Alertness/Fatigue Mitigation Management Strategies

During both the Medicine/Pediatrics intern orientation and the institutional orientation at the end of June just prior to the beginning of residency, the Program Director and the DIO, respectively, address the issues of recognizing the signs of fatigue, sleep management and alertness management and fatigue mitigation strategies.  These strategies are placed on the Medicine/Pediatrics website for 24-hour access and will be sent electronically to all residents at the beginning of each rotation to remind the residents of these easily implementable strategies.

The institution also requires that all residents must successfully complete fatigue and fatigue mitigation strategies modules with a passing score of at least 80% by the end of their intern year which is tracked by both the program coordinator and the institution.

During the faculty meetings, the Program Director reviews the policy regarding fatigue and alertness management and fatigue mitigation strategies.  The faculty members also receive an e-mail that highlights these strategies at the beginning of each ward rotation.

Since fatigue can adversely affect both patient care and learning, residents will be encouraged to either take strategic naps or utilize the back-up call schedule in extreme cases of fatigue.

Sleep Fatigue: Prevention, Identification  and Management

ACGME

·         Requires all training programs to educate faculty and residents to recognize the signs of fatigue and sleep deprivation; alertness management; and fatigue mitigation processes 

·         Must adopt and apply policies to prevent and counteract the potential negative effects on patient care & learning such as naps or back-up call schedules

Duty Hours

•          One day in seven free from all educational and clinical responsibilities, averaged over a four-week period, inclusive of call.

•          All residents must have 8 hours free of duty between scheduled duty periods but should ideally have at least 10 hours free of duty.  (Exception:  residents in the final years of education may have less than 8 hours free of duty between scheduled duty periods to care for their patients to prepare them to enter the unsupervised practice of medicine and care for patients over irregular or extended periods.)

•          All residents must have 14 hours free of duty after 24 hours of in-house duty.  For interns, duty hours cannot exceed 16 consecutive hours

•          For PGY-II through PGY-IV, duty periods of no more than 24 hours (in-house) with up to an additional 4 hours for transitioning patient care

•          Average of 80 hrs/week over 4 weeks

Definition

•          “Excessive daytime sleepiness”

•          Due to variety of factors:

                 -too little sleep

                 -fragmented sleep

                 -anxiety, depression, thyroid disease, etc.

                 -primary sleep disorders

Facts

•          Most residents site “too little sleep”

•          Average person needs 8.2 hours/night

•          However, insufficient time may be spent in deep or restorative sleep on call

•          If on call, residents may be interrupted by other residents, anxiety about beeper call, anticipation of sleep interruption

•          Energy (circadian) lows between 3-7 am and 3-5 pm

•          Disruption in sleep leads to “sleep debt”

•          Sleep debt may occur rapidly

•          Sleep debt requires several consecutive full night’s sleep for adequate recovery 

How does sleep fatigue effect medical performance?

•          In-service training scores lower

•          ER residents performed fewer components of history and physical

•          IM residents less accurate in EKG interpretation

•          Surgical residents required more time than usual to perform simulated skills and more errors 

•          Surgical residents 45% more post-operative complications

•          Declined cognitive and procedural abilities in pediatric residents

•          Decay in empathy, professionalism, empathy and alertness

How does sleep fatigue affect me?

•          Increased risk of personal injury and accident

•          Increased use of alcohol or other agents in order “to cope”

•          Increased motor vehicle collisions (49% of pediatric residents noted “falling asleep at the wheel”)

•          Sleeping 5 hours or less increases crashes 4.5 times

•          Crashes most commonly occur in the morning and mid-afternoon

Warning Symptoms and Signs of Sleep Deprivation

•          Repeated yawning and dozing off during conferences

•          “Microsleeps”

•          Increased tolerance for risk

•          Passivity  - feeling like you just don’t care

•          Inattention to details

•          Rechecking work constantly

•          Restlessness and irritability with staff, colleagues, family

•          Difficulty focusing on patient care

•          Decreased cognitive functions

•          Increased errors

•          Difficulty sleeping

•          Time pressure + Fatigue= Major Risk for Error

•          Sleep inertia: confusion and dysfunction that occurs upon awakening from sleep

•          The disorientation may also include a period of amnesia for the period of awakening

•          May cloud judgment for first 10 minutes to 2 hours after arousal

To minimize the effect of sleep inertia:

•          Get out of bed

•          Stand up

•          Turn on the lights

•          Try to nap every 12 hours

Prevention/Treatment/Management

•          Recognition is key!

