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A systematic review of sleep deprivation and technical skill in surgery
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A systematic review of sleep deprivation and technical skill in surgery Dale F. Whelehan a,b,*, Cathleen A. McCarrick a,b, Paul F. Ridgway a,b a b
Department of Surgery, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland Department of Surgery, Tallaght University Hospital, Dublin, Ireland
article info
abstract
Article history:
Background: It is uncertain if sleep deprivation impacts sleepy surgeons’ technical skills.
Received 7 October 2019
Lapses in surgical performance could increase morbidity and mortality. This review con-
Received in revised form
cludes if sleep deprivation impacts on technical skill performance in simulated
7 January 2020
environments.
Accepted 14 January 2020
Objective: Primary: 1. To identify if sleep deprivation has an impact on technical skill pro-
Available online xxx
ficiency in surgeons. Secondary: a. To identify if the level of surgical experience, quality of sleep, or quantity of sleep influences technical skill proficiency in sleep deprived surgeons.
Keywords:
Methods: The review was conducted according to PRISMA guidelines utilising the databases
Sleep deprivation
Journals Ovid. Validation followed with two independent reviewers utilising an adapted
Surgical performance
version of BEME.
Simulation
Results: Thirty-three heterogeneous studies were included. Sleep deprivation likely nega-
Error
tively impacts technical performance between 11.9 and 32% decrement in performance. No
Technical skill
strong evidence exists with regards to influence of experience, sleep type, or sleep length on technical proficiency. Conclusion: Sleepy surgeons’ technical skills are, on balance, between 11.9 and 32% negatively impacted in a standardised simulated environment. This is likely to have clinical implications for patient safety. © 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Sleep Deprivation in high risk industries has been a proven factor in the loss of civilian life. In surgery, despite the importance of sleep and efforts of the Accreditation Council for Graduate Medical Education (ACGME) guidelines in America, and the EU-working directive (EWTD) in Europe, as a high-risk industry with shift-work work flow there is little agreement with how best to prevent sleepy surgeons from operating. The economic impact of sleep deprivation is burdensome for healthcare workforce engagement with annual cost associated with sleep related work problems (i.e. decreased productivity, accident and error, personal health and absenteeism) estimated at least $60 billion annually1 in
the United States of America and a financial loss of 1.86% GDP2 in the United Kingdom. Standardised assessment is important to ascertain whether surgical performance is affected by sleep deprivation, and if it affects, what aspects of performance. While it is unethical to conduct research of surgery in the clinical setting on patients amongst sleep deprived surgeons, simulation has been shown to be reliable and valid3e5 and may have real-life implications. Simulators record objective metrics that are reflective markers of safety (number of errors), quality (economy of motion), and efficiency (time to completion) of surgical performance. It remains unknown to what extent sleep deprivation has an impact on surgeons’ technical skill performance due to the heterogeneity of literature. There has been a dearth of
* Corresponding author. Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, The University of Dublin at Tallaght University Hospital, Dublin, Ireland. E-mail address: [email protected] (D.F. Whelehan). https://doi.org/10.1016/j.surge.2020.01.004 1479-666X/© 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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research into influence of level of experience, or the type of sleep on surgical performance, including the different effects of acute versus chronic sleep deprivation, and the quality of sleep which can be explored through time spent in REM and NREM sleep patterns. This systematic review will attempt to answer the question e “does sleep deprivation impact on technical skill performance of surgeons in a simulated environment” while also highlighting the potential variable role of level of experience and type of sleep on surgical performance amongst sleep deprived surgeons.
Objectives Primary 1. To identify if sleep deprivation, as measured by valid objective measures in a simulated environment, has an impact on technical skill proficiency in surgeons
publicly, contact was made directly with the author to request availability. Validation of the selection process followed with two independent reviewers (DFW and CM). Both utilised an adapted version of a standard Best Evidence in Medical Education e BEME Guide Coding Sheet. All papers were reviewed independently and assigned a score from 1 to 5 with regard to the strength of the research within the paper. Where there was a difference between reviewers grading of a paper, a decisive final independent adjudication occurred (PFR). An adapted version of the Oxford CEBM level of evidence was used,6 with scores reversed to support weighting of the studies. Studies were categorised into three groups e no impact, positive impact and negative impact. The quality of the studies within these groups were evaluated using four summative measures e average sample size (n), quality scores (q), study design scores (sd), and composite scores (qþsd 2 ). Nonparametric tests were used as the data was not normally distributed to analyse statistically significant differences between the three groups.
Secondary Inclusion criteria a. To identify if the level of surgical experience influences technical skill proficiency in sleep deprived surgeons. b. To explore the level of impact of the quality of the sleep of surgeon, as defined by time spent in REM and NREM sleep cycles, on technical skill proficiency in surgical staff c. To establish the level of impact of length of sleep, defined as short acute and chronic sleep deprivation, on technical skill proficiency in surgeons.
All English language papers including assessment of technical skill proficiency in sleep deprived surgical practitioners were retained. This was inclusive of papers where medical practitioners were in a training surgical scheme. Papers on technical skill proficiency as measured by validated simulation were included. Papers with evidence from other professions were included were included if surgical skill was the primary outcome measurement.
Methodology
Exclusion criteria
Search strategy
Papers were excluded if they did not report on the specific objectives of this study. In addition, In addition, papers were excluded if they focused on sleep deprivation in aspects of non-surgical proficiency. Papers were also excluded if the simulated environment used to assess technical skill did not have evidence of validation.
The review was conducted according to PRISMA guidelines and utilising the electronic databases Journals Ovid for the 1988-present period. In addition to this Medline, Embase, EBSCO (PsychINFO, ERIC) and the Cochrane Library were also searched. The MeSH terms and associated words were refined in conjunction with two other researchers (CMC, PFR). These terms were based on the MeSH terms “sleep deprivation”, “fatigue”, “sleep disorders, circadian rhythm”, “sleep”, “sleep wake disorders”, “clinical competence”, “motor skills”, “psychomotor performance”,“professional competence”, “task performance and analysis”, “laparoscopy”, “surgeons”, “physicians”, “consultants”, “medical staff, hospital”, “internship and residency”, “general surgery”, “simulation training”, “computer simulation”, “patient simulation”, “virtual reality”, and “high fidelity simulation training” yielding a total of 182 articles (Medline), 115 articles (Cinahl), 2810 articles (EMBASE), 11 articles (PsychInfo), 11 articles (Cochrane Library) and 7 articles (additional records identified through other sources). Duplicate results were removed. References, bibliography lists and journal contents pages were hand searched including Medical Education, Medical Teacher, Teaching and Learning in Medicine, Advances in Health Sciences Education and Academic Medicine but no further articles were identified in eligible articles. Where the information was not available
Results From the original 3136 articles identified, an initial screening revealed 154 eligible articles. These were further reviewed against inclusion and exclusion criteria deeming a further 121 ineligible. Thirty-three heterogeneous studies were studies were eligible for review as shown in Fig. 1. The two investigators had a strong inter rater reliability score (k ¼ 0.84). Most study designs were prospective cohort (n ¼ 20) but included studies also comprised of randomised controlled trial (n ¼ 5), case control (n ¼ 3) retrospective cohort study (n ¼ 2), cross sectional study (n ¼ 2) and meta-analysis (n ¼ 1) of varying quality level as seen in Fig. 2. These studies yielded a total of 17 validated simulated assessment tools which measured skill of varying level of difficulty seen in Fig. 3. The most commonly used simulators were Mist-VR (n ¼ 8), The FLS Trainer (n ¼ 5), Lap Mentor (n ¼ 3), DaVinci Surgical Skills (n ¼ 3), ProMIS (n ¼ 3), Own
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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Fig. 1 e PRISMA flow diagram of studies eligible for review in the systematic review.
