Annals of Emergency Medicine
Volume 48, Issue 5 , Pages 596-604.e3 , November 2006

Improving Alertness and Performance in Emergency Department Physicians and Nurses: The Use of Planned Naps

Presented at the Society for Academic Emergency Medicine 2002 annual meeting, October 2002, St. Louis, MO; and the Association for Professional Sleep Societies 16th annual meeting, June 2002, Seattle, WA.

  • Rebecca Smith-Coggins, MD

      Affiliations

    • Stanford University, Palo Alto, CA
    • Corresponding Author InformationAddress for reprints: Rebecca Smith-Coggins, MD, Department of Surgery/Emergency Medicine, Stanford University, 701 Welch Rd, Suite C, Palo Alto, CA 94304-1713; 650-725-5066, fax 650-723-0121
  • ,
  • Steven K. Howard, MD

      Affiliations

    • Stanford University, Palo Alto, CA
    • Department of Anesthesia, VA Palo Alto Health Care System, Palo Alto, CA
  • ,
  • Dat T. Mac, MS

      Affiliations

    • Department of Anesthesia, VA Palo Alto Health Care System, Palo Alto, CA
  • ,
  • Cynthia Wang, MD

      Affiliations

    • Stanford University, Palo Alto, CA
  • ,
  • Sharon Kwan, MD

      Affiliations

    • Stanford University, Palo Alto, CA
  • ,
  • Mark R. Rosekind, PhD

      Affiliations

    • Alertness Solutions, Inc., Cupertino, CA
  • ,
  • Yasser Sowb, PhD

      Affiliations

    • Department of Anesthesia, VA Palo Alto Health Care System, Palo Alto, CA
  • ,
  • Raymond Balise, PhD

      Affiliations

    • Stanford University, Palo Alto, CA
  • ,
  • Joel Levis, MD, PhD

      Affiliations

    • Stanford University, Palo Alto, CA
    • Kaiser Permanente, Santa Clara, CA
  • ,
  • David M. Gaba, MD

      Affiliations

    • Stanford University, Palo Alto, CA
    • Department of Anesthesia, VA Palo Alto Health Care System, Palo Alto, CA

Received 12 September 2005 ,Revised 31 January 2006 ,Accepted 7 February 2006.

