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Thinking Outside the Box: The Use of
Sleep Pods for Strategic Naps for
Fatigue Management – Does it Work?
Conference Session: SES022
2012 ACGME Annual Education Conference
Nancy Piro, PhD
Program Manager/Education Specialist
and Ann Dohn, MA, DIO
Department of Graduate Medical Education
Stanford Hospital & Clinics
Department of Graduate Medical Education (GME)
Conflict of Interest
• No conflicts of interest to report
Department of Graduate Medical Education (GME)
Session Objectives
At the end of this session, participants will be
able to have:
– an increased awareness of the research on the
effectiveness of naps in resident training programs
– an increased understanding of the effectiveness of
innovative solutions such as sleep pods to mitigate
resident and fellow fatigue
– A better understanding of how to (and how not to)
operationalize a nap and fatigue management
strategy in academic GME settings
Department of Graduate Medical Education (GME)
Setting the Stage - History
• Libby Zion case
• July 2003 ACGME Duty Hours Requirements
• IOM Report
• Education for faculty and residents on “The
Effects of Fatigue & Fatigue Mitigation”
• July 2011 New ACGME Duty Hour
Requirements
• Strategic Napping
Department of Graduate Medical Education (GME)
Libby Zion Case/Law
• The Libby Zion law is a regulation that limits the
amount of resident physicians work in New York State
hospitals to roughly 80 hours per week.
• The law was named after Libby Zion who died at the
age of 18 under the care of what her father believed to
be overworked resident physicians and intern
physicians.
• In July 2003 the Accreditation Council for Graduate
Medical Education (ACGME) adopted similar
regulations for all accredited medical training
institutions in the United States.
Department of Graduate Medical Education (GME)
Libby Zion Case/Law (2)
• After the grand jury's indictment of the two residents, the New
York State Health Commissioner David Axelrod decided to
address the systemic problems in residency by establishing a
blue-ribbon panel of experts headed by Bertrand M. Bell, a
primary care physician at the Albert Einstein College of
Medicine in the Bronx.
• Bell was well known for his critical stance regarding the lack
of supervision of physicians-in-training.
• The committee evaluated the training and supervision of
doctors in the state, and developed a series of
recommendations that addressed several patient care issues,
including restraint usage, medication systems, and resident
work hours.
Department of Graduate Medical Education (GME)
Libby Zion Case/Law (3)
• In 1989, New York state adopted the Bell Commission's
recommendations that residents could not work more than 80
hours a week or more than 24 consecutive hours and that
attending physicians needed to be physically present in the
hospital at all times.
• Hospitals instituted “night floats” to spare their colleagues,
allowing residents to adhere to the new rules. Periodic follow-
up audits have prompted the New York State Department of
Health to crack down on violating hospitals.
– Similar limits have since been adopted in numerous other states.
• In July 2003 the Accreditation Council for Graduate Medical
Education (ACGME) adopted similar regulations for all
accredited medical training institutions in the United States.
Department of Graduate Medical Education (GME)
New ACGME Requirements Effective
July 1, 2011
Alertness Management
VI.C.1. The program must:
a) educate all faculty members and residents to recognize the signs
of fatigue and sleep deprivation;
b) educate all faculty members and residents in fatigue mitigation
processes; and,
c) adopt fatigue mitigation processes to manage the potential
negative effects of fatigue on patient care and learning, including
naps and back-up call schedules.
VI.C.2. Each program must have a process to ensure continuity of patient care in
the event that a resident may be unable to perform his/her patient care
duties.
VI.C.3. The sponsoring institution must provide adequate sleep facilities and/or
safe transportation options for residents who may be too fatigued to safely
return home.
Department of Graduate Medical Education (GME)
CATEGORY 2003 ACGME LIMITS 2008-IOM RECOMMENDATION 2011 ACGME REQ’s
Supervision Programs ensure Supervision standards are set by the Residents and attendings
supervision by qualified Resident Review Committee (RRC); inform patients of their roles,
faculty in-house supervision is provided for while PD’s & faculty assign
1st year residents. documented progressive
responsibilities accessible by
the healthcare team.
