Sleep deprivation has been shown to adversely affect clinical performance and impair psychomotor function. It can be challenging for medical systems to ensure that physicians are not fatigued from sleep deprivation because continuity of care and around-the-clock coverage of clinical services are often competing needs. The Accreditation Council for Graduate Medical Education has revised its regulations on resident work hours to restrict trainees in their first postgraduate year to a maximum of 16 hours of continuous work, followed by a minimum of 8 hours off duty. “Unfortunately,” says Michael Nurok, MD, PhD, “there are no such regulations for fully trained physicians.”
There are many reasons why fatigue from sleep deficiency occurs, including long work shifts, long work weeks, sleep disorders, or personal circumstances (Table 1). “Researchers have documented the adverse effects of sleep deprivation and sleep disorders on individual performance,” says Dr. Nurok. “In surgery, the risk of complications (eg, massive hemorrhage, organ injury, or wound failure) is thought to increase in patients who undergo elective daytime surgery when these procedures are performed by attending surgeons who have less than a 6-hour window for sleep between procedures during previous on-call nights. Performing elective surgery under these circumstances cannot be rationalized in the context of patient safety.”
Elective Surgery & Rescheduling
Unlike other practice areas, elective surgery is potentially amenable to rescheduling. However, many competing interests influence the possibility for rescheduling, even when all parties stand to gain by avoiding errors and complications (Table 2). “When no policy exists to facilitate rescheduling or to prohibit sleep-deprived physicians from working, the burden of deciding to proceed with operations or reschedule them largely falls to the treating clinician,” Dr. Nurok says. “Surgeons, however, face competing interests and may choose not to inform patients or engage them in the decision-making process. Sleep-deprived clinicians are not likely to assess accurately the risks that they pose when they perform procedures in such a state. We believe that patients have a right to be notified if their physician is fatigued so that they may make an informed decision about proceeding with elective surgery under these circumstances.”
Institute Effective Policies for Patient Safety
Dr. Nurok notes that it is important to recognize that surgeons who are intermittently scheduled for overnight emergency call for busy group practices or hospitals are likely to be awake much of the night. “Conversely,” he says, “surgeons who practice in a rural area and always carry a pager may only occasionally need to perform overnight surgery in an emergency situation. The key is for administrators to recognize which surgeons are more likely to be at risk for sleep deprivation and then plan accordingly. The ideal solution is for busy urban hospitals to prohibit surgeons from scheduling elective surgery the day after they have been on call. While such policies are being considered, at the very least, hospitals should facilitate timely rescheduling of elective procedures when warranted and require that informed consent be obtained should a patient wish to proceed with an elective operation by a fatigued surgeon.”
“The key is for administrators to recognize which surgeons are more likely to be at risk for sleep deprivation and then plan accordingly.”
According to published surveys, most patients would be concerned about their safety if they knew that their doctor had been awake for 24 hours. These studies also indicate that patients would prefer to be informed of sleep deprivation. One analysis showed that 80% of patients would request a different healthcare provider in cases in which their provider may be sleep deprived. “Considering what’s known about sleep deprivation, the associated risks of surgical complications, and patient preferences, hospitals should institute policies that prohibit the performance of elective surgical procedures when an attending surgeon or anesthesiologist is sleep-deprived,” says Dr. Nurok. “The goal is to optimize the conditions under which elective operations are performed.”
Patient Benefits Outweigh Costs
An additional measure would be to empower patients to inquire about the amount of sleep their clinicians have had the night before elective surgical procedures. “Explicitly informing patients about possible impairments from sleep deprivation and the increased risk of complications, in some people’s views, may damage or change the patient–physician relationship,” Dr. Nurok says. “But, elective surgery is an area of clinical practice that may be amenable to policies that empower patients and surgeons alike, because it is in both of their interests to improve patient safety and optimize outcomes. While it may be challenging to assess sleep deprivation, estimate the risk of harm, and enforce formal sleep policies, the benefit of creating such policies outweighs the burden. These steps might ultimately reduce institutional costs if outcomes are improved and complications are reduced.”
Readings & Resources (click to view)
Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed consent. N Engl J Med. 2010;363:2577-2579. Available at: http://www.nejm.org/doi/full/10.1056/NEJMp1007901.
Nasca TJ, Day SH, Amis ES. The new recommendations on duty hours from the ACGME task force. N Engl J Med. 2010;363:e3-e3.
Rothschild JM, Keohane CA, Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302:1565-1572.
Blum AB, Raiszadeh F, Shea S, et al. U.S. public opinion regarding proposed limits on resident physician work hours. BMC Med. 2010;8:33-33.