Mark R. Rosekind

The risks and implications of excessive daytime sleepiness in resident physicians.

Purpose. To assess the levels of physiologic and subjective sleepiness in residents in three conditions: (1) during a normal (baseline) work schedule, (2) after an in-hospital 24-hour on-call period, and (3) following a period of extended sleep. Method. In 1996, a within-subjects, repeated-measures study was performed with a volunteer sample of 11 anesthesia residents from the Stanford University School of Medicine using three separate experimental conditions. Sixteen residents were recruited and 11 of the 16 completed the three separate experimental conditions. Daytime sleepiness was assessed using the Multiple Sleep Latency Test (MSLT). Results. MSLT scores were shorter in the baseline (6.7 min) and post-call (4.9 min) conditions, compared with the extended-sleep condition (12 min, p = .0001) and there was no significant difference between the baseline and post-call conditions (p = .07). There was a significant main effect for both condition (p = .0001) and time of day (p = .0003). Subjects were inaccurate in subjectively identifying sleep onset compared with EEG measures (incorrect on 49% of EEG-determined sleep episodes). Conclusion. Residents daytime sleepiness in both baseline and post-call conditions was near or below levels associated with clinical sleep disorders. Extending sleep time resulted in normal levels of daytime sleepiness. The residents were subjectively inaccurate determining EEG-defined sleep onset. Based on the findings from this and other studies, reforms of residents work and duty hours are justified.

Sleep disorders and work performance: Findings from the 2008 National Sleep Foundation Sleep in America poll

Chronic sleep deprivation is common among workers, and has been associated with negative work outcomes, including absenteeism and occupational accidents. The objective of the present study is to characterize reciprocal relationships between sleep and work. Specifically, we examined how sleep impacts work performance and how work affects sleep in individuals not at‐risk for a sleep disorder; assessed work performance outcomes for individuals at‐risk for sleep disorders, including insomnia, obstructive sleep apnea (OSA) and restless legs syndrome (RLS); and characterized work performance impairments in shift workers (SW) at‐risk for shift work sleep disorders relative to SW and day workers. One‐thousand Americans who work 30u2003h per week or more were asked questions about employment, work performance and sleep in the National Sleep Foundation’s 2008 Sleep in America telephone poll. Long work hours were associated with shorter sleep times, and shorter sleep times were associated with more work impairments. Thirty‐seven percent of respondents were classified as at‐risk for any sleep disorder. These individuals had more negative work outcomes as compared with those not at‐risk for a sleep disorder. Presenteeism was a significant problem for individuals with insomnia symptoms, OSA and RLS as compared with respondents not at‐risk. These results suggest that long work hours may contribute to chronic sleep loss, which may in turn result in work impairment. Risk for sleep disorders substantially increases the likelihood of negative work outcomes, including occupational accidents, absenteeism and presenteeism.

Simulation Study of Rested Versus Sleep-deprived Anesthesiologists

Background Sleep deprivation causes physiologic and subjective sleepiness. Studies of fatigue effects on anesthesiologist performance have given equivocal results. The authors used a realistic simulation environment to study the effects of sleep deprivation on psychomotor and clinical performance, subjective and objective sleepiness, and mood. Methods Twelve anesthesia residents performed a 4-h anesthetic on a simulated patient the morning after two conditions of prior sleep: sleep-extended (EXT), in which subjects were allowed to arrive at work at 10:00 am for 4 consecutive days, thus allowing an increase in nocturnal sleep time, and total sleep deprivation (DEP), in which subjects were awake at least 25 h. Psychomotor testing was performed at specified periods throughout the night in the DEP condition and at matched times during the simulation session in both conditions. Three types of vigilance probes were presented to subjects at random intervals as well as two clinical events. Task analysis and scoring of alertness were performed retrospectively from videotape. Results In the EXT condition, subjects increased their sleep by more than 2 h from baseline (P = 0.0001). Psychomotor tests revealed progressive impairment of alertness, mood, and performance in the DEP condition over the course of the night and when compared with EXT during the experimental day. DEP subjects showed longer response latency to vigilance probes, although this was statistically significant for only one probe type. Task analysis showed no difference between conditions except that subjects “slept” more in the DEP condition. There was no significant difference in the cases’ clinical management between sleep conditions. Subjects in the DEP condition had lower alertness scores (P = 0.02), and subjects in the EXT condition showed little video evidence of sleepiness. Conclusions Psychomotor performance and mood were impaired while subjective sleepiness and sleepy behaviors increased during simulated patient care in the DEP condition. Clinical performance between conditions was similar.

