THE FATIGUE FACTOR IN PATIENT SAFETY

1. THE FATIGUE FACTOR IN PATIENT SAFETY BONNIE DEVEAU, RN, MSN, MA, NE-BC VICE PRESIDENT, QUALITY & PATIENT SAFETY GOODALL HOSPITAL

2. 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

3. WHAT KEEPS US UP AT NIGHT? We can probably come up with A MILLION causes!

4. 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

5. 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

6. 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

7. The Problem

8. Medical Errors

9. Healthcare Industry Transformation

10. The Physiology of Sleep Essential to understand the correlation between Fatigue and Medical Errors

11. 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

12. 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

13. Stages of Sleep • Brain waves start to slow • Brain waves slow even more, eye movements stop, HR & RR rates slow • Brain less responsive (when awoken in this stage a person is groggy and has poor memory) • Restorative and renewal stage – promotes muscle and tissue growth • REM sleep - muscles are paralyzed (prevents acting out dreams) & frontal lobe activity is depressed. Someone awakened in this stage is moody /irritable

14. 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.

15. 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

16. 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”

17. Where is sleep on your list of daily priorities?

18. 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)

19. Costs and Benefits of the Baylor Program • Costs • Increased the level of staffing needed on a unit • Cost more money to administer this program • 12-hour shifts were starting to be a struggle for the Baby Boomer population • 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 Benefits • Provided instantaneous resolution to the nursing shortage issue in the 1980’s • Acted as not only a recruitment tool but a retention strategy as well • Full-time staff who worked 8 hour shifts worked Monday though Friday • Weekend staffing was no longer the burden it had been in the past

20. 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

21. 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%

22. Working Shift Work

23. 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)

24. 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)

25. 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

26. 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.

27. 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

28. 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

29. Strategies to Reduce or Minimize Patient Harm Your organizational Next steps

30. 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

31. 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 !

32. How Can You Affect Change? • Educate: • Senior Leadership • Management Staff • Direct Care Staff (include medical staff) Share your Assessment Findings Promote an Action Plan

33. 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

34. STAFF SURVEY

35. 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

36. 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)

37. 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)

38. 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)

39. 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!

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

41. DISCUSSION • WHAT’S NEXT ?