Supervisory requirements are
defined for residents in
program specific policies.
Workload Assignments recognize Residents have adequate time for Workload is based on patient
that residents and faculty patient care and reflection. safety, severity and complexity
are both responsible for Complexity of illness and resident of patient cases, available
patient safety and welfare competency is considered in setting support, resident training and
appropriate caseloads. education.
Maximum Duty 30 hrs (with 24 hrs to 16 hrs; extended duty of 30 hrs (with 16 hrs for first-year
admit patients and 6 hours 5 hrs sleep after 16 continuous hrs) residents; 24 hours for other
Period Length for transition and only every third night. residents. Residents must be
educational activities). informed of alertness
strategies, and a nap is strongly
recommended after 16 hours of
continuous duty.
Minimum Time Off 10 hrs 10 hrs after day duty period; 12 hrs 10 hrs (with minimum of 8 hrs
after night duty; 14 hours after duty-free between duty
Between Scheduled extended duty period and no return periods, or 14 hrs duty free
Duty Periods before 6a.m. the next day. after 24 hrs of in-hospital
duty).
Mandatory Off- 24 hrs off per week 24 hrs off per week, no averaging; 24 hrs per week averaged over
averaged over 4 weeks one week four weeks; no home call on
Duty Time off duty days.
Moonlighting Internal moonlighting is Internal and external moonlighting Internal and ext. moonlighting
considered part of the 80- are included in the 80-hr weekly are included in the 80-hr
hr weekly limit limit; approval is required by PD. weekly limit. No moonlighting
Department of Graduate Medical Education (GME)allowed for 1st yr. residents
“Strategic napping, especially after 16 hours
of continuous duty and between the hours
of 10:00 p.m. and 8:00 a.m. is strongly
suggested.”
Department of Graduate Medical Education (GME)
Traditional Hospital Fatigue Mitigation
Strategies
Gurneys Chairs
Mattresses
Call
Coffee
Rooms
Patio
Beds
Furniture
Floor
Futons
Department of Graduate Medical Education (GME)
Thinking Outside the Box
• Looked to Silicon Valley
• Found “nap pods” being used at GOOGLE
• Sent resident “spy” to scope out
• DIO (born in Berkeley) said this is
California---why not?
• Did internet search – found lots of info
Department of Graduate Medical Education (GME)
What Does the Research Tell Us?
• Emergency Medicine Residents
• Sleep Pods – SUNY/VA
Department of Graduate Medical Education (GME)
Problems with Traditional Approaches
• Limited Number of Call Rooms
• Distance Between Clinical Areas and Call
Rooms
• Housekeeping constraints
Department of Graduate Medical Education (GME)
Looking Outside Medical Settings for
Ideas
“Napping Gets a Nod at the Workplace”
J. Hoffman, 8/30/2010, Bloomberg Business Week
• A growing number of companies are encouraging
employees to nap at work—and boost their
productivity
• From Thomas Edison and Winston Churchill to Bill
Clinton and George Costanza, the nap has had many
famous champions.
Department of Graduate Medical Education (GME)
Looking outside Medical
Settings for Ideas
• Ever since sleep scientist David Dinges
helped found the modern science of napping
in the early '80s at the University of
Pennsylvania School of Medicine, short
periods of sleep have been shown to
improve alertness, memory, motor skills,
decision-making, and mood.
– All while cutting down on stress, carelessness,
and even heart disease.
Department of Graduate Medical Education (GME)
Looking outside Medical
Settings for Ideas
• With Americans averaging fewer than seven hours
of sleep per night—and around 20 percent suffering
from sleepiness during the day, according to a
recent Stanford University study—many companies
have turned to naps in an attempt to stave off
billions in lost productivity each year.
