Journal of Sleep Medicine & Disorders

Cite this article: Villafuerte-Trisolini B, Adrianzén-Álvarez F, Serván Lozano SA, Vizcarra Pasapera JA, Duque KR, et al. (2017) Fatigue and Sleep Deprivation in Interns of Medicine and its Burden in Vehicle Driving. J Sleep Med Disord 4(3): 1082.

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*Corresponding authorBrian Villafuerte-Trisolini, Hypnos Instituto del Sueño, Universidad Peruana Cayetano Heredia, Pasaje el Carmen Block B 104, Pueblo Libre, Lima, Peru, Tel: 51-990062751; Email:

Submitted: 03 October 2017

Accepted: 28 November 2017

Published: 30 November 2017

ISSN: 2379-0822

Copyright© 2017 Villafuerte-Trisolini et al.

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Keywords•Sleep deprivation; Fatigue; Actigraphy; Shift work;

Attention

Research Article

Fatigue and Sleep Deprivation in Interns of Medicine and its Burden in Vehicle DrivingBrian Villafuerte-Trisolini*, Fiorella Adrianzén-Álvarez, Sebastián A. Serván Lozano, Joaquín Augusto Vizcarra Pasapera, Kevin R. Duque, Germán Málaga Rodríguez, Etbert Roberto Pizarro Salas, Daniel Fernando Córdova Ccasa, and Darwin Vizcarra-EscobarHypnos Instituto del Sueño, Universidad Peruana Cayetano Heredia, Perú

Abstract

Objective: EDWS ≥ 24 hours remain a characteristic practice of medical education worldwide that affects physician well-being. We aimed to describe fatigue induced by EDWS in medical interns and its burden in vehicle driving.

Methods: Four-day follow-up of 10 interns with ≥ 30 hours EDWS. The EDWS took place on day 2. We employed PSQI, ESS, actigraphs, D-FIS, PVT to measure RT and number of lapses (>500 ms) daily (7am) and every 6 hours during EDWS.

Results: Work hours per week were 83.4 ± 7.2. Eight interns had PSQI score> 5 and 4 had ESS score >10. D-FIS score increased on day 3 (p=0.005) and RT increased during the second half of EDWS (p=0.01). Both decreased on day 4 (p=0.005 and p=0.01), after restful sleep (154 minutes more than the average previous night). Six interns drove, 4 of them nodded off or fell asleep while driving or stopped in traffic. Drivers who fell asleep showed higher RT (506.75 vs 364.9 ms), NoL (7.25 vs 1.25) and D- FIS score (21.5 vs 17) at the end of the EDWS than those who didn’t fall asleep. This study was halted when faculty authorities were informed of the interim analysis and EDWS were reduced to 24 hours.

Conclusions: D-FIS score and RT increased during EDWS and returned to baseline scores after a restful sleep. Drivers who fell asleep while driving showed higher RT at the end of the EDWS than those who did not.

ABBREVIATIONSEDWS: Extended-Duration Work Shifts (EDWS); PSQI:

Pittsburgh Sleep Quality Index; ESS: Epworth Sleepiness Scale; D-FIS: Fatigue Impact Scale for Daily Use; PVT: Psychomotor Vigilance Task; RT: Reaction Time; Nol: Number of Lapses; TST: Total Sleep Time; SE: Sleep Efficiency

INTRODUCTIONShift work is considered as a roster outside a typical “9 to

5” business day [1]. Health workers have to fulfill night shifts, which imply sleep deprivation, causing fatigue, sleepiness, impaired concentration, changes in patterns of waking and sleeping that increase the risk of accidents [2]. Fatigue (physical or cognitive), describes a state that can be reduced by sedentary activity (without sleep), while sleepiness is the tendency to sleep, exacerbated by sedentary activity or rest [2]. Sleep deprivation has been described as a risk factor for medical errors, percutaneous injuries and traffic accidents [3,4]. Moreover,

previous studies show that fatigue and sleepiness increase the risk car accidents [5,6].

Our main aim was to describe fatigue induced by EDWS, and its burden in vehicle driving in a sample of interns of medicine.

