Sleep Loss in Residency: Effect and Strategies for Management

1. Sleep Loss in Residency: Effect and Strategies for Management

2. How does it feel to be a resident? How do you cope, sleepless and stressed?

3. If sleep does not serve an absolutely vital process, it is the biggest mistake the evolutionary process ever made. ~ Allan Rechtschaffen ~

4. And the Value of Sleep is NOT “new news” • “The sleep of a labouring man is sweet, whether he eats little or much” Ecclesiastes 5:12 • “Sleep that knits up the ravel’d sleeve of care. The death of each day’s life, sore labour’s bath.” MacBeth 2.2 46-51

5. The Birth of Sleep Research • The first description of REM sleep at the University of Chicago in 1953 by Drs. Nathaniel Kleitmen and Eugene Aserinsky Science, September 4, 1953

6. The issues for medical residents and fellows…..

7. Sleep rules: “The New Issue” in 2003: enter the Public ,the Congress and the ACGME • Calls for improved safety & hours regulation • New York’s News is generalized • Libby Zion and NY 405 • Conyers Bill • The ACGME Work Hours Restrictions • Examples from other industries (aviation, trucking, railways)

8. How Do We Compare?? Industry (year limit instituted)Monthly limit Aviation (regulation, 1938, 1985) 100 hrs (flight time) Trucking (regulation, 1938) 260 hrs (driving) GME (accreditation, 2003) 320 hrs (in-house service and education) Maritime (statute, reg. 1918, 1997) 360 hrs (at sea) Rail (statute, 1907, 1969) 432 hrs (engineers)

9. Why Is Sleep Loss in Graduate Medical Education an “Enduring Issue” • Health care is a 24 / 7 industry • Health care relies on human cognitive functioning (decision-making, memory, vigilance, information management, communication)

10. The “Enduring Issue” Unintentional human error is THE most frequently identified cause of accidents in all industries House, 3rd season finale, 2007 “Human Error”

11. Why Physicians May Downplay the Importance of Sleep ……… • Most physicians know relatively little about sleep and sleep physiology. • Sleepiness is not measured in a blood test ….yet

12. The cultural context of Medical “training”: • “Sleep is optional” • A sign of weakness • A sign of lack of dedication

13. The ACGME Standards • Call scheduled no more than every third night • One (24-hour) day in seven free of patient care • Limit of 80 duty hours per week • 24-hour limit on continuous duty, up to 6 hours for transfer, debriefing, didactic activities • A 10-hour minimum rest between duty periods • In-house hours during home call count toward weekly hours limit • Education of residents and faculty about sleep loss/fatigue and its management is REQUIRED

14. The “New Recommendations” of the Institute of Medicine • No new admissions after 16 consecutive duty hours • Mandatory 5 hour nap between 10pm and 8 am • One weekend off per month as well as one day off in 7

15. How are we doing with the Old Rules??? • JAMA 2006: 83% of interns surveyed (4015 of 37,253) reported work hours violations during one or more months of training • Most were on inpatient rotations • Most were > 30 consecutive hours • Mean sleep on call: 2.5 hours

16. Compliance with the 30 hour rule Stating the Obvious • 30 hours is indeed 30 hours • Sign outs are imperatives • Team sport behavior • Become accustomed to not being “done”

18. What do we need to know about sleep deprivation in general???

19. Sleep and Job PerformanceAcute vs. Chronic Partial Sleep Deprivation • The same degree of impairment results from 24-48 hr acute sleep loss or from sleeping <6 hrs/night for 7 days or more

20. Sleep and Job Performance • The individual’s perception of sleepiness is leastaffected by sleep deprivation

21. To perform at their best, To learn….Everyone needs sleep…every night

22. Sleep and Job Performance Sleep Inertia “The brain on auto-pilot” • Acting as though awake, you have no subsequent recall of conversations and decisions made I am sure you can give the tylenol IV

23. Sleep Deprivation Adversely Affects Job Performance • Reduces vigilance & recall • Affects complex tasks and problem-solving • Performance deteriorates with time-on-task

24. Sleep Deprivation • Causes perseveration, poor prioritization of tasks • Individuals maintain accuracy at the expense of speed • Negatively affects motivation and mood

25. Sleep Deprivation • Learning ceases

26. Sound Bites from “The Data” Sleep protects declarative memory and renders it resistant to interference…and is important for motor skills acquisition. Neuron 2002 Practice (with sleep) makes perfect !!!