Fig. 2 e Level of quality scores and study designs used in the studies included in the systematic review.
Simulator (n ¼ 3) and LapSim (n ¼ 2). Other simulators which were used included Neurotouch, Vascular Interventional Simulation Trainer, VEST, LapSim Gyn VR Simulator, Eyesi Surgical Simulator, ES3, Rapidfire & Endo Tower Simulator and SimSurgery Educational Platform. Total number of participants in experimental studies was 880 surgeons from a variety of surgical disciplines and training levels (undergraduate, intern, resident and attending).
Sleep deprivation likely has an impact on technical skill proficiency in surgeons Sleep deprivation may result in a decrement in surgical performance of between 11.9% and 32% in studies available to perform effect sizes. Sixteen studies7e22 found a negative impact of sleep deprivation on technical skill performance, two studies23,24 found that sleep deprivation had a positive
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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Fig. 3 e Graph showing the simulators used in the studies to assess technical skill proficiency and procedural tasks assessed. impact on performance, and fifteen studies25e39 found that sleep deprivation had no impact on performance. A key finding in the results indicated a 32% decrement in performance across 10 studies which found a negative impact of sleep deprivation on performance. 6 studies did not provide sufficient data for power scores to be applied to the calculations. When combining these 10 studies which found a negative impact with 2 studies that found a positive impact, there was a 23.8% decrement in performance across 12 studies. When including a further 12 studies which found no impact on performance, and which explicitly elaborated on results to perform effect sizes, an 11.9% decrement in performance was found in 24 studies across the 3 performance indicator outcomes - time to complete, economy of motion and number of errors.
For weighting of study quality, Kruskal Wallis and ManneWhitney U-tests were carried out to compare the summative scores - quality score, study design score, and composite score between the three outcome groups seen in Table 1. A Spearman correlation between quality scores and study design scores showed a statistically significant weak correlation between quality scores and study design at 0.350 (p < 0.05). There was an increasing trend towards higher quality scores and composite scores in studies which found there was a ‘negative impact’ on technical skill performance as seen in the box plots in Fig. 4. These results were not statistically significant. Studies were then pooled into two groups e those which found sleep deprivation had an ‘impact’ and those studies which found sleep deprivation had ‘no impact’.
Table 1 e Table showing the impact of sleep deprivation on technical skill performance into three separate study groups and three summative measures as well as non-statistically significant Kruskal Wallis and ManneWhitney U p values. No Positive Negative Impact (15) Impact Impact (16) Studies
Quality Scores Study Design Score Composite Score Average Sample
(14e16) (17e21) (22e27) (28)
(29, 30)
(31, 32) (5, 33e37) (1, 2, 4, 38e41) (42)
Median Score
Median Score
Median Score
Kruskal Wallis Scores (No impact / Positive impact/ Negative impact)
Mann Whitney U-Scores (No impact / Positive impact)
Mann Whitney U-Scores (Negative impact / Positive impact)
Mann Mann Whitney Whitney U-Scores U-Scores (No impact/ Impact) (No impact / Negative impact)
2 4 3 26
3 3.5 3.25 29
3 4 3.5 18
p¼0.646 p¼0.286 p¼0.589
p¼0.489 p¼0.431 p¼0.819
p¼0.713 p¼0.129 p¼0.660
p¼0.447 p¼0.311 p¼0.320
p¼0.388 p¼0.476 p¼0.333
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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Fig. 4 e Boxplots showing the scores associated with study quality scores and study composite scores between the three study groups indicating a statistically insignificant higher quality and composite score in the ‘positive impact’ and ‘negative impact’ groups.
Fig. 5 e Boxplot showing the scores associated with study quality scores and composite scores between the two pooled study groups indicating a statistically insignificant higher quality score in the ‘impact’ group.
is a reverse in trend with four studies finding sleep deprivation did not impact on performance compared to three which found it did have a negative impact. 25 studies attempted to distinguish between level of training and/or experience. In this case, some studies categorised level of experience by level of career progression,23 while others distinguished between level of training by level of numerical experience performing a particular procedure.7 In order to attempt to control for the learning curve, others explicitly stated in their inclusion criteria that participants must have no experience with the laparoscopic simulation.12 Fig. 6 e Graph showing the relationship between level of training and impact on technical skill proficiency indicating a shift in trend towards ‘no impact’ in attending groups.
ManneWhitney U tests were then conducted on the two pooled groups. There was an increasing trend towards higher quality and composite scores in studies that found sleep deprivation did impact on technical skill performance as seen in the box plots seen in Fig. 5. These results were not statistically significant.
