Title: The Human Factor: The Impact of Work Hours, Sleep Deprivation, and Burnout on Patient Safety Tuesday
1The Human Factor The Impact of Work Hours, Sleep
Deprivation, and Burnout on Patient
SafetyTuesday, March 20, 2007800 900 p.m.
EDT
2 - Moderator
- Christopher Landrigan, MD, MPH, FAAP
- Pediatric Hospitalist, Research and Fellowship
Director - Childrens Hospital Boston, Inpatient Pediatrics
Service - Boston, Massachusetts
3This activity was funded through an educational
grant from the Physicians Foundation for Health
Systems Excellence.
4Disclosure of Financial Relationships and
Resolution of Conflicts of Interest for AAP CME
Activities Grid
- The AAP CME program aims to develop, maintain,
and increase the competency, skills, and
professional performance of pediatric healthcare
professionals by providing high quality,
relevant, accessible and cost-effective
educational experiences. The AAP CME program
provides activities to meet the participants
identified education needs and to support their
lifelong learning towards a goal of improving
care for children and families (AAP CME Program
Mission Statement, August 2004). - The AAP recognizes that there are a variety of
financial relationships between individuals and
commercial interests that require review to
identify possible conflicts of interest in a CME
activity. The AAP Policy on Disclosure of
Financial Relationships and Resolution of
Conflicts of Interest for AAP CME Activities is
designed to ensure quality, objective, balanced,
and scientifically rigorous AAP CME activities by
identifying and resolving all potential conflicts
of interest prior to the confirmation of service
of those in a position to influence and/or
control CME content. The AAP has taken steps to
resolve any potential conflicts of interest. - All AAP CME activities will strictly adhere to
the 2004 Updated Accreditation Council for
Continuing Medical Education (ACCME) Standards
for Commercial Support Standards to Ensure the
Independence of CME Activities. In accordance
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interest identification of CME needs,
determination of educational objectives,
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potential conflicts of interest are identified
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activity are implemented in ways that are
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5DISCLOSURES
6DISCLOSURES
7DISCLOSURES
8CME CREDIT
- The American Academy of Pediatrics (AAP) is
accredited by the Accreditation Council for
Continuing Medical Education to provide
continuing medical education for physicians. -
- The AAP designates this educational activity for
a maximum of 1.0 AMA PRA Category 1 Credit.
Physicians should only claim credit commensurate
with the extent of their participation in the
activity. -
- This activity is acceptable for up to 1.0 AAP
credit. This credit can be applied toward the
AAP CME/CPD Award available to Fellows and
Candidate Fellows of the American Academy of
Pediatrics.
9OTHER CREDIT
- This webinar is approved by the National
Association of Pediatric Nurse Practitioners
(NAPNAP) for 1.2 NAPNAP contact hours of which
0.0 contain pharmacology (Rx) content. The AAP
is designated as Agency 17. Upon completion of
the program, each participant desiring NAPNAP
contact hours should send a completed certificate
of attendance, along with the required recording
fee (10 for NAPNAP members, 15 for nonmembers),
to the NAPNAP National Office at 20 Brace Road,
Suite 200, Cherry Hill, NJ 08034-2633. -
- The American Academy of Physician Assistants
accepts AMA PRA Category 1 Credit(s)TM from
organizations accredited by the ACCME .
