It was when my lung fell out that it hit me. No, come to think of it, it was before that, when a scorpion struck my left calf. Or it might have been when my heart exploded. No, it was earlier than that—probably around the time my right lower abdominal quadrant was gutted by that wild boar. No, actually, it was even earlier than that. Somewhere around the time I pulled my 204th muscle. Yeah, that was it. That’s when I first wondered why there is no “fun run” for safety.

Truth be told, there was no de-lunging, scorpions, cardiac explosion, or wild-boar-goring. It just felt like that. The reason: I was running. The occasion: an annual fun (?) run to support Crohn’s disease and ulcerative colitis. Why I, an out-of-shape specimen blessed with a superhero-like affinity for both chips and the couch, should be pounding the pavement early on a Saturday morning is a case study in wifely nagging.

And misplaced healthcare priorities.

You see, I have neither Crohn’s nor ulcerative colitis, have no friends or family members with them, and, frankly, rarely even provide care for patients with these diseases. What I do have is a gastroenterologist for a wife. A gastroenterologist who passionately supports gastroenterological problems; a gastroenterologist who doesn’t herself like to participate in fun runs; a gastroenterologist who relishes, apparently, seeing her husband sweat lactate while testing the anaerobic limits of the human organism. This was the nagging part.

As the gun reported at 7:30 a.m., there I was, fidgeting nervously at the starting line in a moth-eaten cotton tee from the last road race I had run—in 1989—while those around me gave my too-short, reversible, blue-and-white gym shorts the up-and-down. Cotton socks crotched, feet pre-blistered, I departed, feeling good—for the first four meters.

The next 4.99 kilometers proved slightly more daunting—providing an abundance of K’s to ponder the misplaced healthcare priorities part.

Running in The Trees

After I expertly buried the first 100-meter downhill, the race entered a well-worn, tree-lined footpath. I was shocked by both the splendor of the environs as well as the hordes of people passing me. I was comfortable with the concept of the taut young adults leaving me in their dust and, even, sort of, the superiorly fit elders. The pre-teens were more unsettling. As were the walkers—especially the walker using a walker.

It’s interesting, the relationship between road races and medical diseases. It’s not surprising, really, that generally healthy specimens would band together and use exercise as a weapon against disease—it’s actually quite noble. And common. My guess is your hometown counts numerous foot, bike, and foot-and-bike races supporting the eradication of myriad medical maladies.

In the span of just a few months, I’ve noted local races raising awareness of neurologic disorders (multiple sclerosis, Alzheimer’s, stroke, spinal muscular atrophy), cancer (breast, prostate, lung, leukemia, lymphoma, colon, skin, sarcoma, carcinoid), infectious disease (HIV/AIDS), and other medical conditions or causes (cystic fibrosis, cleft palate, pre-eclampsia, transplant, veterans).

Now, don’t get me wrong: I fully support any fund- or awareness-raising events targeting specific diseases or causes. In fact, if I were only slightly less slothlike, I’d participate in more of them. It’s just that in the grand scheme of things, it seems we are missing the forest through the trees. Finding a cure for cancer will matter little if we can’t deliver that cure in a safe, efficient, high-quality manner. Put another way, we can’t cure cancer patients if our health delivery system kills them first.

Seeing the Forest

And kill them we do. Now, you may not like the word “kill,” and certainly it makes me uncomfortable, but what other word better characterizes the situation? Medical errors result in up to 200,000 preventable deaths per year, according to the recent HealthGrades patient safety report.¹ This study reviewed Medicare data from all 50 states and found a mortality rate that was nearly double that reported in the seminal 1999 Institute of Medicine report (44,000-98,000; extrapolated from data in three states).²

And these are just deaths in hospitals; no mention is made of community or residential deaths from medical error. These data also don’t account for the pain and suffering left in the wake of the estimated 15 million annual episodes of harm (that’s 40,000 per day!).

In the end, the World Health Organization (WHO) estimates that 10% of hospital stays involve a serious, preventable, adverse event. Which of the 10 patients you’ll see tomorrow will suffer that serious, PREVENTABLE harm?

Using a conservative average of the two reports, roughly 100,000 people die annually from hospital-based medical errors. This slots medical error as the sixth-most-common cause of death in the U.S., trailing only heart disease (616,067), cancer (562,875), stroke (135,952), chronic lower respiratory disease (127,924), and accidents (123,706). If we use the 200,000 estimate, then error trails only the heart and cancer as a cause of death. And, in terms of individual cancers, only the lung (156,940) kills as many Americans as medical errors. Colorectal (49,380), breast (39,970), and prostate (33,660) don’t even come close.

Yet these data appear to be lost on the legions of race organizers. A Web search uncovered not a single organized race event trying to counter the perils of medical error. No Lance Armstrong, no Katie Couric, no Jerry Lewis. Nothing.

Thankfully, these data are not lost on the ones who bear the brunt of these errors. A Commonwealth survey reported that 22% of respondents were aware of a medical error in care provided to them or their family. Another paper following the release of the IOM report put the number at 42%.^3,4

Still, nary a race “K” has been devoted to reducing medical errors.

Harriers Against Harm

As the finish line draws near, I note that the overhead scoreboard has taken on the appearance of the national debt clock in Manhattan—a large number rapidly getting larger. The replenishment table is littered with crumpled Dixie cups, the music has drifted, and the crowd has dwindled to a handful of volunteers, many of whom tap their toes awaiting my finish.

I wonder what it’ll take. If 12,000 people with spinal muscular atrophy is enough to convene a race, what of the millions of people harmed annually by medical errors? How many more have to die before patient safety becomes an issue, becomes it’s own cause, gets it own fun run?

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver,where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. HealthGrades Eighth Annual Report on Patient Safety in American Hospitals Study. Available at: www.healthgrades.com. Published March 2011. Accessed Aug. 31, 2011.
2. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
3. The Commonwealth Fund 2002 Annual Report. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Content/Annual-Reports/2002-Annual-Report.aspx. Accessed Sept. 9, 2011.
4. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933-1940.

It was when my lung fell out that it hit me. No, come to think of it, it was before that, when a scorpion struck my left calf. Or it might have been when my heart exploded. No, it was earlier than that—probably around the time my right lower abdominal quadrant was gutted by that wild boar. No, actually, it was even earlier than that. Somewhere around the time I pulled my 204th muscle. Yeah, that was it. That’s when I first wondered why there is no “fun run” for safety.

Truth be told, there was no de-lunging, scorpions, cardiac explosion, or wild-boar-goring. It just felt like that. The reason: I was running. The occasion: an annual fun (?) run to support Crohn’s disease and ulcerative colitis. Why I, an out-of-shape specimen blessed with a superhero-like affinity for both chips and the couch, should be pounding the pavement early on a Saturday morning is a case study in wifely nagging.

And misplaced healthcare priorities.

You see, I have neither Crohn’s nor ulcerative colitis, have no friends or family members with them, and, frankly, rarely even provide care for patients with these diseases. What I do have is a gastroenterologist for a wife. A gastroenterologist who passionately supports gastroenterological problems; a gastroenterologist who doesn’t herself like to participate in fun runs; a gastroenterologist who relishes, apparently, seeing her husband sweat lactate while testing the anaerobic limits of the human organism. This was the nagging part.

As the gun reported at 7:30 a.m., there I was, fidgeting nervously at the starting line in a moth-eaten cotton tee from the last road race I had run—in 1989—while those around me gave my too-short, reversible, blue-and-white gym shorts the up-and-down. Cotton socks crotched, feet pre-blistered, I departed, feeling good—for the first four meters.

The next 4.99 kilometers proved slightly more daunting—providing an abundance of K’s to ponder the misplaced healthcare priorities part.

Running in The Trees

After I expertly buried the first 100-meter downhill, the race entered a well-worn, tree-lined footpath. I was shocked by both the splendor of the environs as well as the hordes of people passing me. I was comfortable with the concept of the taut young adults leaving me in their dust and, even, sort of, the superiorly fit elders. The pre-teens were more unsettling. As were the walkers—especially the walker using a walker.

It’s interesting, the relationship between road races and medical diseases. It’s not surprising, really, that generally healthy specimens would band together and use exercise as a weapon against disease—it’s actually quite noble. And common. My guess is your hometown counts numerous foot, bike, and foot-and-bike races supporting the eradication of myriad medical maladies.

In the span of just a few months, I’ve noted local races raising awareness of neurologic disorders (multiple sclerosis, Alzheimer’s, stroke, spinal muscular atrophy), cancer (breast, prostate, lung, leukemia, lymphoma, colon, skin, sarcoma, carcinoid), infectious disease (HIV/AIDS), and other medical conditions or causes (cystic fibrosis, cleft palate, pre-eclampsia, transplant, veterans).

Now, don’t get me wrong: I fully support any fund- or awareness-raising events targeting specific diseases or causes. In fact, if I were only slightly less slothlike, I’d participate in more of them. It’s just that in the grand scheme of things, it seems we are missing the forest through the trees. Finding a cure for cancer will matter little if we can’t deliver that cure in a safe, efficient, high-quality manner. Put another way, we can’t cure cancer patients if our health delivery system kills them first.

Seeing the Forest

And kill them we do. Now, you may not like the word “kill,” and certainly it makes me uncomfortable, but what other word better characterizes the situation? Medical errors result in up to 200,000 preventable deaths per year, according to the recent HealthGrades patient safety report.¹ This study reviewed Medicare data from all 50 states and found a mortality rate that was nearly double that reported in the seminal 1999 Institute of Medicine report (44,000-98,000; extrapolated from data in three states).²

And these are just deaths in hospitals; no mention is made of community or residential deaths from medical error. These data also don’t account for the pain and suffering left in the wake of the estimated 15 million annual episodes of harm (that’s 40,000 per day!).

In the end, the World Health Organization (WHO) estimates that 10% of hospital stays involve a serious, preventable, adverse event. Which of the 10 patients you’ll see tomorrow will suffer that serious, PREVENTABLE harm?

Using a conservative average of the two reports, roughly 100,000 people die annually from hospital-based medical errors. This slots medical error as the sixth-most-common cause of death in the U.S., trailing only heart disease (616,067), cancer (562,875), stroke (135,952), chronic lower respiratory disease (127,924), and accidents (123,706). If we use the 200,000 estimate, then error trails only the heart and cancer as a cause of death. And, in terms of individual cancers, only the lung (156,940) kills as many Americans as medical errors. Colorectal (49,380), breast (39,970), and prostate (33,660) don’t even come close.

Yet these data appear to be lost on the legions of race organizers. A Web search uncovered not a single organized race event trying to counter the perils of medical error. No Lance Armstrong, no Katie Couric, no Jerry Lewis. Nothing.

Thankfully, these data are not lost on the ones who bear the brunt of these errors. A Commonwealth survey reported that 22% of respondents were aware of a medical error in care provided to them or their family. Another paper following the release of the IOM report put the number at 42%.^3,4

Still, nary a race “K” has been devoted to reducing medical errors.

Harriers Against Harm

As the finish line draws near, I note that the overhead scoreboard has taken on the appearance of the national debt clock in Manhattan—a large number rapidly getting larger. The replenishment table is littered with crumpled Dixie cups, the music has drifted, and the crowd has dwindled to a handful of volunteers, many of whom tap their toes awaiting my finish.

I wonder what it’ll take. If 12,000 people with spinal muscular atrophy is enough to convene a race, what of the millions of people harmed annually by medical errors? How many more have to die before patient safety becomes an issue, becomes it’s own cause, gets it own fun run?

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver,where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. HealthGrades Eighth Annual Report on Patient Safety in American Hospitals Study. Available at: www.healthgrades.com. Published March 2011. Accessed Aug. 31, 2011.
2. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
3. The Commonwealth Fund 2002 Annual Report. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Content/Annual-Reports/2002-Annual-Report.aspx. Accessed Sept. 9, 2011.
4. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933-1940.

It was when my lung fell out that it hit me. No, come to think of it, it was before that, when a scorpion struck my left calf. Or it might have been when my heart exploded. No, it was earlier than that—probably around the time my right lower abdominal quadrant was gutted by that wild boar. No, actually, it was even earlier than that. Somewhere around the time I pulled my 204th muscle. Yeah, that was it. That’s when I first wondered why there is no “fun run” for safety.

Truth be told, there was no de-lunging, scorpions, cardiac explosion, or wild-boar-goring. It just felt like that. The reason: I was running. The occasion: an annual fun (?) run to support Crohn’s disease and ulcerative colitis. Why I, an out-of-shape specimen blessed with a superhero-like affinity for both chips and the couch, should be pounding the pavement early on a Saturday morning is a case study in wifely nagging.

And misplaced healthcare priorities.

You see, I have neither Crohn’s nor ulcerative colitis, have no friends or family members with them, and, frankly, rarely even provide care for patients with these diseases. What I do have is a gastroenterologist for a wife. A gastroenterologist who passionately supports gastroenterological problems; a gastroenterologist who doesn’t herself like to participate in fun runs; a gastroenterologist who relishes, apparently, seeing her husband sweat lactate while testing the anaerobic limits of the human organism. This was the nagging part.

As the gun reported at 7:30 a.m., there I was, fidgeting nervously at the starting line in a moth-eaten cotton tee from the last road race I had run—in 1989—while those around me gave my too-short, reversible, blue-and-white gym shorts the up-and-down. Cotton socks crotched, feet pre-blistered, I departed, feeling good—for the first four meters.

The next 4.99 kilometers proved slightly more daunting—providing an abundance of K’s to ponder the misplaced healthcare priorities part.

Running in The Trees

After I expertly buried the first 100-meter downhill, the race entered a well-worn, tree-lined footpath. I was shocked by both the splendor of the environs as well as the hordes of people passing me. I was comfortable with the concept of the taut young adults leaving me in their dust and, even, sort of, the superiorly fit elders. The pre-teens were more unsettling. As were the walkers—especially the walker using a walker.

It’s interesting, the relationship between road races and medical diseases. It’s not surprising, really, that generally healthy specimens would band together and use exercise as a weapon against disease—it’s actually quite noble. And common. My guess is your hometown counts numerous foot, bike, and foot-and-bike races supporting the eradication of myriad medical maladies.

In the span of just a few months, I’ve noted local races raising awareness of neurologic disorders (multiple sclerosis, Alzheimer’s, stroke, spinal muscular atrophy), cancer (breast, prostate, lung, leukemia, lymphoma, colon, skin, sarcoma, carcinoid), infectious disease (HIV/AIDS), and other medical conditions or causes (cystic fibrosis, cleft palate, pre-eclampsia, transplant, veterans).

Now, don’t get me wrong: I fully support any fund- or awareness-raising events targeting specific diseases or causes. In fact, if I were only slightly less slothlike, I’d participate in more of them. It’s just that in the grand scheme of things, it seems we are missing the forest through the trees. Finding a cure for cancer will matter little if we can’t deliver that cure in a safe, efficient, high-quality manner. Put another way, we can’t cure cancer patients if our health delivery system kills them first.

Seeing the Forest

And kill them we do. Now, you may not like the word “kill,” and certainly it makes me uncomfortable, but what other word better characterizes the situation? Medical errors result in up to 200,000 preventable deaths per year, according to the recent HealthGrades patient safety report.¹ This study reviewed Medicare data from all 50 states and found a mortality rate that was nearly double that reported in the seminal 1999 Institute of Medicine report (44,000-98,000; extrapolated from data in three states).²

And these are just deaths in hospitals; no mention is made of community or residential deaths from medical error. These data also don’t account for the pain and suffering left in the wake of the estimated 15 million annual episodes of harm (that’s 40,000 per day!).

In the end, the World Health Organization (WHO) estimates that 10% of hospital stays involve a serious, preventable, adverse event. Which of the 10 patients you’ll see tomorrow will suffer that serious, PREVENTABLE harm?

Using a conservative average of the two reports, roughly 100,000 people die annually from hospital-based medical errors. This slots medical error as the sixth-most-common cause of death in the U.S., trailing only heart disease (616,067), cancer (562,875), stroke (135,952), chronic lower respiratory disease (127,924), and accidents (123,706). If we use the 200,000 estimate, then error trails only the heart and cancer as a cause of death. And, in terms of individual cancers, only the lung (156,940) kills as many Americans as medical errors. Colorectal (49,380), breast (39,970), and prostate (33,660) don’t even come close.

Yet these data appear to be lost on the legions of race organizers. A Web search uncovered not a single organized race event trying to counter the perils of medical error. No Lance Armstrong, no Katie Couric, no Jerry Lewis. Nothing.

Thankfully, these data are not lost on the ones who bear the brunt of these errors. A Commonwealth survey reported that 22% of respondents were aware of a medical error in care provided to them or their family. Another paper following the release of the IOM report put the number at 42%.^3,4

Still, nary a race “K” has been devoted to reducing medical errors.

