sleep, shift work and the emergency physician mark wahba md, ccfp emergency medicine grand rounds...
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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
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
Shift Work and ErrorShift Work and Error
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
Shift Work and ErrorShift Work and Error
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”
Emergency PhysiciansEmergency Physicians
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”
Emergency PhysiciansEmergency 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
Emergency PhysiciansEmergency Physicians
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
Sleep Before a Night ShiftSleep Before a Night Shift
““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
Sleep Before a Night ShiftSleep Before a Night Shift
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
Sleep Before a Night ShiftSleep Before a Night Shift
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
Lighting in the Emergency Lighting in the Emergency DepartmentDepartment
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
Lighting in the Emergency Lighting in the Emergency DepartmentDepartment
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
Akerstedt T et al. Fiedl studies of shift work: II Temporal petterns in phsychophysiological Akerstedt T et al. Fiedl studies of shift work: II Temporal petterns in phsychophysiological activation in workers alternating between night and day work. Ergnonomics 1977; 20: 621-631activation in workers alternating between night and day work. Ergnonomics 1977; 20: 621-631
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
ReferencesReferences
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
ReferencesReferences
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
night shifts? Acad Emerg Med. 1997;4:951-961night shifts? Acad Emerg Med. 1997;4:951-961 Smith L et al. The perceptions and feelings of shiftworkers’partners.Smith L et al. The perceptions and feelings of shiftworkers’partners. Ergonomics 1993; 36 (1-Ergonomics 1993; 36 (1-
3): 299-3053): 299-305
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