10The Human Factor The Impact of Work Hours, Sleep
Deprivation, and Burnout on Patient Safety
American Academy of Pediatrics WebinarMarch
20, 2007
- Christopher P. Landrigan, MD, MPH
- Director, Sleep and Patient Safety Program,
Brigham and Womens Hospital - Research Director, Childrens Hospital Boston
Inpatient Pediatrics Service - Assistant Professor of Pediatrics and Medicine,
Harvard Medical School
11To Err is Human(Institute of Medicine, 1999)
- 44,000 to 98,000 deaths per year due to adverse
events - Focus on systemic issues
- Report notably silent on issue of provider
working conditions and mental health - lack of empiric data at that time
- Considerable accumulation of information in past
3-4 years -
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14- Harvard Work Hours, Health, and Safety Study
- National Study of Work Hours and Injuries in
2,737 Interns
Motor Vehicle Crashes
Percutaneous Injuries
OR 2.3 (95 CI, 1.6-3.3)
OR 1.6 (95CI, 1.5-1.8)
Extended shifts Non-extended shifts
Ayas, et al. JAMA 2006 2961055-1062
Barger LK et al. NEJM 2005 352125-134
15Intern Sleep and Patient Safety Study
- Randomized Trial comparing interns alertness and
performance on traditional q3 schedule with
24-30 hour shifts (ACGME-compliant ) vs. 16 hr
max schedule - Twice as many EEG-documented attentional failures
at night on traditional schedule
No. of attentional failures from 11pm 7am per
Hour on Duty
p0.02
Lockley, S. W. et al. N Engl J Med
20043511829-1837
16- Intern Sleep and Pt Safety Study, Part 2
- Interns made 36 more serious errors on
traditional schedule, including 5 times as many
serious diagnostic errors
p
Errors per 1000 pt days
p0.03
p
Landrigan, C.P. et al. N Engl J Med
20043511838-1848
Landrigan, C. P. et al. N Engl J Med
20043511838-1848
17ACGME Duty Hour Standards
- of care and education
- 1 day off in 7, averaged over four weeks
- Implemented in July 2003
- Goal to reduce extreme work hours, and
consequently improve patient safety
18ACGME Duty Hours Compliance Study
- 83.6 of interns in violation of standards
during - at least one month of the year
- 61.5 of all inpatient intern-months in violation
Work and Sleep, Pre- vs. Post-Implementation
p
p
Landrigan C.P., et al. JAMA 20062961063-1070
19Patient Safety, Resident Sleep, Depression, and
Burnout
- Mark Joffe sleep deprivation and human
performance - Amy Fahrenkopf burnout, depression, and resident
performance
20 - Mark Joffe, MD, FAAP
- Director, Community Pediatric Medicine
- The Childrens Hospital of Philadelphia
- The University of Pennsylvania School of Medicine
- Philadelphia, Pennsylvania
21The Human Factor The Impact of Work Hours,
Sleep Deprivation, and Burnout on Patient Safety
- Mark Joffe, M.D.
- The Childrens Hospital of Philadelphia
22Physician, heal thyself!
23Consequences of Sleep Deprivation
- Decreased longevity in animal models
- Chronic hypertension
- Increased cardiovascular mortality
- ( 1 PPD cigarettes)
- Infertility
- Injuries
24Social Cost of Sleep Deprivation
- Depression
- Divorce
-
- Alcohol / Drug Addiction
25 Chernobyl 123 AM Bhopal 1240 AM Three
Mile Island 400 AM
26Error Rate vs Time of Day
27Car Crashes vs Time of Day
28Federal Regulationsfor Truckers
- 10 hour maximum without break
- 15 hour max without 8 hour break
- 60 driving hours/7day period
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30Fatigue-Related Impairments
- Passive vigilance
- Reaction time
- Hand-eye coordination
- Clerical accuracy
- Memory
- Reasoning
31Provider Fatigue vs Performancemeta-analysis,
resident physicians
- Sleep debt
- Overall performance reduced 1 std deviation
- Clinical Performance reduced 1.5 std deviation
-
Philibert
32Provider Fatigue vs PerformanceOutcomes
attention and simulated driving
- Heavy call vs light call (residents)
- Reaction time 7 slower
- Commission errors 40 greater
- Lane variability 27 greater
- Speed variability 71 greater
- Post-call performance equal to 0.05 g blood
alcohol - Arnedt
33Provider Fatigue vs Alcohol effects on
performance
- 18-24 hours of continuous wakefulness causes
performance decline equal to blood alcohol level
of 0.1 - (William,
