sleep, shift work and the emergency physician mark wahba md, ccfp emergency medicine grand rounds...

Sleep, Shift Work and Sleep, Shift Work and the Emergency the Emergency

PhysicianPhysician

Mark Wahba MD, CCFP Mark Wahba MD, CCFP

Emergency Medicine Grand RoundsEmergency Medicine Grand Rounds

June 17, 2004June 17, 2004

Special GuestSpecial Guest

Charles H. Samuels MD, CCFPCharles H. Samuels MD, CCFP Diploma, American Board of Sleep MedicineDiploma, American Board of Sleep Medicine Clinical Adjunct Lecturer, Faculty of MedicineClinical Adjunct Lecturer, Faculty of Medicine MainPro C Program Coordinator, Dept of MainPro C Program Coordinator, Dept of

CME/PD,University of CalgaryCME/PD,University of Calgary Vice Chair, Research Ethics Review Vice Chair, Research Ethics Review

Committee, College of Physicians and Committee, College of Physicians and Surgeons of AlbertaSurgeons of Alberta

Shift Work Advisor to the Calgary City PoliceShift Work Advisor to the Calgary City Police

IntroductionIntroduction

Dr. Mike Hodsman:Dr. Mike Hodsman:My HeroMy Hero

Mark Wahba MD, CCFP Mark Wahba MD, CCFP

Emergency Medicine Grand RoundsEmergency Medicine Grand Rounds

June 17, 2004June 17, 2004

OutlineOutline

IntroductionIntroduction Importance to Emergency MedicineImportance to Emergency Medicine Sleep Basics and Circadian PrinciplesSleep Basics and Circadian Principles

Shift WorkShift Work Fatigue and ErrorFatigue and Error Application to Emergency MedicineApplication to Emergency Medicine

Ideas and SuggestionsIdeas and Suggestions QuestionsQuestions

My original thoughtsMy original thoughts

bad for physican health is a cause of medical error

making shifts sensitive to circadian rhythms canimprove physician health and reduce medical error

disrupts circadian rhythms

shift work is bad

sleep is good

““Sleep and circadian physiology are Sleep and circadian physiology are complex, individuals are different, the complex, individuals are different, the task demands of settings are different, task demands of settings are different, and schedules are extremely diverse”and schedules are extremely diverse” Rosekind et al. Alertness Management: strategic naps in Rosekind et al. Alertness Management: strategic naps in

operational settings. J Sleep Research 1995;4:62-66operational settings. J Sleep Research 1995;4:62-66

Definition of Shift WorkDefinition of Shift Work

““work performed primarily outside typical daytime hours work performed primarily outside typical daytime hours and includes evening shifts, rotating shifts, irregular and includes evening shifts, rotating shifts, irregular shifts, extended-duty shifts, and flextime”shifts, extended-duty shifts, and flextime”

Statistics Canada estimates that one in four Canadians Statistics Canada estimates that one in four Canadians is employed in shift workis employed in shift work Outside the hours of 0700h to 1800hOutside the hours of 0700h to 1800h

Klompas M et a. Patients Working Shifts: Treating the Chronic Klompas M et a. Patients Working Shifts: Treating the Chronic Effects. The Canadian Journal of Diagnosis. Feb 1998 p.95Effects. The Canadian Journal of Diagnosis. Feb 1998 p.95

Economic problems associated Economic problems associated with Shift Workwith Shift Work

absenteeismabsenteeism illness and accident costsillness and accident costs insurance premiums associated with insurance premiums associated with

accidents and injuryaccidents and injury rate of work related accidents and rate of work related accidents and

errorserrors employee turnover/retraining costsemployee turnover/retraining costs productivityproductivity

Heselgrave R. Asleep at the Switch: Coping with shift work. The canadian journal of Diagnosis. Feb 1998 p.78

Social problems associated with Social problems associated with Shift WorkShift Work

Twice as more likely to be divorced compared Twice as more likely to be divorced compared to non shift workersto non shift workers

High rates of drug and alcohol abuseHigh rates of drug and alcohol abuse 60% of shift workers’ partners report that their 60% of shift workers’ partners report that their

spouses work schedules have led to:spouses work schedules have led to:1.1. increased conflict in the relationshipincreased conflict in the relationship

2.2. disruption of joint social lifedisruption of joint social life

3.3. poor contact with childrenpoor contact with children

Smith L et al. The perceptions and feelings of shiftworkers’partners.Ergonomics 1993; 36 (1-3): 299-305

Health problems associated with Health problems associated with Shift WorkShift Work

Chronic fatigue Chronic fatigue syndromesyndrome

rate of depression, rate of depression, mood swingsmood swings

rate of GI and rate of GI and immune dysfunction, immune dysfunction, and infertilityand infertility

HypertensionHypertension CV mortality CV mortality rate of accidents rate of accidents

driving to and from driving to and from workwork

•Whitehead DC et al A Rational Approach to Shift Work in Emergency Medicine, Annals of Emergency Medicine Oct 1992 Vol 21 1250-1258