The cost of poor sleep: workplace productivity loss and associated costs.

Objective: To assess the impact of sleep disturbances on work performance/productivity. Methods: Employees (N = 4188) at four US corporations were surveyed about sleep patterns and completed the Work Limitations Questionnaire. Respondents were classified into four categories: insomnia, insufficient sleep syndrome, at-risk, and good sleep. Employer costs related to productivity changes were estimated through the Work Limitations Questionnaire. Performance/productivity, safety, and treatment measures were compared using a one-way analysis of variance model. Results: Compared with at-risk and good-sleep groups, insomnia and insufficient sleep syndrome groups had significantly worse productivity, performance, and safety outcomes. The insomnia group had the highest rate of sleep medication use. The other groups were more likely to use nonmedication treatments. Fatigue-related productivity losses were estimated to cost

Relationship of day versus night sleep to physician performance and mood

1967/employee annually. Conclusions: Sleep disturbances contribute to decreased employee productivity at a high cost to employers.

Fatigue in anesthesia: implications and strategies for patient and provider safety.

STUDY OBJECTIVEnTo document and analyze the quality and quantity of emergency physicians sleep as a function of day and night shift work, and to compare cognitive and motor performance and mood during day and night shifts.nnnDESIGNnSix physicians were monitored for two 24-hour periods. One period consisted of daytime work and nocturnal sleep and the second consisted of daytime sleep and nighttime work.nnnSETTINGnThe emergency department of Stanford University Medical Center and physicians homes.nnnPARTICIPANTSnSix attending emergency physicians.nnnINTERVENTIONSnAmbulatory polysomnographic recorders continuously gathered EEG, electro-oculogram, and electromyograph data throughout each observation period. Physicians filled out hourly mood ratings and completed a set of two performance tests five times throughout the day.nnnRESULTSnPhysicians had significantly less sleep (496.6 minutes versus 328.5 minutes, P = .02) when sleeping during the day as compared with sleeping at night. Significant performance decrements were also found. Physicians working nights were slower at intubating a mannequin (31.56 seconds versus 42.2 seconds, P = .04) and were more likely to commit errors as their shift progressed (P = .04). Physicians in both conditions were more likely to make errors during a simulated triage test toward the end of their shifts (P = .02). Subjects also rated themselves significantly less sleepy (P < .01), happier (P < .01), and more clear thinking (P < .01) when working day versus night shifts.nnnCONCLUSIONnAttending emergency physicians get less sleep and are less effective when performing manual and cognitive tests while working night shifts with day sleep compared with working day shifts with night sleep.

FATIGUE IN OPERATIONAL SETTINGS: EXAMPLES FROM THE AVIATION ENVIRONMENT.

HEALTHCARE delivery takes place 24 h a day, 7 days a week, and is colloquially termed a “24/7” operation. Anesthesia providers are required to deliver critical around-the-clock care to a variety of patients. This parallels the situation in many other domains that provide such services, e.g., transportation, law enforcement, communications, fire fighting, technology, manufacturing, and the military. Even “convenience” industries (e.g., gas stations and grocery stores) now provide uninterrupted access. These continuous operational demands present unique physiologic challenges to the humans who are called on to provide safe operations within these systems. Human physiologic design dictates circadian patterns of alertness and performance and includes a vital need for sleep. Human requirements for sleep and a stable circadian clock can be, and often are, in direct opposition to the societal demand for continuous operations. Recently, patient safety has taken center stage in health care. The Institute of Medicine’s report “To Err Is Human: Building a Safer Health System,” revealed that medical errors contribute to many hospital deaths and serious adverse events. The response to this report was widespread and included the Quality Interagency Coordination Task Force’s response to the President of the United States, “Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact.” 2 This report listed more than 100 action items to be undertaken by federal agencies to improve quality and reduce medical errors. One action promised by the Agency for Healthcare Research and Quality was “the development and dissemination of evidence-based, best safety practices to provider organizations.” In addition to the multiple recommendations to improve patient safety, the report from the Agency for Healthcare Research and Quality included a review chapter on sleep, fatigue,# and medical errors.** There is evidence that the issue of fatigue in health care is coming to prominence on a national level. In April 2001, Public Citizen (a consumer and health advocacy group) and a consortium of interested parties petitioned the Occupational Safety and Health Administration to implement new regulations on resident work hours (table 1). The primary intent of the regulations is to provide more humane working conditions, which the petitioners declare will result in a better standard of care for all patients. Also, the Patient and Physician Safety and Protection Act of 2001, which would limit resident physician work hours, was introduced in Congress. Recently, the Accreditation Council on Graduate Medical Education, the accrediting organization for residency training programs in the United States, has approved common program requirements for resident duty and rest hours that will take effect in July 2003.†† This article is accompanied by an Editorial View. Please see: Lydic R: Fact and fantasy about sleep and anesthesiology. ANESTHESIOLOGY 2002; 97:1050–1.

