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Rev Bras Anestesiol.

2013;63(2):1-3

REVISTA BRASILEIRA DE ANESTESIOLOGIA


EDITORIAL

Of cial Publication of the Brazilian Society of Anesthesiology www.sba.com.br

Occupational Fatigue: Impact on Anesthesiologists Health and the Safety of Surgical Patients
As anesthesiologists we are frequently working in a stressful environment. Do you disagree with this?
Anesthesiology is a medical specialty that has been singled out as having made major advances in patient care safety over the past few decades. Both morbidity and mortality rates have undergone signicant improvements due to innovations in pharmacology, monitoring and clinical approaches. However, patient harm secondary to errors made by anesthesia practitioners continues to exist in spite of the many other advances. One key cause for practitioner error that is well documented in the medical literature is the practitioners level of fatigue 1,2. Increasing work pressure demands coupled with personal and social commitments can be very heavy at times, frequently resulting in Fatigue Syndrome in clinical anesthesiologists. Interestingly, fatigue (also called exhaustion, tiredness, lethargy, languidness, languor, lassitude, and listlessness) can be differentiated into physical and mental categories. Physical fatigue can be dened as the inability to continue functioning at the level of ones normal abilities, and usually becomes particularly noticeable during heavy exercise, though varying from a general state of lethargy to a specic work-induced burning sensation within ones muscles 3. Though anesthesiologists may experience physical fatigue in the course of a busy workday, it is mental fatigue that serves as the primary causative agent for committing medical error among anesthesia practitioners. Mental fatigue manifests as somnolence (sleepiness) with the inability to concentrate or make rapid assessments and decisions. It is this mental state that is impacting anesthesiologists performance and putting the safety of surgical patients at risk! For decades the job of an anesthesiologist has been described as hours of boredom, interspersed with moments of terror. The key issue is to determine approaches that can be taken to prevent hours of boredom from interfering with good medical judgment when moments of terror occur. One study showed that the risk of an accident (medical err) increases exponentially with each hour after nine consecutive hours of work. At 24 hours of sustained wakefulness, the impairment in physicians psychomotor function may be equivalent to a blood alcohol concentration of 0.1%, which is at or above the legal limit for driving in most states in the USA 4. Christopher P . Landrigan highlights the importance of this subject, when he mentions in the American Joint Commission Sentinel Event Alert that We, anesthesiologists, have a culture of working long hours and the impact of fatigue has not been a part of our consciousness. On the other hand, The Institute of Medicines report To Err Is Human: Building a Safer Health System, reveals that medical errors contribute to many hospital deaths and serious adverse events 5,6. Studying fatigue, whether in the laboratory or clinical setting, is highly complex and difcult due to the multifactorial nature of fatigue, the variance over time with different individuals and the overlap of other associated conditions such as Burnout Syndrome, Chemical Dependence, Suicidality and Stress. Nevertheless, the need to study fatigue and the best ways to control it in our medical practices is paramount. Physicians are trained to practice with a patient-centered focus. This often means we ignore our own health and well being. However, when the health of the medical practitioner directly impacts on patient well being, we must turn our attention toward ourselves. In regard to fatigue this means learning to recognize it and learning ways to mitigate its effects, lest this latent threat evolve into patient harm 7. In regard to fatigue and long work hours, there are a few countries that have taken this issue head on. The Association of Anaesthetists of Great Britain and Ireland produced a 25-page document specically dealing with the problem of fatigue in their members and made recommendations to alleviate the personal and patient safety issues of this problem 8. Similarly, the Australian and New Zealand College of Anaesthetists also produced a statement on fatigue where specic principles and responsibilities are dened for individual anesthesiologists, anesthesia departments and hospitals in order to reduce fatigue and attendant medical errors resulting from fatigue 9. In fact, specic recommendations in the United States concerning stringent limitations in work hours of medical residents in training came directly from the recognition that fatigue in the trainee was not only harmful to the trainee,