Drop-out ratesDrop-out rates

Studies of new shift workers demonstrate Studies of new shift workers demonstrate drop-out rates of 20% at 1 year and 33% drop-out rates of 20% at 1 year and 33% at 2 yearsat 2 years

http://www.emedicine.com/emerg/topic835.htmhttp://www.emedicine.com/emerg/topic835.htm accessed april 6/04 accessed april 6/04

20-30% of workers leave within the first 2-20-30% of workers leave within the first 2-3 years because of ill health3 years because of ill health

Kuhn G, Circadian rhythm, shift work, and emergency medicine, Annals of Kuhn G, Circadian rhythm, shift work, and emergency medicine, Annals of Emergency Medicine Vol 37, no1, jan 2001Emergency Medicine Vol 37, no1, jan 2001

Why is Shift Work an important Why is Shift Work an important topic to emergency medicine?topic to emergency medicine?

Identified as the most stressful aspect of Identified as the most stressful aspect of emergency medicineemergency medicine Survey of 108 members of ACEP in 1985Survey of 108 members of ACEP in 1985

Major source of career dissatisfactionMajor source of career dissatisfaction Principal reason for the high rate of Principal reason for the high rate of

attrition seen in emergency medicineattrition seen in emergency medicine

Whitehead DC et al A Rational Approach to Shift Work in Emergency Medicine,Whitehead DC et al A Rational Approach to Shift Work in Emergency Medicine, Annals of Emergency Medicine Oct 1992 Vol 21 1250-1258Annals of Emergency Medicine Oct 1992 Vol 21 1250-1258

Sleep BasicsSleep Basics

© American Academy of Sleep Medicine

American Academy of Sleep Medicine

Interaction of Circadian Rhythms and Sleep

Time

9 PM9 AM 9 AM

SleepWake

Sleep Homeostatic drive (Sleep Load)

Circadian alerting signal

Alertness level

3 PM 3 AM

Other Circadian CyclesOther Circadian Cycles

Hormone and gastric Hormone and gastric secretion secretion

Bronchial reactivity Bronchial reactivity Blood pressure Blood pressure Sexual arousal Sexual arousal Anxiety Anxiety Work performanceWork performance Metabolic rateMetabolic rate

http://www.emedicine.com/emerg/topic835.htm accessed april 6/04

Short-term memoryShort-term memory Electrolyte levelsElectrolyte levels Leukocyte countsLeukocyte counts CognitionCognition MemoryMemory Drug absorption, Drug absorption,

excretion, excretion, metabolism and peak metabolism and peak effecteffect

Klompas M et a. Patients Working Shifts: Treating the Chronic Effects. The Canadian Journal of Diagnosis. Feb 1998 p.95

Circadian Variation and DiseaseCircadian Variation and Disease

60% increase in disease related deaths in NY 60% increase in disease related deaths in NY beginning at 2 am and peaking at 8ambeginning at 2 am and peaking at 8am

Angina and AMI are more common from 6 am to noonAngina and AMI are more common from 6 am to noon AMI most common within 4 hours of awakeningAMI most common within 4 hours of awakening

Stroke is most frequent 6 am to noonStroke is most frequent 6 am to noon Bronchoconstriction in asthma is more severe at nightBronchoconstriction in asthma is more severe at night Single vehicle MVA bimodal distribution peaking Single vehicle MVA bimodal distribution peaking

between 1 and 4am and 1 and 4pmbetween 1 and 4am and 1 and 4pm

Kuhn G, Circadian rhythm, shift work, and emergency medicine,Annals of Emergency Medicine Vol 37, no1, jan 2001

Shift Work and ErrorShift Work and Error


Fatigue and Error has been well studiedFatigue and Error has been well studied Less information specifically on Shift Less information specifically on Shift

Work and ErrorWork and Error Not a lot of literature on shift work as it Not a lot of literature on shift work as it

relates to Emergency Medicinerelates to Emergency Medicine ““Shift work and error” in medline gives 0 hitsShift work and error” in medline gives 0 hits ““Shift work and emergency” gives 6 hitsShift work and emergency” gives 6 hits ““Emergency and night shift” gives 20 moreEmergency and night shift” gives 20 more


Three Mile Island, PennsylvaniaThree Mile Island, Pennsylvania 4am March 28, 1979 nuclear power plant partial meltdown4am March 28, 1979 nuclear power plant partial meltdown

Bhopal, IndiaBhopal, India ““early hours” Dec. 3, 1984, gas leaked from a tank of methyl isocyanateearly hours” Dec. 3, 1984, gas leaked from a tank of methyl isocyanate

Chernobyl, UkraineChernobyl, Ukraine 1:23 am April 25, 1986 Nuclear Reactor explosion1:23 am April 25, 1986 Nuclear Reactor explosion

Exxon Valdez, AlaskaExxon Valdez, Alaska 12:04 am March 24, 1989 11 million gallons of oil spilled12:04 am March 24, 1989 11 million gallons of oil spilled

•Mitler M et al Catastrophes, sleep and public policy: consensus report,

SLEEP, 1988 11:100-109


Cognitive and psychomotor performance Cognitive and psychomotor performance parallel the circadian course of body parallel the circadian course of body temperaturetemperature Show a nadir at the minimum core body Show a nadir at the minimum core body

temperaturetemperature Kuhn G, Circadian rhythm, shift work, and emergency medicine, Annals of Kuhn G, Circadian rhythm, shift work, and emergency medicine, Annals of

