- Email: [email protected]
Impact of sleep deprivation on anaesthesia residents’ non-technical skills: a pilot simulation-based prospective randomized trial
British Journal of Anaesthesia, 119 (1): 125–31 (2017) doi: 10.1093/bja/aex155 Quality and Patient Safety
Impact of sleep deprivation on anaesthesia residents’ non-technical skills: a pilot simulation-based prospective randomized trial A. Neuschwander1,2,*, A. Job3, A. Younes4, A. Mignon2,4, C. Delgoulet3, P. Cabon3, J. Mantz1,5,† and A. Tesniere2,4 1
Department of Anaesthesiology and Critical Care Medicine, Hoˆpital europe´en Georges Pompidou, AP-HP, Universite´ Paris Descartes, Paris, France, 2iLumens Healthcare Simulation Laboratory, Universite´ Paris Descartes, Paris, France, 3LATI, Universite´ Paris Descartes, Paris, France, 4Department of Anaesthesiology and Critical Care Medicine, Hoˆpital Cochin, AP-HP, Paris, France and 5Histopathology and Animal Models Unit, Institut Pasteur, Paris, France *Corresponding author. Anaesthesiology and Critical Care Department, Hoˆpital europe´en Georges Pompidou – Assistance publique hoˆpitaux de Paris, 20 rue Leblanc, 75015 Paris, France. E-mail: [email protected] †
The authors dedicate this article to the memory of their highly respected colleague and co-author Prof. Jean Mantz. Jean has not only led the way for excellent research in anaesthesiology, but he also has been an incredibly dedicated mentor for a number of young anaesthesiologists. He passed away in January 2017.
Abstract Background. Sleep deprivation is common in anaesthesia residents, but its impact on performance remains uncertain. Non-technical skills (team working, situation awareness, decision making, and task management) are key components of quality of care in anaesthesia, particularly in crisis situations occurring in the operating room. The impact of sleep deprivation on non-technical skills is unknown. We tested the hypothesis that in anaesthesia residents sleep deprivation is associated with impaired non-technical skills. Methods. Twenty anaesthesia residents were randomly allocated to undergo a simulation session after a night shift [sleep-deprived (SLD) group, n¼10] or after a night of rest [rested (R) group, n¼10] from January to March 2015. The simulated scenario was a situation of crisis management in the operating room. The primary end point was a composite score of anaesthetists’ non-technical skills (ANTS) assessed by two blinded evaluators. Results. Non-technical skills were significantly impaired in the SLD group [ANTS score 12.2 (interquartile range 10.5–13)] compared with the R group [14.5 (14–15), P<0.02]. This difference was mainly accounted for by a difference in the team working item. On the day of simulation, the SLD group showed increased sleepiness and decreased confidence in anaesthesia skills. Conclusions. In this randomized pilot trial, sleep deprivation was associated with impaired non-technical skills of anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario. Trial registration. NCT02622217. Key words: sleep deprivation; simulation training; thinking skills
Editorial decision: March 17, 2017; Accepted: April 24, 2017 C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. V
For Permissions, please email: [email protected]
125
126
|
Neuschwander et al.
Editor’s key points • Anaesthesia trainees (and consultants) who work at
night are commonly sleep deprived. • Non-technical (social and cognitive) skills play an important
role in clinician performance during stressful situations. • The authors studied non-technical skills of sleepdeprived trainees during a simulated crisis. • These skills were impaired in sleep-deprived individuals compared with non-sleep-deprived individuals.
According to the US Institute of Medicine, 44 000–98 000 people die each year in the USA because of medical errors.1 Sleep deprivation is one factor potentially leading to impaired performance of anaesthesia practice. It has been associated with decreased vigilance of anaesthetists during simulated driving.2 Most of the studies have assessed the impact of sleep deprivation on technical skills and have shown contradictory results. In a simulated medical scenario, Howard and colleagues3 showed that sleepdeprived anaesthesia residents had impairment of alertness, mood, and performance. In a simulated laparoscopic scenario, Eastridge and colleagues4 showed an increased number of technical errors in sleep-deprived surgical residents. On the contrary, no impact of sleep deprivation on tasks such as epidural catheter placement or response to an alarm was observed in other studies performed with anaesthesia residents.4–6 In contrast, non-technical skills have been defined as ‘the cognitive, social, and personal resource skills that complement technical skills and contribute to safe and efficient task performance’.7 These skills include situation awareness, decision making, team working, and task management.8 Although not directly linked to technical performance, they may play a key role in the quality of anaesthetic performance, especially during crisis management and related critical situations.9 10 Anaesthesia residents have irregular working patterns, with long working hours and night shifts at irregular intervals. Several lines of evidence suggest that sleep deprivation may negatively impact cognitive performance and mood, which may therefore affect nontechnical skills.11 12 Among the factors that increase the occurrence of medical errors and serious adverse events, deficiencies in non-technical skills may be key. Their role has long been recognized in high-risk industries, such as aviation or the nuclear power industry.13 14 More recently, their impact has been described in paediatric cardiac surgery, and they were found to be more frequent than technical errors.15 16 Specific programmes of non-technical skills training have been assessed to improve patient safety in obstetrical, intensive care, and cardiology settings.16–18 Non-technical skills, composed of social and cognitive skills, could be more sensitive to sleep deprivation than heavily protocolized and well-trained technical skills. In the present trial, therefore, we tested the hypothesis that sleep deprivation reduces mobilization of non-technical skills in anaesthesia residents facing a situation of simulated crisis management in the operating room. The primary end point was the performance in non-technical skills of anaesthesia residents. Secondary objectives were the impact of sleep deprivation on technical skills, sleepiness, and confidence.
Methods The trial was approved by a central Ethics committee (Comite´ de protection des Personnes Ile de France 3, Paris, France) and
complied with the French regulation of clinical research. The CONSORT guidelines were followed throughout.19
Participants Twenty anaesthesia residents from Paris academic hospitals were randomized in a 1:1 ratio to undergo a simulation session after a night on call [sleep-deprived (SLD) group] or after a night of normal sleep at home [rested (R) group]. They were informed of the anonymous video and audio recording of data and provided informed written consent. All of them had at least 1 yr experience in anaesthesia training and were familiar with high-fidelity simulation. Exclusion criteria were the presence of chronic sleep disorders, assessed by the Epworth questionnaire.20 A sleep diary covering three nights before the simulation session was completed by each participant to ensure proper group allocation. Residents who came after a night on call but had at least 5 h of consecutive sleep were re-allocated to the R group. Randomization was computer generated on the day of inclusion.