R. Moore et al.

but also had the potential for producing major adverse effects on patient safety 10,11. Though resident in training work hours have been curtailed, the same cannot be said for the attending anesthesiologist 12. The concern for the fatigued physician making errors is becoming recognized at national levels and in December 2011 the Joint Commission issued an alert outlining the concerns about fatigue in health care workers as well as approaches that should be taken to reduce this problem 13. The American Joint Commission - Sentinel Event Alert urges greater attention to preventing fatigue and its consequences (Burnout Syndrome, Chemical Dependence, Suicidality, etc.) among health care workers and they suggest specic actions for health care organizations in order to mitigate these risks 13. The purpose of Sentinel Event Alert is to address the effects and risks of an extended work day as well as the cumulative effect of many days of extended work hours. The Joint Commission Alert makes a number of recommendations for health care organizations, such as medical schools, medical training centers, public and private hospitals, national and regional societies, insurance institutions and others. The specic recommendations include: 1. Assess fatigue-related risks such as off-shift hours, consecutive shift work and stafng levels; 2. Examine processes when patients are handed off or transitioned from one caregiver to another, a time of risk that is compounded by fatigue; 3. Seek staff input on how to design work schedules that minimize the potential for fatigue and provide opportunities for staff to express concerns about fatigue; 4. Create and implement a fatigue management plan that include scientic strategies for ghting fatigue such as engaging in conversation, physical activity, strategic caffeine consumption and short naps; 5. Educate staff about good sleep habits and the effects of fatigue on safety of surgical patients; 6. Determine fatigue-related risks such as off-shift hours, consecutive shift work and stafng levels; 7. Examine processes when patients are handed off or transitioned from one caregiver to another, a time of risk that is compounded when fatigue exists; 8. Seek staff input on how to design work schedules that minimize the potential for fatigue and provide opportunities for staff to express concerns about fatigue; 9. Create and implement a fatigue management plan that includes scientic strategies for ghting it such as engaging in conversation, physical activity, strategic caffeine, consumption and short naps; 10. Educate staff about good sleep and the effects of fatigue on patient safety. The Professional Wellbeing Committee of WFSA is planning future projects to evaluate what safeguards are presently in place across nations to ameliorate the problem of fatigue in anesthesia providers with the objective of developing rm recommendations in how National Anesthesia

Societies can implement policies for controlling fatigue. By having the Professional Wellbeing Committee of World Federation of Societies of Anesthesiologists and The Joint Commission working together towards common goal, hopefully the end result will be the worldwide improvement of patient safety and anesthesiologists well being. Can the planned approach prevent us from getting lured into working longer hours as a way to increase revenue and cover the ever-increasing clinical load? Perhaps not, but it should call attention to an existing problem and provide the clinician with international recommendations to support change within their own environment. Being aware of a problem is the rst step in correcting a problem! Members of Professional Wellbeing Committee from World Federation of Societies of Anesthesiologists Roger Moore, USA Pratyush Gupta, India Gasto F. Duval Neto, President

References
1. 2. Howard SK, Rosekind MR, Katz JD, Berry AJ - Fatigue in anesthesia. Anesthesiology. 2002;97(5):1281-1294. Howard SK, Gaba DM, Smith BE et al. - Simulation study of rested verses sleep-deprived anesthesiologists. Anesthesiology. 2003;98(6):1345-1355. Wikipedia. Fatigue (medical). Disponvel em: http://en.wikipedia. org/wiki/Fatigue_(medical). Acessado em 22/11/2012. Howard SK, Rosekind MR, Katz JD et al. - Fatigue in anesthesia. Implications and strategies for patient and provider safety. Anesthesiology. 2002;97:1281-1294 Czeisler CA - The Gordon Wilson lecture: work hours, sleep, and patient safety in residency training. Trans Am Clin Climatol Assoc. 2006;117. Czeisler, CA - Medical and genetic differences in the adverse impact of sleep loss on performance: ethical considerations for the medical profession. 2006;117:159-188. 7. 8.

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Trans Am Clin Climatol Assoc.

Park CS - Fatigue: not just a problem for residents. Newsletter. 2012;76(10):22-24. Ward ME, Bullen KE, Charlton JE - Fatigue and anesthetists. Oxford, The Association of Anaesthetists of Great Britain and Ireland, 2004. Statement of fatigue and the anaesthetist, published by Australian and New Zealand College of Anaesthetists, July 2004.

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10. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 20058;294(9):1025-1032. 11. West C - Association of resident fatigue and distress with perceived medical errors. JAMA.2009;302(12):1294-1300.

12. Kahn LT, Corrigan JM, Donaldson MS - To err is human: building a safer health system. Washington, DC, National Academy Press, 1999;1-223. 13. Joint Commission - Sentinel Event Alert Health care worker fatigue and patient safety, 2011;48.