Emergency Medicine Vol 37, no1, jan 2001Emergency Medicine Vol 37, no1, jan 2001

Fatigue and Medical Fatigue and Medical ErrorError

““Patient care may be compromised if a Patient care may be compromised if a fatigued, sleep-deprived clinician is fatigued, sleep-deprived clinician is allowed to operate, administer an allowed to operate, administer an anesthetic, manage a medical crisis, or anesthetic, manage a medical crisis, or deal with an unusual or cognitively deal with an unusual or cognitively demanding clinical presentation”demanding clinical presentation” Weinger M et at. Sleep Deprivation and Clinical Performance JAMA Weinger M et at. Sleep Deprivation and Clinical Performance JAMA

feb 27, 2002 vol 287, no 8feb 27, 2002 vol 287, no 8

““Although little research has focused Although little research has focused specifically on fatigue in hospital specifically on fatigue in hospital personnel and its relationship to medical personnel and its relationship to medical error, studies outside the medical field error, studies outside the medical field demonstrate the intuitive link between demonstrate the intuitive link between fatigue and degradation performance”fatigue and degradation performance” Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality http://www.ahcpr.gov/clinic/ptsafety/http://www.ahcpr.gov/clinic/ptsafety/

accessed June 1/2004accessed June 1/2004

Study CriticismsStudy Criticisms

Invalidated measures of clinical Invalidated measures of clinical performanceperformance

Inconsistent definitions of fatigued and Inconsistent definitions of fatigued and rested subjectsrested subjects

Failure to measure fatigue objectivelyFailure to measure fatigue objectively Limited statistical powerLimited statistical power Failure to account for circadian effectsFailure to account for circadian effects

Gaba M et al. Fatigue among clinicians and the safety of patients. NEJM vol Gaba M et al. Fatigue among clinicians and the safety of patients. NEJM vol 347, 16, Oct 17, 02347, 16, Oct 17, 02

Emergency PhysiciansEmergency Physicians

Smith-Coggins R et al, Relationship of Day Versus Night Sleep to Smith-Coggins R et al, Relationship of Day Versus Night Sleep to Physician Performance and Mood, Ann of Emerg Med, vol 24, no Physician Performance and Mood, Ann of Emerg Med, vol 24, no 5, November 1994 p928-9345, November 1994 p928-934

Observational studyObservational study Monitored 6 emergency physicians for two 24h Monitored 6 emergency physicians for two 24h

periods:periods: Daytime work with nocturnal sleepDaytime work with nocturnal sleep Nighttime work with daytime sleepNighttime work with daytime sleep

Emergency PhysiciansEmergency Physicians Measurements:Measurements:

Ambulatory polysomnographic Ambulatory polysomnographic recordings, electro-oculogram, recordings, electro-oculogram, electromygraph dataelectromygraph data

Hourly mood ratingsHourly mood ratings Two performance tests completed 5x/dayTwo performance tests completed 5x/day

Intubation of a mannequinIntubation of a mannequin Simulated triage testSimulated triage test

Emergency PhysiciansEmergency Physicians Findings:Findings:

LessLess sleep during day compared to night sleep during day compared to night 328.5 vs 496.6 minutes328.5 vs 496.6 minutes

SlowerSlower at intubating a mannequin at night at intubating a mannequin at night 42.2 vs 31.56 seconds42.2 vs 31.56 seconds

More likelyMore likely to commit error when intubating at night to commit error when intubating at night More likelyMore likely to make errors during a simulated triage to make errors during a simulated triage

test toward the end of their shiftstest toward the end of their shifts Rated themselves as: Less sleepy, happier and more Rated themselves as: Less sleepy, happier and more

clear thinking working day shiftsclear thinking working day shifts

Emergency Physicians:Emergency Physicians:Conclusion:Conclusion:

““emergency physicians get less sleep and emergency physicians get less sleep and are less effective when performing are less effective when performing manual and cognitive tests while working manual and cognitive tests while working night shifts with day sleep compared with night shifts with day sleep compared with working day shifts with night sleep”working day shifts with night sleep”


Smith-Coggins et al. Rotating Shift work Schedules: Smith-Coggins et al. Rotating Shift work Schedules: Can we enhance physician adaptation to night shifts? Can we enhance physician adaptation to night shifts?

