Resident Duty Hours Enhancing Sleep, Supervision, and Safety (2009) / Chapter Skim
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7 Strategies to Reduce Fatigue Risk in Resident Work Schedules
7 Strategies to Reduce Fatigue Risk in Resident Work Schedules
Pages 217-262
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From page 217... ...
when extended duty periods are considered an essential aspect of resident training and continuity of care, a protected sleep period should be provided during that period to reduce the effects of acute sleep loss and to enhance performance. Because of the diversity of specialty and hospital needs, the committee leaves some flexibility for programs, but urges that adequate protected sleep periods be maintained, and that fatigue prevention and mitigation be a matter of professionalism that requires attention by residents, attending physicians and all those charged with maintaining patient safety.
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From page 218... ...
Thus, to retain the training value and flexibility in scheduling required by different specialties and rotations within specialties, while preventing and mitigating sleep loss that contributes to fatigue-related errors and accidents, the recommendations derived from this chapter relative to duty hours are focused more on providing predictable and protected time for sleep and recovery sleep than on limiting total work hours. FATIGUE, WORK HOURS, AND SLEEP LOSS In healthy individuals, fatigue is a general term used to describe feelings of tiredness, reduced energy, and the increased effort needed to perform tasks effectively and avoid errors.
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From page 219... ...
sleep needs are met. Moreover, reviews of the risks posed by residency duty hours have emphasized that prevention of sleep deprivation in residents is the most important way to reduce fatigue risks to patient and resident safety (Baldwin and Daugherty, 2004; Buysse et al., 2003; Cavallo and Mallory, 2004; Gaba and Howard, 2002; Howard et al., 2002; Landrigan et al., 2007; Lockley et al., 2006; Parshuram, 2006; Veasey et al., 2002; Weinger and Ancoli-Israil, 2002)
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From page 220... ...
of residents prior to the 2003 duty hour limits also revealed an inverse relationship between average weekly work hours reported by residents and average weekly sleep time (Figure 7-1A)
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From page 221... ...
Scatterplot of reported average weekly work hours of sleep with reported average weekly work hours, PGY (postgraduate year) 1 and PGY2 combined (regression line plotted, r = –.39)
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From page 222... ...
. Effects of Acute Sleep Deprivation ON Human Performance Findings on the effects of 30-hour extended duty periods on the performance of physicians (Philibert, 2005)
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From page 223... ...
Acute Sleep Deprivation and Resident Performance Current ACGME duty hours set an upper limit on duty hours of 24 hours with an additional 6 hours to allow adequate time for patient follow-up, didactic learning, and patient handovers (ACGME, 2003, 2004)
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From page 224... ...
during extended duty periods were also asked about motor vehicle incidents and crashes. Sleep deprivation from extended shifts contributed to significantly elevated risks of motor vehicle crashes, near-miss incidents, and incidents involving involuntary sleep while driving home from the hospital after an extended duty period (post-call)
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From page 225... ...
. While these results pre-date the current ACGME resident duty hour limits and consequently may not generalize to residents today, they are consistent with the more recent studies by the Harvard Work Hours, Health and Safety Group indicating that sleep deprivation in interns (the least experienced residents)
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From page 226... ...
permitted in the current ACGME resident duty hour limits (ACGME, 2003) promote conditions for fatigue-related errors that pose risks to both patients and residents (Ayas et al., 2006; Barger et al., 2006a; Landrigan et al., 2004; Lockley et al., 2007)
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From page 227... ...
Although reduction of resident duty hours alone is one way to achieve more sleep (Lockley et al., 2004, 2006, 2007) , it is an indirect and inefficient way to increase sleep given the moderate correlation between resident work hours and sleep time (see Figure 7-1)
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From page 228... ...
can help mitigate some of the effects of fatigue during night shifts and extended duty periods, suggesting that naps and longer sleep periods may be a valuable countermeasure to fatigue experienced by residents. Although some residents take ad hoc naps during 24 + 6 hours extended duty periods when work demands permit, napping during extended duty periods is not addressed by the current ACGME duty hours.
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From page 229... ...
Use of Protected Sleep Time by Residents During Extended Duty Periods Two studies have evaluated the feasibility of deploying a protected pager-free sleep period at night during extended duty periods. One study designed to assess the effects of an on-duty protected nighttime period for sleep on first-year residents' sleep and fatigue during 24 + 6 hour work periods provided supplementary night float coverage to interns from 12:00 a.m.