Harriers Against Harm

As the finish line draws near, I note that the overhead scoreboard has taken on the appearance of the national debt clock in Manhattan—a large number rapidly getting larger. The replenishment table is littered with crumpled Dixie cups, the music has drifted, and the crowd has dwindled to a handful of volunteers, many of whom tap their toes awaiting my finish.

I wonder what it’ll take. If 12,000 people with spinal muscular atrophy is enough to convene a race, what of the millions of people harmed annually by medical errors? How many more have to die before patient safety becomes an issue, becomes it’s own cause, gets it own fun run?

Dr. Glasheen is associate professor of medicine at the University of Colorado at Denver,where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. HealthGrades Eighth Annual Report on Patient Safety in American Hospitals Study. Available at: www.healthgrades.com. Published March 2011. Accessed Aug. 31, 2011.
2. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
3. The Commonwealth Fund 2002 Annual Report. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Content/Annual-Reports/2002-Annual-Report.aspx. Accessed Sept. 9, 2011.
4. Blendon RJ, DesRoches CM, Brodie M, et al. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933-1940.

Last month (see “Hospital-Focused Practice,” Septem-ber 2011, p. 61), I discussed the adoption of the hospitalist model of practice by many specialties, some of the common issues they face, and highlighted a national meeting to examine this phenomenon (for more information on the meeting, visit www.hospitalmedicine/hfpm). This month, relying mostly on my own experience with this practice model, I’ll drill deeper into OB hospitalists (also known as laborists). While there are a lot of ways in which hospitalist practice in many specialties are the same, laborists differ from those in other fields in important and interesting ways.

Prevalence

One of the most informative sources about the “laborist movement” is ObGynHospitalist.com, a website started and managed by Dr. Rob Olson, an enterprising laborist in Bellingham, Wash. As of July, the site listed 132 laborist programs nationwide (and that figure likely underestimates the actual number in operation). A survey of registered users of the website in April yielded 106 responses, representing a 24% response rate. Seventy-five of the respondents indicated they were full-time laborists.

Unique Drivers

Because obstetric malpractice costs are so high, and many lawsuits are related to delayed response to obstetric emergencies, there is hope (not much hard proof yet) that outcomes will be better, and lawsuits less common or less costly.¹ So the hope of reduced malpractice costs figures more prominently into the cost-benefit analysis of the OB hospitalist model than most other types of HM practice.

Financial Model

It appears that all hospitalist models require financial support over and above professional fee revenue. Hospitals usually are willing (happy?) to provide this money because they can make back even more as a result of increased patient volume/market share or lower costs. And, as is the case for hospitalists in other specialties, laborist presence can be an asset in recruitment and retention of other OBGYNs.

I think the most interesting feature of laborist practice is that in many settings, it has the potential to open new sources of revenue—both hospital “facility fee” and professional fee revenue. A common practice in many hospitals is for obstetricians to send patients, or for them to self-present, to labor and delivery to be checked for a cold, vomiting, or whether labor has started. Many times, a nurse performs these checks, communicates with a doctor, then discharges the patient—and no bill is generated. An on-site laborist can see the same patients (presumably making for a higher-quality visit for the patient) and, assuming the visit is medically necessary, both a facility and professional charge can be submitted. Revenue from such visits can go a long way toward making up the difference between the total cost of the laborist program and fee collections. This adds to patient safety, as each patient is evaluated in person by a physician rather than only a nurse.

In most settings, the laborist submits a charge for delivery only for unassigned patients. For those patients who “belong to” another OB who provided prenatal care, it is often most practical for that doctor to submit the global fee for prenatal care and delivery, and to pay the laborist program an agreed-upon rate for each service provided.

Compensation

Laborists often are paid an hourly rate, and they typically don’t have a salary component tied to work relative-value unit (wRVU) production or other productivity metrics. Total annual compensation is typically lower than private-practice OBGYN physicians. It also varies widely, depending on local market forces, job description, and workload. Most programs are trying to implement meaningful quality bonuses for laborists.

Scope of Practice

Laborists typically provide care to all unassigned patients who present to labor and delivery, and perform deliveries, C-sections, and other services on patients when requested by OBs in traditional practice. Requests arise when an OB simply needs to be relieved of being on call for their private patients, or when an emergency arises. (These “as-needed” referrals are different from the most common arrangement for “medical hospitalist” practices that ask other doctors to refer all or none of their patients, not just when they are otherwise occupied.)

Lastly, the laborist might serve as surgical assistant to other OBGYNs. In nearly all settings, there is no need to require that any physicians refer to the laborist, and the other OBs are free to decide when to refer.

A reasonably common scenario is that, to avoid disruption of scheduled office hours, an OB in traditional practice might ask that the laborist manage a patient who presents in labor. But if still undelivered at the close of office hours, the traditional OB might assume care from that point on or have the laborist remain responsible through delivery. The traditional OB usually will make post-partum “rounding” visits on all of their patients but could rely on the laborist for these visits.

In most cases, the laborist does not have any scheduled gynecologic procedures, though he or she may see GYN consults throughout the hospital as time permits. Laborists typically have no outpatient responsibilities, but some OBGYN hospitalists cover GYN in the ED.

Operational Structure

Although models vary significantly, the single most common arrangement is for laborists to work 24-hour, in-house shifts. Rarely is there a need or justification to have more than one laborist on at a time. For a single physician, seven or eight 24-hour shifts per month is considered full-time. My experience is that most laborists are employed by the hospital in which they work.

As is the case in every specialty, some large OBGYN groups adopt a rotating laborist model, in which one member of their group becomes the laborist for 24 hours at a time, during which they are relieved of all other responsibilities.

Recruitment

ObGynHospitalist.com shows that, as of July, 40 of the 132 laborist programs that had identified themselves on the site were recruiting. My experience is that unlike “medical hospitalist” practices, which tend to successfully recruit those very early in their career, or “surgical hospitalist” programs, which target mid- to late-career general surgeons, laborist candidates come from any point in their careers. Most programs prefer that a laborist has several years of post-residency experience, but they generally have no other preference.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Reference

1. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008;112(6):1279-1283.

Last month (see “Hospital-Focused Practice,” Septem-ber 2011, p. 61), I discussed the adoption of the hospitalist model of practice by many specialties, some of the common issues they face, and highlighted a national meeting to examine this phenomenon (for more information on the meeting, visit www.hospitalmedicine/hfpm). This month, relying mostly on my own experience with this practice model, I’ll drill deeper into OB hospitalists (also known as laborists). While there are a lot of ways in which hospitalist practice in many specialties are the same, laborists differ from those in other fields in important and interesting ways.

Prevalence

One of the most informative sources about the “laborist movement” is ObGynHospitalist.com, a website started and managed by Dr. Rob Olson, an enterprising laborist in Bellingham, Wash. As of July, the site listed 132 laborist programs nationwide (and that figure likely underestimates the actual number in operation). A survey of registered users of the website in April yielded 106 responses, representing a 24% response rate. Seventy-five of the respondents indicated they were full-time laborists.

Unique Drivers

Because obstetric malpractice costs are so high, and many lawsuits are related to delayed response to obstetric emergencies, there is hope (not much hard proof yet) that outcomes will be better, and lawsuits less common or less costly.¹ So the hope of reduced malpractice costs figures more prominently into the cost-benefit analysis of the OB hospitalist model than most other types of HM practice.

Financial Model

It appears that all hospitalist models require financial support over and above professional fee revenue. Hospitals usually are willing (happy?) to provide this money because they can make back even more as a result of increased patient volume/market share or lower costs. And, as is the case for hospitalists in other specialties, laborist presence can be an asset in recruitment and retention of other OBGYNs.

I think the most interesting feature of laborist practice is that in many settings, it has the potential to open new sources of revenue—both hospital “facility fee” and professional fee revenue. A common practice in many hospitals is for obstetricians to send patients, or for them to self-present, to labor and delivery to be checked for a cold, vomiting, or whether labor has started. Many times, a nurse performs these checks, communicates with a doctor, then discharges the patient—and no bill is generated. An on-site laborist can see the same patients (presumably making for a higher-quality visit for the patient) and, assuming the visit is medically necessary, both a facility and professional charge can be submitted. Revenue from such visits can go a long way toward making up the difference between the total cost of the laborist program and fee collections. This adds to patient safety, as each patient is evaluated in person by a physician rather than only a nurse.

In most settings, the laborist submits a charge for delivery only for unassigned patients. For those patients who “belong to” another OB who provided prenatal care, it is often most practical for that doctor to submit the global fee for prenatal care and delivery, and to pay the laborist program an agreed-upon rate for each service provided.

Compensation

Laborists often are paid an hourly rate, and they typically don’t have a salary component tied to work relative-value unit (wRVU) production or other productivity metrics. Total annual compensation is typically lower than private-practice OBGYN physicians. It also varies widely, depending on local market forces, job description, and workload. Most programs are trying to implement meaningful quality bonuses for laborists.

Scope of Practice

Laborists typically provide care to all unassigned patients who present to labor and delivery, and perform deliveries, C-sections, and other services on patients when requested by OBs in traditional practice. Requests arise when an OB simply needs to be relieved of being on call for their private patients, or when an emergency arises. (These “as-needed” referrals are different from the most common arrangement for “medical hospitalist” practices that ask other doctors to refer all or none of their patients, not just when they are otherwise occupied.)

Lastly, the laborist might serve as surgical assistant to other OBGYNs. In nearly all settings, there is no need to require that any physicians refer to the laborist, and the other OBs are free to decide when to refer.

A reasonably common scenario is that, to avoid disruption of scheduled office hours, an OB in traditional practice might ask that the laborist manage a patient who presents in labor. But if still undelivered at the close of office hours, the traditional OB might assume care from that point on or have the laborist remain responsible through delivery. The traditional OB usually will make post-partum “rounding” visits on all of their patients but could rely on the laborist for these visits.

In most cases, the laborist does not have any scheduled gynecologic procedures, though he or she may see GYN consults throughout the hospital as time permits. Laborists typically have no outpatient responsibilities, but some OBGYN hospitalists cover GYN in the ED.

Operational Structure

Although models vary significantly, the single most common arrangement is for laborists to work 24-hour, in-house shifts. Rarely is there a need or justification to have more than one laborist on at a time. For a single physician, seven or eight 24-hour shifts per month is considered full-time. My experience is that most laborists are employed by the hospital in which they work.

As is the case in every specialty, some large OBGYN groups adopt a rotating laborist model, in which one member of their group becomes the laborist for 24 hours at a time, during which they are relieved of all other responsibilities.

Recruitment

ObGynHospitalist.com shows that, as of July, 40 of the 132 laborist programs that had identified themselves on the site were recruiting. My experience is that unlike “medical hospitalist” practices, which tend to successfully recruit those very early in their career, or “surgical hospitalist” programs, which target mid- to late-career general surgeons, laborist candidates come from any point in their careers. Most programs prefer that a laborist has several years of post-residency experience, but they generally have no other preference.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Reference

1. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008;112(6):1279-1283.

Last month (see “Hospital-Focused Practice,” Septem-ber 2011, p. 61), I discussed the adoption of the hospitalist model of practice by many specialties, some of the common issues they face, and highlighted a national meeting to examine this phenomenon (for more information on the meeting, visit www.hospitalmedicine/hfpm). This month, relying mostly on my own experience with this practice model, I’ll drill deeper into OB hospitalists (also known as laborists). While there are a lot of ways in which hospitalist practice in many specialties are the same, laborists differ from those in other fields in important and interesting ways.

Prevalence

One of the most informative sources about the “laborist movement” is ObGynHospitalist.com, a website started and managed by Dr. Rob Olson, an enterprising laborist in Bellingham, Wash. As of July, the site listed 132 laborist programs nationwide (and that figure likely underestimates the actual number in operation). A survey of registered users of the website in April yielded 106 responses, representing a 24% response rate. Seventy-five of the respondents indicated they were full-time laborists.

Unique Drivers

Because obstetric malpractice costs are so high, and many lawsuits are related to delayed response to obstetric emergencies, there is hope (not much hard proof yet) that outcomes will be better, and lawsuits less common or less costly.¹ So the hope of reduced malpractice costs figures more prominently into the cost-benefit analysis of the OB hospitalist model than most other types of HM practice.

Financial Model

It appears that all hospitalist models require financial support over and above professional fee revenue. Hospitals usually are willing (happy?) to provide this money because they can make back even more as a result of increased patient volume/market share or lower costs. And, as is the case for hospitalists in other specialties, laborist presence can be an asset in recruitment and retention of other OBGYNs.

I think the most interesting feature of laborist practice is that in many settings, it has the potential to open new sources of revenue—both hospital “facility fee” and professional fee revenue. A common practice in many hospitals is for obstetricians to send patients, or for them to self-present, to labor and delivery to be checked for a cold, vomiting, or whether labor has started. Many times, a nurse performs these checks, communicates with a doctor, then discharges the patient—and no bill is generated. An on-site laborist can see the same patients (presumably making for a higher-quality visit for the patient) and, assuming the visit is medically necessary, both a facility and professional charge can be submitted. Revenue from such visits can go a long way toward making up the difference between the total cost of the laborist program and fee collections. This adds to patient safety, as each patient is evaluated in person by a physician rather than only a nurse.

In most settings, the laborist submits a charge for delivery only for unassigned patients. For those patients who “belong to” another OB who provided prenatal care, it is often most practical for that doctor to submit the global fee for prenatal care and delivery, and to pay the laborist program an agreed-upon rate for each service provided.

Compensation

Laborists often are paid an hourly rate, and they typically don’t have a salary component tied to work relative-value unit (wRVU) production or other productivity metrics. Total annual compensation is typically lower than private-practice OBGYN physicians. It also varies widely, depending on local market forces, job description, and workload. Most programs are trying to implement meaningful quality bonuses for laborists.

Scope of Practice

Laborists typically provide care to all unassigned patients who present to labor and delivery, and perform deliveries, C-sections, and other services on patients when requested by OBs in traditional practice. Requests arise when an OB simply needs to be relieved of being on call for their private patients, or when an emergency arises. (These “as-needed” referrals are different from the most common arrangement for “medical hospitalist” practices that ask other doctors to refer all or none of their patients, not just when they are otherwise occupied.)

Lastly, the laborist might serve as surgical assistant to other OBGYNs. In nearly all settings, there is no need to require that any physicians refer to the laborist, and the other OBs are free to decide when to refer.

A reasonably common scenario is that, to avoid disruption of scheduled office hours, an OB in traditional practice might ask that the laborist manage a patient who presents in labor. But if still undelivered at the close of office hours, the traditional OB might assume care from that point on or have the laborist remain responsible through delivery. The traditional OB usually will make post-partum “rounding” visits on all of their patients but could rely on the laborist for these visits.

In most cases, the laborist does not have any scheduled gynecologic procedures, though he or she may see GYN consults throughout the hospital as time permits. Laborists typically have no outpatient responsibilities, but some OBGYN hospitalists cover GYN in the ED.

Operational Structure

Although models vary significantly, the single most common arrangement is for laborists to work 24-hour, in-house shifts. Rarely is there a need or justification to have more than one laborist on at a time. For a single physician, seven or eight 24-hour shifts per month is considered full-time. My experience is that most laborists are employed by the hospital in which they work.

As is the case in every specialty, some large OBGYN groups adopt a rotating laborist model, in which one member of their group becomes the laborist for 24 hours at a time, during which they are relieved of all other responsibilities.

Recruitment

ObGynHospitalist.com shows that, as of July, 40 of the 132 laborist programs that had identified themselves on the site were recruiting. My experience is that unlike “medical hospitalist” practices, which tend to successfully recruit those very early in their career, or “surgical hospitalist” programs, which target mid- to late-career general surgeons, laborist candidates come from any point in their careers. Most programs prefer that a laborist has several years of post-residency experience, but they generally have no other preference.

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course codirector and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Reference

1. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol. 2008;112(6):1279-1283.

I was hoping someone would address Interqual criteria for admission. I have a pretty good knowledge about this and apply it to justify “intensity of service.” It seems that most ED docs don’t understand these criteria and, as a result, we end up having “too many obs,” per our CEO. What do I do? How do I get everyone on board the “hospitalist agenda wagon”?

I.U., Texas

Dr. Hospitalist responds: Many hospitals now use either Interqual or Milliman to help them make determinations as to whether a patient should be inpatient or observation. Regardless of the resource used, there should be some basic understanding as to what determines the admission status—namely, the “intensity of service,” as you describe.

First things first: I would not let the ED doc determine the admission status. The ED physician should continue to occupy their binary decision algorithm of 1) home and 2) admission. Once they decide on admission, they should make no further decisions regarding the care of the patient. Why? Well, they don’t work upstairs (or down the hall), and they generally have a poorer understanding than you do about admission status and the most appropriate unit for your patient.