Simulation and scenario All sessions were performed using a high-fidelity manikin (Sim-man 3G; Laerdel, Stavanger, Norway) and recorded using three video cameras and one microphone through a dedicated piece of software (SimView; Laerdal, Stavanger, Norway). The simulation consisted of the following three consecutive steps: (i) briefing (introduction to the facility, the material, and manikin specificities); (ii) the simulated scenario itself; and (iii) debriefing on trainee’s feelings and performance analysis immediately afterwards. The duration of each individual session was 1 h. The scenario outline is summarized in Fig. 1. It consisted of a patient with acute peritonitis undergoing emergency general anaesthesia, which was complicated by anaphylactic shock secondary to the injection of succinylcholine. All scenarios were performed with the assistance of an anaesthetist nurse, who had completed a master class in simulation and served as facilitator. Facilitators were asked to behave in a reproducible manner during scenarios to minimize their influence on the resident performance. Once the patient was considered to be stabilized (stabilization was defined as peripheral oxygen saturation >95%, mean arterial pressure >65 mm Hg, and heart rate <100 beats min1 for at least 2 min) by a bolus injection of epinephrine 100 mg i.v. to be decided by the resident, a surgeon (simulated by a trainer in simulation) entered the operating room to create a dilemma regarding patient management (continue surgery or intensive care unit admission without surgery). All scenarios were performed between 14.00 and 16.00 h in order to limit the influence of chronotype on fatigue. Moreover, all residents were asked not to sleep during the morning before the simulation session.
Data collection The primary end point was the individual score of nontechnical skills assessed by the Anaesthetists’ Non-Technical Skills (ANTS)21 scale presented in Table 1. The ANTS scale is composed of four categories, with three to five elements in each category. Each element was rated from 1 (poor) to 4 (good). Elements were then averaged to obtain a 1–4 score for each category and added for a final score that yield a maximum of 16. Two independent senior anaesthetists, trained to use the ANTS scale, were blinded to the allocation group and observed performance by video after the session and scored the ANTS.
Impact of sleep deprivation on non-technical skills
|
127
BP 122/78 mm Hg, HR 102 beats min−1, RR 22 bpm, SpO2 97%, GCS 15/15 Intial state
Induction of general anaesthesia
Anaphylactic shock
Epinephrine 100 mg
BP 105/62 mm Hg, HR 88 beats min−1, RR 0 bpm, SpO2 98%, GCS 3/15
BP 77/42 mm Hg, Hr 127 beats min−1, RR 0 bpm, SpO2 88%, Et CO2 23 mm Hg, bilateral lung wheezing, skin rash.
BP 101/68 mm Hg, HR 104 beats min−1, RR 0 bpm, SpO2 94%, Et CO2 30 mm Hg, normal vesicular murmur.
Fig 1 Clinical scenario. BP, blood pressure; E
0
CO2 ,
end-tidal concentration of carbon dioxide; GCS, Glasgow Coma Scale; HR, heart rate; RR, respiratory rate; SpO2 ,
peripheral oxygen saturation.
Table 1 Description and rating system of Anaesthetists’ NonTechnical Skills (ANTS) scale. Rating: 4, good; 3, acceptable; 2, marginal; 1, poor Category
Element
Task management
Planning and preparing Prioritizing Providing and maintaining standards Identifying and using resources Coordinating activities with team members Exchanging information Using authority and assertiveness Assessing capabilities Supporting others Gathering information Recognizing and understanding Anticipating Identifying options Balancing risks and selecting options Re-evaluating
Team working
Situation awareness
Decision making
Technical skills were assessed by the completion of a technical check list containing 16 items regarding rapid sequence induction and management of intraoperative anaphylactic shock detailed in Table 2. This check list was built from guidelines of the French Anaesthesia and Critical Care society (SFAR). Data
(age, sex, duration of residency, sleep diary, etc.) on participants were also collected. Participants filled in an online questionnaire several days before the simulation to assess global confidence with the Rosenberg self-esteem scale and also chronotype with the Horne and Otsberg scale.22 23 On the day of simulation, instant sleepiness was auto-evaluated by using the Karolinska Sleepiness Scale.24 Confidence in anaesthesia skills was also auto-evaluated immediately before the simulation session with a validated 25 points questionnaire.25
Statistical analysis Data are presented as the mean (SD) or median (interquartile range) for continuous data according to statistical distribution (assumption of normality was assessed using the d’Agostino– Pearson test) and as count (percentage) for categorical parameters. Comparisons between the independent groups were made using the v2 or Fisher’s exact tests for categorical variables, and using the Student’s t-test or the Mann–Whitney test for quantitative parameters. Owing to its non-normal statistical distribution, the primary outcome was assessed with a nonparametric Mann–Whitney U-test. Agreement of blinded raters on non-technical skills performance was assessed by a test of inter-rater agreement (Fleiss’ kappa). All reported P-values are two-tailed, and P-values of <0.05 were considered to indicate statistically significant differences. We calculated that a sample of 20 residents would provide an 80% power to detect a two point difference in the ANTS score at a two-sided a level of 5%, assuming a median score of 14/16 in the rested group as observed in our pilot series with the same scenario and in previous studies.26 27
128
|
Neuschwander et al.
Table 2 Check list of technical skills Rapid sequence induction and intubation
Anaphylactic shock management
Material preparation Monitoring (heart rate, blood pressure, peripheral oxygen saturation) Preoxygenation Hypnotic injection (propofol/ etomidate/ketamine þ correct dose) Succinylcholine injection (þ correct dose) Cricoid pressure Balloon inflated
Call for help Increase fractional inspired O2 to 100%
Post-intubation management
Causal agent removal Fluid bolus
Epinephrine 100 mg b-Mimetics Blood sample (tryptase/ histamine) Re-evaluation
Table 3 Characteristics of participants. Continuous variables are expressed as the mean (SD) Variable
Male sex [n (%)] Age (yr, range) Duration of residency (yr) Epworth questionnaire Mood assessment: Profile of Mood Scales Anger Confusion Depression Fatigue Tension Vigour Shifts per month (n) Amount of sleep during previous night (h)
Sleep-deprived group (n¼10)
Rested group (n¼10)
4 (40) 24–29 3.5 (0.5)
5 (50) 25–30 3.5 (1)
9.6 (2.4)
8.5 (3)
3.3 (3.0) 7.0 (2.4) 2.3 (2.1) 11.6 (3.5) 5 (2.8) 8.9 (3.2) 3.9 (1) 4 (1)
3.0 (3.0) 5.9 (5.2) 2.2 (1.7) 6.3 (3.7) 5.8 (3.7) 12.3 (4.0) 4.1 (0.9) 7.5 (1.5)
Results From January to June 2015, 20 residents were randomized in the study, 10 in the SLD group and 10 in the R group. One eligible subject was excluded before randomization because his Epworth score was >15, suggesting a chronic sleep disorder. No randomized resident in the SLD group had to be reallocated to the R group according to the time of sleep during the night shift, and none slept before the simulation session, as required. The characteristics of the participants are displayed in Table 3, and a flow chart of participants is displayed in Fig. 2.