Level of training or experience of surgeons may have an influence on the relationship between sleep deprivation and technical skill proficiency Studies in the intern and resident group found a greater negative impact as seen in Fig. 6. In the attending group, there
There is insufficient evidence on quantifying the level of impact of the quality of the sleep of surgeons on technical skill proficiency Sleep is not objectively measured in the context of any of the included studies. No study attempted to distinguish between the levels of REM sleep and NREM sleep. Four studies24,28,30,35 attempted to objectify assessment of sleep by observing the patterns of participants,30 by capturing physiological processes such as pupillography and saliva cortisol24 which may be used as an objective marker for the impact of sleep deprivation, by monitoring levels of physical activity during the night using actigraphy,28 or by recording hours of sleep in real time using sleep logs.35 Most studies used subjective assessment of sleep using selfreported outcome measures to capture the level of fatigue or tiredness of the participants. These included validated outcome measures include The Stanford Sleepiness Scale,11 The Epworth Sleepiness Scale,37 The Karolinska Sleepiness Scale,28 The
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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Benhrenz and Monga questionnaire31 and self-created tools to measure fatigue such as a 5-point Likert of fatigue.27
There is insufficient evidence to identify if there is a difference in influence between acute sleep deprivation and chronic sleep deprivation on technical skill proficiency in surgeons Six studies attempted to explicitly state what level of sleep loss constituted as ‘sleep deprivation’. In some cases, it is defined as 24 h awake in the clinic,11 after a night on call,7 less than 4 h of sleep in the 24 h,39 less than 3 h of sleep in the last 24 h,33,36 or less than 2 h of sleep in the last 24 h.32 Four studies attempted to control for acute and chronic sleep deprivation in their design7,23,28,33 by ensuring that the control group had 3 nights prior to baseline testing of no-on call status,7,28 by stating in their inclusion criteria that participants had to sleep “6 h each night prior to stress test”,23 or by controlling participants to have >6 h of sleep per night on average for the week prior to baseline testing.33
Discussion Sleep deprivation may have an impact on technical skill proficiency in surgeons The weighting and number of studies, on balance, show that a majority of studies found sleep deprivation did impact on surgical technical performance in simulation (18 vs 15). More so, a majority of studies found technical skill proficiency is likely to be negatively impacted by sleep deprivation. A decrement of up to 32% from baseline performance was found when using studies which found a negative impact on performance and provided enough information to create effect sizes. If including the studies which found a positive impact on performance and no impact on performance this decrement is reduced to 23.8% and 11.9% respectively. It is unsurprising that there remains a lack of consensus on this area of research. Similar contentious debate exists in parallel fields such as anaesthesiology.40,41 One of the major flaws in many of the study designs is the insufficiency in controlling for the learning curve effect of the simulator. Is likely that some studies found no decrement in performance, or even paradoxical improvement in performance of participants in sleep deprived states secondary to consolidated learning of procedural skills to improve subsequent attempts from baseline testing. It may perhaps be the case that the learning curve effect was more powerful than the effects of acute sleep deprivation thus masking its true effects. When exploring the study quality markers, there was higher quality and composite scores in studies which found an impact of sleep deprivation on performance when viewed as three individual group, and two pooled groups. The investigators had a statistically strong inter-rater reliability further strengthening the rigour of these quality markers. Decrement percentages are based on products of an attempt to quantify the overall effect size of performance decrement using three performance indicators - time to complete the task, the economy of motion of the task, and the number of
errors in the task. Similar performance decrements in sleep deprived states have been noted in parallel industries such piloting.42 It is worth noting that other metrics were used to define performance such as overall performance scores.10,23 While these studies did not use the simulated performance metrics, they did use a combination of objective measurements and subjective direct observation of procedural skills (DOPS) such as checklists and global rating scales. These measurements of performance may be useful for future research as they may improve the reliability of effect sizes and allow for a more holistic evaluation of performance which reflects not just technical aspects of surgery. This will be important since technical skill alone is insufficient in ensuring positive patient outcomes. Aspects of cognition are intrinsically linked with surgical performance such as reaction time, effective decision making and situational awareness. On balance, the decrement would exist in real-life performance when comparing it to similar industries such as piloting. Research in sleep deprived pilot performance has shown decrement in attention,43 vigilance44 and precision42 e all of which are key subcomponents to surgical technical skill performance. Such decrements may also be influenced by impaired information processing and delayed decision making highlighting the strong interdependency between the cognitive and psychomotor aspects of our brain. Sleepdeprived surgeons are likely to commit twice as many errors in simulated surgical settings20,21 as a result of decrements in cognition.45 It is important to explore the generalisability of surgical simulated performance to true surgical performance as it is likely that these findings are applicable to real-life settings with retrospective studies finding increases in complication rates amongst sleep deprived surgeons46,47 and mortality rates in night-admitted patients.48 The decrement in technical-skill in simulated settings thus likely has real-life implications leading to an increased risk of medical error.49,50
Does level of training mitigate the effects of sleep deprivation? There is no consensus on whether age or experience acts as a ‘protection factor’ against the effects of sleep deprivation on performance.7,17 From this review, sleep deprivation is likely to impact all levels of training with the exception of the ‘attending’ surgeons where the trend is reversed. This data is limited however to four studies in the attending group making the generalisability of the finding negligible. Prior research has shown that sleep loss impairs performance of simple tasks as opposed to complex cognitive tasks.51 In this instance, more experienced surgeons may utilise or adapt learned strategies to minimise error in simple tasks which will impact their overall performance.36 They may have developed personal fatigue risk management approaches by improved selfregulation of sleep and workload management. Unfortunately, trainees are not privy to the same level of selfmanagement and are often subject to long work-hours, influenced by a culture of being ‘resident’ in the hospital setting which dates back to Halstedian approaches to training. Trainee fatigue and burnout are influenced by personal and professional causes. Regulated working hours such as the
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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EWTD and ACGME are only part of a greater solution to challenging destructive cultures of over-working and poor selfmanagement. Cultural change around the importance of sleep and other personal factors such as nutrition, hydration and physical activity for performance management is warranted to make complement current efforts. Alternatively, while sleep deprivation can impact on memory processing,52 preservation of highly practiced skills in parallel industries is seen when faced with high levels of sleep deprivation.42 This may indicate that repetition of tasks, strongly correlated with level of experience, may support resistance to fatigue-related technical skill decrement.
What type of sleep deprivation matters most? None of the papers distinguished between the relationships of the type of sleep also known as the quality of sleep, and its potential impact on the performance of technical skills. REM sleep deprivation results in a decreased ability of perceptual learning, with particular deficits in memory assimilation and information consolidation. NREM sleep deprivation reduces the ability to perform learned and/or simple tasks.53 By establishing if decrements are seen in specific stages of the sleep cycle researchers can begin to ascertain what type of sleep impacts on particular technical and non-technical skills. Sleep deprivation adversely affects mood which is likely to impact on interpersonal performance of surgeons resulting in poorer intraoperative communication e a known contributor to error. The lack of detail is evident in all of the studies included thereby highlighting the need for further research within this area. The support of the effect of sleep cycles could be incorporated into the working-day of a surgeon to enhance their performance on operative days. ‘Power naps’ have become extremely popular in parallel industries and may mitigate acute cognitive deficits prior to high-stake surgical procedures. Given the subjective nature of self-report assessment, it is unlikely that the questionnaire measures are reliable. Subjective fatigue and objective fatigue report variable results highlighting the effect of sleep deprivation on selfawareness. Actigraphy28 as an objective measurement, has an accuracy of 93% when compared with polysomnography.54 Whilst these are innovative means of assessment, an ascertainment of whether the participant was awake or asleep is not captured. Objective markers such as EEG and eye tracking42 and physiological markers such as metabolite of melatonin (Amt6S) and salivary cortisol55,56 may offer potential use in future measures to quantify the level of impact of sleep deprivation on sleep propensity prior to performing surgery.
Does the length and chronicity of sleep deprivation matter? There is no strong evidence to support research into the differentiation between short and chronic sleep deprivation on technical skill proficiency in surgeons. There is a lack of consensus as to primarily what defines ‘sleep deprivation’ and secondly, what constitutes the difference between acute and chronic sleep deprivation. Little research has been carried out on the potential impact of cumulative fatigue. There is evidence to suggest that daytime sleep following night shifts is
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fragmented and poor in quality57 indicating that chronicity will be present in many controlled scenarios. This could bring about adversely impacted surgical performance that is less detectable on simulator or real-life retrospective findings. Future research should attempt to distinguish the effects of acute sleep deprivation, chronic partial sleep loss, and the combination of both on performance. Accumulated sleep dept, as is evidently present throughout all the studies included in this review, is a major concern for the personal welfare of surgeons. Sleep levels of less than 8 h have been shown to adversely affect physical, cognitive and mental health. Sleep disorders such as narcolepsy, sleep apnoea and insomnia in the profession should also be considered since poor personal well-being will result in poor professional performance.
