Fatigue Among Anesthesia Providers

Introduction

• In a high-stakes environment like the operating room (OR), maintaining focus and minimizing fatigue is critical to ensuring the well-being of healthcare providers and the safety of patients.
• The anesthesia team, in particular, is often involved in high-vigilance tasks that demand sustained attention and rapid response.
• This summary explores current research regarding the prevalence, causes, consequences, and potential solutions for fatigue among anesthesiology providers in the OR.

Prevalence

• Current research suggests that the prevalence of fatigue among anesthesia providers is anywhere from 17% to 84%, depending on the study population and methodology.¹
• In a large survey (N=2170) conducted in the UK by McClelland and colleagues, 67.9% of anesthesiology residents stated that work fatigue interfered with both professional and personal lives, including detriments to physical (73.6%) and mental (71.2%) health.²
• In another survey of 79 respondents in South Africa, anesthetists reported having previously dozed off in the OR during the day (57.9%) and during night calls (79.4%). Additionally, 48.6% admitted to making a mistake related to fatigue.²
• In a survey of 979 anesthetists in New Zealand, 56.6% of respondents admitted to continuing work despite feeling too fatigued to safely do so at least once in the last year.²

Causes of Fatigue

• The primary drivers of fatigue in healthcare workers involve disruptions in sleep homeostasis and the circadian rhythm.

Sleep Homeostasis

• The optimal daily sleep requirement is genetically determined and generally ranges from 7-9 hours.¹
• Accumulated sleep debt has been shown to impair mental alertness and decision-making.^1,2
• Sleep debt is also difficult to recover, as it is only repaid via Stages 3 and 4 sleep, which make up a small fraction of total sleep time.¹

Circadian Rhythm

• The suprachiasmatic nucleus controls the body’s circadian rhythm based on environmental cues. This results in peak human performance between 8-11 AM and 8-11 PM, with performance dips from 3-7 AM and 1-4 PM.¹
• Shift work, particularly night shift, misaligns the natural sleep cycle, making restorative sleep difficult.¹
• Up to 70% of shift workers endorse poor sleep or daytime sleepiness.¹
• In a survey among retired anesthetists, stress from night shifts was identified as the most common reason for retirement among older retirees.¹

Other Factors

• Age: Sleep quality deteriorates as we age despite sleep requirements remaining largely unchanged.¹
• Melatonin: Melatonin is produced by the pineal gland in the absence of light and promotes sleep while also inactivating the primary mechanisms regulating wakefulness.¹
• Alcohol: Alcohol is very commonly used to promote sleep by reducing sleep latency but results in decreased deep sleep (Stage 3/4), resulting in poorer sleep quality overall.¹

Effects on Performance

Cognitive Impairment

• Fatigue and sleep deprivation have been correlated with significant impairments in most aspects of cognition.²
• After around 17-19 hours of wakefulness, performance decline is comparable to that produced by a blood alcohol content (BAC) of 0.05%. At 24 hours, the comparable BAC is 0.1%, above the legal limit for operating a motor vehicle in the US.²
• Verbal learning and working memory dips by 15-25% after overnight shifts and complex decision-making time increases 2-3-fold.
• Intubations take 34% longer among sleep-deprived physicians compared to baseline.¹

Microsleeps

• Defined as spontaneous episodes of sleep lasting up to 30 seconds and typically occur when fighting the urge to sleep.¹
• Hypothesized as a method for the brain to take a “timeout” from sensory overload.¹
• During microsleep, consciousness is lost, often without the subject’s realization.¹
• These can greatly increase the risk of medical error and significantly delay response in critical situations.

