Center for Injury Research and Prevention

A Need to Fix a Blind Spot in Clinical Care

April 11, 2016

I recently co-authored an editorial that was published in Anesthesiology with colleagues, Indira Gurubhagavatula, MD, MPH, and Vinay Nadkarni, MD, PhD. The editors asked us to comment on a study in the same issue by Huffmyer et al [1] that examined simulated driving performance among anesthesia residents before and after a series of night shifts. We were also asked to help raise awareness of motor vehicle crash risk among house staff.

The Huffmyer et al study found that residents working six consecutive night shifts self-reported increased sleepiness, as well as feeling less alert and less safe to drive. When their simulated driving performance was measured, they had difficulty controlling the vehicle to avoid crashing and experienced worse reaction times and attention lapses during the driving task. They also showed poor speed control and lane position.

This is not surprising. One of the major factors that increases the risk of a crash is impaired driving, which not only includes alcohol or drug use, but also distraction, fatigue, and strong emotions. Drowsiness not only increases crash risk when the driver falls asleep, but also impairs judgment, executive function, cognitive speed, and muscle coordination [2]. In addition to the direct impairments, driving while drowsy can also increase the existing risks of distracted driving [3], putting all road users at risk.

Interestingly, limiting the number of hours worked for each night in a series of consecutive night shifts does not address the drowsy driving problem. This is because consecutive night shifts not only cause sleep deprivation, but also circadian misalignment.

There is no 'one-size-fits-all' approach to injury prevention across drivers, and even within the same driver, the interventions may be different over time. While clinicians working consecutive night shifts are at heightened risk of crashing when compared with other adults, some are at even higher increased risk.

As our research shows, each driver approaches the driving task with assets, as well as challenges. Once we figure out what they are, then we can put into place a personalized care management plan. Simulated driving assessments, such as the one used in the study and created by CIRP, are promising tools for use in research about and management of driving risk.

Among other actionable steps we recommend in the editorial, measurement and testing for clinician drowsiness must include:

• extending systems for monitoring staff safety and quality to include motor vehicle citation and crash outcomes

• conducting detailed investigations when crashes occur after shifts to identify work-related, modifiable factors that could have contributed to the crashes

• instituting performance-based, instead of time-based, methods to screen for excessive drowsiness

We also need to support clinician safety by preventing drowsy driving with stepped-up fatigue risk management programs, conducting research to determine optimal shift lengths, and promoting and modeling good sleep hygiene. Then, and only then, will this blind spot in critical care disappear.

References

1. Huffmyer JM, Tashjian JA, Kleiman AM, Scalzo DC, Cox DJ, Nemergut EC. Driving performance of residents after six consecutive overnight work shifts. Anesthesiology 2016; March 30: [epub ahead of print].

2. Wolman DM, Johns MM, Ulmer C. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. National Academies Press, 2009.

3. Anderson C, Horne JA. Driving drowsy also worsens driver distraction. Sleep Med. 2013 May;14(5):466-8.

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