III ESTONIAN SLEEP MEDICINE CONFERENCE : III ESTONIAN SLEEP MEDICINE CONFERENCE SHIFTWORK DISORDERS
DAINIS IRBE, MD
Medical Director of Pacific Northwest Sleep Association, Eugene, Oregon, USA
Slide2 : © American Academy of Sleep Medicine American Academy of Sleep Medicine SLEEP, ALERTNESS, and FATIGUE EDUCATION in RESIDENCY
Slide3 : © American Academy of Sleep Medicine American Academy of Sleep Medicine The following product has been developed by the American Academy of Sleep Medicine
Copyright © 2003 American Academy of Sleep Medicine
One Westbrook Corporate Center, Ste. 920, Westchester, IL 60154
Telephone: (708) 492-0930 Fax: (708) 492-0943 Visit Us at www.aasmnet.org
Slide4 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Learning Objectives 1. List factors that put you at risk for sleepiness and fatigue. 2. Describe the impact of sleep loss on residents’ personal and professional lives. 3. Recognize signs of sleepiness and fatigue in yourself and others. 4. Challenge common misconceptions among physicians about sleep and sleep loss. 5. Adapt alertness management tools and strategies for yourself and your program.
Types of Shifts :
Washington State University Types of Shifts Day
Afternoon/evening
Night
Early morning
Sleep disruption/truncation greatest for night and morning shifts, least for afternoon/evening
Primarily the result of sleeping or awakening at adverse circadian phase
Sleeping in the evening
Awakening in the early morning
Shift-Work and Sleep :
Washington State University Shift-Work and Sleep ~Twenty percent of workers in industrialized countries are shift workers
Working night shifts
Working rotating shifts
~Ten percent of shift workers suffer from shift-work sleep disorder, with primary complaints of
Insomnia and/or
Excessive sleepiness
In association with work shifts that occur during the habitual circadian entrained sleep phase
Shift-lag, similar to jet-lag (trans-meridian desynchronization), except it is chronic Basner, N Engl J Med, 2005
Drake et al., Sleep, 2004
Normal vs. Night Shift-Work Sleep :
Washington State University Normal vs. Night Shift-Work Sleep Graphs matched on time scale
Note naps during work shift and in late afternoon
Note truncated main daytime sleep Normal Sleep Shift-Work Sleep Akerstedt, Occupational Medicine, 2003
Slide8 : © 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
Slide9 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Why So? Physicians know relatively little about sleep needs and sleep physiology.
There is no “drug test” for sleepiness.
Most programs do not recognize and address the problem of resident sleepiness.
The culture of medicine says:
“Sleep is “optional” (and you’re a wimp if you need it)”
“Less sleep = more dedicated doc”
Slide10 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Myth: “It’s the really boring noon conferences that put me to sleep.”
Fact: Environmental factors (passive learning situation, room temperature, low light level, etc) may unmask but DO NOT CAUSE SLEEPINESS.
Slide11 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Conceptual Framework (in Residency) Primary Sleep Disorders (sleep apnea, etc) Fragmented Sleep (pager, phone calls) Circadian Rhythm Disruption (night float, rotating shifts) Insufficient Sleep (on call sleep loss/inadequate recovery sleep) EXCESSIVE DAYTIME SLEEPINESS
Slide12 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Sleep Needed vs Sleep Obtained Myth: “I’m one of those people who only need 5 hours of sleep, so none of this applies to me.” Fact: Individuals may vary somewhat in their tolerance to the effects of sleep loss, but are not able to accurately judge this themselves. Fact: Human beings need 8 hours of sleep to perform at an optimal level. Fact: Getting less than 8 hours of sleep starts to create a “sleep debt” which must be paid off.
Slide13 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Sleep Fragmentation Affects Sleep Quality = Paged NORMAL SLEEP ON CALL SLEEP MORNING ROUNDS
Slide14 : © American Academy of Sleep Medicine American Academy of Sleep Medicine The Circadian Clock Impacts You It is easier to stay up later than to try to fall asleep earlier.
It is easier to adapt to shifts in forward (clockwise) direction (day evening night).
