PowerPoint Presentation

Fatigue Counter Measures: A Toolbox for Healthcare Professionals-Research Based-Christian Updike, MDOccupational MedicineMedical Director Employee Health, HealthONEPREVIEW:Fatigue Countermeasure ToolsTactical Screen/Sunlight ManagementThe Nap Triathlete & Anchor SleepErrors increase at 2 pm and 2 am: Caffeine?Errors increase on 3 night shifts: 72 hoursErrors increase w/time on task: Switch every 30minErrors increase with interruptionsStaff Conflict/Staff Bullying increases fatigue.Recovery: watch funny videos Recovery: Sleep clears brain toxins (coffee cant!)

FATIGUE BASICS Some Fatigue ConsequencesFatigue Stages

JCAHO Alert on FatigueOfficial JCAHO Sentinel Event Alert on HealthCare Worker Fatigue Released 2011Specifically suggest Reform http://www.jointcommission.org/assets/1/18/sea_48.pdf

Work Limits in Safety Sensitive Groups Pilots: FAA (max 30h/wk or 100 h/month)Trucker: DOT (11 hours drive/day, after 10 consecutive hours off) Soldier: US Military (recd 8 hours rest/day!)National Wildfire: 16 hours/dayCDC disaster teams: 12 hours/ dayNuclear power plant: 16 hours/dayHealth Care Workers: EHWHATEVER (?!?!?)General setup for Fatigue in Occupational Setting Emotional Stress > Genetic DispositionCognitive Stress > Training/hour worked prior 7dPhysical Stress> Energy level/Sleep prior 72h

Lack of Situational ControlEffort/Reward Imbalance

PART 1: PHYSICAL FATIGUE (Think hours awake in past 72h)

Relived bynot being awake.Challenger Story

Understand your brain can (partially) turn off even with eyes open.Sleep deprived Rats studies of 10% cells going off line while awakeMicrosleepshigh risk of errorLoss of situational awarenessSleep activates brain cleaningBeta Amyloid rises 6% if miss ONE nightBeta Amyloid associated with hallucinations/dementiaNEW GLYMPHATIC System found in 2012GLYMPHATIC dilates 60% when asleep- incr flow

Light controls Sleep---Manage your light exposure and improve Sleep--

Digital Light ManagementFree programs that gradually lower your screen brightness at night (Google: Screen Dimmer)Bright blue light can delay onset of (needed) sleepThis presentation is in blueFacebook/Twitter/LinkedIn pages in blue

Reduce light from phoneNormal INVERT COLORS

Sunlight ManagementLight Retina SCN suppress MelatoninAlert Stare at the sun vs wear blue blocker sunglasses

Light at night =Cancer? YES Completely blind women have LESS Breast Cancer (43%) than sighted women.Partially blind women =no cancer protection Darkness= incr Melatonin= incr death of cancerous cells. Double Cancer rates of pancreatic, Colon, prostate CA

Be a Nap Triathlete 1 dose of caffeine THEN20 min nap THEN5 minute walk

Official Fatigue Risk Management recommendation from American College of Occupational and Environmental Medicine.

Nap 20 min OR 90 minutesAvoid awaking in middle of a 90 minute cycleSleep Inertia: the confusion if awaken mid sleep cycle

Anchor SleepTry to get 4 hours sleep at the same time each day

Caffeine cant replace sleep .Caffeine T1/2= 4 hoursHalf life= time until 50% is eliminated 3h in smokers/heavy users vs 7h. pregnantLearn your caffeine content: 5 cans Diet coke vs. Starbucks 12 ounce coffee

Adenosine Brain receptors Shut downATP ADP+P AMP+P Adenosine +P Adenosine is like pulling up the parking break.Adenosine is [BLOCKED] by caffeine

Sleep is VERY Active ProcessEnergy surge (Brain ATP levels increase) at start of sleep.Immune proteins made during sleepProbable Emotional interpretation of prior eventsDump Beta Amyloid toxinSleep to Remember & LearnSleep to retain knowledge in memory. Rewiring brainAcetylcholine levels must be low to create perm memories.Counter measures: Talk more at nightLinemen Disaster crew storyKeeps self and coworkers engaged/alertInformal way of tracking each others alertness29Badge of honor working sleep deprived? Need to change our cultureSleep deprivation = similar to being drunk.Would we brag about working drunk?...we do it for sleep deprivation.

Sleep in a CaveQuiet: silicone earplugsCool: 68 degreesDark: Blinders

PART 2: COGNITIVE FATIGUEThink hours worked in past 7 days The Brits Afternoon Tea is a good ideaUse caffeine at 2pm for day shiftUse caffeine at 2 AM for night shift(Exxon Valdez disaster fell asleep at 1 am)(3 Mile Island nuclear melt down 3 am)

Reduce cognitive load with checklistsPilots use checklistsSurgeons now required to do verbal check list (to confirm with surgical team right pt, correct location, correct procedure)Use your brain for more interesting tasksSwitch Tasks Every 30 minRelative risk of injuries and accidents as a function of successive night shifts. Folkard S, Tucker P. Shift work, safety and productivity. Occup Med (Lond). 2003 Mar;53(2):95101.