Acad Emerg Med. 1997;4:951-961Acad Emerg Med. 1997;4:951-961 Prospective, double-blind, placebo Prospective, double-blind, placebo

controlled trial of fatigue counter-measure controlled trial of fatigue counter-measure programprogram Two groups of 3 emergency physiciansTwo groups of 3 emergency physicians intervention, washout period, crossed overintervention, washout period, crossed over

Emergency PhysiciansEmergency PhysiciansIntervention:Intervention:

One group had experimental intervention:One group had experimental intervention:

1.1. 2 hour education session2 hour education session

2.2. Work schedule based on chronobiologic Work schedule based on chronobiologic principlesprinciples

3.3. Provided with 31 countermeasure strategies Provided with 31 countermeasure strategies to maintain alertness and performance during to maintain alertness and performance during workwork

Other group ate a special placebo dietOther group ate a special placebo diet

Emergency PhysiciansEmergency Physicians Measurements: Measurements:

1.1. Subjective logbook regarding level of Subjective logbook regarding level of alertness, mood, quantity and quality of alertness, mood, quantity and quality of sleep obtainedsleep obtained

2.2. Polysomnographic recordingsPolysomnographic recordings3.3. Performance tests 4x/day:Performance tests 4x/day:

a.a. Psychomotor vigilance test: Psychomotor vigilance test: b.b. ECG/rhythm interpretationECG/rhythm interpretationc.c. Intubation skillsIntubation skills

Emergency PhysiciansEmergency Physicians Findings: Findings:

Subjects slept more after Subjects slept more after bothboth interventions interventions The experimental interventions did The experimental interventions did notnot

significantly improve the physician’s significantly improve the physician’s performance, or mood on the night shiftperformance, or mood on the night shift

NoNo difference on ECG analysis and difference on ECG analysis and interpretationinterpretation

Time required to intubate a mannequin was Time required to intubate a mannequin was significantly significantly slowerslower during the night shift during the night shift

Emergency PhysiciansEmergency Physicians Conclusion:Conclusion:

““Circadian-mediated disruptions of Circadian-mediated disruptions of waking neurobehavioral functions and waking neurobehavioral functions and sleep deprivation are problems in sleep deprivation are problems in emergency physicians”emergency physicians”


Dula et al. The effect of working serial night shifts on the Dula et al. The effect of working serial night shifts on the cognitive functioning of emergency physicians. Ann of Emerg cognitive functioning of emergency physicians. Ann of Emerg Med. Vol 38, no 2 August 2001 p. 152Med. Vol 38, no 2 August 2001 p. 152

Does working 5 serial night shifts in the ED Does working 5 serial night shifts in the ED result in a decline in physician performance?result in a decline in physician performance?

Compared cognitive functioning of EP that Compared cognitive functioning of EP that worked the day shift vs. the night shiftworked the day shift vs. the night shift

16 Emerg Residents16 Emerg Residents Tested half while working days, the other half while working Tested half while working days, the other half while working

nightsnights 2 month interval2 month interval Crossed overCrossed over


The Fluid Scale of the Kaufman Adolescent The Fluid Scale of the Kaufman Adolescent and Adult Intelligence Testand Adult Intelligence Test measures a person’s adaptability and flexibility when faced measures a person’s adaptability and flexibility when faced

with new problems using both verbal and nonverbal stimuliwith new problems using both verbal and nonverbal stimuli

““The Fluid Scale measures hypothesis testing The Fluid Scale measures hypothesis testing and decision making, 2 areas of extreme and decision making, 2 areas of extreme importance to individuals functioning in the importance to individuals functioning in the ED”ED”

Every physicianEvery physician but one had a but one had a declinedecline in in performance after working 5 consecutive performance after working 5 consecutive night shiftsnight shifts

Emergency PhysiciansEmergency Physicians ConclusionConclusion::

““Working a series of 5 nights results in a Working a series of 5 nights results in a substantial decline in cognitive substantial decline in cognitive performance in physicians working in the performance in physicians working in the ED.”ED.”

However…However…

None of these studies looked directly at None of these studies looked directly at fatigue and errors in the departmentfatigue and errors in the department

They only indicate that as emergency They only indicate that as emergency physicians become fatigued their physicians become fatigued their cognitive function decreasescognitive function decreases

Difficult to link fatigue directly with errorDifficult to link fatigue directly with error At what point in the medical process does At what point in the medical process does

the error actually occur?the error actually occur?

Ideas to Cope With Shift Ideas to Cope With Shift WorkWork

MelatoninMelatonin

““Several studies have Several studies have examined the examined the effectiveness of oral effectiveness of oral melatonin use in melatonin use in emergency medicine emergency medicine physicians working night physicians working night shifts have failed to shifts have failed to document a significant document a significant effect”effect” Sleep, Alertness, and Fatigue Sleep, Alertness, and Fatigue

Education in Residency (SAFER) Education in Residency (SAFER) Program, Speaker’s Guide, American Program, Speaker’s Guide, American Academy of Sleep Medicine 2003Academy of Sleep Medicine 2003

Sleep Before a Night ShiftSleep Before a Night Shift

40 subjects in two experiments40 subjects in two experiments One group: kept awake for 28 hoursOne group: kept awake for 28 hours Other: consumed 10-15g of alcohol at 30min Other: consumed 10-15g of alcohol at 30min

intervals from 8am until blood alcohol level intervals from 8am until blood alcohol level was 0.1%was 0.1%

Measured cognitive psychomotor Measured cognitive psychomotor performance at half hour intervalsperformance at half hour intervals Computer-administered test of hand-eye Computer-administered test of hand-eye

coordinationcoordination


““After 17 hours of sustained wakefulness After 17 hours of sustained wakefulness (0300h) cognitive psychomotor (0300h) cognitive psychomotor performance decreased to a level performance decreased to a level equivalent to the performance impairment equivalent to the performance impairment observed at a blood alcohol concentration observed at a blood alcohol concentration of 0.05%”of 0.05%” Fatigue, alcohol and performance impairment. Fatigue, alcohol and performance impairment.

