Kate Johnson

June 21, 2011

June 21, 2011 (Minneapolis, Minnesota) — Sleep deprivation in physicians and nurses working extended-hour hospital shifts is compromising patient safety and increasing the risk for car crashes in both Canada and the United States, according to 2 studies presented here at SLEEP 2011: Associated Professional Sleep Societies 25th Annual Meeting .

"This situation is critical," said Diana McMillan, RN, PhD, from the Faculty of Nursing at the University of Manitoba in Winnipeg, Canada. "Nightshift work is fraught with both homeostatic and circadian challenge. It's a perfect storm."

"Twenty-four-hour shifts result in acute total sleep deprivation, and frequency of these shifts leads to chronic partial sleep deprivation," added Laura Barger, PhD, from Division of Sleep Medicine, Brigham and Women's Hospital, and Harvard Medical School, in Boston, Massachusetts.

Both presenters painted a dire picture of shift workers falling asleep on their drive home and during surgery.

Work-Hours Reform for All Residents?

In the Harvard Work Hours Health and Safety Study, a national Web-based survey, data from senior residents (postgraduate years 2 – 7) and 5 years of monthly surveys confirmed what earlier analysis already showed in first-year residents "that extended-duration work shifts post a safety hazard for resident physicians and the patients they care for, and this is true for all postgraduate years," said Dr. Barger.

New standards from the Accreditation Council for Graduate Medical Education, expected to take effect next month (July 2011), will limit first-year residents' shifts to no more than 16 consecutive hours compared with the currently approved 30-hour shifts, she said.

"We believe that work-hours reform that eliminates extended-duration shifts should include all years of residency. We think this will improve safety for the residents themselves, the patients they care for, and for the other motorists on the road."

We believe that work-hours reform that eliminates extended-duration shifts should include all years of residency.

The new analysis of senior residents in the Harvard Work Hours Health and Safety Study included 1884 senior residents and approximately 19,000 monthly surveys asking about work hours, motor vehicle crashes and near misses, medical errors, and attentional failures.

Similar to earlier findings about interns, the analysis found that compared with senior residents who did not work extended hours (defined as 24 consecutive hours or more), those who did reported increased rates of motor vehicle crashes and near misses (odds ratio [OR], 1.72 and 5.03, respectively), an increase in attentional failure while driving (OR, 1.7), an increase in medical errors (OR, 3.5), adverse events resulting from medical errors (OR, 3.4), and fatalities resulting from medical errors (OR, 4.8).

"The evidence suggests that extended-duration work shifts pose a safety hazard for all resident physicians and the patients they care for, and this is true for all postgraduate years," she said.

Critical Nurse Shortage in Critical Care

The same scenario exists north of the border, where nurses struggle with the same challenges, said Dr. McMillan.

"Many critical care nurses are working the night shift and reporting symptoms indicative of significant homeostatic and circadian challenge," she reported.

In a similar Web-based survey of 536 critical care nurses (88% female; mean age, 42 years), from 11 Canadian provinces and territories, 32% "always" felt tired, she said.

The respondents worked primarily 12-hour shifts, on a day/night rotation, with 15% working only night shifts. Between 2 consecutive night shifts, 72% got 6 hours or less of daytime sleep, and 20% got 4 hours or less, she said.

"A large number indicated they were sleepy, sluggish, they felt irritable, forgetful, stressed, chilled, hungry, nauseated, and they also experienced considerable eyestrain."

One-quarter reported personal injury or near injury that was directly attributable to their fatigue, and 16% reported incidents or errors affecting patients that were directly attributable to their fatigue.

On their drive home, 43% reported having fallen asleep while stopped at a traffic light, 31% reported having fallen asleep while driving, and 20% reporting having had a motor vehicle crash or near miss.

"Some of the qualitative data about these accidents or near accidents are chilling," said Dr. McMillan. "They talked about being totally disoriented. They talked about looking up at the road and wondering where they were. They talked about frequently getting home and wondering how they got there."

Some of the qualitative data about these accidents or near accidents are chilling. They talked about being totally disoriented....They talked about frequently getting home and wondering how they got there.

The demands on the critical care nurses are also extremely high, she said. They must be mentally and emotionally engaged at all times and often have to make critical decisions rapidly.

"It's serious. We need to do something to change this — not only for critical care nurses but for all nurses," she said. "Although there is a considerable amount of evidence to suggest there are strategies out there that we can be implementing, the uptake is not good."

Complex Issues

Asked to comment on the presentations, Nancy S. Redeker, PhD, RN, professor and dean of scholarly affairs at Yale University School of Nursing, New Haven, Connecticut, said the issue is complex — and not just about regulations.

"There's been a lot of attention to this issue for medical residents, and that's clearly an issue, but nationwide there's a huge shortage of nurses, especially in hospitals and critical care settings, and so nurses are increasingly being pressed to work more than 1 shift," she told Medscape Medical News.

"Some nurses do it because they want to earn extra money, but most are getting pressure to do it — and in the case of residents they're doing it because they're trainees and they're required to do it," said Dr. Redeker, who is the current editor-in-chief of Heart & Lung: The Journal of Acute and Critical Care.

"It's an occupational health issue because we know that shift work and sleep deprivation lead to personal health issues for these individuals — but it's obviously a patient safety issue too."

Dr. Barger has disclosed no relevant financial relationships. Dr. McMillan disclosed that she offers private sleep health consultation to clients with sleep health problems. However, any advice she gives to professional organizations is offered free of charge. Dr. Redeker has disclosed no relevant financial relationships

SLEEP 2011: Associated Professional Sleep Societies 25th Annual Meeting: Abstracts O977 and O978. Presented June 15, 2011.

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