Nationally, ED physicians (through American College of Emergency Physicians policy statements) have adopted the approach of no longer writing “admission” orders, instead calling them “transition” orders. I would do nothing to discourage this approach, even though it does make more work for us as hospitalists. So, as a starting point, you and your team should determine the admission location and the status. It might require a change in workflow, but it will save you headaches in the long run. When it comes to admission status, things get a little trickier. Evaluation of the admission status includes “severity of illness” and “intensity of service.” Clearly, you have more to do with the determination of the latter than the former (at least we hope so), and that is where you will interact with the hospital’s utilization review service. Let’s focus on that for the time being.

Roughly, observation should be used for patients for whom stabilization and discharge are expected within 24 hours, the patient is hemodynamically stable, and the clinical diagnosis is unclear. It used to be that “obs”—or observation—was only used for 23 hours, but Medicare now allows up to 48 hours of observation. CMS has a list of initial diagnoses that they view as appropriate for obs, such as chest pain, CHF, and syncope.

On the inpatient side, here it is straight from CMS: “Inpatient care, rather than outpatient care, is required only if the beneficiary’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. Without accompanying medical conditions, factors that would only cause the beneficiary inconvenience in terms of time and money needed to care for the beneficiary at home or for travel to a physician’s office, or that may cause the beneficiary to worry, do not justify a continued hospital stay.” (You can read more by downloading this PDF: www.cms.gov/MLNMatters Articles/Downloads/SE1037.pdf.)

Beware, though: This is a bit like going down the rabbit hole—you can get lost in all the regulations and amendments. Which, to no one’s great surprise, explains why Milliman and Interqual operate such big businesses interpreting and applying these guidelines. We all know that you can’t control the phone calls coming from the ED. However, it is paramount that when you accept a patient, you document clearly and appropriately the admission status and the clinical criteria used to make your determination. Will everyone get it right every time? Probably not. Remember, though, that documentation will not only support the admission status, but also your professional fee billing.

Now what? Educate, educate, educate.

Ideally, you should meet with your case management/UR team and decide how to deliver the message to your group. Honestly, I think that a group responds better to explanations coming from one of their own rather than inviting the head of case management to come and speak for an hour. Rather than risk setting up an adversarial relationship with case management, consider filtering the message through your leadership. As a group leader, you need to be able to interpret hospital-driven directives and deliver the information to your group in a constructive manner. As working hospitalists, we need to understand the nonclinical factors that affect us—and our hospitals. It’s part of the job.

I was hoping someone would address Interqual criteria for admission. I have a pretty good knowledge about this and apply it to justify “intensity of service.” It seems that most ED docs don’t understand these criteria and, as a result, we end up having “too many obs,” per our CEO. What do I do? How do I get everyone on board the “hospitalist agenda wagon”?

I.U., Texas

Dr. Hospitalist responds: Many hospitals now use either Interqual or Milliman to help them make determinations as to whether a patient should be inpatient or observation. Regardless of the resource used, there should be some basic understanding as to what determines the admission status—namely, the “intensity of service,” as you describe.

First things first: I would not let the ED doc determine the admission status. The ED physician should continue to occupy their binary decision algorithm of 1) home and 2) admission. Once they decide on admission, they should make no further decisions regarding the care of the patient. Why? Well, they don’t work upstairs (or down the hall), and they generally have a poorer understanding than you do about admission status and the most appropriate unit for your patient.

Nationally, ED physicians (through American College of Emergency Physicians policy statements) have adopted the approach of no longer writing “admission” orders, instead calling them “transition” orders. I would do nothing to discourage this approach, even though it does make more work for us as hospitalists. So, as a starting point, you and your team should determine the admission location and the status. It might require a change in workflow, but it will save you headaches in the long run. When it comes to admission status, things get a little trickier. Evaluation of the admission status includes “severity of illness” and “intensity of service.” Clearly, you have more to do with the determination of the latter than the former (at least we hope so), and that is where you will interact with the hospital’s utilization review service. Let’s focus on that for the time being.

Roughly, observation should be used for patients for whom stabilization and discharge are expected within 24 hours, the patient is hemodynamically stable, and the clinical diagnosis is unclear. It used to be that “obs”—or observation—was only used for 23 hours, but Medicare now allows up to 48 hours of observation. CMS has a list of initial diagnoses that they view as appropriate for obs, such as chest pain, CHF, and syncope.

On the inpatient side, here it is straight from CMS: “Inpatient care, rather than outpatient care, is required only if the beneficiary’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. Without accompanying medical conditions, factors that would only cause the beneficiary inconvenience in terms of time and money needed to care for the beneficiary at home or for travel to a physician’s office, or that may cause the beneficiary to worry, do not justify a continued hospital stay.” (You can read more by downloading this PDF: www.cms.gov/MLNMatters Articles/Downloads/SE1037.pdf.)

Beware, though: This is a bit like going down the rabbit hole—you can get lost in all the regulations and amendments. Which, to no one’s great surprise, explains why Milliman and Interqual operate such big businesses interpreting and applying these guidelines. We all know that you can’t control the phone calls coming from the ED. However, it is paramount that when you accept a patient, you document clearly and appropriately the admission status and the clinical criteria used to make your determination. Will everyone get it right every time? Probably not. Remember, though, that documentation will not only support the admission status, but also your professional fee billing.

Now what? Educate, educate, educate.

Ideally, you should meet with your case management/UR team and decide how to deliver the message to your group. Honestly, I think that a group responds better to explanations coming from one of their own rather than inviting the head of case management to come and speak for an hour. Rather than risk setting up an adversarial relationship with case management, consider filtering the message through your leadership. As a group leader, you need to be able to interpret hospital-driven directives and deliver the information to your group in a constructive manner. As working hospitalists, we need to understand the nonclinical factors that affect us—and our hospitals. It’s part of the job.

I was hoping someone would address Interqual criteria for admission. I have a pretty good knowledge about this and apply it to justify “intensity of service.” It seems that most ED docs don’t understand these criteria and, as a result, we end up having “too many obs,” per our CEO. What do I do? How do I get everyone on board the “hospitalist agenda wagon”?

I.U., Texas

Dr. Hospitalist responds: Many hospitals now use either Interqual or Milliman to help them make determinations as to whether a patient should be inpatient or observation. Regardless of the resource used, there should be some basic understanding as to what determines the admission status—namely, the “intensity of service,” as you describe.

First things first: I would not let the ED doc determine the admission status. The ED physician should continue to occupy their binary decision algorithm of 1) home and 2) admission. Once they decide on admission, they should make no further decisions regarding the care of the patient. Why? Well, they don’t work upstairs (or down the hall), and they generally have a poorer understanding than you do about admission status and the most appropriate unit for your patient.

Nationally, ED physicians (through American College of Emergency Physicians policy statements) have adopted the approach of no longer writing “admission” orders, instead calling them “transition” orders. I would do nothing to discourage this approach, even though it does make more work for us as hospitalists. So, as a starting point, you and your team should determine the admission location and the status. It might require a change in workflow, but it will save you headaches in the long run. When it comes to admission status, things get a little trickier. Evaluation of the admission status includes “severity of illness” and “intensity of service.” Clearly, you have more to do with the determination of the latter than the former (at least we hope so), and that is where you will interact with the hospital’s utilization review service. Let’s focus on that for the time being.

Roughly, observation should be used for patients for whom stabilization and discharge are expected within 24 hours, the patient is hemodynamically stable, and the clinical diagnosis is unclear. It used to be that “obs”—or observation—was only used for 23 hours, but Medicare now allows up to 48 hours of observation. CMS has a list of initial diagnoses that they view as appropriate for obs, such as chest pain, CHF, and syncope.

On the inpatient side, here it is straight from CMS: “Inpatient care, rather than outpatient care, is required only if the beneficiary’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. Without accompanying medical conditions, factors that would only cause the beneficiary inconvenience in terms of time and money needed to care for the beneficiary at home or for travel to a physician’s office, or that may cause the beneficiary to worry, do not justify a continued hospital stay.” (You can read more by downloading this PDF: www.cms.gov/MLNMatters Articles/Downloads/SE1037.pdf.)

Beware, though: This is a bit like going down the rabbit hole—you can get lost in all the regulations and amendments. Which, to no one’s great surprise, explains why Milliman and Interqual operate such big businesses interpreting and applying these guidelines. We all know that you can’t control the phone calls coming from the ED. However, it is paramount that when you accept a patient, you document clearly and appropriately the admission status and the clinical criteria used to make your determination. Will everyone get it right every time? Probably not. Remember, though, that documentation will not only support the admission status, but also your professional fee billing.

Now what? Educate, educate, educate.

Ideally, you should meet with your case management/UR team and decide how to deliver the message to your group. Honestly, I think that a group responds better to explanations coming from one of their own rather than inviting the head of case management to come and speak for an hour. Rather than risk setting up an adversarial relationship with case management, consider filtering the message through your leadership. As a group leader, you need to be able to interpret hospital-driven directives and deliver the information to your group in a constructive manner. As working hospitalists, we need to understand the nonclinical factors that affect us—and our hospitals. It’s part of the job.

Click here to listen to Dr. Sliwka.

Click here to listen to Dr. Cumbler.

Click here to listen to Dr. Sliwka.

Click here to listen to Dr. Cumbler.

Click here to listen to Dr. Sliwka.

Click here to listen to Dr. Cumbler.

Click here to listen to Alan Pisarski.

Click here to listen to Mark Hamm.

Click here to listen to Alan Pisarski.

Click here to listen to Mark Hamm.

Click here to listen to Alan Pisarski.

Click here to listen to Mark Hamm.

In a bit of counterintuition, an empty discharge lounge might be the most successful kind.

Christine Collins, executive director of patient access services at Brigham and Women’s Hospital in Boston, says that the lounge should be a service for discharged patients who have completed medical treatment, but who for some reason remain unable to leave the institution. Such cases can include waiting on a prescription from the pharmacy, or simply waiting on a relative or friend to arrive with transportation.

She does not view Brigham’s discharge lounge, a room with lounge chairs and light meals that is staffed by a registered nurse, as the answer to the throughput conundrum hospitals across the country face each and every day. So when the lounge is empty, it means patients have been discharged without any hang-ups.

“It’s not a patient-care area,” Collins says. “They’re people that should be home.”

Some view discharge lounges as a potential aid in smoothing out the discharge process. In theory, patients ready to be medically discharged but unable to leave the hospital have a place to go. But keeping the patients in the building, and under the eye of a nurse, could create liability issues, says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. Dr. Simone also wonders how the lounge concept impacts patient satisfaction, as some could view it negatively if they’re told they have to sit in what could be construed as a back-end waiting room.

“People need to assess what they’re doing it for and is it really accomplishing what they want it to accomplish,” Collins says.

Discharge lounges “can’t be another nursing unit because a patient is supposed to be discharged. ... Whether you have a discharge lounge or not, you need to improve your systems so that the patients leave when they leave.”

Richard Quinn is a freelance writer based in New Jersey.

In a bit of counterintuition, an empty discharge lounge might be the most successful kind.

Christine Collins, executive director of patient access services at Brigham and Women’s Hospital in Boston, says that the lounge should be a service for discharged patients who have completed medical treatment, but who for some reason remain unable to leave the institution. Such cases can include waiting on a prescription from the pharmacy, or simply waiting on a relative or friend to arrive with transportation.

She does not view Brigham’s discharge lounge, a room with lounge chairs and light meals that is staffed by a registered nurse, as the answer to the throughput conundrum hospitals across the country face each and every day. So when the lounge is empty, it means patients have been discharged without any hang-ups.

“It’s not a patient-care area,” Collins says. “They’re people that should be home.”

Some view discharge lounges as a potential aid in smoothing out the discharge process. In theory, patients ready to be medically discharged but unable to leave the hospital have a place to go. But keeping the patients in the building, and under the eye of a nurse, could create liability issues, says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. Dr. Simone also wonders how the lounge concept impacts patient satisfaction, as some could view it negatively if they’re told they have to sit in what could be construed as a back-end waiting room.

“People need to assess what they’re doing it for and is it really accomplishing what they want it to accomplish,” Collins says.

Discharge lounges “can’t be another nursing unit because a patient is supposed to be discharged. ... Whether you have a discharge lounge or not, you need to improve your systems so that the patients leave when they leave.”

Richard Quinn is a freelance writer based in New Jersey.

In a bit of counterintuition, an empty discharge lounge might be the most successful kind.

Christine Collins, executive director of patient access services at Brigham and Women’s Hospital in Boston, says that the lounge should be a service for discharged patients who have completed medical treatment, but who for some reason remain unable to leave the institution. Such cases can include waiting on a prescription from the pharmacy, or simply waiting on a relative or friend to arrive with transportation.

She does not view Brigham’s discharge lounge, a room with lounge chairs and light meals that is staffed by a registered nurse, as the answer to the throughput conundrum hospitals across the country face each and every day. So when the lounge is empty, it means patients have been discharged without any hang-ups.

“It’s not a patient-care area,” Collins says. “They’re people that should be home.”

Some view discharge lounges as a potential aid in smoothing out the discharge process. In theory, patients ready to be medically discharged but unable to leave the hospital have a place to go. But keeping the patients in the building, and under the eye of a nurse, could create liability issues, says Ken Simone, DO, SFHM, president of Hospitalist and Practice Solutions in Veazie, Maine, and a member of Team Hospitalist. Dr. Simone also wonders how the lounge concept impacts patient satisfaction, as some could view it negatively if they’re told they have to sit in what could be construed as a back-end waiting room.

“People need to assess what they’re doing it for and is it really accomplishing what they want it to accomplish,” Collins says.

Discharge lounges “can’t be another nursing unit because a patient is supposed to be discharged. ... Whether you have a discharge lounge or not, you need to improve your systems so that the patients leave when they leave.”

Richard Quinn is a freelance writer based in New Jersey.

Click here to listen to ENA President AnnMarie Papa.

Click here to listen to Dr. Simone.

Click here to listen to ENA President AnnMarie Papa.

Click here to listen to Dr. Simone.

Click here to listen to ENA President AnnMarie Papa.

Click here to listen to Dr. Simone.

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After nearly a half-century, the subspecialty of critical care medicine—uniquely trained physicians caring for critically ill or injured patients in specialized, discrete nursing units—continues to suffer from an identity crisis.

Too often, the role of the intensivist in caring for the patient is unclear, to the patient, to the family, and to other physicians. Is the intensivist merely a consultant, or does he or she have a larger role?

The time has come to end the identity crisis with a fundamental paradigm shift, to identify intensivists as the principal caregivers of critically ill patients, ie, the “primary critical care physicians,” or PCCPs. We think this is necessary based not only on evidence from clinical studies, but also on our decades of experience as intensivist caregivers in a high-intensity, closed-staffing model.

REASONS FOR THE IDENTITY CRISIS

The reasons for the continued identity crisis of intensivists are many and complex.

To begin with, other physicians tend to be ambiguous about the duties of intensivists, and the general population is mostly unaware of the subspecialty. In contrast to mature subspecialties such as cardiology or gastroenterology, where responsibilities are generally known to physicians and the lay public alike, or in contrast even to recently evolved specialties such as emergency medicine, the enigmatic roles of an intensivist may differ depending on primary specialty (anesthesiology, internal medicine, surgery) and the patient population, or even among intensive care units (ICUs) within the same hospital.

Moreover, that an identity crisis exists is even more surprising given the disproportionately large consumption by critical care medicine of finite economic resources. One would expect that a sector of health care that expends 1% of the GNP¹ would have clearly explicit roles and responsibilities for its physicians.

Nearly three-quarters of the care by intensivists in the United States is delivered in what is considered an “open” or “low-intensity” ICU staffing model²: an intensivist makes treatment recommendations but otherwise has no overarching authority over patient care. In this model, the admitting physician is not trained in critical care and is not available throughout the day to make decisions concerning the management of the patient. In addition, various consulting physicians and single-organ specialists may not be aware of the overall management plan, resulting in potentially unnecessary or conflicting orders and increased expense.² What is more, in an open ICU model, critical care nurses are often left to detect and correct a significant change in a patient’s status without the necessary immediate physician availability, resulting not only in a stressful working environment for nursing staff, but also in potential harm associated with individuals providing care outside their scope of practice.³

In only a small percentage of ICUs—mostly medical ICUs and ICUs in teaching hospitals—is critical care provided in a “high-intensity” or “closed” staffing pattern, in which treatment decisions are cohesively managed under the guidance of an intensivist.²

EVIDENCE IN THE MEDICAL LITERATURE

Staffing patterns in the ICU

Several studies have attempted to identify the consequences of these different ICU staffing patterns on patient care.

Hanson et al⁴ examined two concurrent patient cohorts admitted to a surgical ICU. The study cohort was cared for by an on-site critical care team supervised by an intensivist, while the control cohort received care from a team with patient care responsibilities in multiple sites, supervised by a general surgeon. The results showed that patients cared for by the critical care team spent less time in the ICU, used fewer resources, had fewer complications, and had lower total hospital charges. The difference between the two cohorts was most evident in patients with the worst Acute Physiology and Chronic Health Evaluation (APACHE) II scores.

