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INTRODUCTION

The provision of anaesthesia requires a high level of knowledge, sound judgement, fast and accurate responses to clinical situations, and the capacity for extended periods of vigilance.

In the interests of patient safety, it is important that anaesthetists are aware of the following principles and their responsibilities in respect of working while fatigued.

PRINCIPLES

1.   Fatigue has been demonstrated to impair vigilance and accuracy of response ^(1,2,3). Decreased performance of motor and cognitive functions in a fatigued anaesthetist may result in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record keeping ^(4,5,6,7). The decrement in cognitive psychomotor performance after 17 hours of sustained wakefulness is equivalent to the performance impairment observed with a blood alcohol level of 0.05%, and after 24 hours to a blood alcohol level of 0.1% ⁽⁸⁾.

2.   Fatigue may contribute to adverse events and critical incidents ^(9,10). In other industries these have been shown to be commonest in a bimodal distribution between 0300 and 0700 and between 1300 and 1600, when circadian drowsiness is greatest ^(2,11).

3.   Adults require (on average) eight hours of sleep each night (range 6-10 hours)⁽²⁾. Fatigue will occur with sleep debt; this sleep debt is cumulative and does not dissipate. Short sleep nights (4 - 6.5 hours) are associated with a cumulative impairment in the performance of psychomotor tasks requiring vigilance ⁽¹²⁾. Sleep efficiency decreases with increasing age ⁽¹¹⁾. Ageing reduces the capacity to recover from fatigue ⁽¹³⁾.

4.   Many individuals find it difficult to reset their body time clocks to allow for effective daytime sleep after night duties. Daytime sleep is typically shorter and of inferior quality compared with sleep at night ⁽¹³⁾. Minimising the effects of night-time shift work may be achieved by taking a two hour afternoon sleep prior to the night duty, taking a 20-30 minute nap during the duty time, ensuring proper meals, and sleeping as soon as possible after the duty⁽¹⁴⁾.

5.   Individuals are often unable to recognise fatigue and their reduced capacity to continue working safely ^(13,15,16). “Microsleeps”, a sign of extreme fatigue, may be equally unrecognised ⁽¹⁷⁾.

6.   Use of caffeine and other stimulants is an attempt to combat rather than to prevent the problem and as such is not recommended. Sleep loss-induced deterioration in performance is only mitigated by naps (30-45 min) and caffeine (100-600 mg) for the first 24 hours of continuous wakefulness ^(2,18,19,20). Naps are followed by a period of “sleep inertia” (drowsiness after waking) associated with reduced performance which dissipates over 15-30 minutes ^(21,22).

7.   Health facility employers have a responsibility under occupational health and safety legislation to provide a safe working environment for their employees ^{(23,24,25,26)}.

8.   Inappropriate work practices and rosters that contribute to fatigue may put employees at risk of accidents to themselves and their patients while at work, and while travelling to and from work ^(1,2,27).

RESPONSIBILITIES

1.   Anaesthetists have a responsibility to organise their lives in a way that ensures fatigue does not regularly impact on clinical duties ^(1,2,4). Individuals and Departments must have knowledge of fatigue related risk categories, as set out in the Australian Medical Association National Code of Practice (March 1999) ⁽²⁸⁾. Anaesthetists have a moral and ethical responsibility to consider not proceeding with clinical duties if physical or mental fatigue, stress or ill health, alone or in combination, might interfere with safe patient care.

2.   When working out-of-hours results in significant disturbance to normal rest and sleep, the anaesthetist should ensure that any clinical commitments on the subsequent day are either covered by another anaesthetist or postponed until there has been the opportunity for an adequate rest period.

3.   For shift work, forward-rotating shifts (mornings - evenings - nights) are associated with the least disturbance to normal sleep patterns ^(2,21). Many individuals cannot readily reset their biological clock to accommodate night shifts. ^(21,29). These individuals should be aware that a prolonged period of night shifts may result in serious sleep deficit. Anaesthetists who are involved in shift work, particularly overnight shifts, should be aware that clinical performance may potentially be affected by increasing fatigue due to altered sleep routines and should be prepared to call for assistance if fatigued.

4.   Departments, hospitals and groups of anaesthetists should have a management plan to address the short-term consequences of anaesthetists being unavailable for clinical duties because of fatigue following “on-call” work.

5.   Long-term work patterns should be based on the following principles:

5.1   Adequate time must be available for leisure activities, and for rest and sleep.

5.2   Adequate breaks must be taken during a day of clinical work

5.3   Rosters for shift and weekend work must be available for a significant time ahead to permit planning for leisure activities.

5.4   Recreation leave should be taken regularly.

References

(1)   Merry AF, Warman GR. Fatigue and the Anaesthetist. Anaesthesia and Intensive Care 2006; 34 577-578.

(2)   Howard SK, Rosekind MR, Katz JD, Berry AJ. Fatigue in anaesthesia: implications and strategies for patient and provider safety. Anesthesiology 2002; 97: 1281-1294.

(3)   Gander PH, Merry A, Millar MM, Weller J. Hours of work and Fatigue-Related Error: a Survey of New Zealand anaesthetists. Anaesthesia and Intensive Care 2000; 28: 178-183.

(4)   Parker JBR. The effects of fatigue on physician performance – an underestimated cause of physician impairment and increased patient risk. Canadian Journal of Anaesthesia 1987; 34: 489-495.

