Sleep and Fatigue in The Operational Setting |Providing Value With a Fatigue Risk Management System

In recent years, the annual conference of the Associated Professional Sleep Society has included an increasing number of presentations related to fatigue in the workplace and associated risks. The National Sleep Foundation offers an entire in-depth two-day track on public health and safety, largely focusing on fatigue in the workplace, as part of its annual meeting in Washington, DC. Yet in spite of this growing interest and the clear overlap between clinical sleep medicine and fatigue, many sleep disorder specialists are unfamiliar with fatigue and how it impacts performance in an operational context. More important, they are unaware of the vital role for sleep disorders specialists in reducing fatigue-related risks.

Improved understanding of fatigue science and fatigue risk management systems (FRMS), along with practical suggestions on how to provide value in FRMS, can empower sleep medicine specialists to engage effectively in the important and growing area of workplace safety and occupational health. In an effort to increase awareness, I recently spoke with my colleague and internationally renowned FRMS expert, Dr. Steven Hursh, CEO of the non-profit Institute for Behavior Resources (where I serve on the Board), regarding the future of FRMS, and sleep-disorders management and the role of the sleep disorders specialist in occupational health.

What exactly do we mean by fatigue?

First, what fatigue is not: fatigue is not simply feeling sleepy or drowsy. Although fatigue may be associated with drowsiness, it is a more complex biobehavioral state including decreased alertness and impaired cognitive and physical performance. Fatigue is multifactorial, and may or may not include frank sleepiness. There is no simple direct measure, diagnostic test, or yet-identified biomarker for fatigue, making assessment challenging. Further, relative to objective performance data such as the psychomotor vigilance task (PVT), humans are notoriously poor at self-assessment of fatigue and their own capacity to perform at optimal levels. This means that—just as in clinical sleep medicine—it is important to include both subjective and objective measures when assessing and predicting fatigue.

From a medical perspective, fatigue is rarely a diagnosis in itself. Instead, fatigue can be a symptom of any number of medical or mental health conditions. But it should come as no surprise to sleep disorders specialists that leading causes of fatigue include insufficient sleep and circadian misalignment. And in our 24/7 culture, 30% or more of Americans as well as the US workforce aren’t getting enough sleep. At least this many individuals experience performance-impairing fatigue. Sleep researchers have provided robust evidence that the neurobehavioral impairment associated with sleep loss are severe and cumulative, and from an occupational health perspective these consequences can place workers as well as the public at great risk.

In industries involving shift work, such as transportation, energy, and health care, fatigue is a leading cause of human error. Indeed, in these sectors and others, fatigue-related accidents account for tens of billions of dollars annually in workplace accidents, lost workplace productivity, and direct health care expenses. Anecdotes abound—I just this morning read about a German banker who fell asleep on his keyboard at work and mistakenly transferred $293 million out of the bank. In this case, the money was recovered. Unfortunately, fatigue-related errors are not always so easy to undo. Instead, an ounce of prevention can be worth a pound of cure.

Striking Statistics

Neurobehavioral impairment following 24 hours of consecutive wakefulness is equivalent to that from blood alcohol concentration of 0.10%, above the legal limit in most states.

Since January, 2001, fatigue has been related to 20% of accidents and nearly 40% of highway accidents investigated by the National Transportation Safety Board.

In a study of 300 Schneider National truck drivers with OSA, treatment of OSA was associated with a 30% reduction in preventable crashes, 48% reduction in average cost per crash, and 50% reduction of health care costs. Results were later replicated in a follow-up study of 800 drivers.

Insomnia is associated with both workplace and non-workplace accidents, irrespective of age, sex, or education, and even after controlling for up to 2 comorbid conditions.

Insomnia is associated with 7.2% of all costly workplace accidents, and insomnia-related human errors are more expensive than non-insomnia related errors ($32,062 vs $21, 914).

Based on their work schedules, 18% of the US Labor Force is at risk for shift work disorder.

Shift works are nearly twice as likely as non-shift workers to report having fallen asleep at work and nearly three times as likely to report having an occupational accident in the past year.

After working more than 24 hours, physician residents are five times more likely to commit serious diagnostic errors and nearly twice as likely to have a motor vehicle crash while driving home.

Reducing error with Fatigue Risk Management Systems

In an operational context, the purpose of a fatigue risk management system (FRMS) is to identify and re-schedule or otherwise prevent fatigued employees from engaging in high-risk tasks. These preventative efforts must account not only for general work hours and schedules, but also individual variability and the role of occult sleep disorders in the workforce.

In order to advance the dialogue between applications of fatigue and sleep sciences, I recently spoke with my colleague Dr. Steven Hursh, inventor of the validated and patented Sleep, Activity, Fatigue, and Task Effectiveness (SAFTE) model and the Fatigue Avoidance Scheduling Tool (FAST) used by the US Departments of Defense and Transportation.

A Conversation with Dr. Steven Hursh

Emerson Wickwire: You’ve worked with some major clients, like United Airlines, Delta Airlines and the Washington DC Metro, implementing the SAFTE-FAST model. SAFTE-FAST employs actigraphy as an objective measure of rest and activity, as well as subjective data to predict worker fatigue and even adjust work schedules accordingly. What makes SAFTE-FAST different from other available models?

