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The sleepy surgeon: a look at surgeon fatigue

It doesn’t matter what uniform you put on or what education you have, we are all human beings subject to the laws of nature.

In modern medical research there is less and less criticism of the methodology of published research and more and more criticism of the interpretation of the results.  What does the research really mean outside the context of the immediate research subjects?  Case in point, a January 2015 publication in the American Journal of Surgery entitled: “The Sleepy surgeon: does night-time surgery for trauma affect mortality outcomes?

The research has been characterized as saying that trauma surgery is not any riskier at night than during the day, “The studies here add to a growing body of evidence suggesting that surgeons, particularly experienced surgeons, can devise techniques to compensate for sleep deprivation” (Dr Carlos Pellegrini, University of Washington).

Really? What are these magical techniques? The fact is they don’t exist. This is a classic case of overreach and over interpretation of a narrow study. The research itself appears robust, the conclusions: not so much.

They looked at 2007-2010 data from the National Trauma Bank on 16,096 exploratory laparotomies started between midnight and 6 am and 15,109 between 7 am and 5 pm.  They concluded that there was no statistical difference with respect to patient deaths between night time and day time surgeries.  That sounds interesting.  Except, as Dr Pellegrini points out, “The exploratory laparotomy in general is a relatively straightforward procedure for which mortality and morbidity are very low.”

So, surgeons don’t make more mistakes, leading to patient deaths, following a simple procedure at night.  That’s about it.  Surgeons often perform many more complex surgeries. What about those?

It turns out that surgeons are diurnal human beings like the rest of us. In 2012 the FAA’s Civil Aerospace Medical Institute published a study on fatigue and concluded:

In terms of vulnerability to fatigue, we believe it is reasonable to assume that the professional cabin crew population is not inherently different at the genetic/ biological level than any other sub-group within the aviation community. Similarly, it is reasonable to assume that the commercial aviation population is not inherently different than any other group of generally healthy adults exposed to round-the-clock work schedules.

It doesn’t matter what uniform you put on or what education you have, we are all human beings subject to the laws of nature.  In 2012 Harvard medical school teamed up with Massachusetts General Hospital to study the fatigue of Orthopaedic residents. They measured their actual sleep using FDA cleared Readiband technology and their actual fatigue levels using the highly validated SAFTE bio-mathematical model and concluded:

“Residents were fatigued during 48% and impaired during 27% of their time awake. Among all residents, the mean amount of daily sleep was 5.3 hours. Overall, residents’ fatigue levels were predicted to increase the risk of medical error by 22% compared with well-rested historical control subjects.  Night-float residents were more impaired (P=.02), with an increased risk of medical error (P=.045).”

Residents were fatigued during 48% and impaired during 27% of their time awake.

In 2014 the American College of Surgeons published the following findings:

  • Fatigue has significant detrimental effects, including prolonged reaction time, decreased vigilance, impaired decision making, and delayed recognition of critical situations.*
  • Individuals vary in their response to fatigue; an individual’s response may also differ in relation to pre-existing conditions, accompanying stressors, workload, cumulative sleep loss, and the nature of a specific situation.
  • In objective testing, individuals often inaccurately assess their own level of sleepiness.
  • Data concerning surgeons and fatigue are limited and primarily describe physicians in training.
  • Restricted work hours for residents have not been linked to demonstrable improvements in patient safety and better outcomes or improved education of trainees.

…the overwhelming evidence is that human beings, regardless of occupation, simply cannot perform the same at night as they do during the day.

The same American Journal of Surgery published research in 2008 that concluded:

“Fatigue and sleep deprivation cause a significant deterioration in the surgical residents’ cognitive skills as measured by virtual reality simulation. Psychomotor skills are also negatively impacted during tasks that require a combination of psychomotor and cognitive skills.”

There is a dynamic in the medical community much like other communities that have  ”carved in stone” processes and schedules and want to avoid change.  That is understandable. However, the overwhelming evidence is that human beings, regardless of occupation, simply cannot perform the same at night as they do during the day. Over interpreting narrow research does not change that fact.

How fatigued employees affect your business

The long-term impact of sleep deprivation on employees is real and tangible. It is estimated that 30% of employees sleep fewer than six hours a night. This accumulation of sleep debt can lead to less energy, poorer cognitive function, less productivity, and a decreased ability to cope with stress in the workplace.

