9 Straight Days of Call: Fatigue in the Cath Lab

“Tonight will make 9 straight days on call. I’m exhausted. We’ve been in the hospital 5 nights, and a couple times on 2,” she said.
 “Why so many?”
 “Not enough people to cover. One on vacation, one on sick leave, and two rotated to radiology. Even our nurse manager had to take call.”
“That sounds awful. What about registry nurse help?”
“They’d rather take 12-hour shifts rather than lower paying call. Who wouldn’t?”
“How about traveling nurses?”
“Administration is not hiring. I’m not sure how long we can go on like this.”

I heard this story recently (and have heard it before) from a couple of experienced and dedicated nurses. ‘Call’ was becoming overwhelming and it was evident that soon fatigue and its associated consequences would set in. While probably an atypical situation, it likely occurs at times in every lab, every workplace and for everyone with demanding after-hour duties.

It is no surprise that fatigue is a major issue in almost all areas of the workforce, including medical service care delivery such as the cath lab. From a quick review of the subject (thank you, Google), fatigue is increasing among U.S. workers. Of 820 human resource leaders, over 80% believe that fatigue among workers is worse than in previous years.¹

Of importance to our discussion relating to work in the cath lab, it appears that (like many businesses), the main reason for workplace fatigue is too few employees for the work to be done. Additional, potential factors contributing to workplace fatigue also include the blurring boundaries between work and home life, desire to advance (or to please), and overwork due to fear of losing one’s job.

Fatigue diminishes our cognitive functions, i.e., alertness, perception, and reasoning. It was interesting to learn that severe fatigue, as occurs when someone has been awake for 14 to 17 hours followed by only 6 hours of sleep, can be similar to being under the influence of alcohol.²

Alertness in the workplace pays dividends through increased productivity, safety and quality. Fatigue can be minimized by addressing it on several levels: (1) education, (2) work hours (including start times, shift length, type of shifts (fixed vs. rotating shifts), (3) consecutive work days, and (4) overtime. In certain industries, the risk of fatigue-related work problems has prompted the government to pass legislation to control factors producing fatigue. This legislation is easily seen in the rules related to workers in air traffic control, trucking and other public transportation, and nuclear power plants. Fortunately, for those of us working in the cath lab, fatigue may not have the same “life or death” consequences, but all of us should still be concerned about how it affects cath lab safety and performance.

Sleep deprivation is one of the most common correctable causes of workplace fatigue. Because it is at times a conscious behavior (i.e., staying awake), we should remind ourselves that this decision should be good one. Since people sleep more on their days off than they do on workdays, the people on the longer workdays will end up averaging more sleep than those on the 8-hour workdays. Managers should consider longer but fewer shifts to reduce fatigue. The number of consecutive days of work is also related directly to the degree of fatigue. The more days in a row one works, the more one’s sleep deficit accumulates, often in an undetectable fashion. Most people will not realize a small drop in cognitive function as each day passes. With each passing work night, fatigue through sleep deprivation reduces safety and productivity. Reducing the number of consecutive days worked will provide a respite to catch up on sleep. Although the recovery time is uncertain, most researchers believe that at least two days off in a row will have the most beneficial recuperative impact.

Fatigue factors: Rotating vs. fixed shifts and overtime

From an alertness point of view, fixed shifts are superior to rotating shifts. There is a significant amount of research indicating higher health risks and lower overall alertness on rotating shifts.

Overtime (and on-call time) disrupts people’s lives. Many personal plans must be cancelled, resulting in a degree of stress and job dissatisfaction. Forfeited sleep hours are often traded for overtime hours. How much overtime is too much is a difficult question to answer. Most companies feel that an annual average between 5% and 15% is about right.³ However, the overtime related to cath lab work is highly variable and, as most know, totally unpredictable. The consequences of fatigue, such as diminished alertness, will translate into decreased productivity, safety and quality. Eliminating fatigue and improving alertness can be facilitated by: (1) creating a work structure that promotes awareness and (2) giving the staff the education, training, and support needed to make good decisions.³

It was interesting that in my conversation with the nurses, they also said that they think that call back performance, despite any degree of fatigue, is still of high quality (i.e., patient care is not comprised) due to the adrenaline rush. Although overworked and under-paid (and as an aside, in my opinion, everyone is under-paid who works in the cath lab), these nurses are still as conscientious and caring about work in the cath lab as they have ever been. As in every cath lab I have worked in or visited, the nurses and technologists are the most dedicated, involved, and responsible people in medicine, but they are certainly not immune from fatigue.