Dawson et al. Nature vol 388 17 july 1997, p.235Dawson et al. Nature vol 388 17 july 1997, p.235


0.05 is blood alcohol limit in:0.05 is blood alcohol limit in: Argentina, Australia, Austria, Argentina, Australia, Austria,

Belarus, Belgium, Bosnia Belarus, Belgium, Bosnia Herzegovina, Bulgaria, Costa Herzegovina, Bulgaria, Costa Rica, Croatia, Denmark, Finland, Rica, Croatia, Denmark, Finland, France, Germany, Greece, France, Germany, Greece, Iceland, Israel, Latvia, Iceland, Israel, Latvia, Macedonia, Monaco, Namibia, Macedonia, Monaco, Namibia, Netherlands, Portugal, Russia, Netherlands, Portugal, Russia, Slovenia, South Africa, South Slovenia, South Africa, South Korea, Spain, Switzerland, Korea, Spain, Switzerland, Taiwan, Thailand, Turkey, Taiwan, Thailand, Turkey, YugoslaviaYugoslavia

http://www.driveandstayalive.com/articles%20and%20topics/drunk%20driving/artcl--drunk-driving-0005--global-BAC-limits.htm accessed june 4/04


At 0800h “performance decreased to a level equivalent At 0800h “performance decreased to a level equivalent to the performance deficit observed at a blood alcohol to the performance deficit observed at a blood alcohol concentration of roughly 0.1%”concentration of roughly 0.1%” Fatigue, alcohol and performance impairment. Dawson et al. Fatigue, alcohol and performance impairment. Dawson et al.

Nature vol 388 17 july 1997, p.235Nature vol 388 17 july 1997, p.235

USA limit is 0.1%USA limit is 0.1% Swaziland limit is 0.15%Swaziland limit is 0.15%

http://www.driveandstayalive.com/articles%20and%20topics/drunk%20driving/ahttp://www.driveandstayalive.com/articles%20and%20topics/drunk%20driving/artcl--drunk-driving-0005--global-BAC-limits.htmrtcl--drunk-driving-0005--global-BAC-limits.htm accessed june 4/04 accessed june 4/04

Napping at workNapping at work

““Generally studies have Generally studies have demonstrated that naps demonstrated that naps maintain performance maintain performance compared to baseline compared to baseline conditions or improve conditions or improve performance compared performance compared to conditions of to conditions of prolonged wakefulness prolonged wakefulness without naps”without naps”

Rosekind et al. Alertness Management: strategic naps Rosekind et al. Alertness Management: strategic naps in operational settings. J Sleep Research 1995;4:62-in operational settings. J Sleep Research 1995;4:62-6666

Napping at workNapping at work

Not appropriate during a shift with Not appropriate during a shift with demand for “potential emergency”demand for “potential emergency”

Sleep inertiaSleep inertia Must consider the timing of the nap with Must consider the timing of the nap with

respect to the circadian rhythmrespect to the circadian rhythm

Rosekind et al. Alertness Management: strategic naps in operational settings. J Sleep Research 1995;4:62-66

Decrease the number of nights Decrease the number of nights with increasing agewith increasing age

Older physicians are less tolerantOlder physicians are less tolerant Has been suggested that workers begin to show deterioration Has been suggested that workers begin to show deterioration

in job function on night shifts in the 45-50 yr age rangein job function on night shifts in the 45-50 yr age range Akerstedt T et al. Fiedl studies of shift work: II Temporal patterns in psychophysiological activation in workers alternating Akerstedt T et al. Fiedl studies of shift work: II Temporal patterns in psychophysiological activation in workers alternating

between night and day work. Ergonomics 1977; 20: 621-631between night and day work. Ergonomics 1977; 20: 621-631

Younger physicians more tolerant, need more money to Younger physicians more tolerant, need more money to pay off debtspay off debts

Seniority factorSeniority factor In some specialties physicians with >20 yrs of service don’t do In some specialties physicians with >20 yrs of service don’t do

callcall

Casino ShiftsCasino Shifts

Silver Dollar Casino, Silver Dollar Casino, Calgary, ABCalgary, AB Not open 24 h/dayNot open 24 h/day

CasinoRama, OntarioCasinoRama, Ontario Circus Circus and Circus Circus and

Bally’s in Las VegasBally’s in Las Vegas Won’t return my Won’t return my

emails, phone callsemails, phone calls

Casino ShiftCasino Shift

Dartmouth General Hospital Site, Dartmouth General Hospital Site, Dartmouth, NSDartmouth, NS

Changed from 2 physicians working 23-Changed from 2 physicians working 23-0700 to:0700 to: 1 physician working 2300-07001 physician working 2300-0700 1 physician working 1900-0400 (casino shift)1 physician working 1900-0400 (casino shift)

Did this for 2 yearsDid this for 2 years Survey of 15 physiciansSurvey of 15 physicians