Dawson) - Fatigue-related impairment expressed as
blood-alcohol equivalent
34Provider Fatigue and Medical Errors
- Medication errors 2.5 times more likely between
4-8 AM (Kozer) - Fatigued surgeons make 20 more errors in
simulated laporoscopic surgery -
(Taffinder)
35Physiology of Sleep
36Circadian cycling promotes the acquisition of
regular and adequate sleep
- Overcoming this intrinsic biological
predisposition is very, very difficult
37Circadian Timekeeping
- A property of all higher life forms
- Humans evolved to work during the daylight hours
- After-hours work is a recent societal need that
is out of harmony with our evolutionary
inheritance
38Circadian Rhythms
- Organisms have their own endogenous biological
clock - Circadian rhythms are affected by endogenous and
exogenous factors - Exogenous time setters Zeitgebers light more
potent than cultural/social cues
39Suprachiasmatic Nucleus
- Locus of biologic rhythmicity
- Neurons have circadian rhythmicity that is
intracellular in origin - Genes coding for the clock function have been
identified
40Body Temperature Cycle
O F
99
99
sleep
Sleep
98
97
97
8 12 16 20 0
4 8
8
12
16
20
MN
4
8
Hour
41Measures of alertness track closely with body
temperature, with nadirs is the very early morning
42(No Transcript)
43Mean Leg Strength after westward flight across 5
time zones
44Sleep Architecture
- Stage 1 if awakened people say they werent
asleep. Automatic behavior may be Stage 1 sleep - Stage 2 half of sleep time in stage 2 Comes
between periods of deep
sleep and REM
45Stages 3 - 4 (Slow wave or delta sleep - SWS)
- Most vital, for recuperation, immune function
- First to be made up after sleep deprivation
- SWS increases after intellectually challenging
tasks - Most SWS occurs during the first half of the
sleep period
46REM (brain on, body off)
- Rapid eye movements
- Wakeful EEG pattern
- Increased cerebral blood flow
- Absent spinal reflexes
47Sleep Architecture
W
1
REM
2
34
(SWS)
1 2 3
4 5 6 7 8
75 SWS
75 REM
48Slow Wave Sleep deprivation is associated with
reduction in cognitive performance
49REM Deprivation
- Moodiness
- Hypersensitivity
- Inability to consolidate complex learning
- REM appears to be important for psychological
well-being
50Sleep Debt
- Sleep latency can be measured
- Very poor correlation between self-reported
sleepiness and objective measures of fatigue
51Variability in Sleep Requirements
- 7 1/2 hours is optimal for most adults
- Tolerance of sleep deprivation varies
- Night owls vs early birds
52Light and Melatonin
- Bright light very early in the morning can cause
a phase advance - Melatonin secreted by pineal gland signals brain
that it is time to sleep - Light suppresses melatonin secretion
53Bright lighting can reduce fatigue for workers
forced to work at night
54Sedative-Hypnotics
- Alcohol causes sleep fragmentation and decreased
REM - Most sedative-hypnotics disrupt the architecture
of sleep
55Age Effects
- REM and melatonin secretion decreases
- Quality not maintained over 12 hour shifts
- Do not tolerate irregular shifts, disrupted sleep
as well as younger workers - Age correlates with increased morningness
- At what age should overnight coverage end?
56 Circadian Adjustment
- Circadian shift of 1-2 hours per day is maximum
- Days off on regular schedule shifts cycle back
towards normal - It takes at least a week and usually longer to
adjust to a new shift
57Short-term Countermeasures
58Strategic Napping
- Schedule your sleep as you schedule your work
- Avoid caffeine and alcohol before nap time
- Darken the room
- Make sure room is quiet or have white noise
(micro-awakenings decreases time in SWS and REM)
59Napping
- 23,681 Greek adults
- Controlled for diet, other confounders
- Mean 6.3 yr follow-up
- Regular siesta was associated with 37
reduction in coronary mortality -
(Naska)
60 Interventions - caffeine Worlds most
popular drug
- Mild CNS stimulant
- 3.5 - 6 hr half-life
- 250 mg improves psychomotor function if sleep
deprived, 500 mg side effects w/o improvement - Tachyphylaxis
- Withdrawal headaches
- Affects sleep latency and sleep quality
61Do you know what dose youre taking?