Sleep apnea and commercial motor vehicle operators: statement from the joint Task Force of the American College of Chest Physicians, American College of Occupational and Environmental Medicine, and the National Sleep Foundation

The need for 24-h operations creates nonstandard and altered work schedules that can lead to cumulative sleep loss and circadian disruption. These factors can lead to fatigue and sleepiness and affect performance and productivity on the job. The approach, research, and results of the NASA Ames Fatigue Countermeasures Program are described to illustrate one attempt to address these issues in the aviation environment. The scientific and operational relevance of these factors is discussed, and provocative issues for future research are presented.

Managing Fatigue in Operational Settings 1: Physiological Considerations and Countermeasures

M edical research supports the finding that obstructive sleep apnea (OSA) is a significant cause of motor vehicle crashes (MVCs) resulting in twoto sevenfold increased risk. Recent reports indicate OSA is present in a greater prevalence in operators of commercial motor vehicle (CMV) operators than in the general population. Although U.S. commercial drivers are required by federal statute to undergo medical qualification examinations at least every 2 years, the most recent OSA recommendations for medical examiners were prepared during a 1991 conference sponsored by the Federal Highway Administration (FHWA). Since then, the clinical diagnosis, evaluation, treatment, and follow-up criteria have changed significantly. Lacking current recommendations from the U.S. Department of Transportation (DOT), commercial driver medical examiners (CDMEs) must rely on outdated guidance and are thus forced to fill in the many existing gaps when evaluating CMV operators for this safety-sensitive type of work. In addition to causing difficulties for the medical examiner, the current guidelines, or lack thereof, foster an environment in which drivers who possibly have OSA are afraid to be evaluated because it might result in their removal from work. This set of circumstances may lead to the underrecognition of this condition and an increase in MVCs. From OccuMedix, Inc. (Dr Hartenbaum), Dresher, Pennsylvania; the Department of Medicine, Division of Pulmonary/Critical Care Medicine (Dr Collop), Johns Hopkins University, Baltimore, Maryland; the Department of Medicine, Divisions of Sleep Medicine and Pulmonary, Allergy & Critical Care Medicine (Dr Rosen), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; the Division of Pulmonary Critical Care and Sleep Medicine (Dr Phillips), University of Kentucky College of Medicine, Lexington, Kentucky; the Department of Medicine, Division of Respirology (Dr George), University of Western Ontario, and the Sleep Laboratory, London Health Sciences Centre, South Street Hospital, London, Ontario, Canada; the Department of Medicine, Division of Pulmonary, Critical Care & Sleep Medicine, Department of Internal Medicine (Dr Rowley), Wayne State University School of Medicine, Harper University Hospital, Detroit, Michigan; The Sleep and Behavior Medicine Institute and Pulmonary Physicians of the North Shore (Dr Freedman), Bannockburn, Illinois; Biobehavioral and Health Sciences Division (Dr Weaver), University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; the Department of Medicine, Divisions of Sleep, Pulmonary and Critical Care Medicine (Dr Gurubhagavatula), University of Pennsylvania Medical Center, Philadelphia, Pennsylvania; the Department of Medicine, Director (Dr Strohl), Center for Sleep Disorders Research, Case Western Reserve University School of Medicine, Louis Stokes DVA Medical Center, Cleveland, Ohio; the IHC Health Services to Business (Dr Leaman), Intermountain WorkMed, Salt Lake City, Utah; and Arkansas Occupational Health (Dr Moffitt), Springdale, Arkansas; Alertness Solutions (Dr Rosekind), Cupertino, CA. Address correspondence to: Natalie Hartenbaum, MD, MPH, FACOEM, President and Chief Medical Officer, OccuMedix, Inc., P.O. Box 197, Dresher, PA 19025; E-mail: occumedix@comcast.net. Copyright

Managing Fatigue in Operational Settings 2: An Integrated Approach

The authors consider three aspects of managing fatigue in the workplace. They provide a brief overview of important scientific findings related to sleep and circadian physiology that establish the psychobiological foundation of fatigue. Their major focus is on the relevance of these findings to operational settings. In addition, they provide examples to describe practical fatigue countermeasures that can be used in operational settings.