Shift preferenceShift preference

Physician: Casino Physician: Casino 14/17 14/17

(82%)(82%)

Family: Casino Family: Casino 9/159/15 (60%)(60%)

Total Sleep Time (mins.) Total Sleep Time (mins.) ________________________________________________________ Mean SD Mean SD pp__________________________________ __________________________________ Casino 369 72 Casino 369 72

0.00060.0006Regular 267 80 Regular 267 80 ____________________________________________________________________

Estimated Estimated Cognitive Impairment (%)Cognitive Impairment (%)________________________________________________________ Mean SD Mean SD pp__________________________________ __________________________________ Casino 18 11 Casino 18 11

0.020.02Regular 30 12 Regular 30 12 ____________________________________________________________________

Estimated Time to Recovery Estimated Time to Recovery (days) (days)________________________________________________________ Mean SD Mean SD pp__________________________________ __________________________________ Casino 1.3 0.6 Casino 1.3 0.6

0.0040.004Regular 2.0 0.8 Regular 2.0 0.8 ____________________________________________________________________

Casino Shift Casino Shift Conclusion:Conclusion:

““Potential benefits from casino scheduling Potential benefits from casino scheduling (more sleep, perceived shortened (more sleep, perceived shortened recovery time and a perceived reduction recovery time and a perceived reduction in cognitive impairment) would be in cognitive impairment) would be expected to benefit clinical performance expected to benefit clinical performance and reduce error.”and reduce error.”

UnfortunatelyUnfortunately

The concept is flawed because anchor The concept is flawed because anchor period sleep does not anchor the circadian period sleep does not anchor the circadian rhythm rhythm

No studies have shown thisNo studies have shown this Idea comes from: Idea comes from:

Mills JN et al. Circadian rhythms and irregular sleep Mills JN et al. Circadian rhythms and irregular sleep schedules. Journal of Physiology, April 1977, 31pschedules. Journal of Physiology, April 1977, 31p

Minors DS et al. Stabilizing rhythms on irregular Minors DS et al. Stabilizing rhythms on irregular schedules. Journal of Physiology, Sept 1979, 31pschedules. Journal of Physiology, Sept 1979, 31p

SuggestionsSuggestions

Treat people as individualsTreat people as individuals

““Research has shown that self-autonomy for Research has shown that self-autonomy for emergency physicians in scheduling results in emergency physicians in scheduling results in less stress.”less stress.” Kuhn G, Circadian rhythm, shift work, and emergency medicine, Annals Kuhn G, Circadian rhythm, shift work, and emergency medicine, Annals

of Emergency Medicine Vol 37, no1, jan 2001of Emergency Medicine Vol 37, no1, jan 2001

Let those who like days, do daysLet those who like days, do days Morning LarksMorning Larks

Let those who like nights, do nightsLet those who like nights, do nights Night Owls- Dr. M. HodsmanNight Owls- Dr. M. Hodsman Look for more of the sameLook for more of the same Start recruiting them in Medical SchoolStart recruiting them in Medical School

Maximize Circadian RhythmsMaximize Circadian Rhythms

Shift rotationShift rotation Rapid vs Slow RotationsRapid vs Slow Rotations Lighting in the Emergency DepartmentLighting in the Emergency Department

Shift RotationShift Rotation

Easy to stay up laterEasy to stay up later delay sleepdelay sleep

More difficult to try to fall asleep earlierMore difficult to try to fall asleep earlier advance sleepadvance sleep

This the principle behind forward This the principle behind forward (clockwise) rotation of shifts(clockwise) rotation of shifts Day Day Evening Evening Night Night

Rapid RotationRapid Rotation

1 to 2 night shifts in a row1 to 2 night shifts in a row Favored by those who wish to keep the Favored by those who wish to keep the

circadian rhythm diurnalcircadian rhythm diurnal Isolated night shifts are easier for some Isolated night shifts are easier for some

workers because there is no resetting of workers because there is no resetting of the circadian rhythms the circadian rhythms

Slow rotationSlow rotation

““At least a week is required for the At least a week is required for the circadian system to switch from a diurnal circadian system to switch from a diurnal to a nocturnal pattern”to a nocturnal pattern” Monk TK. Advantages and Disadvantages of Rapidly rotating Monk TK. Advantages and Disadvantages of Rapidly rotating

shift schedules-A Circadian Viewpoint Human Factors 1986, shift schedules-A Circadian Viewpoint Human Factors 1986, 28(5) 553-55728(5) 553-557

21 to 28 day rotation21 to 28 day rotation Then do no nights for a yearThen do no nights for a year

Lighting in the Emergency Lighting in the Emergency DepartmentDepartment

Bright light between 7000 and 12000 lux at night Bright light between 7000 and 12000 lux at night significantly increases subjective alertness and significantly increases subjective alertness and cognitive performance in shift workers cognitive performance in shift workers Czeisler C et al. Exposure to bright light and darkness to treat physiologic Czeisler C et al. Exposure to bright light and darkness to treat physiologic

maladaptation to night work. NEJM 1990; 322: 1253-1259maladaptation to night work. NEJM 1990; 322: 1253-1259