Occupational Fatigue: Impact on Anesthesiologists Health and the Safety of Surgical Patients

COMPLEMENTARY RECOMMENDED BIBLIOGRAPHY


1. Institute of Medicine - Sleep disorders and sleep deprivation: an unmet public health problem. March 21, 2006. Available at: hp://www.iom.edu/Reports/2006/Sleep-Disorders-and-SleepDeprivaon-An-Unmet-Public-Health-Problem.aspx. Institute of Medicine - Resident duty hours: enhancing sleep, supervision, and safety. December 15, 2008. Available at: hp:// www.iom.edu/Reports/2008/Resident-Duty-Hours-Enhancing-SleepSupervision-and-Safety.aspx. Institute of Medicine - Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academy Press, November 3, 2003. Available at: hp://iom. edu/Reports/2003/Keeping-Paents-Safe-Transforming-the-WorkEnvironment-of- Nurses.aspx.

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Agency for Healthcare Research and Quality - Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043, April 2008. Available at: http://www. ahrq.gov/qual/nurseshdbk/. Lockley SW, Barger LK, Ayas NT et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(11)7-18. Blum AB, Shea S, Czeisler CA et al. - Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety. Nat Sci Sleep. 2011;3:139.

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Rev Bras Anestesiol. 2013;63(2):1-3

REVISTA BRASILEIRA DE ANESTESIOLOGIA


EDITORIAL

Of cial Publication of the Brazilian Society of Anesthesiology www.sba.com.br

Fadiga Ocupacional: Impacto na Sade do Anestesiologista e a Segurana dos Pacientes Cirrgicos


Ns, como anestesiologistas estamos frequentemente trabalhando em um ambiente estressante. Voc discorda disso?
A anestesiologia uma especialidade mdica apontada como realizadora de grandes avanos na segurana do atendimento ao paciente durante as ltimas dcadas. As taxas tanto de morbidade quanto de mortalidade sofreram melhorias signicativas por causa das inovaes nas abordagens de monitoramento, farmacologia e clnica. Contudo, os danos ao paciente, secundrios a erros causados pelos praticantes de anestesia, continuam existindo, apesar dos muitos avanos. Uma das principais causas de erro mdico, bem documentadas na literatura mdica, o nvel de fadiga desses prossionais 1,2. Demandas crescentes por causa da presso no trabalho, juntamente com os compromissos pessoais e sociais, podem ser uma carga muito pesada, muitas vezes resultando em sndrome de fadiga em anestesiologistas clnicos. Curiosamente, a fadiga (tambm chamada de exausto, cansao, letargia, estafa, apatia, prostrao, esgotamento e lassido) pode ser diferenciada nas categorias fsica e mental. A fadiga fsica pode ser denida como a incapacidade de manter o funcionamento de suas habilidades normais e, geralmente, torna-se claramente visvel durante o exerccio intenso, podendo variar de um estado geral de letargia para uma sensao especca de queimao nos msculos induzida pelo trabalho 3. Embora os anestesiologistas possam experimentar fadiga fsica durante um dia de trabalho intenso, a fadiga mental vista como o principal agente causador de erro mdico entre os praticantes de anestesia. A fadiga mental se manifesta como sonolncia, com incapacidade de concentrao ou de fazer avaliaes e tomar decises rpidas. esse estado mental que est causando impacto no desempenho dos anestesiologistas e colocando a segurana dos pacientes cirrgicos em risco! Por dcadas, o trabalho do anestesiologista tem sido descrito como horas de tdio intercaladas por momentos de terror. A questo-chave est em quais medidas podem ser tomadas para evitar que as horas de tdio interram no bom julgamento mdico quando os momentos de terror ocorrerem. Foi demonstrado em um estudo que o risco de um acidente (erro mdico) aumenta exponencialmente a cada hora aps nove horas consecutivas de trabalho. Em 24 horas de viglia sustentada, o comprometimento da funo psicomotora nos mdicos pode ser equivalente a uma concentrao de 0,1% de lcool no sangue, o que igual ou superior ao limite legal para dirigir na maioria dos estados dos EUA 4. Christopher P. Landrigan destaca a importncia desse assunto quando menciona na American Joint Commission Sentinel Event Alert (Comisso Mista Americana de Sentinela para Evento de Alerta): Ns, anestesiologistas, temos uma cultura de longas horas de trabalho e o impacto da fadiga no tem feito parte da nossa conscincia. Por outro lado, o relatrio do Instituto de Medicina To err is human: building a safer health system (Errar humano: construindo um sistema de sade seguro) revela que os erros mdicos contribuem para muitas mortes hospitalares e graves eventos adversos 5,6. O estudo da fadiga, em ambiente laboratorial ou clnico, altamente complexo e difcil por causa da natureza multifatorial da fadiga, da variao ao longo do tempo em pessoas diferentes e da sobreposio de outras condies associadas, tais como sndrome de Burnout, dependncia qumica, suicdio e estresse. Contudo, a necessidade de estudar a fadiga e as melhores formas de control-la em nossas prticas mdicas fundamental. Os mdicos so treinados para exercer sua prtica voltados para o paciente. Isso signica que muitas vezes ignoram a prpria sade e o bem-estar. Porm, quando a sade do mdico tem impacto direto no bem-estar do paciente, devemos voltar nossa ateno para ns mesmos. Em relao fadiga, isso signica que devemos aprender a reconhec-la e encontrar formas de atenuar seus efeitos, para que essa ameaa latente no evolua para danos ao paciente 7. Quanto fadiga e s longas horas de trabalho, j existem alguns pases que esto tomando medidas para corrigir esse problema. A Associao de Anestesiologistas da Irlanda e Gr-Bretanha produziu um documento com 25 pginas especicamente para lidar com o problema da fadiga em seus membros e fez recomendaes sobre as questes de segurana da equipe e dos pacientes 8. Da mesma forma, o Colegiado Australiano e Neozelandeso de Anestesiologistas tambm produziu uma declarao sobre a fadiga em que os princpios e as responsabilidades especcos so individual-