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From page 230... ...
In other words, interns recognized the advantages of the night float -- protected sleep schedule for increased sleep time and reduced fatigue -- but they tended not to use it because of concerns about their patients and discontinuity of care (i.e., potential for risks posed by two transitions of care -- one at the start and one at the end of their protected sleep period) (Arora et al., 2006)
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From page 231... ...
. Improving Adherence to Use of PROTECTED SLEEP PERIODS While a protected nighttime sleep of up to 4-5 hours duration appears feasible as a way to prevent acute sleep deprivation in resident physicians during an extended duty period, the limited data available indicate that adherence to such a schedule was relatively poor (22-56 percent)
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From page 232... ...
PREVENTION OF CHRONIC SLEEP DEPRIVATION Chronic sleep deprivation occurs when the quantity and quality of sleep being obtained across days is insufficient to prevent daytime sleepiness, elevated sleep propensity, cognitive deficits, and other neurobehavioral problems (e.g., drowsy driving) produced by repeated days of inadequate recovery sleep (Dinges et al., 2005)
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From page 233... ...
reveal statistically reliable near-linear cumulative increases in cognitive deficits across days of sleep restriction (see Figure 7-2) (Belenky, 2003; Dinges et al., 1997; Van Dongen et al., 2003)
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From page 234... ...
. Approaches to Prevent Chronic Sleep Loss Resident duty hours should protect against chronic sleep restriction over consecutive days and weeks of work.
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From page 235... ...
In addition to the potential safety risks posed by overly long work hours (Caruso et al., 2004) , the ACGME duty hours stipulate that "adequate time for rest and personal activities must be provided.
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From page 236... ...
, recovery sleep time is reduced and the resident's cumulative sleep debt grows. As a result, a failure to mandate and enforce the 10-hour "adequate rest" rule poses a challenge to the prevention of chronic sleep restriction and its consequences for cumulative performance impairments in residents, even more so after night shifts and overnight call than day shifts.
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From page 237... ...
The committee believes that identification of these factors, and ensuring that resident sleep time is protected and optimized, offer important avenues for prevention of fatigue-related resident errors and their risks to patient and resident safety. Recovery Sleep Recovery Sleep Following Extended Duty Hours The current ACGME rules have no minimum off-duty requirement that ensures residents obtain adequate recovery sleep following an extended duty period (24 + 6 hours)
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From page 238... ...
the next day will ensure that residents can acquire at least 8-9 hours recovery sleep during the nocturnal period after an extended duty period in the hospital. Recovery Sleep Following Night Shifts As noted at the beginning of this chapter, a number of factors interact to influence the relationship of work and fatigue.
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From page 239... ...
, as well as adequate time for recovery sleep following each night shift. ACGME duty hours currently have no special provisions for the duration of night-shift work -- which is typically 12 hours -- or for the duration of off-duty recovery time for sleep after night shifts (except for the 10 hours of "adequate rest" requirement)
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From page 240... ...
Without a day off in 7, as permitted by averaging days off, residents have a greater likelihood of chronic sleep restriction that can progress to levels of severe performance impairment. An experiment in healthy adults revealed that restriction of nightly sleep to between 4 and 6 hours resulted in cumulative performance deficits that reached levels equivalent to 48-64 hours of total sleep deprivation after 9 consecutive days without a day off for extra recovery sleep (Van Dongen et al., 2003)
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From page 241... ...
Appendix B provides sample monthly schedules for an individual resident comparing the application of current ACGME duty hour limits and the committee's recommendations that illustrate enhanced regularity of days off and protected sleep during extended duty periods under the latter. Focusing on resident off-duty time (for sleep)
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From page 242... ...
Programs should design resident schedules using the following parameters: • Duty hours must not exceed 80 per week, averaged over 4 weeks. • Scheduled continuous duty periods must not exceed 16 hours unless a 5-hour uninterrupted continuous sleep period is pro vided between 10 p.m.
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From page 243... ...