““The United States Nuclear Regulatory Commission The United States Nuclear Regulatory Commission has implemented bright lighting for its night workers and has implemented bright lighting for its night workers and found less fatigue and better alertness on the job”found less fatigue and better alertness on the job” Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality

http://www.ahcpr.gov/clinic/ptsafety/http://www.ahcpr.gov/clinic/ptsafety/ accessed June 1/2004 p.524 accessed June 1/2004 p.524


New FMC department will have sky lightsNew FMC department will have sky lights Bad ideaBad idea As it gets darker at night so will As it gets darker at night so will

departmentdepartment Staff will want to sleepStaff will want to sleep


Staff often turn off lights Staff often turn off lights in pt’s cubicles at nightin pt’s cubicles at night

Bad ideaBad idea Brain thinks it is night Brain thinks it is night

timetime Makes staff sleepyMakes staff sleepy

Instead:Instead: Maintain same level of Maintain same level of

lighting 24 h/daylighting 24 h/day Provide patients with mask Provide patients with mask

and earplugsand earplugs

ConclusionConclusion

Unfortunately…Unfortunately…

There is no great panacea for the There is no great panacea for the problems associated with shift workproblems associated with shift work

““The most important thing a shift worker The most important thing a shift worker can do is protect their sleep time”can do is protect their sleep time” Dr. C. Samuels May 5, 2004Dr. C. Samuels May 5, 2004

Sleep when you are tiredSleep when you are tired

““A(n afternoon) siesta will produce a higher A(n afternoon) siesta will produce a higher proportion of REM than sleep at other times proportion of REM than sleep at other times because of the circadian nature of REM sleep”because of the circadian nature of REM sleep”

Whitehead DC et al A Rational Approach to Shift Work in Emergency Medicine, Annals of Whitehead DC et al A Rational Approach to Shift Work in Emergency Medicine, Annals of Emergency Medicine Oct 1992 Vol 21 1250-1258Emergency Medicine Oct 1992 Vol 21 1250-1258

ExerciseExercise

““Vigorous aerobic exercise after rising Vigorous aerobic exercise after rising may diminish the time needed to adjust to may diminish the time needed to adjust to new shifts”new shifts” Whitehead DC et al A Rational Approach to Shift Work in Emergency Medicine, Whitehead DC et al A Rational Approach to Shift Work in Emergency Medicine,

Annals of Emergency Medicine Oct 1992 Vol 21 1250-1258Annals of Emergency Medicine Oct 1992 Vol 21 1250-1258

But…But… avoid exercising 2 to 4 hours before sleepavoid exercising 2 to 4 hours before sleep

Maximize sleep potentialMaximize sleep potential

Avoid morning light stimulusAvoid morning light stimulus Consider sleeping at hospital Consider sleeping at hospital Drive home with sunglasses onDrive home with sunglasses on

Avoid light in generalAvoid light in general Room in basement Room in basement Dark blinds in roomDark blinds in room

Cool environmentCool environment QuietQuiet

EarplugsEarplugs Room away from household activityRoom away from household activity

CommunicateCommunicate

Put do not disturb notes on front doorPut do not disturb notes on front door Turn off telephoneTurn off telephone Don’t schedule events during planned sleep Don’t schedule events during planned sleep

timetime Don’t plan strenuous events after a series of Don’t plan strenuous events after a series of

nightsnights More sleep will be required to make up the sleep More sleep will be required to make up the sleep

debtdebt

SummarySummary

1.1. Shift work has detrimental health effectsShift work has detrimental health effects

2.2. Lack of literature regarding emergency Lack of literature regarding emergency physicians and shift workphysicians and shift work

3.3. Lack of literature regarding emergency Lack of literature regarding emergency department error related to fatiguedepartment error related to fatigue

4.4. No easy solution to the problem of shift workNo easy solution to the problem of shift work

5.5. Maximize sleep hygiene to get the most out of Maximize sleep hygiene to get the most out of sleepsleep

ThanksThanks

Dr. A. AntonDr. A. Anton Dr. G. CurryDr. G. Curry Dr. M. HodsmanDr. M. Hodsman Dr. J. MclellanDr. J. Mclellan

Dr. J. NationDr. J. Nation Dr. T. RichDr. T. Rich Dr. C. SamuelsDr. C. Samuels Dr. B. YoungDr. B. Young

ReferencesReferences

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http://www.emedicine.com/emerg/topic835.htm accessed april 6/04http://www.emedicine.com/emerg/topic835.htm accessed april 6/04 Croskerry P Emergency et al, Casino Shift-Scheduling in the Department - A Strategy for Croskerry P Emergency et al, Casino Shift-Scheduling in the Department - A Strategy for

Abolishing the Night Shift?, AbstractAbolishing the Night Shift?, Abstract Personal correspondence with Dr. P. Croskerry May 17, 2004Personal correspondence with Dr. P. Croskerry May 17, 2004 Fatigue, alcohol and performance impairment. Dawson et al. Nature vol 388 17 july 1997, Fatigue, alcohol and performance impairment. Dawson et al. Nature vol 388 17 july 1997,

p.235p.235 Heselgrave R. Asleep at the Switch: Coping with shift work. The canadian journal of Diagnosis. Heselgrave R. Asleep at the Switch: Coping with shift work. The canadian journal of Diagnosis.