Limitations and recommendations The findings of this systematic review are limited by the inclusion criteria established by the investigators. Similarly, there may be publication bias in this field of research given the international interest in patient safety and reducing risk of medical error. Research indicating that sleep deprivation does not impact on performance may be less likely to be published as it counter argues ACGME and EU working directive initiatives. The results of this systematic review are limited by the internal validity, external validity, and conclusion validity of the researchers involved. The quality of the data from the studies is variable but according to BEME quality evaluation, a majority of studies lie above the conclusion that a trend likely exists. Heterogeneity with regards to sleep deprivation levels, performance assessments and controlling for variables limits the generalisability of conclusion. However, there was a strong association in inter-rater reliability when evaluating the quality of the studies between the researchers thus strengthening the results of this systematic review alone. Prospective efforts should made in a standardised setting to control for confounding variables such as the learning curve effect wherein two of the 18 studies included found sleep deprivation actually improved performance in a simulated environment. The type of sleep (both in terms of NREM and REM as well as sleep length), standardising simulated assessment and metrics are also important to control for. Finally, understanding specific surrogate markers in simulation that have a high correlation with actual clinical performance will determine which are useful to include in studies concerning sleep deprivation.63
Mitigation strategies Levels of sleep disturbance are inevitable in professions which require 24-h work e as is the case for surgery and continuity of patient care. Acute strategies such as micro breaks from surgery, and known ‘zeitgebers’ such as regular interaction with colleagues, bright lit rooms, and caffeine may reduce the impact of fatigue felt by surgeons and these warrant further investigation.58e62 In addition, surrounding environmental factors may also influence alertness of surgeons which are not reflected in many of the simulated environments of the studies. While beneficial in some cases,
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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and decremental in others, the presence of other staff may alter surgical performance. Regular effectively communication and process checking with colleagues may preserve performance in sleep deprived states or may distract surgeons further if the communication at hand is not pertinent to the procedure. Policies around work-hours should also be cognisant of the impact of the circadian rhythm on performance also. Efforts should be made to educate surgeons on workload management which compliment peaks and troughs of alertness. Shift-work patterns should also be completed prior to sunrise to allow surgeons to return home to sleep in dark conditions The use of performance eugeroic drugs such as Modafinil in the air industry has shown promising effects in preserving predeprivation performance43 and thus may warrant investigation amongst surgeons who are sleep-deprived e though this should not be considered the model on which attempts to address fatigue should be primarily focused given the potential adverse effect of taking long-term medication may have on surgeons health. While drawing parallels to industries such as aviation, who have by in large successfully improved pilot performance and reduced adverse events, surgery is often conducted with limited resourcing. Surgeons on-call are also expected to wake with enhanced alertness and deal with complex cases in acute contexts,64 and no such study has explored the potential decremental impact of sleep inertia on performance on surgeons who are called to action in these contexts. Policies such as ACGME and EWTD have begun the process of improving regulation of working hours, but cultural changes to sleep are necessary in many healthcare disciplines. Fatigue risk management systems in healthcare which emphasise the importance of personal well-being and a supportive workplace on error disclosure to enhance surgeon's ability to performance optimally may bring about such change.
Conclusion On the basis of the 33 objective studies included in this systematic review, the balance of studies in this systematic review have found sleep deprivation likely negatively impacts on technical skill performance in a standardised simulated setting. Studies which found a decrement in performance were of a higher quality on three markers e quality scores, study design scores and composite scores. This decrement in performance is estimated to be between 11.9% and 32%. This may have clinical implications for patient safety and efforts to address should consist of a combination of personal and professional alterations.
Disclosure statement Financial disclosure This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Non-financial disclosure None.
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Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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18. DeMaria EJ, McBride CL, Broderick TJ, Kaplan BJ. Night call does not impair learning of laparoscopic skills. Surg Innovat 2005;12(2):145e9. 19. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep 2005;28(11):1392e402. 20. Eastridge BJ, Hamilton EC, O'Keefe GE, Rege RV, Valentine RJ, Jones DJ, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg 2003;186(2):169e74. 21. Grantcharov TP, Bardram L, Peter F-J, Rosenberg J. Laparoscopic performance after one night on call in a surgical department: prospective study. BMJ 2001;323(7323):1222e3. 22. Taffinder NJ, McManus IC, Gul Y, Russell RCG, Darzi A. Effect of sleep deprivation on surgeons' dexterity on laparoscopy simulator. Lancet 1998;352(9135):1191. 23. Micko A, Knopp K, Knosp E, Wolfsberger S. Microsurgical performance after sleep interruption: a NeuroTouch simulator study. World Neurosurg 2017;106:92e101. 24. Schlosser K, Maschuw K, Kupietz E, Weyers P, Schneider R, Rothmund M, et al. Call-associated acute fatigue in surgical residentsdsubjective perception or objective fact? A crosssectional observational study to examine the influence of fatigue on surgical performance. World J Surg 2012;36(10):2276e87. 25. Robison W, Patel SK, Mehta A, Senkowski T, Allen J, Shaw E, et al. Can fatigue affect acquisition of new surgical skills? A prospective trial of pre-and post-call general surgery residents using the da Vinci surgical skills simulator. Surg Endosc 2018;32(3):1389e96. 26. Veddeng A, Husby T, Engelsen IB, Kent A, Flaatten H. Impact of night shifts on laparoscopic skills and cognitive function among gynecologists. Acta Obstet Gynecol Scand 2014;93(12):1255e61. 27. Olasky J, Chellali A, Sankaranarayanan G, Zhang L, Miller A, De S, et al. Effects of sleep hours and fatigue on performance in laparoscopic surgery simulators. Surg Endosc 2014;28(9):2564e8. € genur I. Laparoscopic 28. Amirian I, Andersen LT, Rosenberg J, Go skills and cognitive function are not affected in surgeons during a night shift. J Surg Educ 2014;71(4):543e50. 29. William SY, Hafiz S, Sava JA. Effects of night-float and 24-h call on resident psychomotor performance. J Surg Res 2013;184(1):49e53. 30. Sugden C, Housden CR, Aggarwal R, Sahakian BJ, Darzi A. Effect of pharmacological enhancement on the cognitive and clinical psychomotor performance of sleep-deprived doctors: a randomized controlled trial. Ann Surg 2012;255(2):222e7. 31. Ganju A, Kahol K, Lee P, Simonian N, Quinn SJ, Ferrara JJ, et al. The effect of call on neurosurgery residents' skills: implications for policy regarding resident call periods. J Neurosurg 2012;116(3):478e82. 32. Tomasko JM, Pauli EM, Kunselman AR, Haluck RS. Sleep deprivation increases cognitive workload during simulated surgical tasks. Am J Surg 2012;203(1):37e43. 33. Erie EA, Mahr MA, Hodge DO, Erie JC. Effect of sleep deprivation on the performance of simulated anterior segment surgical skill. Can J Ophthalmol 2011;46(1):61e5. 34. Hegar MV, Truitt MS, Mangram AJ, Dunn EL. Resident fatigue in 2010: where is the beef? Am J Surg 2011;202(6):727e32. 35. Lehmann KS, Martus P, Little-Elk S, Maass H, Holmer C, Zurbuchen U, et al. Impact of sleep deprivation on mediumterm psychomotor and cognitive performance of surgeons: prospective cross-over study with a virtual surgery simulator and psychometric tests. Surgery 2010;147(2):246e54. 36. Jakubowicz DM, Price EM, Glassman HJ, Gallagher AJG, Mandava N, Ralph WP, et al. Effects of a twenty-four hour call period on resident performance during simulated endoscopic
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€ genur I. Working 55. Amirian I, Andersen LT, Rosenberg J, Go night shifts affects surgeons' biological rhythm. Am J Surg 2015;210(2):389e95. 56. Harris A, Waage S, Ursin H, Hansen AM, Bjorvatn B, Eriksen HR. Cortisol, reaction time test and health among offshore shift workers. Psychoneuroendocrinology 2010;35(9):1339e47. 57. Akerstedt T. Shift work and disturbed sleep/wakefulness. Occup Med 2003;53(2):89e94. 58. Dorion D, Darveau S. Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery? An experimental prospective study. Ann Surg 2013;257(2):256e9. 59. Engelmann C, Schneider M, Kirschbaum C, Grote G, Dingemann J, Schoof S, et al. Effects of intraoperative breaks on mental and somatic operator fatigue: a randomized clinical trial. Surg Endosc 2011;25(4):1245e50.