This infographic from the Pulse Institute demonstrates the challenges to workplace productivity that exist when employees are not sufficiently rested, including:

  • 23% reduced concentration
  • 18% reduced memory function
  • 9% increased difficulty in performing work or volunteer tasks

Fatigued workers contribute to on the job errors – the cost of which affects an organization’s performance, safety and bottom line. What are you doing to address fatigue in your workforce?

AsleepOnTheJob

It’s 3 am, do you know how fatigued your workers are?

When the news of the Chicago train derailment came across our desks last week, we immediately took notice of the time of day the incident occurred. We know from experience and science, that 3 AM is not an optimal time for us to be up and about, performing safety sensitive tasks.

In our 24-hour society, however, the world doesn’t shut down at night so that everyone can go to sleep. Police officers need to respond to emergencies, nurses need to tend to patients, machinery operators need to make sure facilities keep running, and transportation workers need to make sure travellers are delivered safely to their destinations – at all hours of the day.

The responsibility to ensure these, and other shift-related jobs, are performed effectively and without risk to human safety must be shared by both the employer and the worker. There are number of variables which can contribute to someone’s level of fatigue on the job – Are the work shifts inconsistent? Does their work schedule give them enough time off to sleep? Does the worker have a sleep disorder? Does the worker have children at home who are keeping them up? Does the sleeping environment of the worker allow for restful sleep? Does the worker make an effort to obtain 7-9 hours of sleep per day? … this list could go on.

The fact is, all of these specific variables (and more) can be addressed if an employer asks two questions:

  • Does the work schedule provide the worker with the opportunity to maintain regular, sufficient sleep?
  • Is the worker taking advantage of the sleep opportunity being provided to them?

Obtaining objective answers to these questions is actually easier than one might think. The technology and tools to analyze work schedules and measure worker’s sleep is commercially available. (Full disclosure here, we are talking about Fatigue Science technology.) These tools can help employers identify the possibility of worker’s accumulating sleep debt based on their schedules, in a scientifically-validated and meaningful way. They can also help organizations identify if their workers are indeed accumulating risk-inducing levels of sleep debt due to insufficient sleep, whether related to schedule, lifestyle, health or a combination of these factors. By identifying the causes of fatigue in the workplace, organizations and employees can start to manage these variables.

In the case of the O’Hare Airport train crash, the operator has admitted to falling asleep while driving. Additionally, it was noted that she had previously fallen asleep on the job only last month. While it is extremely fortunate there have been no fatalities in either incidents, the risk to human life and the growing financial costs associated with last Monday’s event should serve as a wake up to organizations in any industry. It is not enough to just investigate whether or not fatigue is a factor in a workplace accident, employers and authorities need to take the next steps to address it and reduce the risk of it happening again. Whether a roster of train operators, police officers, or heavy machinery operators, Fatigue can be both measured and managed – before someone makes a mistake that puts themselves, and other human life at risk.

Readiband technology to be included in WSU presentation at White House Safety Datapalooza

Researchers at Washington State University (WSU) have been looking at ways of leveraging data from wearable or mobile technology to help keep police officers safe and effective on the job. Enter their ‘BeSharp’ app which utilizes Fatigue Science’s Readiband technology and our SAFTE algorithm.

Readiband models performance based on sleep activity, provides real-time effectiveness scores, and determines when fatigue levels will reach a point where safety and performance are at risk. WSU researchers have created a mobile app, that will take Readiband’s real-time feedback and proactively alert officers via text message when it is time to take a break to recharge their mental effectiveness and reaction time.

 

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The test version of this app, along with the Readiband, will be presented at this week’s White House Safety Datapalooza Conference by WSU Spokane professor of criminal justice, Bryan Vila. The project will contribute to the White House’s open data initiative, and help “enhance understanding of how fatigue affects safety on the road and in the community” and “enable evaluation of the impact of fatigue management efforts on officer safety.”

Fatigue Science CEO, Sean Kerklaan, has been part of the project team, which includes Jo Strang (American Short Line & Regional Railroad Association) and Gregory Godbout (White House-OSTP Presidential Fellow) and WSU Professor, Bryan Vila.
“We are pleased to have been included in this project and have our technology presented as part of ‘BeSharp’ at the White House Safety Datapalooza Conference.” Sean says, “While this app is still in a test version, it’s been great to work with the BeSharp team and see our technology incorporated into a new platform, which only increases the reach of this powerful data, and could contribute to police officer on-the-job safety and effectiveness.”

