Sleep Deprivation and its Effects on Health Care Providers Ansley Buckhalter Advisor: Dr Weaver

Sleep Deprivation and Sleep Deprivation and its Effects on Health its Effects on Health

Care ProvidersCare ProvidersAnsley BuckhalterAnsley Buckhalter

Advisor: Dr WeaverAdvisor: Dr Weaver

DefinitionDefinition

Webster’s New Millennium Dictionary of English defines sleep deprivation as “the condition of being robbed of sleep, in real life or in experiment, as opposed to being unable to sleep”.

What does sleep do for What does sleep do for us?us?

Not everything is understood about the Not everything is understood about the influence sleep has on the body but through influence sleep has on the body but through numerous studies, it has been determined that numerous studies, it has been determined that sleep plays a major role in the proper function sleep plays a major role in the proper function

of both the endocrine and immune systemsof both the endocrine and immune systems..

What happens when What happens when you don’t get enough you don’t get enough

sleep?sleep?


sleepsleep• Some serious illnesses such as obesity, Some serious illnesses such as obesity,

hypertension, depression, and diabetes are being hypertension, depression, and diabetes are being linked to the deprived of sleep.linked to the deprived of sleep.(sleepfoundation.org)(sleepfoundation.org)

• It has been reported that “gastrointestinal and It has been reported that “gastrointestinal and cardiovascular complaints increase, immune cardiovascular complaints increase, immune function, carbohydrate metabolism, and endocrine function, carbohydrate metabolism, and endocrine function are impaired to some degree”. function are impaired to some degree”.

• A study conducted by Kripke et al showed a rise in A study conducted by Kripke et al showed a rise in mortality with “severe shortening of daily sleep” mortality with “severe shortening of daily sleep” and that “sleep of <4 hours increased likelihood of and that “sleep of <4 hours increased likelihood of death by a factor of 2.8 in a 6-year follow-up death by a factor of 2.8 in a 6-year follow-up period”. period”.

Sleep deprivation and Sleep deprivation and the health care the health care

providerprovider• A survey study, conducted from July 2002 to A survey study, conducted from July 2002 to

May 2003, found that doctors working 1-4 or 5 May 2003, found that doctors working 1-4 or 5 or greater extended shifts (>24 h or greater extended shifts (>24 h continuously) per month increased adverse continuously) per month increased adverse events related to fatigue by seven to eight events related to fatigue by seven to eight times compared to months in which no times compared to months in which no extended-duration shifts were worked extended-duration shifts were worked

• ABC new reported in 2006 that after 5 or more ABC new reported in 2006 that after 5 or more marathon shifts medical providers were four marathon shifts medical providers were four times more likely to make errors that result in times more likely to make errors that result in patient deaths.patient deaths.


sleep?sleep?• To emphasize the effect sleep To emphasize the effect sleep

deprivation has on the body and its deprivation has on the body and its potential harm that could come; it has potential harm that could come; it has been show that after 24 hours of been show that after 24 hours of consecutive wakefulness, psychomotor consecutive wakefulness, psychomotor function was equivalent to a blood function was equivalent to a blood alcohol concentration of alcohol concentration of 0.1%0.1%. .


providerprovider• In 2004 Rosen published a paper stating that acute In 2004 Rosen published a paper stating that acute

sleep deprivation, or lack of sleep over a short period sleep deprivation, or lack of sleep over a short period of time, has been shown to be related to a decrease in of time, has been shown to be related to a decrease in “rote memory, verbal comprehension, and “rote memory, verbal comprehension, and mathematical calculations” as well as errors in mathematical calculations” as well as errors in prescribing medications and recording medical history. prescribing medications and recording medical history.


providerprovider• In 2001, a study interested in the sleep behaviors and In 2001, a study interested in the sleep behaviors and

attitudes among internal medicine residents was attitudes among internal medicine residents was conducted at the University of Pennsylvania. Surveys conducted at the University of Pennsylvania. Surveys were given to 52 incoming interns and 79 “current were given to 52 incoming interns and 79 “current housestaff”. There was a 100% completion rate of the housestaff”. There was a 100% completion rate of the survey and their findings revealed that among the survey and their findings revealed that among the current housestaff, 69% said it was possible that they current housestaff, 69% said it was possible that they could fall asleep while doing charts, 61% while reading could fall asleep while doing charts, 61% while reading medications, 51% while reviewing labs, and 46% while medications, 51% while reviewing labs, and 46% while doing orders. 48% reported to suffer from acute sleep doing orders. 48% reported to suffer from acute sleep deprivation while doing ward rotations as well as 81% deprivation while doing ward rotations as well as 81% post-call. The study also reported that about two-thirds post-call. The study also reported that about two-thirds of the housestaff on the wards and in ICU admitted to of the housestaff on the wards and in ICU admitted to chronic sleep deprivation. chronic sleep deprivation.


