Minneapolis, Minn.—Among the issues highlighted here last month at SLEEP 2011, the 25th Annual Meeting of the Associated Professional Sleep Societies, was the effect of inadequate sleep on both the health of the individual and on society at large. Two studies presented at the meeting, for example, looked at the effects of inadequate sleep on health care providers and the risks posed to their health and the health of their patients. Another study put into context just how underreported inadequate sleep and sleep disorders are and elaborated on the challenge this poses to otolaryngologists and others who are on the frontlines managing these disorders.
Critical Care Nurses
In a study that generated much discussion among conference attendees, Diana E. McMillan, RN, PhD, associate professor of nursing at the University of Manitoba, reported on the results of a Canadian National Survey that looked at how working night shifts affects critical care nurses. A web-based survey containing 62 questions was sent out to members of the Canadian Association of Critical Care Nurses. Questions included nurses’ perceptions of symptoms experienced while working night shifts, their sleep health on work and non-work days, napping practices, nurse and patient safety during the night shift and nurse safety on the drive home after working a night shift.
Dr. McMillan’s research is part of a pilot study, the entirety of which was presented at SLEEP 2011 as a poster titled “Canadian National Survey of Critical Care Nurses: Practices and Perceptions of Napping on Night Shift.”
A total of 536 people responded to the survey (88 percent female; mean age of 42 years), 66 percent or more of whom were critical care nurses with more than six years of experience and worked full time (at least 75 percent) in a tertiary hospital (65 percent). Most worked 12 hour shifts (88 percent).
Symptoms reported included nausea, chills, eye strain, fatigue, irritability, forgetfulness and stress. According to Dr. McMillan, 32 percent of respondents reported always feeling tired on night shifts. Researchers discovered that of these respondents, 43 percent had fallen asleep at a traffic light driving home from work and 31 percent while the car was moving; 26 percent reported fatigue-related personal work injury or near injury. Patients were also affected, with 16.4 percent of nurses reporting fatigue-related incidents and errors affecting patients.
Dr. McMillan emphasized the need to educate nurses and administrators about the issues involved in sleep health for nurses and said that otolaryngologists can help these efforts by supporting education and implementation of strategies that prioritize sleep health in general at all levels of health care. “We need to help people understand the wealth of research that exists to support effective strategies, such as light therapy, preemptive naps, nap rooms and the vital need for a nap during break to avoid homeostatic and circadian vulnerability,” she said.
According to Dr. McMillan, current research focusing on the efficacy of napping to reduce problems associated with inadequate sleep shows that this proven strategy to help nurses reduce fatigue-related problems is still met with skepticism among administrators and that, as a result, nurses remain anxious about taking naps during breaks. In her study, only 66 percent of nurses napped during break. “In my view, every unit needs a designated nap room,” she said, “not only for critical care nurses, but every nurse.”
Laura Barger, PhD, associate physiologist in the division of sleep medicine at Brigham and Women’s Hospital and instructor in medicine at Harvard Medical School in Boston, reported on a study that looked at the impact of the traditional long work hours of residents in training on motor vehicle crashes, medical errors and adverse events.
Dr. Barger presented the current results as part of a poster titled “Impact of Extended-Duration Shifts on Motor Vehicle Crashes, Medical Errors, and Adverse Events in PGY 2-7 Resident Physicians.”
Using a nationwide web-based survey administered over five years, 13,737 person-months of data were collected from resident physicians in postgraduate years two to seven. In 46 percent of these person-months, the residents reported working 24 hours or more on their longest work shift. The study found a significantly increased risk of motor vehicle crashes or near-miss incidents in residents working long shifts compared to those working shorter shifts, with an odds ratio (OR) of 1.72 (95 percent confidence interval [CI]:1.01-2.90) and 5.13 (95 percent CI: 4.40-5.96), respectively.
As in the nursing study, this study also found a significant increase in medical errors and adverse events associated with fatigue in the health care provider, in this case residents. A significant increase in fatigue-related medical errors was reported by residents who worked months that included one to four extended shifts (OR of 1.77, 95 percent CI:1.01-2.90) or months that included working five or more extended shifts (OR of 5.2, 95% CI:3.79-7.1) compared to months in which they worked no extended shifts.
Fatigue-related adverse events that injured a patient also significantly increased with monthly shifts that included one to four extended shifts (OR of 2.53, 95 percent CI:1.02-6.25) or five or more extended shifts (OR of 3.36, 95% CI:1.52-7.41) compared to months with no extended shifts.
“Work-hour reform is needed that eliminates extended-duration shifts for all residents,” said Dr. Barger, who said that residents other than first-year residents are still allowed to work extended hours despite new guidelines by the Accreditation Council for Graduate Medical Education that, when implemented on July 1, 2011, newly mandate the reduction of work shifts for first-year residents to a maximum of 16 hours.
Scope of the Problem
Outside the health care system, inadequate sleep and sleep disorders are major problems that also need better recognition and reporting to improve health outcomes. Jon-Erik C. Holty, MD, MS, staff pulmonologist at the Palo Alto VA Health Care System, presented a study that looked at the relationship of sleep complaints and health care utilization in 2,183 randomly selected adult U.S. residents participating in the National Health and Nutrition Examination Survey (NHANES) from 2005-2006. Dr. Holty presented his research as part of a poster titled “Patients with sleep complaints utilize more healthcare: an analysis of NHANES.”
The study found that although 99 percent of adults reported at least one sleep-related complaint that occurred five or more times per month, and most reported four or more concomitant complaints, only 24 percent had reported their sleep problems to a health care provider. These sleep complaints included nonrestorative sleep (56 percent), not enough sleep (54 percent), snoring (46 percent), daytime sleepiness (45 percent), waking too early (44 percent) and trouble falling asleep (37 percent).
In the respondents who did receive a medical evaluation for non-sleep problems such as diabetes and arthritis, these problems were associated with their sleep complaints. Of these, 37 percent of respondents were deemed at risk for insomnia and 33 percent for sleep apnea, but only 1 percent and 5 percent, respectively, had a prior diagnosis.
The study found that people who did report sleep problems had a significantly higher use of health care resources, including health care visits, overnight hospitalizations and evaluation by a mental health provider, as well as higher rates of work absenteeism.
These results underscore the need for health care providers to routinely assess the presence of sleep complaints and disorders in their patients, Dr. Holty said.