Department of Graduate Medical Education (GME)
Looking outside Medical
Settings for Ideas
• Nike workers now have access to nap-friendly
"quiet rooms" that can also be used for
meditation.
• Google, a forerunner in employee perks, has a
number of nap pods scattered throughout its
Mountain View CA campus.
Department of Graduate Medical Education (GME)
Department of Graduate Medical Education (GME)
Naps Are Not Just for Kindergartners
Anymore!
Department of Graduate Medical Education (GME)
Stanford Nap Research
• Objective: Examine whether a 40-minute nap
opportunity at 3 AM can improve cognitive and
psychomotor performance in physicians and
nurses working 12-hour night shifts.
Rebecca Smith-Coggins, MD et al.” Improving Alertness and Performance in Emergency Department
Physicians and Nurses: The Use of Planned Naps” (2006)
Department of Graduate Medical Education (GME)
Stanford Nap Research
• Methods: A randomized controlled trial of
49 physicians and nurses working 3
consecutive night shifts in an academic
emergency department.
• Subjects were randomized to a control
group (no nap condition - NONE) or nap
intervention group (40-minute nap
opportunity at 3 AM NAP).
Rebecca Smith-Coggins, MD et al.” Improving Alertness and Performance in Emergency Department
Physicians and Nurses: The Use of Planned Naps” (2006
Department of Graduate Medical Education (GME)
Main Outcome Measures
• Psychomotor Vigilance Task
• Probe Recall Memory Task
• CathSim intravenous insertion virtual reality
simulation
• Profile of Mood States
– Administered before (6:30 PM), during (4 AM), and
after (7:30 AM) night shifts.
Rebecca Smith-Coggins, MD et al.” Improving Alertness and Performance in Emergency Department
Physicians and Nurses: The Use of Planned Naps” (2006)
Department of Graduate Medical Education (GME)
Methodology
• A 40-minute driving simulation was
administered at 8 AM and videotaped for
behavioral signs of sleepiness and driving
accuracy.
• During the nap period, standard
polysomnographic data were recorded.
Rebecca Smith-Coggins, MD et al.” Improving Alertness and Performance in Emergency Department
Physicians and Nurses: The Use of Planned Naps” (2006)
Department of Graduate Medical Education (GME)
Results
• Polysomnographic data revealed that 90% of
nap subjects were able to sleep for an
average of 24.8 minutes (SD 11.1).
• At 7:30 AM, the nap group had fewer
performance lapses
– reported more vigor
– less fatigue
– less sleepiness
Rebecca Smith-Coggins, MD et al.” Improving Alertness and Performance in Emergency Department
Physicians and Nurses: The Use of Planned Naps” (2006)
Department of Graduate Medical Education (GME)
Results
• At 7:30 AM, the nap group had fewer
performance lapses
– tended to more quickly complete the intravenous
insertion
– exhibited less dangerous driving and display fewer
behavioral signs of sleepiness during the driving
simulation.
• Immediately after the nap (4 AM), the subjects
scored more poorly on Probed Recall Memory
Rebecca Smith-Coggins, MD et al.” Improving Alertness and Performance in Emergency Department
Physicians and Nurses: The Use of Planned Naps” (2006)
Department of Graduate Medical Education (GME)
The effects of a mid-day nap on the neuro-
cognitive performance of medical interns
• Methods: Twenty-nine 1st year medical residents
were divided into a nap group of 18 participants
and a control group of 11 participants.
• Participants were connected to a portable
monitoring device prior to their tour of duty so
that the occurrence of rolling eye movements,
attention failures, could be monitored.
Mohammad M. Amin, MD et al. (2011)
Department of Graduate Medical Education (GME)
The effects of a mid-day nap on the neuro-
cognitive performance of medical interns
• At mid-day, both groups underwent cognitive
testing with Conner’s Continuous Performance
Test (CPT II) and then were placed in a nap
pod.
