Sleep Loss in Residency: Effect and Strategies for Management

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Sleep Loss in Residency Effect and Strategies
for Management
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How does it feel to be a resident? How do you
cope, sleepless and stressed?
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• If sleep does not serve an absolutely vital
  process, it is the biggest mistake the
  evolutionary process ever made.
• Allan Rechtschaffen  

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And the Value of Sleep is NOT new news

• The sleep of a labouring man is sweet, whether
  he eats little or much Ecclesiastes 512
• Sleep that knits up the raveld sleeve of care.
  The death of each days life, sore labours
  bath. MacBeth 2.2 46-51

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The Birth of Sleep Research

• The first description of REM sleep at the
  University of Chicago in 1953 by Drs. Nathaniel
  Kleitmen and Eugene Aserinsky
• Science, September 4, 1953

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The issues for medical residents and fellows..
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Sleep rules The New Issue in 2003
enter the Public ,the Congress and
the ACGME

• Calls for improved safety hours regulation
• New Yorks News is generalized
• Libby Zion and NY 405
• Conyers Bill
• The ACGME Work Hours Restrictions
• Examples from other industries (aviation,
  trucking, railways)

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How Do We Compare??

• Industry (year limit instituted) Monthly
  limit
• Aviation (regulation, 1938, 1985) 100 hrs
  (flight time)
• Trucking (regulation, 1938) 260 hrs
  (driving)
• GME (accreditation, 2003) 320 hrs
  (in-house
  service and
• education)
• Maritime (statute, reg. 1918, 1997) 360 hrs
  (at sea)
• Rail (statute, 1907, 1969)
  432 hrs (engineers)

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Why Is Sleep Loss in Graduate Medical Education
an Enduring Issue

• Health care is a
• 24 / 7 industry
• Health care relies on human cognitive functioning
  (decision-making, memory, vigilance, information
  management, communication)

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The Enduring Issue

• Unintentional human error is THE most
  frequently identified cause of accidents in all
  industries

House, 3rd season finale, 2007 Human Error
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Why Physicians May Downplay the Importance of
Sleep

• Most physicians know relatively little about
  sleep and sleep physiology.
• Sleepiness is not measured in a blood test .yet

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• The cultural context of Medical training
• Sleep is optional
• A sign of weakness
• A sign of lack of dedication

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The ACGME Standards

• Call scheduled no more than every third night
• One (24-hour) day in seven free of patient care
• Limit of 80 duty hours per week
• 24-hour limit on continuous duty, up to 6 hours
  for transfer, debriefing, didactic activities
• A 10-hour minimum rest between duty periods
• In-house hours during home call count toward
  weekly hours limit
• Education of residents and faculty about sleep
  loss/fatigue and its management is REQUIRED

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The New Recommendations of the Institute of
Medicine

• No new admissions after 16 consecutive duty hours
  
• Mandatory 5 hour nap between 10pm and 8 am
• One weekend off per month as well as one day off
  in 7

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How are we doing with the Old Rules???

• JAMA 2006 83 of interns surveyed (4015 of
  37,253) reported work hours violations during one
  or more months of training
• Most were on inpatient rotations
• Most were gt 30 consecutive hours
• Mean sleep on call 2.5 hours

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Compliance with the 30 hour rule
Stating the Obvious

• 30 hours is indeed 30 hours
• Sign outs are imperatives
• Team sport behavior
• Become accustomed to not being done

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What do we need to know about sleep deprivation
in general???
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Sleep and Job Performance Acute vs. Chronic
Partial Sleep Deprivation

• The same degree of impairment results from 24-48
  hr acute sleep loss or from sleeping lt6 hrs/night
  for 7 days or more

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Sleep and Job Performance

• The individuals perception of sleepiness is
  least affected by sleep deprivation

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To perform at their best, To learn.Everyone
needs sleepevery night
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Sleep and Job Performance Sleep Inertia The
brain on auto-pilot

• Acting as though awake, you have no subsequent
  recall of conversations and decisions made

I am sure you can give the tylenol IV
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Sleep Deprivation Adversely Affects Job
Performance

• Reduces vigilance recall
• Affects complex tasks and problem-solving
• Performance deteriorates with time-on-task

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Sleep Deprivation

• Causes perseveration, poor prioritization of
  tasks
• Individuals maintain accuracy at the expense of
  speed
• Negatively affects motivation and mood

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Sleep Deprivation

• Learning ceases

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Sound Bites from The Data

• Sleep protects declarative memory and renders
  it resistant to interferenceand is important for
  motor skills acquisition. Neuron 2002
• Practice (with sleep) makes perfect !!!