Night owls may find it easier to adapt to night shifts.
Slide15 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Interaction of Circadian Rhythms and Sleep Time 9 PM 9 AM 9 AM Sleep Wake Sleep Homeostatic drive (Sleep Load) Circadian alerting signal Alertness level 3 PM
3 AM
Slide16 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Sleep Disorders: Are you at risk? Physicians can have sleep disorders too!
-- Obstructive sleep apnea
-- Restless legs syndrome
-- Periodic limb movement disorder
-- Learned or “conditioned” insomnia
-- Medication-induced insomnia
Slide17 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Adaptation to Sleep Loss Myth: “I’ve learned not to need as much sleep during my residency.” Fact: Sleep needs are genetically determined and cannot be changed. Fact: Human beings do not “adapt” to getting less sleep than they need. Fact: Although performance of tasks may improve somewhat with effort, optimal performance and consistency of performance do not!
Slide18 : © 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
Slide19 : © 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
Slide20 : © American Academy of Sleep Medicine American Academy of Sleep Medicine *Baldwin and Daugherty,
1998-9 Survey of 3604 PGY1,2 Residents Work Hours, Medical Errors, and Workplace Conflicts by Average Daily Hours of Sleep*
Slide21 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Adverse Health Consequences by Average Daily Hours of Sleep* *Baldwin and Daugherty,
1998-9 Survey of 3604 PGY1,2 Residents
Slide22 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Sleep Loss and Fatigue: Safety Issues 58% of emergency medicine residents reported near-crashes driving.
-- 80% post night-shift
-- Increased with number of night shifts/month
Steele et al 1999
50% greater risk of blood-borne pathogen exposure incidents (needlestick, laceration, etc) in residents between 10pm and 6am. Parks 2000
Slide23 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Impact on Medical Education Residents working longer hours report decreased satisfaction with learning environment and decreased motivation to learn. Baldwin et al 1997
Study of surgical residents showed less operative participation associated with more frequent call. Sawyer et al 1999
Slide24 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Impact on Medical Errors Surveys: more than 60 % of anesthesiologists report making fatigue-related errors. Gravenstein 1990
Case Reviews:
- 3% of anesthesia incidents Morris 2000
- 5% “preventable incidents” “fatigue-related”
- 10% drug errors Williamson 1993
- Post-op surgical complication rates 45%,
higher if resident was post-call Haynes et al 1995
Slide25 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Myth: “If I can just get through the night (on call), I’m fine in the morning.”
Fact: A decline in performance starts after about 15-16 hours of continued wakefulness.
Fact: The period of lowest alertness after being up all night is between 6am and 11am (eg, morning rounds).
Slide26 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Estimating Sleepiness Myth:“I can tell how tired I am and I know when I’m not functioning up to par.”
Fact: Studies show that sleepy people underestimate their level of sleepiness and overestimate their alertness.
Fact: The sleepier you are, the less accurate your perception of degree of impairment.
Fact: You can fall asleep briefly (“microsleeps”) without knowing it!
Slide27 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Anesthesia Resident Study Residents did not perceive themselves to be asleep almost half of the time they had actually fallen asleep.
Residents were wrong 76% of the time when they reported having stayed awake.
Howard et al 2002
Slide28 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Recognize The Warning Signs of Sleepiness Falling asleep in conferences or on rounds
Feeling restless and irritable with staff, colleagues, family, and friends
Having to check your work repeatedly
Having difficulty focusing on the care of your patients
Feeling like you really just don’t care
Slide29 : © American Academy of Sleep Medicine American Academy of Sleep Medicine If you don’t recognize that you’re sleepy,
you’re not likely
to do anything about it.
Slide30 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Myth: “I’d rather just “power through” when I’m tired; besides, even when I can nap, it just makes me feel worse.”
Fact: Some sleep is always better than no sleep.
Fact: At what time and for how long you sleep are key to getting the most out of napping.
Slide31 : © 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)
Slide32 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Napping Timing:
-- if possible, take advantage of circadian “windows of opportunity” (2-5 am and 2-5 pm);
-- but if not, nap whenever you can!
