shift work & the efficient emergency department 1 shift work and the efficient ed n vicken y....

Shift Work & the EfficientEmergency Department

1

Shift Work and the Efficient EDShift Work and the Efficient EDShift Work and the Efficient EDShift Work and the Efficient ED

Vicken Y. Totten MD:Vicken Y. Totten MD: Emergency Physician Emergency Physician and Career-long Shift Workerand Career-long Shift Worker


2


3

Goals and Objectives: Goals and Objectives: Goals and Objectives: Goals and Objectives:

Offer concrete suggestions to optimize your Offer concrete suggestions to optimize your ED workforce by...ED workforce by...

Discussing the effects of poorly conceived Discussing the effects of poorly conceived shift work on work performance by:shift work on work performance by:

Describe normal sleep structure Describe normal sleep structure Definitions and shift patternsDefinitions and shift patterns


4

SLEEPSLEEPSLEEPSLEEP

Sleep, that knits the ravell'd sleave of care,Sleep, that knits the ravell'd sleave of care, The death of each day's life, sore labour's The death of each day's life, sore labour's

bath,bath, Balm of hurt minds, great nature's second Balm of hurt minds, great nature's second

course,course, Chief nourisher in life's feast.Chief nourisher in life's feast.

- Shakespeare, Macbeth, Act II, Scene I- Shakespeare, Macbeth, Act II, Scene I


5


6

Definitions Definitions Definitions Definitions Chronodisruption -- the circadian rhythms Chronodisruption -- the circadian rhythms

are out of synchronization with each other are out of synchronization with each other and with the external world. Classic and with the external world. Classic example is jet lag.example is jet lag.

Sleep deprivation -- lack of core sleepSleep deprivation -- lack of core sleep Sleepiness -- the feeling of wishing to Sleepiness -- the feeling of wishing to

sleep; drowsinesssleep; drowsiness


7

Normal Human Circadian CycleNormal Human Circadian CycleNormal Human Circadian CycleNormal Human Circadian Cycle

Day = alert; night = sleep. Day = alert; night = sleep. Most physiologic systems cycle through the Most physiologic systems cycle through the

24 hour “day”24 hour “day” Modern life is increasingly 24/7, especially Modern life is increasingly 24/7, especially

Emergency MedicineEmergency Medicine Medicine is far behind industry in Medicine is far behind industry in

recognizing the inefficiencies of shift work recognizing the inefficiencies of shift work


8

Circadian rhythmsCircadian rhythmsCircadian rhythmsCircadian rhythms

All body systems change rhythmicallyAll body systems change rhythmically Most humans have about 25-26 hour Most humans have about 25-26 hour

circadian cyclecircadian cycle Other well known cycles have different Other well known cycles have different

periods: 90 minute alertness cycle, fertility periods: 90 minute alertness cycle, fertility monthly cycle, etc. monthly cycle, etc.

Not all systems adapt to a new schedule at Not all systems adapt to a new schedule at same rate!same rate!


9

Concept of “Core Sleep” Concept of “Core Sleep” Concept of “Core Sleep” Concept of “Core Sleep”

Horne: first three SWS cycles with their Horne: first three SWS cycles with their REM periods REM periods

"optional" sleep the rest of the night: more "optional" sleep the rest of the night: more REM, less SWS REM, less SWS

Core sleep: about 5 hours for most personsCore sleep: about 5 hours for most persons Only core sleep made up.Only core sleep made up.


10

Concept of SleepinessConcept of SleepinessConcept of SleepinessConcept of Sleepiness

2 components: core versus optional2 components: core versus optional missing core sleep (physiologic) -- disrupts missing core sleep (physiologic) -- disrupts

physiologic systems physiologic systems missing optional sleep (psychological) -- missing optional sleep (psychological) --

mostly psychological / mood effectsmostly psychological / mood effects both feel drowsyboth feel drowsy


11

Sleep deprivation Sleep deprivation Sleep deprivation Sleep deprivation

loss of "optional sleep" (sleeping less than loss of "optional sleep" (sleeping less than one's habit) causes drowsiness, no other one's habit) causes drowsiness, no other serious effects serious effects

"core sleep" deprivation (less than 5 hours "core sleep" deprivation (less than 5 hours of slow wave sleep) -- true sleep deprivationof slow wave sleep) -- true sleep deprivation