- No-Doz max strength
- Brewed Coffee (average)
- Excedrin (2)
- Instant Coffee
- Mountain Dew
- Orange Pekoe Tea
- Coke Classic
- Hersheys Dark Chocolate
- Green Tea
- Hersheys Milk Chocolate
- Decaffeinated Coffee
- 200 mg
- 135 mg
- 130 mg
- 100 mg
- 55 mg
- 50 mg
- 35 mg
- 30 mg
- 30 mg
- 10 mg
- 5 mg
62Modafinil Provigil
- Narcolepsy
- Obstructive Sleep Apnea
- Military short-term fatigue countermeasure
- Shift Work Sleep Disorder
63The only way to completely reverse the
physiologic need for sleep is to sleep
64Summary
- The evidence that fatigue impairs human
performance is incontrovertible - Physicians are human
- Fatigue is a root cause of many medical errors
65Summary
- Optimizing performance requires that sleep
management be high-priority! - Schedule clinical work with sleep in mind
- Just say no to meetings and other commitments
that disrupt optimal sleep management (and expect
it from colleagues) - Family life must accommodate to sleep needs for
physicians with after-hours responsibilities
66References
- Naska A, Oikonomou E, Trichopoulou A. Siesta in
healthy adults and coronary mortality in the
general population. Arch Intern Med 167296,
2007. - William AM, Feyer A. Moderate sleep deprivation
produces impairments in cognitive and motor
performance equivalent to legally prescribed
levels of alcohol intoxication. Occ Environ Med
57(10)649-655, 2000. - Philibert I. Sleep loss and performance in
residents and nonphysicians a meta-analytic
examination. Sleep 28(11)1392, 2005. - Arnedt JT, Owens J, et al. Neurobehavioral
performance of residents after heavy night call
vs after alcohol ingestion. JAMA 294(9)1025,
2005. - Dawson D, Reid K. Fatigue, alcohol and
performance impairment. Nature 388(6639)235,
1997. - Taffinder NJ, McManus IC, Gul Y, et al. Effect
of sleep deprivation on surgeons dexterity on
laparoscopy simulator. Lancet 1191352, 1998. - Leape LL, Brennan TA, Laird N, et al. The nature
of adverse events in hospitalized patients. NEJM
324(6)377-384, 1991. - Institute of Medicine, To Err is Human, National
Academy Press 2000, Washington, D.C., p 49. - Kaushal R, Bates DW, Landrigan C, et al.
Medication errors and adverse drug events in
pediatric inpatients. JAMA 2852114-2120, 2001. - Kozer E, Scolnik D, Macpherson A, et al.
Variables associated with medication errors in
pediatric emergency medicine. Pediatrics
110(4)737-742, 2002.
67References
- Dement WC. The Promise of Sleep, Delacorte Press,
NY 1999, p262-263. - Akerstedt T, Knutsson a, AlfredssonL, et al.
Shift work and cardiovascular disease. Scand J
Work Environ Health 10490, 1984. - Earnest DJ, Liang F, Ratcliff M, et al. Immortal
time Circadian clock properties of rat
suprachiasmatic cell lines. Science
283(5404)693, 1999. - Van Dongen HP. Baynard MD. Maislin G. Dinges DF.
Systematic interindividual differences in
neurobehavioral impairment from sleep loss
evidence of trait-like differential
vulnerability. Sleep. 27(3)423-33, 2004. - Van Dongen HP. Vitellaro KM. Dinges DF.
Individual differences in adult human sleep and
wakefulness Leitmotif for a research agenda.
Sleep 28(4)479-96, 2005. - Weitman ED, Moline ML, et al. Chronobiology of
aging Temperature, sleep-wake rhythms and
entrainment. Neurobiol Aging 3299-309, 1982. - Reid K, Dawson D. Comparing performance on a
simulated 12 hour shift rotation in young and
older subjects. Occ Environ Med 58(1)58-62,
2001. - Landrigan CP, Rothschild JM, et al. Effect of
reducing interns work hours on serious medical
errors in intensive care units. NEJM
351(18)1838, 2004. - van Duinen H, Lorist MM, Zijdewind I. The effect
of caffeine on cognitive task performance and
motor fatigue. Psychopharmacology. 180(3)539-47,
2005. - Czeisler CA, Walsh JK, Roth T, et al. Modafinil
for excessive sleepiness associated with
shift-work sleep disorder. NEJM 353(5)476, 2005.