Primary end point The median value of non-technical skills was higher in the rested group [14.5 (14–15)] than the median value in the SLD
group [12.2 (10.5–13), P<0.02; Fig. 3]. Inter-rater agreement was 0.65 (0.09). At a categorical level of non-technical skills, team working scores were significantly lower in the sleep-deprived group compared with the rested group [3 (2.6–3) vs 4 (3.2–4); P<0.01], whereas situation awareness, decision making, and task management were not significantly different between groups [3 (3–3.7) vs 4 (3.5–4), P¼0.07; 3 (2.5–3.5) vs 3 (3–4), P¼0.31; and 3 (2.1–3.7) vs 4 (3.5–4), P¼0.05, respectively].
Secondary end points Technical skills performance, assessed by a composite scale, was not different between groups [12 (10.5–13) R group vs 12 (10.5–13) SLD group, P¼0.95]. There was no difference in overall confidence [Rosenberg score 30 (29–33) in SLD group vs 31 (30– 34.5) in R group, P¼0.46] or chronotype between groups (Horne and Otsberg 46 (43–48) in SLD group vs 51 (45–58) in R group, P¼0.16]. On the day of simulation, sleepiness was greater in the SLD group [KSS 6.5 (1.4)] than in the R group [KSS 3.7 (1.7), P<0.01] (KSS ¼ Karolinska sleepiness scale). Self confidence in anaesthesia skills assessed immediately before the simulation session was also lower in the SLD group than in the R group [64.1 (10.5) vs 84.8 (14.20), respectively, P<0.01)
Discussion The main original finding made in this prospective pilot randomized trial can be summarized as follows: sleep deprivation was associated with reduced non-technical skills in a population of anaesthesia residents exposed to a crisis management simulated scenario. This reduced mobilization of nontechnical skills was associated with impaired team working, increased sleepiness, and decreased confidence in anaesthesia skills. To our knowledge, this is the first pilot randomized trial indicating that anaesthetists’ non-technical skills are affected by sleep deprivation. Howard and colleagues3 studied the effects of total sleep deprivation in a population of 12 anaesthesia residents. They showed that anaesthetists had impairment of alertness and mood but found no difference in terms of clinical performance. This finding was possibly explained by a lack of statistical power of the study. Non-technical skills were not evaluated, however. More recently, Maltese and colleagues28 assessed the impact of a night shift on cognitive performance of intensivists. They showed significant alteration of cognitive abilities, regardless of experience or duration of sleep, compared with their own performance after a night of rest. These results are consistent with our findings, because non-technical skills consist of both social and cognitive skills and could therefore be affected by alteration of cognitive performance. Non-technical skills have also been found to be positively correlated with technical skills in simulated intraoperative crisis scenarios with 50 anaesthesia residents.29 This result suggests a possible association between non-technical skills performance and overall performance. No association between technical and non-technical skills was found in our study, but half of our subjects were sleep deprived, whereas none were sleep deprived in the study by Riem and colleagues.29 Also, technical skills were not assessed in detail in our study. Ours findings suggest that decreased confidence in anaesthesia skills could contribute to the reduction in non-technical skills. In contrast, global self-esteem of residents was similar in both groups several days before the simulation. This emphasizes that, in our population, sleep deprivation was
Impact of sleep deprivation on non-technical skills
Screened n=100
Included n=21
Excluded n=1 (Epworth > 1)
Included in the rested group (R) n=10
Included in the sleep deprived group (SD) n=10
10 (100%) included in the analysis
10 (100%) included in the analysis
Fig 2 Flow chart of participants.
Anaesthetists non-technical skills (ANTS)
16
14
12
*P<0.02
10
8
6
4 Rested group (R) n=10
Sleep-deprived (SLD) n=10
Fig 3 Comparison of non-technical skills between sleep-deprived and rested anaesthesia residents.
|
129
130
|
Neuschwander et al.
associated with reduced confidence on the day of simulation. Nevertheless, it was not possible to study the impact of confidence on performance because of our limited sample size. Non-technical skills are not familiar to French anaesthesia residents because they are not included in formal resident training programmes, standing in sharp contrast to other countries’ residents programmes and military and commercial airline training programmes. However, several lines of evidence suggest that a deficiency in non-technical skills may increase the risk of error. They are therefore probably required for safe and efficient performance in the operating theatre.30 This may pave the road leading to adverse medical events, as it has been shown that human errors play a crucial role in accident causation.31 32 Technical skills, such as difficult airway management, can be trained in a specific simulation training programme, with significant improvement of trainees’ performance.33 Interestingly, this may also be the case for non-technical skills. A 3 yr crisis resource management programme including lectures on human factors and crisis resource management and interactive sessions led to reduced incidence of critical events in an intensive care unit.17 Hughes an colleagues34 showed promising results of specific crisis resource management team training with emphasis on non-technical skills for trauma resuscitation teams in terms of team working and task management. In a simulated cardiac arrest scenario, Fernandez Castelao and colleagues18 found an association between nontechnical skills training and adherence to guidelines. Our study comes with some limitations. Firstly, the number of residents included is relatively small, which exposes our study to selection bias. Indeed, a large number of eligible subjects were screened but not included because participation in the study was voluntary. However, a lack of power regarding the primary outcome is unlikely, because we found a significant difference between groups with respect to non-technical skills. However, we cannot exclude the possibility that other differences, (i.e. in technical skills) could appear if using a larger sample size. The limited sample size also limits the interpretation of the pattern of deficiency in non-technical skills at a categorical level. Secondly, non-technical skills assessment may be difficult as it is partly subjective. Graham and colleagues35 observed low inter-rater reliability in a cohort of anaesthetists after a short training course. The inter-rater agreement between our two blinded evaluators was nevertheless considered good, with a j score >0.6. Thirdly, observation and comparison of nontechnical skills are closely linked to the environment and the team at stake. All scenarios were therefore played with exactly the same simulated crew (simulated surgeon and anaesthetic nurse), trainers in high-fidelity simulation, who tried to behave in a reproducible manner. As residents were expected to take over leadership in the situation, the impact of facilitators in team working can be minimized by keeping a follower attitude. Any extrapolation to another crisis management scenario or the real-life operating room has not been investigated in the present study and would be an over-interpretation of our results. Additionally, there was no objective physiological confirmation of sleep deprivation in our population of sleep-deprived residents. Sleep diaries nevertheless remain a reliable tool,36 and sleep-deprived residents showed increased sleepiness on the Karolinska Sleepiness Scale. The three-point difference between our groups is comparable to what was described in anaesthesia trainees after night shifts by Lancman.37 Finally, our study included only French anaesthesia residents, and generalizability to senior anaesthetists or residents from other countries is uncertain because no study has explored the impact of experience
or non-technical skills training programmes on coping with sleep deprivation. In conclusion, sleep deprivation induced by a night shift was associated with impaired non-technical skills in anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario. Future trials should assess whether teaching and training non-technical skills at the same level as technical ones in anaesthesia resident educational programmes might improve their performance in the operating room and perhaps contribute to reduce the rate of medical errors in routine practice.