•          Enforce work hour limits

•          Limit moonlighting

•          Reduce nonessential tasks and enhance learning during clinical time

•          Faculty assist residents to identify co-existent medical or emotional issues that may affect sleep

•          Prevention/Treatment/Management

•          Cross-cover and Check-out

•          Enlist fellows (residents) in combating issues with sleep fatigue

•          Set priorities for “time off”:  Protect your recovery time! You cannot cram it all into a 24-hour off day

•          Be smart about schedule swapping

•          Prevention/Treatment/Management

SLEEP/FATIGUE MITIGATION/ALERTNESS STRATEGIES:

1)    Strategies for healthy sleep for PRE CALL Residents

• aim for 7-9 hours per night – sleeping <7hrs/day can lead to sleep deficit
• catch up sleep on days off – if sleep <7 hrs/d during the week, you need  >9 hrs on both Saturday and Sunday to catch up.
• try to keep a routine
• avoid alcohol to help you sleep
• avoid stimulants to keep you up
• avoid heavy meals within 3 hours of sleep
• adequate exercise but avoid 3 hours before sleep
• eat right
• sleep hygiene – sleep same time every day

·         Relaxation rituals before sleep (bath, read, watch Seinfeld, etc.)

·         protect sleep time

·         get light exposure when awake

2) Alertness Management Strategies for ON CALL Residents:

·         nap whenever you can –

o   1-2 hour nap prior to 24 hr on call

o   15 min naps q 2-3 hrs improves performance between 2am and 9am

·         nap during circadian lows – BEST Circadian Window 2pm-5pm and 2am-5am for >30min or less than 2 hours

·         Strategic consumption of coffee (t1/2 3-7 hrs)faculty or resident if you are too sleep to work

·         Know your own alertness/sleep pattern

·         Tell your resident or faculty if you are too sleepy to work! (See Back-Up Call Policy)

3) Safe Habits for POST CALL residents:

·         Safe Driving

• consider how close you should live to the hospital
  • avoid driving if tired – instead take a taxi or other available transportation
  • Warning signs – it only takes 4 seconds to have crash!
    • Trouble focusing on the road
    • Can’t keep eyes open
    • Nodding
    • Yawning repeatedly
    • Drifting from lane to lane
    • Closing eyes at stoplights
    • Not remembering driving the last few miles
    • Missing signs/exits
  • Either nap for 20 minutes or consume 1 cup of coffee 30 minutes before driving!
  • lowest alertness 6am-11am after being up all night
  • if drowsy while driving, pull over to a safe location and take a nap

·         full recovery from sleep deficit usually takes 2 nights

·         most people need 8 hours of sleep per night; significant cognitive declines occur with just one night of missed sleep

•          Caffeine: NOT A SLEEP SUBSTITUTE

•          Effects within 15 to 30 minutes

•          Only a temporary help

•          Adverse effects: disruption in sleep quality, tolerance, diuresis and irritability

Other medications and drugs:

•          Sleep medications only after medical/sleep consultation

•          Avoid alcohol for sleep

•          Avoid over the counter stimulants

STRATEGIC NAPPING

 For shifts exceeding 16 hours, residents are encouraged to take strategic naps especially between the hours of 10pm through 8am to combat the adverse effects of fatigue and self-deprivation. Such napping such not be scheduled but should be based on patient needs and resident fatigue.  At least annually, all faculty and residents receive instruction from the Program Director to both recognize the signs of fatigue and self-deprivation and to provide acceptable solutions for the degree of fatigue/self-deprivation.  For example, faculty can either instruct the house officers to nap in the hospital call rooms or go home if warranted.   Residents must also successfully complete the on-line Alertness Management and Fatigue Mitigation modules that specifically emphasize strategic napping to be promoted to the PGYII year. The successful completion of these modules with an 80% passage rate are monitored by the institution and program coordinator.

 Residents must also track the number of hours of strategic napping while on-call and comment on its benefit if any with mitigating fatigue and improving patient care.  Resident evaluations will include frequency of medical errors associated with fatigue and what measure could have been taken to prevent the errors.

Who do I turn to?

•          Any faculty but especially program director

•          http://www.aasmnet.org/sfer.htm

•          (Sleep, Alertness and Fatigue Education in Residency)

•          www.acgme.org