Sleepy & Shifty The impact of shift working on training and health Mr Dominic Slade SpR 5 Honorary Secretary ASiT All round general disliker of shifts

No such thing as a good shift.. Shifts absenteeism, hypertension, peptic ulceration, depression 1 Shifts absenteeism, hypertension, peptic ulceration, depression 1 12 hour shifts significantly worse for your health than 8 (alcohol, caffeine and nicotine dependence) 2 12 hour shifts significantly worse for your health than 8 (alcohol, caffeine and nicotine dependence) 2 Staying awake at night is unnatural Staying awake at night is unnatural 5 shifts to develop alertness or “circadian phase shift” 3 5 shifts to develop alertness or “circadian phase shift” 3 Similar period to readapt to day working Similar period to readapt to day working 1 K Sakate et al 2003 J Occup Envir Med 2 Joi 2001 Ergology 3 “Healthy Nights” Home Office

No such thing as a good shift.. Considerable evidence for maximum of 4 consecutive duties in task specific jobs 4 Considerable evidence for maximum of 4 consecutive duties in task specific jobs 4 Physiology prevents quality daytime sleep with reduced REM component Physiology prevents quality daytime sleep with reduced REM component 0300 significant dip in alertness (peak time for car accidents) 0300 significant dip in alertness (peak time for car accidents) Irony! Irony! 4 S Folkard 1999 Transport:Rhythm & Blues

Fatigue and Shift Work 3 mile island, Chernobyl, Exxon Valdez, Bhopal & Challenger explosions 3 mile island, Chernobyl, Exxon Valdez, Bhopal & Challenger explosions

Fatigue 17hrs awake=50mg% 17hrs awake=50mg% 24 hours=100mg% 24 hours=100mg% Survey of Pilots and Doctors Survey of Pilots and Doctors “Even when fatigued I perform effectively at all times” 26% pilots vs 70% of surgeons! 7 “Even when fatigued I perform effectively at all times” 26% pilots vs 70% of surgeons! 7 ECG interpretation errors, tasks take longer, diminished intubation skills on night shifts, increased response time to gas board monitor changes ECG interpretation errors, tasks take longer, diminished intubation skills on night shifts, increased response time to gas board monitor changes 7 RL Helmreich 2000 BMJ

Working the night shift-Royal Free hour shift, week of nights, 2004 over 8 week period-questionnaire 13 hour shift, week of nights, 2004 over 8 week period-questionnaire 39 SpRs (Surg 7, Ortho 7, physicians 25) 39 SpRs (Surg 7, Ortho 7, physicians 25) 30 male:9 female, 9 had one child<6yr 30 male:9 female, 9 had one child<6yr 95% return rate 95% return rate Daytime sleep 4-5hrs Daytime sleep 4-5hrs Alcohol to help sleep (9), 60% coffee, cigs to stay awake esp day Alcohol to help sleep (9), 60% coffee, cigs to stay awake esp day % slept during shift, usually at nadir 3am 70% slept during shift, usually at nadir 3am

Improved work-life balance? 46% seriously affects social/family life 46% seriously affects social/family life Adverse effects on health in 50% Adverse effects on health in 50% Recovery 2-5 days on average Recovery 2-5 days on average 74% worse quality of care at night 74% worse quality of care at night 89% would rather work on-call 89% would rather work on-call 50% concerned re negative fx on training 50% concerned re negative fx on training

Controversies of shift work Loss of on call room (4%) –how petty Loss of on call room (4%) –how petty Poor facilities Poor facilities Cross Cover in A&E (2 trusts) – What about training? Cross Cover in A&E (2 trusts) – What about training?

The Maths of Surgical Training & Shifts 99% SpRs on full shifts 99% SpRs on full shifts 1 week nights 1 week nights 1 week on call 1 week on call Consultant week on call Consultant week on call No relationship No relationship Loss of elective operating= Loss of elective operating= ¼ or 25% AT LEAST & DOESN’T INCLUDE 10 WEEKS LEAVE!!!

Impact on training ,000 hours hours Near future6000 hours Equates to 25-30% reduction in elective operating Improvement in quality of training Reduced standards

US stand: The American College of Surgeons published an official statement of its views on resident work hours (Public health law: < 80 hours/ week!) “It is illogical to make specific time-work recommendations without considering the effect on education”

Awake & Informed NEJM 2004; 351: Brigham & Womens ICU Brigham & Womens ICU Split shift with 4 th intern Split shift with 4 th intern 193 vs 158 serious medical errors/1000 pt days 193 vs 158 serious medical errors/1000 pt days 1 serious, preventable event every 3-4 weeks 1 serious, preventable event every 3-4 weeks It is not just about reducing hours, you need to know your patients It is not just about reducing hours, you need to know your patients

“Decreased total working hours does not equate with decreased fatigue levels and does not improve patient care” Police & accidents 5 Pilots and fatigue related entirely to shift design 6 Shifts should be 8 hours long, flexible, and no more than 4 consecutive duties Opt out Allow non-resident on-call working 5 S.Garbarino 1999 Intl synposium on Night & Shiftwork 6 S Bourgeois-Bougrine 1999 “““

Liability Health & Safety legislation makes managers personally liable for employees harmed by the way they work Health & Safety legislation makes managers personally liable for employees harmed by the way they work In Public sector shifts are often devised by low level management with NO resource management training In Public sector shifts are often devised by low level management with NO resource management training “Anyone responsible for resourcing shifts needs to be aware of principles of good practice and advances in the field of chronobiology, shift work and fatigue studies” 8 “Anyone responsible for resourcing shifts needs to be aware of principles of good practice and advances in the field of chronobiology, shift work and fatigue studies” 8 8 Fatigue & Anaesthetists

Shifts are bad for Health Health Family Family Work-life balance Work-life balance Patient care Patient care TRAINING TRAINING