68 - Amy Fahrenkopf, MD, MPH
- Pediatric Hospitalist
- Childrens Hospital Boston
- Boston, Massachusetts
69Effects of Housestaff Burnout and Depression on
Patient Safety
- American Academy of Pediatrics Webinar
- March 20, 2007
- Amy M. Fahrenkopf, M.D., M.P.H.
- Department of Medicine
- Childrens Hospital Boston
70Introduction
- Depression and burnout are highly prevalent among
medical residents - Studies have documented burnout rates of 41-76,
while depression rates have ranged from 7-56 - Despite their frequency, little research has
sought to quantify the effects of depression and
burnout on patient care.
71Burnout Definition
- Burnout is a syndrome of emotional depletion and
detachment that develops in response to chronic
occupational stress - Burnout more likely to develop when job stress is
high and personal autonomy is low - Differs from depression in that it primarily
affects functioning within the work context, not
other areas of an individuals life
72Burnout Screening
- Maslach Burnout Inventory
- Gold standard for evaluating burnout
- 22 question validated screening tool
- Version available that is specific to health care
industry - Identifies three domains of burnout
- Emotional exhaustion
- Depersonalization
- Low personal achievement
73Burnout in ResidencyWhat do we know?
- Growing area of research, though studies tend to
be small and single-centered - Burnout is a significant problem in all
specialties - Medicine 41-76
- OB/Gyn 50
- Pediatrics 76
- Anesthesia 47
- Surgery 50-56
74Burnout in ResidencyWhat do we know?
- Burnout levels rise quickly within the first few
months of residency - Burnout affects residents of all PGY levels
equally, although depersonalization scores rise
with each additional year of residency - Men may be affected more than women
- ACGME work hour changes appear to have decreased
burnout rates moderately, but study results have
been contradictory
75Depression Definition and Screening
- Depressed mood and loss of interests for at least
two consecutive weeks that interferes with daily
life and normal functioning - In any given 1-year period, 9.5 of the general
population will suffer from a depressive episode - Clinical diagnosis with many excellent, validated
screening tools available
76Depression in Residency What do we know?
- Considerably less research done on resident
depression than on burnout - Studies report prevalence rates from 7-56
- Studies to date focus solely on intern year
- Multiple studies have shown residents start
intern year with low rates of depression (2-4)
and jump to 30-56 within 3 to 6 months
77Depression in Residency What do we know?
- Most depressed residents are also burned out
(80-95) - Most residents who screen positive for depression
in these studies have no prior history of
depression - Female residents more likely to be depressed
78Depression and BurnoutIs there a link to
medical errors?
- All published studies to date have focused on
burnout and the link to self-reported medical
errors or quality of care - No published study has attempted to link
depression to medical errors - We will look at three studies that highlight the
important issues
79Burnout and Self-Reported Patient Care in an
Internal Medicine Residency ProgramShanafelt TD,
Bradley KA, Wipf JE, Back AL Ann Intern Med.
2002 136358-367
- Survey of 115 internal medicine residents at
University of Washington - Burnout measured by MBI
- Self-reported patient care determined using tool
developed for this study - Depression measured using two-question PRIME-MD
screen
80Burnout and Self-Reported Patient Care in an
Internal Medicine Residency ProgramShanafelt TD,
Bradley KA, Wipf JE, Back AL Ann Intern Med.