According to Hanson et al, the lack of an accepted prototype for the delivery of critical care is due to factors such as the relative youth of the discipline, contention over control of individual patient management, and the absence of a single academic advocate.⁴

Moreover, Pronovost et al⁵ concluded that high-intensity staffing (mandatory intensivist consultation or closed ICU) was associated with lower ICU mortality rates in 93% of studies and with a reduced ICU length of stay in the high-intensity staffing units when compared with ICUs with low-intensity staffing (no intensivist or elective intensivist consultation).

Critics of our PCCP paradigm may point to a study by Levy et al⁶ that, using a database of more than 100,000 patients, could not demonstrate any survival benefit with management by critical care physicians. Indeed the study found that patients managed by intensivists had a higher mortality rate than patients managed by physicians not trained in critical care. However, they also showed that more patients managed for the entire stay by intensivists received interventions such as intravenous drugs, mechanical ventilation, and continuous sedation and that they had a higher mean severity of illness as measured by the expanded Simplified Acute Physiology Score (SAPS II) and higher hospital mortality rates than patients who were not managed by a critical care team.

According to Levy et al, most ICUs in the United States are structured as completely open units in which the admitting physicians retain full clinical and decisional responsibility and thus have the option to care for their patients with or without input from intensivists.⁶

However, a recent study by Kim et al⁷ likely rebuts the findings of Levy et al. Kim et al analyzed more than 100,000 ICU admissions and found that the lowest odds of death within 30 days were in ICUs that had high-intensity physician staffing and multidisciplinary care teams, suggesting that the presence of an intensivist confers a survival benefit.

Other studies have also shown that high-intensity staffing improves patient outcomes in the ICU.^5,8,9

Issues of cost and use of resources

Issues concerning cost and human resources for staffing ICUs have acquired increasing importance. According to Angus et al,¹⁰ intensivists provided care to only 36.8% of all ICU patients. The demand for critical care services will continue to grow rapidly as the population ages. It is this shift in the care of the critically ill that requires intensivists to take on the role of the PCCP, so as to provide high-quality, evidence-based critical care and to promote a long-term sustainable model of physician and nursing care.

OUR EXPERIENCE

Our intensivist group has been providing a near-primary-care style of critical care practice for almost 40 years, from its inception in 1977 by one of the authors (A.B.), to our current group of 15 board-certified intensivists. We can easily cite the clinical value of our practice approach, with outcome data showing consistent and better-than-expected Standardized Mortality Ratio accounts from our APACHE IV data (personal communication, Cleveland Clinic Cerner/APACHE IV report), or with reports showing that the presence of a full-time, attending-level, in-house staff physician ensures that patients, surgeons, and consultants have confidence and respect for the care provided. However, we feel that the intangible components are what make our practice a prototype for the PCCP model.

A dedicated team with a low turnover rate

First, we have a team of anesthesiology- and surgery-based intensivists dedicated to ICU practice, with a very low turnover or burnout rate, in contrast to most ICUs in the United States, where intensivists tend to practice part-time (at other times either providing operating-room-based anesthesia or surgical care or working in a pulmonary- or sleep-lab-based practice). We believe this point should not go unstressed: we have a team of physicians who have dedicated their career to working in the ICU full-time, and some have done so in excess of 20 years, even as long as 30 years! It is our opinion that we are able to provide such a highly desirable working environment by a unique daily staffing model that does not utilize the conventional practice style of one intensivist on-call per week.

We also feel that our model dramatically reduces the risk of burnout by permitting our attending intensivists to break up on-call sequences so that there are days on which work in the ICU is not also associated with on-call responsibilities.

A successful fellowship program

Second, we have an extremely successful fellowship program, which began in 1974 when one of the authors (A.B.) advocated the training of anesthesiology residents as intensivists.¹¹ The American Board of Anesthesiology certifies on average 55 candidates per year in critical care medicine, and our program trains about 10% of the physicians applying for certification. In most years, there are actually more candidates for our program than there are available positions, which is atypical for anesthesiology-based critical care training programs. This wealth of young, talented candidates interested in critical care as a career is, again, in contrast to most anesthesiology-based programs, which find it difficult to enroll even one fellow per year.

Critical care programs grounded in anesthesiology typically struggle because of the realities of economics.¹² The payoff of operating-room-based anesthesiology practices generally outshines those in critical care, yet we already have three times as many candidates as there are positions to start our training program in the next 2 years. We feel that candidates are attracted to our program simply because our environment (dedicated staffing, equal clinical footing with surgeons, low burnout rates) is seen as an exciting, positively charged role-modeling atmosphere for young physicians who may have a career interest that involves more than just their original base specialty.

A collegial working relationship

Third, we have a thriving, collegial working relationship—including daily bedside and weekly bioethics rounds with our nursing staff—which has fueled a high degree of professional satisfaction among nurses. This is evidenced by the extremely low turnover rate of nurses (less than 5% per year in the last 5 years) and by national recognition for nursing excellence (Beacon Award for Critical Care Excellence, American Association of Critical Care Nurses) (personal communication, S. Wilson, Nurse Manager). In 2009, the four nurses out of 174 who left did so to further their careers.

While low turnover rates among nurses and award-winning practices are surely a testament to a highly motivated and skilled nursing team, there is no question that a constructive collegiality among the physicians and nurses has provided an environment to allow these positive aspects to flourish.

OVERCOMING ROADBLOCKS

Obviously, although in theory it is easy to proclaim a PCCP paradigm, in reality the roadblocks are many.

For example, standardization of education and credentialing would be an essential hurdle to overcome. The current educational arrangement of the various adult specialties (anesthesiology, internal medicine, surgery), each offering disparate subspecialty critical care training and certification, is deeply rooted in interdisciplinary politics, but without any demonstration of improved patient care.¹³ As described recently by Kaplan and Shaw,¹⁴ an all-encompassing training and credentialing standard for critical care is essential for 21st century medicine and would go a long way toward development of the PCCP paradigm.

Another major roadblock is the shortage of intensivists in the United States.¹³ There are many reasons why physicians opt not to select critical care as a career, such as a non-straight-forward training pathway (as described above), recognition that the 24-hours per day, 7-days-per-week nature of critical care affects lifestyle issues, and inconsistent physician compensation.¹³

However, technological and personnel advances, including the use of electronic (e-ICU)¹⁵ and mid-level practitioner models, have led to creative approaches to extend critical care coverage.¹³

Additionally, the multitude of physician specialty stakeholders and the overall flux of the future of medical care in the United States all would contribute to the difficulties of prioritizing the implementation of the PCCP concept. Also, our practice style—a large intensivist group working in an ostensibly closed surgical ICU in a tertiary-care hospital—is one possible model, as is the even more highly evolved Cleveland Clinic medical ICU, where medical intensivists are already essentially PCCPs. But these models of care may not be generalizable among the local care patterns and medical politics across hospitals or ICUs.

Based on the described successes of our practice model, coupled with evidence in the literature, we have proposed a paradigm shift toward the concept of a PCCP. To be sure, paradigm shifts nearly always require time, effort, and wherewithal. In the end, however, we feel that embracement of the PCCP paradigm would result in a concise, discrete understanding of the role of intensivist, eliminate the specialty’s identity crisis, and ultimately improve patient care.

After nearly a half-century, the subspecialty of critical care medicine—uniquely trained physicians caring for critically ill or injured patients in specialized, discrete nursing units—continues to suffer from an identity crisis.

Too often, the role of the intensivist in caring for the patient is unclear, to the patient, to the family, and to other physicians. Is the intensivist merely a consultant, or does he or she have a larger role?

The time has come to end the identity crisis with a fundamental paradigm shift, to identify intensivists as the principal caregivers of critically ill patients, ie, the “primary critical care physicians,” or PCCPs. We think this is necessary based not only on evidence from clinical studies, but also on our decades of experience as intensivist caregivers in a high-intensity, closed-staffing model.

REASONS FOR THE IDENTITY CRISIS

The reasons for the continued identity crisis of intensivists are many and complex.

To begin with, other physicians tend to be ambiguous about the duties of intensivists, and the general population is mostly unaware of the subspecialty. In contrast to mature subspecialties such as cardiology or gastroenterology, where responsibilities are generally known to physicians and the lay public alike, or in contrast even to recently evolved specialties such as emergency medicine, the enigmatic roles of an intensivist may differ depending on primary specialty (anesthesiology, internal medicine, surgery) and the patient population, or even among intensive care units (ICUs) within the same hospital.

Moreover, that an identity crisis exists is even more surprising given the disproportionately large consumption by critical care medicine of finite economic resources. One would expect that a sector of health care that expends 1% of the GNP¹ would have clearly explicit roles and responsibilities for its physicians.

Nearly three-quarters of the care by intensivists in the United States is delivered in what is considered an “open” or “low-intensity” ICU staffing model²: an intensivist makes treatment recommendations but otherwise has no overarching authority over patient care. In this model, the admitting physician is not trained in critical care and is not available throughout the day to make decisions concerning the management of the patient. In addition, various consulting physicians and single-organ specialists may not be aware of the overall management plan, resulting in potentially unnecessary or conflicting orders and increased expense.² What is more, in an open ICU model, critical care nurses are often left to detect and correct a significant change in a patient’s status without the necessary immediate physician availability, resulting not only in a stressful working environment for nursing staff, but also in potential harm associated with individuals providing care outside their scope of practice.³

In only a small percentage of ICUs—mostly medical ICUs and ICUs in teaching hospitals—is critical care provided in a “high-intensity” or “closed” staffing pattern, in which treatment decisions are cohesively managed under the guidance of an intensivist.²

EVIDENCE IN THE MEDICAL LITERATURE

Staffing patterns in the ICU

Several studies have attempted to identify the consequences of these different ICU staffing patterns on patient care.

Hanson et al⁴ examined two concurrent patient cohorts admitted to a surgical ICU. The study cohort was cared for by an on-site critical care team supervised by an intensivist, while the control cohort received care from a team with patient care responsibilities in multiple sites, supervised by a general surgeon. The results showed that patients cared for by the critical care team spent less time in the ICU, used fewer resources, had fewer complications, and had lower total hospital charges. The difference between the two cohorts was most evident in patients with the worst Acute Physiology and Chronic Health Evaluation (APACHE) II scores.

According to Hanson et al, the lack of an accepted prototype for the delivery of critical care is due to factors such as the relative youth of the discipline, contention over control of individual patient management, and the absence of a single academic advocate.⁴

Moreover, Pronovost et al⁵ concluded that high-intensity staffing (mandatory intensivist consultation or closed ICU) was associated with lower ICU mortality rates in 93% of studies and with a reduced ICU length of stay in the high-intensity staffing units when compared with ICUs with low-intensity staffing (no intensivist or elective intensivist consultation).

Critics of our PCCP paradigm may point to a study by Levy et al⁶ that, using a database of more than 100,000 patients, could not demonstrate any survival benefit with management by critical care physicians. Indeed the study found that patients managed by intensivists had a higher mortality rate than patients managed by physicians not trained in critical care. However, they also showed that more patients managed for the entire stay by intensivists received interventions such as intravenous drugs, mechanical ventilation, and continuous sedation and that they had a higher mean severity of illness as measured by the expanded Simplified Acute Physiology Score (SAPS II) and higher hospital mortality rates than patients who were not managed by a critical care team.

According to Levy et al, most ICUs in the United States are structured as completely open units in which the admitting physicians retain full clinical and decisional responsibility and thus have the option to care for their patients with or without input from intensivists.⁶

However, a recent study by Kim et al⁷ likely rebuts the findings of Levy et al. Kim et al analyzed more than 100,000 ICU admissions and found that the lowest odds of death within 30 days were in ICUs that had high-intensity physician staffing and multidisciplinary care teams, suggesting that the presence of an intensivist confers a survival benefit.

Other studies have also shown that high-intensity staffing improves patient outcomes in the ICU.^5,8,9

Issues of cost and use of resources

Issues concerning cost and human resources for staffing ICUs have acquired increasing importance. According to Angus et al,¹⁰ intensivists provided care to only 36.8% of all ICU patients. The demand for critical care services will continue to grow rapidly as the population ages. It is this shift in the care of the critically ill that requires intensivists to take on the role of the PCCP, so as to provide high-quality, evidence-based critical care and to promote a long-term sustainable model of physician and nursing care.

OUR EXPERIENCE

Our intensivist group has been providing a near-primary-care style of critical care practice for almost 40 years, from its inception in 1977 by one of the authors (A.B.), to our current group of 15 board-certified intensivists. We can easily cite the clinical value of our practice approach, with outcome data showing consistent and better-than-expected Standardized Mortality Ratio accounts from our APACHE IV data (personal communication, Cleveland Clinic Cerner/APACHE IV report), or with reports showing that the presence of a full-time, attending-level, in-house staff physician ensures that patients, surgeons, and consultants have confidence and respect for the care provided. However, we feel that the intangible components are what make our practice a prototype for the PCCP model.

A dedicated team with a low turnover rate

First, we have a team of anesthesiology- and surgery-based intensivists dedicated to ICU practice, with a very low turnover or burnout rate, in contrast to most ICUs in the United States, where intensivists tend to practice part-time (at other times either providing operating-room-based anesthesia or surgical care or working in a pulmonary- or sleep-lab-based practice). We believe this point should not go unstressed: we have a team of physicians who have dedicated their career to working in the ICU full-time, and some have done so in excess of 20 years, even as long as 30 years! It is our opinion that we are able to provide such a highly desirable working environment by a unique daily staffing model that does not utilize the conventional practice style of one intensivist on-call per week.

We also feel that our model dramatically reduces the risk of burnout by permitting our attending intensivists to break up on-call sequences so that there are days on which work in the ICU is not also associated with on-call responsibilities.

A successful fellowship program

Second, we have an extremely successful fellowship program, which began in 1974 when one of the authors (A.B.) advocated the training of anesthesiology residents as intensivists.¹¹ The American Board of Anesthesiology certifies on average 55 candidates per year in critical care medicine, and our program trains about 10% of the physicians applying for certification. In most years, there are actually more candidates for our program than there are available positions, which is atypical for anesthesiology-based critical care training programs. This wealth of young, talented candidates interested in critical care as a career is, again, in contrast to most anesthesiology-based programs, which find it difficult to enroll even one fellow per year.

Critical care programs grounded in anesthesiology typically struggle because of the realities of economics.¹² The payoff of operating-room-based anesthesiology practices generally outshines those in critical care, yet we already have three times as many candidates as there are positions to start our training program in the next 2 years. We feel that candidates are attracted to our program simply because our environment (dedicated staffing, equal clinical footing with surgeons, low burnout rates) is seen as an exciting, positively charged role-modeling atmosphere for young physicians who may have a career interest that involves more than just their original base specialty.

A collegial working relationship

Third, we have a thriving, collegial working relationship—including daily bedside and weekly bioethics rounds with our nursing staff—which has fueled a high degree of professional satisfaction among nurses. This is evidenced by the extremely low turnover rate of nurses (less than 5% per year in the last 5 years) and by national recognition for nursing excellence (Beacon Award for Critical Care Excellence, American Association of Critical Care Nurses) (personal communication, S. Wilson, Nurse Manager). In 2009, the four nurses out of 174 who left did so to further their careers.

While low turnover rates among nurses and award-winning practices are surely a testament to a highly motivated and skilled nursing team, there is no question that a constructive collegiality among the physicians and nurses has provided an environment to allow these positive aspects to flourish.

OVERCOMING ROADBLOCKS

Obviously, although in theory it is easy to proclaim a PCCP paradigm, in reality the roadblocks are many.

For example, standardization of education and credentialing would be an essential hurdle to overcome. The current educational arrangement of the various adult specialties (anesthesiology, internal medicine, surgery), each offering disparate subspecialty critical care training and certification, is deeply rooted in interdisciplinary politics, but without any demonstration of improved patient care.¹³ As described recently by Kaplan and Shaw,¹⁴ an all-encompassing training and credentialing standard for critical care is essential for 21st century medicine and would go a long way toward development of the PCCP paradigm.

Another major roadblock is the shortage of intensivists in the United States.¹³ There are many reasons why physicians opt not to select critical care as a career, such as a non-straight-forward training pathway (as described above), recognition that the 24-hours per day, 7-days-per-week nature of critical care affects lifestyle issues, and inconsistent physician compensation.¹³

However, technological and personnel advances, including the use of electronic (e-ICU)¹⁵ and mid-level practitioner models, have led to creative approaches to extend critical care coverage.¹³

Additionally, the multitude of physician specialty stakeholders and the overall flux of the future of medical care in the United States all would contribute to the difficulties of prioritizing the implementation of the PCCP concept. Also, our practice style—a large intensivist group working in an ostensibly closed surgical ICU in a tertiary-care hospital—is one possible model, as is the even more highly evolved Cleveland Clinic medical ICU, where medical intensivists are already essentially PCCPs. But these models of care may not be generalizable among the local care patterns and medical politics across hospitals or ICUs.

