3 Ways to Limit ER Physician Use of Sleeping Aid Drugs

Sleep deprivation and fatigue have plagued emergency room physicians for decades but apparent widespread use of sleeping aid medications entails risks.

Use of sleeping aid medication among emergency department physicians is likely far more common than previously reported, recent research shows.

Fatigue has been linked to cognitive impairment among ER physicians but sleeping aid medication is a problematic solution. Sleeping aid medication fails to induce normal sleep stages and their progression to natural sleep, and health concerns have implications for physician wellbeing such as rebound insomnia after discontinuance of medications.

A study involving 144 ER physicians in Alberta, Canada, found higher than expected rates of sleeping aid medication use. The study found 67% of the physicians had used a sleeping aid medication at some point in their career, and 56% were actively using a sleeping aid medication. The most commonly used medication was a nonbenzodiazepine hypnotic such as Ambien.

Use of nonbenzodiazepine hypnotics among emergency physicians was estimated at 3 to 4 times higher than the usage rate in the general population.

"Pharmacologic sleep aid use among Canadian emergency physicians may be more common than previously assumed. This could have implications for physician wellbeing and performance," the researchers wrote in Annals of Emergency Medicine.

In an accompanying editorial, Scott Votey, MD, of the David Geffen School of Medicine at UCLA, wrote that the Canadian research is a wakeup call for all emergency departments.

"The adverse cognitive effects of pharmacologic sleep aids linger for hours beyond awakening, resulting in the grogginess and 'hangover' well known to users and prescribers alike. This is particularly concerning, given that 47% of individuals using pharmacologic sleep aids reported taking these medications to sleep before a night shift," wrote Votey, a professor of clinical emergency medicine in the Department of Emergency Medicine at the Geffen School.

This week, Votey told HealthLeaders there are three approaches to reducing sleeping aid medication usage among ER physicians.

1. Educating ER physicians
 

There are a pair of educational strategies to address the problem, Votey said.

"One is that these medications are not good for ER physicians, and there is enough information on fatigue to make a good case for that," he said.

The professional association for ER physicians could be the best vehicle to carry this message, Votey said. "The American College of Emergency Physicians could provide education and reach the majority of emergency physicians in the country."

He said the second educational strategy is to encourage ER physicians to find behavioral alternatives to sleeping aid medications such as the National Institutes of Health's list of sleeping tips.

"People are using these drugs because they perceive a need. That's true of pretty much everybody who takes an Ambien and certainly true of emergency room physicians. They feel their sleep is disrupted and they are desperate enough to give this a try. You have to address how you can improve sleep without medication," Votey said.

2. Changing ER schedules
 

Changing ER physician schedules can ease fatigue and stress such as limiting the number of night shifts a physician works and shortening night shifts, he said.

Votey works in a large emergency department with several faculty-level physicians, so the ER schedule can be crafted to avoid multiple overnight shifts in any given month.

Shortening overnight shifts can establish regular schedules for ER physicians, which eases the Circadian burden on clinicians, Votey said.

"To get people to stay on these shifts, hospitals will pay the same amount for a six-hour shift that they pay for an eight-hour shift. You can get someone to take these shifts on a regular basis and adapt to that Circadian rhythm. They are incentivized to do it and get less fatigued."

3. Adopting new policies
 

ER physicians need the same kind of duty-hour restrictions that were established for medicine residents by the accrediting agency for graduate education, Votey said.

"They created policies for how long a doctor in training could work, how much rest they needed between their shifts, and other rules that were enforced by the institutions in the training programs as part of their accreditation," he said.

Hospital also have a role to play and should adopt more enlightened staffing policies, Votey said.

"You want to have enough doctors and you want them to be working few enough hours to avoid fatigue. The business rationale for that is pretty reasonable—tired doctors are less effective. They have worse communication skills and they have poorer patient satisfaction. There are several studies that have shown that if you tire them out, they aren't good at their job. If you want doctors to be good at their job in your hospital, you should create rules that make sure they don't work too much."