Sleep Deprivation/Fatigue
Chief Resident Conference 2009
Objectives
• Review history culminating in the IOM
Report, “Opitimizing Graduate Medical
Trainee Schedules to Improve Patient
Safety”
• Discuss sleep and performance
• Review options for managing fatigue
William Osler
William Stewart Halsted
Courtesy: Czeisler, C
• Founder of Surgical
Training at Johns
Hopkins
Historical Perspective
on Residency
William Stewart Halsted
Performing Surgery at Johns
Hopkins Hospital 1904
“…. by the age of 33, the
physician [William
Stewart Halsted] faced …
a losing battle against a
relentless addiction to
cocaine. Yet … enjoyed
international renown as
one of the greatest
surgeons ever to wield a
scalpel.”
Markel H. The Accidental Addict. N Engl J Med 2005;352:966-968.
Libby and Sidney Zion
1989
New York changes health code
American Academy of Sleep Medicine
Epworth Sleepiness Scale
Narcolepsy
20
Residents
Sleep Apnea
15
10
Normal
Insomnia
5
0
Sleepiness in residents is equivalent to that found in patients
with serious sleep disorders. Mustafa and Strohl, unpublished data. Papp, 2002
© American Academy of Sleep Medicine
Case study shows medical residents report sleep loss
and fatigue take toll on learning, work and personal
lives. Nearly 85 percent of residents studied fall into
a range calling for clinical intervention for sleep
problems.
June 7, 2004 George Stamatis
American Academy of Sleep Medicine
Across Tasks
Emergency Medicine: significant reductions
in comprehensiveness of history & physical
exam documentation in second-year
residents Bertram 1988
Family Medicine: scores achieved on the
ABFM practice in-training exam negatively
correlated with pre-test sleep amounts Jacques
et al 1990
© American Academy of Sleep Medicine
American Academy of Sleep Medicine
• Surgery: 20% more errors and
14% more time required to
perform simulated laparoscopy
post-call (two studies) Taffinder et al,
1998; Grantcharov et al, 2001
• Internal Medicine: efficiency and
accuracy of ECG interpretation
impaired in sleep-deprived
interns Lingenfelser et al, 1994
• Pediatrics: time required to place
an intra-arterial line increased
significantly in sleep-deprived
Storer et al, 1989
© American Academy of Sleep Medicine
American Academy of Sleep Medicine
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
< 4 hrs
5-6 hrs
> 7 hrs
Work Hrs/wk
Percent
Work Hrs/wk
Work Hours, Medical Errors, and Workplace Conflicts
by Average Daily Hours of Sleep*
% Reporting
Serious Medical
Errors
% Reporting
Serious Staff
Conflicts
*Baldwin and Daugherty,
1998-9 Survey of 3604 PGY1,2 Residents
Hours of Sleep
© American Academy of Sleep Medicine
Serious Medical Error Rates of Interns
Working in Intensive Care Units
Traditional Shift
(> 24 hrs)
Scheduled Shift
(< 16 hrs)
50
150
40
100
30
20
50
10
0
Serious Medical Errors
0
Non-Intercepted
Serious Diagnostic
Serious Medical Errors
Errors
American Academy of Sleep Medicine
Sleep Loss and Fatigue:
Safety Issues
• 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 nearcrashes driving.
-- 80% post night-shift
-- Increased with number of night shifts/month
Steele et al 1999
•
© American Academy of Sleep Medicine
Driving While Drowsy:
The Threat to
Resident Physicians & Public Safety
Submitted at the
Second Meeting of the Committee on
Optimizing Graduate Medical Trainee (Resident)
Schedules to Improve Patient Safety
March 4, 2008
Irvine, CA
Maggie’s Law
American Academy of Sleep Medicine
Sleep Fragmentation Affects
Sleep Quality
NORMAL SLEEP
= Paged
MORNING
ROUNDS
ON CALL SLEEP
© American Academy of Sleep Medicine
RESPONSE TO INFLUENZA
VACCINATION
Mean Antibody Titers (106)
1.5
p<0.03
1.25
1
0.75
ns
Sleep Deprived, n=11
Control, n=14
0.5
0.25
ns
0
0
10
21-31
Time relative to influenza vaccination
(days)
GLUCOSE METABOLISM
* p = 0.03
* p = 0.01
Insulin sensitivity
(mU/l-1. min-1)
Glucose tolerance
(Kg; %. min-1)
10
2
8
6
1
ns
4
* p = 0.02
2
0
0
Baseline
After 3 nights of SWS Suppression
Baseline
After 3 nights of SWS Suppression
American Academy of Sleep Medicine
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)
© American Academy of Sleep Medicine
American Academy of Sleep Medicine
Healthy Sleep Habits
•Regular sleep hours
•Develop a pre-sleep routine.
• Use relaxation to help you fall asleep.
• Protect sleep time; enlist family; Use time off to
sleep!
• Get adequate (7 to 9 hours) sleep before
anticipated sleep loss. Avoid starting out with
a sleep deficit!
© American Academy of Sleep Medicine
American Academy of Sleep Medicine
Healthy Sleep Habits
• Sleeping environment:
– 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.
© American Academy of Sleep Medicine
American Academy of Sleep Medicine
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
(be cool and wear dark glasses driving home from
work).
© American Academy of Sleep Medicine
American Academy of Sleep Medicine
Drugs
• Melatonin: little data in residents
• Hypnotics: may be helpful in specific situations (eg,
persistent insomnia)
• AVOID: using stimulants (methylphenidate,
dextroamphetamine, modafinil) to stay awake
• AVOID: using alcohol to help you fall asleep; it induces
sleep onset but disrupts sleep later on
© American Academy of Sleep Medicine
American Academy of Sleep Medicine
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
© American Academy of Sleep Medicine
December 5, 2008
DOCTOR AND PATIENT
Does More Sleep Make for Better Doctors?
By PAULINE W. CHEN, M.D.
“Every treatment is a double
edged sword”
SUPERCHIEF!