5 minute read
Prioritizing Sleep for High-Performance Teams in the Emergency Department
By Amanda J. Deutsch, MD, and Al’ai Alvarez, MD, on behalf of the SAEM Wellness Committee
Like our mobile phones and other handheld devices, our energy depletes over time and needs to be recharged. Likewise, when it comes to our energy at work, we are recharged and our performance is optimized by a few critical things: food, exercise, and rest — especially a good night’s sleep. Not only is lack of sleep not good for your long-term health, in the short term, it can impact performance and put you at risk for mistakes and accidents.
The long-term effects of sleep impairment are astounding. Briefly, lack of sleep shortens our lives. Adults who sleep fewer than six hours a night have a 200% increased likelihood of a heart attack or stroke in their lifetime and a 40% increased risk of developing cancer. Short sleep time leads to a 45% increase in developing coronary heart disease. In one study, restricted sleep for one week (<6 hr) caused an individual’s cells to be insulin resistant, and in another, sleep-deprived mice showed a 200% increase in speed and size of cancer growth. If that is not enough, sleeping less impacts our DNA by physically damaging telomeres. While long-term complications of sleep disruptions are well established, it is essential to consider the impact of impairment in sleep on our performance. Emergency physicians are not unlike elite athletes and other highperformance teams — the moment we step into the emergency department, we are on the go and performing at a high level until we leave. EKGs are handed to us to gauge whether to quickly activate the Cath lab. We are constantly assessing the board for patients who need expedited rooming and acute interventions, serially taskswitching our focus on various highpriority decisions, all while taking time to convey treatment plans to patients and families in a compassionate manner. Imagine going through medical school with people telling you, “You need to go home and get some sleep to better learn the skills you’re being taught.” Studies have shown the importance of sleep on motor skills to the extent that the International Olympic Committee released a consensus statement highlighting the need for sleep across all sports and genders. Performance, specifically with elite athletes, has been studied to see what happens when athletes get fewer than eight hours of sleep. In his book, Why We Sleep, Matthew Walker shared statistics of Golden State Warrior Andre Iguodala’s performance based on his sleep habits. When he had more than eight hours of sleep, he had a 12% increase in minutes played, 29% increase in points per minute, 2% increase in three-point
percentage, and 9% increase in freethrow percentage. However, when he slept less than eight hours, he had a 37% increase in turnovers and a 45% increase in fouls committed.
Think about your last shift and imagine how sleep might have impacted your performance. If you’d had at least eight hours of sleep, would you have seen more patients per hour? Written more notes? Done one extra procedure? Increased your efficiency of discharges? Or, if you’d been sleep-deprived, would you have been more likely to order unnecessary imaging or consultations? Would you have been more dismissive and/or abrupt with your colleagues, patients, and families?
Even slight sleep impairment has significant effects on concentration. For example, sleep impairment can lead to fatigue-related driving collisions. This is often due to a phenomenon called microsleep. Microsleep, while lasting only seconds in duration, creates a momentary lapse in concentration whereby no form of perception gets through to your brain, and no motor responses make it out. These microsleeps are often more dangerous than drunk driving, as there is a delayed response instead of the inability to respond. Fortunately, microsleeps occur in those chronically sleep-restricted. But what counts as “chronically sleeprestricted?”
Chronically sleep-restricted is defined as getting less than seven hours of sleep on a routine basis. Many of us likely fall into this category; some of our wearable devices collect biometric data that can confirm this. When we find ourselves exhausted after a shift, how many of us pause to check our fitness for driving home? One of my mentors, Dr. Rebecca Smith-Coggins, studied the change in psychomotor performance in emergency physicians and nurses, highlighting that even a short nap improved IV insertions, exhibited less dangerous driving, and displayed fewer behavioral signs of sleepiness during driving simulation. Another study found that night shifts have a negative influence on job satisfaction and can be a factor in the decision to retire.
The effects of microsleep have also been studied in controlled environments. David Dinges studied the impact of getting different doses of sleep deprivation. One set of subjects stayed up for 24 hours and then measured response times for clicking a button to visual stimuli. Those who lacked sleep showed a 400% increase in missed responses compared to those that slept for eight hours a night. Strikingly, they also found that restricting subjects to no more than six hours of sleep a night for 10 days in a row resulted in the same underperformance as those who pulled all-nighters. Even missing a few hours of sleep drastically impacts our ability to focus and perform when going about our regular activities, especially during our shifts.
Sleep is vital for performing well and for our long-term health, yet working the night shift is part of our job. Let us endeavor to minimize sleep cycle disruptions. Switching into shifts that counter the circadian rhythm (e.g., afternoon shift followed by morning shift or quick turnarounds from overnight to morning shifts) has detrimental effects. As a department, we can explore ways to minimize disruptions to the circadian rhythm by creating scheduling logic that promotes forward progression from morning to afternoon to night shifts. We can develop nocturnist teams and recognize them for their work. How else might we prioritize sleep cycles to minimize circadian rhythm disruptions?
ABOUT THE AUTHORS
Dr. Deutsch is an EM Physician Wellness Fellow at Stanford Emergency Medicine. @amandajdeutsch
Dr. Alvarez, is the director of well-being at Stanford Emergency Medicine. @alvarezzzy