60. Bonnet M, Tancer M, Uhde T, Yeragani VK. Effects of caffeine on heart rate and QT variability during sleep. Depress Anxiety 2005;22(3):150e5. 61. Crochet P, Aggarwal R, Mishra A, Sirimanna P, Darzi A. Caffeine and taurine reverse the deterioration in laparoscopic and cognitive skill following sleep deprivation. J Am Coll Surg 2009;209(3):S111. 62. Wesensten NJ, Killgore WDS, Balkin TJ. Performance and alertness effects of caffeine, dextroamphetamine, and modafinil during sleep deprivation. J Sleep Res 2005;14(3):255e66. 63. Sturm L, Dawson D, Vaughan R, Hewett P, Hill AG, Graham JC, et al. Effects of fatigue on surgeon performance and surgical outcomes: a systematic review. ANZ J Surg 2011;81(7-8):502e9. 64. Jones JW, McCullough LB. To sleep or not to sleep, that is the question. J Vasc Surg 2010;51(4):1033e4.
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A systematic review of sleep deprivation and technical skill in surgery Dale F. Whelehan a,b,*, Cathleen A. McCarrick a,b, Paul F. Ridgway a,b a b
Department of Surgery, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland Department of Surgery, Tallaght University Hospital, Dublin, Ireland
article info
abstract
Article history:
Background: It is uncertain if sleep deprivation impacts sleepy surgeons’ technical skills.
Received 7 October 2019
Lapses in surgical performance could increase morbidity and mortality. This review con-
Received in revised form
cludes if sleep deprivation impacts on technical skill performance in simulated
7 January 2020
environments.
Accepted 14 January 2020
Objective: Primary: 1. To identify if sleep deprivation has an impact on technical skill pro-
Available online xxx
ficiency in surgeons. Secondary: a. To identify if the level of surgical experience, quality of sleep, or quantity of sleep influences technical skill proficiency in sleep deprived surgeons.
Keywords:
Methods: The review was conducted according to PRISMA guidelines utilising the databases
Sleep deprivation
Journals Ovid. Validation followed with two independent reviewers utilising an adapted
Surgical performance
version of BEME.
Simulation
Results: Thirty-three heterogeneous studies were included. Sleep deprivation likely nega-
Error
tively impacts technical performance between 11.9 and 32% decrement in performance. No
Technical skill
strong evidence exists with regards to influence of experience, sleep type, or sleep length on technical proficiency. Conclusion: Sleepy surgeons’ technical skills are, on balance, between 11.9 and 32% negatively impacted in a standardised simulated environment. This is likely to have clinical implications for patient safety. © 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Sleep Deprivation in high risk industries has been a proven factor in the loss of civilian life. In surgery, despite the importance of sleep and efforts of the Accreditation Council for Graduate Medical Education (ACGME) guidelines in America, and the EU-working directive (EWTD) in Europe, as a high-risk industry with shift-work work flow there is little agreement with how best to prevent sleepy surgeons from operating. The economic impact of sleep deprivation is burdensome for healthcare workforce engagement with annual cost associated with sleep related work problems (i.e. decreased productivity, accident and error, personal health and absenteeism) estimated at least $60 billion annually1 in
the United States of America and a financial loss of 1.86% GDP2 in the United Kingdom. Standardised assessment is important to ascertain whether surgical performance is affected by sleep deprivation, and if it affects, what aspects of performance. While it is unethical to conduct research of surgery in the clinical setting on patients amongst sleep deprived surgeons, simulation has been shown to be reliable and valid3e5 and may have real-life implications. Simulators record objective metrics that are reflective markers of safety (number of errors), quality (economy of motion), and efficiency (time to completion) of surgical performance. It remains unknown to what extent sleep deprivation has an impact on surgeons’ technical skill performance due to the heterogeneity of literature. There has been a dearth of
* Corresponding author. Department of Surgery, Trinity Centre for Health Sciences, Trinity College Dublin, The University of Dublin at Tallaght University Hospital, Dublin, Ireland. E-mail address: [email protected] (D.F. Whelehan). https://doi.org/10.1016/j.surge.2020.01.004 1479-666X/© 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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research into influence of level of experience, or the type of sleep on surgical performance, including the different effects of acute versus chronic sleep deprivation, and the quality of sleep which can be explored through time spent in REM and NREM sleep patterns. This systematic review will attempt to answer the question e “does sleep deprivation impact on technical skill performance of surgeons in a simulated environment” while also highlighting the potential variable role of level of experience and type of sleep on surgical performance amongst sleep deprived surgeons.
Objectives Primary 1. To identify if sleep deprivation, as measured by valid objective measures in a simulated environment, has an impact on technical skill proficiency in surgeons
publicly, contact was made directly with the author to request availability. Validation of the selection process followed with two independent reviewers (DFW and CM). Both utilised an adapted version of a standard Best Evidence in Medical Education e BEME Guide Coding Sheet. All papers were reviewed independently and assigned a score from 1 to 5 with regard to the strength of the research within the paper. Where there was a difference between reviewers grading of a paper, a decisive final independent adjudication occurred (PFR). An adapted version of the Oxford CEBM level of evidence was used,6 with scores reversed to support weighting of the studies. Studies were categorised into three groups e no impact, positive impact and negative impact. The quality of the studies within these groups were evaluated using four summative measures e average sample size (n), quality scores (q), study design scores (sd), and composite scores (qþsd 2 ). Nonparametric tests were used as the data was not normally distributed to analyse statistically significant differences between the three groups.
