A review at this year's Euroanaesthesia congress in Milan, Italy (4-6 June) on the potentially lethal effects of fatigue on doctors and nurses themselves, and its impact on the quality of their clinical work and judgment and therefore patient safety, will be given by Consultant Anaesthetist Dr Nancy Redfern of Newcastle Hospitals NHS Foundation Trust, Newcastle, UK. She will conclude that due to these risks, "healthcare should have formal risk management systems like those required by law in every other safety-critical industry".
She will also recommend that all doctors and nurses need 20-minute power naps during night shifts to keep patients safe (and make their own journeys home after work safer), and also recommend that no doctor or nurse does more than 3 consecutive night shifts.
Dr Redfern will discuss evidence from various sources including surveys from the joint Association of Anaesthetists, Royal College of Anaesthetists and Faculty of Intensive Care Medicine fatigue working group, published in the journal Anaesthesia, that showed around half of trainee doctors, consultants and nurses had experienced either an accident or a near miss driving home after a night shift. Indeed, research has shown driving after being awake for 20 hours or more and at the body's circadian low point (in the night or very early morning when it most needs sleep) is as dangerous as driving with blood alcohol levels above the legal limit. And workers who drive home after a 12-hour shifts are twice as likely to crash as those working 8-hour shifts.
A 'sleep debt' begins building after 2 or more nights of restricted sleep, and it takes at least 2 nights of good sleep to recover from this. Cognitive function is impaired after 16-18 hours awake leading to a deterioration in the medical worker's ability to interact effectively with patients and colleagues. "When fatigue sets in, we in the medical and nursing team are less empathic with patients and colleagues, vigilance becomes more variable, and logical reasoning is affected, making it hard to calculate, for example, the correct doses of drugs a patient needs," explains Dr Redfern. "We find it hard to think flexibility, or to retain new information which make it difficult to manage quickly changing emergency situations. Our mood gets worse, so our teamwork suffers. Hence, everything that makes us and our patients safe is affected."
She will discuss how fatigue induces spontaneous, unrecognized uncontrolled 'sleep lapses' or 'microsleeps', which means driving home tired is the most dangerous thing a healthcare practitioner does. Evidence around short 20-minute power naps in improving staff and patient safety will be presented and ways of building this into night shift work discussed.
There is work going on at many levels to address the impact of fatigue. The European Society of Anaesthesiology and Intensive Care (ESAIC) (that hosts Euroanaesthesia) is working on producing guidelines for night working, while the Association of Anaesthetists has an active #fightfatigue campaign. The European Board of Anaesthesiology and the European Patient Safety Foundation are also active in this area, and Dr Redfern notes that several European countries are leading the way with action, including the UK, Romania, The Netherlands and Portugal.
We hope in the end that regulators will recognize that healthcare workers have the same physiology as employees in every other safety-critical industry and require formal fatigue risk management as part of its overall approach to patient and staff safety."
Dr Nancy Redfern of Newcastle Hospitals NHS Foundation Trust, Newcastle
She concludes: "We need to change the way we manage night shifts to mitigate the effects of fatigue. Those working shifts must ensure everyone gets a power nap, and that we support each other to remain safe and vigilant when we work through the night. Staffing schedules should allow sufficient time between shifts for proper rest, and no-one should do more than 3 night shifts in a row."
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