Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion

Imaging cognitive fatigability in multiple sclerosis: objective quantification of cerebral blood flow during a task of sustained attention using ASL perfusion fMRI

Cognitive fatigability (CF) can be defined as an inability to maintain performance throughout a sustained cognitive task. Individuals with multiple sclerosis (MS) are more susceptible to CF than healthy controls (HCs); however, the neural correlates underlying CF are still under investigation. Arterial spin labeling (ASL) perfusion imaging provides a non-invasive method of objectively quantifying cerebral blood flow (CBF) during sustained attention tasks. To date, no study has yet evaluated CF in MS using this methodology. 10 MS and 10 HCs completed a 20-min psychomotor vigilance task (PVT). CF was evaluated by dividing the PVT into quintiles and examining performance from the 1st to the last. Mean reaction times (RTs) and number of lapses were recorded. Global and regional CBF changes were evaluated throughout the PVT as well as during pre- and post-task rest. Increased susceptibility to CF was noted in the MS group. Distinct patterns of CBF activation were observed in areas comprising fronto-parietal, cortico-striatal, cerebellar, and basal ganglia regions; however, when and how these regions were engaged differed between the MS and HC groups. In particular, dysfunction in CBF to the middle frontal gyrus may underlie the CF effects observed. In addition, individuals with MS appear to struggle with "switching off" regions of the attentional network at rest following sustained cognitive effort. Findings support the use of ASL as an appropriate methodology for evaluating CF in MS with an overall pattern of attentional network dysfunction being observed. Objectively quantifying CF in this manner can help validate patients' subjective complaints.

Insula and putamen centered functional connectivity networks reflect healthy agers' subjective experience of cognitive fatigue in multiple tasks

Cognitive fatigue (CF) impairs ability to perform daily activities, is a common complaint of aging and a symptom of multiple neurological conditions. However, knowledge of the neural basis of CF is limited. This is partially because CF is difficult to systematically modulate in brain imaging experiments. The most common approach has been to scan brain activity during effortful cognitive tasks. Consequently, neural correlates of CF tend to be task-specific and may vary across tasks. This makes it difficult to know how results generalize across studies and is outside the subjective experience of CF which tends to be similar in different tasks. It has been hypothesized that the subjective experience of CF might arise from domain general systems monitoring and acting on energy depletion in task specific circuits. Direct supporting neural evidence is lacking. By repeatedly scanning aging individuals undertaking four different tasks using functional Magnetic Resonance Imaging and referencing scans to detailed CF self-ratings taken before and after scanning, we sought task-general correlates of CF. We ran a data-driven representational similarity analysis, treating each brain region as a candidate CF functional connectivity hub, and correlating inter-participant differences in hub-based connectivity patterns with inter-participant differences in self-rated CF-profiles (a pattern of ratings across 18 questions). Both right insula and right putamen-based network connectivity patterns reflected CF across all tasks and could underpin subjective experience of CF.

Effects of Sleep Deprivation on Surgeons Dexterity

Sleep deprivation is an ordinary aspect in the global society and its prevalence is increasing. Chronic and acute sleep deprivation have been linked to diabetes and heart diseases as well as depression and enhanced impulsive behaviors. Surgeons are often exposed to long hour on call and few hours of sleep in the previous days. Nevertheless, few studies have focused their attention on the effects of sleep deprivation on surgeons and more specifically on the effects of sleep deprivation on surgical dexterity, often relying on virtual surgical simulators. A better understanding of the consequences of sleep loss on the key surgical skill of dexterity can shed light on the possible risks associated to a sleepy surgeon. In this paper, the authors aim to provide a comprehensive review of the relationship between sleep deprivation and surgical dexterity.

Resident Physicians are at Increased Risk for Dangerous Driving after Extended-duration Work Shifts: A Systematic Review

BACKGROUND

Resident physicians often work longer than 24 consecutive hours with little or no sleep. A systematic review of the literature was conducted to investigate the risk of resident physician motor vehicle collisions (MVC), and dangerous driving, after extended-duration work shifts (EDWS).

MATERIAL AND METHODS

A keyword search was performed for original research articles evaluating any aspect of driving safety following EDWS for the resident physician population. Two authors independently reviewed articles for inclusion. Subsequent independent data abstraction and quality appraisal were carried out. Five articles met the study inclusion criteria.

RESULTS

The quality of the evidence was low to very low. Results were not pooled due to study heterogeneity. Residents reported between 2.3 to 3.8 hours of sleep during EDWS. Three survey-based studies identified an increased risk of MVCs and falling asleep at the wheel after EDWS. One study associated weekly cumulative sleep hours lost with the risk of falling asleep while driving. Both driving simulation and survey studies linked EDWS with MVCs. Notably, a driving simulation study found an increase in crash frequency in male residents post-EDWS. Additionally, a survey reported that the risk of an MVC post-EDWS increased by 16.2% per shift worked in a month.

CONCLUSION

The period following EDWS is associated with an increased risk of potentially life-threatening driving safety risks for resident physicians. These observations warrant careful consideration. They suggest that there is a need for greater awareness and action in order to avoid the occupational and public health risks of driving after EDWS.

