006;296:1055-1062.

  17. Institute of Medicine Report Seeks Tougher Limits on Resident Hours, December 2008 • Maximum of 80-hour week averaged over 4 weeks • Limiting shifts for the most part to 16 consecutive hours • Allow 30-hour shifts if 5 hours of sleep are provided after 16 hours of work • 12 hours off after a night shift and 14 hours after extended shifts (30 hours) • Allowing 1 day off per week and 5 days off per month • Counting moonlighting towards the allotted 80 hours • Increase in costs: 1.7 billion per year • DEBATE: Will patient care improve or might it actually suffer?

  18. “New” ACGME Work Hour Requirements, July 2011 • Duty hours must be limited to 80 hours per week, averaged over 4 weeks, inclusive of all in-house call activities and all moonlighting. • Time spent by residents in moonlighting must be counted towards the 80-hour Maximum Weekly Hour Limit. • PGY-1 residents are not permitted to moonlight.

  19. “New” ACGME Work Hour Requirements, July 2011 • Residents must be scheduled for a minimum of one day free of duty every week (averaged over 4 weeks). At-home call cannot be assigned. • Duty periods of PGY-1 residents must not exceed 16 hrs • Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. (napping recommended) • Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.

  20. “New” ACGME Work Hour Requirements, July 2011 • PGY-1s must have eight hours free of duty between scheduled duty periods. • Intermediate-level residents must have eight hours between scheduled duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty. • Residents in their final years of education may stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty.

  21. “New” ACGME Work Hour Requirements, July 2011 • Residents must not be scheduled for more than six consecutive nights of night float. • PGY-2 residents and above must be scheduled for in-house call no more frequently than every-third-night (when averaged over 4 weeks). • Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit.

  22. Work Hour Restrictions • ACGME mandates address FATIGUE • Each resident should have 1 day in 7 off. • Housestaff MUST not work more than 80 hours/wk • Call is no more frequent than every third night. • No one shift can be more than 30 hours • No mandates about sleep requirements

  23. Overview • Why are we having this talk? • What is the evidence to support these policies? • How is sleepiness measured? • Who is at risk? • What is the risk? • How to protect yourself

  24. Effect of Intern Work Hours on Serious Medical Errors • Prospective, randomized study comparing medical errors made by interns working extended shifts (>24 hours) vs interns working an intervention schedule • Extended duration shifts (>24 hours) were eliminated on the intervention schedule during which scheduled shifts were limited to 16 hours • Medical errors were assessed in 2203 patient-days involving 634 admissions Landrigan CP et al. N Engl J Med. 2004;351:1838-1848.

  25. Serious Medical Error Rates of Interns Working in Intensive Care Units Traditional Shift (>24h) Scheduled Shift (≤16h) +57% +57% * +464% Non-Intercepted Serious Medical Errors Serious Diagnostic Errors *P<0.001 Adapted from Landrigan CP et al. N Engl J Med. 2004;351:1838-1848.

  26. Serious Medical Error Rates of Interns Working in Intensive Care Units +36% +36% * * *P<0.001 Adapted from Landrigan CP et al. N Engl J Med. 2004;351:1838-1848.

  27. Attentional Failures at Night in Residents 11 PM - 7 AM Traditional Intervention (16 h or less) 2.5 1.00 2.0 0.75 1.5 # of Attentional Failures/Hour on Duty 0.50 * 1.0 0.25 0.5 0.00 0.0 Group Individual Night Time Work Hours (23:00-7:00) 0.69 (traditional) vs 0.33 (intervention) attentional failures per hour, *P=0.02; Attentional failures were defined as occurring when slow rolling eye movements (measured with electrooculogram) intruded into waking episodes during scheduled work hours Lockley SW et al. N Engl J Med. 2004;351:1829-1837.

  28. Risk of Motor Vehicle Accidents – Study Results After Extended and Non-extended Shifts Barger LK et al. N Engl J Med. 2005;352:125-134.