Sleep deprivation causes both physiologic Sleep deprivation causes both physiologic and psychological ill effectsand psychological ill effects


12

Emergency Medicine vs. Emergency Medicine vs. Office-based SpecialtiesOffice-based SpecialtiesEmergency Medicine vs. Emergency Medicine vs. Office-based SpecialtiesOffice-based Specialties On call -- potential for disrupted sleep or On call -- potential for disrupted sleep or

sleep deprivation. Does not affect zeitgibers sleep deprivation. Does not affect zeitgibers or circadian rhythmor circadian rhythm

On duty -- In the work environment, On duty -- In the work environment, performing diurnal tasks during a “day” performing diurnal tasks during a “day” defined by a clock rather than by social defined by a clock rather than by social zeitgibers. Potential for circadian zeitgibers. Potential for circadian disruption.disruption.


13


14

Normal Physiology and SleepNormal Physiology and SleepNormal Physiology and SleepNormal Physiology and Sleep

Most physiologic functions follow the daily Most physiologic functions follow the daily temperature cycle temperature cycle

Alertness greatest when body temperature is Alertness greatest when body temperature is at its physiologic peak, minimal when at its physiologic peak, minimal when cortizol and temperature at their nadircortizol and temperature at their nadir


15


16

At Night, the unadjusted worker:At Night, the unadjusted worker:At Night, the unadjusted worker:At Night, the unadjusted worker:

Performance for stimulating, high-attention Performance for stimulating, high-attention tasks is unchanged tasks is unchanged

Attention wanders for routine, non-Attention wanders for routine, non-demanding tasks demanding tasks

““Daydreams” and micro-sleeps intrudeDaydreams” and micro-sleeps intrude ““Code” performance ok, but subtle things Code” performance ok, but subtle things

missed.missed.


17


18

Normal Sleep Architecture: Normal Sleep Architecture: Stages of sleepStages of sleepNormal Sleep Architecture: Normal Sleep Architecture: Stages of sleepStages of sleep Non-REM (NREM) sleep - Stages I-IV Non-REM (NREM) sleep - Stages I-IV

brain idle, body mobile brain idle, body mobile REM - Body paralyzed, Brain active (more REM - Body paralyzed, Brain active (more

metabolically active than during waking!)metabolically active than during waking!)


19

Stage 1 - transition period. Stage 1 - transition period. Stage 1 - transition period. Stage 1 - transition period.

Normally 10 minutes. Eyes rove. Normally 10 minutes. Eyes rove. Most people awakened during Stage 1 claim Most people awakened during Stage 1 claim

they are not asleep.they are not asleep.


20

Stage 2 - Deeper, fewer eye Stage 2 - Deeper, fewer eye movements. movements. Stage 2 - Deeper, fewer eye Stage 2 - Deeper, fewer eye movements. movements. Shallowest restorative sleep. Shallowest restorative sleep. About half of adult sleep in Stage 2. About half of adult sleep in Stage 2. 20 min. before progressing to next stage. 20 min. before progressing to next stage.


21

Stages 3/4 - Slow wave sleep Stages 3/4 - Slow wave sleep (SWS), (delta sleep) (SWS), (delta sleep) Stages 3/4 - Slow wave sleep Stages 3/4 - Slow wave sleep (SWS), (delta sleep) (SWS), (delta sleep) Most restorative & restful; vital for physical Most restorative & restful; vital for physical

recuperation. recuperation. Majority occurs early in the sleep period.Majority occurs early in the sleep period. Difficult to arouse from SWS.Difficult to arouse from SWS. First stage to be “made up” after sleep First stage to be “made up” after sleep

deprivation.deprivation. SWS deprivation causes fatigue, muscle SWS deprivation causes fatigue, muscle

aches and worse. aches and worse.


22

REM sleep: brain on, body offREM sleep: brain on, body offREM sleep: brain on, body offREM sleep: brain on, body off

Vital for psychological well-being; Vital for psychological well-being; May be critical for learningMay be critical for learning Isolated REM deprivation causes irritability, Isolated REM deprivation causes irritability,

progresses to psychosis, then death progresses to psychosis, then death EEG similar to wakefulness. Dreams, EEG similar to wakefulness. Dreams,

irregular pulse, respiration, increased BP, irregular pulse, respiration, increased BP, loss of muscle tone, and absent spinal loss of muscle tone, and absent spinal reflexes. reflexes.


