Fatigue and the practice of anesthesiology Fatigue Impacts CRNA Performance and Patient Safety Garalynn V. Tomas, M.Ed, CRNA

Fatigue is a common symptom of normal physiologic and psychological response to exertion or stress. Fatigue has remained commonplace in anesthesia practice and is either ignored or accepted due to persistent, high-intensity work demands and employment expectations (Sinha et al, 2013).

Terminology Fatigue Sleepiness Sleep inertia Sleep deprivation Sleep debt Microsleeps

Terminology Attentional failures Fatigue-avoidance strategies Fatigue countermeasures Circadian Rhythm

Vigilance…the Key to Appropriate and Safe Patient Care Vigilance defined as “state of readiness to detect and respond to small changes occurring at random intervals in the environment” (Jorm and O’Sullivan, 2012) Standards of the AANA and the ASA regarding patient monitoring highlight the constant presence of a vigilant anesthesia provider (AANA, 2013 & ASA, 2009) Ethical duty to protect patients against undue risk and harm and be fit for duty (AANA, 2005 & ASA, 2015)

Anesthesia Provider Fatigue Scientific evidence linking fatigue with deficits in human performance, accidents, and errors in industries from aeronautics to medicine, nuclear power, and transportation has mounted over the last 40 years (Blum, 2011) For decades healthcare workers have worked under the assumption they can work 60-80 hours per week and not be fatigued (Council for Public Interest in Anesthesia, 2008) No standards or mandates exist that defines rest and work hours for post-graduate CRNAs and anesthesiologists (Biddle & Akers, 2011) despite anesthesia’s label of a “safety-sensitive” profession (Domen et al, 2015) The Anesthesia Patient Safety Foundation Newsletter (2005) included 7 articles specifically related to the impact of sleep- related fatigue

In the Literature No national epidemiological studies on sleep-related behaviors of CRNAs or anesthesiologists Biddle & Akers (2011) study was the first to report on a national sampling of the sleep-related behaviors of CRNAs and the attendant professional implications Purpose of the study to quantify and elucidate the sleep activity on a large, national, random sample of CRNAs Findings of respondents: 15.7% reported falling asleep during an anesthetic case 25% reported using sleep aids to achieve or maintain sleep 48.8% reported observing colleagues engaged in sleep related behaviors

In the Literature Domen et al (2015) conducted a national survey of CRNAs on their frequency of call-shift fatigue, fatigue symptoms, medical errors associated with fatigue, and use of fatigue countermeasures and avoidance strategies Findings 82% reported experiencing call-shift fatigue 87% reported using fatigue countermeasures 77% reported using fatigue-avoidance measures 73% believed fatigue was a common problem 66.5% experienced both physiologic or psychological symptoms with fatigue 28.2% reported they had committed a patient care error because of fatigue

In the Literature A secondary aim of the study was to identify predictors of call-shift fatigue Findings 5 independent predictors of call shift fatigue were identified Hours to recover from a call shift Working 5-6 calls/month Working 7 or more calls/month Use of fatigue countermeasures Fatigue symptoms

Fatigue in Anesthesia Providers Workplace Contributing Factors Shortages in anesthesia providers Increased complexity of procedures Increase comorbidity of patients 24/7/365 profession Case volume and turnover Sleep deprivation and sleep debt Facility/department contributing factors, e.g. scheduling, anesthetizing locations Shift work Greater than 12.5 hours worked associated with 3 times more likely to make a patient error (Rogers et al, 2004) Working 24-hour shifts associated drowsy driving and increased car crashes (Blum et al, 2011) Shift work sleep disorder has increase of 10% in night and rotating shift workers (Drake et al, 2004)

Workplace Fatigue for Anesthesia Providers Poses Public Health and Safety Concerns ⇒ Cognitive slowing ⇒ Impaired vigilance ⇒ Increased performance variability ⇒ Neglect of non-essential activities ⇒ Learning of new information decreases ⇒ Problem solving declines ⇒ Memory degrades ⇒ Motivation declines