A review of current approaches for evaluating impaired performance in around-the-clock medical professionals

The need for data to study the relationship between fatigued healthcare professionals and performance outcomes is evident, however, it is unclear which methodology is most appropriate to provide these insights. To address this issue, we performed a systematic review of relevant articles by searching the MEDLINE, EMBASE, Cochrane, Web of Science, and CINAHL databases. The literature search identified 2960 unique references, of which 82 were identified eligible. The impact on performance was studied on clinical outcomes, medical simulation, neurocognitive performance, sleep quantification and subjective assessment. In general results on performance are conflicting; impairment, no effect, and improvement were found. This review outlines the various methods currently available for assessing fatigue-impaired performance. The contrasting outcomes can be attributed to three main factors: differences in the operationalisation of fatigue, incomplete control data, and the wide variety in the methods used. We recommend the implementation of a clinically applicable tool that can provide uniform data. Until these data become available, caution should be used when developing regulations that can have implications for physicians, education, manpower planning, and ‒ ultimately ‒ patient care.

Implementation of a resident night float system in a surgery department in Korea for 6 months: electronic medical record-based big data analysis and medical staff survey

Purpose

To evaluate superiority of a night float (NF) system in comparison to a traditional night on-call (NO) system for surgical residents at a single institution in terms of efficacy, safety, and satisfaction.

Methods

A NF system was implemented from March to September 2017 and big data analysis from electronic medical records was performed for all patients admitted for surgery or contacted from the emergency room (ER). Parameters including vital signs, mortality, and morbidity rates, as well as promptness of response to ER calls, were compared against a comparable period (March to September 2016) during which a NO system was in effect. A survey was also performed for physicians and nurses who had experienced both systems.

Results

A total of 150,000 clinical data were analyzed. Under the NO and NF systems, a total of 3,900 and 3,726 patients were admitted for surgery. Mortality rates were similar but postoperative bleeding was significantly higher in the NO system (0.5% vs. 0.2%, P = 0.031). From the 1,462 and 1,354 patients under the NO and NF systems respectively, that required surgical consultation from the ER, the time to response was significantly shorter in the NF system (54.5 ± 70.7 minutes vs. 66.8 ± 83.8 minutes, P < 0.001). Both physicians (90.4%) and nurses (91.4%) agreed that the NF system was more beneficial.

Conclusion

This is the first report of a NF system using big data analysis in Korea, and potential benefits of this new system were observed in both ward and ER patient management.

Design and recruitment of the randomized order safety trial evaluating resident-physician schedules (ROSTERS) study

INTRODUCTION

While the Accreditation Council for Graduate Medical Education limited first year resident-physicians to 16 consecutive work hours from 2011 to 2017, resident-physicians in their second year or higher were permitted to work up to 28 h consecutively. This paper describes the Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS) study, a clustered-randomized crossover clinical trial designed to evaluate the effectiveness of eliminating traditional shifts of 24 h or longer for second year or higher resident-physicians in pediatric intensive care units (PICUs).

METHODS

ROSTERS was a multi-center non-blinded trial in 6 PICUs at US academic medical centers. The primary aim was to compare patient safety between the extended duration work roster (EDWR), which included shifts ≥24 h, and a rapidly cycling work roster (RCWR), where shifts were limited to a maximum of 16 h. Information on potential medical errors was gathered and used for classification by centrally trained physician reviewers who were blinded to the study arm. Secondary aims were to assess the relationship of the study arm to resident-physician sleep duration, work hours and neurobehavioral performance.

RESULTS

The study involved 6577 patients with a total of 38,821 patient days (n = 18,749 EDWR, n = 20,072 RCWR). There were 413 resident-physician rotations included in the study (n = 203 EDWR, n = 210 RCWR). Resident-physician questionnaire data were over 95% complete.

CONCLUSIONS

Results from data collected in the ROSTERS study will be evaluated for the impact of resident-physician schedule roster on patient safety outcomes in PICUs, and will allow for examination of a number of secondary outcome measures. ClinicalTrials.gov Identifier: NCT02134847.

Are Pediatric Critical Personnel Satisfied With Their Lives? Prediction of Satisfaction With Life From Burnout, Posttraumatic Stress, and Posttraumatic Growth, and Comparison With Noncritical Pediatric Staff

OBJECTIVES

Staff in PICUs shows high burnout, posttraumatic stress disorder symptoms, and posttraumatic growth levels. However, their levels of satisfaction with life and how positive and negative posttrauma outcomes relate to each other and contribute to predict satisfaction with life remain unknown. Thus, we attempted to explore these aspects and to compare the findings with data from pediatric professionals working in noncritical units.

DESIGN

This is an observational multicentric, cross-sectional study.

SETTING

The PICU of nine hospitals in Spain, and other pediatric units in the same hospitals.

SUBJECTS

Two hundred ninety-eight PICU workers (57 physicians, 177 nurses, and 64 nursing assistants) and 189 professionals working in noncritical pediatric units (53 physicians, 104 nurses, and 32 nursing assistants).

INTERVENTION

Participants completed the Maslach Burnout Inventory, the Trauma Screening Questionnaire, the Posttraumatic Growth Inventory, and the Satisfaction With Life Scale.

MEASUREMENTS AND MAIN RESULTS

Of PICU staff, 16.4% were very satisfied with their lives, 34.2% were satisfied, 34.6% showed average satisfaction with life, and 14.8% were below average. No differences were found between PICU and non-PICU workers. Women reported lower satisfaction with life than men, and physicians reported higher satisfaction with life than other professional groups. The correlation between posttraumatic stress disorder and posttraumatic growth was low, but significant and positive. According to the path analysis with latent variables, 20% of the variance satisfaction with life could be predicted from burnout, posttraumatic stress disorder symptoms, and posttraumatic growth. Higher distress was inversely associated to satisfaction with life, whereas posttraumatic growth contributed to higher satisfaction with life.