23

REM sleepREM sleepREM sleepREM sleep

First episode occurs after 90-120 minutes of First episode occurs after 90-120 minutes of NREM sleep. NREM sleep.

Recurs in about 90 minute cycles, getting Recurs in about 90 minute cycles, getting more frequent towards awakeningmore frequent towards awakening

REM periods become longer as night REM periods become longer as night progresses. progresses.


24

On Call versus On DutyOn Call versus On DutyOn Call versus On DutyOn Call versus On Duty


25


26

On CallOn CallOn CallOn Call

On call: night work between working days = On call: night work between working days = pure sleep deprivationpure sleep deprivation

Possibility of sleep while on callPossibility of sleep while on call Main work is still during the daytimeMain work is still during the daytime Usually does not cause circadian rhythm Usually does not cause circadian rhythm

disruptions -- body cycles remain in phasedisruptions -- body cycles remain in phase Isolated night shifts (< 1 /week) function as Isolated night shifts (< 1 /week) function as

‘on call’‘on call’


27

On DutyOn DutyOn DutyOn Duty

On duty implies time of usual type of work, On duty implies time of usual type of work, not an isolated eventnot an isolated event

Often called “Shift Work” Often called “Shift Work” Several common patternsSeveral common patterns Often a major cause of work dissatisfactionOften a major cause of work dissatisfaction Nurses are more likely to have permanently Nurses are more likely to have permanently

assigned shifts than physicians (Unionized) assigned shifts than physicians (Unionized)


28

Circadian disruptionCircadian disruptionCircadian disruptionCircadian disruption

Happens when waking / sleeping does not Happens when waking / sleeping does not correspond with innate circadian rhythmscorrespond with innate circadian rhythms

Desynchronizes physiologic cycles Desynchronizes physiologic cycles Desynchronized systems cause significant Desynchronized systems cause significant

physiologic and psychological malaisephysiologic and psychological malaise Sleep at the wrong time IS NOT equivalent Sleep at the wrong time IS NOT equivalent

to the same amount of sleep at the right time.to the same amount of sleep at the right time.


29

Chronic circadian disruptionChronic circadian disruptionChronic circadian disruptionChronic circadian disruption

Can cause life-long sleep problemsCan cause life-long sleep problems Shortens life expectancy Shortens life expectancy Worsens psychiatric problemsWorsens psychiatric problems Worsens interpersonal skillsWorsens interpersonal skills


30

Examples of circadian disruptionExamples of circadian disruptionExamples of circadian disruptionExamples of circadian disruption

Jet lag: crossing time zonesJet lag: crossing time zones Shift workShift work Hospitalization with loss of ‘Zeitgibers”--> Hospitalization with loss of ‘Zeitgibers”-->

“ICU Psychosis” “Sundowning”“ICU Psychosis” “Sundowning” Even the most rapid physiologic parameters Even the most rapid physiologic parameters

cannot adjust much faster than one or two cannot adjust much faster than one or two hours per 24hours per 24


31


32

Concept of “Zeitgibers”Concept of “Zeitgibers”Concept of “Zeitgibers”Concept of “Zeitgibers”

Physical and social clues which tell us what Physical and social clues which tell us what time it is.time it is.

Most powerful is light. Most powerful is light. Others include taste and smell of usual Others include taste and smell of usual

breakfast food, going to work, sound of breakfast food, going to work, sound of daytime activities, social activitiesdaytime activities, social activities


33


34

Shift workShift workShift workShift work

Not a new phenomenon, but now vastly Not a new phenomenon, but now vastly more frequent. more frequent.

25% of American workers are shift workers 25% of American workers are shift workers at some point in their lives.at some point in their lives.

Invention of the light bulb: 1883Invention of the light bulb: 1883


35

Shift work Shift work Shift work Shift work

Work a defined period of time, then off for a Work a defined period of time, then off for a periodperiod

Working time can be at any time of the 24-hr Working time can be at any time of the 24-hr dayday

Fixed shifts -- working the same time every Fixed shifts -- working the same time every dayday

Rotating shifts -- working time of day Rotating shifts -- working time of day changes from time to timechanges from time to time


36


37

Shift work in IndustryShift work in IndustryShift work in IndustryShift work in Industry

Iron foundries and steel mills introduced Iron foundries and steel mills introduced shift with with rapid rotation.shift with with rapid rotation.