Secondary Inclusion criteria a. To identify if the level of surgical experience influences technical skill proficiency in sleep deprived surgeons. b. To explore the level of impact of the quality of the sleep of surgeon, as defined by time spent in REM and NREM sleep cycles, on technical skill proficiency in surgical staff c. To establish the level of impact of length of sleep, defined as short acute and chronic sleep deprivation, on technical skill proficiency in surgeons.
All English language papers including assessment of technical skill proficiency in sleep deprived surgical practitioners were retained. This was inclusive of papers where medical practitioners were in a training surgical scheme. Papers on technical skill proficiency as measured by validated simulation were included. Papers with evidence from other professions were included were included if surgical skill was the primary outcome measurement.
Methodology
Exclusion criteria
Search strategy
Papers were excluded if they did not report on the specific objectives of this study. In addition, In addition, papers were excluded if they focused on sleep deprivation in aspects of non-surgical proficiency. Papers were also excluded if the simulated environment used to assess technical skill did not have evidence of validation.
The review was conducted according to PRISMA guidelines and utilising the electronic databases Journals Ovid for the 1988-present period. In addition to this Medline, Embase, EBSCO (PsychINFO, ERIC) and the Cochrane Library were also searched. The MeSH terms and associated words were refined in conjunction with two other researchers (CMC, PFR). These terms were based on the MeSH terms “sleep deprivation”, “fatigue”, “sleep disorders, circadian rhythm”, “sleep”, “sleep wake disorders”, “clinical competence”, “motor skills”, “psychomotor performance”,“professional competence”, “task performance and analysis”, “laparoscopy”, “surgeons”, “physicians”, “consultants”, “medical staff, hospital”, “internship and residency”, “general surgery”, “simulation training”, “computer simulation”, “patient simulation”, “virtual reality”, and “high fidelity simulation training” yielding a total of 182 articles (Medline), 115 articles (Cinahl), 2810 articles (EMBASE), 11 articles (PsychInfo), 11 articles (Cochrane Library) and 7 articles (additional records identified through other sources). Duplicate results were removed. References, bibliography lists and journal contents pages were hand searched including Medical Education, Medical Teacher, Teaching and Learning in Medicine, Advances in Health Sciences Education and Academic Medicine but no further articles were identified in eligible articles. Where the information was not available
Results From the original 3136 articles identified, an initial screening revealed 154 eligible articles. These were further reviewed against inclusion and exclusion criteria deeming a further 121 ineligible. Thirty-three heterogeneous studies were studies were eligible for review as shown in Fig. 1. The two investigators had a strong inter rater reliability score (k ¼ 0.84). Most study designs were prospective cohort (n ¼ 20) but included studies also comprised of randomised controlled trial (n ¼ 5), case control (n ¼ 3) retrospective cohort study (n ¼ 2), cross sectional study (n ¼ 2) and meta-analysis (n ¼ 1) of varying quality level as seen in Fig. 2. These studies yielded a total of 17 validated simulated assessment tools which measured skill of varying level of difficulty seen in Fig. 3. The most commonly used simulators were Mist-VR (n ¼ 8), The FLS Trainer (n ¼ 5), Lap Mentor (n ¼ 3), DaVinci Surgical Skills (n ¼ 3), ProMIS (n ¼ 3), Own
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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Fig. 1 e PRISMA flow diagram of studies eligible for review in the systematic review.
Fig. 2 e Level of quality scores and study designs used in the studies included in the systematic review.
Simulator (n ¼ 3) and LapSim (n ¼ 2). Other simulators which were used included Neurotouch, Vascular Interventional Simulation Trainer, VEST, LapSim Gyn VR Simulator, Eyesi Surgical Simulator, ES3, Rapidfire & Endo Tower Simulator and SimSurgery Educational Platform. Total number of participants in experimental studies was 880 surgeons from a variety of surgical disciplines and training levels (undergraduate, intern, resident and attending).
Sleep deprivation likely has an impact on technical skill proficiency in surgeons Sleep deprivation may result in a decrement in surgical performance of between 11.9% and 32% in studies available to perform effect sizes. Sixteen studies7e22 found a negative impact of sleep deprivation on technical skill performance, two studies23,24 found that sleep deprivation had a positive
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Fig. 3 e Graph showing the simulators used in the studies to assess technical skill proficiency and procedural tasks assessed. impact on performance, and fifteen studies25e39 found that sleep deprivation had no impact on performance. A key finding in the results indicated a 32% decrement in performance across 10 studies which found a negative impact of sleep deprivation on performance. 6 studies did not provide sufficient data for power scores to be applied to the calculations. When combining these 10 studies which found a negative impact with 2 studies that found a positive impact, there was a 23.8% decrement in performance across 12 studies. When including a further 12 studies which found no impact on performance, and which explicitly elaborated on results to perform effect sizes, an 11.9% decrement in performance was found in 24 studies across the 3 performance indicator outcomes - time to complete, economy of motion and number of errors.
For weighting of study quality, Kruskal Wallis and ManneWhitney U-tests were carried out to compare the summative scores - quality score, study design score, and composite score between the three outcome groups seen in Table 1. A Spearman correlation between quality scores and study design scores showed a statistically significant weak correlation between quality scores and study design at 0.350 (p < 0.05). There was an increasing trend towards higher quality scores and composite scores in studies which found there was a ‘negative impact’ on technical skill performance as seen in the box plots in Fig. 4. These results were not statistically significant. Studies were then pooled into two groups e those which found sleep deprivation had an ‘impact’ and those studies which found sleep deprivation had ‘no impact’.
Table 1 e Table showing the impact of sleep deprivation on technical skill performance into three separate study groups and three summative measures as well as non-statistically significant Kruskal Wallis and ManneWhitney U p values. No Positive Negative Impact (15) Impact Impact (16) Studies
Quality Scores Study Design Score Composite Score Average Sample
(14e16) (17e21) (22e27) (28)
(29, 30)
(31, 32) (5, 33e37) (1, 2, 4, 38e41) (42)
Median Score
Median Score
Median Score
Kruskal Wallis Scores (No impact / Positive impact/ Negative impact)
Mann Whitney U-Scores (No impact / Positive impact)
Mann Whitney U-Scores (Negative impact / Positive impact)
Mann Mann Whitney Whitney U-Scores U-Scores (No impact/ Impact) (No impact / Negative impact)
2 4 3 26
3 3.5 3.25 29
3 4 3.5 18
p¼0.646 p¼0.286 p¼0.589
p¼0.489 p¼0.431 p¼0.819
p¼0.713 p¼0.129 p¼0.660
p¼0.447 p¼0.311 p¼0.320
p¼0.388 p¼0.476 p¼0.333
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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Fig. 4 e Boxplots showing the scores associated with study quality scores and study composite scores between the three study groups indicating a statistically insignificant higher quality and composite score in the ‘positive impact’ and ‘negative impact’ groups.
