Christian Updike, MD
Occupational Medicine
Medical Director Employee Health, HealthONE
PREVIEW:
Fatigue Countermeasure Tools
 Tactical Screen/Sunlight Management
 The Nap “Triathlete” & Anchor Sleep
 Errors increase at 2 pm and 2 am: Caffeine?
 Errors increase on 3 night shifts: 72 hours
 Errors increase w/time on task: Switch every 30min
 Errors increase with interruptions
 Staff Conflict/Staff Bullying increases fatigue.
 Recovery: watch funny videos
 Recovery: Sleep clears brain toxins (coffee can’t!)
What is Fatigue?
 Stressors exceed Resources
Fatigue types:
Guide to picking Countermeasure
Cognitive
Emotional
Physical
Some Fatigue Consequences
Staff conflict
More
Frivolous
Work Comp
FAMILY
CONFLICT
Fatigue
Turnover
/Absenteeism
MEDICAL
ERRORS
Misery
Fatigue Stages
STILL TIRED
FROM PRIOR
SHIFT
ACUTE
FATIGUE
CHRONIC
SHIFT
FATIGUE
BURNOUT
QUIT
JCAHO Alert on Fatigue
 Official JCAHO Sentinel Event Alert on HealthCare
Worker Fatigue
 Released 2011
 Specifically suggest Reform
 http://www.jointcommission.org/assets/1/18/sea_
48.pdf
Work Limits in Safety Sensitive
Groups
 Pilots: FAA (max 30h/wk or 100 h/month)
 Trucker: DOT (11 hours drive/day, after 10 consecutive





hours off)
Soldier: US Military (rec’d 8 hours rest/day!)
National Wildfire: 16 hours/day
CDC disaster teams: 12 hours/ day
Nuclear power plant: 16 hours/day
Health Care Workers: EH…WHATEVER (?!?!?)
General setup for Fatigue in
Occupational Setting
• Emotional Stress > Genetic Disposition
• Cognitive Stress > Training/hour worked prior 7d
• Physical Stress> Energy level/Sleep prior 72h
 Lack of Situational Control
 Effort/Reward Imbalance
Relived by…not being awake.
Challenger Story
Understand your brain can (partially)
turn off even with eyes open.
 Sleep deprived Rats studies of 10% cells going off line
while awake
 Microsleeps—high risk of error
 Loss of situational awareness
Sleep activates brain cleaning
 Beta Amyloid rises 6% if miss ONE night
 Beta Amyloid associated with hallucinations/dementia
 NEW GLYMPHATIC System found in 2012
 GLYMPHATIC dilates 60% when asleep- incr flow
---Manage your light exposure and improve Sleep--
Digital Light Management
 Free programs that gradually lower your screen
brightness at night (Google: “Screen Dimmer”)
 Bright blue light can delay onset of (needed) sleep
 This presentation is in blue
 Facebook/Twitter/LinkedIn pages in blue
Reduce light from phone
Normal
“INVERT COLORS”
Sunlight Management
 Light Retina SCN suppress MelatoninAlert
 Stare at the sun vs wear blue blocker sunglasses
Light at night =Cancer? YES
 Completely blind women have LESS Breast Cancer
(43%) than sighted women.
 Partially blind women =no cancer protection
 Darkness= incr Melatonin= incr death of cancerous
cells.
 Double Cancer rates of pancreatic, Colon, prostate
CA
Be a Nap “Triathlete”
 1 dose of caffeine THEN
 20 min nap THEN
 5 minute walk
 Official Fatigue Risk Management recommendation
from American College of Occupational and
Environmental Medicine.
Nap 20 min OR 90 minutes
 Avoid awaking in “middle” of a 90 minute cycle
 Sleep Inertia: the confusion if awaken mid sleep cycle
Anchor Sleep
 Try to get 4 hours sleep at the same time each day
.
Caffeine T1/2= 4 hours
 Half life= time until 50% is eliminated
 3h in smokers/heavy users vs 7h. pregnant
 Learn your caffeine content:
5 cans Diet coke vs. Starbucks 12 ounce coffee
Adenosine  Brain receptors Shut down
 ATP ADP+P AMP+P Adenosine +P
 Adenosine is like pulling up the parking break.
