1. Public Health and Sleep Implications Robyn Woidtke MSN, RN, MoKan November 2015 1

2. Objectives Identify at risk working populations for sleep deprivation accidents Discuss the impact of sleep on workplace productivity Recommend opportunities to improve sleep Create sleep related programs for industry 2

3. What is Public Health? Public health is the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases (CDC Foundation) 3

4. Your Challenge Promotion of Sleep in Our Communities 4 Improved Health RecognitionImportanceAwareness

5. Must be Curious Fatigue: Due to sleep loss or physical activity; may be relieved by sedentary activity Sleepiness: Due to lack of sleep; sedentary activity exacerbates the sleepiness Tired Drowsy Exhausted Weary 5

6. Two processes that help us sleep Homeostatic Drive to Sleep Circadian Drive to Sleep Two Process Model of Sleep-Wake Regulation Fatigue is related to duration of sleep and the circadian rhythm

7. 7 Accessed 8/8/2015 CDC

8. How much sleep do we really need? ~8 hours! U shaped curve of sleep duration U People reporting consistently sleeping five hours or less per night should be regarded as a higher-risk group for cardiovascular morbidity and mortality; higher odds of having diabetes and insulin resistance People sleeping nine hours or more per night may represent a useful diagnostic tool for detecting subclinical or undiagnosed comorbidity; higher odds of having diabetes and insulin resistance Cappucchio et al, 2011, Eur Heart Journal

9. Sleep and the Work Place Sleep viewed as “private activity” Expectation that the worker come to work with optimum mental and physical capacity o Less than X (5) or Y (12 ) number of hours of sleep interfere with optimum functioning (X/Y=minimum duration of hour of sleep the past 24 or 48 hrs) o This model requires a certain minimum duration (X and Y hours, respectively) of sleep during the 24-hour and 48-hour period prior to work, in order to prevent errors and accidents during wakefulness from awakening to end of work. Extreme tiredness is associated with sleep duration prior to shift, shift length, night shift and workload Takahashi, M (2012) 9

10. Sleep Deprivation Facts Subjective sleep may be stated as higher compared to objective measures OSA associated with CVD, cognitive impairment, increased risk of motor vehicle accidents Insomnia associated with depression, hypertension, daytime functional impairments (increased absenteeism, decreased productivity Shift Work Disorder contributes to CVD, digestive troubles, cancer, depression Rogers, A (2008) In Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert Wood Johnson Foundation). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March 2008. 10

11. Consequences of Sleep Deprivation Sleep Deprivation Daytime Dysfunction Injury to self or others Morbidity (contribute to chronic conditions) MortalityCosts Quality of Life

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13. The Importance of Adequate Sleep in the Workplace “According to 2004 data from the Bureau of Labor Statistics, almost 15 million Americans work full time on evening shift, night shift, rotating shifts, or other employer arranged irregular schedules” CDC (2013) Types of Shift Work o Outside of “normal” work shift hours i.e. 7AM to 6 PM o Overtime work (beyond 40 hrs) o Extended Shifts (i.e. longer than 8 hours) (Lerman et al., 2012, ACOEM Guidance Statement) 13

14. The Flip Side: Performance Benefits of Adequate Sleep Improved Productivity Improved Learning Enhanced Memory Improved Judgment Enhanced Mood Improved Attention and Reaction Times Decreased Likelihood of Motor Vehicle Accidents Decreased Safety Risks 14

15. In General Less Sleep = More Injury 15

16. Insomnia and the Performance of US Workers: Results from the America Insomnia Survey (Kessler, et al.) Design/Setting: Cross-sectional telephone survey. Participants: National sample of 7,428 employed health plan subscribers (ages 18+). The estimated prevalence of insomnia was 23.2%. “The individual-level human capital value of this net estimate was $2,280”. “If we provisionally assume these estimates generalize to the total US workforce, they are equivalent to annualized population-level estimates of 252.7 days and $63.2 billion” 16

17. Notable Tragedies 17

18. Sleep Critical Occupations Pilots Truck Drivers Nurses Physicians Air Traffic Controllers Sleep Technologists EMS Other? 18

19. Shift Work Sleep Disorder Characterized by o Excessive sleepiness during work; insomnia during sleep periods Nights and jobs which begin earlier than 6 AM 20% of work force on other than day shift Prevalence is 1-5% <3% entrain to daytime sleep More difficult to cope with after the age of 50 Consequences o Fatigue related impairments in physical and cognitive performance o Work performance deficits=human error o Increased MVA commute home 19