ADDITIONAL CONSIDERATIONS UNDERPINNING RECOMMENDATION 7-1 As noted above, the intent of the committee's recommendations for changes to resident duty hours was to prevent fatigue when possible and to provide measures to relieve both acute and chronic sleep deprivation, recognizing that some fatigue may be inevitable when attempting to provide service in the hospital 24 hours a day, 7 days a week. Because of the diversity of specialty education needs, program sizes, and patient populations, the committee believes some flexibility in duty hour rules is needed for programs to design their own resident training schedules within certain limits supported by the evidence in this chapter.
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From page 244... ...
Furthermore reducing hours of work could limit the time for education and training experiences of residents without resulting in increased hours of sleep since, as noted earlier in this chapter, reducing total work hours alone is an inefficient and indirect way to increase sleep time (Baldwin and Dougherty, 2004; Lockley et al., 2004; Ludmerer and Johns, 2005)
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From page 245... ...
remaining hours for transition and educational activities) • hours with no protected 16 sleep period Maximum in- Every third night, on average Every third night, no averaging hospital on-call frequency Minimum time off 10 hours after shift length • hours after day shift 10 between scheduled • hours after night shift 12 shifts • hours after any extended 14 duty period of 30 hours and not return until 6 a.m.
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From page 246... ...
. The committee is not mandating that duty periods be 16 hours, but rather is setting 16 hours as the upper limit for continuous work without a protected sleep period.
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From page 247... ...
so that residents are available when other family and friends are off work to provide some work-life balance. Protected Sleep Period During Extended Duty Period The committee debated the best course for continuity of patient care, educational purposes, and addressing fatigue when deliberating on whether to maintain the 30-hour extended duty period.
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From page 248... ...
residents would prefer to and would be inclined to leave the hospital to sleep in their own beds for such a long break, driving home while overtired and not obtaining sufficient sleep before they returned regardless of how the official schedule is drawn. Thus, the committee recommends incorporating a 5-hour sleep period in any duty period over 16 hours and recommends that this sleep period be counted as part of total duty hours.
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From page 249... ...
The committee expects that there will not be routine violations, either scheduled or ad hoc, of duty hours. This expectation applies whether it involves a duty period of 10, 16, or 30 hours, or any other variation.
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From page 250... ...
Currently the ACGME is testing scheduling approaches and limits, including different napping strategies during extended duty periods, limiting the separation between shifts to 8 hours, and investigating whether duty hour limits should apply to residents in their last year of training. The committee encourages ACGME and the respective Residency Review Committees to document why they need to continue 30-hour duty periods as it was the most contentious part of the duty hour debate before the committee. Implementation of all of the committee's duty hour recommendations should include a national evaluation of the following: the changes individual programs make; the extent to which the recommended changes to ACGME duty hour limits actually result in increased sleep for residents and maintenance of alertness and performance during work; the costs of implemented changes; the effect on labor supply and patient coverage; and which specific schedules with protected sleep programs more or less effectively promote sleep and alertness.
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From page 251... ...
. Currently, ACGME only requires that "in-house" or internal moonlighting for patient care be considered part of the 80-hour weekly limit on duty hours; that moonlighting requires prospective, written permission from the program director; and that resident performance be monitored to ensure no adverse effects that may lead to withdrawal of permission (ACGME, 2003, 2007a)
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From page 252... ...
2004. Report of the workgroup on resident duty hours and the learning environment.
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From page 253... ...
2005. The use of stimulants to modify performance during sleep loss: A review by the sleep deprivation and stimulant task force of the American Academy of Sleep Medicine.
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From page 254... ...
2006. Pedi atric residency duty hours before and after limitations.
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From page 255... ...
In Sleep deprivation: Clinical issues, pharmacol ogy and sleep loss effects, edited by C Kushida.
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From page 256... ...
2005. Acute sleep deprivation in the thoracic surgical resident does not affect operative outcomes.
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From page 257... ...
2006. Sleep disorders and sleep deprivation: An unmet public health problem.
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From page 258... ...
2007. Effects of health care provider work hours and sleep deprivation on safety and per formance.
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From page 259... ...
2005. Sleep loss and performance in residents and nonphysicians: A meta-analytic examination.
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From page 260... ...
2003. The cumulative cost of additional wakefulness: Dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation.
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From page 261... ...
2006. Frontal lobe metabolic decreases with sleep deprivation not totally reversed by recovery sleep.
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