THE FATIGUE FACTOR IN PATIENT SAFETYBONNIE DEVEAU, RN, MSN, MA, NE-BCVICE PRESIDENT, QUALITY & PATIENT SAFETYGOODALL HOSPITAL

Goals and Objectives◦ 1. Identify risks associated with healthcare worker fatigue at

the patient and staff level◦ 2. Describe contributing factors to healthcare worker fatigue◦ 3. Critique evidence-based strategies effective to combat

healthcare worker fatigue◦ 4. Apply evidence-based strategies to educate staff regarding

the effects of fatigue on patient and staff safety◦ 5. Analyze how evidence-based strategies could be applied

within the facility

WHAT KEEPS US UP AT NIGHT?WE CAN PROBABLY COME UP WITH A MILLION CAUSES!

Building a Safer Healthcare System◦ Where did this concern come from:

◦ Government & regulatory agencies, the public, and healthcare leaders are looking to healthcare professionals to focus attention on safety

◦ To Err is Human: Links medical errors to the human factor recognizing fatigue as an underlying cause of medical errors

◦ The National Center of Sleep Disorders confirms the scientific evidence that chronic sleep deprivation leads to chronic disease, injury disability and premature death. This evidence has been well documented since the 1980’s and will be the basis for this presentation and discussion today

Background and Significance of the Issue

Sleep duration and quality and its importance:◦ Studied by National Institutes of Health (NIH)◦ National Centers for Sleep Disorders◦ Centers for Disease Control (CDC)◦ National Institute of Occupational Health & Safety (NIOSH).

The Joint Commission’s Sentinel Event Alert of December 2011:◦ Spotlights fatigue as a result of:

◦ Shift work◦ Shift length◦ Work schedules

National Efforts to Reduce Medical Errors

The driving force behind quality initiatives are in the statistics:◦ Medical Errors in a 2012 US News & World Reports:

Medical Errors harm a huge number of patients◦ In 2010 CMS found 134,000 Medicare beneficiaries

suffered an adverse event that was either clearly or likely preventable

◦ A North Carolina study conducted over 5 years reported 25% of all admissions received medical care that resulted in some form of harm – that is 1 in 4 patients!

◦ Sentinel Event Data from Joint Commission over a 10 year period (1996 to 2006) 3,881 sentinel events reported to TJC, by type

The ProblemHealthcare is a 24 hour operation• Consists of extended work

hours• and shift work

Shift work is essential component• Leads to healthcare worker

fatigue and medical errors

Medical Errors

Financial burden: Patient and healthcare system

Emotional Burden: Patient and facility

Results: Mandatory quality initiatives and regulations

Healthcare Industry Transformation

Cost Quality

The Physiology of SleepESSENTIAL TO UNDERSTAND THE CORRELATION BETWEEN FATIGUE AND MEDICAL ERRORS

Sleep Research◦National Institute of Health started to research sleep and its effects in the 1970’s◦ Defined sleep and its relationship to the human “biological clock” through

the use of EEG◦ The human brain has a circadian clock (24 hour duration) that controls the

timing, duration and stages of sleep◦ Sleep is responsible for the optimal development and operation of the brain

and therefore CENTRAL to SLEEP!◦ Sleep and Wakefulness = The sleep cycle is a series of chemical and electrical

activities stimulated by daylight and darkness

WHAT IS SLEEP? A result of highly complex network of central neurons that utilize neurotransmitters (chemicals) to communicate important messages from the brain to the rest of the body.

Neurotransmitters affect mood, sleep patterns, concentration ability and body weight.

Commonly known neurotransmitters are:◦ Histamine◦ Acetylcholine◦ Dopamine◦ Norepinephrine◦ Serotonin◦ Melatonin

Stages of Sleep1. Brain waves start to slow2. Brain waves slow even more, eye

movements stop, HR & RR rates slow3. Brain less responsive (when awoken in

this stage a person is groggy and has poor memory)

4. Restorative and renewal stage – promotes muscle and tissue growth

5. REM sleep - muscles are paralyzed (prevents acting out dreams) & frontal lobe activity is depressed. Someone awakened in this stage is moody /irritable

What Affects Neurotransmitters?