MATERIALS AND METHODSStudy design

Observational, prospective study

Study participants

Interns from a Faculty of Medicine in Peru. Inclusion criteria: interns in a clerkship with EDWS (≥ 30 hours); previous EDWS at least one week before follow-up. No exclusion criteria were applied. Information regarding previous diagnosis of sleep disorders (including but not limited to: insomnia, sleep-related breathing disorders, narcolepsy or restless legs syndrome); mental disorders with active symptoms (such as anxiety,

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depression, alcohol use disorders and use of recreational drugs) was collected. Thirteen participants were included; 3 denied to participate.

Ethical approval and informed consent

The protocol was approved by the Institutional Ethics Review Board of Universidad Peruana Cayetano Heredia.

Devices

PVT touch app is a neurocognitive test that requires the subject to press the touch screen of an android device as soon as visual stimulus appears. Test duration was set to 5 minutes, as previously validated [7]. RT (in ms) and NoL ≥ 500 (responsems) were time asured. The Acti watch 2 (Philips-Respironics) is a portable device with the size of a wrist watch, and it consists of a solid accelerometer with the following features: 0.5-2G, bandwidth 0.35-7.5 Hz, sensitivity of 0.025 G and a sampling rate of 32 Hz. It is used to describe sleep patterns by sensing movement in the upper limb [8]. The Actiwatch 2 database was analyzed using the software Encore Pro2.2 (Patient Management System). The database included Total Sleep Time (TST) and Sleep Efficiency (SE) for analysis [8].

1. 5.5. QuestionnaireEpworth Sleepiness Scale validated in a Peruvian population (>10/24 indicates excessive daytime sleepiness) [9]

2. Pittsburgh Sleep Quality Index (PSQI) validated in a Peruvian population (>5/21 indicates poor sleep quality) [10]

3. Sleep diary

4. Daily Fatigue Impact Scale (D-FIS)

5. Questions of “Shifts and the risk of motor vehicle crashes” [11]: did you nod or fall asleep while driving? And, did you nod or fall asleep while stopped in traffic?

PROCEDUREA sample of interns was evaluated for comprehension

and feasibility of the questionnaires Firstly, an interview was developed using PSQI, ESS, and a questionnaire with anthropometric and work details. Then the follow-up took 4 days and the EDWS took place on the second day. A wrist actigraph was worn during this time. PVT touch was used daily at 7 am, and during the EDWS, every 6 hours. D-FIS was assessed every day at 7 am. Finally, questions were used for evaluating risks of car accidents.

RESULTSAverage TST was: 355.4, 30.0, 510.2 and 380.6 minutes for

day 1, 2, 3 and 4; respectively. Self-reported average time on duty was 83.4 per week. Eight of the 10 participants had PSQI > 5 and 4 had ESS > 10. During the EDWS, there was a progressive increase in RT and NoL. D-FIS score increased on day 3 (day 3: 16.6 ± 7.3 versus day 2: 7.8 ± 3.0, p=0.005). At 1 pm, RT on day 3 was significantly higher than on day 2 (p=0.001). Both RT and NoL decreased on day 4 (330.7 ± 58.3, p=0.01 and 5.4 ± 4.6,

p=0.005), after a night of restful sleep (154 minutes more than the night before).

During day 2 and 3 of follow-up, participants remained awake for an average of 35.6 hours and had 1.3 hours of sleep. The highest value of continuous wakefulness was 41 hours while the minimum was 30.2. Only 3 participants took a nap (30 minutes).

Six drivers were included, 4 of them reported driving problems (3 fell asleep or nodded off during transit and 4 of them, stuck in traffic). During the EDWS, drivers without driving problems showed lower RT (335.87 vs 444.27) and no lapses (0 vs 5) at 1 am; and lower RT at 7 am (364.91 vs 506.75) and 1 pm (335.87 vs 444.27), compared to those who did have driving problems (Table 1).

The study was halted, when results were reported to university authorities and EDWS were reduced > 30 to 24 hours.

DISCUSSIONDuring the EDWS, we observed a progressive increase in RT,

NoL and values of D-FIS as interns remained awake for more hours at work (Figure 1). A critical finding was the evident risk of automobile accidents in medical interns who drive after the EDWS. Over half of them, referred having nodded or fallen asleep while driving. Medical interns risking their lives on EDWS is unacceptable, but not unheard of. A nationwide survey of 2737 medical residents in the USA, showed an OR of 2.3 and 5.9 for car accidents and near-miss accidents, respectively [11].