I have discussed many different physical and psychological aspects of personal interactions that affect the cath lab work environment in these pages before, but it is worth reviewing what we can do to improve the work lives of our team.

Overcoming obstacles to ‘call’ fatigue

1. Plan your work hours. Find the right balance. Not too many, not too few, and not too late (when possible). It is possible to look at the schedule and plan. Plan not only the day and reshuffle the schedule during the day as the case flow dictates, but also the call schedule every week or, if necessary, every day. Poor planning often leads to late hours and perhaps, unnecessary hours.
2. Find the right staff balance. The team should have enough bodies to do the job and then one more (in case someone requires medical or personal leave, including vacations). With a skeleton crew, it is even more important that the team functions well together and is on the ‘same page,” meaning they hold the same goals regarding patient care, safety and satisfaction. To reduce unnecessary stressors, all of us, especially the physicians, should show up to the procedure on time, work to assist in faster patient preparation, be organized, and share the needs of the procedure to make the steps more efficient. After the procedure, help move the patient, turn the room over, and prepare for the next patient. How many nurses and techs are needed? The answer depends on the lab activity, budget and goals, but it really is a simple answer: “More.”
3. Encourage physician and administrative support in establishing the “best place to work.” Team leaders should try to minimize activities that lead to unnecessary overtime and prolonged worked days. We all know that there will be unavoidable delays in the cath lab, either from a prolonged patient procedure or from systematic malfunctions (physician delays, transportation, computer glitches, pharmacy duties, etc.). 

Among the many aspects of the cath lab environment, the attitude and support of physicians and their approach to the team has a large effect that can be either positive or negative. The cath lab is not just another ‘lab’. It is an organic, functioning unit comprised of interacting team members benefiting from favorable, polite, and efficiently communicated interactions.

Finally, it makes sense to me that we should be sure everyone has time off and time to grow (leisure time and educational time). On-call hours are usually well paid, but at times, painful. The more call taken without a break, the more exhaustion accumulates, leading to fatigue, inattention, mood swings, and rarely, medical error. Is there a limit to the amount of call a team member can take? I am not sure on this one, but it seems the answer is no. In the end, it is up to the individual to be their own best advocate for rational on-call duty.

References

1. WorkForce Software. 2010 Workforce Management Trend Survey. WorkForce Software White Papers. Available online at https://go.workforcesoftware.com/2010-Workforce-Management-Trend-Survey.html?lsd= WhitePaper&ls=/. Accessed March 15, 2012.
2. Society for Human Resource Management. Available online at https://www.shrm.org/Publications/HRNews/Pages/FatigueFactors.aspx. Accessed March 15, 2012.
3. Attacking fatigue in the workplace. May 11, 2011. Available online at https://www.prweb.com/releases/2011/5/prweb8402631.htm. Accessed March 15, 2012.

Disclosure: Dr. Kern reports that he is a speaker for Volcano Therapeutics and St. Jude Medical, and is a consultant for Merit Medical and InfraReDx, Inc.

LETTER TO THE CLINICAL EDITOR

Re: A Better Way to Secure Radial Artery Sheaths

February 24, 2012

Dr. Kern,

I wanted to share with you and the readers a better way I found to keep radial sheaths in place. Instead of a Tegaderm (3M) or an Opsite (Smith & Nephew), we use a Statlock device (MAQUET Cardiovascular) that uses the Statlock to secure the intra-aortic balloon pump catheter to the leg. The Statlock locks the sheath in place and it will not move when doing catheter exchanges (see figures). The doctors really love it. The model number is 0684-00-0472.

The method of applying the Statlock to radial approach is as follows:

• After the radial sheath is in place, make sure skin area is clean and dry.
• Apply benzoin to area and let dry.
• Position the Statlock proximal to sheath, pull sheath out 5 to 10 mm, and verify position of tubing and suture tab.
• Remove adhesive backing and secure to skin, then lock down tab.

The cost of the Statlock is $18.25 and cost of large Tegaderm $0.63. Due to cost, you may not want to use it on every case, but if you are doing multiple catheter exchanges with this technique, your sheath will stay secure.

I have never had any problem removing the Statlock from the arm. Alcohol is how you are supposed to remove it, I believe, but we never have to use it.  

Thanks for taking the time to present this.

Natalie Beyer
Western Baptist Hospital
Paducah, Kentucky
Email: nataliesbailey@hotmail.com