Cons: sleep inertia; allow adequate recovery time (15-30 minutes)
Bottom line: Naps take the edge off but do not replace adequate sleep.
Slide33 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Get adequate (7 to 9 hours) sleep before anticipated sleep loss.
Avoid starting out with a sleep deficit! Healthy Sleep Habits
Slide34 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Recovery from Sleep Loss Myth: “All I need is my usual 5 to 6 hours the night after call and I’m fine.”
Fact: Recovery from on-call sleep loss generally takes 2 nights of extended sleep to restore baseline alertness.
Fact: Recovery sleep generally has a higher percentage of deep sleep, which is needed to counteract the effects of sleep loss.
Slide35 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Time to fall asleep
on MSLT (min) Sleepiness level post-call vs on a normal (baseline) schedule was equivalent in anesthesia residents.
A period of extended sleep (over 4 nights) normalized post-call sleepiness levels. Howard 2002
Slide36 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Healthy Sleep Habits Go to bed and get up at about the same time every day.
Develop a pre-sleep routine.
Use relaxation to help you fall asleep.
Protect your sleep time; enlist your family and friends!
Slide37 : © 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.
Slide38 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Recognize Signs of DWD * Trouble focusing on the road
Difficulty keeping your eyes open
Nodding
Yawning repeatedly
Drifting from your lane, missing signs or exits
Not remembering driving the last few miles
Closing your eyes at stoplights
* Driving While Drowsy
Slide39 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Risk Factors for Drowsy Driving Time of Day Number of Crashes Driving home post-call Pack et al 1995 Taking any sedating medications
Drinking even small amounts of alcohol
Having a sleep disorder (sleep apnea)
Driving long distances without breaks
Driving alone or on a boring road
Slide40 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Drive Smart; Drive Safe AVOID driving if drowsy.
If you are really sleepy, get a ride home, take a taxi, or use public transportation.
Take a 20 minute nap and/or drink a cup of coffee before going home post-call.
Stop driving if you notice the warning signs of sleepiness.
Pull off the road at a safe place, take a short nap.
Slide41 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Drowsy Driving: What Does Not Work Turning up the radio
Opening the car window
Chewing gum
Blowing cold air (water) on your face
Slapping (pinching) yourself hard
Promising yourself a reward for staying awake
Slide42 : © American Academy of Sleep Medicine American Academy of Sleep Medicine It takes only a 4 second lapse in attention to have a drowsy driving crash.
Slide43 : © 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
Slide44 : © 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
Slide45 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Adapting To Night Shifts Myth: “I get used to night shifts right away; no problem.”
Fact: It takes at least a week for circadian rhythms and sleep patterns to adjust.
Fact: Adjustment often includes physical and mental symptoms (think jet lag).
Fact: Direction of shift rotation affects adaptation (forward/clockwise easier to adapt).
Slide46 : © 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).
Slide47 : © American Academy of Sleep Medicine American Academy of Sleep Medicine “The best laid plans…” Study: Impact of night float coverage (2am to 6am)
Results: “protected” interns slept less than controls; used time to catch up on work, not sleep; thus there was no improvement in performance
Richardson et al 1996
Slide48 : © American Academy of Sleep Medicine American Academy of Sleep Medicine Alertness Strategies There is no “magic bullet.”
Know your own vulnerability to sleep loss.
Learn what works for you from a range of strategies.
There needs to be a shared responsibility for fatigue management and a “culture of support” in the training program.
Slide49 : © American Academy of Sleep Medicine American Academy of Sleep Medicine In Summary… Fatigue is an impairment like alcohol or drugs.
Drowsiness, sleepiness, and fatigue cannot be eliminated in residency, but can be managed.
Recognition of sleepiness and fatigue and use of alertness management strategies are simple ways to help combat sleepiness in residency.
When sleepiness interferes with your performance or health, talk to your supervisors and program director.
“Patients have a right to expect a healthy, alert, responsible, and responsive physician.” : © American Academy of Sleep Medicine American Academy of Sleep Medicine “Patients have a right to expect a healthy, alert, responsible, and responsive physician.” January 1994 statement by American College of Surgeons
Re-approved and re-issued June 2002