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

2. 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).

3. Terminology Fatigue Sleepiness Sleep inertia Sleep deprivation
Sleep debt
Microsleeps

4. Terminology Attentional failures Fatigue-avoidance strategies
Fatigue countermeasures
Circadian Rhythm

5. 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)

6. 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 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

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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)

15. 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

16. 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)

17. 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)

18. 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 , and
More people tend to fall asleep more who live in urban areas (24%) versus rural or suburban (17%)
(National Sleep Foundation, 2015)

19. 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)

20. 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)

21. 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)

22. 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)

23. References
American Association of Nurse Anesthetists. Certified Registered Nurse Anesthetists (CRNAs) at a glance. Accessed July 31, American Association of Nurse Anesthetists. Code of Ethics for the Certified Registered Nurse Anesthetist. Accessed July 31, American Association of Nurse Anesthetists. Patient Safety: Fatigue, Sleep, and Work Schedule Effects. Fatigue-Sleep-Work-Schedule-Effects.aspx. Accessed August 1, 2017 American Society of Anesthesiologists. Website. Standards guidelines and statements. Accessed July 31, Biddle C, Aker J. The National Study of Sleep-Related Behaviors of Nurse Anesthetists: Personal and Professional Implications. AANAJ.2011;79(4):

24. 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 Accessed August 1, 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): Drake CL, Roehrs T, Richardson G, et al. Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers. Sleep 2004;27: HealthyPeople 202. Sleep Health. 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

25. References
National Sleep Foundation. Facts and Stats. 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): 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 Accessed August 1, Sinha A, Sinha A, Tewari A. The fatigued anesthesiologist: A threat to patient safety? J Anaesthesiol Clin Pharmacol. April 2013;29(2): Stokowski LA. A Wake-up call for nurses: sleep loss, safety, and health. Accessed August 1, 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

26. Thank you for your attention
Garalynn V. Tomas