The chrono-stress gave impetus to The chrono-stress gave impetus to unionism. unionism.

Shift work is a major issue in union Shift work is a major issue in union negotiations even todaynegotiations even today


38

Shift lengthShift lengthShift lengthShift length

Length of shift: most common is 8 hoursLength of shift: most common is 8 hours Others are 10, 12 and 6 hoursOthers are 10, 12 and 6 hours More mistakes made in the last 4 hours of a More mistakes made in the last 4 hours of a

12 hour shift than in the first 8 hours12 hour shift than in the first 8 hours Shift changes become more difficult after Shift changes become more difficult after

age 40age 40


39

Do long shifts increase output Do long shifts increase output per worker?per worker?Do long shifts increase output Do long shifts increase output per worker?per worker? No.No. Ergonomics, the science of the Industrial Ergonomics, the science of the Industrial

RevolutionRevolution Henry Ford first reduced working shifts from Henry Ford first reduced working shifts from

12 hours to 8 hour12 hours to 8 hour Productivity increasedProductivity increased Length of night shift more crucial than length Length of night shift more crucial than length

of day shiftof day shift


40

Serious adverse consequences of Serious adverse consequences of shift workshift workSerious adverse consequences of Serious adverse consequences of shift workshift work 20% decrease in life span20% decrease in life span 62% sleep disturbance62% sleep disturbance higher rate of accidents on the jobhigher rate of accidents on the job high risks of fatal commuting accidentshigh risks of fatal commuting accidents 800% risk of ulcers 800% risk of ulcers 1500% incidence of depression and mood 1500% incidence of depression and mood

swings swings


41


42

Shift work is also linked to: Shift work is also linked to: Shift work is also linked to: Shift work is also linked to:

drug and alcohol abusedrug and alcohol abuse altered immune responsealtered immune response infertility in womeninfertility in women high divorce rate.high divorce rate.


43

Drug abuseDrug abuseDrug abuseDrug abuse


44

Shift work and the HeartShift work and the HeartShift work and the HeartShift work and the Heart

increased cardiovascular mortality increased cardiovascular mortality (risk worse than smoking a pack of (risk worse than smoking a pack of

cigarettes per day)cigarettes per day) risk for dysrhythmias (PVC, MAT, SVT)risk for dysrhythmias (PVC, MAT, SVT) risk of sinus arrest (up to 12 sec in one risk of sinus arrest (up to 12 sec in one

study)study) chronic hypertensionchronic hypertension


45

Tolerance to shift workTolerance to shift workTolerance to shift workTolerance to shift work

Better in younger persons (under 40, or pre-Better in younger persons (under 40, or pre-menopausal)menopausal)

Better in childless personsBetter in childless persons Better in natural owls than natural larks Better in natural owls than natural larks 20% of people have no trouble changing shifts, 20% of people have no trouble changing shifts, 60% have moderate hardship, and 60% have moderate hardship, and 20% have extreme difficulty. 20% have extreme difficulty.


46

Night People vs. Morning PeopleNight People vs. Morning PeopleNight People vs. Morning PeopleNight People vs. Morning People Night people = easier adjustment to shift workNight people = easier adjustment to shift work Tend to be phase delayed Tend to be phase delayed Day people = harder with shift change; more Day people = harder with shift change; more

stable once adjustedstable once adjusted Tend to be more synchronized and more Tend to be more synchronized and more

resistant to re-settingresistant to re-setting Residency survey: EP s have more night types Residency survey: EP s have more night types

than normal populationsthan normal populations


47

Shift lengthShift lengthShift lengthShift length Most research has been done on 8 hr shiftsMost research has been done on 8 hr shifts 12 hour shifts no longer permitted in most 12 hour shifts no longer permitted in most

industriesindustries


48

Why 8 hour shifts?Why 8 hour shifts?Why 8 hour shifts?Why 8 hour shifts?

Work output per physician (nurse) per hour Work output per physician (nurse) per hour is greater with 8 hour shifts.is greater with 8 hour shifts.