Alcohol Consumption

Caffeine Consumption

Smoking

Stress

Poor Diet

Prescription / Recreational Drugs

Sleep Deprivation◦ Erratic Sleep Schedules◦ Work schedules◦ Social Media – living in a 24 hour society

Aging Process◦ Bladder control issues◦ Menopause: Hot flashes /night sweats

The startling statistic: 86% of Americans have suboptimal neurotransmitter levels !

Humans were meant to be awake during the daytime and asleep during the nighttime hours.

The Value of Sleep High quality sleep is essential to good health and future well-being Eight (8) hours of sleep is defined as the optimal benchmark Sleep patterns change throughout the human lifecycle We are often forfeiting sleep for other activities

How did we become a 24-hour Society◦ The industrial revolution redefined the

work environment and hours of operations to 24 hours a day

◦ Healthcare has always been 24 hours but:◦ Technology is now a major component◦ Patients are sicker / higher acuity◦ Shift work activity can be very busy

◦ Our ever so “social society”

Where is sleep on your list of daily priorities?

SELF?

• MEAL PLANNING• HOUSE CLEANING/

LAUNDRY• ERRANDS

HOME

• FULL-TIME• PART-TIME / PER DIEM• OVERTIME• MANDATORY

MEETINGS/EDUCATION AT THE END OF NIGHT SHIFT

WORK

• SPOUSE/SIGNIFICANT OTHER

• CHILDREN• PARENTS (AGING / ILL)

FAMILY

The Influence of Nursing Shortages◦ Nursing shortages and long work hours can be traced back as far as the 19th

century during the Civil War◦ Nursing education programs had students working 12 hour shifts however,

they had very strict rules for monitoring time off and sleep periods◦ The 1980’s rolled out the “Baylor Program” to draw nurses back to work and

alleviate a nursing shortage◦ The Baylor program was the “band aid” on the proverbial Nursing Shortage

“hemorrhage”◦ The Baylor Program consisted of 12 hour shifts over a full weekend with full pay and benefits◦ The Baylor Program was eventually eliminated due to costs - but the 12 hour shifts remained◦ Today – the norm is 12 hour shifts and the preference of staff (reduced days at work)

Costs and Benefits of the Baylor Program

Costs1. Increased the level of staffing needed on a

unit

2. Cost more money to administer this program

3. 12-hour shifts were starting to be a struggle for the Baby Boomer population

4. 12-hour shifts were identified as a desire by non-weekend staff to decrease their time at work; leaving the nurse to have more free time

Benefits1. Provided instantaneous resolution to the

nursing shortage issue in the 1980’s

2. Acted as not only a recruitment tool but a retention strategy as well

3. Full-time staff who worked 8 hour shifts worked Monday though Friday

4. Weekend staffing was no longer the burden it had been in the past

The Aging Nurse: What are the Challenges

The nurse may be coping with the following challenges:◦ Physical and mental health changes◦ Decreased aerobic ability ◦ Decreased muscle strength and endurance◦ Decreased reaction time◦ Decreased acuity with vision and hearing◦ Thermoregulation changes (hot flashes / night sweats)◦ Increased sleep disturbances ◦ Changes in bladder control◦ Chronic illness / medications◦ Part of the “sandwich” generation

A Snapshot of the Maine Nursing Workforce

Average age of RN’s: 50.6 versus 47 nationwide

Average Employed RN: 49.4 (48% are over 51)

Work Life: 57% of those > 51 years plans to work 5 more years

National Study in 2011: RN’s in their 4th decade of work tend to exit acute care settings

In 2000: The RN vacancy rate was 12%

In 2008: RN’s returned to the workforce or delayed retirement due to the economic downturn

In 2020: The RN vacancy rate is expected to be 31%

Working Shift Work

Disrupts Circadian CycleDisrupts Family /

Social Life

Leads to Sleep Loss and Sleep

Disturbance

Chronic Sleep Deprivation Increases Risks For:

