Adherence to Resident Work Limits No Guard Against Sleepiness
By Megan Rauscher
NEW YORK (Reuters Health) May 21 – Medical residents continue to experience severe sleepiness, despite adhering to the Accreditation Council for Graduate Medical Education (ACGME) guidelines that limit their work hours to not more than 80 hours per week and 24 hours at a stretch, a new study shows.
The finding, reported at the American Thoracic Society’s 103rd International Conference Sunday, may have implications for patient and resident safety, according to clinicians from Baylor College of Medicine in Houston.
They measured objective and subjective sleepiness in 29 medical residents the day before and the day after they were on-call for 24 hours at the hospital’s ICU.
For two nights prior to call, residents slept an average of 7.15 and 7.75 hours; average sleep duration while on call was 2.5 hours. The mean Stanford Sleepiness Score was significantly different between the pre-call and post-call day (1.5 vs 3.15, p The majority of the residents’ post-call sleep latency (time to fall asleep) was in the pathological range (less than 5 minutes).” This degree of sleepiness is seen in medical conditions such as obstructive sleep apnea and narcolepsy, the researcher explained.
Even on the pre-call day, the sleep latency was lower than normal (9 minutes).
“The findings were surprising,” Dr. Reddy noted. “We did not expect the residents to be this sleepy.”
For the most part, scores on reaction time tests and simple motor skills tests showed no difference between pre- and post-call days, with the exception of two tests in which residents unexpectedly showed better performance post-call than pre-call.
“Training program directors and residents need to be aware of residents’ sleepiness,” Dr. Reddy told Reuters Health, “so that adequate rest and supervision during patient care may be provided for sleepy residents.”
“Residents need to take precautions driving back home after a call, like not driving long distances or taking a nap before driving home,” the researcher added.
The impact of the ACGME guidelines has not been well studied, according to the study team. Based on the finding of this single-center study, “a multicenter study should be conducted and, if the findings are similar, then guidelines to cut down the number of hours per week during ICU rotations may be needed,” Dr. Reddy concluded.
There is no doubt that medical residents are sleep deprived, but apparently so are CEO’s, nurses, ambulance drivers, policemen, and factory workers; all of whom apparently get slightly more sleep than the average doctor, according to a sleep survey conducted by Travelodge in the UK. The report said the top 10 most sleep-deprived professions are:
Company directors (averaging 5.9 hours of sleep a night)
Ambulance crew/paramedics (6 hours)
Tradesmen (6 hours) Leisure and hospitality workers (6 hours)
Police officers (6.1 hours)
Factory workers (6.2 hours)
Nurses (6.3 hours)
Engineers (6.3 hours)
Doctors (6.4 hours)
Civil servants (6.4 hours).
While the Baylor study quoted above showed no difference in reaction times and motor skills pre and post-call, other studies have shown that sleep deprivation has a particularly debilitating effect on decision-making processes that depend heavily on emotion.
A study at the Walter Reed Army Institute of Research in Silver Spring, Maryland, US, set up an experiment where active-duty military personnel were presented with a variety of hypothetical dilemmas, first when well rested and later, after staying awake for 53 hours. Situations included complex life-and-death moral quandaries as well as situations without a moral component.
While participants did not become less “moral” when sleep deprived, they did require two seconds longer on average to answer complex moral questions. Questions without a moral component did not take longer to answer after participants were kept awake. According to principal study author Dr. William Killgore, the findings, along with previous brain-imaging studies, suggest that sleep deprivation has a particularly debilitating effect on decision-making processes that depend heavily on emotion. “When people go for more than 24 hours without sleep there are dramatic decreases in brain activity in the prefrontal cortex [the area of the brain involved in processing emotions and decision-making].”
Both studies recommend that further research, including brain imaging, should be conducted as laboratory results do not always translate to real world situations.
Experts urge residents to find healthy ways to both stay awake and go to sleep. Here are some tips they offer to avoid sleep deprivation:
Make sleep a priority. Most adults need seven to nine hours of sleep a night to function optimally.
Experts recommend preparing for a long shift ahead by getting enough sleep the night before. Also, practice healthy sleep habits, such as adopting a pre-sleep routine and avoiding heavy meals or strenuous exercise within three hours before bedtime.
Learn to recognize the signs of fatigue. According to the SAFER program developed by the American Academy of Sleep Medicine, performance starts to decline after about 15 to 16 hours of continued wakefulness. You are also less alert between 6 a.m. and 11 a.m. after being up all night. Red flags include irritability, trouble focusing, and checking and re-checking work.
Give yourself time to recover after call and adapt to new shifts. The SAFER program claims that it takes two nights of extended sleep to restore baseline alertness and recover from on-call sleep loss. It also takes at least a week for circadian rhythms to adjust after switching from a day to a night shift.
Shift forward. If you have to change shifts, try moving forward in the day, from afternoon to night, for example.
Nap strategically. Naps can be effective fatigue-fighters, as long as they’re taken at the right time and don’t last too long. Napping strategies should include “prophylactic” naps before work. If possible, schedule sleep to take advantage of those times in the circadian cycle when you tend to feel the most sleepy. For most people, that means between 3 p.m. and 4 p.m. and in the very early morning, after 3 a.m.—optimal times for a short nap.
If you can’t hit those windows of opportunities, experts recommend napping whenever possible, as some sleep is better than none at all. It’s best to nap in a quiet environment and for no more than 30 minutes to avoid entering a deep sleep. If you need to recover from sleep inertia—a brief period of grogginess that can last between 15 and 30 minutes—a small cup of coffee may help.
Use caffeine wisely, but it may have diuretic effects, and it has a half-life of seven hours. Experts recommend moderate, strategic consumption, while a study in the May 2004 issue of Sleep claimed that frequent, low doses of caffeine (about two ounces of coffee) may be more effective for staying alert than larger, less frequent doses.
A small cup of coffee might help you recover from a nap or to stay awake for the drive home. But drinking large amounts during the day can stop you from getting to sleep later. Obviously, stimulants such as nicotine and alcohol won’t induce sleep.
Be aware of light. Bright light can cue the brain to stay awake, so get as much light exposure as possible to stay alert. Conversely, wearing dark glasses can help you avoid being stimulated by light during the drive home.
Don’t drive while drowsy. Getting a ride is the best solution, but if that’s not possible, take a nap first or drink coffee. Pull over and take a nap if necessary.
Get educated. The ACGME requires hospitals to provide education on sleep deprivation and fatigue.
The biggest hurdle to be faced may be the culture of medical residency itself. Sleeplessness is viewed as a “rite of passage” and a resident or intern may be hesitant to ask for help for fear of being viewed as “weak” or lazy. The ACGME and ACP are to be credited with addressing this problem, although far more needs to be done.
LINK: from ACP online-Despite New Work Hours, Residents Need More Rest