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Public Health and SleepImplications

Robyn Woidtke MSN, RN, MoKan November 2015

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Objectives• Identify at risk working populations

for sleep deprivation accidents• Discuss the impact of sleep on

workplace productivity• Recommend opportunities to

improve sleep• Create sleep related programs for

industry

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What is Public Health?• Public health is the science of

protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases (CDC Foundation)

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Your ChallengePromotion of Sleep in Our Communities

Improved Health

Recognition

Importance

Awareness

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Must be Curious• Fatigue: Due to sleep loss or physical activity;

may be relieved by sedentary activity• Sleepiness: Due to lack of sleep; sedentary

activity exacerbates the sleepiness• Tired• Drowsy• Exhausted• Weary

Two processes that help us sleep

Homeostatic Drive to Sleep

Circadian Drive to Sleep

Two Process Model of Sleep-Wake Regulation

Fatigue is related to duration of

sleep and the circadian rhythm

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Accessed 8/8/2015 CDC

How much sleep do we really need?

• ~8 hours! • U shaped curve of sleep duration

UPeople reporting consistently sleeping five hours or less per night should be regarded as a higher-risk group for cardiovascular morbidity and mortality; higher odds of having diabetes and insulin resistance

People sleeping nine hours or more per night may represent a useful diagnostic tool for detecting subclinical or undiagnosed comorbidity; higher odds of having diabetes and insulin resistance

Cappucchio et al, 2011, Eur Heart Journal

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Sleep and the Work Place

• Sleep viewed as “private activity”• Expectation that the worker come to work with

optimum mental and physical capacityo Less than X (5) or Y (12 ) number of hours of sleep interfere with

optimum functioning (X/Y=minimum duration of hour of sleep the past 24 or 48 hrs)

o This model requires a certain minimum duration (X and Y hours, respectively) of sleep during the 24-hour and 48-hour period prior to work, in order to prevent errors and accidents during wakefulness from awakening to end of work.

• Extreme tiredness is associated with sleep duration prior to shift, shift length, night shift and workload

Takahashi, M (2012)

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Sleep Deprivation Facts

• Subjective sleep may be stated as higher compared to objective measures

• OSA associated with CVD, cognitive impairment, increased risk of motor vehicle accidents

• Insomnia associated with depression, hypertension, daytime functional impairments (increased absenteeism, decreased productivity

• Shift Work Disorder contributes to CVD, digestive troubles, cancer, depression

Rogers, A (2008) In Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008.

Consequences of Sleep Deprivation

Sleep Deprivatio

n

Daytime Dysfunctio

n

Injury to self or others

Morbidity (contribut

e to chronic

conditions)

Mortality

Costs

Quality of Life

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The Importance of Adequate Sleep in the

Workplace• “According to 2004 data from the Bureau of Labor

Statistics, almost 15 million Americans work full time on evening shift, night shift, rotating shifts, or other employer arranged irregular schedules” CDC (2013)

• Types of Shift Worko Outside of “normal” work shift hours i.e. 7AM to 6 PMo Overtime work (beyond 40 hrs)o Extended Shifts (i.e. longer than 8 hours) (Lerman et al., 2012, ACOEM

Guidance Statement)

The Flip Side: Performance Benefits of Adequate Sleep

Improved ProductivityImproved LearningEnhanced MemoryImproved JudgmentEnhanced MoodImproved Attention and Reaction TimesDecreased Likelihood of Motor Vehicle

Accidents Decreased Safety Risks

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In GeneralLess Sleep = More

Injury

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Insomnia and the Performance of US Workers: Results from the AmericaInsomnia Survey (Kessler, et al.)

• Design/Setting: Cross-sectional telephone survey.• Participants: National sample of 7,428 employed

health plan subscribers (ages 18+).

• The estimated prevalence of insomnia was 23.2%.

• “The individual-level human capital value of this net estimate was $2,280”.

• “If we provisionally assume these estimates generalize to the total US workforce, they are equivalent to annualized population-level estimates of 252.7 days and $63.2 billion”

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Notable Tragedies

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Sleep Critical Occupations

• Pilots• Truck Drivers• Nurses• Physicians• Air Traffic Controllers• Sleep Technologists• EMS• Other?