◦ Cardiovascular disease◦ Cerebrovascular disease (CVA)◦ Cancer: Breast, colorectal, and

prostate◦ Obesity◦ Diabetes◦ GI Disturbances◦ Memory Impairment◦ Social / relationship issues◦ Trauma – motor vehicle accidents

Performance Related Issues:◦ Impaired job performance

◦ Flawed hand-offs◦ Lack of teamwork◦ Decreased employee morale

◦ Increased risks for errors◦ Increased risk for work-related

injuries and workers’ compensation costs (needlesticks / sprains/ strains)

Sleep Deprivation Intoxication

17 continuous hours of work = A Blood Alcohol level of 0.05%

24 continuous hours of work = A Blood Alcohol level of 0.10% ( defined as legally drunk)

How Prevalent is Fatigue in the US

70% of Teens sleep < 8-9 hours / day (as recommended)◦ Sleep deprived teens are at risk for suicide, obesity, depression, mood problems, low grades and

delinquent behavior

70 % of adults report insufficient sleep monthly◦ 11% of this 70% report insufficient sleep daily

65% report having sleep problems◦ Either falling asleep or staying asleep◦ Waking feeling drowsy

20% of all serious motor vehicle accidents are attributed to drowsy driving / sleep deprivation

Restriction on Medical Students / Residents

The ACGME instituted changes in resident / medical school student maximum hours. Healthcare’s first and only attempt at addressing fatigue in 2003. Intermediate-level residents must have at least 14 hours free of duty after 24 hours of in-house duty Residents must not be scheduled for more than six consecutive nights of night float

Test Case:

2005 A lawsuit was filed against a medical center whose resident fell asleep at the wheel on their way home from work claiming liability for injuries sustained. The case was not upheld but it was a case that could have merit in the future.

The aviation industry has scoffed at the new rules as being ineffective and not nearly strict enough to impact patient safety.

The effects of 1 hour loss of sleep per night

Altered concentration

Slowed reaction time

Reduced problem solving ability

Lapses in attention and memory

Reduced motivation

Irritability and moodiness

Decreased ability to notice subtle changes

Slowed information processing

Difficulty dealing with unexpected situations

Indifference and loss of empathy

Communication difficulties

Medication calculation/critical reasoning

Codes and RRT’s/urgency to communicate information

Patient Assessment

Forgetting to follow through on a request / order

Absenteeism/apathy

Ability to get along with coworkers / Lack of Teamwork

Accurate and ongoing Telemetry or monitoring data

Alarm Fatigue

Patient Satisfaction / Patient Complaints

Burnout

Shift report / Patient Hand-offs

How to Combat Fatigue? Keep consecutive night shifts to a minimum

Avoid quick shift changes

Plan some free weekends

Avoid several days of work followed by 4-7 days off “mini-vacations”

Keep long work shifts and overtime to a minimum

Examine start and end times of shifts

Keep schedule regular and predictable

Examine rest breaks at work

Make sleep a priority

Strategies to Reduce or Minimize Patient HarmYOUR ORGANIZATIONAL NEXT STEPS

How Can You Affect Change?Assess the organization for fatigue-related risks: Evaluate staff schedules for consecutive shifts (particularly night shit schedules) Review organizational staffing policies Assess overtime needs / use Are the managers aware if staff is working per diem in other organizations Assess the organization’s hand-off process – are they effective Are staff self-scheduling or have input to their schedules Assess the multigenerational composition of your nursing staff Assess if an error or event could have been caused from fatigue Assess when meetings are scheduled

How Can You Affect Change? Create and Implement a Fatigue Management Plan: Incorporate scientific strategies for fighting fatigue:

Strategic Caffeine Consumption (but not near bedtime) Physical Activity Active Conversations Importance of Meal and Rest Breaks Teamwork Strategic Naps !