 Adenosine is [BLOCKED] by caffeine
Sleep is VERY Active Process
 Energy surge (Brain ATP levels increase) at start of
sleep.
 Immune proteins made during sleep
 Probable Emotional interpretation of prior events
 Dump Beta –Amyloid toxin
Sleep to Remember & Learn
 Sleep to retain knowledge in memory.
 Rewiring brain
 Acetylcholine levels must be low to create perm
memories.
Counter measures:
Talk more at night
 Linemen Disaster crew story
 Keeps self and coworkers engaged/alert
 Informal way of tracking each others alertness
Badge of honor working sleep
deprived? Need to change our culture
 Sleep deprivation = similar to being drunk.
 Would we brag about working drunk?...we do it for
sleep deprivation.
Sleep in a Cave
 Quiet: silicone earplugs
 Cool: 68 degrees
 Dark: Blinders
The Brits’ Afternoon Tea is a good
idea
 Use caffeine at 2pm for day shift
 Use caffeine at 2 AM for night shift
 (Exxon Valdez disaster –fell asleep at 1 am)
 (3 Mile Island nuclear melt down 3 am)
Reduce cognitive load with
checklists
 Pilots use checklists
 Surgeons now required to do verbal check list (to
confirm with surgical team right pt, correct location,
correct procedure)
 Use your brain for more interesting tasks
Switch Tasks Every 30 min
Relative risk of injuries and accidents as a function of successive night shifts.
Folkard S, Tucker P. Shift work, safety and productivity. Occup Med (Lond). 2003 Mar;53(2):95–101.
More Errors at 2 pm and 2AM
Relative real-job speed and accuracy measures across the hours of the day. Folkard S, Tucker P. Shift work, safety and productivity. Occup
Med (Lond). 2003 Mar;53(2):95–101.
Interruptions are Risky!
 Data is showing multi-tasking is a good way to make
errors.
 The nursing medication/interruption study
 DISCOURAGE INTERRUPTIONS when giving meds
Undiagnosed Sleep Apnea
 Sleep Apnea is VERY likely if:
 Body mass index >35
 Neck >17” (16” females)
 Can’t see the uvula (Mallampati Score)
 BP takes 3 meds to control
Suppressing emotion is exhausting
 Not showing emotion is a risk factor for burnout.
(Consiglio, C.2014, Burnout Research p. 70)
 Our profession expects emotional control
 Takes energy to suppress emotions, and we have a
limited supply of energy.
Use Dark Humor
 The South Orange Rescue Story
 Body recovery/BP
Watch Funny Videos, really
 30-60 min laughter
 Lower cortisol
 Lower catecholamines (epi)
 Raised endorphins (feel good chemicals)
 Raised IgG/IgM x 12 hours (immune chemicals)
 Human growth hormones increased
 Anticipation of videos had similar effect
Schedule shifts 60 days in advance
(Minimum!)
 Give staff time to review social plans and swap as
needed.
 Reduces having to miss events with family & friends,
thus reduce the “work resentment factor”.
Negative hospital staff gossip
directly linked with Burnout
 Toxic environment
 Increases depersonalization and intent to leave.
(Georganta, K 2014)
 Negative Gossip: Ostracize and bully
CDC/NIOSH Recognize staff conflict
is a patient safety issue
 Does a team communicate well if dysfunctional?
 Nurse bullying:
 CDC course #WB-1865
 NIOSH course #2013-155
 Agency for Healthcare Research and Quality and Dept
of Defense: ”TeamSTEPPS”
 Consider formal anti-bullying policy
Lateral Staff Conflict
(Interpersonal Strain at Work- ISW)
 Team Conflict: INCREASES as fatigue increases.
 Silent Conflict: Withholding info that would help
 UNDERREPORTED
 Staff turns on each other if distressed by leadership
 [SEE AOHP JOURNAL Spring 2015!]