CONCLUSIONS

Posttraumatic growth can moderate the negative effect of traumatic work-related experiences in satisfaction with life. PICU and non-PICU workers were equally satisfied with their lives. Positive and negative impact of work-related potentially traumatic events can coexist in the same person. Interventions aimed at reducing distress and fostering posttraumatic growth could impact in an improvement in pediatric health professionals' satisfaction with life.

Measurement of resident fatigue using rapid number naming

OBJECTIVE

Sleep deprivation has a negative effect on neurocognitive performance. The King-Devick test (KDT), which tests speed and accuracy of number-reading, requires integrity of saccades, visual processing, and cognition. This study investigated effects of sleep deprivation in on-call residents using KDT.

METHODS

A prospective cohort study was conducted among 80 residents. KDT was performed at the beginning and end of an overnight call shift for the residents in the experimental group. A control group was tested at the beginning of 2 consecutive day shifts. Estimates of hours of sleep, Karolinska Sleepiness Scale (KSS)(1 = extremely alert, 9 = extremely sleepy), and time and accuracy of KDT were recorded.

RESULTS

42 residents were tested before and after overnight call shifts and 38 served as controls. Change in test time differed between the groups, with the experimental group performing 0.54(SD = 4.0) seconds slower after their night on call and the control group performing 2.32(SD = 3.0) seconds faster on the second day, p < 0.001. This difference was larger in surgical compared to medical residents.

CONCLUSIONS

Sleep deprivation was inversely correlated with neurocognitive performance as measured by KDT, with more effect on surgical than medical residents. Further research could investigate whether this test could help determine fatigue level and ability to continue working after a long shift.

Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment

INTRODUCTION

The purpose of this systematic review is to provide supporting evidence for the clinical practice guideline for the treatment of obstructive sleep apnea (OSA) in adults using positive airway pressure (PAP).

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of PAP with no treatment as well as studies that compared different PAP modalities. Meta-analyses were performed to determine the clinical significance of using PAP in several modalities (ie, continuous PAP, auto-adjusting PAP, and bilevel PAP), to treat OSA in adults. In addition, meta-analyses were performed to determine the clinical significance of using an in-laboratory versus ambulatory strategy for the initiation of PAP, educational and behavioral interventions, telemonitoring, humidification, different mask interfaces, and flexible or modified pressure profile PAP in conjunction with PAP to treat OSA in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 336 studies that met inclusion criteria; 184 studies provided data suitable for meta-analyses. The data demonstrated that PAP compared to no treatment results in a clinically significant reduction in disease severity, sleepiness, blood pressure, and motor vehicle accidents, and improvement in sleep-related quality of life in adults with OSA. In addition, the initiation of PAP in the home demonstrated equivalent effects on patient outcomes when compared to an in-laboratory titration approach. The data also demonstrated that the use of auto-adjusting or bilevel PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP. Furthermore, data demonstrated a clinically significant improvement in PAP adherence with the use of educational, behavioral, troubleshooting, and telemonitoring interventions. Systematic reviews for specific PAP delivery method were also performed and suggested that nasal interfaces compared to oronasal interfaces have improved adherence and slightly greater reductions in OSA severity, heated humidification compared to no humidification reduces some continuous PAP-related side effects, and pressure profile PAP did not result in clinically significant differences in patient outcomes compared with standard continuous PAP.

Immediate-term cognitive impairment following intravenous (IV) chemotherapy: a prospective pre-post design study

BACKGROUND

Cognitive impairment is commonly reported in patients receiving chemotherapy, but the acuity of onset is not known. This study utilized the psychomotor vigilance test (PVT) and trail-making test B (TMT-B) to assess cognitive impairment immediately post-chemotherapy.

METHODS

Patients aged 18-80 years receiving first-line intravenous chemotherapy for any stage of breast or colorectal cancer were eligible. Patient symptoms, peripheral neuropathy and Stanford Sleepiness Scale were assessed. A five-minute PVT and TMT-B were completed on a tablet computer pre-chemotherapy and immediately post-chemotherapy. Using a mixed linear regression model, changes in reciprocal transformed PVT reaction time (mean 1/RT) were assessed. A priori, an increase in median PVT reaction times by > 20 ms (approximating PVT changes with blood alcohol concentrations of 0.04-0.05 g%) was considered clinically relevant.

RESULTS

One hundred forty-two cancer patients (73 breast, 69 colorectal, median age 55.5 years) were tested. Post-chemotherapy, mean 1/RT values were significantly slowed compared to pre-chemotherapy baseline (p = 0.01). This corresponded to a median PVT reaction time slowed by an average of 12.4 ms. Changes in PVT reaction times were not correlated with age, sex, cancer type, treatment setting, or use of supportive medications. Median post-chemotherapy PVT reaction time slowed by an average of 22.5 ms in breast cancer patients and by 1.6 ms in colorectal cancer patients. Post-chemotherapy median PVT times slowed by > 20 ms in 57 patients (40.1%). Exploratory analyses found no statistically significant association between the primary outcome and self-reported anxiety, fatigue or depression. TMT-B completion speed improved significantly post-chemotherapy (p = 0.03), likely due to test-retest phenomenon.

CONCLUSIONS

PVT reaction time slowed significantly immediately post-chemotherapy compared to a pre-chemotherapy baseline, and levels of impairment similar to effects of alcohol consumption in other studies was seen in 40% of patients. Further studies assessing functional impact of cognitive impairment on patients immediately after chemotherapy are warranted.

Surgical quality in organ procurement during day and night: an analysis of quality forms

OBJECTIVES

To analyse a potential association between surgical quality and time of day.