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Shift Work Sleep Disorder

• Characterized by o Excessive sleepiness during work; insomnia during sleep periods

• Nights and jobs which begin earlier than 6 AM• 20% of work force on other than day shift• Prevalence is 1-5%• <3% entrain to daytime sleep• More difficult to cope with after the age of 50

• Consequenceso Fatigue related impairments in physical and cognitive performanceo Work performance deficits=human erroro Increased MVA commute home

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Sleep and Night Shift Work

• Occupational Sleep Disorderso Sleep becomes desynchronized from the natural circadian rhythmo Even in optimum circumstances (no light, no noise, good sleeping

surface), sleep still disruptedo Night shift associated with

• Increased gastrointestinal complaints• Depressive symptoms and mood disorders• Higher risk for cardiovascular disease such as hypertension

o Rotating shifts • Speed and direction (better to go forward; i.e.. Days to eve; eve to

night)• Permanent night workers do have better sleep

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Drowsy Driving MVANational Highway Traffic Safety Administration

• The problem occurs during late night/ early morning or midafternoon.

• The crash is likely to be serious.

• A single vehicle leaves the roadway.

• The crash occurs on a high-speed road.

• The driver does not attempt to avoid a crash.

• The driver is alone in the vehicle.

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MVA-Driver Fatigue• 100,000 police reported crashes• 1550 fatalities• 71,000 injuries

• 12.5 Billion Costs

JOEM 54 (12), 2012

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2013 ATS CPG• Am J Respir Crit Care Med Vol 187, Iss. 11, pp 1259–1266,

Jun 1, 2013

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At Risk• Young people (ages 16 to 29), especially males.

• Shift workers whose sleep is disrupted by working at night or working long or irregular hours.

• People with untreated sleep apnea syndrome (SAS) and narcolepsy.

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Commercial Drivers• Bus drivers, rail workers and truck drivers• Hours of service

o Typically achieve less than 5 hours of sleep per day (NSF, 2013)

• Medical Conditions impacting safetyo Diabeteso Hypertensiono Sleep Apnea

• Drivers with < 5 hours =Higher MVA (1)

Takahashi, M. (2012)

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A Few Studies• Obstructive Sleep Apnea and Risk of MVC

(Tregear, Reston, Schoelles & Phillips, 2009JCSM)o 18 articles met inclusion criteriao Findings

• OSA puts drivers at risk for MVC• Mean crash ratio 1.21 and 4.89

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Emergency Medical Services (Patterson, et al., 2012)

• 1900 surveys completed• PSQI; Chalder Fatigue Questionnaire; EMS Safety

Inventory• Results

o 540 Surveys received; 30 EMS Agencieso PSQI

• >50% scored as having poor sleep (Full time, working 24 hours shifts and for more than one agency)

o CFQ• 55% reported excessive fatigue (full time, 6-15 shifts monthly, 24

hour schedule, poorer health overall)o Odds of Injury 2.3 times for that of poor sleepers; odds of reporting

medical error or adverse event 50% higher in those reporting poor sleep

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Sleep Technologists and Sleep?

August, 2015

September, 2013

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Nursing • High prevalence of shift work disorder• Sleep deprivation linked to increase risk to

patient safety• High stress levels reduced sleep Higher levels

of absenteeism inadequate nurse-patient ratios (Hasson& Gustovvson, 2010)

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Figure 2. Percentage of respondents rating their sleep quality as pretty poor or poor.

Hasson D, Gustavsson P (2010) Declining Sleep Quality among Nurses: A Population-Based Four-Year Longitudinal Study on the Transition from Nursing Education to Working Life. PLoS ONE 5(12): e14265. doi:10.1371/journal.pone.0014265http://www.plosone.org/article/info:doi/10.1371/journal.pone.0014265

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IOM, 2004

“To reduce error-producing fatigue, state regulatory bodies should prohibit nursing staff from providing patient care in any combination of scheduled shifts, mandatory overtime, or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours in any given 7-day period”

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Patient Safety

Rogers, A. 2008 in Patient Safety and Quality: An Evidenced Based Handbook for Nursing

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Physicians/Residents• ACGME Work Hours (2011)• Duty hours must be limited to 80 hours per week,

averaged over a four‐week period, inclusive of all in‐house call activities and all moonlighting

• A Review Committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs based on a sound educational rationale.

• PGY-1 residents must not remain on-site after their 16-hour shifts. Periods of duty for first-year residents must not exceed 16 hours in duration.

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Patient Safety• Practicing physicians

o AHRQ “Duty hour regulations for residents have also spurred interest in the issue of fatigue among practicing clinicians. A recent study found that many attending physicians, particularly surgeons, routinely work hours that would be prohibited in residency programs. To date, no study has found a definitive link between attending physician fatigue and adverse clinical or safety outcomes, although one study did find an increased risk of surgical complications when surgeons had the opportunity to sleep less than 6 hours the night before the procedure.