More Errors at 2 pm and 2AMRelative real-job speed and accuracy measures across the hours of the day. Folkard S, Tucker P. Shift work, safety and productivity. Occup Med (Lond). 2003 Mar;53(2):95101.

Interruptions are Risky!Data is showing multi-tasking is a good way to make errors.The nursing medication/interruption studyDISCOURAGE INTERRUPTIONS when giving meds

37Undiagnosed Sleep ApneaSleep Apnea is VERY likely if:Body mass index >35Neck >17 (16 females)Cant see the uvula (Mallampati Score)BP takes 3 meds to control EMOTIONAL FATIGUE Suppressing emotion is exhaustingNot showing emotion is a risk factor for burnout. (Consiglio, C.2014, Burnout Research p. 70) Our profession expects emotional controlTakes energy to suppress emotions, and we have a limited supply of energy.

Use Dark Humor The South Orange Rescue StoryBody recovery/BP

Watch Funny Videos, really30-60 min laughterLower cortisolLower catecholamines (epi)Raised endorphins (feel good chemicals)Raised IgG/IgM x 12 hours (immune chemicals)Human growth hormones increasedAnticipation of videos had similar effectSchedule shifts 60 days in advance (Minimum!)Give staff time to review social plans and swap as needed.Reduces having to miss events with family & friends, thus reduce the work resentment factor.

Negative hospital staff gossip directly linked with BurnoutToxic environmentIncreases depersonalization and intent to leave. (Georganta, K 2014)Negative Gossip: Ostracize and bully

CDC/NIOSH Recognize staff conflict is a patient safety issueDoes a team communicate well if dysfunctional?Nurse bullying:CDC course #WB-1865NIOSH course #2013-155Agency for Healthcare Research and Quality and Dept of Defense: TeamSTEPPSConsider formal anti-bullying policy

Lateral Staff Conflict(Interpersonal Strain at Work- ISW)Team Conflict: INCREASES as fatigue increases. Silent Conflict: Withholding info that would helpUNDERREPORTED Staff turns on each other if distressed by leadership

[SEE AOHP JOURNAL Spring 2015!]Emotional Fatigue Counter measure: Exercise at 85% for 10 minRaises Dopamine (Pleasure)Raises Adrenaline (Energy)Raises Serotonin, maybe. ( Calm )

Emotional Fatigue Counter measure: POSITIVE social support Some people/friends can LOWER your emotional fatigue. MAKE TIME for them.

Some people/ frenemies can INCREASE emotional fatigue LIMIT time for them.

Emotional Fatigue higher risk substance abuseHealthcare workers have a HIGHER risk of substance abuse than community.Certain Specialties have higher risk (ER 3x alcohol abuse)American Nursing Association lists substance abuse of nurses at approx 10%. Need CLEAR WRITTEN POLICY: no CONTROLLED Substances (DEA Schedule II,III, IV) 8 hours prior to or at workTAKE HOMENow in your Fatigue Toolbox!Tactical Screen/Sunlight ManagementThe Nap Triathlete & Anchor SleepErrors increase at 2 pm and 2 am: Caffeine?Errors increase on 3 night shifts: 72 hoursErrors increase w/time on task: Switch every 30 min.Errors increase with interruptionsStaff Conflict/Staff Bullying increases fatigue.Recovery: watch funny videos Recovery: Sleep clears brain toxins (coffee cant!)

Thanks

Contact me at Christian.Updike@HealthOnecares.com

www.Fatiguetips.Weebly.com

References American Nursing Association. (2015). Bullying and Workplace Violence. Retrieved 6/15,2015. http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/bullyingworkplaceviolenceBreast Cancer Fund. (2015). Shift Work, Light-at-Night and Melatonin. Retrieved 6/30,2015 from http://www.breastcancerfund.org/clear-science/radiation-chemicals-and-breast-cancer/light-at-night-and-melatonin.html.Bria, M., Spanu., F., Baban, A., Dumitrascu, D.L. (2014). Maslach Burnout Inventory General Survey: Factorial validity and invariance among Romanian healthcare professional. Burnout Journal. 1(3):103-111. Doi: 10.1016/j.burn.2014.09.001. Carla, S.M., et al.(2013). Effects of insufficient sleep on circadian rhythmicity nas. Effects of insufficient sleep on circadian rhythmicity and expression amplitude of the human blood transcriptome. Proceedings of the National Academy of Sciences of the United States of America. 110(12):E1132-E1141. Doi:10.1073/p

References, Continued -2 Consiglio, C. (2014). Interpersonal strain at work: A new burnout facet relevant for the health of hospital staff. Burnout Research. 1(2014):69-74. Doi: 10.1016/j.burn.2014.07.002.