Fig. 5 e Boxplot showing the scores associated with study quality scores and composite scores between the two pooled study groups indicating a statistically insignificant higher quality score in the ‘impact’ group.
is a reverse in trend with four studies finding sleep deprivation did not impact on performance compared to three which found it did have a negative impact. 25 studies attempted to distinguish between level of training and/or experience. In this case, some studies categorised level of experience by level of career progression,23 while others distinguished between level of training by level of numerical experience performing a particular procedure.7 In order to attempt to control for the learning curve, others explicitly stated in their inclusion criteria that participants must have no experience with the laparoscopic simulation.12 Fig. 6 e Graph showing the relationship between level of training and impact on technical skill proficiency indicating a shift in trend towards ‘no impact’ in attending groups.
ManneWhitney U tests were then conducted on the two pooled groups. There was an increasing trend towards higher quality and composite scores in studies that found sleep deprivation did impact on technical skill performance as seen in the box plots seen in Fig. 5. These results were not statistically significant.
Level of training or experience of surgeons may have an influence on the relationship between sleep deprivation and technical skill proficiency Studies in the intern and resident group found a greater negative impact as seen in Fig. 6. In the attending group, there
There is insufficient evidence on quantifying the level of impact of the quality of the sleep of surgeons on technical skill proficiency Sleep is not objectively measured in the context of any of the included studies. No study attempted to distinguish between the levels of REM sleep and NREM sleep. Four studies24,28,30,35 attempted to objectify assessment of sleep by observing the patterns of participants,30 by capturing physiological processes such as pupillography and saliva cortisol24 which may be used as an objective marker for the impact of sleep deprivation, by monitoring levels of physical activity during the night using actigraphy,28 or by recording hours of sleep in real time using sleep logs.35 Most studies used subjective assessment of sleep using selfreported outcome measures to capture the level of fatigue or tiredness of the participants. These included validated outcome measures include The Stanford Sleepiness Scale,11 The Epworth Sleepiness Scale,37 The Karolinska Sleepiness Scale,28 The
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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Benhrenz and Monga questionnaire31 and self-created tools to measure fatigue such as a 5-point Likert of fatigue.27
There is insufficient evidence to identify if there is a difference in influence between acute sleep deprivation and chronic sleep deprivation on technical skill proficiency in surgeons Six studies attempted to explicitly state what level of sleep loss constituted as ‘sleep deprivation’. In some cases, it is defined as 24 h awake in the clinic,11 after a night on call,7 less than 4 h of sleep in the 24 h,39 less than 3 h of sleep in the last 24 h,33,36 or less than 2 h of sleep in the last 24 h.32 Four studies attempted to control for acute and chronic sleep deprivation in their design7,23,28,33 by ensuring that the control group had 3 nights prior to baseline testing of no-on call status,7,28 by stating in their inclusion criteria that participants had to sleep “6 h each night prior to stress test”,23 or by controlling participants to have >6 h of sleep per night on average for the week prior to baseline testing.33
Discussion Sleep deprivation may have an impact on technical skill proficiency in surgeons The weighting and number of studies, on balance, show that a majority of studies found sleep deprivation did impact on surgical technical performance in simulation (18 vs 15). More so, a majority of studies found technical skill proficiency is likely to be negatively impacted by sleep deprivation. A decrement of up to 32% from baseline performance was found when using studies which found a negative impact on performance and provided enough information to create effect sizes. If including the studies which found a positive impact on performance and no impact on performance this decrement is reduced to 23.8% and 11.9% respectively. It is unsurprising that there remains a lack of consensus on this area of research. Similar contentious debate exists in parallel fields such as anaesthesiology.40,41 One of the major flaws in many of the study designs is the insufficiency in controlling for the learning curve effect of the simulator. Is likely that some studies found no decrement in performance, or even paradoxical improvement in performance of participants in sleep deprived states secondary to consolidated learning of procedural skills to improve subsequent attempts from baseline testing. It may perhaps be the case that the learning curve effect was more powerful than the effects of acute sleep deprivation thus masking its true effects. When exploring the study quality markers, there was higher quality and composite scores in studies which found an impact of sleep deprivation on performance when viewed as three individual group, and two pooled groups. The investigators had a statistically strong inter-rater reliability further strengthening the rigour of these quality markers. Decrement percentages are based on products of an attempt to quantify the overall effect size of performance decrement using three performance indicators - time to complete the task, the economy of motion of the task, and the number of
errors in the task. Similar performance decrements in sleep deprived states have been noted in parallel industries such piloting.42 It is worth noting that other metrics were used to define performance such as overall performance scores.10,23 While these studies did not use the simulated performance metrics, they did use a combination of objective measurements and subjective direct observation of procedural skills (DOPS) such as checklists and global rating scales. These measurements of performance may be useful for future research as they may improve the reliability of effect sizes and allow for a more holistic evaluation of performance which reflects not just technical aspects of surgery. This will be important since technical skill alone is insufficient in ensuring positive patient outcomes. Aspects of cognition are intrinsically linked with surgical performance such as reaction time, effective decision making and situational awareness. On balance, the decrement would exist in real-life performance when comparing it to similar industries such as piloting. Research in sleep deprived pilot performance has shown decrement in attention,43 vigilance44 and precision42 e all of which are key subcomponents to surgical technical skill performance. Such decrements may also be influenced by impaired information processing and delayed decision making highlighting the strong interdependency between the cognitive and psychomotor aspects of our brain. Sleepdeprived surgeons are likely to commit twice as many errors in simulated surgical settings20,21 as a result of decrements in cognition.45 It is important to explore the generalisability of surgical simulated performance to true surgical performance as it is likely that these findings are applicable to real-life settings with retrospective studies finding increases in complication rates amongst sleep deprived surgeons46,47 and mortality rates in night-admitted patients.48 The decrement in technical-skill in simulated settings thus likely has real-life implications leading to an increased risk of medical error.49,50
Does level of training mitigate the effects of sleep deprivation? There is no consensus on whether age or experience acts as a ‘protection factor’ against the effects of sleep deprivation on performance.7,17 From this review, sleep deprivation is likely to impact all levels of training with the exception of the ‘attending’ surgeons where the trend is reversed. This data is limited however to four studies in the attending group making the generalisability of the finding negligible. Prior research has shown that sleep loss impairs performance of simple tasks as opposed to complex cognitive tasks.51 In this instance, more experienced surgeons may utilise or adapt learned strategies to minimise error in simple tasks which will impact their overall performance.36 They may have developed personal fatigue risk management approaches by improved selfregulation of sleep and workload management. Unfortunately, trainees are not privy to the same level of selfmanagement and are often subject to long work-hours, influenced by a culture of being ‘resident’ in the hospital setting which dates back to Halstedian approaches to training. Trainee fatigue and burnout are influenced by personal and professional causes. Regulated working hours such as the
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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EWTD and ACGME are only part of a greater solution to challenging destructive cultures of over-working and poor selfmanagement. Cultural change around the importance of sleep and other personal factors such as nutrition, hydration and physical activity for performance management is warranted to make complement current efforts. Alternatively, while sleep deprivation can impact on memory processing,52 preservation of highly practiced skills in parallel industries is seen when faced with high levels of sleep deprivation.42 This may indicate that repetition of tasks, strongly correlated with level of experience, may support resistance to fatigue-related technical skill decrement.