Mistakes less per worker with 8 hour shiftsMistakes less per worker with 8 hour shifts Patient satisfaction: patients more satisfied Patient satisfaction: patients more satisfied

when health care worker is happywhen health care worker is happy 12 hr shifts appeal most to younger, less 12 hr shifts appeal most to younger, less

experienced physicians / nursesexperienced physicians / nurses


49

Worker wellbeingWorker wellbeingWorker wellbeingWorker wellbeing

Optimum: days onlyOptimum: days only Next best: same shift every day, even if not Next best: same shift every day, even if not

most suited to your optimal timemost suited to your optimal time Acceptable: Isolated (night) shifts with core Acceptable: Isolated (night) shifts with core

working time the same each dayworking time the same each day Worst of all: randomly rotating shiftsWorst of all: randomly rotating shifts


50

Shift rotation Shift rotation patternspatternsShift rotation Shift rotation patternspatterns rotating (swing) shifts -- several common rotating (swing) shifts -- several common

patternspatterns ““Isolated nights” work one shift regularly, Isolated nights” work one shift regularly,

with “isolated” different shifts no more than with “isolated” different shifts no more than once per weekonce per week

randomly rotating shift -- any shift, any day, randomly rotating shift -- any shift, any day, no patternno pattern


51

Swing shifts (rotation patterns)Swing shifts (rotation patterns)Swing shifts (rotation patterns)Swing shifts (rotation patterns) Phase advance: one week days, one week Phase advance: one week days, one week

evenings, one week nights (can be monthly)evenings, one week nights (can be monthly) Phase retreat: (Southern Swing): one week Phase retreat: (Southern Swing): one week

days, one week nights, one week eveningsdays, one week nights, one week evenings Phase advance is more physiologic and more Phase advance is more physiologic and more

easily toleratedeasily tolerated ““Owls” with their innate phase delay, Owls” with their innate phase delay,

acclimatize faster and tolerate phase advance acclimatize faster and tolerate phase advance better than “Larks”better than “Larks”


52

Randomly changing shiftsRandomly changing shiftsRandomly changing shiftsRandomly changing shifts

almost universally condemnedalmost universally condemned forbidden by most unionsforbidden by most unions highest physiologic risk and stresshighest physiologic risk and stress practiced mostly by physicianspracticed mostly by physicians


53

Isolated nightsIsolated nightsIsolated nightsIsolated nights

defined as less than one night per weekdefined as less than one night per week equivalent to a bad night on callequivalent to a bad night on call


54

Adjusting to a new shift Adjusting to a new shift Adjusting to a new shift Adjusting to a new shift

Body can adjust by 1-2 hrs. / 24, or one Body can adjust by 1-2 hrs. / 24, or one week to move forward by one (8 hr) shift.week to move forward by one (8 hr) shift.

Although weekly rotations are most Although weekly rotations are most common, acommon, a

Monthly rotation is better, IFMonthly rotation is better, IF Worker will maintain the same sleep/wake Worker will maintain the same sleep/wake

schedule when not workingschedule when not working


55

DownsideDownsideDownsideDownside

Unfortunately, most permanent night Unfortunately, most permanent night workers switch to day-life when not at workworkers switch to day-life when not at work

Never acclimatize Never acclimatize Same ill effects as random-shift changersSame ill effects as random-shift changers


56

What about physicians?What about physicians?What about physicians?What about physicians?

MD = Maximum DenialMD = Maximum Denial Socialized to ignore their own needsSocialized to ignore their own needs Trained to be ‘tough’Trained to be ‘tough’ poor role modelspoor role models


57

Performance of physiciansPerformance of physiciansPerformance of physiciansPerformance of physicians

Åkerstedt et al:Åkerstedt et al:

documented poor performance with micro-documented poor performance with micro-sleeps (non-restorative) during rote taskssleeps (non-restorative) during rote tasks

documented micro and mini-sleeps during documented micro and mini-sleeps during drive home even in those who did not think drive home even in those who did not think they had slept they had slept


58

Physician learningPhysician learningPhysician learningPhysician learning

Asken MJ, Raham DC: Resident Performance and Sleep Deprivation: Asken MJ, Raham DC: Resident Performance and Sleep Deprivation: A Review. J. Med Educ 1983;58:382-388A Review. J. Med Educ 1983;58:382-388

Demonstrated decreased performance, Demonstrated decreased performance, learning of deleterious habits and learning of deleterious habits and physiologic harm.physiologic harm.


