The Effect of Sleep Deprivation on Perfusionists

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Sleep deprivation among healthcare clinicians as a result of irregular, demanding work schedules has been shown to be a significant obstacle in the healthcare field (Friedman et al., 1973). In comparison to other cognitively demanding industries such as aviation, healthcare professionals work longer and more continuous permittable hours (Owens, 2001). A wide range of literature has shown that acute sleep deprivation (recent 24-hour complete sleep loss) impairs one’s performance in the workplace which allows for more clinical errors (Gaba et al., 2002). Health professionals may regularly work during the night. Biologically, during this time alertness is decreased. The circadian pacemaker controls rhythms of sleep. Due to the endogenous circadian pacemaker, greatest alertness occurs during the biological day, and the greatness feeling of sleepiness occurs during the biological night. By varying work schedules from day to night on an irregular basis, the circadian rhythmic system is unable to adapt. This phenomenon is called “circadian misalignment” (Cajochen et al., 1999). When an individual has 24 hours of wakefulness its psychomotor dysfunction is equivalent to a blood alcohol concentration of .10% (Leung et al., 1992). While many states have a blood alcohol limit for performing cognitive tasks, there may not be a limit on the amount of hours healthcare clinicians can continue performing tasks without sleep.

Cardiovascular perfusionists work extended hours and may have unpredictable events which may force them back to the hospital. Perfusionists must be available at times to operate the heart-lung machine. According to the American Society of ExtraCorporeal Technology Standards and Guidelines for Perfusion Practice, a guideline is that an on-call Perfusionist should be present and clinically ready for unscheduled and emergent procedures within sixty minutes of being called. Along with cardiopulmonary bypass procedures, this may also include a perfusionist supervising extracorporeal membrane oxygenation (AmSECT Standards and Guidelines for Perfusion Practice, 2017). According to standard 16.1, in order for the perfusionist to ensure proper provision of care, he/she shall receive an adequate rest period between schedules work hours. Unfortunately for perfusionist, the adequate rest period described in the standard is not quantified and that number may vary based on institutional policies.

[bookmark: OLE_LINK1][bookmark: OLE_LINK2]While sleep deprivation and performance have been examined in other medical specialties, only one study has investigated the effect of sleep deprivation on the performance of perfusionists. Trew and colleagues surveyed 445 perfusionists to collect data on their experiences with fatigue and working variable, extended hours. Three-fourths of the respondents had concerns that their operation of the heart-lung machine was impaired when they are sleep-deprived. According to the results of this study, perfusionists are not excused from the effects of job-induced sleep deprivation. Unfortunately, no study has investigated the effect of sleep deprivation on the performance of perfusionists. A study by Hodge and colleagues looked at the effects of sleep deprivation on the performance of perfusion students however this study may not be applied to professional perfusionists with years of experience running the heart-lung machine. In this study, the simulation sessions lasted only 7 minutes which does not represent a realistic clinical scenario (Hodge et al., 2012). Also, using a small and homogenous study population makes it difficult for the results to be generalizable.

Previously, it would be unethical to perform randomized controlled studies using real patients as subjects. Due to recent advances in technology, we could now use high-fidelity simulation to study the effects of sleep deprivation on perfusionists. In this research proposal, I would like to use a mixed-methods approach that involves using the Orpheus cardiopulmonary bypass simulator and subjective questionnaires on sleepiness to elicit the effect of sleep deprivation on simulated clinical performance in experienced perfusionists.

A survey by Trew and colleagues at SUNY Upstate Medical University (2011), sought to collect preliminary data on the prevalence of fatigue in perfusion and to identify if there were concerns regarding fatigue, performance and perfusion safety. A 50-question survey was distributed to perfusionist in May of 2010. 68.9% of surveyed perfusionists have worked at the hospital for greater than 23 hours straight. 17.5% of perfusionists have worked continuously for over 36 hours. Microsleep while performing cardiopulmonary bypass was reported by 49.5% of respondents. 51.5% of perfusionists believe they perform less effectively when they are fatigued. Another 75.9% of perfusionists indicate that they have been concerned about their ability to perform their job adequately due to fatigue-related acute sleep deprivation. The survey data establishes that there are concerns of fatigue and acute sleep deprivation in the perfusion community. The study notes that further research must be performed to understand actual performance degradation that may occur in fatigued perfusionists performing cardiopulmonary bypass. This study captures the need for the research I am proposing to complete. A study on real perfusionists should be completed where sleep deprivation is measured on cardiopulmonary bypass performance.

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Utilizing a mixed-methods approach involving a focus group discussion, subjective questionnaires, and the high-fidelity Orpheus cardiopulmonary bypass simulator, Hodge and colleagues (2012) sought to determine the effect of sleep deprivation on simulated clinical performance in perfusion students compared with their rested, baseline states. Seven second-year Medical University of South Carolina cardiovascular perfusion students were enrolled in the study. Each student was experienced with the Orpheus cardiopulmonary bypass stimulator and had not been medically diagnosed with a sleep disorder. For the control, participants received a normal night of rest before their first simulation session which was started at 6:00AM. The last simulation consisted of the subjects being kept awake for 24 hours without the consumption of any caffeine or stimulants. Before each study the sleep scale questionnaires were completed. Subjects were given a patient history and protocol for adult surgeries. During the seven-minute cardiopulmonary bypass case, the investigators manipulated several parameters while the subjects ran the heart-lung machine. Performance was based on the subject’s response time to initiate correcting the action. The study’s results demonstrated that cardiovascular perfusion students were affected by sleep deprivation. Significant differences in reaction times were found between the baseline values and the different intervals in which the participants were retested (Hodge et al., 2012). I included this study in the literature review because the Orpheus cardiopulmonary bypass stimulator is used as a research tool. This is a device I plan to use in my research project. I also plan to use the repeated-measures ANOVA to establish a baseline and then retest my subjects as I deprive them of sleep.

