Page 1 © American Academy of Sleep Medicine American Academy of Sleep Medicine S LEEP, A LERTNESS,...

Page 1© American Academy of Sleep Medicine

American Academy of Sleep Medicine

SLEEP,

ALERTNESS, and

FATIGUE

EDUCATION in

RESIDENCY

Page 2

The official requirement

• Faculty and residents must be educated to recognize the signs of fatigue, and adopt and apply policies to prevent and counteract its potential negative effects.

– ACGME Common Requirements 2004• VI, A3



“Patients have a right to expect a healthy, alert, responsible, and responsive physician.”

January 1994 statement by American College of Surgeons Re-approved and re-issued June 2002

The REAL requirement

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Objectives1. Recognize universal need for adequate

sleep2. Review risks of sleep deprivation3. Consider methods to promote

alertness when sleep-deprived4. Consider methods to reduce risk of

fatigue-related errors5. Identify methods to recover from sleep

deprivation6. Review preventive measures

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Humans need adequate sleep

Adequate means both duration and quality



Time

9 PM9 AM 9 AM

SleepWake

Sleep Homeostatic drive (Sleep Load)

Circadian alerting signal

Alertness level

3 PM 3 AM

Human Circadian Rhythm is fairly consistent



Epworth Sleepiness Scale

Sleepiness in residents is equivalent to that found in patients with serious sleep disorders. Mustafa and Strohl, unpublished data. Papp, 2002

Residency and sleep deprivation

© American Academy of Sleep Medicine


Sleep Needed vs Sleep Obtained

• Myth: “I’m one of those people who only need 5 hours of sleep, so none of this applies to me.”• Fact: Individuals may vary somewhat in their

tolerance to the effects of sleep loss, but are not able to accurately judge this themselves.• Fact: Human beings need 8 hours of sleep to

perform at an optimal level.• Fact: Getting less than 8 hours of sleep starts to create a “sleep debt” which must be paid off.

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Sleep deprivation is hazardous to others



• Surgery: 20% more errors and 14% more time required to perform simulated laparoscopy post-call (two studies) Taffinder et al, 1998; Grantcharov et al, 2001

• Internal Medicine: efficiency and accuracy of ECG interpretation impaired in sleep-deprived interns Lingenfelser et al, 1994

• Pediatrics: time required to place an intra-arterial line increased significantly in sleep-deprived Storer et al, 1989

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Sleep deprivation is hazardous to you

“Dan, moments before he fell asleep at the wheel”



Sleep Loss and Fatigue: Safety Issues

• 58% of emergency medicine residents reported near-crashes driving.-- 80% post night-shift-- Increased with number of night shifts/month

Steele et al 1999

• 50% greater risk of blood-borne pathogen exposure incidents (needlestick, laceration, etc) in residents between 10pm and 6am. Parks

2000



Adverse Health Consequences by Average Daily Hours of Sleep*

0

10

20

30

40

50

60

<4 hrs 5-6hrs >7 hrs

Hours of Sleep

Perc

ent

% Reporting SignifWt Change

% Reporting MedUse to Stay Awake

% ReportingIncreased AlcoholUse

*Baldwin and Daugherty,1998-9 Survey of 3604

PGY1,2 Residents



Drive Smart; Drive Safe

• AVOID driving if drowsy. • If you are really sleepy, get a ride home, take

a taxi, or use public transportation.• Take a 20 minute nap and/or drink a cup of

coffee before going home post-call.• Stop driving if you notice the warning signs of

sleepiness.• Pull off the road at a safe place, take a short

nap.



Drowsy Driving: What Does Not Work• Turning up the radio• Opening the car window• Chewing gum• Blowing cold air (water) on your face• Slapping (pinching) yourself hard• Promising yourself a reward for staying awake

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“Alertness management” strategies

Caffeine

Exercise

Light

Napping

Medication

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Caffeine

Time use judiciously e.g. before circadian low point

Onset: 15 - 30 min

Effects last 3-4 hours

But, sleep-disruptive: if possible, d/c 3-4 hours before planned sleep

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Exercise

Stretch, run in place, or do jumping jacks

Walk briskly from house to car, car to hospital

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Light

Best: full-spectrum light (e.g. sunlight)

Any bright light helps

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Napping

20-45 minutes

Up to 2:00

(allows REM + restorative sleep)

BUT longer naps > risk of sleep inertia

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Medication

Modafinil

ONLY IF PRESCRIBED by your personal physician

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And watch out for these

MicrosleepsSleep inertiaCircadian lowsIsolationSelf-deceptionHigh risk jobs

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Microsleeps

“Faceplants”,or “nodding off”

Sleeper often unaware

Alert your colleagues!

Response: thank colleague; exercise; talk

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Sleep Inertia:

10-120 min of grogginess, cognitive slowing, decreased vigilance after awakening.

Worsened by sleep deprivation

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Circadian lows

12-4 a.m.

12-4 p.m.

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Isolation:

• sleepiness predicts underestimates of level of sleepiness and overestimates of alertness;

•residents in 1 study did not perceive themselves to be asleep almost half of the time they had actually fallen asleep (Howard et al, 2002)

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Self-deception

•“If I can just get through the night (on call), I’m fine in the morning.”

•“I’m better off ‘toughing it out’, napping just makes me feel worse.”

•“I get used to night shifts right away; no problem.”

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High-risk jobs

low stimulation + high need for vigilance



Adapting To Night Shifts

• Myth: “I get used to night shifts right away; no problem.”

• Fact: It takes at least a week for circadian rhythms and sleep patterns to adjust.

• Fact: Adjustment often includes physical and mental symptoms (think jet lag).

• Fact: Direction of shift rotation affects adaptation (forward/clockwise easier to adapt).



How To Survive Night Float

• Protect your sleep.• Nap before work. • Consider “splitting” sleep into two 4 hour

periods.• Have as much exposure to bright light as

possible when you need to be alert.• Avoid light exposure in the morning after

night shift (be cool and wear dark glasses driving home from work).

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Recovering from sleep deprivation

On average, two nights’ recovery sleep (approx 9 h) needed

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Preventive measures• Sleep ahead: • Optimize your sleep environment

– Cool, dark, quiet

• Practice good sleep hygiene– Presleep relaxation, reduce alerting

stimuli, make bed a cue for sleep



In Summary…• Sleepiness and fatigue can’ t be eliminated

in residency, but can be managed.• Recognizing sleepiness and fatigue in

yourself and your colleagues is the 1st step• Practice alertness management strategies

regularly• Don’t overlook recovery periods• If self-management isn’t working, talk to

your seniors and/or program director

Page 34

For further information

• Hauri Peter & Linde, S. No more sleepless nights. NY: Wiley, 1996.

• Sleep problems: Sleepquest (William Dement MD). http://www.sleepquest.com

• Relaxation techniques: http://www.learningmeditation.com/room.htm

• GASnet.org (fatigue in residency video): http://www.gasnet.org/videos/

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