Based on the described successes of our practice model, coupled with evidence in the literature, we have proposed a paradigm shift toward the concept of a PCCP. To be sure, paradigm shifts nearly always require time, effort, and wherewithal. In the end, however, we feel that embracement of the PCCP paradigm would result in a concise, discrete understanding of the role of intensivist, eliminate the specialty’s identity crisis, and ultimately improve patient care.

After nearly a half-century, the subspecialty of critical care medicine—uniquely trained physicians caring for critically ill or injured patients in specialized, discrete nursing units—continues to suffer from an identity crisis.

Too often, the role of the intensivist in caring for the patient is unclear, to the patient, to the family, and to other physicians. Is the intensivist merely a consultant, or does he or she have a larger role?

The time has come to end the identity crisis with a fundamental paradigm shift, to identify intensivists as the principal caregivers of critically ill patients, ie, the “primary critical care physicians,” or PCCPs. We think this is necessary based not only on evidence from clinical studies, but also on our decades of experience as intensivist caregivers in a high-intensity, closed-staffing model.

REASONS FOR THE IDENTITY CRISIS

The reasons for the continued identity crisis of intensivists are many and complex.

To begin with, other physicians tend to be ambiguous about the duties of intensivists, and the general population is mostly unaware of the subspecialty. In contrast to mature subspecialties such as cardiology or gastroenterology, where responsibilities are generally known to physicians and the lay public alike, or in contrast even to recently evolved specialties such as emergency medicine, the enigmatic roles of an intensivist may differ depending on primary specialty (anesthesiology, internal medicine, surgery) and the patient population, or even among intensive care units (ICUs) within the same hospital.

Moreover, that an identity crisis exists is even more surprising given the disproportionately large consumption by critical care medicine of finite economic resources. One would expect that a sector of health care that expends 1% of the GNP¹ would have clearly explicit roles and responsibilities for its physicians.

Nearly three-quarters of the care by intensivists in the United States is delivered in what is considered an “open” or “low-intensity” ICU staffing model²: an intensivist makes treatment recommendations but otherwise has no overarching authority over patient care. In this model, the admitting physician is not trained in critical care and is not available throughout the day to make decisions concerning the management of the patient. In addition, various consulting physicians and single-organ specialists may not be aware of the overall management plan, resulting in potentially unnecessary or conflicting orders and increased expense.² What is more, in an open ICU model, critical care nurses are often left to detect and correct a significant change in a patient’s status without the necessary immediate physician availability, resulting not only in a stressful working environment for nursing staff, but also in potential harm associated with individuals providing care outside their scope of practice.³

In only a small percentage of ICUs—mostly medical ICUs and ICUs in teaching hospitals—is critical care provided in a “high-intensity” or “closed” staffing pattern, in which treatment decisions are cohesively managed under the guidance of an intensivist.²

EVIDENCE IN THE MEDICAL LITERATURE

Staffing patterns in the ICU

Several studies have attempted to identify the consequences of these different ICU staffing patterns on patient care.

Hanson et al⁴ examined two concurrent patient cohorts admitted to a surgical ICU. The study cohort was cared for by an on-site critical care team supervised by an intensivist, while the control cohort received care from a team with patient care responsibilities in multiple sites, supervised by a general surgeon. The results showed that patients cared for by the critical care team spent less time in the ICU, used fewer resources, had fewer complications, and had lower total hospital charges. The difference between the two cohorts was most evident in patients with the worst Acute Physiology and Chronic Health Evaluation (APACHE) II scores.

According to Hanson et al, the lack of an accepted prototype for the delivery of critical care is due to factors such as the relative youth of the discipline, contention over control of individual patient management, and the absence of a single academic advocate.⁴

Moreover, Pronovost et al⁵ concluded that high-intensity staffing (mandatory intensivist consultation or closed ICU) was associated with lower ICU mortality rates in 93% of studies and with a reduced ICU length of stay in the high-intensity staffing units when compared with ICUs with low-intensity staffing (no intensivist or elective intensivist consultation).

Critics of our PCCP paradigm may point to a study by Levy et al⁶ that, using a database of more than 100,000 patients, could not demonstrate any survival benefit with management by critical care physicians. Indeed the study found that patients managed by intensivists had a higher mortality rate than patients managed by physicians not trained in critical care. However, they also showed that more patients managed for the entire stay by intensivists received interventions such as intravenous drugs, mechanical ventilation, and continuous sedation and that they had a higher mean severity of illness as measured by the expanded Simplified Acute Physiology Score (SAPS II) and higher hospital mortality rates than patients who were not managed by a critical care team.

According to Levy et al, most ICUs in the United States are structured as completely open units in which the admitting physicians retain full clinical and decisional responsibility and thus have the option to care for their patients with or without input from intensivists.⁶

However, a recent study by Kim et al⁷ likely rebuts the findings of Levy et al. Kim et al analyzed more than 100,000 ICU admissions and found that the lowest odds of death within 30 days were in ICUs that had high-intensity physician staffing and multidisciplinary care teams, suggesting that the presence of an intensivist confers a survival benefit.

Other studies have also shown that high-intensity staffing improves patient outcomes in the ICU.^5,8,9

Issues of cost and use of resources

Issues concerning cost and human resources for staffing ICUs have acquired increasing importance. According to Angus et al,¹⁰ intensivists provided care to only 36.8% of all ICU patients. The demand for critical care services will continue to grow rapidly as the population ages. It is this shift in the care of the critically ill that requires intensivists to take on the role of the PCCP, so as to provide high-quality, evidence-based critical care and to promote a long-term sustainable model of physician and nursing care.

OUR EXPERIENCE

Our intensivist group has been providing a near-primary-care style of critical care practice for almost 40 years, from its inception in 1977 by one of the authors (A.B.), to our current group of 15 board-certified intensivists. We can easily cite the clinical value of our practice approach, with outcome data showing consistent and better-than-expected Standardized Mortality Ratio accounts from our APACHE IV data (personal communication, Cleveland Clinic Cerner/APACHE IV report), or with reports showing that the presence of a full-time, attending-level, in-house staff physician ensures that patients, surgeons, and consultants have confidence and respect for the care provided. However, we feel that the intangible components are what make our practice a prototype for the PCCP model.

A dedicated team with a low turnover rate

First, we have a team of anesthesiology- and surgery-based intensivists dedicated to ICU practice, with a very low turnover or burnout rate, in contrast to most ICUs in the United States, where intensivists tend to practice part-time (at other times either providing operating-room-based anesthesia or surgical care or working in a pulmonary- or sleep-lab-based practice). We believe this point should not go unstressed: we have a team of physicians who have dedicated their career to working in the ICU full-time, and some have done so in excess of 20 years, even as long as 30 years! It is our opinion that we are able to provide such a highly desirable working environment by a unique daily staffing model that does not utilize the conventional practice style of one intensivist on-call per week.

We also feel that our model dramatically reduces the risk of burnout by permitting our attending intensivists to break up on-call sequences so that there are days on which work in the ICU is not also associated with on-call responsibilities.

A successful fellowship program

Second, we have an extremely successful fellowship program, which began in 1974 when one of the authors (A.B.) advocated the training of anesthesiology residents as intensivists.¹¹ The American Board of Anesthesiology certifies on average 55 candidates per year in critical care medicine, and our program trains about 10% of the physicians applying for certification. In most years, there are actually more candidates for our program than there are available positions, which is atypical for anesthesiology-based critical care training programs. This wealth of young, talented candidates interested in critical care as a career is, again, in contrast to most anesthesiology-based programs, which find it difficult to enroll even one fellow per year.

Critical care programs grounded in anesthesiology typically struggle because of the realities of economics.¹² The payoff of operating-room-based anesthesiology practices generally outshines those in critical care, yet we already have three times as many candidates as there are positions to start our training program in the next 2 years. We feel that candidates are attracted to our program simply because our environment (dedicated staffing, equal clinical footing with surgeons, low burnout rates) is seen as an exciting, positively charged role-modeling atmosphere for young physicians who may have a career interest that involves more than just their original base specialty.

A collegial working relationship

Third, we have a thriving, collegial working relationship—including daily bedside and weekly bioethics rounds with our nursing staff—which has fueled a high degree of professional satisfaction among nurses. This is evidenced by the extremely low turnover rate of nurses (less than 5% per year in the last 5 years) and by national recognition for nursing excellence (Beacon Award for Critical Care Excellence, American Association of Critical Care Nurses) (personal communication, S. Wilson, Nurse Manager). In 2009, the four nurses out of 174 who left did so to further their careers.

While low turnover rates among nurses and award-winning practices are surely a testament to a highly motivated and skilled nursing team, there is no question that a constructive collegiality among the physicians and nurses has provided an environment to allow these positive aspects to flourish.

OVERCOMING ROADBLOCKS

Obviously, although in theory it is easy to proclaim a PCCP paradigm, in reality the roadblocks are many.

For example, standardization of education and credentialing would be an essential hurdle to overcome. The current educational arrangement of the various adult specialties (anesthesiology, internal medicine, surgery), each offering disparate subspecialty critical care training and certification, is deeply rooted in interdisciplinary politics, but without any demonstration of improved patient care.¹³ As described recently by Kaplan and Shaw,¹⁴ an all-encompassing training and credentialing standard for critical care is essential for 21st century medicine and would go a long way toward development of the PCCP paradigm.

Another major roadblock is the shortage of intensivists in the United States.¹³ There are many reasons why physicians opt not to select critical care as a career, such as a non-straight-forward training pathway (as described above), recognition that the 24-hours per day, 7-days-per-week nature of critical care affects lifestyle issues, and inconsistent physician compensation.¹³

However, technological and personnel advances, including the use of electronic (e-ICU)¹⁵ and mid-level practitioner models, have led to creative approaches to extend critical care coverage.¹³

Additionally, the multitude of physician specialty stakeholders and the overall flux of the future of medical care in the United States all would contribute to the difficulties of prioritizing the implementation of the PCCP concept. Also, our practice style—a large intensivist group working in an ostensibly closed surgical ICU in a tertiary-care hospital—is one possible model, as is the even more highly evolved Cleveland Clinic medical ICU, where medical intensivists are already essentially PCCPs. But these models of care may not be generalizable among the local care patterns and medical politics across hospitals or ICUs.

Based on the described successes of our practice model, coupled with evidence in the literature, we have proposed a paradigm shift toward the concept of a PCCP. To be sure, paradigm shifts nearly always require time, effort, and wherewithal. In the end, however, we feel that embracement of the PCCP paradigm would result in a concise, discrete understanding of the role of intensivist, eliminate the specialty’s identity crisis, and ultimately improve patient care.

For people who must travel long distances east or west by air or who must work the night shift, some relief is possible for the grogginess and disorientation that often ensue. The problems arise from the body’s internal clock being out of sync with the sun. Part of the solution involves helping reset the internal clock, or sometimes, preventing it from resetting itself.

This review will focus on jet lag sleep disorder and shift work sleep disorder, with an emphasis on the causes, the clinical assessment, and evidence-based treatment options.

WHEN THE INTERNAL CLOCK IS OUT OF SYNC WITH THE SUN

Circadian rhythm sleep disorders are the result of dyssynchrony between the body’s internal clock and the external 24-hour light-dark cycle. Patients typically present with insomnia or excessive somnolence. These disorders may represent an intrinsic disorder, such as delayed or advanced sleep-phase disorder, or may be the result of transmeridian air travel or working nonstandard shifts.¹

Modified with permission of Elsevier LTD. From Beersma DG, Gordijn MC. Circadian control of the sleep-wake cycle. Physiol Behav 2007; 90:190–195.

The intrinsic human circadian period is typically slightly longer than 24 hours,⁹ but it is synchronized (“entrained”) to the 24-hour day by various environmental inputs, or zeitgebers (German for “time-givers”), the most important of which is light exposure.¹⁰

When the internal clock is out of sync with the sun, the misalignment can result in daytime anergia, alternating complaints of insomnia and hypersomnia, and various other symptoms, including emotional disturbances and gastrointestinal distress. In particular, long-distance air travel or a nocturnal work schedule overwhelms the ability of the intrinsic clock to adjust rapidly enough, and the result is jet lag sleep disorder or shift work sleep disorder.¹

TOOLS TO EVALUATE CIRCADIAN RHYTHM DISTURBANCES

A thorough history is the cornerstone of the evaluation for all sleep disorders, and if a circadian rhythm disturbance is suspected, the sleep history is supplemented with specific questions to establish a clear diagnosis.

When assessing for jet lag disorder, ask about:

• The patient’s degree of sleep deprivation before and during travel
• His or her innate circadian preference (ie, whether he or she is a “night owl” or “early bird”)
• Patterns of alcohol and caffeine consumption.

When assessing for shift work disorder, include the above questions and also look for differences in the sleep-wake schedule on working days vs nonworking days, as well as external contributors to poor sleep quality (eg, the degree to which daytime sleep is not “protected”).

The following tools help in acquiring this information.

Sleep diary

In a sleep diary or log, patients record the times that they take naps, maintain consolidated sleep, and subsequently arise. The diary also prompts the patient for information about sleep latency, wakefulness after sleep onset, time in bed, medication and caffeine intake, and the restorative quality of sleep.

While the sleep diary by itself may provide insight into counteractive sleep-related behaviors and misperceptions the patient may have, compliance is often limited. Therefore, the sleep diary is best used in conjunction with actigraphy.

Actigraphy

An actigraph is a wristwatch-size motion detector, typically worn continuously for 7 days or longer. The data it gathers and stores serve as a surrogate measure of various sleep-wake variables.¹¹

Either a sleep diary or actigraphy is required to demonstrate the stability of sleep patterns and circadian preference, but the actigraph typically generates more reliable data.^11,12 It is also valuable in assessing the response to treatment of circadian rhythm sleep disorders.¹³

Are you an early bird or a night owl?

The Morningness-Eveningness questionnaire contains 19 items. Night owls tend to score lower on it than early birds do.¹⁴ This information may help some people avoid situations in which they may not do well, such as an early bird going on a permanent night-shift schedule.

Other assessment tools

Polysomnography is used primarily to rule out sleep-disordered breathing; it is not indicated for routine evaluation of circadian rhythm sleep disorders.

The minimum core body temperature and the peak melatonin secretion follow a 24-hour cycle. Although these measures are often used in research, they are not routinely used in clinical practice. (The minimum core body temperature is discussed further below.)

JET LAG SLEEP DISORDER

Jet lag results from air travel across multiple time zones, with a resultant discordance between the internal circadian clock and the destination’s light-dark cycle. Most sufferers report sleeping poorly at night and feeling groggy during the day, and some also experience general malaise and gastrointestinal distress.¹

The severity depends on a number of variables.

Going west is easier than going east

Westward travel is normally less taxing than eastward travel, as it requires setting one’s internal clock later rather than earlier. Presumably, because the circadian period tends to exceed 24 hours, we can move our internal clock later by about 2 hours per day, but we can move it earlier by only 1 to 1.5 hours.^15,16

The more time zones crossed, the longer it takes the circadian pacemaker to re-entrain and the longer-lasting and more severe are the symptoms of jet lag. Travel across one or two time zones is only transiently troublesome.

Does age affect jet lag?

Whether age affects the severity of jet lag is not yet known.

In a study of simulated jet lag (requiring a 6-hour advance), middle-aged people (ages 37 to 52) experienced a greater degree of fragmented sleep on polysomnography than younger ones (ages 18 to 25). The older group also had greater impairment in daytime alertness, suggesting that phase tolerance—ie, the ability to sleep at an abnormal time in the circadian cycle¹⁷—decreases with age. However, two field studies involving both eastward and westward travel yielded the opposite results, suggesting that older age may actually protect against jet lag.^18–20

Methodologic differences preclude direct comparisons of the studies, as do differences in the age groups studied.

Light exposure can help or hurt, depending on the timing

Reprinted with permission of Elsevier LTD. From Burgess HJ, et al. Bright light, dark, and melatonin can promote circadian adaptation in night shift workers. Sleep Med Rev 2002; 6:407–420.

Our core body temperature dips to its lowest point about 2 to 3 hours before we habitually awake. Exposure to bright light in the hours leading up to this minimum (the inverted triangle in Figure 2) sets our internal clock later (a phase delay)—desirable, say, for someone travelling from New York City to Los Angeles. Conversely, exposure to bright light after this temperature minimum sets the clock earlier.

Inadvertent shifting of circadian phase in the wrong direction (“antidromic re-entrainment”) is common and delays circadian reacclimation and the dissipation of jet lag symptoms.

Burgess HJ, Eastman CT. Prevention of jet lag. American College of Physicians, 2010. Modified with permission of the American College of Physicians.

We discuss ways to reduce antidromic reentrainment in more detail further below.

Other factors

Other factors that contribute to travel fatigue include sleep deprivation (before the flight or en route), acute discomfort as the plane ascends to its cruising altitude,²⁵ and excessive alcohol or caffeine intake during the flight. Although the effects of these factors rapidly diminish once one reaches the travel destination, jet lag will persist until circadian re-entrainment occurs.¹⁵

NONDRUG THERAPIES FOR JET LAG SLEEP DISORDER

The goal of treatment is to realign the circadian rhythm in the most rapid and efficient way and to minimize symptoms in the meantime. Frequent shifts to different time zones, often required in business travel, are very difficult to accommodate, and business travelers actually may do better if they remain on their home-based schedule.