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• JAMA Neurobehavioral Performance of Brown
  University Pediatrics Residents after call
  blood alcohol 0.05g
• Tested Sustained attention, vigilance, simulated
  driving
• Previous data likened call to a blood alcohol of
  0.1g

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• Sleep Meta-analysis. After 30 hours there is
  a significant decline in cognitive function,
  vigilance, memory, clinical performance. Caution
  to recognize sometimes the controls are
  chronically sleep deprived.

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• JAMA Interns (British Columbia and Harvard)
  report more percutaneous injuries at a mean of 29
  hours on duty. Odds ratio 1.6

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• Sleep Canadian IM residents tested for
  vigilance and reaction time on a Q4 night
  schedule. Controls path residents and endo
  fellows with no call. Findings decreased
  vigilance and reaction times, NO RECOVERY BETWEEN
  CALLS. Post call residents did not sleep more but
  chose other activities, e.g. sports.

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Assessing Alertness How do you know when you
are tired?

• Falling asleep in conferences or on rounds
• Feeling restless and irritable with everyone
• Having to check your work repeatedly
• New onset of drooling

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• Having difficulty focusing on the care of your
  patients
• Feeling like you really just dont care
• Do you really think the patient is the enemy?
• You make bad judgments!

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Coping Strategies

• Eat well
• Exercise
• Take a shower
• Dont push the send button when you are tired
• Ask for advice and LISTEN to it

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Coping Strategies

• Better sleep at home (good sleep hygiene, i.e.,
  sleep duration, quality, timing, frequency)
• Weekly recovery sleep
• Optimal sleep environment in work

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AND a nap is always a good thing
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Naps

• Two types
• Preventive (prior to being on-call)
• Operational (while on-call)
• Remember Because of sleep inertia,
• you need to allow adequate recovery time
• (15-30 minutes)

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More coping skills..

• Strategic use of bright light
• Strategic use of caffeine
• Standing body-position.. Do not make any
  important decisions while lying down
• Appropriate driving strategies (morning
  post-call) TAKE A CAB!
• 58 of emergency medicine residents reported
  near-crashes driving (80 post night-shift)
  Steele et al, 1999

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Sleep Deprivation and YOUR HealthHeads UP!
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Naps arent a CURE for all.

• Annals of Emergency Med 3 am naps for 40
  minutes improve 730 am performance for ER MDs and
  RNs. Actual sleep time24 minutes. Vigilance and
  reaction time improved. Simulated driving did NOT.

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• Behavioral Sleep Medicine At Eastern Va, IM
  residents post call simulated driving
  deteriorated particularly in MEN

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Your Health..if you sleep more than 8 hours or
less than 7 hours per night increases you risk
for.

• CAD
• Hypertension
• Obesity

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Short sleep and neuro-endocrine control of
appetite
grehlin
Short sleep
leptin
WEIGHT GAIN
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Short Sleep
appetite
energy
Glucose intolerance
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Short sleep..

• More Type 2 Diabetes
• More weight gain
• Sleep to lose weight???

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Sleep and the Immune System
The virtues of a good nights sleep just got
better, with the arrival of the news that the
immune system functions best during the night. 
Researchers at Stanford University used fruit
flies to test their theory but there is strong
evidence that the effect carries through to
humans as well. December, 2008
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• JAMA Yale IM residents in the MICU
  inflammatory markers measured at 1 pm in fasted
  individuals, after 30 hours and after 6 hours
  work
• Sleep 20 minutes v 6 hours
• IL6, Norepi, CRP all increased
• Marked reduction in brachial artery flow mediated
  dilation

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SO..
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Providing 24/7 Medical Care The Ongoing Dilemma
Quality of Life v. Quality of Care???
Continuity v. Fatigue
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There are no perfect answers current
scheduling rules and solutions have many
unintended consequencesImportantly, YOU need
insight and coping skills,
And sometimes some friendly advice
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Or a guardian angel
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Remember.
Take Home Messages about Sleep

• Take Home Messages about Sleep

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• Sleep deprivation negatively affects learning,
  memory, clinical performance, vigilance and YOUR
  HEALTH
• Sleep enough when you can and use good sleep
  hygiene

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• Plan for Recovery Sleep when you cannot
• Use caffeine when you need it

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• Remember to use bright lights and to stand up
  before making any important decisions
• DONT DRIVE and dont let your friends drive
  sleepy

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Short sleep and neuro-endocrine control of
appetite
appetite
Short sleep
energy
Glucose intolerance