Education About Sleep Restriction and Fatigue
These recommendations expand the role of program directors, faculty, and resident colleagues in identifying and intervening in instances of residents exhibiting signs of fatigue. To prepare them for this, programs directors, faculty and residents must be educated about the effects of sleep loss on performance and well-being, and how to recognize fatigue and apply countermeasures. This should also enable residents to recognize their own limits and request to be relieved when those limits have been reached. Campbell Clinic will institute the necessary changes in their informal learning environment to allow tired residents to request to be relieved. As part of the new standards, ACGME calls on programs to encourage residents to use "alertness management strategies", "strategic napping" and other mechanisms to identify when they may be becoming fatigued. We believe these techniques are critically important, and perhaps more important than the structured resident work schedules, to ensuring residents provide high-quality patient care. Patient errors occur for a number of reasons. While some errors may be due to resident fatigue, others may occur due to excessive resident workloads, poor care coordination, or ineffective resident supervision.
- Fatigue Prevention, Identification, and Management
- Causes of Fatigue
- Signs and Symptoms of Sleep Deprivation
- Adverse Effects of Sleep Deprivation
- Prevention/Treatment/Management Of Fatigue
The Accreditation Council on Graduate Medical Education requires all training programs to "…educate faculty and residents… to recognize the signs of fatigue…and adopt and apply policies to prevent and counteract the potential negative effects." Examples of such policies include, specialty –specific duty hour requirements such as maximum of 80 duty hours per week, in-house call no more frequently than one in three nights, a minimum of one 24-hour period off each week, a minimum of 10 hours free between consecutive duty periods, and duty periods of no more than 24 hours with up to an additional 6 hours for continuity or education.
The American Medical Association Council on Ethical and Judicial Affairs considers physicians attending to their own health and wellness, as well as the health of their colleagues, an ethical imperative.
Compliance with duty hours is monitored. Residents are urged to report any concern regarding duty hours, fatigue, and other issues to the GME Office.
Parallel to the focus on "duty hours" are efforts to increase the awareness of fatigue's impact on trainee well-being, learning, and patient safety. These include dissemination of:
- Evidence-based information regarding the prevention, recognition and management of fatigue
- Awareness of institutional sleep experts and options
- Access to national and specialized resources
Restricting duty hours alone does not preclude fatigue. Of particular concern, is that the very strategies that training programs may adopt in a good faith effort to adhere to the 80-hour work week may result in unintended adverse consequences. Programs may feel their work is "done" if they demonstrate compliance with duty hours standards, even though 80 hours is twice the work week duration of the average employed American. Programs may miss identifying persistent fatigue.
Although perhaps better rested, resident stress may increase if residents are concerned about losing significant learning opportunities, procedural experience, and interaction with colleagues. Residents may feel trapped by competing demands between work hours and professionalism. They may feel support is lacking from senior residents and faculty who may have an inadequate understanding of this mandate and perhaps are resentful of restrictions on duty hours.
Fatigue, or "excessive daytime sleepiness", may be due to a variety of factors. These may exist singly or in combination and includes:
- Too little sleep
- Fragmented sleep
- Circadian rhythm disruption (such as occurs with night float work)
- Other conditions may masquerade as fatigue
- Primary sleep disorders
Too Little Sleep
This may be the most common reason for sleepiness among medical trainees, occurring when residents get less sleep than optimal. Although there is individual variation, most adults require an average of 8.2 hours of sleep each night. Residents may not have developed "good sleep habits" in high school, college and medical school for adequate sleep even on their nights "off".
Alternatively the duration of sleep may be optimal but the sleep itself is fragmented. Insufficient time may be spent in the "deeper, restorative" stages of sleep. Though "in bed", trainees may be interrupted by frequent phone calls, pages, the need to follow up on patients, or to supervise more junior trainees. Residents may also be interrupted by residents who share the same call space. Even the "anxiety" of call or anticipation of sleep interruption can impair sleep. Call from home, though not counted in the duty hours, may still put residents at risk due to sleep disruption with frequent phone calls or the drive back and forth to the hospital.
Circadian Rhythm Disruption
Residency training may disrupt natural circadian rhythm. This problem may be exacerbated as programs implement solutions, such as "night floats" to adhere to duty hour requirements. Night float systems and shifts may put residents on duty during periods in which there are predictable mismatches between circadian and endogenous rhythms of asleep and awake. Energy lows, for example, characteristically occur around 3-7 am and 3-5 pm. Residents may be more prone to errors during these times. It is extremely difficult to adapt to "shift work", regardless of how it is scheduled or its duration. Over 90% of individuals never adapt and may be at risk for sub-optimal performance. Working more nights in a row, rather than acclimatizing someone to night work, almost always only make someone more tired.