Nontechnical Skills

• Multiple studies have shown deterioration in nontechnical skills in sleep-deprived anesthetists compared to baseline.²
• Sleep-deprived groups tended to score worse in areas of teamwork, confidence, and communication compared to well-rested colleagues.²
• Studies have also shown that fatigue hinders leadership abilities, which can make it more difficult for anesthetists to effectively manage critical situations.²

Clinical Implications

Medical Errors

• Consequences of fatigue and decreased vigilance can, unfortunately, transfer to patients in the form of medical errors.
• In a review of 5,600 error reports as part of the Australian Incident Monitoring Study, 2.7% of all errors were related to fatigue. Additionally, fatigued providers were four times more likely to administer incorrect drug dosages.³
• In an analysis of 1,489 obstetric epidural procedures, the risk of accidental dural puncture was over six times greater during night-time shifts compared to daytime.⁴
• More than nearly 6,000 hours of direct observation of interns working in the medical intensive care unit and coronary care unit, those working traditional working schemes (including 24-hour shifts) made 20.8% more serious medication errors than those working without such extended work shifts.²

Occupational Risks

• Needlestick injuries are 3 times more common during the night-shift period than dayshift.¹
• Fatigued healthcare workers are twice as likely to be involved in a motor vehicle accident after a shift.¹

Patient Outcomes

• An incident monitoring study showed that fatigue-related errors prolong recovery times and increase ICU transfers.²
• Based on data from the Anesthesia Closed Claims Project database, failures in communication, many due to work fatigue, contributed to patient injury in 43% of malpractice claims.⁵
• While many studies have explored the effects of fatigue on error rates, larger-scale studies regarding impacts on patient mortality are still needed.

Countermeasures

Strategic Naps

• Short naps have been shown to be effective in improving alertness, memory, and reaction time during long shifts.¹

Improved Sleep Hygiene

• Maintaining a consistent sleep schedule, even on days off work.¹
• Reducing blue-light exposure before sleep, as this can interfere with natural melatonin production.¹
• Utilizing blackout curtains and white noise machines to improve sleep quality during the day for night-shift workers.

Pharmacological Interventions

• Caffeine, while widely used and effective for combating drowsiness, should be used strategically and avoided 4-6 hours before bedtime.¹
• Melatonin can help regulate circadian rhythm, particularly for night-shift workers.¹
• Modafinil and similar medications have been explored as potentially beneficial wakefulness-promoting agents in shift workers, but safety profiles in anesthesia workers have not been thoroughly studied.¹
• Zolpidem and other hypnotics are commonly used for short-term insomnia by decreasing sleep latency and improving sleep efficiency, but their long-term use in healthcare workers to counteract work-related fatigue is not well supported.
  • Hypnotics like zolpidem can cause next-day impairment, including drowsiness and reduced psychomotor performance, which may be problematic for healthcare workers whose tasks demand high focus and alertness. Long-term use is also heavily associated with dependency and withdrawal symptoms.⁶
  • A survey of 997 shift work nurses found that workers using multiple hypnotic medications for sleep had more work-related errors as well as an increased incidence of depression. Nightshift workers also had an increased likelihood of developing lifelong dependence on these medications.⁷

Organizational Strategies

• Hospitals can reduce the risk of fatigue by incorporating strategic scheduling policies.
  • Duty hour regulations: Trainee duty hours are a growing global issue and are continuing to be adjusted. For example, the European Union restricts duty hours for trainees to 48 hours per week to balance clinical demands with personal well-being.⁸
  • Pre-call: Programs should offer trainees formal fatigue education and training and access to a primary care professional on a regular basis to monitor ongoing health concerns.⁸
  • On-call: Given the clear benefits of short naps, programs should ensure these are accounted for in scheduling and that call rooms are kept dark, cool, and distraction-free. Trainees should also have easy access to nutritious food and hydration options, as well as regular exposure to natural light and fresh air.⁸
  • Post-call: Handovers take place at the end of the shift when mental alertness may be compromised. Because of this, structured yet efficient handovers are essential to reduce errors and ensure continuity of care. Additionally, programs should provide ample time for recovery after a night shift to ensure proper restoration of circadian balance.⁸

Summary