Workplace Fatigue for Anesthesia Providers Poses Public Health and Safety Concerns ⇒ Conducting multiple rechecks of completed tasks ⇒ Drooping eyelids or red eyes ⇒ Indecisiveness ⇒ Unaware of surroundings ⇒ Difficulty awakening after adequate sleep ⇒ Decreased situational awareness ⇒ Decreased reaction time ⇒ Sleep intrudes into wakefulness, e.g. nodding off while awake ⇒ Increased irritability, negativity, and apathy

Physiology of Fatigue Sleep homeostasis Consecutive hours of wakefulness Circadian factors Sleep disorders (narcolepsy, insomnia, sleep apnea) Other factors that affect waking function Noise Depressant or stimulate drugs Chronic or acute illness, e.g. chronic pain Extreme of temperature Lack of environmental stimuli

Fatigue and Its Effect on the Health of the Anesthesia Provider Decreased reaction time Impaired language and motor skills Short-term memory disruption and diminished reasoning skills Hormonal changes Increased insulin resistance underlying cause of metabolic syndrome Changes in melatonin, leptin, ghrelin, cortisol, and serotonin Increase in risky behaviors Increased use of alcohol (Virtanen et al, 2015)

Fatigue and Its Effect on the Health of the Anesthesia Provider Increase risk of disease and all-cause mortality Obesity, depression, GI disorders, CV related comorbidity, inhibition of the immune cells and cytokines (HealthyPeople2020) Increased incidence of certain types of cancers (Stowkowski, 2004) Breast cancer amongst postmenopausal women who worked > 30 years on rotating night shift Colorectal cancer in women working rotating night shift (3x/week) for > 15 years

Fatigue and Its Effects on Human Performance > 18 hours of wakefulness associated to a blood alcohol concentration (BAC) of 0.05% Impaired judgment, lowered alertness, loss small muscle control (eye coordination) > 24 hours of wakefulness associated to a BAC of 0.10% Decrease in hand-to-eye coordination Deterioration of reaction time, poor coordination, impaired memory BAC of 0.08% is considered legally impaired for driving (CDC, 2015)

Drowsy Driving National Sleep Foundation’s 2005 Sleep in America poll found that 60% of adult drivers drive drowsy and 37% have fallen asleep at the wheel 13% of drowsy drivers have nodded off at least once per month The National Highway Traffic Safety administration estimates over 100,000 people are killed or injured each year in crashes attributed to drivers who fell asleep at the wheel or were impaired by drowsiness According to the European nations, England, Australia, and Finland data, 10-30% of crashes is attributed to drowsy driving (National Sleep Foundation, 2015)

Risk Factors Associated with Drowsy Driving Sleep deprivation and fatigue make lapses of attention more likely to occur Shift workers (36%) versus those who work a normal work schedule (25%) Sleep deprivation increases the risk of related crashes Sleeping < 5 hours increases risk 4-5 times Sleeping 6-7 hours increases risk 2 times Most crashes or near misses occur between 0400-0600, 0000- 0200 and 1400-1600 More people tend to fall asleep more who live in urban areas (24%) versus rural or suburban (17%) (National Sleep Foundation, 2015)

Fatigue Countermeasures Use of stimulants or medications Self medication with coffee, tea, energy drinks, and supplements Standing and walking around OR during long cases Interacting with the surgical team Engaging in non-anesthesia related activities such as reading Frequent breaks Taking naps while on long shifts or calls Increasing light intensity Regular exercise Consistent sleep-wake patterns Recovery sleep between shifts (AANA, 2015)

Fatigue Avoidance Strategies Sleep health education Practice healthy sleep habits Avoid stimulants before bedtime Practice a uniform sleep-wake cycle Take a nap before long shifts Consider the use of sleep aids (OTC and prescription) Caffeine most widely used Prescription for shift work disorder (Biddle & Aker, 2011)