One study compared keeping home-based sleep hours as opposed to adopting local sleep hours during a 2-day stay after a 9-hour westward flight.²⁶ Travelers who remained on home-based hours were less sleepy and had lower (ie, better) global jet lag ratings than those who adopted local sleep hours, in part because of better sleep quality and duration. Nevertheless, about one-third of the participants said they preferred to adhere to the local schedule.

Strategic avoidance of, and exposure to, light

If the traveler intends to remain at the destination long enough, he or she can adjust better (and avoid an antidromic process) via strategic avoidance of and exposure to light.²⁴

Burgess HJ, Eastman CT. Prevention of jet lag. American College of Physicians, 2010. Modified with permission of the American College of Physicians.

People travelling east, who want to set their clocks ahead (a phase advance), need to keep to the dark in the 3 hours leading up to the time they reach their minimum core body temperature (depicted as “D” in Figure 3), and then expose themselves to light in the 3 hours immediately after (“L” in Figure 3). Thus, the traveler from Chicago to Paris would do better by avoiding light exposure on arrival, either by remaining in darkness in his or her hotel room, or by wearing dark sunglasses when outdoors. Wearing sunglasses during transit to the hotel would also help avoid light exposure.

When attempting to delay circadian rhythms, the opposite light-dark patterns are sought, as depicted in Figure 4. As flight and layover patterns often do not permit strict adherence to these measures, they represent idealized scenarios.

The first step is to make a grid with a concurrent listing of home and destination times. In the example in Figure 3, the person is traveling seven time zones east. On day 0, a rectangle is drawn around the times representing home-based sleep hours.

Next, we mark the time at which we expect the traveler’s core body temperature to reach its minimum (inverted triangle). If the person habitually sleeps no more than 7 hours per night, then we mark this point as 2 hours before his or her habitual wake-up time; if the person sleeps more than 7 hours, then we place it 3 hours before wake-up time.^23,29 This process is repeated at the bottom of the grid to represent the desired sleep schedule at the traveler’s destination. The distance between the home and the destination-based minimum core body temperature symbols represents the required degree of circadian realignment.

If a phase advance is required (eg, if travelling from Chicago to Paris), the core body temperature symbol is drawn on day 1 in the same location as day 0. For each subsequent day, the symbol is moved 1 hour earlier (which is about how fast the internal clock can advance),^15,27 until a clock time within 1 hour of the desired destination core body temperature time is reached or satisfactory sleep and daytime functioning are achieved (Figure 3). If a phase delay is required (eg, if travelling from New York City to Los Angeles), the symbol is drawn 2 hours later on day 1 than on day 0 (reflecting the greater ease at which delays are achieved),^15,27 with subsequent daily shifts in 2-hour increments, again until a clock time within 1 hour of the desired destination minimum core body temperature time is reached or satisfactory sleep and daytime functioning are achieved.

Requirements for darkness can be met with protective eyewear (ie, dark sunglasses), or by remaining in a dark room. Light requirements can be met with outdoor exposure, with a commercial light box, or with a separate apparatus (eg, goggles, visors) portable enough for travel.

DRUGS TO TREAT JET LAG SLEEP DISORDER

Melatonin appears safe

Most field studies have found that nightly doses of melatonin (2–8 mg) improve the quality of sleep^30–32 or alleviate daytime symptoms of jet lag, or both.^{20,30,31,33–36} Immediate-release preparations appear to be more effective than slow-release ones.³¹ Although most studies looked exclusively at adaptation to eastward travel,^{30–32,35,36} one studied westward travel,³³ and another assessed melatonin’s effects during both departure and return trips that traversed 11 time zones.³⁴

In studies of preflight dosing, melatonin was scheduled for up to 3 days before departure (and en route in two instances),^30,34 at clock hours corresponding to the nocturnal sleep period at the travel destination (consistent times daily), and then for a subsequent 3 to 4 days between a destination time of 22:00 and 00:00 hours (ie, at bedtime).^{30,31,34–36} Several other studies further simplified this regimen, with participants taking nocturnal melatonin only on arrival at the destination, either for eastward^31,32 or for westward travel.³³

The study involving solely westward travel (Los Angeles to New Zealand) was the only one of the studies with positive findings that allowed for comparisons between participants who received melatonin before departure (3 days at 5-mg doses, taken between 07:00 and 08:00 Los Angeles time) and continuing for 5 days after arrival at 22:00 to 00:00 New Zealand time, and those who received melatonin beginning only on arrival.³³ Significantly better jet lag outcomes were found in the latter group.

An important caveat is that melatonin is sold over the counter as a nutritional supplement and is not regulated by the United States Food and Drug Administration (FDA), so verification of purity of the product is difficult.

A comprehensive review by the National Academy of Sciences stated that, given the available data, short-term use of melatonin in total daily doses of 10 mg or less in healthy adults appears to be safe.³⁷

Benzodiazepine receptor agonists improve sleep, but maybe not sleepiness

The use of standard hypnotics during periods of circadian realignment appears to be commonplace but has not been well studied.²⁰ Trials of the newer benzodiazepine receptor agonists—three studies of zolpidem (Ambien) 10 mg^30,38,39 and two of zopiclone 5 to 7.5 mg^32,40—found consistently favorable subjective^30,38 and objective^32,39,40 outcomes in counteracting jet-lag-induced insomnia (for both eastward and westward travel). (Note: Zopiclone is not available in the United States, but its enantiomer eszopiclone [Lunesta] is.) However, the evidence is less clear for daytime symptoms of jet lag, with outcomes reported as favorable,³⁰ equivocal,⁴⁰ or inaccessible.^32,38,39

The discrepancy between studies incorporating systematic daytime assessments may be due to differential medication effects (zolpidem vs zopiclone).

In two studies that compared these standard hypnotics to oral melatonin, one found that zopiclone 5 mg and melatonin 2 mg were equally beneficial with respect to sleep variables (other jet lag symptoms were not assessed).³² In another study, zolpidem 10 mg was superior to melatonin 5 mg for sleep and other jet lag symptoms, and the combination of zolpidem and melatonin was no better than zolpidem alone.³⁰

Importantly, however, adverse effects were more frequent in those taking zolpidem and included nausea, vomiting, and confusion.³⁰ Although these effects were not deemed serious, 14 participants (10%) withdrew from the study.

Stimulants

Caffeine is commonly used to combat the sleepiness of jet lag, but only two controlled field studies have assessed its efficacy.^41,42 Both used slow-release preparations at a daily dosage of 300 mg.

In one study, after an eastward flight traversing seven time zones, participants took the pill at 08:00 destination time every day for 5 days.⁴¹ Curiously, alertness and other jet lag symptoms were not assessed, but circadian rhythms (determined by levels of cortisol in saliva) were re-entrained at a more rapid rate with caffeine than with placebo, and to a degree comparable with that achieved by exogenous melatonin.

In a follow-up study by the same group, those receiving caffeine were objectively less sleepy (as assessed by multiple sleep latency tests) than those taking melatonin or placebo, but subjective differences between groups were not identified.⁴² Furthermore, those taking caffeine had significantly more nocturnal sleep complaints, as assessed both objectively and subjectively.

A recent randomized, double-blind, placebo-controlled trial of the stimulant armodafinil (Nuvigil) found less sleepiness on multiple sleep latency testing and a decrease in jet leg symptoms with a dosage of 150 mg than with placebo.⁴³

SHIFT WORK SLEEP DISORDER: DEFINITION, PREDISPOSING FACTORS

Shift work refers to nonstandard work schedules, including on-call duty, rotating shifts, and permanent night work. In the United States, one in five workers works a nonstandard shift.²⁰

While shift work presents obvious difficulties, the diagnosis of shift work sleep disorder is reserved for those who have chronic insomnia or sleepiness at times that are not conducive to the externally demanded sleep-wake schedule, despite having the opportunity for sufficient daytime sleep.¹ When defined in such a fashion, this disorder may afflict nearly a third of workers,⁴⁴ with potential adverse effects on safety, health, and quality of life.

Older age is considered a risk factor for intolerance to shift work.²⁰ In a study of physiologic phase shifts in response to night work, older workers were less able to recover after several night shifts.⁴⁵ A large survey of police officers working the night shift supported the finding of more sleep disruption and on-duty sleepiness in older people.⁴⁶

TREATMENT OF SHIFT WORK SLEEP DISORDER

Bright light at work, sunglasses on the way home

Various field studies have described hastening of circadian adaptation (and immediate alerting effects) during night shifts with the use of bright light.²⁰

Boivin and James⁴⁷ found that workers who received 6 hours of intermittent bright light during their shifts experienced significantly greater phase delays than those who received no such intervention. Those receiving bright light also wore sunglasses during the commute home (to protect from an undesired phase advance), and this has demonstrated favorable effects as an independent intervention.⁴⁸

Drug treatment of shift work sleep disorder

Melatonin: Mixed results. Two field studies found that taking melatonin (5–6 mg) before the daytime sleep period had a favorable impact on subjective sleep quality.^49,50 However, two other studies found no such benefit with doses ranging from 6 to 10 mg.^51,52 Differences between these studies—eg, shift schedules, dosages, and the time the melatonin was taken—preclude definitive comparisons.

Effects of melatonin on workplace alertness are indeterminate because of inconsistent measurements of this variable. Importantly, a simulated shift work study found no phase-shifting advantages of melatonin in those who concomitantly used bright light during their work shift with or without morning protective eyewear.⁴⁸

Hypnotic drugs. In simulation studies and field studies, people taking benzodiazepine receptor agonists have consistently said they sleep better.^53–58 A simulation study noted additional benefit in the ability to stay alert during the night shift (assessed by maintenance of wakefulness testing),⁵⁵ but two other studies saw no changes in manifest sleepiness (assessed with multiple sleep latency tests).^53,54 These divergent findings may represent different effects on these two dimensions of sleepiness.

The only field study to assess post-sleep psychomotor performance found no impairments after taking 7.5 mg of zopiclone, a relatively long-acting nonbenzodiazepine hypnotic.⁵⁷

Stimulants. In the largest trial to date of shift work sleep disorder, modafinil 200 mg (the only drug currently FDA-approved for shift work sleep disorder) had significant benefits compared with placebo with respect to objective measurements of workplace sleepiness, reaction time performance testing, and self-rated improvement of symptoms.⁵⁹ Perhaps because of the low dose studied, both treated and untreated patients continued to manifest sleepiness within the pathologic range on objective testing.

Although the efficacy of caffeine is well documented as a countermeasure for sleepiness during experimentally induced sleep deprivation,²⁰ very few field trials have specifically addressed impairments associated with shift work sleep disorder. In one study, caffeine at a dose of 4 mg/kg taken 30 minutes before starting a night shift provided objective improvement in both performance and alertness.⁶⁰

Strategic napping is an additional practical intervention to promote alertness during night shifts, and cumulative data indicate that it provides objective and subjective improvements in alertness and performance.^61,62 Earlier timed naps (ie, before or during the early portion of a shift) of short duration (ie, 20 minutes or less) are likely to produce maximal benefit, because they avoid sleep inertia (the grogginess or sleepiness that may follow a long nap), and also because they have no effect on the subsequent daytime sleep bout.^61,63

Interventions may also be used in combination. For example, napping in conjunction with caffeine results in a greater degree of increased objective alertness than either intervention alone.⁶⁰

How about days off?

The recommendations described here presume that shift workers maintain the workday sleep-wake schedule continuously, including when they are not at work. This is likely not a real-world scenario.

Smith et al⁶⁴ developed a “compromise” phase position, whereby internal rhythms are optimized to facilitate alertness during work and sleepiness during the day, while allowing one to adopt a non-workday sleep schedule that maintains accessibility to family and social activities. In brief, non-workday sleep starts about 5.5 hours earlier than workday sleep; all sleep bouts are followed by brief exposure to bright light (to avoid excessive phase delay); and, as described previously, both workplace bright light and protection from morning light are implemented.

Although further studies are needed to determine whether this regimen is practical in real life, study participants who achieved desired partial phase shifts had performance ratings on a par with baseline levels, and comparable to those in a group that achieved complete re-entrainment.⁶⁴

Finally, all shift workers need to be encouraged to protect the daytime bedroom environment just as daytime workers protect their nighttime environment. Sleep should be sought in an appropriately darkened and quiet environment, phones and doorbells silenced, and appointments scheduled accordingly.

For people who must travel long distances east or west by air or who must work the night shift, some relief is possible for the grogginess and disorientation that often ensue. The problems arise from the body’s internal clock being out of sync with the sun. Part of the solution involves helping reset the internal clock, or sometimes, preventing it from resetting itself.

This review will focus on jet lag sleep disorder and shift work sleep disorder, with an emphasis on the causes, the clinical assessment, and evidence-based treatment options.

WHEN THE INTERNAL CLOCK IS OUT OF SYNC WITH THE SUN

Circadian rhythm sleep disorders are the result of dyssynchrony between the body’s internal clock and the external 24-hour light-dark cycle. Patients typically present with insomnia or excessive somnolence. These disorders may represent an intrinsic disorder, such as delayed or advanced sleep-phase disorder, or may be the result of transmeridian air travel or working nonstandard shifts.¹

Modified with permission of Elsevier LTD. From Beersma DG, Gordijn MC. Circadian control of the sleep-wake cycle. Physiol Behav 2007; 90:190–195.

The intrinsic human circadian period is typically slightly longer than 24 hours,⁹ but it is synchronized (“entrained”) to the 24-hour day by various environmental inputs, or zeitgebers (German for “time-givers”), the most important of which is light exposure.¹⁰

When the internal clock is out of sync with the sun, the misalignment can result in daytime anergia, alternating complaints of insomnia and hypersomnia, and various other symptoms, including emotional disturbances and gastrointestinal distress. In particular, long-distance air travel or a nocturnal work schedule overwhelms the ability of the intrinsic clock to adjust rapidly enough, and the result is jet lag sleep disorder or shift work sleep disorder.¹

TOOLS TO EVALUATE CIRCADIAN RHYTHM DISTURBANCES

A thorough history is the cornerstone of the evaluation for all sleep disorders, and if a circadian rhythm disturbance is suspected, the sleep history is supplemented with specific questions to establish a clear diagnosis.

When assessing for jet lag disorder, ask about:

• The patient’s degree of sleep deprivation before and during travel
• His or her innate circadian preference (ie, whether he or she is a “night owl” or “early bird”)
• Patterns of alcohol and caffeine consumption.

When assessing for shift work disorder, include the above questions and also look for differences in the sleep-wake schedule on working days vs nonworking days, as well as external contributors to poor sleep quality (eg, the degree to which daytime sleep is not “protected”).

The following tools help in acquiring this information.

Sleep diary

In a sleep diary or log, patients record the times that they take naps, maintain consolidated sleep, and subsequently arise. The diary also prompts the patient for information about sleep latency, wakefulness after sleep onset, time in bed, medication and caffeine intake, and the restorative quality of sleep.

While the sleep diary by itself may provide insight into counteractive sleep-related behaviors and misperceptions the patient may have, compliance is often limited. Therefore, the sleep diary is best used in conjunction with actigraphy.

Actigraphy

An actigraph is a wristwatch-size motion detector, typically worn continuously for 7 days or longer. The data it gathers and stores serve as a surrogate measure of various sleep-wake variables.¹¹

Either a sleep diary or actigraphy is required to demonstrate the stability of sleep patterns and circadian preference, but the actigraph typically generates more reliable data.^11,12 It is also valuable in assessing the response to treatment of circadian rhythm sleep disorders.¹³

Are you an early bird or a night owl?

The Morningness-Eveningness questionnaire contains 19 items. Night owls tend to score lower on it than early birds do.¹⁴ This information may help some people avoid situations in which they may not do well, such as an early bird going on a permanent night-shift schedule.

Other assessment tools

Polysomnography is used primarily to rule out sleep-disordered breathing; it is not indicated for routine evaluation of circadian rhythm sleep disorders.

The minimum core body temperature and the peak melatonin secretion follow a 24-hour cycle. Although these measures are often used in research, they are not routinely used in clinical practice. (The minimum core body temperature is discussed further below.)

JET LAG SLEEP DISORDER

Jet lag results from air travel across multiple time zones, with a resultant discordance between the internal circadian clock and the destination’s light-dark cycle. Most sufferers report sleeping poorly at night and feeling groggy during the day, and some also experience general malaise and gastrointestinal distress.¹

The severity depends on a number of variables.