(5)   Carkadon MA, Roth T. Sleep restriction. In Sleep, Sleepiness and Performance Monk TH Editor. (1991) Chichester: Wiley. 155 – 167.

(6)   Torsvall L, Akerstedt T. Disturbed Sleep while being on call. An EEG study of apprehension in ships engineers. Sleep 1988; 11: 35–38.

(7)   McCall TB. The impact of long working hours on resident physicians. New England Journal of Medicine 1988; 318: 775-778.

(8)   Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature 1997; 688: 235.

(9)   Webb R et al. Australian Incident Monitoring Study - first 2000 cases.

Anaesthesia and Intensive Care 1993; 21: 520-528.

(10)   Gravenstein JS, Cooper JB, Orkin FK. Work and Rest cycles in Anesthesia Practice.

Anesthesiology 1990; 72: 737-742.

(11)   Dement WC. The Perils of Drowsy Driving. New England Journal of Medicine 1997; 337: 783-784.

(12)   Dinges DF, Pack F, Williams K, Gillen KA, Powell JW, Ott GE, Aptowicz C, Pack AI. Cumulative sleepiness, mood disturbance, and psychomotor vigilance decrements during a week of sleep restricted to 4-5 hours per night. Sleep 1997; 20: 267-277.

(13)   Dinges DF, Graeber CR. Crew Fatigue Monitoring. Flight Safety Digest; October 1989. 65-75

(14)   http://www.rcplondon.ac.uk/pubs/books/nightshift/index.asp (accessed May 2007)

(15)   Dement WC, Seidel WF, Cohen SA, Bliwise NG, Carkadon MA. Sleep and wakefulness in aircrew before and after transoceanic flights. Aviation, Space and Environmental Medicine. 1986; 57: B14-B28.

(16)   Van Dongen HA, Maislin G, Mullington J, Dinges DF. The cumulative cost of additional wakefulness: dose- response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation.Sleep 2002; 26: 117-126.

(17)   Howard SK, Gaba DM. Human performance and patient safety: Manual of Patient Safety. Eichhorn J, Morrell R Editors. New York: Churchill Livingstone, 1997 pp431-465.

(18)   Takahashi M. The role of prescribed napping in sleep medicine. Sleep Medicine Reviews 2003; 7: 227-235.

(19)   McEvoy RD, Lack LL. Medical staff working the night shift: can naps help? Medical Journal of Australia 2006; 185: 349-350.

(20)   Bonnett MH, Gomez S, Worth O, Arand DL. The use of caffeine versus prophylactic naps in sustained performance. Sleep 1995; 18: 97-104.

(21)   Garden S, Currie M & Gander P. Sleep loss, Performance & the Safe Conduct of Anaesthesia. Australasian Anaesthesia 1996; 43-51.

(22)   Tassi P, Muzet A. Sleep inertia. Sleep Medicine Reviews 2000; 4: 341-353.

(23)   Nocera A, Strange Khursandi D. Doctors’ working hours – can the medical profession afford to let the courts decide what is reasonable ? Medical Journal of Australia 1998; 168: 616-618.

(24)   Homes G. Junior doctors’ working hours: an unhealthy tradition. Medical Journal of Australia 1998; 168: 587-588.

(25)   McNoble DJ. Expanded liability of hospitals for the negligence of fatigued residents.Journal of Legal Medicine 1990; 11: 427-449.

(26)   Kachalia A, Studdert DM. Professional liability issues in graduate medical education. JAMA 2006; 292: 1051-1056.

(27)   Geer RT, Jobes DR, Tew JD, Stepsis LH. Incidence of Automobile Accidents involving Anesthesia residents after on-call Duty Cycles. Anaesthesiology 1997; 87: A938.

(28)   National Code of Practice - Hours of Work, Shiftwork and Rostering for Hospital Doctors. AMA January 2005:

http://www.ama.com.au/web.nsf/doc/WEEN-6V76DZ/$file/National_Code_of_Practice_January_2005.pdf (accessed May 2007).

(29)   Olson L, Ambrogetti A. Working harder – working dangerously ?

Medical Journal of Australia 1998; 168: 614-616.

COLLEGE PROFESSIONAL DOCUMENTS

College Professional Documents are progressively being coded as follows:

TE Training and Educational

EX Examinations

PS Professional Standards

T Technical

POLICY – defined as ‘a course of action adopted and pursued by the College’. These are matters coming within the authority and control of the College.

RECOMMENDATIONS – defined as ‘advisable courses of action’.

GUIDELINES – defined as ‘a document offering advice’. These may be clinical (in which case they will eventually be evidence-based), or non-clinical.

STATEMENTS – defined as ‘a communication setting out information’.

This document has been prepared having regard to general circumstances, and it is the responsibility of the practitioner to have express regard to the particular circumstances of each case, and the application of this document in each case.

Professional documents are reviewed from time to time, and it is the responsibility of the practitioner to ensure that the practitioner has obtained the current version. Professional documents have been prepared having regard to the information available at the time of their preparation, and the practitioner should therefore have regard to any information, research or material which may have been published or become available subsequently.

Whilst the College endeavours to ensure that professional documents are as current as possible at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Promulgated: 2001

Date of current document: June 2007

© This document is copyright and cannot be reproduced in whole or in part without prior permission.

College Website: http://www.anzca.edu.au/