The New England Journal of Medicine published a Perspective on December 30, 2010, that screams common sense and should be embraced as a starting point to implement some new patient-safety standards of practice.
Place yourself in the position of a patient getting ready to undergo an elective (i.e. non-emergency) surgical procedure. You’re wheeled into the operating room for your surgery and are greeted by your surgeon in the process. Your mind is focused on just coming out alive and better than when you went in. What you don’t know, however, is your surgeon has been up all night handling a busy call schedule. If you knew he/she was dead tired as any human being would be under the circumstances, would you really want this surgeon operating on you? If you don’t care, then this post is really of no interest to you. If you do care, then read on.
Well, you’re still reading…so you must have some level of concern for your safety. Good for you because here’s a startling number in terms of adverse incidents when involving sleep deprived surgeons:
Researchers have documented the adverse effects of sleep deprivation and sleep disorders on individual performance. In surgery, there is an 83% increase in the risk of complications (e.g., massive hemorrhage, organ injury, or wound failure) in patients who undergo elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep between procedures during a previous on-call night.
Note that this relates to elective surgery – you elected to have it; it is not an emergency. Sure, if the surgery has to be rescheduled, that’s a major inconvenience and not emotionally satisfying after you have prepared yourself for the “magic hour” when you are to be taken to the operating room. In most surgeries, you have not been allowed to eat since midnight (NPO status) if you are going to be anesthetized during your surgery. But let me ask – would you rather be inconvenienced or suffer from “a massive hemorrhage, organ injury, or wound failure” – to name but a few of the things that could go wrong at the hands of a sleep deprived surgeon?
The NEJM article reports that “most patients would be concerned about their safety if they knew their doctor had been awake for the prior 24 hours.” I really don’t think they needed a survey to reach that conclusion. Do you?
So how is this risky situation supposed to be avoided? Are you supposed to ask your surgeon: “So did you get a good night’s sleep?” Or – “How you feeling today, Doc? Well rested?” While some more assertive patients might take this approach, way too many, I’m afraid, would just “trust” their doctor to know better than to operate under such a condition and advise the patient now is not a good time for him/her to do the surgery. In an ideal world, that’s what should happen – but we don’t inhabit such a world now do we? For whatever motivation – some good; some not so good, I sincerely doubt this is going to happen and certainly should not be the standard. In fact, the following excerpt from the NEJM piece addresses this very issue – at least in part:
Chronic sleep deprivation degrades one’s ability to recognize the impairments induced by sleep loss.5 Sleep-deprived clinicians are therefore not likely to assess accurately the risks posed when they perform procedures in such a state, and they should not be permitted to decide whether or not to proceed with elective surgery without obtaining the patient’s informed consent.
That’s a start, but frankly, I’m not really a big advocate of this approach. Obtaining my informed consent? So what happens – I’m told as I’m awaiting my surgery that my doctor has been up all night and the prior day. He then asks, “Are you willing to have your surgery anyway?” I then ask: “Well how are you feeling? Are you up to doing this?” If I get an affirmative response, why should the burden be on me (read: YOU in this scenario) to make a decision if it’s alright to proceed?
I much prefer the primary suggestion of the authors:
As a first step, we recommend that institutions implement policies to minimize the likelihood of sleep deprivation before a clinician performs elective surgery and to facilitate priority rescheduling of elective procedures when a clinician is sleep-deprived. In addition, patients should be empowered to inquire about the amount of sleep their clinicians have had the night before such procedures.
While I say I “prefer” this approach of “implementing policies to minimize the likelihood of sleep deprivation,” I would modify this “recommendation” to read – “to implement policies to eradicate the likelihood of sleep deprivation or in those instances where certain “sleep guidelines” have not been met, to mandate the rescheduling of this elective surgery. Note that the latter part of this “first step” recommendation puts the burden back on the patient “to inquire about the amount of sleep their clinicians have had the night before such procedures.” Same issues; same problems. The patient should not be put in this position. The hospitals ought to be protecting the patient in such situations, not empowering them – whatever that means!
This is a problem whose solution is not that complex. It is a problem whose solution is way too long overdue. I would urge the medical profession and hospital administrators to stop trying to be “balanced” on this issue. Sure it’s an inconvenience for all concerned. No doubt this can wreak havoc in terms of a hospital’s operating room scheduling. Too bad! Figure out ways to deal with “call schedules” then. Don’t place the onus on the patient. The health industry claims it is constantly in search of ways to improve safety. Well isn’t this a pretty simple issue to tackle if that’s the case?
What are your thoughts on this issue? Would you be concerned if the person holding the surgical instrument for your procedure has sleep deprivation? Would you ask the questions about their sleep patterns or how much sleep they got the night before? Should this be a patient’s burden? What policies make sense? Share your thoughts with our readers. Maybe – just maybe – the right people might read your comments and come up with some solid policies to protect all of us in such circumstances.