20. Sleep and Night Shift Work Occupational Sleep Disorders o Sleep becomes desynchronized from the natural circadian rhythm o Even in optimum circumstances (no light, no noise, good sleeping surface), sleep still disrupted o Night shift associated with Increased gastrointestinal complaints Depressive symptoms and mood disorders Higher risk for cardiovascular disease such as hypertension o Rotating shifts Speed and direction (better to go forward; i.e.. Days to eve; eve to night) Permanent night workers do have better sleep 20

21. Drowsy Driving MVA National Highway Traffic Safety Administration The problem occurs during late night/ early morning or midafternoon. The crash is likely to be serious. A single vehicle leaves the roadway. The crash occurs on a high-speed road. The driver does not attempt to avoid a crash. The driver is alone in the vehicle. 21

22. MVA-Driver Fatigue 100,000 police reported crashes 1550 fatalities 71,000 injuries 12.5 Billion Costs 22 JOEM 54 (12), 2012

23. 2013 ATS CPG Am J Respir Crit Care Med Vol 187, Iss. 11, pp 1259–1266, Jun 1, 2013 23

24. At Risk Young people (ages 16 to 29), especially males. Shift workers whose sleep is disrupted by working at night or working long or irregular hours. People with untreated sleep apnea syndrome (SAS) and narcolepsy. 24

25. Commercial Drivers Bus drivers, rail workers and truck drivers Hours of service o Typically achieve less than 5 hours of sleep per day (NSF, 2013) Medical Conditions impacting safety o Diabetes o Hypertension o Sleep Apnea Drivers with < 5 hours =Higher MVA (1) Takahashi, M. (2012) 25

26. A Few Studies Obstructive Sleep Apnea and Risk of MVC (Tregear, Reston, Schoelles & Phillips, 2009JCSM) o 18 articles met inclusion criteria o Findings OSA puts drivers at risk for MVC Mean crash ratio 1.21 and 4.89 26

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28. Emergency Medical Services (Patterson, et al., 2012) 1900 surveys completed PSQI; Chalder Fatigue Questionnaire; EMS Safety Inventory Results o 540 Surveys received; 30 EMS Agencies o PSQI >50% scored as having poor sleep (Full time, working 24 hours shifts and for more than one agency) o CFQ 55% reported excessive fatigue (full time, 6-15 shifts monthly, 24 hour schedule, poorer health overall) o Odds of Injury 2.3 times for that of poor sleepers; odds of reporting medical error or adverse event 50% higher in those reporting poor sleep 28

29. Sleep Technologists and Sleep? 29 August, 2015 September, 2013

30. Nursing High prevalence of shift work disorder Sleep deprivation linked to increase risk to patient safety High stress levels  reduced sleep  Higher levels of absenteeism  inadequate nurse-patient ratios (Hasson& Gustovvson, 2010) 30

31. Figure 2. Percentage of respondents rating their sleep quality as pretty poor or poor. Hasson D, Gustavsson P (2010) Declining Sleep Quality among Nurses: A Population-Based Four-Year Longitudinal Study on the Transition from Nursing Education to Working Life. PLoS ONE 5(12): e14265. doi:10.1371/journal.pone.0014265 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0014265 31

32. IOM, 2004 “To reduce error-producing fatigue, state regulatory bodies should prohibit nursing staff from providing patient care in any combination of scheduled shifts, mandatory overtime, or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours in any given 7-day period” 32

33. Patient Safety Rogers, A. 2008 in Patient Safety and Quality: An Evidenced Based Handbook for Nursing 33

34. Physicians/Residents ACGME Work Hours (2011) Duty hours must be limited to 80 hours per week, averaged over a four ‐ week period, inclusive of all in ‐ house call activities and all moonlighting A Review Committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs based on a sound educational rationale. PGY-1 residents must not remain on-site after their 16-hour shifts. Periods of duty for first-year residents must not exceed 16 hours in duration. 34

35. Patient Safety Practicing physicians o AHRQ “Duty hour regulations for residents have also spurred interest in the issue of fatigue among practicing clinicians. A recent study found that many attending physicians, particularly surgeons, routinely work hours that would be prohibited in residency programs. To date, no study has found a definitive link between attending physician fatigue and adverse clinical or safety outcomes, although one study did find an increased risk of surgical complications when surgeons had the opportunity to sleep less than 6 hours the night before the procedure. 35

36. Pilots Short Haul (Roach et al, 2011, Accident Analysis and Prevention) o With flights originating between 4-5 AM; fewer hours of sleep prior o Start day with feeling sleepy o 15 minutes of sleep is lost for each hour starting before 0900 36