DESIGN

A retrospective analysis of complete sets of quality forms filled out by the procuring and accepting surgeon on organs from deceased donors.

SETTING

Procurement procedures in the Netherlands are organised per region. All procedures are performed by an independent, dedicated procurement team that is associated with an academic medical centre in the region.

PARTICIPANTS

In 18 months' time, 771 organs were accepted and procured in The Netherlands. Of these, 17 organs were declined before transport and therefore excluded. For the remaining 754 organs, 591 (78%) sets of forms were completed (procurement and transplantation). Baseline characteristics were comparable in both daytime and evening/night-time with the exception of height (p=0.003).

PRIMARY OUTCOME MEASURE

All complete sets of quality forms were retrospectively analysed for the primary outcome, procurement-related surgical injury. Organs were categorised based on the starting time of the procurement in either daytime (8:00-17:00) or evening/night-time (17:00-8:00).

RESULTS

Out of 591 procured organs, 129 organs (22%) were procured during daytime and 462 organs (78%) during evening/night-time. The incidence of surgical injury was significantly lower during daytime; 22 organs (17%) compared with 126 organs (27%) procured during evening/night-time (p=0.016). This association persists when adjusted for confounders.

CONCLUSIONS

This study shows an increased incidence of procurement-related surgical injury in evening/night-time procedures as compared with daytime. Time of day might (in)directly influence surgical performance and should be considered a potential risk factor for injury in organ procurement procedures.

Effect of γ-hydroxybutyrate (GHB) on driving as measured by a driving simulator

RATIONALE

Gamma-hydroxybutyrate acid (GHB), a GABA_B receptor agonist approved for treatment of narcolepsy, impairs driving ability, but little is known about doses and plasma concentrations associated with impairment and time course of recovery.

OBJECTIVE

To assess effects of oral GHB (Xyrem®) upon driving as measured by a driving simulator, and to determine plasma concentrations associated with impairment and the time course of recovery.

METHODS

Randomized, double-blind, two-arm crossover study, during which 16 participants received GHB 50 mg/kg orally or placebo. GHB blood samples were collected prior to and at 1, 3, and 6 h post dosing. Driving simulator sessions occurred immediately after blood sampling.

RESULTS

Plasma GHB was not detectable at baseline or 6 h post dosing. Median GHB concentrations at 1 and 3 h were 83.1 mg/L (range 54-110) and 24.4 mg/L (range 7.2-49.7), respectively. Compared to placebo, at 1 h post GHB dosing, significant differences were seen for the life-threatening outcome collisions (p < 0.001) and off-road accidents (p = 0.018). Although driving was not faster, there was significantly more weaving and erratic driving with GHB as measured by speed deviation (p = 0.002) and lane position deviation (p = 0.004). No significant impairment regarding driving outcomes was found in the GHB group at 3 and 6 h post dose.

CONCLUSION

GHB in doses used to treat narcolepsy resulted in severe driving impairment at 1 h post dosing. After 3 to 6 h, there was full recovery indicating that safe driving is expected the next morning after bedtime therapeutic GHB use in the absence of other substances.

Scheduled Emergency Trauma Operation: The Green Line Orthopedic Trauma Surgery Process Of Care

BACKGROUND AND AIMS

Traditionally, patients requiring an orthopedic emergency operation were admitted to an inpatient ward to await surgery. This often led to congestion of wards and operation rooms while, for less urgent traumas, the time spent waiting for the operation often became unacceptably long. The purpose of this study was to evaluate the flow of patients coded green in a traffic light-based coding process aimed at decreasing the burden on wards and enabling a scheduled emergency operation in Central Finland Hospital.

MATERIALS AND METHODS

Operation urgency was divided into three categories: green (>48 h), yellow (8-48 h), and red (<8 h). Patients, who had sustained an orthopedic trauma requiring surgery, but not inpatient care (green), were assigned an operation via green line process. They were discharged until the operation, which was scheduled to take place during office hours.

RESULTS

Between January 2010 and April 2015, 1830 green line process operations and 5838 inpatient emergency operations were performed. The most common green line process diagnoses were distal radial fracture (15.4% of green line process), (postoperative) complications (7.7%), and finger fractures (4.9%). The most common inpatient emergency operation diagnosis was hip fracture (24.3%). Green line process and inpatient emergency operation patients differed in age, physical status, diagnoses, and surgical procedures.

CONCLUSION

The system was found to be a safe and effective method of implementing orthopedic trauma care. It has the potential to release operation room time for more urgent surgery, shorten the time spent in hospital, and reduce the need to operate outside normal office hours.

Improving Work and Rest Patterns of Military Personnel in Operational Settings with Frequent Unplanned Events

Members of the military get inadequate sleep due to a variety of reasons. Reduced manning, extended work hours, shiftwork schedules that result in circadian misalignment – all of these factors contribute to the sleep debt and degraded alertness observed in much of the military population. The issue of watchstanding schedules, performance, and alertness is of critical importance to the US military and is the focus of the current study. Based on a sample of active duty military members (N=75), this study had two goals. First, to conduct a field-based monitoring of the sleep and performance of military personnel while performing their duties. Second, to create and validate optimal recommendations based on the results of this empirical study. Participants wore actigraphs over a two-week period, completed daily activity logs, and took three-minute reaction time tests before and after standing watch on their regular schedules. Participants worked on a 2-day on/2-day off schedule, either in 3-section 8-hour shifts, or 2-section 12-hour shifts. Although there were no significant differences in the sleep amounts between the two schedules, results showed that participants on 8-hr shifts had fewer errors and less variable reaction time performance than those working 12-hr shifts. The 8-hr group reported better sleep quality, too. Our results suggest that the 8-hour schedule is better than the 12-hour schedule in terms of sleep and performance but may be more difficult to be applied. This study clearly shows the difficulty of implementing a specific watchstanding schedule in operational environments overloaded with unplanned, and irregular operational duties.