Emotional Fatigue Counter measure:
Exercise at 85% for 10 min
 Raises Dopamine (Pleasure)
 Raises Adrenaline (Energy)
 Raises Serotonin, maybe. ( Calm )
Emotional Fatigue Counter
measure: POSITIVE social support
 Some people/friends can LOWER your emotional
fatigue. MAKE TIME for them.
 Some people/ “frenemies” can INCREASE emotional
fatigue  LIMIT time for them.
Emotional Fatigue 
higher risk substance abuse
 Healthcare workers have a HIGHER risk of substance
abuse than community.
 Certain Specialties have higher risk (ER 3x alcohol
abuse)
 American Nursing Association lists substance abuse of
nurses at approx 10%.
 Need CLEAR WRITTEN POLICY: no CONTROLLED
Substances (DEA Schedule II,III, IV) 8 hours prior to
or at work
Now in your Fatigue Toolbox!
 Tactical Screen/Sunlight Management
 The Nap “Triathlete” & Anchor Sleep
 Errors increase at 2 pm and 2 am: Caffeine?
 Errors increase on 3 night shifts: 72 hours
 Errors increase w/time on task: Switch every 30 min.
 Errors increase with interruptions
 Staff Conflict/Staff Bullying increases fatigue.
 Recovery: watch funny videos
 Recovery: Sleep clears brain toxins (coffee can’t!)
Contact me at Christian.Updike@HealthOnecares.com
www.Fatiguetips.Weebly.com
References
American Nursing Association. (2015). Bullying and Workplace Violence. Retrieved
6/15,2015.
http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/bullyingworkplacevi
olence
Breast Cancer Fund. (2015). Shift Work, Light-at-Night and Melatonin. Retrieved 6/30,2015
from http://www.breastcancerfund.org/clear-science/radiation-chemicals-and-breastcancer/light-at-night-and-melatonin.html.
Bria, M., Spanu., F., Baban, A., Dumitrascu, D.L. (2014). Maslach Burnout Inventory –
General Survey: Factorial validity and invariance among Romanian healthcare professional.
Burnout Journal. 1(3):103-111. Doi: 10.1016/j.burn.2014.09.001.
Carla, S.M., et al.(2013). Effects of insufficient sleep on circadian rhythmicity nas. Effects of
insufficient sleep on circadian rhythmicity and expression amplitude of the human blood
transcriptome. Proceedings of the National Academy of Sciences of the United States of
America. 110(12):E1132-E1141. Doi:10.1073/p
References, Continued -2
Consiglio, C. (2014). Interpersonal strain at work: A new burnout facet relevant for the
health of hospital staff. Burnout Research. 1(2014):69-74. Doi: 10.1016/j.burn.2014.07.002.
Dawson D, et al., Fatigue-proo!ng: A new approach to reducing fatigue-related risk using the
principles of error management, Sleep Medicine Reviews (2011),
doi:10.1016/j.smrv.2011.05.004
Flynn-Evans EE, Stevens RG, Tabandeh H, Schernhammer ES, Lockley, SW Total visual
blindness is protective against breast cancer. Cancer Causes Control. 2009 Nov;20(9):1753-6.
doi: 10.1007/s10552-009-9405-0. Epub 2009 Aug 1.
Gabel V., et al. (2014). Dawn simulation light impacts on different cognitive domains under
sleep
Behavioral Brain Research Factor. 12/2014; 281. DOI: 10.1016/j.bbr.2014.12.043.
Georganta, K., Panagopoulou E., Montgomery, A. (2014). Talking behind their backs:
Negative gossip and burnout in Hospitals. Burnout Journal. 1(2014).76-81.
Doi:10.1016/j.burn.2014.07.003.
Gu, F. et al. (2015) Total and Cause-Specific Mortality of U.S. Nurses Working Rotating Night
Shifts. American Journal of Preventative Medicine. 48(3).241-252
DOI: http://dx.doi.org/10.1016/j.amepre.2014.10.018
References, Continued-3
Iliff, J.J., et al. (2012). A paravascular pathway facilitates CSF flow through the brain
parenchyma and the clearance of interstitial solutes, including Beta Amyloid . Science
Translational Medicine. 4(147):147ra111. Doi: 10.1126/scitranslmed.3003748.