R. Moore et al.

mente denidos para anestesiologistas, departamentos de anestesia e hospitais, com o objetivo de reduzir a fadiga e tambm os erros mdicos resultantes dela 9. De fato, as recomendaes especficas dos Estados Unidos em relao a limitaes mais rigorosas das horas de trabalho de mdicos residentes em treinamento surgiram diretamente do reconhecimento de que a fadiga do residente no prejudicial apenas para ele, mas tambm pode comprometer seriamente a segurana do paciente 10,11. Embora as horas de trabalho de mdicos em treinamento tenham sido reduzidas, o mesmo no pode ser dito para o anestesiologista de planto 12. A preocupao com os erros que um mdico acometido pela fadiga pode cometer est sendo reconhecida em nvel nacional. Em dezembro de 2011, a Comisso Mista Americana emitiu um alerta delineando as preocupaes sobre a fadiga em prossionais de sade e as medidas que devem ser tomadas para reduzir esse problema 13. A Comisso Mista Americana de Sentinela para Evento de Alerta demanda que se tenha uma maior ateno para evitar a fadiga e suas consequncias (sndrome de Burnout, dependncia qumica, comportamento suicida, etc.) entre os prossionais de sade e sugere aes especcas para as instituies de assistncia sade, com o objetivo de mitigar esses riscos 13. O propsito da Sentinela para Evento de Alerta discutir os efeitos e riscos de um longo dia de trabalho, bem como o efeito cumulativo de muitos dias de longas jornadas de trabalho. A Comisso Mista de Alerta faz uma srie de recomendaes para as instituies de assistncia sade, tais como escolas de medicina, centros de formao mdica, hospitais pblicos e privados, sociedades nacionais e regionais, instituies de seguro e outros. As recomendaes especcas incluem: 1. Avaliar os riscos relacionados fadiga, tais como horas alm do planto, turnos consecutivos de trabalho e nveis na equipe; 2. Examinar os registros quando os pacientes so transferidos ou encaminhados de um cuidador para outro, momento de risco que agravado pela fadiga; 3. Solicitar a contribuio da equipe para planejar uma escala de trabalho que minimize o potencial para a fadiga e proporcionar oportunidades para que a equipe expresse suas preocupaes sobre a fadiga; 4. Criar e implementar um plano de controle da fadiga que inclua estratgias cientcas para combat-la, como conversaes, atividades fsicas, consumo estratgico de cafena e cochilos; 5. Educar sobre bons hbitos de sono e os efeitos da fadiga na segurana dos pacientes cirrgicos; 6. Determinar os riscos relacionados fadiga, tais como turnos consecutivos de trabalho e nveis da equipe; 7. Examinar os processos quando os pacientes so transferidos ou encaminhados de um cuidador para outro, um momento de risco que agravado pela fadiga; 8. Solicitar a contribuio da equipe para projetar uma escala de trabalho que minimize o potencial para a fadiga e proporcionar oportunidades para que a equipe expresse suas preocupaes sobre a fadiga;

