Sleep Deprivation/Fatigue

1. Sleep Deprivation/Fatigue Chief Resident Conference 2009

2. 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

3. William Osler

4. Founder of Surgical Training at Johns Hopkins William Stewart Halsted Courtesy: Czeisler, C

5. 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;352:966-968.

6. Libby and Sidney Zion 1989 New York changes health code

7. 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 Mustafa and Strohl, unpublished data.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 © American Academy of Sleep Medicine

8. 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

9. 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

10. 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 internsLingenfelser et al, 1994 • Pediatrics: time required to place an intra-arterial line increased significantly in sleep-deprivedStorer et al, 1989 © American Academy of Sleep Medicine

11. American Academy of Sleep Medicine Work Hours, Medical Errors, and Workplace Conflicts by Average Daily Hours of Sleep* *Baldwin and Daugherty, 1998-9 Survey of 3604 PGY1,2 Residents © American Academy of Sleep Medicine

12. Serious Medical Error Rates of InternsWorking in Intensive Care Units Traditional Shift (> 24 hrs)Scheduled Shift (< 16 hrs)

13. 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 near-crashes driving. • -- 80% post night-shift • -- Increased with number of night shifts/month • Steele et al 1999 © American Academy of Sleep Medicine

14. 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

15. Maggie’s Law

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

17. RESPONSE TO INFLUENZAVACCINATION Mean Antibody Titers (106) p<0.03 ns ns Time relative to influenza vaccination (days)

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

20. 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 sleeplong naps: 2 hours (range 30 to 180 minutes) © American Academy of Sleep Medicine

21. 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

22. 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

23. 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

24. 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

25. 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

26. “Every treatment is a double edged sword” December 5, 2008 DOCTOR AND PATIENT Does More Sleep Make for Better Doctors? By PAULINE W. CHEN, M.D.

27. SUPERCHIEF!