providerprovider• Physical on-the-job injury could occur to the Physical on-the-job injury could occur to the

health care provider. A case-crossover study health care provider. A case-crossover study from five teaching medical centers in both the from five teaching medical centers in both the US and Canada, has shown that sleep US and Canada, has shown that sleep deprivation in interns was associated with a deprivation in interns was associated with a “3-fold increase” for being injured with a sharp “3-fold increase” for being injured with a sharp instrument. instrument.


providerprovider Barger conducted a nationwide prospective Barger conducted a nationwide prospective

study using a web-based survey. 2,737 first study using a web-based survey. 2,737 first year postgraduate residents participated and year postgraduate residents participated and completed 17,003 monthly reports that inquired completed 17,003 monthly reports that inquired about hours of work, extended hour work shifts, about hours of work, extended hour work shifts, “documented car accidents”, almost accidents, “documented car accidents”, almost accidents, and involuntary sleeping. From the information and involuntary sleeping. From the information that was obtained from the interns, Barger that was obtained from the interns, Barger determined that the monthly chances of him/her determined that the monthly chances of him/her being involved in an automobile accident while being involved in an automobile accident while commuting from work is raised 16.2 percent commuting from work is raised 16.2 percent


providerprovider• There have been efforts to address this There have been efforts to address this

problem. In 2003, the Accreditation Council for problem. In 2003, the Accreditation Council for Graduate Medical Education set work-hour Graduate Medical Education set work-hour limits for all residents in the United States. limits for all residents in the United States. These regulations limit residents to work a These regulations limit residents to work a maximum of 30 hours nonstop per shift and no maximum of 30 hours nonstop per shift and no more than 80 hours a week. more than 80 hours a week.

• But the regulations still allow residents to work But the regulations still allow residents to work two 30-hour shifts a week and up to nine 30-two 30-hour shifts a week and up to nine 30-hour shifts a monthhour shifts a month


providerprovider• ACGME also investigates the compliance of the ACGME also investigates the compliance of the

accredited programs and found that for the accredited programs and found that for the academic year of 2006-2007, “8.8% received academic year of 2006-2007, “8.8% received one or more citations for duty hour violations. one or more citations for duty hour violations. This represented a slight increase over the This represented a slight increase over the 7.9% of programs reviewed in academic year 7.9% of programs reviewed in academic year

2005-06 that received duty hour citations2005-06 that received duty hour citations..• So it appears that most of the accredited So it appears that most of the accredited

programs are following the 80 hour work week programs are following the 80 hour work week limit. limit.

What can be done?What can be done?

• It has been found beneficial for workers to take It has been found beneficial for workers to take a 20 minute nap before their shift begins. a 20 minute nap before their shift begins.

• Some studies have shown that allowing a nap Some studies have shown that allowing a nap during an extended duty hour shift can help during an extended duty hour shift can help reduce fatigue; however, this required reduce fatigue; however, this required coverage of patients while the intern was coverage of patients while the intern was napping.napping.

• However, this brings up the issue of “patient However, this brings up the issue of “patient handoff”handoff”

What can be done?What can be done?

• The health care provider should make every effort The health care provider should make every effort possible to ensure that they are prepared for possible to ensure that they are prepared for whatever the shift or work hour duration will be. whatever the shift or work hour duration will be. By exercising good sleep hygiene (good sleep By exercising good sleep hygiene (good sleep habits), the quality of their sleep might be habits), the quality of their sleep might be improved. A good sleep hygiene consists of a improved. A good sleep hygiene consists of a regular sleep schedule, getting at least 8 hours of regular sleep schedule, getting at least 8 hours of sleep, avoid caffeine 4-8 hours before bedtime, sleep, avoid caffeine 4-8 hours before bedtime, avoid nicotine before bedtime, no alcohol or heavy avoid nicotine before bedtime, no alcohol or heavy meals late in the evening, regular exercise, and meals late in the evening, regular exercise, and reduce noise, light, and extreme temperatures reduce noise, light, and extreme temperatures while trying to sleepwhile trying to sleep

ReferencesReferences• Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA. Neurobehavioral performance of residents after heavy

night call vs after alcohol ingestion. JAMA. 2005 Sep 7; 294(9): 1025-33.night call vs after alcohol ingestion. JAMA. 2005 Sep 7; 294(9): 1025-33.• • Arora VM, Dunphy C, Chang VY, Ahmad F, Humphrey HJ, Meltzer D. The effects of on-duty napping on intern Arora VM, Dunphy C, Chang VY, Ahmad F, Humphrey HJ, Meltzer D. The effects of on-duty napping on intern

sleep time and fatigue. Ann Intern Med. 2006 Jun 6; 144(11): 792-8.sleep time and fatigue. Ann Intern Med. 2006 Jun 6; 144(11): 792-8.• • Arora VM, Georgitis E, Woodruff JN, Humphrey HJ, Meltzer D. Improving sleep hygiene of medical interns: can Arora VM, Georgitis E, Woodruff JN, Humphrey HJ, Meltzer D. Improving sleep hygiene of medical interns: can

the sleep, alertness, and fatigue education in residency program help?. Arch Intern Med. 2007 Sep 10; 167(16): the sleep, alertness, and fatigue education in residency program help?. Arch Intern Med. 2007 Sep 10; 167(16): 1738-44.1738-44.