What type of sleep deprivation matters most? None of the papers distinguished between the relationships of the type of sleep also known as the quality of sleep, and its potential impact on the performance of technical skills. REM sleep deprivation results in a decreased ability of perceptual learning, with particular deficits in memory assimilation and information consolidation. NREM sleep deprivation reduces the ability to perform learned and/or simple tasks.53 By establishing if decrements are seen in specific stages of the sleep cycle researchers can begin to ascertain what type of sleep impacts on particular technical and non-technical skills. Sleep deprivation adversely affects mood which is likely to impact on interpersonal performance of surgeons resulting in poorer intraoperative communication e a known contributor to error. The lack of detail is evident in all of the studies included thereby highlighting the need for further research within this area. The support of the effect of sleep cycles could be incorporated into the working-day of a surgeon to enhance their performance on operative days. ‘Power naps’ have become extremely popular in parallel industries and may mitigate acute cognitive deficits prior to high-stake surgical procedures. Given the subjective nature of self-report assessment, it is unlikely that the questionnaire measures are reliable. Subjective fatigue and objective fatigue report variable results highlighting the effect of sleep deprivation on selfawareness. Actigraphy28 as an objective measurement, has an accuracy of 93% when compared with polysomnography.54 Whilst these are innovative means of assessment, an ascertainment of whether the participant was awake or asleep is not captured. Objective markers such as EEG and eye tracking42 and physiological markers such as metabolite of melatonin (Amt6S) and salivary cortisol55,56 may offer potential use in future measures to quantify the level of impact of sleep deprivation on sleep propensity prior to performing surgery.
Does the length and chronicity of sleep deprivation matter? There is no strong evidence to support research into the differentiation between short and chronic sleep deprivation on technical skill proficiency in surgeons. There is a lack of consensus as to primarily what defines ‘sleep deprivation’ and secondly, what constitutes the difference between acute and chronic sleep deprivation. Little research has been carried out on the potential impact of cumulative fatigue. There is evidence to suggest that daytime sleep following night shifts is
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fragmented and poor in quality57 indicating that chronicity will be present in many controlled scenarios. This could bring about adversely impacted surgical performance that is less detectable on simulator or real-life retrospective findings. Future research should attempt to distinguish the effects of acute sleep deprivation, chronic partial sleep loss, and the combination of both on performance. Accumulated sleep dept, as is evidently present throughout all the studies included in this review, is a major concern for the personal welfare of surgeons. Sleep levels of less than 8 h have been shown to adversely affect physical, cognitive and mental health. Sleep disorders such as narcolepsy, sleep apnoea and insomnia in the profession should also be considered since poor personal well-being will result in poor professional performance.
Limitations and recommendations The findings of this systematic review are limited by the inclusion criteria established by the investigators. Similarly, there may be publication bias in this field of research given the international interest in patient safety and reducing risk of medical error. Research indicating that sleep deprivation does not impact on performance may be less likely to be published as it counter argues ACGME and EU working directive initiatives. The results of this systematic review are limited by the internal validity, external validity, and conclusion validity of the researchers involved. The quality of the data from the studies is variable but according to BEME quality evaluation, a majority of studies lie above the conclusion that a trend likely exists. Heterogeneity with regards to sleep deprivation levels, performance assessments and controlling for variables limits the generalisability of conclusion. However, there was a strong association in inter-rater reliability when evaluating the quality of the studies between the researchers thus strengthening the results of this systematic review alone. Prospective efforts should made in a standardised setting to control for confounding variables such as the learning curve effect wherein two of the 18 studies included found sleep deprivation actually improved performance in a simulated environment. The type of sleep (both in terms of NREM and REM as well as sleep length), standardising simulated assessment and metrics are also important to control for. Finally, understanding specific surrogate markers in simulation that have a high correlation with actual clinical performance will determine which are useful to include in studies concerning sleep deprivation.63
Mitigation strategies Levels of sleep disturbance are inevitable in professions which require 24-h work e as is the case for surgery and continuity of patient care. Acute strategies such as micro breaks from surgery, and known ‘zeitgebers’ such as regular interaction with colleagues, bright lit rooms, and caffeine may reduce the impact of fatigue felt by surgeons and these warrant further investigation.58e62 In addition, surrounding environmental factors may also influence alertness of surgeons which are not reflected in many of the simulated environments of the studies. While beneficial in some cases,
Please cite this article as: Whelehan DF et al., A systematic review of sleep deprivation and technical skill in surgery, The Surgeon, https://doi.org/10.1016/j.surge.2020.01.004
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and decremental in others, the presence of other staff may alter surgical performance. Regular effectively communication and process checking with colleagues may preserve performance in sleep deprived states or may distract surgeons further if the communication at hand is not pertinent to the procedure. Policies around work-hours should also be cognisant of the impact of the circadian rhythm on performance also. Efforts should be made to educate surgeons on workload management which compliment peaks and troughs of alertness. Shift-work patterns should also be completed prior to sunrise to allow surgeons to return home to sleep in dark conditions The use of performance eugeroic drugs such as Modafinil in the air industry has shown promising effects in preserving predeprivation performance43 and thus may warrant investigation amongst surgeons who are sleep-deprived e though this should not be considered the model on which attempts to address fatigue should be primarily focused given the potential adverse effect of taking long-term medication may have on surgeons health. While drawing parallels to industries such as aviation, who have by in large successfully improved pilot performance and reduced adverse events, surgery is often conducted with limited resourcing. Surgeons on-call are also expected to wake with enhanced alertness and deal with complex cases in acute contexts,64 and no such study has explored the potential decremental impact of sleep inertia on performance on surgeons who are called to action in these contexts. Policies such as ACGME and EWTD have begun the process of improving regulation of working hours, but cultural changes to sleep are necessary in many healthcare disciplines. Fatigue risk management systems in healthcare which emphasise the importance of personal well-being and a supportive workplace on error disclosure to enhance surgeon's ability to performance optimally may bring about such change.
Conclusion On the basis of the 33 objective studies included in this systematic review, the balance of studies in this systematic review have found sleep deprivation likely negatively impacts on technical skill performance in a standardised simulated setting. Studies which found a decrement in performance were of a higher quality on three markers e quality scores, study design scores and composite scores. This decrement in performance is estimated to be between 11.9% and 32%. This may have clinical implications for patient safety and efforts to address should consist of a combination of personal and professional alterations.
Disclosure statement Financial disclosure This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Non-financial disclosure None.
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