59

Overall performance Overall performance Overall performance Overall performance

Tilley et al The sleep and performance of shift workers. Human Tilley et al The sleep and performance of shift workers. Human Factors, 1982;24:624-41Factors, 1982;24:624-41

Found that shift work affected rote tasks Found that shift work affected rote tasks and the highest intellectual tasks equally as and the highest intellectual tasks equally as much; moderately challenging but well much; moderately challenging but well known tasks suffered least. Implication for known tasks suffered least. Implication for physicians: we make more mistakes on the physicians: we make more mistakes on the more serious casesmore serious cases


60

Implications for the efficient EDImplications for the efficient EDImplications for the efficient EDImplications for the efficient ED

8 hour shifts are optimal8 hour shifts are optimal minimize circadian disruption through minimize circadian disruption through

meticulous attention to circadian principlesmeticulous attention to circadian principles Non-sleep-disrupted physicians and nurses are Non-sleep-disrupted physicians and nurses are

more productive and less prone to drug or more productive and less prone to drug or alcohol use, and therefore safer for patients and alcohol use, and therefore safer for patients and the employerthe employer


61

Strategies to improve efficiency Strategies to improve efficiency of shift workersof shift workersStrategies to improve efficiency Strategies to improve efficiency of shift workersof shift workers Teach and encourage proper sleep hygiene Teach and encourage proper sleep hygiene

(literature available upon request)(literature available upon request) Optimize shift rotation patternsOptimize shift rotation patterns Provide opportunities for food & exerciseProvide opportunities for food & exercise Encourage social lifeEncourage social life


62


63

Sleep Hygiene Sleep Hygiene Sleep Hygiene Sleep Hygiene Keep sleep time sacredKeep sleep time sacred Minimize care-giving responsibilities during sleep time.Minimize care-giving responsibilities during sleep time. Optimize sleeping temperatureOptimize sleeping temperature Exercise 20 min per day, but at least 1 hr prior to going Exercise 20 min per day, but at least 1 hr prior to going

to sleep to sleep ““When you feel least like doing it, is when you need it When you feel least like doing it, is when you need it

the most”the most”


64

Diet Diet Diet Diet

Great care to eat appropriately during the Great care to eat appropriately during the working / waking timeworking / waking time

Hospitals need to provide access to good, Hospitals need to provide access to good, nutritious food for night workers as well as nutritious food for night workers as well as day workersday workers

Eating while socializing is a more powerful Eating while socializing is a more powerful zeitgiber than eating alone.zeitgiber than eating alone.


65

Light: optimizeLight: optimizeLight: optimizeLight: optimize

single most powerful zeitgiber for single most powerful zeitgiber for humanshumans

without adequate light, many without adequate light, many humans never completely adapt to a humans never completely adapt to a new schedulenew schedule

intensity is important: 7,000 Lux, intensity is important: 7,000 Lux, like a heavily overcast daylike a heavily overcast day

most indoor lighting is inadequatemost indoor lighting is inadequate


66

Light: problemsLight: problemsLight: problemsLight: problems new ‘energy saving’ fixtures are even more new ‘energy saving’ fixtures are even more

inadequateinadequate Saving money by putting low output lighting in Saving money by putting low output lighting in

the Emergency Department is false economy.the Emergency Department is false economy. implication to hospital administration: high implication to hospital administration: high

intensity lights over physicians / nurses intensity lights over physicians / nurses working areas improves productivity and working areas improves productivity and minimizes mistakes.minimizes mistakes.


67

Optimize night-shift performanceOptimize night-shift performanceOptimize night-shift performanceOptimize night-shift performance

Light ED at 7000 lux in at least some parts Light ED at 7000 lux in at least some parts Scheduled night hours for the cafeteria -- Scheduled night hours for the cafeteria --

adequate for everyone to get some while still adequate for everyone to get some while still staffing the EDstaffing the ED

Provide a quiet dark place for worker naps Provide a quiet dark place for worker naps during breaksduring breaks

Exercise facilities on campus improves Exercise facilities on campus improves worker performance.worker performance.