Impact of Resident Overnight Duty Hour Changes on Obstetrical Outcomes: A Population-Based Cohort Study

OBJECTIVE

To determine whether obstetrical patient outcomes have changed following the introduction of restricted resident work hours.

METHODS

A population-based retrospective cohort study of the effects of restricted duty hours for residents in July 2013 at three academic hospitals in Toronto, ON using linked health care databases. The study included 6763 deliveries in the 2 years pre-exposure and 5548 deliveries in the 2 years post-exposure.

RESULTS

The primary outcome, planned prior to data collection, was a composite index of 29 maternal/fetal outcomes including maternal transfusion/postpartum hemorrhage, maternal infection, fetal mortality, NICU admissions, and surgical/obstetrical complications. There were seven secondary outcomes analysed: NICU admissions; neonatal death; maternal transfusion or postpartum hemorrhage; maternal infection; and three composite measures. A generalized estimating equation model, clustered by institution, was utilized to assess for differences post-intervention. We found no significant differences in baseline demographics between groups. After the implementation of duty hour restrictions, no significant difference was seen in the primary outcome. However, an increased incidence of composite maternal surgical/obstetrical outcomes (OR 1.191; 95% CI 1.037-1.367, P = 0.013) and transfusion/postpartum hemorrhage (OR 1.232; 95% CI 1.074-1.413, P = 0.003) was found. There were no significant differences in other secondary outcomes.

CONCLUSION

Since the implementation of resident duty hour restrictions, there was no overall change in patient outcomes. However, there was an increase in surgical/obstetrical complications and transfusion/postpartum hemorrhage. This suggests that duty hour restrictions may not be beneficial to patient outcomes. It highlights the need to further investigate the clinical impact of a change in resident duty hours.

Effects of night duty events on blood pressure and autonomic modulation in physicians

BACKGROUND

The dynamic effects of duty events on the blood pressure (BP) and heart rate variability (HRV) of physicians on duty are unknown.

METHODS

A study was conducted among 12 physicians on night duty. BP and HRV with and without the effect of a duty event were compared. The risk of higher BP and impaired HRV after a phone call were calculated.

RESULTS

Physicians had higher mean BP (122.4 ± 11.1; 76.9 ± 7.1 mmHg) within 30 min after a phone calls than without a phone call (113.5 ± 5.3; 69.0 ± 3.8) and higher sympathetic tone (low frequency normalized units (LFnu) 68.5 ± 8.9; high frequency normalized units (HFnu) 27.7 ± 8.7) within 10 min of a phone call than without a phone call (62.9 ± 8.51; 33.5 ± 8.4). Elevated BP and sympathetic tone recovered to baseline levels 30 min after a phone call.

CONCLUSIONS

Among physicians on night duty, sympathetic tone and BP might be elevated by clinical events, and these effects last for 30 min.

Burnout and posttraumatic stress in paediatric critical care personnel: Prediction from resilience and coping styles

INTRODUCTION

Our aims were (1) to explore the prevalence of burnout syndrome (BOS) and posttraumatic stress disorder (PTSD) in a sample of Spanish staff working in the paediatric intensive care unit (PICU) and compare these rates with a sample of general paediatric staff and (2) to explore how resilience, coping strategies, and professional and demographic variables influence BOS and PTSD.

MATERIALS AND METHODS

This is a multicentre, cross-sectional study. Data were collected in the PICU and in other paediatric wards of nine hospitals. Participants consisted of 298 PICU staff members (57 physicians, 177 nurses, and 64 nursing assistants) and 189 professionals working in non-critical paediatric units (53 physicians, 104 nurses, and 32 nursing assistants). They completed the Brief Resilience Scale, the Coping Strategies Questionnaire for healthcare providers, the Maslach Burnout Inventory, and the Trauma Screening Questionnaire.

RESULTS

Fifty-six percent of PICU working staff reported burnout in at least one dimension (36.20% scored over the cut-off for emotional exhaustion, 27.20% for depersonalisation, and 20.10% for low personal accomplishment), and 20.1% reported PTSD. There were no differences in burnout and PTSD scores between PICU and non-PICU staff members, either among physicians, nurses, or nursing assistants. Higher burnout and PTSD rates emerged after the death of a child and/or conflicts with patients/families or colleagues. Around 30% of the variance in BOS and PTSD is predicted by a frequent usage of the emotion-focused coping style and an infrequent usage of the problem-focused coping style.

DISCUSSION AND CONCLUSIONS

Interventions to prevent and treat distress among paediatric staff members are needed and should be focused on: (i) promoting active emotional processing of traumatic events and encouraging positive thinking; (ii) developing a sense of detached concern; (iii) improving the ability to solve interpersonal conflicts, and (iv) providing adequate training in end-of-life care.

Impact of night shifts on emergency medicine resident resuscitation performance

AIM

Emergency medicine (EM) trainees often work nightshifts. We sought to measure how this circadian disruption affects EM resident performance during simulated resuscitations.