JACHO. (2011). Sentinel Event Alert on HealthCare Worker Fatigue. Retrived 9/15, 2013,
from http://www.jointcommision.org/assets/1/18/sea_48.pdf
Kimmel, N. & Whittington, J. (2011). Greater than previously measured ‘Global Trigger Tool’
shows that adverse events in Hospitals May be ten times greater than previously measured.
Health Affairs, 30(4),581-589 Doi: 10.1377/hlthaff.2011.0190.
Lee, Y., Lee, M., Bernstein, K. (2013). Effect of Workplace Bullying and Job Stress on
Turnover Intention in Hospital Nurses. Journal of Korean Academy of Psychiatric and
Mental Health Nursing. 22(2):77-87. Korean. doi:
http://dx.doi.org/10.12934/jkpmhn.2013.22.2.77
Lerman, S.E., et al. (2012). ACOEM Guidance Statement: Fatigue Risk Management in the
Workplace. Journal of Occupational and Environmental Medicine. 54(2):231-257.
References, Continued-4
Martinez, E. (2015). EmoBurnout: An Approach for Supporting Burnout
Syndrome Diagnosis. Studies in Health Technology and Information. 211, 111-118.
Miller, J. (2013). Fundamentals of Shiftwork, 3rd Edition: Fixing Stupid.
Smashwords eBook. ISBN: 9781301961894
Miller, J. (2013). Anatomy of a Fatigue-Related Accident. Smashwords eBook ISBN:
9781310879265
Ooms, S., Overeem, S., Besse, K., Rikkert, M.O., Verbeek, M., & Claassen J.A.
(2014). Effect of 1 night of total sleep deprivation on cerebralspinal Fluid Beta
Amyloid in 42 healthy middle-aged men: a randomized clinical trial. Journal of
American Medical Association Neurology71(8).971-977. Doi:
10.1001/jamaneurol.2014.1173
Paret, M.E. (2012). Night work and the risk of Cancer Among men. American
Journal of Epidemiology. 176(9): 751-759. doi: 10.1093/aje/kws318
References, Continued-5
Ribeiro, J.A., Sebastiao, A.M. (2010). Caffeine and Adenosine. Journal of Alzheimer’s
Disease. 20(Supplement 1):S3-S15. Doi: 10.3233/JAD-2010-1379.
Slideshare. (2015). 10 Signs You’re Burning Out and What to Do About it. Wandick Rocha de
Aquino Retrieved 7/1,2015, http://www.slideshare.net/wandickrochadeaquino/10-signsyoure-burning-out
Steffen, G., Born, J. (2004). Low Acetylcholine during slow-wave sleep is critical for
declarative memory consolidation. Proceedings of the National Academy of Sciences of the
United States of America. 101(7):2140-2144. Doi: 10.1073/pnas.0305404101.
Trinkoff, A.M., Storr, C.L. (1998).Substance use among nurses: differences between
specialties. American Journal of Public Health. 88(4), 581-585.
Vyazovskiy, V., Olcese, U., Hanlon, E., Nir, Y., Cirelli, C., & Tononi G. (2011). Local sleep in
awake rats.Nature. 472,443-447. Doi:10.1038/nature10009.
References, Continued-6
Winwood, P.C., Winefield A.H., Dawson, D., Lushington, K. (2005). Development and
validation of a scale to measure work-related fatigue and recovery: the Occupational Fatigue
Exhaustion/Recovery Scale (OFER). Journal of Occupational and Environmental Medicine.
47 (6):594-606.
Xie, L., et al. (2013). Sleep drives metabolite clearance from the adult brain. Science. 342:373373.
Appendix: Department
 Predictable schedule/ 60 days out
Appendix: Institution
 Zero Tolerance nurse bullying policy
 Fatigue Risk Management System
 Dysfunctional Team interventions: Crew Resource
Management (TeamSTEPPS)
 Limits on foul language