  29. Overview • Why are we having this talk? • What is the evidence to support these policies? • How is sleepiness measured? • Who is at risk? • What is the risk? • How to protect yourself

  30. Anesthesia Resident Study • Residents did not perceive themselves to be asleep almost half of the time when they had actually fallen asleep. • Residents were wrong 76% of the time when they reported having stayed awake. Howard et al 2002

  31. Assessment of Sleepiness • Behavioral • Facial expression, posture, yawning, myosis • Subjective • Epworth Sleepiness Scale (ESS) • Stanford Sleepiness Scale (SSS) • Objective • Multiple Sleep Latency Test (MSLT) • Maintenance of Wakefulness Test (MWT) • Polysomnography (PSG) • Actigraphy Mitler and Miller. Behav Med. 1996;21:171.

  32. The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to chose the most appropriate number for each situation: 0=would never doze 1=slight chance of dozing 2= moderate chance of dozing 3=high chance of dozing Situation Chance of Dozing Sitting and reading _____ Watching TV _____ Sitting, inactive, in a public place _____ As a passenger in a car for an hour ____ Lying down in the afternoon _____ Sitting and talking to someone _____ Sitting quietly after a lunch without alcohol _____ In a car, while stopped for a few minutes in traffic _____

  33. Typical ESS Scores (Johns, 1991) Subject ESS mean (SD) Normal controls 5.9 (2.2) Primary snorers 6.5 (3.0) OSA 11.7 (4.6) Narcolepsy 17.5 (3.5) Idiopathic Hypersomnia 17.9 (3.1) Insomnia 2.2 (2.0)

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

  35. Daytime Sleepiness in the Population n = 3283 mean = 8.0 ± 4.6 10% 9% 8% 20% 7% 6% % Population Moderate OSA = 11.5 5% 4% 3% Severe OSA = 16.0 2% Narcolepsy = 17.3 1% 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Epworth Sleepiness Scale Score (0-24) Papp K et al. Acad Med. 2004;79:394-406.Myers EJ, et al. Sleep.2003;26:A194.

  36. Daytime Sleepiness in the Population n = 3283 mean = 8.0 ± 4.6 n = 149 Mean = 14.6 ± 4.4 84% 10% 9% 8% 20% 7% 6% % Population Moderate OSA = 11.5 5% 4% Residents 3% Severe OSA = 16.0 2% Narcolepsy = 17.3 1% 0% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Epworth Sleepiness Scale Score (0-24) Papp K et al. Acad Med. 2004;79:394-406.Myers EJ, et al. Sleep.2003;26:A194.

  37. Overview • Why are we having this talk? • What is the evidence to support these policies? • How is sleepiness measured? • Who is at risk? • What is the risk? • How to protect yourself

  38. Your Sleep Need

  39. Sleep Duration, Sleepiness and Morning-Eveningness are Genetically Influenced

  40. Biology or Culture? Surgeons Dermatologists

  41. Differential Vulnerability To Cognitive Effects Of Sleep Loss: Type 1 (Resistant) Versus Type 3 (Vulnerable) People Van Dongen HPA, Sleep 2004.

  42. Overview • Why are we having this talk? • What is the evidence to support these policies? • How is sleepiness measured? • Who is at risk? • What is the risk? • How to protect yourself

  43. ESS Score Associated with MVA Subjects who reported ≥1 near-miss sleepy accident were 1.13 times more likely to actually have an accident 45% 32% Subjects With ≥1 Accident, % 28% 23% 6.57 8.41 9.56 12.10 ESS Score *P<0.0001; n=35,217 Powell NB et al. Sleep. 2007;30:331-342.

  44. Comparative Impairment of Alcohol vs Sleep Loss Roehrs T et al. Sleep. 2003;26:981-985.

  45. Overview • Why are we having this talk? • What is the evidence to support these policies? • How is sleepiness measured? • Who is at risk? • What is the risk? • How to protect yourself

  46. Four Main Strategies • Napping • Caffeine • Bright light • Avoid driving post call

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