Authors’ Contributions Contributed to the design of the work, acquisition of data: A.N., A.J., A.Y., A.M., A.T. Drafted the manuscript: A.N., A.J. Revised the work for important intellectual content: C.D., P.C., J.M. Conducted the analysis and interpretation of data: A.N., A.J., A.T. All authors approved the submitted version of the manuscript.
Declaration of interest None declared.
Funding French national research agency (ANR-14-CE24-0021).
References 1.
Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press (US), 2000. Available from http://www.ncbi.nlm.nih.gov/books/NBK225182/ (accessed 12 November 2014) 2. Murray D, Dodds C. The effect of sleep disruption on performance of anaesthetists – a pilot study. Anaesthesia 2003; 58: 520–5 3. Howard SK, Gaba DM, Smith BE, et al. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology 2003; 98: 1345–55; discussion 5A 4. Eastridge BJ, Hamilton EC, O’Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg 2003; 186: 169–74 5. Hayter MA, Friedman Z, Katznelson R, Hanlon JG, Borges B, Naik VN. Effect of sleep deprivation on labour epidural catheter placement. Br J Anaesth 2010; 104: 619–27 6. Cao CGL, Weinger MB, Slagle J, et al. Differences in day and night shift clinical performance in anesthesiology. Hum Factors 2008; 50: 276–90 7. Flin RH, O’Connor P, Crichton M. Safety at the Sharp End: A Guide to Non-Technical Skills. Ashgate Publishing, Ltd, 2008. 8. Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ nontechnical skills. Br J Anaesth 2010; 105: 38–44 9. Gaba DM, Fish KJ, Howard SK, Crisis Management in Anesthesiology. Churchill Livingstone, 1994 10. Rutherford JS, Flin R, Irwin A. The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008. Anaesth Intensive Care 2015; 43: 512–7 11. Neu D, Kajosch H, Peigneux P, Verbanck P, Linkowski P, Le Bon O. Cognitive impairment in fatigue and sleepiness associated conditions. Psychiatry Res 2011; 189: 128–34
Impact of sleep deprivation on non-technical skills
12. Wali SO, Qutah K, Abushanab L, Basamh R, Abushanab J, Krayem A. Effect of on-call-related sleep deprivation on physicians’ mood and alertness. Ann Thorac Med 2013; 8: 22–7 13. Zeltser MV, Nash DB. Approaching the evidence basis for aviation-derived teamwork training in medicine. Am J Med Qual 2010; 25: 13–23 14. Flin R, O’Connor P, Mearns K. Crew resource management: improving team work in high reliability industries. Team Perform Manag Int J 2002; 8: 68–78 15. Catchpole KR, Giddings AEB, de Leval MR, et al. Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 2006; 49: 567–88 16. Haller G, Garnerin P, Morales M-A, et al. Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J Qual Health Care 2008; 20: 254–63 17. Haerkens MHTM, Kox M, Lemson J, Houterman S, van der Hoeven JG, Pickkers P. Crew Resource Management in the Intensive Care Unit: a prospective 3-year cohort study. Acta Anaesthesiol Scand 2015; 59: 1319–29 18. Fernandez Castelao E, Boos M, Ringer C, Eich C, Russo SG. Effect of CRM team leader training on team performance and leadership behavior in simulated cardiac arrest scenarios: a prospective, randomized, controlled study. BMC Med Educ 2015; 15: 116 19. Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Br Med J 2010; 340: c332 20. Johns MWA. New method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991; 14: 540–5 21. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 2003; 90: 580–8 22. Wongpakaran T, Tinakon W, Wongpakaran N, Nahathai WA. Comparison of reliability and construct validity between the original and revised versions of the Rosenberg Self-Esteem Scale. Psychiatry Investig 2012; 9: 54–8 23. Horne JA, Ostberg O. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int J Chronobiol 1976; 4: 97–110 24. Akerstedt T, Gillberg M. Subjective and objective sleepiness in the active individual. Int J Neurosci 1990; 52: 29–37
|
131
25. Morgan PJ, Cleave-Hogg D. Comparison between medical students’ experience, confidence and competence. Med Educ 2002; 36: 534–9 26. Skelton T, Nshimyumuremyi I, Mukwesi C, Whynot S, Zolpys L, Livingston P. Low-cost simulation to teach anesthetists’ non-technical skills in Rwanda. Anesth Analg 2016; 123: 474–80 27. Yee B, Naik VN, Joo HS, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulationbased education. J Am Soc Anesthesiol 2005; 103: 241–8 28. Maltese F, Adda M, Bablon A, et al. Night shift decreases cognitive performance of ICU physicians. Intensive Care Med 2016; 42: 393–400 29. Riem N, Boet S, Bould MD, Tavares W, Naik VN. Do technical skills correlate with non-technical skills in crisis resource management: a simulation study. Br J Anaesth 2012; 109: 723–8 30. Fletcher GCL, McGeorge P, Flin RH, Glavin RJ, Maran NJ. The role of non-technical skills in anaesthesia: a review of current literature. Br J Anaesth 2002; 88: 418–29 31. Reason J. Human error: models and management. Br Med J 2000; 320: 768–70 32. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med 2002; 347: 1249–55 33. Hubert V, Duwat A, Deransy R, Mahjoub Y, Dupont H. Effect of simulation training on compliance with difficult airway management algorithms, technical ability, and skills retention for emergency cricothyrotomy. Anesthesiology 2014; 120: 999–1008 34. Hughes KM, Benenson RS, Krichten AE, Clancy KD, Ryan JP, Hammond CA. Crew resource management program tailored to trauma resuscitation improves team behavior and communication. J Am Coll Surg 2014; 219: 545–51 35. Graham J, Hocking G, Giles E. Anaesthesia non-technical skills: can anaesthetists be trained to reliably use this behavioural marker system in 1 day? Br J Anaesth 2010; 104: 440–5 36. Buysse DJ, Ancoli-Israel S, Edinger JD, Lichstein KL, Morin CM. Recommendations for a standard research assessment of insomnia. Sleep 2006; 29: 1155–73 37. Lancman BM. Night shift fatigue among anaesthesia trainees at a major metropolitan teaching hospital. Anaesth Intensive Care 2016; 44: 364–70 Handling editor: A. R. Absalom
Impact of sleep deprivation on anaesthesia residents’ non-technical skills: a pilot simulation-based prospective randomized trial A. Neuschwander1,2,*, A. Job3, A. Younes4, A. Mignon2,4, C. Delgoulet3, P. Cabon3, J. Mantz1,5,† and A. Tesniere2,4 1
Department of Anaesthesiology and Critical Care Medicine, Hoˆpital europe´en Georges Pompidou, AP-HP, Universite´ Paris Descartes, Paris, France, 2iLumens Healthcare Simulation Laboratory, Universite´ Paris Descartes, Paris, France, 3LATI, Universite´ Paris Descartes, Paris, France, 4Department of Anaesthesiology and Critical Care Medicine, Hoˆpital Cochin, AP-HP, Paris, France and 5Histopathology and Animal Models Unit, Institut Pasteur, Paris, France *Corresponding author. Anaesthesiology and Critical Care Department, Hoˆpital europe´en Georges Pompidou – Assistance publique hoˆpitaux de Paris, 20 rue Leblanc, 75015 Paris, France. E-mail: [email protected] †
The authors dedicate this article to the memory of their highly respected colleague and co-author Prof. Jean Mantz. Jean has not only led the way for excellent research in anaesthesiology, but he also has been an incredibly dedicated mentor for a number of young anaesthesiologists. He passed away in January 2017.