Steven Hursh: The SAFTE-FAST model has been validated to predict accident risk and severity in railroads and to predict performance variations in aviation personnel. That is the first key requirement of a model: it must be trusted to predict the problem a company is trying to solve. Second, it is built on an estimate of sleep patterns in operational environments that itself has been shown to be able to predict sleep and wake periods with about 88% accuracy and average amounts of sleep per day with less than 1% error. And third, it provides more than just a “fatigue score;” it estimates for the user the underlying fatigue factors that are causing the fatigue, and the contextual factors that lead to fatigue, so that the user can quickly focus on mitigations to solve the problem. In short, it is both accurate and useful in the operational environment and that is why large corporations chose to use it.

Wickwire: In your experience, how much do clinical sleep disorders contribute to fatigue in the operational setting?

Hursh: It is hard to give an exact estimate but many of the accidents attributed to fatigue by the National Transportation Safety Board (NTSB) have been traced to operators with an untreated sleep disorder. I routinely recommend that any FRMS include a medical evaluation for sleep disorders of any employee involved in safety critical tasks.

Wickwire: How well are companies integrating sleep disorders screening, assessment, and treatment into their FRMS?

Hursh: Sleep disorder screening is not being implemented fast enough, in my opinion. The trucking industry, for example, has been very slow to adopt screening with several notable exceptions. But the ones that have done it have reaped the benefits of increased productivity and reduced costs. There are a number of potential reasons for slow adoption of sleep disorders screening in a number of settings, and it is not just the companies that are fearful; employee groups are also unsure about it. Both management and labor are concerned about cost and the economic hardship it may impose if a disorder is discovered. We need to do a better job of educating people to dispel such concerns.

Wickwire: For a number of years you have served as the fatigue subject matter expert and lead reviewer for the Federal Aviation Administration (FAA). To what degree are sleep disorders on the FAA radar?

Hursh: The FAA has a dedicated medical unit that is responsible for certifying all air traffic controllers. We have worked with them to implement new approaches to screening and treatment to ensure that all controllers are properly screened and treated within a framework that minimizes economic disincentives. That process is ongoing.

Wickwire: Most sleep disorders specialists are unfamiliar with either fatigue risk or the operational setting, yet clinical sleep disorders clearly account for a significant portion of fatigue-related risk. What is the role of the sleep disorders specialist in FRMS?

Hursh: Increasingly, corporations will be enhancing their sleep disorders screening as part of FRMS and the sleep disorder specialist will be key to providing rapid diagnosis and treatment with follow-up to ensure compliance. The sleep disorders treatment community can make a huge contribution if they can provide services that will return employees to work quickly and minimize the loss of livelihood. Once employees see that their colleagues are benefiting from treatment without undue cost, the resistance to screening will soon disappear.

Wickwire: What do you see in the future in regards to FRMS, occupational health, and sleep-disorders management?

Hursh: Fatigue risk management systems will not only highlight the importance of screening and treatment for sleep disorders but it will also highlight the chronic conditions of sleep disturbance in individuals working schedules that interfere with opportunities for recuperative sleep. This can be the result of limited time to get sufficient sleep or opportunities to sleep that are at odds with our circadian system.

Wickwire: Exactly. And this applies even in non-shift work settings. For example, every week, in my practice at The Center for Sleep Disorders, in Columbia, MD, I see patients who commute 90 minutes each way to Washington, DC. That’s 3 hours a day, 15 hours a week, 60 hours a month. Sleep opportunity is going to suffer. Clinically, I have my patients run a behavioral experiment, extending sleep opportunity for a two-week period and tracking results. Of course, this is easier said than done. What’s the answer from an FRMS perspective?

Hursh: The solution is a shared responsibility of companies and their employees. There are two major lines of defense against excessive fatigue risk: The first defense is creating schedules that provide better sleep opportunities, and that is where modeling with a tool like SAFTE-FAST can aid the process by forecasting fatigue so it can be mitigated. The second defense is teaching employees how to better use their sleep opportunities by applying good sleep hygiene and using behavioral sleep management skills. That would include teaching them about the benefits of treatment for sleep disorders. Ultimately, I am convinced that corporations will find that there is substantial return on investment by applying FRMS.

Wickwire: Absolutely, and this ROI is found in increased employee productivity, retention, and well-being, as well as reduced accident liability and decreased health care expenditures. Independent of medical costs for self-insured employers, clinical sleep disorders represent a significant cost burden. To date, with the increase in home sleep testing, most efforts have focused on reducing diagnostic costs of OSA. Fair enough. But recent data from the American Insomnia Survey found that insomnia was the single most costly condition in the workplace, more so than diabetes, depression, and so on. These are real issues with real, hard dollar costs. So when I’m consulted regarding sleep in the workplace, these two disorders are where I start. And increasingly, even when an OSA program is already in place, I’m asked about expanding to include general sleep wellness and targeted insomnia programs. This is exciting from both a corporate as well as a sleep perspective, and especially for those of us who believe in a comprehensive approach. Our group is working hard to address these issues. And the ROI of addressing these problems will be substantial.

Hursh: This is entirely consistent with an FRMS approach. For example, in the railroad environment, when schedules were devised that reduced fatigue, absenteeism was cut in half. In aviation, FRMS increases productivity, increases operational efficiency, improves morale, lowers turnover, and decreases insurance costs. And ultimately these industries will be safer and employees will be healthier. I can see FRMS spreading from transportation to all sorts of shift work environments, such as petro-chemical manufacturing, mining, medical care, and law enforcement.

Take charge of your vision

The more we learn about sleep, fatigue, and human performance—not to mention looming changes in the health care system—the more incumbent it is for sleep specialists to take charge of their future and realize the value they can provide. The future of sleep medicine is bright. Take charge to broaden your vision, identify opportunities, and leverage your value as a sleep expert.