References 

  1. Rogers A, Holmes S, Spencer M. The effect of shiftwork on driving to and from work. J Hum Ergol (Tokyo). 2001;30:131–136
  2. van der Hulst M. Long workhours and health. Scand J Work Environ Health. 2003;29:171–188
  3. Stutts JC, Wilkins JW, Osberg SJ, et al. Driver risk factors for sleep-related crashes. Accid Anal Prev. 2003;35:321–331
  4. Ayas NT, White DP, Manson JE, et al. A prospective study of sleep duration and coronary heart disease in women. Arch Intern Med. 2003;163:205–209
  5. Liu Y, Tanaka H. Overtime work, insufficient sleep, and risk of non-fatal acute myocardial infarction in Japanese men. Occup Environ Med. 2002;59:447–451
  6. Richardson GS, Miner JD, Czeisler CA. Impaired driving performance in shiftworkers: the role of the circadian system in a multifactorial model. Alcohol Drugs Driving. 1989;5-6:265–273
  7. Smith-Coggins R, Rosekind MR, Hurd S, et al. Relationship of day versus night sleep to physician performance and mood. Ann Emerg Med. 1994;24:928–934
  8. Smith-Coggins R, Rosekind MR, Buccino KR, et al. Rotating shiftwork schedules: can we enhance physician adaptation to night shifts?. Acad Emerg Med. 1997;4:951–961
  9. Connor J, Whitlock G, Norton R, et al. The role of driver sleepiness in car crashes: a systematic review of epidemiological studies. Accid Anal Prev. 2001;33:31–41
  10. Gold DR, Rogacz S, Bock N, et al. Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. Am J Public Health. 1992;82:1011–1014
  11. Holbrook MI, White MH, Hutt MJ. Increasing awareness of sleep hygiene in rotating shift workers: arming law-enforcement officers against impaired performance. Percept Mot Skills. 1994;79:520–522
  12. Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125–134
  13. Gander PH, Gregory KB, Connell LJ, et al. Crew Factors in Flight Operations VII: Psychophysiological Responses to Overnight Cargo Operations. Moffett Field, CA: National Aeronautics and Space Administration, Ames Research Center; 1996;
  14. Naitoh P. Minimal sleep to maintain performance. In:  Stampi B editors. Why We Nap. Boston, MA: Birkhauser; 1992;p. 199–210
  15. Batejat DM, Lagarde DP. Naps and modafinil as countermeasures for the effects of sleep deprivation on cognitive performance. Aviat Space Environ Med. 1999;70:493–498
  16. Lagarde D, Batejat D. Some measures to reduce effects of prolonged sleep deprivation. Neurophysiol Clin. 1995;25:376–385
  17. Gillberg M. The effects of two alternative timings of a one-hour nap on early morning performance. Biol Psychol. 1984;19:45–54
  18. Rosekind MR. Crew Factors in Flight Operations IX: Effects of Planned Cockpit Rest on Crew Performance and Alertness in Long-Haul Operations. Moffett Field, CA: National Aeronautics and Space Administration; 1994;
  19. Morrow PC, Crum MR. Antecedents of fatigue, close calls, and crashes among commercial motor-vehicle drivers. J Safety Res. 2004;35:59–69
  20. Adams-Guppy J, Guppy A. Truck driver fatigue risk assessment and management: a multinational survey. Ergonomics. 2003;46:763–779
  21. Rosekind MR, Smith RM, Miller DL, et al. Alertness management: strategic naps in operational settings. J Sleep Res. 1995;4:62–66
  22. Dement WC, Vaughan C. The Promise of Sleep. New York, NY: Random House; 1999;
  23. Sadeh A, Hauri P, Kripke D, et al. Role of actigraphy in the evaluation of sleep disorders. Sleep. 1995;18:288–302
  24. Carskadon MA, Dement WC. Normal human sleep: an overview. In:  Kryger MH,  Roth T,  Dement WC editor. Principles and Practice of Sleep Medicine. Philadelphia, PA: WB Saunders; 2000;p. 15–25
  25. Rechtschaffen A, Kales A. A Manual of Standardized Terminology: Techniques and Scoring System for Sleep Stages of Human Subjects. Los Angeles, CA: UCLA Brain Information Service/Brain Research Institute; 1968;
  26. Dinges DF, Powell J. Microcomputer analyses of performance on a portable, simple visual RT task during sustained operations. Behav Res Methods Instr Comp. 1985;17:652–655
  27. Dinges DF. Probing the Limits of Functional Capability: The Effects of Sleep Loss on Short-Duration Tasks. Boston, MA: Birkhouser; 1992;
  28. Dinges DF, Pack F, Williams K, et al. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep. 1997;20:267–277
  29. Dinges DF, Kribbs NB. Performing While Sleepy: Effects of Experimentally-Induced Sleepiness. Chichester: Wiley; 1991;
  30. Dinges DF, Kribbs NB, Bates B, et al. A very brief probed recall memory task: sensitivity to sleep loss. Sleep Res. 1993;22:330
  31. Reznek MA, Rawn CL, Krummel TM. Evaluation of the educational effectiveness of a virtual reality intravenous insertion simulator. Acad Emerg Med. 2002;9:1319–1325
  32. Howard SK, Gaba DM, Smith BE, et al. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology. 2003;98:1345–1355
  33. Akerstedt T, Gillberg M. Subjective and objective sleepiness in the active individual. Int J Neurosci. 1990;52:29–37
  34. Kryger MH, Roth T, Dement WC. Principles and Practice of Sleep Medicine. 3rd ed.. Philadelphia, PA: W. B. Saunders Company; 2000;
  35. Dinges DF. Adult napping and its effect on ability to function. In:  Stampi B editors. Why We Nap. Boston, MA: Birkhauser; 1992;p. 118–134
  36. Gaba DM. Costs of clinician fatigue and its prevention. Anesth Patient Safety Found Newsletter. 2005;20:15–16
  37. Van Dongen HP, Baynard MD, Maislin G, et al. Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of trait-like differential vulnerability. Sleep. 2004;27:423–433
  38. Landrigan CP, Rothschild J, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838–1848
  39. Lockley SW, Cronin J, Evans EE, et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med. 2004;351:1829–1837
  40. Fessler HE. Interns’ work hours. N Engl J Med. 2005;352:726–728
  41. Powell NB, Schechtman KB, Riley RW, et al. The road to danger: the comparative risks of driving while sleepy. Laryngoscope. 2001;111:887–893
  42. Maggie’s Law. Geist GF MR, Altamuro S, trans. 210th Legislature ed; 2003.

 Supervising editor: Debra E. Houry, MD, MPHAuthor contributions: RS-C, SKH, MRR, and DMG conceived the study and designed the trial. RS-C, SKH, DTM, CW, SK, and JL supervised the conduct of the trial and data collection. RS-C, SKH, DTM, CW, SK, and JL undertook recruitment of participating subjects and managed the data, including quality control. YS, RB, and DMG provided statistical advice on study design and analyzed the data. RSC drafted the manuscript, and all authors contributed substantially to its revision. RSC takes responsibility for the paper as a whole.Funding and support: The authors report this study did not receive any outside funding or support.Publication dates: Available online May 2, 2006.

PII: S0196-0644(06)00239-3

doi: 10.1016/j.annemergmed.2006.02.005

Annals of Emergency Medicine
Volume 48, Issue 5 , Pages 596-604.e3 , November 2006