Abstract Background. Sleep deprivation is common in anaesthesia residents, but its impact on performance remains uncertain. Non-technical skills (team working, situation awareness, decision making, and task management) are key components of quality of care in anaesthesia, particularly in crisis situations occurring in the operating room. The impact of sleep deprivation on non-technical skills is unknown. We tested the hypothesis that in anaesthesia residents sleep deprivation is associated with impaired non-technical skills. Methods. Twenty anaesthesia residents were randomly allocated to undergo a simulation session after a night shift [sleep-deprived (SLD) group, n¼10] or after a night of rest [rested (R) group, n¼10] from January to March 2015. The simulated scenario was a situation of crisis management in the operating room. The primary end point was a composite score of anaesthetists’ non-technical skills (ANTS) assessed by two blinded evaluators. Results. Non-technical skills were significantly impaired in the SLD group [ANTS score 12.2 (interquartile range 10.5–13)] compared with the R group [14.5 (14–15), P<0.02]. This difference was mainly accounted for by a difference in the team working item. On the day of simulation, the SLD group showed increased sleepiness and decreased confidence in anaesthesia skills. Conclusions. In this randomized pilot trial, sleep deprivation was associated with impaired non-technical skills of anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario. Trial registration. NCT02622217. Key words: sleep deprivation; simulation training; thinking skills
Editorial decision: March 17, 2017; Accepted: April 24, 2017 C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. V
For Permissions, please email: [email protected]
125
126
|
Neuschwander et al.
Editor’s key points • Anaesthesia trainees (and consultants) who work at
night are commonly sleep deprived. • Non-technical (social and cognitive) skills play an important
role in clinician performance during stressful situations. • The authors studied non-technical skills of sleepdeprived trainees during a simulated crisis. • These skills were impaired in sleep-deprived individuals compared with non-sleep-deprived individuals.
According to the US Institute of Medicine, 44 000–98 000 people die each year in the USA because of medical errors.1 Sleep deprivation is one factor potentially leading to impaired performance of anaesthesia practice. It has been associated with decreased vigilance of anaesthetists during simulated driving.2 Most of the studies have assessed the impact of sleep deprivation on technical skills and have shown contradictory results. In a simulated medical scenario, Howard and colleagues3 showed that sleepdeprived anaesthesia residents had impairment of alertness, mood, and performance. In a simulated laparoscopic scenario, Eastridge and colleagues4 showed an increased number of technical errors in sleep-deprived surgical residents. On the contrary, no impact of sleep deprivation on tasks such as epidural catheter placement or response to an alarm was observed in other studies performed with anaesthesia residents.4–6 In contrast, non-technical skills have been defined as ‘the cognitive, social, and personal resource skills that complement technical skills and contribute to safe and efficient task performance’.7 These skills include situation awareness, decision making, team working, and task management.8 Although not directly linked to technical performance, they may play a key role in the quality of anaesthetic performance, especially during crisis management and related critical situations.9 10 Anaesthesia residents have irregular working patterns, with long working hours and night shifts at irregular intervals. Several lines of evidence suggest that sleep deprivation may negatively impact cognitive performance and mood, which may therefore affect nontechnical skills.11 12 Among the factors that increase the occurrence of medical errors and serious adverse events, deficiencies in non-technical skills may be key. Their role has long been recognized in high-risk industries, such as aviation or the nuclear power industry.13 14 More recently, their impact has been described in paediatric cardiac surgery, and they were found to be more frequent than technical errors.15 16 Specific programmes of non-technical skills training have been assessed to improve patient safety in obstetrical, intensive care, and cardiology settings.16–18 Non-technical skills, composed of social and cognitive skills, could be more sensitive to sleep deprivation than heavily protocolized and well-trained technical skills. In the present trial, therefore, we tested the hypothesis that sleep deprivation reduces mobilization of non-technical skills in anaesthesia residents facing a situation of simulated crisis management in the operating room. The primary end point was the performance in non-technical skills of anaesthesia residents. Secondary objectives were the impact of sleep deprivation on technical skills, sleepiness, and confidence.
Methods The trial was approved by a central Ethics committee (Comite´ de protection des Personnes Ile de France 3, Paris, France) and
complied with the French regulation of clinical research. The CONSORT guidelines were followed throughout.19
Participants Twenty anaesthesia residents from Paris academic hospitals were randomized in a 1:1 ratio to undergo a simulation session after a night on call [sleep-deprived (SLD) group] or after a night of normal sleep at home [rested (R) group]. They were informed of the anonymous video and audio recording of data and provided informed written consent. All of them had at least 1 yr experience in anaesthesia training and were familiar with high-fidelity simulation. Exclusion criteria were the presence of chronic sleep disorders, assessed by the Epworth questionnaire.20 A sleep diary covering three nights before the simulation session was completed by each participant to ensure proper group allocation. Residents who came after a night on call but had at least 5 h of consecutive sleep were re-allocated to the R group. Randomization was computer generated on the day of inclusion.