Dawson D, et al., Fatigue-proo!ng: A new approach to reducing fatigue-related risk using the principles of error management, Sleep Medicine Reviews (2011), doi:10.1016/j.smrv.2011.05.004

Flynn-Evans EE, Stevens RG, Tabandeh H, Schernhammer ES, Lockley, SW Total visual blindness is protective against breast cancer. Cancer Causes Control. 2009 Nov;20(9):1753-6. doi: 10.1007/s10552-009-9405-0. Epub 2009 Aug 1.

Gabel V., et al. (2014). Dawn simulation light impacts on different cognitive domains under sleep Behavioral Brain Research Factor. 12/2014; 281. DOI: 10.1016/j.bbr.2014.12.043. Georganta, K., Panagopoulou E., Montgomery, A. (2014). Talking behind their backs: Negative gossip and burnout in Hospitals. Burnout Journal. 1(2014).76-81. Doi:10.1016/j.burn.2014.07.003.

Gu, F. et al. (2015) Total and Cause-Specific Mortality of U.S. Nurses Working Rotating Night Shifts. American Journal of Preventative Medicine. 48(3).241-252DOI: http://dx.doi.org/10.1016/j.amepre.2014.10.018

References, Continued-3Iliff, J.J., et al. (2012). A paravascular pathway facilitates CSF flow through the brain parenchyma and the clearance of interstitial solutes, including Beta Amyloid . Science Translational Medicine. 4(147):147ra111. Doi: 10.1126/scitranslmed.3003748. JACHO. (2011). Sentinel Event Alert on HealthCare Worker Fatigue. Retrived 9/15, 2013, from http://www.jointcommision.org/assets/1/18/sea_48.pdfKimmel, N. & Whittington, J. (2011). Greater than previously measured Global Trigger Tool shows that adverse events in Hospitals May be ten times greater than previously measured. Health Affairs, 30(4),581-589 Doi: 10.1377/hlthaff.2011.0190.Lee, Y., Lee, M., Bernstein, K. (2013). Effect of Workplace Bullying and Job Stress on Turnover Intention in Hospital Nurses. Journal of Korean Academy of Psychiatric and Mental Health Nursing. 22(2):77-87. Korean. doi: http://dx.doi.org/10.12934/jkpmhn.2013.22.2.77Lerman, S.E., et al. (2012). ACOEM Guidance Statement: Fatigue Risk Management in the Workplace. Journal of Occupational and Environmental Medicine. 54(2):231-257.

References, Continued-4Martinez, E. (2015). EmoBurnout: An Approach for Supporting Burnout Syndrome Diagnosis. Studies in Health Technology and Information. 211, 111-118.Miller, J. (2013). Fundamentals of Shiftwork, 3rd Edition: Fixing Stupid. Smashwords eBook. ISBN: 9781301961894Miller, J. (2013). Anatomy of a Fatigue-Related Accident. Smashwords eBook ISBN: 9781310879265

Ooms, S., Overeem, S., Besse, K., Rikkert, M.O., Verbeek, M., & Claassen J.A. (2014). Effect of 1 night of total sleep deprivation on cerebralspinal Fluid Beta Amyloid in 42 healthy middle-aged men: a randomized clinical trial. Journal of American Medical Association Neurology71(8).971-977. Doi: 10.1001/jamaneurol.2014.1173Paret, M.E. (2012). Night work and the risk of Cancer Among men. American Journal of Epidemiology. 176(9): 751-759. doi: 10.1093/aje/kws318

References, Continued-5

Ribeiro, J.A., Sebastiao, A.M. (2010). Caffeine and Adenosine. Journal of Alzheimers Disease. 20(Supplement 1):S3-S15. Doi: 10.3233/JAD-2010-1379.

Slideshare. (2015). 10 Signs Youre Burning Out and What to Do About it. Wandick Rocha de Aquino Retrieved 7/1,2015, http://www.slideshare.net/wandickrochadeaquino/10-signs-youre-burning-outSteffen, G., Born, J. (2004). Low Acetylcholine during slow-wave sleep is critical for declarative memory consolidation. Proceedings of the National Academy of Sciences of the United States of America. 101(7):2140-2144. Doi: 10.1073/pnas.0305404101.Trinkoff, A.M., Storr, C.L. (1998).Substance use among nurses: differences between specialties. American Journal of Public Health. 88(4), 581-585.Vyazovskiy, V., Olcese, U., Hanlon, E., Nir, Y., Cirelli, C., & Tononi G. (2011). Local sleep in awake rats.Nature. 472,443-447. Doi:10.1038/nature10009.

References, Continued-6

Winwood, P.C., Winefield A.H., Dawson, D., Lushington, K. (2005). Development and validation of a scale to measure work-related fatigue and recovery: the Occupational Fatigue Exhaustion/Recovery Scale (OFER). Journal of Occupational and Environmental Medicine. 47 (6):594-606.Xie, L., et al. (2013). Sleep drives metabolite clearance from the adult brain. Science. 342:373-373.

Appendix: DepartmentPredictable schedule/ 60 days out

Appendix: Institution Zero Tolerance nurse bullying policy Fatigue Risk Management SystemDysfunctional Team interventions: Crew Resource Management (TeamSTEPPS)Limits on foul language