METHODS

This retrospective cohort study enrolled EM residents at a single Canadian academic centre over a six-year period. Residents completed twice-annual simulation-based resuscitation-focused objective structured clinical examinations (OSCEs) with assessment in four domains (primary assessment, diagnostic actions, therapeutic actions and communication), and a global assessment score (GAS). Primary and secondary exposures of interest were the presence of a nightshift (late-evening shifts ending between midnight and 03h00 or overnight shifts ending after 06h00) the day before or within three days before an OSCE. A random effects linear regression model was used to quantify the association between nightshifts and OSCE scores.

RESULTS

From 57 residents, 136 OSCE scores were collected. Working a nightshift the day before an OSCE did not affect male trainee scores but was associated with a significant absolute decrease in mean total scores (-6% [95% CI -12% to 0%]), GAS (-7% [-13% to 0%]), and communication (-9% [-16% to -2%]) scores among women. Working any nightshift within three days before an OSCE lowered absolute mean total scores by 4% [-7% to 0%] and communication scores by 5% [-5% to 0%] irrespective of gender.

CONCLUSION

Our results suggest that shift work may impact EM resident resuscitation performance, particularly in the communication domain. This impact may be more significant in women than men, suggesting a need for further investigation.

Fatigue in Residency Education: Understanding the Influence of Work Hours Regulations in Europe

PURPOSE

Although one proposed solution to the problem of fatigued medical trainees is the implementation of work hours regulations, concerns about the effectiveness of these regulations are growing. Canada remains one of the few Western jurisdictions without legislated regulation. Recent research suggests that fatigue is a complex social construct, rather than simply a lack of sleep; thus, the authors explored how regulations and fatigue are understood in countries with established work hours frameworks to better inform other jurisdictions looking to address trainee fatigue.

METHOD

Using constructivist grounded theory methodology, the authors conducted individual, semistructured interviews in 2015-2016 with 13 postgraduate medical trainees from four European countries with established work hours regulations. Data collection and analysis proceeded iteratively, and the authors used a constant comparative approach to analysis.

RESULTS

Trainees reported that they were commonly fatigued and that they violated the work hours restrictions for various reasons, including educational pursuits. Although they understood the regulations were legislated specifically to ensure safe patient care and optimize trainee well-being, they also described implicit meanings (e.g., monitoring for trainee efficiency) and unintended consequences (e.g., losing a sense of vocation).

CONCLUSIONS

Work hours regulations carry multiple, conflicting meanings for trainees that are captured by three predominant rhetorics: the rhetoric of patient safety, of well-being, and of efficiency. Tensions within each of those rhetorics reveal that managing fatigue within clinical training environments is complex. These findings suggest that straightforward solutions are unlikely to solve the problem of fatigue, assure patient safety, and improve trainee well-being.

Sleep deprivation in interventional cardiology: Implications for patient care and physician-health

The burden and impact of sleep deprivation on both patient care and on the health of interventional cardiologists is not well understood. Due to the nature of emergent procedures occurring in the cardiac catheterization laboratory, interventionalists are prone to suffer from acute and/or chronic sleep deprivation. Sleep deprivation has been associated with numerous adverse effects, such as impaired performance, cognitive deficits, reduced psychomotor vigilance, and workplace errors and injuries, among many others. Although sleep deprivation has been linked to more errors in trainees, there is paucity of data addressing outcomes in interventional cardiology. The purpose of this overview is to explore the possible impact of sleep deprivation on interventional cardiology in relation to patient care and physician health, and examine potential approaches to this issue.

Sleepiness in Adolescents

Sleepiness and sleep deprivation among adolescents are increasingly being recognized as a public health concern. Many of the determinants of this growing problem lie beyond the biomedical scope of explanation. In this article, the authors begin with a review of the prevalence and consequences of sleepiness in adolescents and then present the approach to a sleepy adolescent and the underlying cause. The topic is discussed from clinical as well as public health perspectives.

Outcomes of After-Hours Hip Fracture Surgery

BACKGROUND

Given single-institution studies showing trends between after-hours hip fracture surgical procedures and adverse outcomes, as well as fixation time targets that may increasingly compel after-hours operations, we investigated the relationship between after-hours hip fracture surgical procedures and adverse outcomes in a large, population-based cohort.

METHODS

All Ontarians who were ≥60 years of age and underwent a hip fracture surgical procedure between April 2002 and March 2014 were eligible for study inclusion. Data were obtained from linked health administrative databases. The primary exposure was after-hours provision of surgical procedures, occurring weekday evenings between the hours of 5 P.M. and 12 A.M. or over the weekend, but not overnight (after 12 A.M. to 7 A.M.). Surgical complications up to 6 months following a hip fracture surgical procedure comprised the primary outcome. Medical complications, including mortality, up to 90 days postoperatively were also assessed. Odds ratios (ORs) were calculated using a logistic regression model that accounted for clustering at the hospital level and adjusted for patient, provider, and fracture characteristics previously shown to explain the majority of variance in hip fracture outcomes.

RESULTS

During the study period, 87,647 patients underwent an isolated hip fracture surgical procedure; 51.2% of these patients had femoral neck fractures, 44.1% had intertrochanteric fractures, and 4.7% had subtrochanteric fractures. The surgical procedure occurred after hours in 59,562 patients (68.0%), and 27,240 patients (31.1%) underwent a surgical procedure during normal hours (7 A.M. to 5 P.M.). Only 845 patients (1%) underwent a surgical procedure overnight. We observed no significant relationships between timing of the surgical procedure and adverse outcomes, except for patients who had undergone an after-hours surgical procedure and had fewer inpatient surgical complications (OR, 0.90 [95% confidence interval, 0.83 to 0.99]; p = 0.01).