Simulation and scenario All sessions were performed using a high-fidelity manikin (Sim-man 3G; Laerdel, Stavanger, Norway) and recorded using three video cameras and one microphone through a dedicated piece of software (SimView; Laerdal, Stavanger, Norway). The simulation consisted of the following three consecutive steps: (i) briefing (introduction to the facility, the material, and manikin specificities); (ii) the simulated scenario itself; and (iii) debriefing on trainee’s feelings and performance analysis immediately afterwards. The duration of each individual session was 1 h. The scenario outline is summarized in Fig. 1. It consisted of a patient with acute peritonitis undergoing emergency general anaesthesia, which was complicated by anaphylactic shock secondary to the injection of succinylcholine. All scenarios were performed with the assistance of an anaesthetist nurse, who had completed a master class in simulation and served as facilitator. Facilitators were asked to behave in a reproducible manner during scenarios to minimize their influence on the resident performance. Once the patient was considered to be stabilized (stabilization was defined as peripheral oxygen saturation >95%, mean arterial pressure >65 mm Hg, and heart rate <100 beats min1 for at least 2 min) by a bolus injection of epinephrine 100 mg i.v. to be decided by the resident, a surgeon (simulated by a trainer in simulation) entered the operating room to create a dilemma regarding patient management (continue surgery or intensive care unit admission without surgery). All scenarios were performed between 14.00 and 16.00 h in order to limit the influence of chronotype on fatigue. Moreover, all residents were asked not to sleep during the morning before the simulation session.
Data collection The primary end point was the individual score of nontechnical skills assessed by the Anaesthetists’ Non-Technical Skills (ANTS)21 scale presented in Table 1. The ANTS scale is composed of four categories, with three to five elements in each category. Each element was rated from 1 (poor) to 4 (good). Elements were then averaged to obtain a 1–4 score for each category and added for a final score that yield a maximum of 16. Two independent senior anaesthetists, trained to use the ANTS scale, were blinded to the allocation group and observed performance by video after the session and scored the ANTS.
Impact of sleep deprivation on non-technical skills
|
127
BP 122/78 mm Hg, HR 102 beats min−1, RR 22 bpm, SpO2 97%, GCS 15/15 Intial state
Induction of general anaesthesia
Anaphylactic shock
Epinephrine 100 mg
BP 105/62 mm Hg, HR 88 beats min−1, RR 0 bpm, SpO2 98%, GCS 3/15
BP 77/42 mm Hg, Hr 127 beats min−1, RR 0 bpm, SpO2 88%, Et CO2 23 mm Hg, bilateral lung wheezing, skin rash.
BP 101/68 mm Hg, HR 104 beats min−1, RR 0 bpm, SpO2 94%, Et CO2 30 mm Hg, normal vesicular murmur.
Fig 1 Clinical scenario. BP, blood pressure; E
0
CO2 ,
end-tidal concentration of carbon dioxide; GCS, Glasgow Coma Scale; HR, heart rate; RR, respiratory rate; SpO2 ,
peripheral oxygen saturation.
Table 1 Description and rating system of Anaesthetists’ NonTechnical Skills (ANTS) scale. Rating: 4, good; 3, acceptable; 2, marginal; 1, poor Category
Element
Task management
Planning and preparing Prioritizing Providing and maintaining standards Identifying and using resources Coordinating activities with team members Exchanging information Using authority and assertiveness Assessing capabilities Supporting others Gathering information Recognizing and understanding Anticipating Identifying options Balancing risks and selecting options Re-evaluating
Team working
Situation awareness
Decision making
Technical skills were assessed by the completion of a technical check list containing 16 items regarding rapid sequence induction and management of intraoperative anaphylactic shock detailed in Table 2. This check list was built from guidelines of the French Anaesthesia and Critical Care society (SFAR). Data
(age, sex, duration of residency, sleep diary, etc.) on participants were also collected. Participants filled in an online questionnaire several days before the simulation to assess global confidence with the Rosenberg self-esteem scale and also chronotype with the Horne and Otsberg scale.22 23 On the day of simulation, instant sleepiness was auto-evaluated by using the Karolinska Sleepiness Scale.24 Confidence in anaesthesia skills was also auto-evaluated immediately before the simulation session with a validated 25 points questionnaire.25
Statistical analysis Data are presented as the mean (SD) or median (interquartile range) for continuous data according to statistical distribution (assumption of normality was assessed using the d’Agostino– Pearson test) and as count (percentage) for categorical parameters. Comparisons between the independent groups were made using the v2 or Fisher’s exact tests for categorical variables, and using the Student’s t-test or the Mann–Whitney test for quantitative parameters. Owing to its non-normal statistical distribution, the primary outcome was assessed with a nonparametric Mann–Whitney U-test. Agreement of blinded raters on non-technical skills performance was assessed by a test of inter-rater agreement (Fleiss’ kappa). All reported P-values are two-tailed, and P-values of <0.05 were considered to indicate statistically significant differences. We calculated that a sample of 20 residents would provide an 80% power to detect a two point difference in the ANTS score at a two-sided a level of 5%, assuming a median score of 14/16 in the rested group as observed in our pilot series with the same scenario and in previous studies.26 27
128
|
Neuschwander et al.
Table 2 Check list of technical skills Rapid sequence induction and intubation
Anaphylactic shock management
Material preparation Monitoring (heart rate, blood pressure, peripheral oxygen saturation) Preoxygenation Hypnotic injection (propofol/ etomidate/ketamine þ correct dose) Succinylcholine injection (þ correct dose) Cricoid pressure Balloon inflated
Call for help Increase fractional inspired O2 to 100%
Post-intubation management
Causal agent removal Fluid bolus
Epinephrine 100 mg b-Mimetics Blood sample (tryptase/ histamine) Re-evaluation
Table 3 Characteristics of participants. Continuous variables are expressed as the mean (SD) Variable
Male sex [n (%)] Age (yr, range) Duration of residency (yr) Epworth questionnaire Mood assessment: Profile of Mood Scales Anger Confusion Depression Fatigue Tension Vigour Shifts per month (n) Amount of sleep during previous night (h)
Sleep-deprived group (n¼10)
Rested group (n¼10)
4 (40) 24–29 3.5 (0.5)
5 (50) 25–30 3.5 (1)
9.6 (2.4)
8.5 (3)
3.3 (3.0) 7.0 (2.4) 2.3 (2.1) 11.6 (3.5) 5 (2.8) 8.9 (3.2) 3.9 (1) 4 (1)
3.0 (3.0) 5.9 (5.2) 2.2 (1.7) 6.3 (3.7) 5.8 (3.7) 12.3 (4.0) 4.1 (0.9) 7.5 (1.5)
Results From January to June 2015, 20 residents were randomized in the study, 10 in the SLD group and 10 in the R group. One eligible subject was excluded before randomization because his Epworth score was >15, suggesting a chronic sleep disorder. No randomized resident in the SLD group had to be reallocated to the R group according to the time of sleep during the night shift, and none slept before the simulation session, as required. The characteristics of the participants are displayed in Table 3, and a flow chart of participants is displayed in Fig. 2.