• • Aubrey A. Health Care Night-Shift Workers Often Neglect Selves. NPR. 2005 Sept 20; Morning Edition. Aubrey A. Health Care Night-Shift Workers Often Neglect Selves. NPR. 2005 Sept 20; Morning Edition.

http://www.npr.org/templates/story/story.php?storyId=4855626http://www.npr.org/templates/story/story.php?storyId=4855626• • Ayas N T, Barger LK, Cade BE, Hashimoto DM, Rosner B, Cronin JW et al. Extended Work Duration and the Risk of Ayas N T, Barger LK, Cade BE, Hashimoto DM, Rosner B, Cronin JW et al. Extended Work Duration and the Risk of

self-reported percutaneous injuries in interns. JAMA. 2006; 296: 1055-1062.self-reported percutaneous injuries in interns. JAMA. 2006; 296: 1055-1062.• • Barger LK, Ayas NT, Cade BE, Cronin JW, Rosner B, Speizer FE, Czeisler CA. Impact of extended duration shifts on Barger LK, Ayas NT, Cade BE, Cronin JW, Rosner B, Speizer FE, Czeisler CA. Impact of extended duration shifts on

medical errors, adverse events, and attentional failures. PLos Med. 2006 Dec; 3(12): e487.medical errors, adverse events, and attentional failures. PLos Med. 2006 Dec; 3(12): e487.• • Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE et al. Extended work shifts and the risk of motor Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE et al. Extended work shifts and the risk of motor

vehicle crashes among interns. N Engl J Med. 2005 Jan 13; 352(2): 125-34.vehicle crashes among interns. N Engl J Med. 2005 Jan 13; 352(2): 125-34.• • Fisman DN, Harris AD, Rubin M, Sorock GS, Mittleman MA. Fatigue increases the risk of injury from sharp devices Fisman DN, Harris AD, Rubin M, Sorock GS, Mittleman MA. Fatigue increases the risk of injury from sharp devices

in medical trainees: results from a case-crossover study. Infect Control Hosp Epidemiol. 2007 Jan; 28(1): 20-7.in medical trainees: results from a case-crossover study. Infect Control Hosp Epidemiol. 2007 Jan; 28(1): 20-7.

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http://www.apsf.org/resource_center/newsletter/2005/spring/01fatigue.htmhttp://www.apsf.org/resource_center/newsletter/2005/spring/01fatigue.htm• • Kiernan M, Civetta J, Bartus C, Walsh S. 24 Hours on-call and acute fatigue no longer worsen resident mood Kiernan M, Civetta J, Bartus C, Walsh S. 24 Hours on-call and acute fatigue no longer worsen resident mood

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• • • Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT et al. Effect of reducing interns’ work hours Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT et al. Effect of reducing interns’ work hours

on serious medical errors in intensive care units. N Engl J Med. 2004 Oct 28; 351(18): 1838-48. on serious medical errors in intensive care units. N Engl J Med. 2004 Oct 28; 351(18): 1838-48. • • Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP et al. Effect of reducing interns’ weekly work Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP et al. Effect of reducing interns’ weekly work

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empathy, and burnout among interns. Acad Med. 2006 Jan;81(1): 82-5empathy, and burnout among interns. Acad Med. 2006 Jan;81(1): 82-5• • Sleep Education. www.sleepeducation.com/SleepScale.aspxSleep Education. www.sleepeducation.com/SleepScale.aspx• • Sleep Foundation. Sleep Foundation. www.sleepfoundation.org• Van Dongen HP, Maislin G, Mullington JM, Dinges DF, et all. The cumulative cost of additional wakefulness, dose Van Dongen HP, Maislin G, Mullington JM, Dinges DF, et all. The cumulative cost of additional wakefulness, dose

response effects on neurobehavioral function and sleep physiology from chronic sleep restriction and total sleep response effects on neurobehavioral function and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep. 2003 May 15; 26(2): 117-26.deprivation. Sleep. 2003 May 15; 26(2): 117-26.

• • www.wordnet.comwww.wordnet.com• Armstrong, A M.D. Sleepy Doctors a threat to Patients. ABC News Medical Unit. 12 Dec 2006 Armstrong, A M.D. Sleepy Doctors a threat to Patients. ABC News Medical Unit. 12 Dec 2006

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Sleep Deprivation and its Effects on Health Care Providers Ansley Buckhalter Advisor: Dr Weaver