Feb 1998 p.78Feb 1998 p.78 Personal Corrrespondence with Dr. J. Mclellan, Shift Coordinator Rocky Mountian Emergency Personal Corrrespondence with Dr. J. Mclellan, Shift Coordinator Rocky Mountian Emergency

Services April 19, 2004Services April 19, 2004 Personal Correspondence: Dr. A. Anton, Medical Director of Calgary EMS April 16, 2004Personal Correspondence: Dr. A. Anton, Medical Director of Calgary EMS April 16, 2004 Rungta K. Sleepless on the shift. The Canadian Journal of Diagnosis/ Feb 1998. P.1Rungta K. Sleepless on the shift. The Canadian Journal of Diagnosis/ Feb 1998. P.1


Mitler M et al Catastrophes, sleep and public policy: consensus report, SLEEP, Mitler M et al Catastrophes, sleep and public policy: consensus report, SLEEP, 1988 11:100-1091988 11:100-109

Smith-Coggins R et al, Relationship of Day Versus Night Sleep to Physician Smith-Coggins R et al, Relationship of Day Versus Night Sleep to Physician Performance and Mood, Ann of Emerg Med, vol 24, no 5, November 1994 p928-Performance and Mood, Ann of Emerg Med, vol 24, no 5, November 1994 p928-934934

Smith-Coggins et al. Rotating Shiftwork Schedules: Can we enhance physician Smith-Coggins et al. Rotating Shiftwork Schedules: Can we enhance physician adaptation to night shifts? Acad Emerg Med. 1997;4:951-961adaptation to night shifts? Acad Emerg Med. 1997;4:951-961

Weinger M et at. Sleep Deprivation and Clinical Performance JAMA feb 27, 2002 Weinger M et at. Sleep Deprivation and Clinical Performance JAMA feb 27, 2002 vol287, no 8vol287, no 8

Sleep, Alertness, and Fatigue Education in Residency (SAFER) Program, Sleep, Alertness, and Fatigue Education in Residency (SAFER) Program, Speaker’s Guide, American Academy of Sleep Medicine 2003Speaker’s Guide, American Academy of Sleep Medicine 2003

Whitehead DC et al A Rational Approach to Shift Work in Emergency Medicine, Whitehead DC et al A Rational Approach to Shift Work in Emergency Medicine, Annals of Emergency Medicine Oct 1992 Vol 21 1250-1258Annals of Emergency Medicine Oct 1992 Vol 21 1250-1258

Drunk Driving Blood Alcohol Limits Worldwide Drunk Driving Blood Alcohol Limits Worldwide http://www.driveandstayalive.com/articles%20and%20topics/drunk%20driving/artcl--http://www.driveandstayalive.com/articles%20and%20topics/drunk%20driving/artcl--drunk-driving-0005--global-BAC-limits.htmdrunk-driving-0005--global-BAC-limits.htm accessed june 4/04 accessed june 4/04


Gaba M et al. Fatigue among clinicians and the safety of patients. NEJM vol 347, 16, Oct 17, Gaba M et al. Fatigue among clinicians and the safety of patients. NEJM vol 347, 16, Oct 17, 0202

Klompas M et a. Patients Working Shifts: Treating the Chronic Effects. The Canadian Journal Klompas M et a. Patients Working Shifts: Treating the Chronic Effects. The Canadian Journal of Diagnosis. Feb 1998 p.95of Diagnosis. Feb 1998 p.95

Leach DC. Residents’work hours: Achilles heel of the profession? Acad Med 2000;75: 1156-7Leach DC. Residents’work hours: Achilles heel of the profession? Acad Med 2000;75: 1156-7 Monk TK. Advantages and Disadvantages of Rapidly rotating shift schedules-A Circadian Monk TK. Advantages and Disadvantages of Rapidly rotating shift schedules-A Circadian

Viewpoint Human Factors 1986, 28(5) 553-557Viewpoint Human Factors 1986, 28(5) 553-557 Kuhn G, Circadian rhythm, shift work, and emergency medicine, Annals of Emergency Kuhn G, Circadian rhythm, shift work, and emergency medicine, Annals of Emergency

Medicine Vol 37, no1, jan 2001Medicine Vol 37, no1, jan 2001 Rosekind et al. Alertness Management: strategic naps in operational settings. J Sleep Rosekind et al. Alertness Management: strategic naps in operational settings. J Sleep

Research 1995;4:62-66Research 1995;4:62-66 Samuels C, Fatigue and Sleep: Making the Connection. The Canadian Journal of CME. Oct. Samuels C, Fatigue and Sleep: Making the Connection. The Canadian Journal of CME. Oct.

2001. P.51-612001. P.51-61 Smith Coggins et al. Rotating Shiftwork Schedules: Can we enhance physician adaptation to Smith Coggins et al. Rotating Shiftwork Schedules: Can we enhance physician adaptation to

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3): 299-3053): 299-305

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