Primary end point The median value of non-technical skills was higher in the rested group [14.5 (14–15)] than the median value in the SLD
group [12.2 (10.5–13), P<0.02; Fig. 3]. Inter-rater agreement was 0.65 (0.09). At a categorical level of non-technical skills, team working scores were significantly lower in the sleep-deprived group compared with the rested group [3 (2.6–3) vs 4 (3.2–4); P<0.01], whereas situation awareness, decision making, and task management were not significantly different between groups [3 (3–3.7) vs 4 (3.5–4), P¼0.07; 3 (2.5–3.5) vs 3 (3–4), P¼0.31; and 3 (2.1–3.7) vs 4 (3.5–4), P¼0.05, respectively].
Secondary end points Technical skills performance, assessed by a composite scale, was not different between groups [12 (10.5–13) R group vs 12 (10.5–13) SLD group, P¼0.95]. There was no difference in overall confidence [Rosenberg score 30 (29–33) in SLD group vs 31 (30– 34.5) in R group, P¼0.46] or chronotype between groups (Horne and Otsberg 46 (43–48) in SLD group vs 51 (45–58) in R group, P¼0.16]. On the day of simulation, sleepiness was greater in the SLD group [KSS 6.5 (1.4)] than in the R group [KSS 3.7 (1.7), P<0.01] (KSS ¼ Karolinska sleepiness scale). Self confidence in anaesthesia skills assessed immediately before the simulation session was also lower in the SLD group than in the R group [64.1 (10.5) vs 84.8 (14.20), respectively, P<0.01)
Discussion The main original finding made in this prospective pilot randomized trial can be summarized as follows: sleep deprivation was associated with reduced non-technical skills in a population of anaesthesia residents exposed to a crisis management simulated scenario. This reduced mobilization of nontechnical skills was associated with impaired team working, increased sleepiness, and decreased confidence in anaesthesia skills. To our knowledge, this is the first pilot randomized trial indicating that anaesthetists’ non-technical skills are affected by sleep deprivation. Howard and colleagues3 studied the effects of total sleep deprivation in a population of 12 anaesthesia residents. They showed that anaesthetists had impairment of alertness and mood but found no difference in terms of clinical performance. This finding was possibly explained by a lack of statistical power of the study. Non-technical skills were not evaluated, however. More recently, Maltese and colleagues28 assessed the impact of a night shift on cognitive performance of intensivists. They showed significant alteration of cognitive abilities, regardless of experience or duration of sleep, compared with their own performance after a night of rest. These results are consistent with our findings, because non-technical skills consist of both social and cognitive skills and could therefore be affected by alteration of cognitive performance. Non-technical skills have also been found to be positively correlated with technical skills in simulated intraoperative crisis scenarios with 50 anaesthesia residents.29 This result suggests a possible association between non-technical skills performance and overall performance. No association between technical and non-technical skills was found in our study, but half of our subjects were sleep deprived, whereas none were sleep deprived in the study by Riem and colleagues.29 Also, technical skills were not assessed in detail in our study. Ours findings suggest that decreased confidence in anaesthesia skills could contribute to the reduction in non-technical skills. In contrast, global self-esteem of residents was similar in both groups several days before the simulation. This emphasizes that, in our population, sleep deprivation was
Impact of sleep deprivation on non-technical skills
Screened n=100
Included n=21
Excluded n=1 (Epworth > 1)
Included in the rested group (R) n=10
Included in the sleep deprived group (SD) n=10
10 (100%) included in the analysis
10 (100%) included in the analysis
Fig 2 Flow chart of participants.
Anaesthetists non-technical skills (ANTS)
16
14
12
*P<0.02
10
8
6
4 Rested group (R) n=10
Sleep-deprived (SLD) n=10
Fig 3 Comparison of non-technical skills between sleep-deprived and rested anaesthesia residents.
|
129
130
|
Neuschwander et al.
associated with reduced confidence on the day of simulation. Nevertheless, it was not possible to study the impact of confidence on performance because of our limited sample size. Non-technical skills are not familiar to French anaesthesia residents because they are not included in formal resident training programmes, standing in sharp contrast to other countries’ residents programmes and military and commercial airline training programmes. However, several lines of evidence suggest that a deficiency in non-technical skills may increase the risk of error. They are therefore probably required for safe and efficient performance in the operating theatre.30 This may pave the road leading to adverse medical events, as it has been shown that human errors play a crucial role in accident causation.31 32 Technical skills, such as difficult airway management, can be trained in a specific simulation training programme, with significant improvement of trainees’ performance.33 Interestingly, this may also be the case for non-technical skills. A 3 yr crisis resource management programme including lectures on human factors and crisis resource management and interactive sessions led to reduced incidence of critical events in an intensive care unit.17 Hughes an colleagues34 showed promising results of specific crisis resource management team training with emphasis on non-technical skills for trauma resuscitation teams in terms of team working and task management. In a simulated cardiac arrest scenario, Fernandez Castelao and colleagues18 found an association between nontechnical skills training and adherence to guidelines. Our study comes with some limitations. Firstly, the number of residents included is relatively small, which exposes our study to selection bias. Indeed, a large number of eligible subjects were screened but not included because participation in the study was voluntary. However, a lack of power regarding the primary outcome is unlikely, because we found a significant difference between groups with respect to non-technical skills. However, we cannot exclude the possibility that other differences, (i.e. in technical skills) could appear if using a larger sample size. The limited sample size also limits the interpretation of the pattern of deficiency in non-technical skills at a categorical level. Secondly, non-technical skills assessment may be difficult as it is partly subjective. Graham and colleagues35 observed low inter-rater reliability in a cohort of anaesthetists after a short training course. The inter-rater agreement between our two blinded evaluators was nevertheless considered good, with a j score >0.6. Thirdly, observation and comparison of nontechnical skills are closely linked to the environment and the team at stake. All scenarios were therefore played with exactly the same simulated crew (simulated surgeon and anaesthetic nurse), trainers in high-fidelity simulation, who tried to behave in a reproducible manner. As residents were expected to take over leadership in the situation, the impact of facilitators in team working can be minimized by keeping a follower attitude. Any extrapolation to another crisis management scenario or the real-life operating room has not been investigated in the present study and would be an over-interpretation of our results. Additionally, there was no objective physiological confirmation of sleep deprivation in our population of sleep-deprived residents. Sleep diaries nevertheless remain a reliable tool,36 and sleep-deprived residents showed increased sleepiness on the Karolinska Sleepiness Scale. The three-point difference between our groups is comparable to what was described in anaesthesia trainees after night shifts by Lancman.37 Finally, our study included only French anaesthesia residents, and generalizability to senior anaesthetists or residents from other countries is uncertain because no study has explored the impact of experience
or non-technical skills training programmes on coping with sleep deprivation. In conclusion, sleep deprivation induced by a night shift was associated with impaired non-technical skills in anaesthesia residents in a simulated anaesthesia intraoperative crisis scenario. Future trials should assess whether teaching and training non-technical skills at the same level as technical ones in anaesthesia resident educational programmes might improve their performance in the operating room and perhaps contribute to reduce the rate of medical errors in routine practice.