Other Conditions Masquerading as Fatigue
Residents may also display symptoms of "fatigue" or attribute symptoms to fatigue when the etiology is in fact anxiety, depression, stress, thyroid disease, other medical conditions, medication side effects, burnout, or career dissatisfaction.
Primary Sleep Disorders
Finally, residents may have a primary, undiagnosed sleep disorder such as obstructive sleep apnea, narcolepsy, restless leg syndrome, or insomnia.
Disruption in sleep leads to a sleep debt. Performance can be impaired with two hours less sleep than "normal" per night. Significant sleep debt may occur if sleep is sub-optimal over as few as 2-3 nights. Adverse health consequences may occur if sleep debt is allowed to accumulate. Sleep debt requires several consecutive full nights sleep for adequate recovery, depending upon the number of days during which the sleep debt was accumulated as well as the individual's susceptibility and ability to "recover". Though it is difficult to quantify what is "sufficient", the individual should feel "rested" after their recovery sleep.
Psychomotor function after 24 without sleep is equivalent to a blood alcohol content of 0.08%, a level recognized legally as inebriation. As is true with alcohol, one cannot depend on the individuals to perceive their own degree of impairment. Studies confirm residents, as true of other individuals, can't adequately evaluate their own degree of sleepiness. Furthermore, the ability to recognize "sleepiness" declines the sleepier someone is.
Characteristic symptoms of sleepiness may be unrecognized. These include:
- Repeatedly yawning and nodding off during conferences
- "Microsleeps" . . . a few seconds of "sleep" the "awake" resident may not even recognize
- Increased tolerance for risk
- Inattention to details
- Decreased cognitive functions
- Motor vehicle collisions (or near misses)
- Increased errors
- Impact on sleep process itself
- Voluntary and involuntary latencies (the time to fall asleep) shorten
- Increased number of "microsleeps"
One of the first skills lost is the ability to do something quickly. If you show down at a task, you may be able to compensate. But if the task requires a quick response, errors are more likely. Time pressure + fatigue are a major risk.
Of particular significance for residents, perhaps, is sleep inertia, the confusion and dysfunction that occurs upon awakening from deep sleep during deep NREM sleep, sleep in the middle of the night, or following a period of sleep deprivation. This may occur after as brief an interval as 30 minutes of sleep. This disorientation may include a period of amnesia for the period of awakening. The impairment from sleep inertia may be greater than that from sleep loss. Opinions in the sleep medicine field differ on the significance of sleep inertia.
Residents may be vulnerable to error when awakened during the night. Increased metabolic activity, such as exercise may minimize effects. Although the research evidence is inconsistent and people react with a great deal of individual variability, be aware this phenomenon may occur and may color judgment and responses for the first 10 minutes (and up to 2 hours) following arousal.
Sleep deprivation results in adverse physiologic changes such as hypoxemia, insulin resistance, increased sympathetic activity, a blunted arousal response, immunologic changes, increased appetite, weight gain and diminished motor coordination. It impairs cognitive processes resulting in diminished attention, vigilance, decision-making, and memory. It increases tolerance for risk and decreases motivation for learning. Other professions, such as aviation and the military have previously recognized the potential impact of both acute and chronic sleep loss on job performance. Belenky, a psychiatrist who has studied sleep for the Army notes, "…If you're sleep deprived, you're not going to make good decisions." The same observation seems valid in other professions. Fatigue has been linked to errors resulting in serious accidents (Exxon Valdez Bhopal, Chernobyl, and Three Mile Island). It is estimated to be responsible for 15-20% of transportation accidents, more than attributed to drugs and alcohol combined.
Governmental and Associations Recognition of Fatigue
The Institute of Medicine highlights the importance of medical errors as a major cause of mortality and morbidity. Fatigue probably contributes to at least some of these errors.
JCAHO considers fatigue so important that it had health care worker fatigue in its draft 2007 Patient Safety Goals
Other western countries have substantially decreased the resident work week and will potentially decrease hours even further. Denmark currently mandates a 37˝ hour week compared to the Australian duty hour limit of 72 hours. The UK will adopt a 48-hour work week for its residents.