• Participants in the intervention group were
instructed to nap for up to 20 minutes while
controls were prevented from napping.
Mohammad M. Amin, MD et al. (2011)
Department of Graduate Medical Education (GME)
The effects of a mid-day nap on the neuro-
cognitive performance of medical interns
• The CPT II was repeated immediately following
the 20-minute period and attention failures were
recorded until the end of the tour of duty.
• Mean outcome parameters were compared across
both groups with ANOVA with effect of
treatment and baseline covariate using SAS.
Mohammad M. Amin, MD et al. (2011)
Department of Graduate Medical Education (GME)
The effects of a mid-day nap on the neuro-
cognitive performance of medical interns
• Conclusion: A mid-day nap can improve
attention and cognitive function among first
year medical residents.
Mohammad M. Amin, MD et al. (2011)
Department of Graduate Medical Education (GME)
Conclusions from the Research
• Naps DO mitigate fatigue and improve
cognitive performance overall
Department of Graduate Medical Education (GME)
How Did We Proceed?
• Brainstormed Possible Solutions with:
– Sleep Experts
– Program Directors
– GMEC
– Chief Residents
Department of Graduate Medical Education (GME)
What Did We Decide?
• Pilot nap pods to see if they would be a
means to enhance strategic napping and
mitigate fatigue
Department of Graduate Medical Education (GME)
Department of Graduate Medical Education (GME)
Why Did We Choose Nap Pods?
• Could Be Located Almost Anywhere
• Didn’t require linen changes – could be
wiped down
• Had Track Record in Industry and at the
VA
Department of Graduate Medical Education (GME)
Pilot Implementation
• Key Considerations:
– Where do we locate them?
• Call Quarters vs near the ICUs?
– How Do We Market Them to the Residents and
Fellows?
– How Do We Encourage Attending/Faculty
Support?
– How Do We Evaluate Effectiveness?
Department of Graduate Medical Education (GME)
Implementation
• Installed two trial nap pods
– Collaborated with a source of nap pods
• One in the Call Quarters
• One outside the ICU
• Informed GMEC, Program Directors and
Residents
• Started Gathering Data of Usage
• Planned for Survey of Resident Perceptions
about the nap pods
Department of Graduate Medical Education (GME)
Data Gathering
• Quantitative Data • Qualitative Data for
Analysis
Department of Graduate Medical Education (GME)
Quantitative Data
Department of Graduate Medical Education (GME)
Quantitative Data
Department of Graduate Medical Education (GME)
Quantitative Data
Department of Graduate Medical Education (GME)
Quantitative Data
Department of Graduate Medical Education (GME)
Department of Graduate Medical Education (GME)
Department of Graduate Medical Education (GME)
Department of Graduate Medical Education (GME)
Department of Graduate Medical Education (GME)
Preliminary Qualitative Survey Results
• Pods don’t take the place of beds
• Better awareness as to other factors e.g.,
noise, paging that impact sleep
– noise in the hallway
– quieter quarters for napping
Department of Graduate Medical Education (GME)
Takeaways from The Data
• ICU Pod is getting more use than the one in
the Call Rooms
– Most Used 12-4 AM
• Pods don’t take the place of beds
• Better awareness as to other factors e.g.,
noise, paging that impact sleep
Department of Graduate Medical Education (GME)
What Could we Have Improved On?
• Better Education
• Better Marketing
• More Champions
Department of Graduate Medical Education (GME)
So….Are Nap Pods A Successful
Mitigation Strategy?
• 10 months into the pilot . . .
– Preliminary Findings
• Pods do work
• Pods do not take the place of beds
• Pods do work better for mitigation during duty
hours (especially between 4-6AM) than at the end of
the duty period
• Need to market to the residents and fellows
• Need to empower Faculty Champions
– Upcoming Meeting with Chief Residents
Department of Graduate Medical Education (GME)
Questions
Department of Graduate Medical Education (GME)