2002 136358-367
- 76 burnout rate, of whom 50 also screened
positive for depression - Burned out residents significantly more likely
than non-burned out residents to report one or
more suboptimal patient care monthly (53 vs 21
p0.004) - In multivariate analyses burnout (but not sex or
depression) associated with self-report of
suboptimal patient care monthly (odds ratio 8.3
95 CI, 2.6-26.5)
81Association of Perceived Medical Errors with
Resident Distress and EmpathyWest CP, Huschka
MM, Novotny PJ, et. al. JAMA. 2006 2961071-1078
- Prospective longitudinal cohort study of 184
internal medicine residents at Mayo Clinic - Residents completed surveys of their quality of
life and self-reported medical errors every three
months for one year - Quality of life survey included MBI, 2-question
depression screen, and a validated quality of
life scale
82Association of Perceived Medical Errors with
Resident Distress and EmpathyWest CP, Huschka
MM, Novotny PJ, et. al. JAMA. 2006 2961071-1078
- 34 of residents reported making at least one
major medical error - Self-perceived errors were associated with
increased burnout in all domains (DP 3.23,
p
83Association of Perceived Medical Errors with
Resident Distress and EmpathyWest CP, Huschka
MM, Novotny PJ, et. al. JAMA. 2006 2961071-1078
- Self-perceived errors associated with odds ratio
of 3.29 (95CI, 1.90-5.64) of screening positive
for depression at next survey point - Increased burnout scores, in turn, associated
with increased odds of self-reported errors in
following 3 months
84Rates of Medication Errors Among Depressed and
Burned Out House OfficersFahrenkopf AM, Sectish
TC, Barger LK, et.al (Presented at )
- Prospective cohort study of 123 pediatrics
residents at 3 large Childrens Hospitals - Childrens Hospital Boston
- Lucile Packard Childrens Hospital
- Childrens National Medical Center
- Involved 3 components
- Baseline resident questionnaire with MBI and 10
question HANDS depression screen - 6 week resident sleep and work hour logs
- Medication error collection at two sites
85Housestaff Burnout and Depression The Link to
Patient SafetyFahrenkopf AM, Sectish TC, Barger
LK, et.al. Platform presentation, Agency for
Healthcare Research and Quality Patient Safety
Conference, Washington D.C., 2006
- 19.5 of residents depressed and 74 burned out
- 96 of depressed residents also burned out
- 74 of those depressed had no prior history of
depression - No correlation between depression or burnout with
PGY year, gender, marital status, or
self-reported sleep or work hours
86Housestaff Burnout and Depression The Link to
Patient SafetyFahrenkopf AM, Sectish TC, Barger
LK, et.al. Platform presentation, Agency for
Healthcare Research and Quality Patient Safety
Conference, Washington D.C., 2006
- 10,277 orders reviewed with 125 errors identified
- 45 errors made by study subjects
- 0 preventable adverse drug events, 28 potential
adverse events, and 17 errors with little
potential for harm. - 1 non-preventable ADE
87Housestaff Burnout and Depression The Link to
Patient SafetyFahrenkopf AM, Sectish TC, Barger
LK, et.al. Platform presentation, Agency for
Healthcare Research and Quality Patient Safety
Conference, Washington D.C., 2006
Depression, Burnout, and Medication Errors per
Resident-Month
Errors per resident-month
depressed
burned out
88Housestaff Burnout and Depression The Link to
Patient SafetyFahrenkopf AM, Sectish TC, Barger
LK, et.al. Platform presentation, Agency for
Healthcare Research and Quality Patient Safety
Conference, Washington D.C., 2006
Depression, Burnout, and Self-reported Medical
Errors
p
89Areas for Further Research
- Investigate the causal relationship between
depression and errors - Better define how depression and burnout affect
residents and patient care in other specialties
AND among fellows and practicing physicians - Rigorously conducted intervention trials are
needed to evaluate how to improve the mental
health of trainees while decreasing medical
errors and preserving educational quality.
90Conclusion
- Depression and burnout are significant problems
among pediatric residents in all years of
training - Both depressed and burned out residents
self-report high rates of errors and poor health - Preliminary studies suggest that depressed
residents have a nearly eight-fold increase in
errors compared to their non-depressed colleagues
91Conclusion
- ACGME work hour regulations may have decreased
burnout, but no change in depression - Further studies are needed to better establish
the relationship between depression, burnout, and
medical errors
92Acknowledgements
- Pediatric Work Hours Study Group
- Harvard Work Hours, Health and Safety Group
- Christopher Landrigan, MD, MPH