Going west is easier than going east

Westward travel is normally less taxing than eastward travel, as it requires setting one’s internal clock later rather than earlier. Presumably, because the circadian period tends to exceed 24 hours, we can move our internal clock later by about 2 hours per day, but we can move it earlier by only 1 to 1.5 hours.^15,16

The more time zones crossed, the longer it takes the circadian pacemaker to re-entrain and the longer-lasting and more severe are the symptoms of jet lag. Travel across one or two time zones is only transiently troublesome.

Does age affect jet lag?

Whether age affects the severity of jet lag is not yet known.

In a study of simulated jet lag (requiring a 6-hour advance), middle-aged people (ages 37 to 52) experienced a greater degree of fragmented sleep on polysomnography than younger ones (ages 18 to 25). The older group also had greater impairment in daytime alertness, suggesting that phase tolerance—ie, the ability to sleep at an abnormal time in the circadian cycle¹⁷—decreases with age. However, two field studies involving both eastward and westward travel yielded the opposite results, suggesting that older age may actually protect against jet lag.^18–20

Methodologic differences preclude direct comparisons of the studies, as do differences in the age groups studied.

Light exposure can help or hurt, depending on the timing

Reprinted with permission of Elsevier LTD. From Burgess HJ, et al. Bright light, dark, and melatonin can promote circadian adaptation in night shift workers. Sleep Med Rev 2002; 6:407–420.

Our core body temperature dips to its lowest point about 2 to 3 hours before we habitually awake. Exposure to bright light in the hours leading up to this minimum (the inverted triangle in Figure 2) sets our internal clock later (a phase delay)—desirable, say, for someone travelling from New York City to Los Angeles. Conversely, exposure to bright light after this temperature minimum sets the clock earlier.

Inadvertent shifting of circadian phase in the wrong direction (“antidromic re-entrainment”) is common and delays circadian reacclimation and the dissipation of jet lag symptoms.

Burgess HJ, Eastman CT. Prevention of jet lag. American College of Physicians, 2010. Modified with permission of the American College of Physicians.

We discuss ways to reduce antidromic reentrainment in more detail further below.

Other factors

Other factors that contribute to travel fatigue include sleep deprivation (before the flight or en route), acute discomfort as the plane ascends to its cruising altitude,²⁵ and excessive alcohol or caffeine intake during the flight. Although the effects of these factors rapidly diminish once one reaches the travel destination, jet lag will persist until circadian re-entrainment occurs.¹⁵

NONDRUG THERAPIES FOR JET LAG SLEEP DISORDER

The goal of treatment is to realign the circadian rhythm in the most rapid and efficient way and to minimize symptoms in the meantime. Frequent shifts to different time zones, often required in business travel, are very difficult to accommodate, and business travelers actually may do better if they remain on their home-based schedule.

One study compared keeping home-based sleep hours as opposed to adopting local sleep hours during a 2-day stay after a 9-hour westward flight.²⁶ Travelers who remained on home-based hours were less sleepy and had lower (ie, better) global jet lag ratings than those who adopted local sleep hours, in part because of better sleep quality and duration. Nevertheless, about one-third of the participants said they preferred to adhere to the local schedule.

Strategic avoidance of, and exposure to, light

If the traveler intends to remain at the destination long enough, he or she can adjust better (and avoid an antidromic process) via strategic avoidance of and exposure to light.²⁴

Burgess HJ, Eastman CT. Prevention of jet lag. American College of Physicians, 2010. Modified with permission of the American College of Physicians.

People travelling east, who want to set their clocks ahead (a phase advance), need to keep to the dark in the 3 hours leading up to the time they reach their minimum core body temperature (depicted as “D” in Figure 3), and then expose themselves to light in the 3 hours immediately after (“L” in Figure 3). Thus, the traveler from Chicago to Paris would do better by avoiding light exposure on arrival, either by remaining in darkness in his or her hotel room, or by wearing dark sunglasses when outdoors. Wearing sunglasses during transit to the hotel would also help avoid light exposure.

When attempting to delay circadian rhythms, the opposite light-dark patterns are sought, as depicted in Figure 4. As flight and layover patterns often do not permit strict adherence to these measures, they represent idealized scenarios.

The first step is to make a grid with a concurrent listing of home and destination times. In the example in Figure 3, the person is traveling seven time zones east. On day 0, a rectangle is drawn around the times representing home-based sleep hours.

Next, we mark the time at which we expect the traveler’s core body temperature to reach its minimum (inverted triangle). If the person habitually sleeps no more than 7 hours per night, then we mark this point as 2 hours before his or her habitual wake-up time; if the person sleeps more than 7 hours, then we place it 3 hours before wake-up time.^23,29 This process is repeated at the bottom of the grid to represent the desired sleep schedule at the traveler’s destination. The distance between the home and the destination-based minimum core body temperature symbols represents the required degree of circadian realignment.

If a phase advance is required (eg, if travelling from Chicago to Paris), the core body temperature symbol is drawn on day 1 in the same location as day 0. For each subsequent day, the symbol is moved 1 hour earlier (which is about how fast the internal clock can advance),^15,27 until a clock time within 1 hour of the desired destination core body temperature time is reached or satisfactory sleep and daytime functioning are achieved (Figure 3). If a phase delay is required (eg, if travelling from New York City to Los Angeles), the symbol is drawn 2 hours later on day 1 than on day 0 (reflecting the greater ease at which delays are achieved),^15,27 with subsequent daily shifts in 2-hour increments, again until a clock time within 1 hour of the desired destination minimum core body temperature time is reached or satisfactory sleep and daytime functioning are achieved.

Requirements for darkness can be met with protective eyewear (ie, dark sunglasses), or by remaining in a dark room. Light requirements can be met with outdoor exposure, with a commercial light box, or with a separate apparatus (eg, goggles, visors) portable enough for travel.

DRUGS TO TREAT JET LAG SLEEP DISORDER

Melatonin appears safe

Most field studies have found that nightly doses of melatonin (2–8 mg) improve the quality of sleep^30–32 or alleviate daytime symptoms of jet lag, or both.^{20,30,31,33–36} Immediate-release preparations appear to be more effective than slow-release ones.³¹ Although most studies looked exclusively at adaptation to eastward travel,^{30–32,35,36} one studied westward travel,³³ and another assessed melatonin’s effects during both departure and return trips that traversed 11 time zones.³⁴

In studies of preflight dosing, melatonin was scheduled for up to 3 days before departure (and en route in two instances),^30,34 at clock hours corresponding to the nocturnal sleep period at the travel destination (consistent times daily), and then for a subsequent 3 to 4 days between a destination time of 22:00 and 00:00 hours (ie, at bedtime).^{30,31,34–36} Several other studies further simplified this regimen, with participants taking nocturnal melatonin only on arrival at the destination, either for eastward^31,32 or for westward travel.³³

The study involving solely westward travel (Los Angeles to New Zealand) was the only one of the studies with positive findings that allowed for comparisons between participants who received melatonin before departure (3 days at 5-mg doses, taken between 07:00 and 08:00 Los Angeles time) and continuing for 5 days after arrival at 22:00 to 00:00 New Zealand time, and those who received melatonin beginning only on arrival.³³ Significantly better jet lag outcomes were found in the latter group.

An important caveat is that melatonin is sold over the counter as a nutritional supplement and is not regulated by the United States Food and Drug Administration (FDA), so verification of purity of the product is difficult.

A comprehensive review by the National Academy of Sciences stated that, given the available data, short-term use of melatonin in total daily doses of 10 mg or less in healthy adults appears to be safe.³⁷

Benzodiazepine receptor agonists improve sleep, but maybe not sleepiness

The use of standard hypnotics during periods of circadian realignment appears to be commonplace but has not been well studied.²⁰ Trials of the newer benzodiazepine receptor agonists—three studies of zolpidem (Ambien) 10 mg^30,38,39 and two of zopiclone 5 to 7.5 mg^32,40—found consistently favorable subjective^30,38 and objective^32,39,40 outcomes in counteracting jet-lag-induced insomnia (for both eastward and westward travel). (Note: Zopiclone is not available in the United States, but its enantiomer eszopiclone [Lunesta] is.) However, the evidence is less clear for daytime symptoms of jet lag, with outcomes reported as favorable,³⁰ equivocal,⁴⁰ or inaccessible.^32,38,39

The discrepancy between studies incorporating systematic daytime assessments may be due to differential medication effects (zolpidem vs zopiclone).

In two studies that compared these standard hypnotics to oral melatonin, one found that zopiclone 5 mg and melatonin 2 mg were equally beneficial with respect to sleep variables (other jet lag symptoms were not assessed).³² In another study, zolpidem 10 mg was superior to melatonin 5 mg for sleep and other jet lag symptoms, and the combination of zolpidem and melatonin was no better than zolpidem alone.³⁰

Importantly, however, adverse effects were more frequent in those taking zolpidem and included nausea, vomiting, and confusion.³⁰ Although these effects were not deemed serious, 14 participants (10%) withdrew from the study.

Stimulants

Caffeine is commonly used to combat the sleepiness of jet lag, but only two controlled field studies have assessed its efficacy.^41,42 Both used slow-release preparations at a daily dosage of 300 mg.

In one study, after an eastward flight traversing seven time zones, participants took the pill at 08:00 destination time every day for 5 days.⁴¹ Curiously, alertness and other jet lag symptoms were not assessed, but circadian rhythms (determined by levels of cortisol in saliva) were re-entrained at a more rapid rate with caffeine than with placebo, and to a degree comparable with that achieved by exogenous melatonin.

In a follow-up study by the same group, those receiving caffeine were objectively less sleepy (as assessed by multiple sleep latency tests) than those taking melatonin or placebo, but subjective differences between groups were not identified.⁴² Furthermore, those taking caffeine had significantly more nocturnal sleep complaints, as assessed both objectively and subjectively.

A recent randomized, double-blind, placebo-controlled trial of the stimulant armodafinil (Nuvigil) found less sleepiness on multiple sleep latency testing and a decrease in jet leg symptoms with a dosage of 150 mg than with placebo.⁴³

SHIFT WORK SLEEP DISORDER: DEFINITION, PREDISPOSING FACTORS

Shift work refers to nonstandard work schedules, including on-call duty, rotating shifts, and permanent night work. In the United States, one in five workers works a nonstandard shift.²⁰

While shift work presents obvious difficulties, the diagnosis of shift work sleep disorder is reserved for those who have chronic insomnia or sleepiness at times that are not conducive to the externally demanded sleep-wake schedule, despite having the opportunity for sufficient daytime sleep.¹ When defined in such a fashion, this disorder may afflict nearly a third of workers,⁴⁴ with potential adverse effects on safety, health, and quality of life.

Older age is considered a risk factor for intolerance to shift work.²⁰ In a study of physiologic phase shifts in response to night work, older workers were less able to recover after several night shifts.⁴⁵ A large survey of police officers working the night shift supported the finding of more sleep disruption and on-duty sleepiness in older people.⁴⁶

TREATMENT OF SHIFT WORK SLEEP DISORDER

Bright light at work, sunglasses on the way home

Various field studies have described hastening of circadian adaptation (and immediate alerting effects) during night shifts with the use of bright light.²⁰

Boivin and James⁴⁷ found that workers who received 6 hours of intermittent bright light during their shifts experienced significantly greater phase delays than those who received no such intervention. Those receiving bright light also wore sunglasses during the commute home (to protect from an undesired phase advance), and this has demonstrated favorable effects as an independent intervention.⁴⁸

Drug treatment of shift work sleep disorder

Melatonin: Mixed results. Two field studies found that taking melatonin (5–6 mg) before the daytime sleep period had a favorable impact on subjective sleep quality.^49,50 However, two other studies found no such benefit with doses ranging from 6 to 10 mg.^51,52 Differences between these studies—eg, shift schedules, dosages, and the time the melatonin was taken—preclude definitive comparisons.

Effects of melatonin on workplace alertness are indeterminate because of inconsistent measurements of this variable. Importantly, a simulated shift work study found no phase-shifting advantages of melatonin in those who concomitantly used bright light during their work shift with or without morning protective eyewear.⁴⁸

Hypnotic drugs. In simulation studies and field studies, people taking benzodiazepine receptor agonists have consistently said they sleep better.^53–58 A simulation study noted additional benefit in the ability to stay alert during the night shift (assessed by maintenance of wakefulness testing),⁵⁵ but two other studies saw no changes in manifest sleepiness (assessed with multiple sleep latency tests).^53,54 These divergent findings may represent different effects on these two dimensions of sleepiness.

The only field study to assess post-sleep psychomotor performance found no impairments after taking 7.5 mg of zopiclone, a relatively long-acting nonbenzodiazepine hypnotic.⁵⁷

Stimulants. In the largest trial to date of shift work sleep disorder, modafinil 200 mg (the only drug currently FDA-approved for shift work sleep disorder) had significant benefits compared with placebo with respect to objective measurements of workplace sleepiness, reaction time performance testing, and self-rated improvement of symptoms.⁵⁹ Perhaps because of the low dose studied, both treated and untreated patients continued to manifest sleepiness within the pathologic range on objective testing.

Although the efficacy of caffeine is well documented as a countermeasure for sleepiness during experimentally induced sleep deprivation,²⁰ very few field trials have specifically addressed impairments associated with shift work sleep disorder. In one study, caffeine at a dose of 4 mg/kg taken 30 minutes before starting a night shift provided objective improvement in both performance and alertness.⁶⁰

Strategic napping is an additional practical intervention to promote alertness during night shifts, and cumulative data indicate that it provides objective and subjective improvements in alertness and performance.^61,62 Earlier timed naps (ie, before or during the early portion of a shift) of short duration (ie, 20 minutes or less) are likely to produce maximal benefit, because they avoid sleep inertia (the grogginess or sleepiness that may follow a long nap), and also because they have no effect on the subsequent daytime sleep bout.^61,63

Interventions may also be used in combination. For example, napping in conjunction with caffeine results in a greater degree of increased objective alertness than either intervention alone.⁶⁰

How about days off?

The recommendations described here presume that shift workers maintain the workday sleep-wake schedule continuously, including when they are not at work. This is likely not a real-world scenario.

Smith et al⁶⁴ developed a “compromise” phase position, whereby internal rhythms are optimized to facilitate alertness during work and sleepiness during the day, while allowing one to adopt a non-workday sleep schedule that maintains accessibility to family and social activities. In brief, non-workday sleep starts about 5.5 hours earlier than workday sleep; all sleep bouts are followed by brief exposure to bright light (to avoid excessive phase delay); and, as described previously, both workplace bright light and protection from morning light are implemented.

Although further studies are needed to determine whether this regimen is practical in real life, study participants who achieved desired partial phase shifts had performance ratings on a par with baseline levels, and comparable to those in a group that achieved complete re-entrainment.⁶⁴

Finally, all shift workers need to be encouraged to protect the daytime bedroom environment just as daytime workers protect their nighttime environment. Sleep should be sought in an appropriately darkened and quiet environment, phones and doorbells silenced, and appointments scheduled accordingly.

For people who must travel long distances east or west by air or who must work the night shift, some relief is possible for the grogginess and disorientation that often ensue. The problems arise from the body’s internal clock being out of sync with the sun. Part of the solution involves helping reset the internal clock, or sometimes, preventing it from resetting itself.

This review will focus on jet lag sleep disorder and shift work sleep disorder, with an emphasis on the causes, the clinical assessment, and evidence-based treatment options.

WHEN THE INTERNAL CLOCK IS OUT OF SYNC WITH THE SUN

Circadian rhythm sleep disorders are the result of dyssynchrony between the body’s internal clock and the external 24-hour light-dark cycle. Patients typically present with insomnia or excessive somnolence. These disorders may represent an intrinsic disorder, such as delayed or advanced sleep-phase disorder, or may be the result of transmeridian air travel or working nonstandard shifts.¹

Modified with permission of Elsevier LTD. From Beersma DG, Gordijn MC. Circadian control of the sleep-wake cycle. Physiol Behav 2007; 90:190–195.

The intrinsic human circadian period is typically slightly longer than 24 hours,⁹ but it is synchronized (“entrained”) to the 24-hour day by various environmental inputs, or zeitgebers (German for “time-givers”), the most important of which is light exposure.¹⁰

When the internal clock is out of sync with the sun, the misalignment can result in daytime anergia, alternating complaints of insomnia and hypersomnia, and various other symptoms, including emotional disturbances and gastrointestinal distress. In particular, long-distance air travel or a nocturnal work schedule overwhelms the ability of the intrinsic clock to adjust rapidly enough, and the result is jet lag sleep disorder or shift work sleep disorder.¹

TOOLS TO EVALUATE CIRCADIAN RHYTHM DISTURBANCES

A thorough history is the cornerstone of the evaluation for all sleep disorders, and if a circadian rhythm disturbance is suspected, the sleep history is supplemented with specific questions to establish a clear diagnosis.

When assessing for jet lag disorder, ask about:

• The patient’s degree of sleep deprivation before and during travel
• His or her innate circadian preference (ie, whether he or she is a “night owl” or “early bird”)
• Patterns of alcohol and caffeine consumption.