27. JAMA: Neurobehavioral Performance of Brown University Pediatrics Residents after call = blood alcohol 0.05g% • Tested: Sustained attention, vigilance, simulated driving • Previous data likened call to a blood alcohol of 0.1g%

28. Sleep: Meta-analysis. After 30 hours there is a significant decline in cognitive function, vigilance, memory, clinical performance. Caution to recognize sometimes the “controls” are chronically sleep deprived.

29. JAMA: Interns (British Columbia and Harvard) report more percutaneous injuries at a mean of 29 hours on duty. Odds ratio: 1.6

30. Sleep: Canadian IM residents tested for vigilance and reaction time on a Q4 night schedule. Controls: path residents and endo fellows with no call. Findings: decreased vigilance and reaction times, NO RECOVERY BETWEEN CALLS. Post call residents did not sleep more but chose other activities, e.g. sports.

31. Assessing Alertness: How do you know when you are tired? • Falling asleep in conferences or on rounds • Feeling restless and irritable with everyone • Having to check your work repeatedly • New onset of drooling

32. Having difficulty focusing on the care of your patients • Feeling like you really just don’t care • Do you really think the patient is the enemy? • You make bad judgments!

33. Coping Strategies • Eat well • Exercise • Take a shower • Don’t push the send button when you are tired • Ask for advice and LISTEN to it

34. Coping Strategies • Better sleep at home (good sleep hygiene, i.e., sleep duration, quality, timing, frequency) • Weekly recovery sleep • Optimal sleep environment in work

35. AND …a nap is always a good thing

36. Naps • Two types: • Preventive (prior to being on-call) • Operational (while on-call) • Remember: Because of sleep inertia, you need to allow adequate recovery time (15-30 minutes)

37. More coping skills…….. • Strategic use of bright light • Strategic use of caffeine • Standing body-position….. “Do not make any important decisions while lying down” • Appropriate driving strategies (morning post-call) TAKE A CAB! • 58% of emergency medicine residents reported near-crashes driving (80% post night-shift) Steele et al, 1999

38. Sleep Deprivation and YOUR HealthHeads UP!

39. Naps aren’t a CURE for all…. Annals of Emergency Med: 3 am naps for 40 minutes improve 730 am performance for ER MDs and RNs. Actual sleep time:24 minutes. Vigilance and reaction time improved. Simulated driving did NOT.

40. Behavioral Sleep Medicine: At Eastern Va, IM residents post call simulated driving deteriorated …particularly in MEN

41. Your Health..if you sleep more than 8 hours or less than 7 hours per night increases you risk for…. • CAD • Hypertension • Obesity

42. “Short sleep” and neuro-endocrine control of appetite grehlin Short sleep leptin WEIGHT GAIN

43. Short Sleep appetite energy Glucoseintolerance

44. Short sleep……….. • More Type 2 Diabetes • More weight gain Sleep to lose weight???

45. Sleep and the Immune System The virtues of a good night’s sleep just got better, with the arrival of the news that the immune system functions best during the night.  Researchers at Stanford University used fruit flies to test their theory but there is strong evidence that the effect carries through to humans as well. December, 2008

46. JAMA: Yale IM residents in the MICU; inflammatory markers measured at 1 pm in fasted individuals, after 30 hours and after 6 hours work • Sleep: 20 minutes v 6 hours • IL6, Norepi, CRP all increased • Marked reduction in brachial artery flow mediated dilation

47. SO……………..

48. Providing 24/7 Medical Care The Ongoing Dilemma:Quality of Life v. Quality of Care???Continuity v. Fatigue

49. There are no perfect answers……… current scheduling rules and solutions have many unintended consequencesImportantly, YOUneed insight and coping skills, And sometimes some friendly advice

50. Or a guardian angel……