Global Approaches to Address Fatigue Education is fundamental for any effort to address anesthesia provider fatigue Comprehensive alertness management approach Component 1: Education Component 2: Alertness Strategies Component 3: Schedules Practices and Policies Component 4: Healthy Sleep Component 5: Scientific and Policy Support (Rosekind, 2005)

Summary Patient safety is at the core of the mission statements of both the AANA and ASA Fatigue and sleep deprivation are professional and patient safety issues Managing fatigue-related risks in health care is complicated It is imperative that anesthesia providers recognize the importance of fatigue and its effect on providers, patients, and public health Administrators and leaders in the anesthesia profession must move beyond discussion and documentation and take a proactive approach that will manage the known risks associated with fatigue in health care (Rosekind, 2005)

References American Association of Nurse Anesthetists. Certified Registered Nurse Anesthetists (CRNAs) at a glance. http://www.aana.com/ataglance.aspx. Accessed July 31, 2017. American Association of Nurse Anesthetists. Code of Ethics for the Certified Registered Nurse Anesthetist. http://www.aana.com/resources2/professionalpractice/Pages/Code-of-Ethics.aspx. Accessed July 31, 2017. American Association of Nurse Anesthetists. Patient Safety: Fatigue, Sleep, and Work Schedule Effects. http://www.aana.com/resources2/professionalpractice/Pages/Patient-Safety- Fatigue-Sleep-Work-Schedule-Effects.aspx. Accessed August 1, 2017 American Society of Anesthesiologists. Website. Standards guidelines and statements. http://www.asahq.org/publicationsAndServices/sgstoc.htm. Accessed July 31, 2017. Biddle C, Aker J. The National Study of Sleep-Related Behaviors of Nurse Anesthetists: Personal and Professional Implications. AANAJ.2011;79(4):324-331

References Blum AB, Shea S, Czeisler CA, Landrigan CP, Leape L. Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety. Nature and Science of Sleep. 2011;3:45-85 Centers for Disease Control and Prevention. Impaired Driving: Asleep at the Wheel. 2014. http://www.cdc.gov/MotorVehicleSafety/Impaired_Driving. Accessed August 1, 2017. Domen R, Connelly CD, Spence D. Call-shift fatigue and use of countermeasures and avoidance strategies by Certified Registered Nurse Anesthetists: a national survey. AANAJ. 2015;83(2): 123-131 Drake CL, Roehrs T, Richardson G, et al. Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers. Sleep 2004;27:1453-62 HealthyPeople 202. Sleep Health. https://www.healthypeople.gov/2020/topics- objectives/topic/sleep-health. Accessed July 31, 2017 Jorm CM, O’Sullivan G. Laptops and smartphones in the operating theatre—how does our knowledge of vigilance, multi-tasking and anesthetist performance help us in our approach to this new distraction? Anaesth Intensive Care. Jan 2012;40(1):71- 78

References National Sleep Foundation. Facts and Stats. http://drowsydriving.org/about/facts- and-stats/. Accessed August 1, 2017 Council for Public Interest in Anesthesia. Fatigues anesthesia providers make errors. Quality Review in Anesthesia. 2008;11(3) Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff Millwood. 2004;23(4):202-212 Rogers AE. The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety. In:Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD)2008 Rosekind, MR, guest ed. Fatigue & the practice of anesthesiology. Anest Patient Safety Found Newslett. Spring 2005. http://apsf.org/newsletters/html/2005/spring/01fatigue.htm. Accessed August 1, 2017. Sinha A, Sinha A, Tewari A. The fatigued anesthesiologist: A threat to patient safety? J Anaesthesiol Clin Pharmacol. April 2013;29(2):151-159 Stokowski LA. A Wake-up call for nurses: sleep loss, safety, and health. http://www.Medscape.org/viewarticle/481189_print. Accessed August 1, 2017. Virtanen M, Jokela M, Nyberg ST, et al. Long working hours and alcohol use: systematic review and meta-analysis of published studies and unpublished individual participant data. BMJ2015;250:g7772

Thank you for your attention Garalynn V. Tomas gvtcrna@gmail.com 440-479-1353