New research has found that surgeons were sleep deprived prior to on-call shifts and afterwards even more so, and crucially, that sleep deprivation impacted surgical performance.
The study is the first to focus on Irish surgeons and is published in the Journal of Surgical Research. A separate study found that short naps of 30 to 60 minutes do little to reduce sleep deprivation.
Focussing on the effects of being ‘on-call’, a frequent state for surgeons, the study explored subjective and objective metrics around sleep and performance using ‘on-call’ as a particular influencer for increased fatigue.
Surgeons frequently work 24 straight hours (or more) resulting in unavoidable sleep disturbance. This is partly due to historical associations of the Halstedian Era of Surgery to ‘reside’ in the hospital in order to properly learn, but also current staffing levels mandating surgeons to complete regular on-call work.
Participants were hooked up to electroencephalogram (EEG) machines and a validated modified Multiple Sleep Latency Test testing was used to objectively measure sleep on the morning of their on-call shift. The researchers also record other validated tests for subjective sleep and fatigue measurement. ‘Sleep latency’ refers to the time it takes to go from being fully awake to sleeping and is often an indicator of sleepiness. The surgeons in the study had early onset sleep latency before on-call, which was exacerbated further in post-call settings.
Performance was measured with standardised and validated tools. Technical performance of surgeons was assessed using the validated Simendo © surgical simulator, while cognitive performance was measured using the Psychomotor Vigilance Task (PVT) to assess objective alertness and reaction time, a known aspect of cognitive performance.
The study is the first to attempt to control for a series of confounding variables such as experience, quality and quantity of sleep, the influence of caffeine and circadian rhythm influences.
The study found that:
- Surgeons had poor baseline sleep quality and were objectively sleep-deprived, even pre-call, when they should be in a ‘rested state’.
- In all study participants, early onset sleep latency was seen in pre-call settings and worsened in post-call settings.
- Early onset sleep latency was worse in trainees compared to consultants, though both groups experienced early onset sleep latency post-call.
- As sleep-deprivation increased, diminished performance was seen in cognitive tasks and surgical tasks with greater cognitive components.
- Higher levels of self-reported fatigue and daytime sleepiness were recorded post-call.
Technical skill performance was relatively preserved in acutely sleep deprived states but may be influenced by learning curve effects and experience in surgical tasks.
Existing models of surgical on-call were not conducive to optimising sleep for surgeons, the research found. But making changes for better sleep has challenges, such as loss of continuity of patient care, loss of trainee exposure, and reduced service delivery.
Dale Whelehan, PhD researcher in Behaviour Science at the School of Medicine and lead researcher commented: “The findings of this study tell us that current provision of on-call models preclude the opportunity for surgeons to get enough rest. Similarly, surgeons are sleep deprived before going on-call which further perpetuates the issue. The implications for performance suggest aspects of surgeons performance is diminished, particularly tasks which might be more cognitively demanding.
“We need meaningful engagement from all stakeholders in the process, working towards the common goal of optimising performance in surgeons. This involves looking at the multifactorial causes and effects of fatigue. Part of that discussion involves consideration around how current models of on-call influence sleep levels in healthcare staff, and how it creates barriers to fatigue management in staff.”
Professor Paul Ridgway, Department of Surgery at Trinity, who supervised the study, said: “Our study is further evidence that the way we deliver emergency work alongside normal work in Ireland has to change. We need to learn from our colleagues in aviation who have mandatory rest periods before flights.”
Source: Trinity College Dublin