9. Criar e implementar um plano de controle da fadiga que inclua estratgias cientcas para combat-la, como entabular conversaes, praticar atividades fsicas, consumo estratgico de cafena e cochilos curtos; 10. Educar os funcionrios sobre bons hbitos de sono e os efeitos da fadiga na segurana dos pacientes cirrgicos; O Professional Wellbeing Committee of World Federation of Societies of Anesthesiologists (Comit para o Bemestar Prossional da Federao Mundial das Sociedades de Anestesiologistas) est planejando projetos para avaliar que medidas de segurana esto atualmente em vigor em todas as naes para melhorar o problema da fadiga em anestesiologistas, com o objetivo de desenvolver recomendaes consistentes de como as Sociedades Nacionais de Anestesiologia podem implementar polticas de controle da fadiga. Com o trabalho em conjunto do Comit para o Bem-estar Prossional e da Comisso Mista, espera-se que o resultado nal seja a melhora mundial da segurana do paciente e do bem-estar do anestesiologista. Ser que a abordagem planejada nos poupar da atrao de assumirmos longas horas de trabalho, como forma de aumentar a receita e cobrir a carga clnica cada vez maior? Talvez no, mas ela deve chamar a ateno para um problema existente e fornecer aos prossionais de sade recomendaes internacionais que apoiem uma mudana dentro de seu prprio ambiente. Estar ciente do problema o primeiro passo para resolv-lo! Membros do Comit para o Bem-Estar Prossional da Federao Mundial das Sociedades de Anestesiologistas Roger Moore, EUA Pratyush Gupta, ndia Gasto F. Duval Neto, Presidente

Referncias
1. 2. Howard SK, Rosekind MR, Katz JD, Berry AJ - Fatigue in anesthesia. Anesthesiology. 2002;97(5):1281-1294. Howard SK, Gaba DM, Smith BE et al. - Simulation study of rested verses sleep-deprived anesthesiologists. Anesthesiology. 2003;98(6):1345-1355. Wikipedia. Fatigue (medical). Disponvel em: http:// en.wikipedia.org/wiki/Fatigue_(medical). Acessado em 22/11/2012. Howard SK, Rosekind MR, Katz JD et al. - Fatigue in anesthesia. Implications and strategies for patient and provider safety. Anesthesiology. 2002;97:1281-1294 Czeisler CA - The Gordon Wilson lecture: work hours, sleep, and patient safety in residency training. Trans Am Clin Climatol Assoc. 2006;117. Czeisler, CA - Medical and genetic differences in the adverse impact of sleep loss on performance: ethical considerations for the medical profession. Trans Am Clin Climatol Assoc. 2006;117:159-188. Park CS - Fatigue: not just a problem for residents. Newsletter. 2012;76(10):22-24.

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Fadiga Ocupacional: Impacto na Sade do Anestesiologista e a Segurana dos Pacientes Cirrgicos


8. Ward ME, Bullen KE, Charlton JE - Fatigue and anesthetists. Oxford, The Association of Anaesthetists of Great Britain and Ireland, 2004. Statement of fatigue and the anaesthetist, published by Australian and New Zealand College of Anaesthetists, July 2004. Arnedt JT, Owens J, Crouch M, Stahl J, Carskadon MA Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 20058;294(9):1025-1032. West C - Association of resident fatigue and distress with perceived medical errors. JAMA.2009;302(12):1294-1300. Kahn LT, Corrigan JM, Donaldson MS - To err is human: building a safer health system. Washington, DC, National Academy Press, 1999;1-223. Joint Commission - Sentinel Event Alert Health care worker fatigue and patient safety, 2011;48. 2.

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BIBLIOGRAFIA COMPLEMENTAR RECOMENDADA


1. Institute of Medicine - Sleep disorders and sleep deprivation: an unmet public health problem. March 21, 2006. Disponvel em: http://www.iom.edu/Reports/2006/Sleep-Disorders-andSleep-Deprivation-An-Unmet-Public-Health-Problem.aspx.

Institute of Medicine - Resident duty hours: enhancing sleep, supervision, and safety. December 15, 2008. Disponvel em: http://www.iom.edu/Reports/2008/Resident-Duty-HoursEnhancing-Sleep-Supervision-and-Safety.aspx. Institute of Medicine - Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academy Press, November 3, 2003. Disponvel em: http://iom.edu/ Reports/2003/Keeping-Patients-Safe-Transforming-the-WorkEnvironment-of- Nurses.aspx. Agency for Healthcare Research and Quality - Patient safety and quality: an evidence-based handbook for nurses. AHRQ Publication N. 08-0043, April 2008. Disponvel em: http:// www.ahrq.gov/qual/nurseshdbk/. Lockley SW, Barger LK, Ayas NT et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(11)7-18. Blum AB, Shea S, Czeisler CA et al. - Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety. Nat Sci Sleep. 2011;3:139.