Authors’ Contributions Contributed to the design of the work, acquisition of data: A.N., A.J., A.Y., A.M., A.T. Drafted the manuscript: A.N., A.J. Revised the work for important intellectual content: C.D., P.C., J.M. Conducted the analysis and interpretation of data: A.N., A.J., A.T. All authors approved the submitted version of the manuscript.
Declaration of interest None declared.
Funding French national research agency (ANR-14-CE24-0021).
References 1.
Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press (US), 2000. Available from http://www.ncbi.nlm.nih.gov/books/NBK225182/ (accessed 12 November 2014) 2. Murray D, Dodds C. The effect of sleep disruption on performance of anaesthetists – a pilot study. Anaesthesia 2003; 58: 520–5 3. Howard SK, Gaba DM, Smith BE, et al. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology 2003; 98: 1345–55; discussion 5A 4. Eastridge BJ, Hamilton EC, O’Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg 2003; 186: 169–74 5. Hayter MA, Friedman Z, Katznelson R, Hanlon JG, Borges B, Naik VN. Effect of sleep deprivation on labour epidural catheter placement. Br J Anaesth 2010; 104: 619–27 6. Cao CGL, Weinger MB, Slagle J, et al. Differences in day and night shift clinical performance in anesthesiology. Hum Factors 2008; 50: 276–90 7. Flin RH, O’Connor P, Crichton M. Safety at the Sharp End: A Guide to Non-Technical Skills. Ashgate Publishing, Ltd, 2008. 8. Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ nontechnical skills. Br J Anaesth 2010; 105: 38–44 9. Gaba DM, Fish KJ, Howard SK, Crisis Management in Anesthesiology. Churchill Livingstone, 1994 10. Rutherford JS, Flin R, Irwin A. The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008. Anaesth Intensive Care 2015; 43: 512–7 11. Neu D, Kajosch H, Peigneux P, Verbanck P, Linkowski P, Le Bon O. Cognitive impairment in fatigue and sleepiness associated conditions. Psychiatry Res 2011; 189: 128–34
Impact of sleep deprivation on non-technical skills
12. Wali SO, Qutah K, Abushanab L, Basamh R, Abushanab J, Krayem A. Effect of on-call-related sleep deprivation on physicians’ mood and alertness. Ann Thorac Med 2013; 8: 22–7 13. Zeltser MV, Nash DB. Approaching the evidence basis for aviation-derived teamwork training in medicine. Am J Med Qual 2010; 25: 13–23 14. Flin R, O’Connor P, Mearns K. Crew resource management: improving team work in high reliability industries. Team Perform Manag Int J 2002; 8: 68–78 15. Catchpole KR, Giddings AEB, de Leval MR, et al. Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 2006; 49: 567–88 16. Haller G, Garnerin P, Morales M-A, et al. Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J Qual Health Care 2008; 20: 254–63 17. Haerkens MHTM, Kox M, Lemson J, Houterman S, van der Hoeven JG, Pickkers P. Crew Resource Management in the Intensive Care Unit: a prospective 3-year cohort study. Acta Anaesthesiol Scand 2015; 59: 1319–29 18. Fernandez Castelao E, Boos M, Ringer C, Eich C, Russo SG. Effect of CRM team leader training on team performance and leadership behavior in simulated cardiac arrest scenarios: a prospective, randomized, controlled study. BMC Med Educ 2015; 15: 116 19. Schulz KF, Altman DG, Moher D; CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. Br Med J 2010; 340: c332 20. Johns MWA. New method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991; 14: 540–5 21. Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 2003; 90: 580–8 22. Wongpakaran T, Tinakon W, Wongpakaran N, Nahathai WA. Comparison of reliability and construct validity between the original and revised versions of the Rosenberg Self-Esteem Scale. Psychiatry Investig 2012; 9: 54–8 23. Horne JA, Ostberg O. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int J Chronobiol 1976; 4: 97–110 24. Akerstedt T, Gillberg M. Subjective and objective sleepiness in the active individual. Int J Neurosci 1990; 52: 29–37
|
131
25. Morgan PJ, Cleave-Hogg D. Comparison between medical students’ experience, confidence and competence. Med Educ 2002; 36: 534–9 26. Skelton T, Nshimyumuremyi I, Mukwesi C, Whynot S, Zolpys L, Livingston P. Low-cost simulation to teach anesthetists’ non-technical skills in Rwanda. Anesth Analg 2016; 123: 474–80 27. Yee B, Naik VN, Joo HS, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulationbased education. J Am Soc Anesthesiol 2005; 103: 241–8 28. Maltese F, Adda M, Bablon A, et al. Night shift decreases cognitive performance of ICU physicians. Intensive Care Med 2016; 42: 393–400 29. Riem N, Boet S, Bould MD, Tavares W, Naik VN. Do technical skills correlate with non-technical skills in crisis resource management: a simulation study. Br J Anaesth 2012; 109: 723–8 30. Fletcher GCL, McGeorge P, Flin RH, Glavin RJ, Maran NJ. The role of non-technical skills in anaesthesia: a review of current literature. Br J Anaesth 2002; 88: 418–29 31. Reason J. Human error: models and management. Br Med J 2000; 320: 768–70 32. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med 2002; 347: 1249–55 33. Hubert V, Duwat A, Deransy R, Mahjoub Y, Dupont H. Effect of simulation training on compliance with difficult airway management algorithms, technical ability, and skills retention for emergency cricothyrotomy. Anesthesiology 2014; 120: 999–1008 34. Hughes KM, Benenson RS, Krichten AE, Clancy KD, Ryan JP, Hammond CA. Crew resource management program tailored to trauma resuscitation improves team behavior and communication. J Am Coll Surg 2014; 219: 545–51 35. Graham J, Hocking G, Giles E. Anaesthesia non-technical skills: can anaesthetists be trained to reliably use this behavioural marker system in 1 day? Br J Anaesth 2010; 104: 440–5 36. Buysse DJ, Ancoli-Israel S, Edinger JD, Lichstein KL, Morin CM. Recommendations for a standard research assessment of insomnia. Sleep 2006; 29: 1155–73 37. Lancman BM. Night shift fatigue among anaesthesia trainees at a major metropolitan teaching hospital. Anaesth Intensive Care 2016; 44: 364–70 Handling editor: A. R. Absalom