60% of Respondents Admit Fatigue Caused Errors

In the summer of 1988, a questionnaire was distributed to the recipients of this APSF Newsletter of the Anesthesia Patient Safety Foundation. In it, we encouraged anesthesiologists and nurse anesthetists to 0 us their personal opinion about their hours of work and rest.

Some of the questions (and average responses in hours) were:

1 . After how many continuous hours of administering anesthesia do you need a break? (About 4.7)

2 . Assuming you were able to take brief rest periods or breaks, for how many hours per day can you safely administer anesthesia? (13.5)

3 . During the past six months what is the longest continuous period that you have personally administered anesthesia without a break? (7.2)

4. During the past six months what is the longest with or without breaks that you have personally administered anesthesia? (15.3)

Even though we received almost 3,000 replies this constitutes only about 6.5% of all anesthesiologists, residents, and nurse anesthetists in the United States. The data, therefore, need to be interpreted with this in mind.

Nevertheless, there are those among us who work longer than they themselves consider safe and some 60% of the respondents reported that they had committed an error in anesthetic administration that they attributed to fatigue. This raises & question whether or not the work and rest cycles in anesthesia practice should be regulated, as is the case with commercial airline pilots, truck drivers, maritime personnel, and railroad crews.

Intuitive Rules

Interestingly enough, we could not find scientific studies demonstrating that fatigue has been responsible for accidents and disasters that had happened in these professions nor data that would justify the work-hour limits chosen by the regulators. The rules governing pilots, truck drivers, etc. were devised because it seemed to be intuitively and eminently reasonable that overwork, a lack of rest, and resulting fatigue night lead to the commission of errors and, thus, cause accidents and disasters. Well known are the rules promulgated by the state of New York that govern the work-rest patterns of house staff and emergency room physicians. However, no scientific data exist with which to support the New York or other specific regulations affecting the work/rest cycles of medical personnel.

An Ancient Tradition

In medicine, the tradition of working long hours dates back to medieval times when both male and female members of religious orders provided care to the sick and debilitated. In modern medicine, the concern for the continuity of care and the anesthesia provider-to-patient relationship make it inadvisable to establish rigid rules on work hours; yet, practitioners should examine their practice patterns and determine whether they work longer than they themselves consider safe (as in our sample almost 75% had indicated).

We must also recognize that excessive working hours may interfere with family fife, education, and with the satisfaction that we and our colleagues derive from our practice.

Role of Rhythms?

In arriving at reasonable recommendations for work and rest cycles, many factors need to be considered. Tolerance for extended work may differ greatly among individuals. There is some evidence that after 18 hours, and particularly after 24 and 36 hours, the performance of workers begins to decrease. Also, circadian rhythms affect our performance, especially with periodic decreases in activity and alertness, particularly between 4:00 a.m. and 6:00 a.m. for people on regular day-shifts schedules. We may also be affected by our personal health, by the emotional freight we bring along from our families and homes, the atmosphere in & operating room, and by our relative experience.

The report “Work and Rest Cycles in Anesthesia Practice”, sponsored by the Anesthesia Patient Safety Foundation, was published in Anesthesiology 1990; 27:737-742.

Dr. Gravenstein, University of Florida College of Medicine, Gainesville, is a member of the APSF Executive Committee.

Editor’s Note: This brief summary of responses to the questionnaire reveals some astounding information. Even considering the possibility that the respondents were partially self-selected because they work very long hours, note that the longest continuous period for administering anesthesia without a break averaged 72 hours (suggesting there were many periods considerably longer than that). Similar concern can be expressed about the 15.3 hour average for the longest period of administering anesthesia. Are there safety implications of these remarkably extended working hours in the OR? Reader comments are invited.