In a simulated surgical case performed by twelve anesthesiology residents, the effects of sleep deprivation on psychomotor and clinical performance, subjective and objective sleepiness, and mood were examined (Howard et al., 2003). The anesthesiology residents performed a four-hour anesthetic on a simulated patient the morning after two conditions. In the first condition, the residents were sleep-extended. Here, they did not need to arrive at work until 10:00AM. In the second condition, residents were awake for at least 25 hours. The subjective data was collected by using the Profile of Mood States and the Stanford Sleepiness Scale. There was also a psychomotor test battery completed to retrieve psychomotor vigilance task data in both the sleep-extended and sleep-deprived controls. During the psychomotor performance probe there was a longer but no statistically significant mean response time during sleep-deprived vs. sleep-extended states. The task patterns and reported workload of subjects was not significantly affected by the lack of sleep. The study did not have a definitive relationship between sleep deprivation and clinically relevant errors. This study shows that there may not always be a relationship between sleep deprivation and clinical performance.

In a cross-sectional comparative study, the effect of acute sleep deprivation, due to working long on-call shifts, on mood and alertness was examined. The study included eighty-eight junior physicians in Saudi Arabia (Wali et al., 2012). A self-reported profile of mood states questionnaire was used measuring depression, anger, tension, confusion, fatigue, and vigor. The total score was calculated to determine the mood of the junior physicians. The junior physicians also completed the Stanford Sleepiness Scale to measure the impact of short-term sleep loss on subjective sleepiness. For on-call days, 25% of the participants reported sleeping fewer than 2 hours and 87% reported obtaining 5 or fewer hours. The percentage of physicians who were alert post on-call was significantly reduced compared to the percentage pre on-call. The profile of mood states was significantly worse post-call than pre-call. The variables of depression, anger, confusion, fatigue, and vigor all have an effect on job performance. Increased confusion may impair a perfusionist’s ability to operate the heart-lung machine and may jeopardize patient safety.

Methods In July of 2020, cardiovascular perfusionists will be sent an invitation to participate in our study via Perfmail and Perflist. Participants will be enrolled in the study under a protocol approved by the SUNY Upstate Medical University Institutional Review Board. All participants must give written informed consent. Each participant should have similar experience with the Orpheus CPB simulator and should demonstrate baseline competencies using it. A maximum of twenty subjects will be able to participate in the study. According to Lewis and colleagues (2016) the majority of perfusionists are over the age of 55 years of age with 3 male perfusionists for every 1 female perfusionist. For this reason, I would like the study to be composed of 15 males and 5 females over the age of 55. Participants may not have a diagnosed sleep disorder.

Materials Participants will complete the Epworth Sleepiness Scale (ESS) and the Stanford Sleepiness Scale (SSS) to assess their level of sleepiness (Appendix A). Both questionnaires have been used in as a means of establishing baseline data when testing a change in performance (Johns, 1991& Hoddes et al.,1993). The ESS questionnaire is a self-administered sleep propensity test that measures one’s likelihood of falling asleep during eight common, daily activities (Johns, 1991). ESS scores range from 0–24 and a sum score of 16 or greater indicates excessive daytime sleepiness (Johns, 1991). In contrast, the SSS questionnaire is a simple way to measure subjective sleepiness at a given time interval. Subjects will rate their level of sleepiness on a 7-point, predetermined scale. Both questionnaires will be administered before each simulation session. Clinical performance will be measured by the high-fidelity Orpheus cardiopulmonary bypass perfusion simulator. The system comprises a hydraulic simulator, an electronic interface unit and a controlling computer with associated real-time computer models. It is designed for use within an actual operating theatre, or within a specialized simulation facility. The hydraulic simulator will be positioned on an operating table and physically connected to the circuit of the SUNY Upstate Medical University high-fidelity center’s heart-lung machine (Morris et al., 2007). Both machines are commonly used in hospital settings and each participant can pick the machine they feel more comfortable with. The SUNY Upstate Medical University high fidelity center OR used for this study will consist of an operating table with sterile blue drapes and a patient mannequin to mask the hydraulic simulator. Two monitoring screens will display real-time mean arterial and central venous pressures, electrocardiography (EKG) waveforms, sinus pressure and temperature.

Procedures The participants will be instructed to get a full night’s rest before the start of the study. The subjects will serve as their own controls and will be assessed at three intervals. We will start with a baseline and then reassess them at 12, 18, and 24 hours. Before each assessment, participants will take the sleepiness scale questionnaires. An investigator will remain with the participants at all times to make sure there is no sleep taking place. Each session will be 30 minutes long. An investigator will act as the surgeon and will manipulate variables. The subjects will be timed on how long it takes them to initiate correcting the variables. Mean arterial pressures, Partial pressures of oxygen and carbon dioxide, decreased venous return, high line pressures and mixed venous oxygen saturation will all be manipulated throughout the case. If participants neglect a variable they will be given the maximum time allocated.


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