How Can You Affect Change? Educate: Senior Leadership Management Staff Direct Care Staff (include medical staff)

Share your Assessment Findings

Promote an Action Plan

What I Discovered Nearly all nursing staff who worked in direct care roles worked 12 hour shifts

Most of the day staff worked 2 consecutive shifts with a day off

Most of the night staff clustered their shifts to have a large number of days off

Overtime was used frequently to fill vacancies and sick calls

More than 24 RN’s worked per diem or fulltime in another organization

Staffing and overtime policies existed but were not proactive to promote safety limitations

Hand-offs were an opportunity for improvement

Teamwork was not well developed

STAFF SURVEYQuestion Yes No

Do you average between 6.5 and 8 hours a sleep a day?

60 41

Do you feel fatigued regularly at work?

45 56

Do you think fatigue could contribute to a patient error or employee injury?

94 7

Do you know or see any fatigue related issues in your department?

47 54

Would you be interested in knowing more about healthcare worker fatigue?

55 45Note: 1 survey had no response on this question

SHIFT WORKER HELPFUL HINTS Food, Drink, and Sedating and Stimulating Medications Avoid food, alcohol, and drinks that are high in caffeine at least six hours before

going to bed Stop smoking or avoid nicotine before going to bed Follow a diet and activity routine to maintain an ideal body weight. If

overweight or obese, consider a plan to lose weight Avoid eating a heavy meal three to four hours before going to bed; eat the

biggest meal of the day after waking Eat high-protein, light meals while at work and before going to bed Limit fluid intake to 8 oz. just before going to bed If you awaken during the day, get up to use the bathroom and, if hungry, eat a

light protein snack in a dim or dark environment, then return to bed. Discuss the use of over-the-counter melatonin, sleep medications and/or herbal

remedies with a primary care provider  

SHIFT WORKER HELPFUL HINTS Bedroom Environment Design the bedroom to make it suitable for day sleep Maintain the room’s temperature from 65°F–70°F Wear light bedclothes and use light bedcovers Cover all windows with room-darkening or blackout shades Hide crystal clock displays Reduce all potential disturbing noises (e.g., telephone, clock noises, and

pets) and wear earplugs or use white noise to block out environmental noises

Do not bring worries or stress to bed Develop a habit of a bedtime relaxation period before attempting to go to

sleep; learn how to relax the body and mind before attempting to sleep Select a relaxation method to use within an hour of going to bed (e.g., deep

breathing, warm bath / shower, reading)

SHIFT WORKER HELPFUL HINTS Exercise Establish a 30-minute period of time or longer for physical

activity three to seven days per week after waking. Stop exercising three hours before bedtime

  Family and Social Issues Hang a sign on the bedroom door noting “day sleeper” as a

reminder to family Discuss individual needs for sleep with family and friends Choose social activities wisely (i.e., avoid activities at the time

sleep typically is scheduled)

SHIFT WORKER HELPFUL HINTS Recommendations for Rotating Shift Workers Maintain consistent bedtimes and wake-up times on the shift that most

commonly is worked Use the anchor sleep method during rotations to other shifts Work a maximum of three consecutive shifts per week when on an

alternate shift (days) Be sure to have two days off in a row when working an alternate shift Explore reducing shift-work rotations; attempt to hire more permanent

night-shift workers If unable to hire an adequate number of permanent night-shift workers, use

forward rotation (i.e., day, evening, and night) at two-week intervals. Regular rotating shift workers should modify their lifestyles to allow for

participation in social activities within the limitations of the work schedule (e.g., join a health club that is open all day instead of joining a group that meets at a specific time)

While at work, take regular rest breaks and power naps (if facilities are available and permitted by employer)

Summary 12 hour shifts have been identified as detrimental to Nurses and Patients Shift work is not healthy = but night shift staff can adapt with a lot of focused attention and

work Humans were meant to sleep at night and be awake during the day The human body has not adapted to the 24 hour society we live in The research links poor sleep and chronic fatigue with physical and mental health disorders The nursing profession has yet to take any proactive steps to implement strategies to reduce

fatigue Staff education is needed Patients and nurses are not safe!

Would we all like to remember what is was like to “Sleep Like a Baby”?

Ruby

DISCUSSION

WHAT’S NEXT ?