Table 1: Differences between interns with driving problems and without driving problems.

Driving problems (N=4)

No driving problems (N=2)

Gender 1:3 2:0

BMI (kg/m2) 23.05 24.67

Weekly work hours 85.5 81

PSQI 7 5.5

ESS 11.5 10.5

D-FIS on day 3 21.5 17

RT on day 1,2,4 (7am) 362.68 294.31

RT on day 3 (7am) 506.75 364.91Ratio of TR, before and after shift (7am) 0.7 0.8

RT on day 3 (1pm) 444.27 335.87

Lapses on day 3 (1am) 5.5 0

Lapses on day 3 (7am) 7.25 1.25Lapses on day 3 (1pm) 5.25 2.5

Awake time on day 2 and 3 (min) 1957.5 2137.5

Time of rest during shift 30 90

(day 2 and 3) in minutesAbbreviations: BMI: Body Mass Index in kg/m2; D-FIS: Fatigue Impact Scale for daily use; RT: Reaction Time in minutes.

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Interns with driving problems showed increased NoL and higher RT after being awake for 29 hours (in average) in comparison to those who did not experience problems while driving. These findings do not appear to be related to the grade of driving expertise as evidenced by a study that evaluated 20 professional drivers versus 20 non-professional drivers, in which a simulated driving task and PVT during 24 hours was performed. Both professional and non-professional experienced a progressive increase in RT [12].

None of the interns had a nap during or previous to the shift. There are not enough regulations in favor of interns of medicine regarding EDWS (napping during EDWS or pre-call rest). A study showed that naps of 2 - 3 hours in nurses, made improvements in performance after EDWS [13].

In our study, the mean number of work hours per week was 83.4. ACGME regulations (2011), designed to protect patient safety, enhance learning and improve resident well-being, established the limit hours per week to 80, with a maximum of 16 continuous hours per shift and a day off every week [14].

In our study, no significant differences in RT, NoL and values of D-FIS were shown when comparing day 1 and day 4 of follow-up. This finding could indicate sleep recovery to a level of basal fatigue 24 hours after the end of EDWS. Other studies, that used surveys, showed that more than 24 hours were necessary for the recovery of cognitive function and mood [15]. A study that evaluated sleep and recovery in physicians on night call concluded that residents of Pediatrics and Anesthesiology had main sleep restitution in the first 24 hours after night call, while full recovery was achieved after an additional 24 hours [16].

CONCLUSIONTo sum up, interns in our study presented progressive fatigue

during the EDWS that made them sleepier while driving or stuck in traffic. Adequate sleep recovery was achieved 24 hours after the end of the shift. The impact of interim results of the study led to immediate actions in order to improve working conditions of medical interns as this particular university changed a traditional practice of EDWS to a more protective duration of 24 hours.

Furthermore, we suggest that the following measures be

taken; firstly, ensure adequate rest previous to the EDWS (2 or 3 hours previous to the shift) and during the shift (taking turns to take naps from 12 - 6 am). Secondly, the duration of shifts in interns of medicine should be ≤ 24 hours. Finally, we suggest that interns do not drive immediately after the end of the shift, but rather use public transport or take a nap before driving.

The small number of participants in the sample was an important limitation for finding statistically significant differences. However, follow-up had to be discontinued because of reduction of hours of EDWS (30 to 24), as previously mentioned.

ACKNOWLEDGEMENTSThe study was completely self-financed. Hypnos Instituto

de Sueño provided the actiwatchs used for the study. PVT touch app was provided for research purposes only by Ph.D. Michael Grandner.

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Figure 1 In this figure it can be appreciated the median Number of lapses, score of D-FIS during the follow-up.

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Villafuerte-Trisolini B, Adrianzén-Álvarez F, Serván Lozano SA, Vizcarra Pasapera JA, Duque KR, et al. (2017) Fatigue and Sleep Deprivation in Interns of Medicine and its Burden in Vehicle Driving. J Sleep Med Disord 4(3): 1082.

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