Sleep Deprivation/Fatigue Chief Resident Conference 2010

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 Founder of Surgical Training at Johns Hopkins Courtesy: Czeisler, C

Historical Perspective on Residency “…. 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.” William Stewart Halsted Performing Surgery at Johns Hopkins Hospital 1904 Markel H. The Accidental Addict. N Engl J Med 2005;352:

Libby and Sidney Zion 1989 New York changes health code

© American Academy of Sleep Medicine American Academy of Sleep Medicine Epworth Sleepiness Scale Sleepiness in residents is equivalent to that found in patients with serious sleep disorders. Mustafa and Strohl, unpublished data. Papp, 2002

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 StamatisGeorge Stamatis

© American Academy of Sleep Medicine 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 *Baldwin and Daugherty, Survey of 3604 PGY1,2 Residents Work Hours, Medical Errors, and Workplace Conflicts by Average Daily Hours of Sleep*

Serious Medical Error Rates of Interns Working in Intensive Care Units Traditional Shift (> 24 hrs) Scheduled Shift (< 16 hrs)

© American Academy of Sleep Medicine 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 % of emergency medicine residents reported near- crashes driving % post night-shift -- Increased with number of night shifts/month Steele et al 1999

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 American Academy of Sleep Medicine Sleep Fragmentation Affects Sleep Quality = Paged NORMAL SLEEP ON CALL SLEEP MORNING ROUNDS

RESPONSE TO INFLUENZA VACCINATION Mean Antibody Titers (10 6 ) p<0.03 ns Time relative to influenza vaccination (days)

GLUCOSE METABOLISM Glucose tolerance (Kg; %. min-1) Insulin sensitivity (mU/l-1. min-1) * p = 0.03 * p = 0.01 * p = 0.02 ns

© American Academy of Sleep Medicine 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

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!