37. Pilots Long –Haul (1) o Night flights and jet lag as the highest contributor to fatigue Short Haul o Successive work days, multi-segment flights and early morning flight times Self-report of fatigue in 60% of LHF pilots and 49% of SHF pilots included reduction in alertness and attention, and a lack of concentration. Sleep time during long-haul flights is not as good as in-bed sleep (2) < 6 hours sleep prior to flight =poor operational performance and errors (3) (1)Bourgeois-Bougrine S, Cabon P, Gounelle C, Mollard R, Coblentz A. Perceived fatigue for short- and long-haul flights: a survey of 739 airline pilots. Aviat Space Environ Med 2003; 74:1072-7. (2) Roach GD, Darwent D, Dawson D. How well do pilots sleep during long-haul flights? Ergonomics. 2010 Sep;53(9):1072-5. doi: 10.1080/00140139.2010.506246. (3) Takahashi,M (2012) Prioritizing sleep for healthy work schedules. Journal of Physiological Anthroplogy 31 (6). 37

38. Recent Events NTSB investigators… whether pilot fatigue played a role in the accident, which occurred after a 10-hour nighttime flight. As is typical for long flights, four pilots were aboard, allowing the crew to take turns flying and resting. But pilots who regularly fly long routes say it's difficult to get restful sleep on planes. The accident occurred in the late morning in San Francisco, but in Seoul it was 3:37 a.m. "Fatigue is there. It is a factor," said Kevin Hiatt, a former Delta Air Lines chief international pilot. "At the end of a 10-hour flight, regardless of whether you have had a two-hour nap or not, it has been a long flight 38

39. Air Traffic Controllers-FIT The meta-analysis produced a list of factors that were assessed in the development of FIT. These factors are “sleep debt”, “sleep loss”, “sleep quality”, “recovery time between shifts”, “shift start time”, “time on duty “circadian rhythms”, “shift length”, “workload”, “breaks”, plus “naps”, “stress”, and “boredom”. FIT-Fatigue Index Tool Cebola & Kilner, EuroControl n.d. 39

40. Law Enforcement Large study published in JAMA (n=4957) o 79.3 % overweight or obese o 28.% had an ESS over 11 o 45.0% reported nodding off or falling asleep while driving (baseline) o 40.4% screened for at least one sleep disorder 33.6 %OSA 6.5% moderate to severe insomnia 5.4% Shift Work Disorder 1.6 %RLS Sleep Disorder Risk and Performance o 20% + Screen fell asleep while driving o 17.9% important administrative errors o 34.1% uncontrolled anger toward a citizen or suspect o Positive screen for any sleep disorder translated into more health and safety concerns 10.7% with a sleep disorder also reported depression 40

41. Conclusions Large numbers of police officers demonstrate one or more sleep disorders High association between sleep disorders and other medical/health related conditions Adversely impacts interaction with public 41

42. Modifiable Risk Factors 42

43. Fatigue Risk Management System 43

44. Countermeasures Planned naps (15-20 Min) o Improved productivity o Positive impacts on health Lighting o Blue light o Cockpit Lighting Driving o Planning rest stops o Caffeine Shift Work (Circadian Technologies) o Sequence of Shifts o Scheduled work time o Distribution of time off 44

45. Practice Implications for Technologists Question patients regarding their normal working environment Provide suggestions to improve sleep in general o If shift worker, provide information specifically related to shift work disorder if appropriate Consider the under-reporting of sleepiness and the impact to public and personal safety 45

46. Creating Value Participate in health fairs Create community partnerships Align with local corporations HR department o Write an article regarding sleep and sleep deprivation o Include productivity statistics o Provide insight to improvement o Offer lunch and learns o Demonstration projects Outcome measures Employee Assistance Programs o Conduct lunch and learns o Educate EAP Executives on the importance of Sleep 46

47. Summary Be aware of “sleep critical” jobs; listen to your patients! o Ask about job related fatigue, remember they may not attribute work place problems to sleep issues Research fatigue countermeasures for the various roles o Formulate individual plans to improve sleep/fatigue related issues o You may have to schedule a follow-on phone call or appt Contact and participate in your community o HR Departments o Industry o Lunch and Learns o EAP o Focus on productivity and loss of work time 47

48. Call to Action Public health professionals (SLEEP PROFESSIONALS) try to prevent problems from happening or recurring through implementing educational programs, recommending policies, administering services and conducting research 48

49. Questions? Contact Information Robyn.Woidtke@gmail.com 510-728-0828 If you email me for the presentation, please include in the subject line “MoKan” 49