Sleep Debt: Could you have one and not know it?
Most people don't accurately assess how sleepy they are. You may be chronically tired and not know it. The easiest way to determine if you have a sleep debit is to imagine what time you would wake up spontaneously if you were allowed to sleep in on a morning without an alarm clock, child, pet, etc. awakening. Would you sleep "past" your usual wake up time on days you're working? If you sleep two or more hours extra on your days off compared to work days, you're carrying some "sleep debt" and your body is trying to "recover" lost sleep.
There is a considerable body of literature on fatigue and graduate medical education trainees. A multicenter survey of residents in a variety of specialties suggests that residents have Epworth Sleepiness Scale values comparable to patients with diagnosed sleep disorders such as sleep apnea and narcolepsy. This scale assesses and individual's tendency for dozing).
Sustained attention and vigilance tasks were impaired equally when residents were exposed to a heavy call schedule versus light call schedule with a blood alcohol level of 0.04-0.05g%.
Yet another survey of internal medicine house staff found that 64% were chronically sleep deprived; many admitted to dozing while writing notes (69%), reviewing medication lists (61%), interpreting labs (51%), and writing orders (46%).
In-service training exam scores among family practice residents correlated with their amount of "sleep" prior to the test.
Internal medicine residents post-call were less accurate in ECG interpretation.
Emergency Room residents documented fewer components of a history and physical examination depending upon their shift. They also performed less well during a simulation of intubation skills.
Surgical residents demonstrated more errors and required more time than usual during simulations of common procedures. Measured postoperative complications increased by 45% for resident surgeons for those procedures they performed the day following their night on call.
Cognitive and Procedural Abilities Decline
One study noted that residents working on a traditional schedule (>24 hours worked when on call) made 36% more serious medical errors and 6 times as many diagnostic errors as compared to their colleagues whose work hours were limited to 16 hours while on call.
Twenty percent of anesthesia residents indicated that sleepiness prevented them from performing clinical duties and 12% attributed errors to fatigue. Another study of anesthesia residents found objective evidence of sleepiness when residents were tested after their "normal" (not post-call or on-call) sleep period. The same residents were tested again after allowing 2 extra hours in bed. The sleepiness improved and normal scores were obtained, implying that residents sleep deprive themselves even in a non-call situation.
Residents self-reported decay of professionalism, empathy, and attentiveness to patient well-being when tired.
A national sample of first and second year residents correlated working more than 80 hours per week with a greater likelihood of personal accident or injury, serious conflict, significant medical error, significant weight change, increased use of alcohol and other medications "to cope". Residents reported sleeping on average fewer than 6 hours per night.
Several studies have examined the relationship between sleep deprivation and fatigue to the well-being of the health care provider. Needle stick accidents increase by 50% at night (compared to the day), increasing the risk of exposure to blood borne pathogens.
A study performed with surgical residents after implementation of the new work hour rules suggested that there were less mood disturbances than prior to the new rules.
Motor Vehicle Collisions Increase
Pediatric house offers were more likely than faculty to fall asleep while at the wheel either while driving or stopped at a traffic light (49% of the residents vs. 13% of the faculty) and more likely to have a motor vehicle accident (20 vs. 11). Most incidents occurred post-call. Nearly 60% of ER residents reported a near miss motor vehicle collision, 80% of which followed their work on a night shift. The risk increased with the number of night shifts they did per month. Another study found that residents who worked longer than 24 hours were 2.3 times more likely to have a motor vehicle accident.
Mixed Effects on Patient Care
It should be noted that since institution of the duty hour regulations by the ACGME, not all aspects of medical education and patient care have improved. Many studies have noted that residents' satisfaction with their jobs, personal lives, well-being, and overall quality of life is better. However, the effects on patient care appear to be mixed. Whereas some studies have not noted any compromise in patient care, other have noticed an improvement and still others deterioration. Studies in which patient care appears to have suffered due to the duty hour regulations is usually due to inadequate communication and sign off between residents.
It is probably inevitable there will be some sleep loss and fatigue in the course of medical training. However, it must be managed so it doesn't interfere with patient care and safety, education, and resident well-being. Developing strategies to minimize the effects of sleepiness in physicians is paramount. Learning to recognize and manage fatigue is essential. Anecdotal and empirical evidence suggest that limits on work hours in and of themselves do not guarantee well-rested and optimally functioning residents. Work hour limits are difficult to enforce, particularly if residents have workaholic tendencies or if faculty does not support work hour restrictions. In addition, resident behavior outside of the work place is difficult to govern (i.e., moonlighting activities, home responsibilities). Residents are adults who cannot be "forced" to be adequately rested.