CONCLUSIONS

Adverse outcomes following a hip fracture surgical procedure were similar whether a surgical procedure occurred during normal hours or after hours. Concerns regarding the quality of after-hours surgical procedures should not influence hip fracture prioritization policy. However, given that the great majority of hip fracture surgical procedures occurred after hours, future research should examine other potential consequences of this practice, such as financial impact and surgeon burnout.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effects of acute alcohol consumption on measures of simulated driving: A systematic review and meta-analysis

Driving simulators are used in a wide range of research settings to help develop an understanding of driver behavior in complex environments. Acute alcohol impairment is an important research topic for traffic safety and a large number of studies have indicated levels of simulated driving impairment imposed by alcohol across a range of performance outcome variables. The aim of the present study was to examine the impact of acute alcohol consumption on simulated driving performance by conducting a systematic review and meta-analysis of the available evidence. The online databases PubMed (MEDLINE), Web of Science (via Thomas Reuters) and Scopus were searched to identify studies that measured simulated car driving performance under control ('no alcohol' or 'placebo alcohol' ingestion) and intervention (acute alcohol ingestion) conditions, using repeated-measures experimental designs. Primary research outcomes were standard deviation of lane position (SDLP) and standard deviation of speed (SDSP); (total number of lane crossings (LC) and average speed (Speed) were secondary research outcomes). Meta-analytic procedures were used to quantify the effect of acute alcohol consumption on vehicle control, and to determine the influence of methodological variables (i.e. the duration of the simulated driving task, the limb of the BAC curve (ascending vs. descending) and the type of driving simulator employed (i.e. car vs. PC-based)) on the magnitude of the performance change due to alcohol consumption. 423 records were screened, and 50 repeated-measures trials (n=962 participants, 62% male) derived from 17 original publications were reviewed. 37 trials (n=721 participants) used a 'placebo alcohol' comparator to determine the effect of alcohol consumption on SDLP (32/37) and SDSP (22/37). Alcohol consumption significantly increased SDLP by 4.0±0.5cm (95% CI: 3.0, 5.1) and SDSP by 0.38±0.10km⋅h^-1 (95% CI: 0.19, 0.57). Regression analyses indicate BAC (p=0.004) and driving simulator platform (p<0.001) influence the magnitude of the SDLP change, such that higher BAC levels and the use of PC-based driving simulators were associated with larger performance decrements (R²=0.80). The limb of the BAC curve and the duration of the driving task did not significantly alter the magnitude of the performance change. Eleven trials (n=205 participants) used a 'no alcohol' comparator to measure the effect of alcohol consumption on SDLP (10/11); few trials assessed SDSP (3/11). Alcohol consumption resulted in a small significant increase in SDLP under these conditions (standardized difference in means=0.23, 95% CI: 0.06, 0.39). These results demonstrate that lateral (SDLP and LC) and longitudinal (SDSP) vehicle control measures in a driving simulator are impaired with acute alcohol consumption. However, SDLP appears to be a more sensitive indicator of driving impairment than other driving performance variables and the results of the present study support its use as a performance outcome when examining alcohol-induced simulated driving impairment.

Effects of vibration on occupant driving performance under simulated driving conditions

Although much research has been devoted to the characterization of the effects of whole-body vibration on seated occupants' comfort, drowsiness induced by vibration has received less attention to date. There are also little validated measurement methods available to quantify whole body vibration-induced drowsiness. Here, the effects of vibration on drowsiness were investigated. Twenty male volunteers were recruited for this experiment. Drowsiness was measured in a driving simulator, before and after 30-min exposure to vibration. Gaussian random vibration, with 1-15 Hz frequency bandwidth was used for excitation. During the driving session, volunteers were required to obey the speed limit of 100 kph and maintain a steady position on the left-hand lane. A deviation in lane position, steering angle variability, and speed deviation were recorded and analysed. Alternatively, volunteers rated their subjective drowsiness by Karolinska Sleepiness Scale (KSS) scores every 5-min. Following 30-min of exposure to vibration, a significant increase of lane deviation, steering angle variability, and KSS scores were observed in all volunteers suggesting the adverse effects of vibration on human alertness level.

Fatigue and training of obstetrics and gynaecology trainees in Australia and New Zealand

BACKGROUND

Several studies have linked doctor fatigue with adverse patient events and an increase in risk to doctors' personal safety and wellbeing. The present study assesses the rostering structure of Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) trainees and its association with trainees' reported fatigue levels, training opportunities and wellbeing, which were secondary outcomes of a larger study of trainee working hours which has been separately reported.

METHODS

An anonymous, online survey of RANZCOG trainees was conducted. Demographic data collected included: age, gender, level of training and current rotation. Data were also collected on hours worked per week, long shifts (>12 h), self-reported fatigue levels, and opinions regarding current rostering and training.

RESULTS

A majority (72.9%) of respondents regularly felt fatigued, with higher fatigue levels being associated with more hours worked per week (P = <0.001) and working long shifts (>12 h) (P = 0.007). Fatigue was associated with an increased risk of dozing while driving (P = 0.028), with 56.1% of respondents reporting that this occurs. Trainees appeared to be less confident in achieving their technical skill requirements, with increasing hours not increasing confidence in achieving these skills (P = 0.594). Trainees who worked under 50 h per week were less likely to report fatigue (P = <0.001) and more likely to report greater work enjoyment (P = 0.043), and working hours being conducive to learning (P = 0.015).