When assessing for shift work disorder, include the above questions and also look for differences in the sleep-wake schedule on working days vs nonworking days, as well as external contributors to poor sleep quality (eg, the degree to which daytime sleep is not “protected”).

The following tools help in acquiring this information.

Sleep diary

In a sleep diary or log, patients record the times that they take naps, maintain consolidated sleep, and subsequently arise. The diary also prompts the patient for information about sleep latency, wakefulness after sleep onset, time in bed, medication and caffeine intake, and the restorative quality of sleep.

While the sleep diary by itself may provide insight into counteractive sleep-related behaviors and misperceptions the patient may have, compliance is often limited. Therefore, the sleep diary is best used in conjunction with actigraphy.

Actigraphy

An actigraph is a wristwatch-size motion detector, typically worn continuously for 7 days or longer. The data it gathers and stores serve as a surrogate measure of various sleep-wake variables.¹¹

Either a sleep diary or actigraphy is required to demonstrate the stability of sleep patterns and circadian preference, but the actigraph typically generates more reliable data.^11,12 It is also valuable in assessing the response to treatment of circadian rhythm sleep disorders.¹³

Are you an early bird or a night owl?

The Morningness-Eveningness questionnaire contains 19 items. Night owls tend to score lower on it than early birds do.¹⁴ This information may help some people avoid situations in which they may not do well, such as an early bird going on a permanent night-shift schedule.

Other assessment tools

Polysomnography is used primarily to rule out sleep-disordered breathing; it is not indicated for routine evaluation of circadian rhythm sleep disorders.

The minimum core body temperature and the peak melatonin secretion follow a 24-hour cycle. Although these measures are often used in research, they are not routinely used in clinical practice. (The minimum core body temperature is discussed further below.)

JET LAG SLEEP DISORDER

Jet lag results from air travel across multiple time zones, with a resultant discordance between the internal circadian clock and the destination’s light-dark cycle. Most sufferers report sleeping poorly at night and feeling groggy during the day, and some also experience general malaise and gastrointestinal distress.¹

The severity depends on a number of variables.

Going west is easier than going east

Westward travel is normally less taxing than eastward travel, as it requires setting one’s internal clock later rather than earlier. Presumably, because the circadian period tends to exceed 24 hours, we can move our internal clock later by about 2 hours per day, but we can move it earlier by only 1 to 1.5 hours.^15,16

The more time zones crossed, the longer it takes the circadian pacemaker to re-entrain and the longer-lasting and more severe are the symptoms of jet lag. Travel across one or two time zones is only transiently troublesome.

Does age affect jet lag?

Whether age affects the severity of jet lag is not yet known.

In a study of simulated jet lag (requiring a 6-hour advance), middle-aged people (ages 37 to 52) experienced a greater degree of fragmented sleep on polysomnography than younger ones (ages 18 to 25). The older group also had greater impairment in daytime alertness, suggesting that phase tolerance—ie, the ability to sleep at an abnormal time in the circadian cycle¹⁷—decreases with age. However, two field studies involving both eastward and westward travel yielded the opposite results, suggesting that older age may actually protect against jet lag.^18–20

Methodologic differences preclude direct comparisons of the studies, as do differences in the age groups studied.

Light exposure can help or hurt, depending on the timing

Reprinted with permission of Elsevier LTD. From Burgess HJ, et al. Bright light, dark, and melatonin can promote circadian adaptation in night shift workers. Sleep Med Rev 2002; 6:407–420.

Our core body temperature dips to its lowest point about 2 to 3 hours before we habitually awake. Exposure to bright light in the hours leading up to this minimum (the inverted triangle in Figure 2) sets our internal clock later (a phase delay)—desirable, say, for someone travelling from New York City to Los Angeles. Conversely, exposure to bright light after this temperature minimum sets the clock earlier.

Inadvertent shifting of circadian phase in the wrong direction (“antidromic re-entrainment”) is common and delays circadian reacclimation and the dissipation of jet lag symptoms.

Burgess HJ, Eastman CT. Prevention of jet lag. American College of Physicians, 2010. Modified with permission of the American College of Physicians.

We discuss ways to reduce antidromic reentrainment in more detail further below.

Other factors

Other factors that contribute to travel fatigue include sleep deprivation (before the flight or en route), acute discomfort as the plane ascends to its cruising altitude,²⁵ and excessive alcohol or caffeine intake during the flight. Although the effects of these factors rapidly diminish once one reaches the travel destination, jet lag will persist until circadian re-entrainment occurs.¹⁵

NONDRUG THERAPIES FOR JET LAG SLEEP DISORDER

The goal of treatment is to realign the circadian rhythm in the most rapid and efficient way and to minimize symptoms in the meantime. Frequent shifts to different time zones, often required in business travel, are very difficult to accommodate, and business travelers actually may do better if they remain on their home-based schedule.

One study compared keeping home-based sleep hours as opposed to adopting local sleep hours during a 2-day stay after a 9-hour westward flight.²⁶ Travelers who remained on home-based hours were less sleepy and had lower (ie, better) global jet lag ratings than those who adopted local sleep hours, in part because of better sleep quality and duration. Nevertheless, about one-third of the participants said they preferred to adhere to the local schedule.

Strategic avoidance of, and exposure to, light

If the traveler intends to remain at the destination long enough, he or she can adjust better (and avoid an antidromic process) via strategic avoidance of and exposure to light.²⁴

Burgess HJ, Eastman CT. Prevention of jet lag. American College of Physicians, 2010. Modified with permission of the American College of Physicians.

People travelling east, who want to set their clocks ahead (a phase advance), need to keep to the dark in the 3 hours leading up to the time they reach their minimum core body temperature (depicted as “D” in Figure 3), and then expose themselves to light in the 3 hours immediately after (“L” in Figure 3). Thus, the traveler from Chicago to Paris would do better by avoiding light exposure on arrival, either by remaining in darkness in his or her hotel room, or by wearing dark sunglasses when outdoors. Wearing sunglasses during transit to the hotel would also help avoid light exposure.

When attempting to delay circadian rhythms, the opposite light-dark patterns are sought, as depicted in Figure 4. As flight and layover patterns often do not permit strict adherence to these measures, they represent idealized scenarios.

The first step is to make a grid with a concurrent listing of home and destination times. In the example in Figure 3, the person is traveling seven time zones east. On day 0, a rectangle is drawn around the times representing home-based sleep hours.

Next, we mark the time at which we expect the traveler’s core body temperature to reach its minimum (inverted triangle). If the person habitually sleeps no more than 7 hours per night, then we mark this point as 2 hours before his or her habitual wake-up time; if the person sleeps more than 7 hours, then we place it 3 hours before wake-up time.^23,29 This process is repeated at the bottom of the grid to represent the desired sleep schedule at the traveler’s destination. The distance between the home and the destination-based minimum core body temperature symbols represents the required degree of circadian realignment.

If a phase advance is required (eg, if travelling from Chicago to Paris), the core body temperature symbol is drawn on day 1 in the same location as day 0. For each subsequent day, the symbol is moved 1 hour earlier (which is about how fast the internal clock can advance),^15,27 until a clock time within 1 hour of the desired destination core body temperature time is reached or satisfactory sleep and daytime functioning are achieved (Figure 3). If a phase delay is required (eg, if travelling from New York City to Los Angeles), the symbol is drawn 2 hours later on day 1 than on day 0 (reflecting the greater ease at which delays are achieved),^15,27 with subsequent daily shifts in 2-hour increments, again until a clock time within 1 hour of the desired destination minimum core body temperature time is reached or satisfactory sleep and daytime functioning are achieved.

Requirements for darkness can be met with protective eyewear (ie, dark sunglasses), or by remaining in a dark room. Light requirements can be met with outdoor exposure, with a commercial light box, or with a separate apparatus (eg, goggles, visors) portable enough for travel.

DRUGS TO TREAT JET LAG SLEEP DISORDER

Melatonin appears safe

Most field studies have found that nightly doses of melatonin (2–8 mg) improve the quality of sleep^30–32 or alleviate daytime symptoms of jet lag, or both.^{20,30,31,33–36} Immediate-release preparations appear to be more effective than slow-release ones.³¹ Although most studies looked exclusively at adaptation to eastward travel,^{30–32,35,36} one studied westward travel,³³ and another assessed melatonin’s effects during both departure and return trips that traversed 11 time zones.³⁴

In studies of preflight dosing, melatonin was scheduled for up to 3 days before departure (and en route in two instances),^30,34 at clock hours corresponding to the nocturnal sleep period at the travel destination (consistent times daily), and then for a subsequent 3 to 4 days between a destination time of 22:00 and 00:00 hours (ie, at bedtime).^{30,31,34–36} Several other studies further simplified this regimen, with participants taking nocturnal melatonin only on arrival at the destination, either for eastward^31,32 or for westward travel.³³

The study involving solely westward travel (Los Angeles to New Zealand) was the only one of the studies with positive findings that allowed for comparisons between participants who received melatonin before departure (3 days at 5-mg doses, taken between 07:00 and 08:00 Los Angeles time) and continuing for 5 days after arrival at 22:00 to 00:00 New Zealand time, and those who received melatonin beginning only on arrival.³³ Significantly better jet lag outcomes were found in the latter group.

An important caveat is that melatonin is sold over the counter as a nutritional supplement and is not regulated by the United States Food and Drug Administration (FDA), so verification of purity of the product is difficult.

A comprehensive review by the National Academy of Sciences stated that, given the available data, short-term use of melatonin in total daily doses of 10 mg or less in healthy adults appears to be safe.³⁷

Benzodiazepine receptor agonists improve sleep, but maybe not sleepiness

The use of standard hypnotics during periods of circadian realignment appears to be commonplace but has not been well studied.²⁰ Trials of the newer benzodiazepine receptor agonists—three studies of zolpidem (Ambien) 10 mg^30,38,39 and two of zopiclone 5 to 7.5 mg^32,40—found consistently favorable subjective^30,38 and objective^32,39,40 outcomes in counteracting jet-lag-induced insomnia (for both eastward and westward travel). (Note: Zopiclone is not available in the United States, but its enantiomer eszopiclone [Lunesta] is.) However, the evidence is less clear for daytime symptoms of jet lag, with outcomes reported as favorable,³⁰ equivocal,⁴⁰ or inaccessible.^32,38,39

The discrepancy between studies incorporating systematic daytime assessments may be due to differential medication effects (zolpidem vs zopiclone).

In two studies that compared these standard hypnotics to oral melatonin, one found that zopiclone 5 mg and melatonin 2 mg were equally beneficial with respect to sleep variables (other jet lag symptoms were not assessed).³² In another study, zolpidem 10 mg was superior to melatonin 5 mg for sleep and other jet lag symptoms, and the combination of zolpidem and melatonin was no better than zolpidem alone.³⁰

Importantly, however, adverse effects were more frequent in those taking zolpidem and included nausea, vomiting, and confusion.³⁰ Although these effects were not deemed serious, 14 participants (10%) withdrew from the study.

Stimulants

Caffeine is commonly used to combat the sleepiness of jet lag, but only two controlled field studies have assessed its efficacy.^41,42 Both used slow-release preparations at a daily dosage of 300 mg.

In one study, after an eastward flight traversing seven time zones, participants took the pill at 08:00 destination time every day for 5 days.⁴¹ Curiously, alertness and other jet lag symptoms were not assessed, but circadian rhythms (determined by levels of cortisol in saliva) were re-entrained at a more rapid rate with caffeine than with placebo, and to a degree comparable with that achieved by exogenous melatonin.

In a follow-up study by the same group, those receiving caffeine were objectively less sleepy (as assessed by multiple sleep latency tests) than those taking melatonin or placebo, but subjective differences between groups were not identified.⁴² Furthermore, those taking caffeine had significantly more nocturnal sleep complaints, as assessed both objectively and subjectively.

A recent randomized, double-blind, placebo-controlled trial of the stimulant armodafinil (Nuvigil) found less sleepiness on multiple sleep latency testing and a decrease in jet leg symptoms with a dosage of 150 mg than with placebo.⁴³

SHIFT WORK SLEEP DISORDER: DEFINITION, PREDISPOSING FACTORS

Shift work refers to nonstandard work schedules, including on-call duty, rotating shifts, and permanent night work. In the United States, one in five workers works a nonstandard shift.²⁰

While shift work presents obvious difficulties, the diagnosis of shift work sleep disorder is reserved for those who have chronic insomnia or sleepiness at times that are not conducive to the externally demanded sleep-wake schedule, despite having the opportunity for sufficient daytime sleep.¹ When defined in such a fashion, this disorder may afflict nearly a third of workers,⁴⁴ with potential adverse effects on safety, health, and quality of life.

Older age is considered a risk factor for intolerance to shift work.²⁰ In a study of physiologic phase shifts in response to night work, older workers were less able to recover after several night shifts.⁴⁵ A large survey of police officers working the night shift supported the finding of more sleep disruption and on-duty sleepiness in older people.⁴⁶

TREATMENT OF SHIFT WORK SLEEP DISORDER

Bright light at work, sunglasses on the way home

Various field studies have described hastening of circadian adaptation (and immediate alerting effects) during night shifts with the use of bright light.²⁰

Boivin and James⁴⁷ found that workers who received 6 hours of intermittent bright light during their shifts experienced significantly greater phase delays than those who received no such intervention. Those receiving bright light also wore sunglasses during the commute home (to protect from an undesired phase advance), and this has demonstrated favorable effects as an independent intervention.⁴⁸

Drug treatment of shift work sleep disorder

Melatonin: Mixed results. Two field studies found that taking melatonin (5–6 mg) before the daytime sleep period had a favorable impact on subjective sleep quality.^49,50 However, two other studies found no such benefit with doses ranging from 6 to 10 mg.^51,52 Differences between these studies—eg, shift schedules, dosages, and the time the melatonin was taken—preclude definitive comparisons.

Effects of melatonin on workplace alertness are indeterminate because of inconsistent measurements of this variable. Importantly, a simulated shift work study found no phase-shifting advantages of melatonin in those who concomitantly used bright light during their work shift with or without morning protective eyewear.⁴⁸

Hypnotic drugs. In simulation studies and field studies, people taking benzodiazepine receptor agonists have consistently said they sleep better.^53–58 A simulation study noted additional benefit in the ability to stay alert during the night shift (assessed by maintenance of wakefulness testing),⁵⁵ but two other studies saw no changes in manifest sleepiness (assessed with multiple sleep latency tests).^53,54 These divergent findings may represent different effects on these two dimensions of sleepiness.

The only field study to assess post-sleep psychomotor performance found no impairments after taking 7.5 mg of zopiclone, a relatively long-acting nonbenzodiazepine hypnotic.⁵⁷

Stimulants. In the largest trial to date of shift work sleep disorder, modafinil 200 mg (the only drug currently FDA-approved for shift work sleep disorder) had significant benefits compared with placebo with respect to objective measurements of workplace sleepiness, reaction time performance testing, and self-rated improvement of symptoms.⁵⁹ Perhaps because of the low dose studied, both treated and untreated patients continued to manifest sleepiness within the pathologic range on objective testing.

Although the efficacy of caffeine is well documented as a countermeasure for sleepiness during experimentally induced sleep deprivation,²⁰ very few field trials have specifically addressed impairments associated with shift work sleep disorder. In one study, caffeine at a dose of 4 mg/kg taken 30 minutes before starting a night shift provided objective improvement in both performance and alertness.⁶⁰

Strategic napping is an additional practical intervention to promote alertness during night shifts, and cumulative data indicate that it provides objective and subjective improvements in alertness and performance.^61,62 Earlier timed naps (ie, before or during the early portion of a shift) of short duration (ie, 20 minutes or less) are likely to produce maximal benefit, because they avoid sleep inertia (the grogginess or sleepiness that may follow a long nap), and also because they have no effect on the subsequent daytime sleep bout.^61,63

Interventions may also be used in combination. For example, napping in conjunction with caffeine results in a greater degree of increased objective alertness than either intervention alone.⁶⁰

How about days off?

The recommendations described here presume that shift workers maintain the workday sleep-wake schedule continuously, including when they are not at work. This is likely not a real-world scenario.

Smith et al⁶⁴ developed a “compromise” phase position, whereby internal rhythms are optimized to facilitate alertness during work and sleepiness during the day, while allowing one to adopt a non-workday sleep schedule that maintains accessibility to family and social activities. In brief, non-workday sleep starts about 5.5 hours earlier than workday sleep; all sleep bouts are followed by brief exposure to bright light (to avoid excessive phase delay); and, as described previously, both workplace bright light and protection from morning light are implemented.

Although further studies are needed to determine whether this regimen is practical in real life, study participants who achieved desired partial phase shifts had performance ratings on a par with baseline levels, and comparable to those in a group that achieved complete re-entrainment.⁶⁴

Finally, all shift workers need to be encouraged to protect the daytime bedroom environment just as daytime workers protect their nighttime environment. Sleep should be sought in an appropriately darkened and quiet environment, phones and doorbells silenced, and appointments scheduled accordingly.