Case

It’s 7 a.m. and your day shift relief finds you face-down, asleep, and drooling on the desk. They gently wake you up to get handover. You confess to your colleague that shift work is killing your circadian rhythm and worry that fatigue could impact your clinical judgement.

Clinical Question

Are emergency physicians spending a significant amount of time on shift in an impaired state of fatigue?

Background

All shift workers are likely aware of the negative impact shift work has on sleep quality. However, we may not appreciate how our interrupted sleep schedules can impact our overall health.

Shift work is associated with increased rates of cancer, cardiovascular disease, and accidents.¹ Many of us probably know of a colleague who has been in a motor vehicle collision when driving home from work.

While the personal risk is important, a big concern for physicians is that fatigue could impact the care we provide for our patients. Even moderate levels of fatigue can impact performance similarly to being intoxicated with alcohol.²

There are studies from other industries that show errors can increase by as much as 30–50 percent on night shifts. Most of the available evidence in medicine comes from studies on residents.³ It shows an association between fatigue and clinical errors, impaired cognition, reduced empathy, and increased interpersonal conflict. There is little to no evidence of the clinical impact of fatigue on practicing emergency physicians.

Reference: Observational study by Fowler, et al., seeking objective evidence for sleep and fatigue risk in emergency medicine physicians⁴

Participants: A convenience sample was used of emergency physicians from a single academic emergency department.

Data sources and measurement: Sleep periods recorded with actigraphy, using a commercially available device that measures wrist movement

Authors’ Conclusions:

“Fatigue is an issue for many emergency physicians. The present study addressed the percentage of time emergency physicians are in a fatigued state when on shift over an extended duration of time. More research is needed to examine system-level interventions for reducing fatigue in emergency physicians.”

Results: Seventeen emergency physicians in a department of 131 volunteered to participate in the study. Nine were female and two were full-time nocturnists.

A “Readiscore” fatigue score was measured before and during clinical shifts. This score consists of three factors: sleep quality, sleep duration, and sleep efficiency (total sleep time divided by total time in bed).

Over a two-month period they collected data on 392 shifts (23 shifts per participant).

Key Result: Almost 25 percent of the time on shift the emergency physicians had fatigue scores indicating significant impairment.

Primary Outcome: Readiscore fatigue score (sleep quality, duration, and efficiency)

• Sleep Quality: Average, 7.7 out of 10 (Standard Deviation [SD], 1.84), indicative of poor sleep quality
• Sleep Duration: Mean number of hours slept per night was 6.77 (SD, 1.84)
• Sleep Efficiency: Mean 87 (SD, 9)
  • Participants spent 725 hours (23.52 percent) on shifts with fatigue scores indicative of significant impairment

EBM Commentary

1. Selection Bias: Only 13 percent (17 out of 131) of the emergency physicians volunteered to participate. Perhaps those who participated were suffering from sleep issues or those who decided not to volunteer were too tired to be involved.
2. Hawthorne Effect: Participants knew they were in a study focused on sleep. It is possible that simply by being observed they changed their usual sleep habits. This could have impacted the results of the study.
3. Lack of a Comparison: How do these scores compare to other medical specialties or health care workers (nurses, physician assistants, diagnostic imaging, laboratory technologists, etc.)? Are emergency physicians sleep-deprived more, less, or at the same level as others?
4. The Readiscore and Clinical Significance: We do not know from this data whether a poor Readiscore, which indicates significant impairment, results in a clinically important poor patient outcome.

SGEM Bottom Line

Fatigue is a serious issue for emergency physicians’ health, and we need to find ways to mitigate the negative personal impact and any potential negative impact on patient care. 

Case Resolution

You decide that, after going home and getting some much-needed rest, you are going to email the chief of the department, asking that the issue of sleep and fatigue be discussed at the next department meeting.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Thank you to Dr. Justin Morgenstern, an emergency physician and the creator of the #FOAMed project called www.First10EM.com for his help on this review.

References:

1. Knutsson A. Health disorders of shift workers. Occup Med (Lond). 2003;53(2):103-8.
2. Dawson D, Reid K. Fatigue, alcohol and performance impairment. 1997;388(6639):235.
3. Akerstedt T, Wright KP Jr. sleep loss and fatigue in shift work and shift work disorder. Sleep Med Clin. 2009;4(2):257-271.
4. Fowler LA, Hirsh EL, Klinefelter Z, Sulzbach M, Britt TW. Objective assessement of sleep and fatigue risk in emergency medicine physicians. Acad Emerg Med. 2023;30(3):166-171.