A Scheduling Toolkit for Medical Professionals
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| Assessing Changes in Resident Sleep |
Duty schedules should be organized in such a way that house staff have adequate time off for sleep at night. Sleep need varies among individuals, but on average most people perform best with 7-9 hours of sleep per night (Van Dongen 2003). It is unrealistic to assume that housestaff will be able to achieve this every night, but special attention should be given to the rotation of housestaff schedules to optimize opportunities to achieve this amount on average. A successful schedule will allow more time off at night whenever possible to ensure housestaff are able to get catch-up sleep. For example, a resident scheduled to work until late in the evening, should be given enough time to sleep in the morning before being required to return to work. It is possible to reduce the number of hours worked without increasing the amount of sleep a resident will get. The figure below shows two scheduling possibilities. In the first scenario the resident is scheduled to work from 7:00 AM until 11:00 PM the first day and is scheduled to work from 7:00 AM until 5:00 PM the following day. Scenario 2 shows a resident scheduled from 7:00 AM until 11:00 PM the first day and then from 12:00 PM until 10:00 PM on the following day. Scenario 2 is much better from a sleep perspective in that it will allow the resident to have a longer bout of consolidated sleep at night. Neither scenario accounts for additional work time on day one or for commuting time. In most institutions it is likely that a resident will not be able to leave at the “scheduled” time. Patient follow up, sign out and charting duties will often lead to a resident leaving much later than scheduled. When commuting time is factored in, it could be 1:00 AM or later before a resident is finally able to sleep. When scheduled to return the following morning at 7:00 AM, showering, eating, commuting and pre-rounding duties may lead to a wake time at 5:00 AM or earlier. This means that although scenario one allows 8 hours between scheduled shifts it is unlikely that nocturnal sleep will be more than 6 hours on average and could be fewer than 4 hours on a regular basis! By scheduling the resident to arrive later on the second day in scenario 2, the resident is much more likely to achieve the recommended 7-9 hours of sleep.
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| Reduction of Sleep Pressure |
Duty schedules must reduce acute sleep deprivation as well as chronic sleep deprivation. Increasing the number of hours of sleep prior to each shift will ease sleep pressure while at work. Sleep pressure during night shifts can be mitigated through a prophylactic nap prior to night duty. This nap is best taken in the mid-afternoon for people with a regular nightly sleep schedule, and must be timed to avoid the circadian “wake maintenance zone.” The wake maintenance zone is a period of time before one’s habitual bedtime when a strong drive for wakefulness occurs. This period of time usually occurs between 6:00 PM and 10:00 PM in people who have a regular nightly sleep schedule. The wake maintenance zone is the hardest time to attempt to initiate sleep. One approach to scheduling to allow for a nap is to ensure night duty does not start until 6:00 PM to allow for a mid-afternoon nap prior to duty. Another approach is to allow protected “nap time” while on shift. The danger in the first approach is that residents may not take a nap. The danger in the second approach is that residents may use the protected time to catch up on charting duties etc. For more information on these concerns please see Important Considerations. |
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| Sleep Assessment Tools |
There are two non-invasive, low cost methods for assessing changes in resident sleep. The easiest method is to ask housestaff to complete daily sleep logs. A comprehensive sleep log should include detailed information about use of sleep aids, reasons for nightly awakenings etc. An institutional assessment does not necessarily need to include as much detail and could simply ask, “How many hours and minutes of sleep have you had in the last 24 hours?” and “When did you sleep?” Initiating such a log prior to a scheduling intervention and continuing it through the intervention will provide evidence for the success of the schedule. Studies have shown the comprehensive sleep diary assessment to be reliable in housestaff (Lockley 2004). A second method for assessing housestaff sleep is to invest in monitors that measure activity (actiwatches). There are several wrist worn devices that measure relative levels of activity to estimate sleep. An advantage to using activity monitors is that an institution will be able to measure sleep objectively. Unfortunately, there are also several drawbacks to this method of measurement. First, the devices are costly and to purchase enough devices to sample a large scale schedule change may not be feasible. Further, the assessment algorithm for many of these devices requires keeping a log as well as using the device; i.e., many actigraphy algorithms do not allow for the interpretation of actiwatch data without the concurrent collection of log data. Finally, although these devices are often no larger than a watch, it is possible that wearing such a device may be cumbersome to housestaff. A comprehensive way to assess changes in sleep would be to use both methods simultaneously.
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