Recognizing fatigue as a safety hazard
Healthcare lags in related regs and procedures
If you knew the person piloting your plane had been up for the last 20 hours, working non-stop, would you feel safe having him fly you across the country? Would you feel safe having him drive you across town? Probably not. But we let doctors who have been up for tens of hours on end diagnose illness, perform surgeries, and make decisions that could be the very death of us.
Despite that, there are virtually no regulations related to physicians, nurses and other allied health professionals concerning determining the level of fatigue one has, or training the providers to deal with it or recognize when it is debilitating.
But fatigue is an issue of concern — The Joint Commission wrote a book about it (http://www.amazon.com/Strategies-Addressing-Health-Worker-Fatigue/dp/1599402297/ref=sr_1_7?ie=UTF8&qid=1405074174&sr=8-7&keywords=fatigue+countermeasures) in 2008.
Ask physicians, and many will tell you it’s perfectly safe, because a tired doc is better than multiple hand-offs. "Every other dangerous industry has stringent regulations for managing fatigue," says Steve Harden, chairman and CEO of Life Wings, a Tennessee-based health care consultancy that has helped hospitals deal with issues related to fatigue among providers. "Transportation, aviation, nuclear power — they all have those regulations. But in medicine, the options you have are either a tired doc or a handoff. As a patient, I think those are two bad options. You are telling patients they don’t have the right to an aware physician with all the relevant information."
There is plenty of science behind the deterioration of performance as one grows more tired, Harden says. "Doctors will tell you that fatigue doesn’t affect them like others, that they are taught how to handle it, that fatigue has been designed out of healthcare."
When he hears that, he suggests that they create a study in which patients are randomly assigned to either a fresh surgeon or one who has been up all night and then check the outcomes. But the physicians always tell him that such a study would be unethical, that to put a patient knowingly in the hands of a doctor who wasn’t fresh as a daisy wouldn’t pass muster with the institutional review boards. Which proves his point that doctors really are human, and somewhere deep down, they recognize that fatigue is a problem, even for them.
So you know it’s a problem, but how much? Harden says you can do anonymous surveys or use tools from other industries to determine just how prevalent the problem is at your facility. Harden, who has a part-time job as a pilot (it used to be his full-time job until his consulting took off), says the company he flies for uses tests out of NASA to determine error rates on tests after certain kinds of shifts — overnight shifts, those that cross multiple time zones, those that are done by midnight — and apps that detect instances of micro-sleep.
Having a cohort of providers from each kind of shift take equivalent tests might be a good way to see if there was a particular kind of shift that produced markedly more symptoms of fatigue.
Pilots are also asked to self-track, noting when they eat, sleep, feel tired, and when they see themselves making errors. Harden says this too is a good way to track the impact of different shifts on different providers. Even if the information isn’t collected, it’s a good way for individuals to be aware of their own responses, he says.
The importance of measurement
"Measuring it is important because this is a culture of science," he says. "They want evidence. So to create a case for change, you have to show them the burning platform. Figure out the scope of the problem and show it to them."
If they balk at letting you measure the problem, don’t let that delay action, Harden advises. There is plenty of evidence that fatigue is bad for safety, so use that as a starting point.
After that, start with fatigue countermeasures training. What fatigue does to the body is well known. NASA, among other organizations, has spent a long time looking at the effect of long duty periods and the disruption of circadian rhythms, says Harden. What you eat and drink and when you do so, when you exercise and how much and what kind of exercise you do — those things can have an impact on how fatigue works on your body.
If you are working "the back side of the clock" — or when you would normally be asleep — you should avoid foods like milk and turkey, which have compounds in them that promote sleep. If you have a cup of coffee, time it for 30 minutes before you want peak alertness. (See box with 10 countermeasures you can suggest to staff, right.)
Make sure your providers are prepared to both hear and speak truth to peers about fatigue. Harden says they need to be able to tell someone that they are tired and want to be watched closely. "To refuse to say something like that because it makes you look bad is unprofessional," he says. "You would never see anything like that in the cockpit. If we are tired, we ask for that extra set of eyes. If we are asked, we provide it without judgment."
It can be an uphill battle with some physicians, Harden says, but one that is vital to patient safety. Getting everyone to acknowledge that fatigue is an issue for anyone who works long hours is probably the hardest part. Once they are on board, you can more easily get them to buy into the countermeasures training, and to contingency planning for when there is a situation where fatigued staff are needed to work regardless of their lack of sleep. Make it worth their while by creating a program that meets CE requirements for those who need it.
"The goal is to detect the effect and trap it before an error becomes harm," he says.
For more information on this topic contact Steve Harden, Chairman and CEO, Life Wings, Collierville, TN. Email: [email protected]
10 Fatigue Countermeasures
Here are ten fatigue countermeasures you can suggest to staff, according to Steve Harden, chairman and CEO of Life Wings, a Tennessee-based health care consultancy:
1. Have a room to rest in available for providers on the night shift. Recliners and a dark quiet place to shut their eyes for 25 minutes can make a world of difference in performance of complex tasks.
2. Stay away from complex carbs, milk products, and big slabs of turkey. All of these foods can have a dulling effect.
3. Caffeine is at its peak 30 minutes after drinking. Imbibe accordingly.
4. Avoid caffeine and alcohol before sleep.
5. Make sure the quality of your sleep is good before you have a long shift.
6. If you need a nap, make it a short one — 45 minutes or less — to avoid grogginess.
7. If you do take a long nap, make it 2 hours so you complete a full sleep cycle.
8. Make sure you get adequate protein with your meals, and skip the sugary snacks: The energy rush will be followed by a crash.
9. Keep hydrated. Not getting enough to drink can exacerbate fatigue.
10. Exercising between 12:30 a.m. and 2 a.m. can improve mental alertness on overnight shifts with minimal impact on the ability to fall asleep in the morning.