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Pilots• Short Haul (Roach et al, 2011, Accident Analysis

and Prevention)o With flights originating between 4-5 AM; fewer

hours of sleep prioro Start day with feeling sleepyo 15 minutes of sleep is lost for each hour

starting before 0900

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Pilots• Long –Haul (1)

o Night flights and jet lag as the highest contributor to fatigue

• Short Haulo Successive work days, multi-segment flights and early morning flight

times

• Self-report of fatigue in 60% of LHF pilots and 49% of SHF pilots included reduction in alertness and attention, and a lack of concentration.

• Sleep time during long-haul flights is not as good as in-bed sleep (2)

• < 6 hours sleep prior to flight =poor operational performance and errors (3) (1) Bourgeois-Bougrine S, Cabon P, Gounelle C, Mollard R, Coblentz A. Perceived fatigue for short- and

long-haul flights: a survey of 739 airline pilots. Aviat Space Environ Med 2003; 74:1072-7.(2) Roach GD, Darwent D, Dawson D. How well do pilots sleep during long-haul flights?Ergonomics. 2010 Sep;53(9):1072-5. doi: 10.1080/00140139.2010.506246.(3) Takahashi,M (2012) Prioritizing sleep for healthy work schedules. Journal of Physiological Anthroplogy 31 (6).

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Recent Events• NTSB investigators… whether pilot

fatigue played a role in the accident, which occurred after a 10-hour nighttime flight. As is typical for long flights, four pilots were aboard, allowing the crew to take turns flying and resting. But pilots who regularly fly long routes say it's difficult to get restful sleep on planes.

• The accident occurred in the late morning in San Francisco, but in Seoul it was 3:37 a.m.

• "Fatigue is there. It is a factor," said Kevin Hiatt, a former Delta Air Lines chief international pilot. "At the end of a 10-hour flight, regardless of whether you have had a two-hour nap or not, it has been a long flight

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Air Traffic Controllers-FIT

• The meta-analysis produced a list of factors that were assessed in the development of FIT. These factors are

• “sleep debt”, “sleep loss”, “sleep quality”, “recovery time between shifts”, “shift start time”, “time on duty “circadian rhythms”, “shift length”, “workload”, “breaks”, plus “naps”, “stress”, and “boredom”.

• FIT-Fatigue Index Tool

Cebola & Kilner, EuroControl n.d.

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Law Enforcement • Large study published in JAMA (n=4957)

o 79.3 % overweight or obeseo 28.% had an ESS over 11o 45.0% reported nodding off or falling asleep while driving (baseline)o 40.4% screened for at least one sleep disorder

• 33.6 %OSA• 6.5% moderate to severe insomnia• 5.4% Shift Work Disorder• 1.6 %RLS

• Sleep Disorder Risk and Performanceo 20% + Screen fell asleep while drivingo 17.9% important administrative errorso 34.1% uncontrolled anger toward a citizen or suspecto Positive screen for any sleep disorder translated into more health and

safety concerns• 10.7% with a sleep disorder also reported depression

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Conclusions• Large numbers of police officers demonstrate one

or more sleep disorders• High association between sleep disorders and

other medical/health related conditions• Adversely impacts interaction with public

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Modifiable Risk Factors

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Fatigue Risk Management System

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Countermeasures• Planned naps (15-20 Min)

o Improved productivity o Positive impacts on health

• Lightingo Blue lighto Cockpit Lighting

• Drivingo Planning rest stopso Caffeine

• Shift Work (Circadian Technologies)

o Sequence of Shiftso Scheduled work timeo Distribution of time off

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Practice Implications for Technologists

• Question patients regarding their normal working environment

• Provide suggestions to improve sleep in generalo If shift worker, provide information specifically related to shift work

disorder if appropriate

• Consider the under-reporting of sleepiness and the impact to public and personal safety

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Creating Value• Participate in health fairs• Create community partnerships• Align with local corporations HR department

o Write an article regarding sleep and sleep deprivationo Include productivity statisticso Provide insight to improvemento Offer lunch and learnso Demonstration projects

• Outcome measures

• Employee Assistance Programso Conduct lunch and learnso Educate EAP Executives on the importance of Sleep

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Summary• Be aware of “sleep critical” jobs; listen to your

patients!o Ask about job related fatigue, remember they may not attribute work

place problems to sleep issues

• Research fatigue countermeasures for the various roleso Formulate individual plans to improve sleep/fatigue related issueso You may have to schedule a follow-on phone call or appt

• Contact and participate in your communityo HR Departmentso Industryo Lunch and Learnso EAPo Focus on productivity and loss of work time

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Call to Action • Public health

professionals (SLEEP PROFESSIONALS) try to prevent problems from happening or recurring through implementing educational programs, recommending policies, administering services and conducting research

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Questions?

• Contact Information• Robyn.Woidtke@gmail.com• 510-728-0828• If you email me for the presentation, please

include in the subject line “MoKan”