68

Scheduling to optimize worker Scheduling to optimize worker performanceperformanceScheduling to optimize worker Scheduling to optimize worker performanceperformance 8 hour shifts8 hour shifts Permanent night shift workers (days, Permanent night shift workers (days,

evenings, nights) evenings, nights) Night differential is helpful in recruiting Night differential is helpful in recruiting

permanent night workerspermanent night workers Rotations: equal distribution of undesirable Rotations: equal distribution of undesirable

shiftsshifts


69

Creative scheduling: ultra shortCreative scheduling: ultra shortCreative scheduling: ultra shortCreative scheduling: ultra short

Ultra-short night shift: night shift is only 6 Ultra-short night shift: night shift is only 6 hours long; it provides time for the worker hours long; it provides time for the worker to sleep before and after the shift. to sleep before and after the shift.

Minimizes circadian disruption. Works best Minimizes circadian disruption. Works best with Isolated Night pattern and next best with Isolated Night pattern and next best with Random Rotationwith Random Rotation


70

Creative Scheduling: split nightCreative Scheduling: split nightCreative Scheduling: split nightCreative Scheduling: split night

Split night: One shift ends very, very late Split night: One shift ends very, very late (say 3 am) and the next starts very, very (say 3 am) and the next starts very, very early (3 am) early (3 am)

Each person gets to sleep part of the normal Each person gets to sleep part of the normal night time, and be up during most of the night time, and be up during most of the normal day. Excellent commuting normal day. Excellent commuting conditions, too.conditions, too.


71

Exercise Exercise Exercise Exercise

Athletes: get more delta Athletes: get more delta (SWS, restorative) sleep. (SWS, restorative) sleep.

Time of day important: pm Time of day important: pm exercise has more effect.exercise has more effect.

Exercise should be over Exercise should be over more than one hour before more than one hour before sleep timesleep time


72

Exercise implications for the Exercise implications for the workplaceworkplaceExercise implications for the Exercise implications for the workplaceworkplace Exercise at the workplace enhances alertness Exercise at the workplace enhances alertness

and worker wellbeingand worker wellbeing Brief episodes of vigorous exercise enhances Brief episodes of vigorous exercise enhances

alertness -- 10 min in middle of the nightalertness -- 10 min in middle of the night Exercise improves sleep quality -- if Exercise improves sleep quality -- if

completed at least 1 hour before sleep timecompleted at least 1 hour before sleep time Exercise before driving home -- fewer Exercise before driving home -- fewer

accidents during commuteaccidents during commute


73

SocializationSocializationSocializationSocialization

An important zeitgiber for humansAn important zeitgiber for humans Improves workforce wellbeingImproves workforce wellbeing Social Life is main cause of night-workers Social Life is main cause of night-workers

NOT maintaining same schedule on days-NOT maintaining same schedule on days-off. Night workers need a social life, toooff. Night workers need a social life, too

Spouses must be supportiveSpouses must be supportive


74


75

The employer can:The employer can:The employer can:The employer can:

Encourage off-duty night workers to Encourage off-duty night workers to socialize during their normal waking hours socialize during their normal waking hours

Notify night workers of other night-time Notify night workers of other night-time opportunities.opportunities.

Involve spouses in learning about shift work Involve spouses in learning about shift work and sleep hygieneand sleep hygiene


76

SummarySummarySummarySummary

Emergency Medicine is of necessity 24 / 7Emergency Medicine is of necessity 24 / 7 physicians, nurses, clerks, aides, physicians, nurses, clerks, aides,

housekeeping...housekeeping... Careful attention to circadian issues and Careful attention to circadian issues and

shift scheduling can improve worker shift scheduling can improve worker efficiency, improve retention, improve efficiency, improve retention, improve community relations, reduce medical community relations, reduce medical mistakes...mistakes...


77

Best single reference Best single reference Best single reference Best single reference

"Why we Sleep" by James Horne. Published "Why we Sleep" by James Horne. Published by Oxford University Press Walton St by Oxford University Press Walton St Oxford OX2 6DP 1988Oxford OX2 6DP 1988

a classic overall referencea classic overall reference


78

shift work & the efficient emergency department 1 shift work and the efficient ed n vicken y....

Documents

n emergency physician

n performance

delta sleep n

sleepsleep n sleep

n vital

persons n

n majority

n difficult