The prevention, treatment, and management of resident fatigue are therefore a shared responsibility of accrediting bodies, Campbell Clinic, programs, faculty, and residents.
Accrediting bodies have set "the rules". These should be construed as minimums. Some states have additional regulations.
- adhere to duty hour requirements and specialty specific duty hour requirements (whichever is the more stringent)
- minimize prolonged work (>24 hours of clinical duties)
- protect periods designed to address sleep debt (i.e., the minimum of at least 24 hours off each week free from all clinical responsibilities)
- reduce non-essential tasks and enhance learning during clinical time
- reduce non-essential interruptions (i.e., added ancillary services, triage of phone calls by charge nurse etc.)
- assist residents to identify co-existent medical issues which impair their sleep (i.e., undiagnosed sleep disorder, depression, stress)
- educate regarding awareness and management of fatigue
- critically appraise the best way to implement shift work
- provide napping resources
- explore options with residents to return home safely
Night float systems are increasingly used to comply with duty hours. It takes at least a few "nights" to adjust to the night float schedule and another few nights to adjust to a return to "routine hours". Individuals on night float should consider keeping their night float sleep-wake schedule on their days off and adhere to this schedule for the duration of their rotation. Over 90% of individuals never habituate to night float even if they work them chronically. When night floats are used, they should be designed to take advantage of the fact that it is easier to change rotations from days to evenings, rather than vice versa.
Program Directors should include specific discussions regarding the management of fatigue in their regular discussions with each resident/residency group.
Program Directors should directly ask about issues pertaining to getting adequate sleep, resident safety such as concerning post-call driving, and resident concerns about the balance between professionalism and work hour restrictions. Where an individual program has particular issues with fatigue, enlist residents in developing particular program solutions.
Driving home post-call is a particular concern for the safety and well-being of residents. It takes 4 seconds to drive off the road and have a motor vehicle collision. Four-second "micro sleeps" are common in sleepy residents. Some states (NJ) have adopted laws which now make a criminal, not just civil offense for motor vehicle collisions after 24 hours without sleep. Other states will probably follow. Trainees may want to live close enough that they don't have a long drive post-call.
For many residents, the ability to manage fatigue will be a necessary life-long skill.
Recognize Vulnerability and Symptoms in Residents and Colleagues
Although there is individual variation, most adults need ~ 8 hours of sleep per night. The impact of too little sleep is cumulative. You can't "will yourself" to act against the neurobehavioral efforts of sleep loss. Sleepiness is affected by the amount of time since you last slept, whether or not you have any pre-existing sleep debt, as well as the time of day reflecting circadian rhythm. People typically under-estimate their degree of sleepiness. So as with alcohol, by the time you think you're sleepy you're probably profoundly affected. Your performance level will fall especially with tasks that require a great deal of attention. Even if you feel you're not at risk, consider that your colleagues may be. Watch out for your fellow residents.
It Is Not Normal to Fall Asleep in a Lecture
If it is a boring lecture, noted author Dinges says, "You'll be awake and annoyed but not asleep." If you are nodding off or falling asleep this is a major symptom that you're too fatigued. You're experiencing "microsleep." Your system is making you sleep without you being able to control this phenomenon. This makes you extremely vulnerable for diminished attention and cognition You can more easily make poor judgments medically and/or sustain a motor vehicle collision when you're driving home post-call.
Residents must set priorities and be careful stewards of their time off. There is a temptation to cram way too much into the hours free from programmatic responsibilities. During off hour pursuits include time for professional reading, family and friends, hobbies, and spiritual and community connections. Although all these are important, protect your recovery time.
You should practice setting reasonable priorities, especially if this is something that you have not had sufficient practice with during your years in college and medical school. It will be an important habit for the rest of your career.
Excessive fatigue can affect every facet of your life. Try to be appropriately selfish about your needed sleep time. You can honestly never, for instance, read enough. Don't short change your sleep to try to "read it all".
Sometimes you're approached about making a swap of schedules and you certainly want to accommodate a colleague. But consider your own sleep need as part of this decision and you may need to pull in a chief resident or program director to see if you're the best person to meet this need.