3 good reasons to manage your sleep this holiday season

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This time of year, festivities are plenty and most are likely to find themselves participating in numerous social engagements, last minute shopping trips, and family dinners.

There are many good reasons to get quality sleep year round, but during the holidays making the effort to properly manage your sleep will mean better enjoyment of your time and a safe and productive return to work. Here are three reasons why:

1. What holiday stress? – Studies show that well rested people have better stress management – Getting good sleep means handling that dinner with the meddling family member or sibling rivalry with much more grace and much less stress.

2. Consume less calories – Well rested people are known to consume less calories and make better dietary judgements. Studies show that you are more likely to eat fat and calorie laden food when you are tired. Of course you want to enjoy those cookies, festive cheese platters, and Dad’s famous gravy, but getting sleep might be a good way to make sure you aren’t so inclined to overdo it.

3. Safe and happy travels – An abundance of holiday gatherings can mean a lot of miles on the road. Keeping up with your sleep means you will have better reaction time and make smarter decisions while driving.

If you are fortunate enough to enjoy some extra time off during the holidays, take advantage of the opportunity to bank sleep or make up for your previous sleep debt so you can return to work safe and productive in the new year. If your schedule requires that you keep working alongside all the seasonal festivities, be sure to take advantage of any opportunity you have to maintain sleep and have friends or family support your need to be productive at work throughout the holidays by providing a quiet environment to sleep or nap when you need it.

While 7-9 hours of nightly sleep is ideal to maintain good mental effectiveness and safety, there may be a few whose holiday social and work demands interfere with getting sufficient sleep. If you are balancing a number of demands and aren’t able to get all the sleep you need, take extra caution with or postpone safety sensitive tasks as the holidays wind up and plan to make sleep your #1 priority in the new year.

From the team at Fatigue Science, have a safe and restful holiday season!

Using technology to address driver fatigue in the railroad industry

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As new details of the recent train derailment in New York emerge, questions about risk management in the railroad industry keep surfacing. We won’t know for certain what the cause or causes of this unfortunate accident were until the final investigative report is released but in the meantime, media is leaning towards driver fatigue as the cause of the train derailment and have started raising questions about the possible use of various technologies to prevent accidents and save lives.

One such piece of technology in question is known as ‘positive train control’ (PTC) and works by setting permissions to onboard computers authorizing the vehicle’s safe travel route – including distances, speeds, and location. The movement of the train is then monitored and the technology will shut down or slow a train that falls outsides it’s permitted travel parameters. In the case of this recent derailment, the train would have been halted before it was able to travel into a turn at such a high speed.

The Federal Railroad Administration (FRA) believes this PTC technology will save lives but studies show that the cost to implement are as much at $9-12 billion over the next 20 years and involves the complications of upgrading 60,000 miles of track and 20,000 locomotives with new technologies.

Richard Blumenthal is one of several New York Senators recommending that trains be equipped with audio and visual recorders to prove fatigue as a factor in collisions and catch ‘behaviour patterns’ that could be prevented in the future. While the costs of implementing this technology are said to be ‘negligible’ compared to what this recent crash will cost, it is not a technology that can prevent future tragedies, like the Bronx train derailment, from occurring.

Fatigue Science Co-Founder, Pat Byrne, has over 30 years of experience in occupational health and safety and understands the costs of these incidences quite well: “Fatigue accidents are rare but when they happen are catastrophic and, on average, cost five times the amount of non-fatigue related accidents.” he says, “With the cost of this recent New York train accident estimated to come in at hundreds of millions of dollars, the railroad industry should take another heavy look at the timing and budgeting of implementing fatigue monitoring technologies. Though, none of these technologies in question actually address the problem in identifying why the drivers are starting their shifts in a fatigued state and mitigating that in the first place.”

It is unlikely that the investigation will reveal work scheduling as a fatiguing factor, since railroads are required by federal regulation to use Fatigue Science’s FAST (Fatigue Avoidance Scheduling Tool)  to ensure they are providing workers the opportunity to get the sleep they need. If fatigue is determined to be a factor in this accident it is more likely that the driver was not able to sleep well enough or long enough, in spite of the sleep opportunity being provided to him. These circumstances are normally due to sleep disorders and/or lifestyle issues, requiring medical intervention and sleep hygiene training as part of an organizational fatigue risk management program. Unfortunately, at this time, railroads typically do little to support workers in dealing with these severe sleep and fatigue issues – and they won’t be remedied by installing a video monitoring device in the cab of a train.