CONCLUSION

Fatigue was frequently reported by RANZCOG trainees with increased working hours and long shifts being significant factors in fatigue levels. Strategies should be developed and trialled to enable trainees to obtain adequate case exposure and teaching without compromising patient and doctor safety.

Alcohol use in shiftworkers

It has been suggested that shiftworkers may consume alcohol to help them sleep, resulting in greater consumption. A large study in Australian workers suggested that those on non-standard schedules (outside 8am-6pm, Monday-Friday) do not drink more, but are at increased odds of binge drinking (heavy periods of drinking followed by abstinence) than workers on standard schedules. However, differences in types of non-standard schedules were not examined in the study. The current study examined the alcohol intake of Australian shiftworkers on fixed and rotating shifts. Shiftworkers (n=118, age=43.4±9.9y, 68% male) on 12h-rotating (n=29), 8h-rotating (n=29), morning (n=33) and night (n=27) schedules from printing, postal, nursing and oil industries participated. They completed a Cancer Council Dietary Questionnaire, recording frequency and amount of alcohol consumed on average per day over the preceding year. They also completed a shortened Standard Shiftwork Index, including questions on shift schedule, sleep duration, tiredness, gender and age. Average alcohol consumption was 9.6±13.1 standard drinks/week. One in six reported using alcohol as a sleep aid between shifts at least sometimes and nearly one third reported consuming 12 or more drinks in 24h. Alcohol consumption was higher for males and decreased with age. Controlling for gender and age, there were no significant differences between shift types in standard drinks/week (p=0.50). However, those on 12-h rotating shifts consumed more drinks per 24h (p=0.04) and had less sleep (p<0.001). Results support the suggestion that shiftworkers are likely to binge drink, particularly younger, male workers and those on long, rotating shifts. Alcohol use in shiftworkers may put increased pressure on already vulnerable physiological systems.

Influence of night duty on endoscopic therapy for bile duct stones

AIM

To examine the influence of night duty (ND) on endoscopic therapy for biliary duct stones.

METHODS

The subjects consisted of 133 patients who received initial endoscopic therapy for biliary duct stones performed by eight endoscopists after they had been on (ND group, n = 34 patients) or not [day duty (DD) group, n = 99 patients]. Patient characteristics (age, gender, history of abdominal surgery, transverse diameter of the largest stone, number of stones), years of experience of the endoscopists, endoscopic procedures [sphincterotomy, papillary balloon dilation (EPBD), papillary large balloon dilation (EPLBD)], and outcomes of initial endoscopy (procedure time; rate of stone removal by the first endoscopist; procedure success rate by the first endoscopist: removal of stones or endoscopic retrograde biliary drainage; rate of final stone removal; final procedure success rate; complications; hospitalization after the procedure) were compared retrospectively between the two groups. History of abdominal surgery and treatment outcomes were also compared between the groups for each of the four endoscopists who performed most of the procedures in the ND group.

RESULTS

There were no significant differences regarding the number of treatments performed by each endoscopist or the years of experience between the ND and DD groups. The frequency of endoscopic retrograde cholangiopancreatography procedures did not differ significantly between the groups. There were also no significant differences regarding patient characteristics: age, gender, history of abdominal surgery (ND 7: Billroth II 4, R-Y 3; DD 18: double tract reconstruction 1, Billroth I 3, Billroth II 6, R-Y 7, duodenoduodenostomy for annular pancreas 1), transverse diameter of largest stone, and number of stones between the two groups. Among the treatment procedures, the endoscopic sphincterotomy and EPBD rates did not differ significantly between the groups. However, EPLBD was performed more frequently in the ND group [47.1% (16/34) vs 19.2% (19/99)]. Regarding outcomes, there were no significant differences in the rate of stone removal, procedure success rate, complications (ND: pancreatitis 1; DD: pancreatitis 6, duodenal bleeding 1, decreased blood pressure 1, hypoxia 2), or hospitalization after the procedure. However, the procedure time was significantly longer in the ND group (71.5 ± 44.7 vs 54.2 ± 28.8). Among the four endoscopists, there were no significant differences in patient history of abdominal surgery, removal of stones, or procedure success rate. However, the procedure time for one endoscopist was significantly longer in the ND group.

CONCLUSION

The time required for endoscopic therapy for bile duct stones might be influenced by ND.

Resident Physician Duty-hour Requirements: What Does the Public Think?

INTRODUCTION

To date, no study has reported on the public's opinion of orthopaedic resident duty-hour requirements (DHR).

METHODS

A survey was administered to people in orthopaedic waiting rooms and at three senior centers. Responses were analyzed to evaluate seven domains: knowledge of duty hours; opinions about duty hours; attitudes regarding shift work; patient safety concerns; and the effects of DHRs on continuity of care, on resident training, and on resident professionalism.

RESULTS

Respondents felt that fatigue was unsafe and duty hours were beneficial in preventing resident physician fatigue. They supported the idea of residents working in shifts but did not support shifts for attending physicians. However, respondents wanted the same resident to provide continuity of care, even if that violated DHRs. They were supportive of increasing the length of residency to complete training. DHRs were not believed to affect professionalism. Half of the respondents believed that patient opinion should influence policy on this topic.

DISCUSSION

Orthopaedic patients and those likely to require orthopaedic care have inconsistent opinions regarding DHRs, making it potentially difficult to incorporate their preferences into policy.

Impact of extended duty hours on medical trainees

Many studies on resident physicians have demonstrated that extended work hours are associated with a negative impact on well-being, education, and patient care. However, the relationship between the work schedule and the degree of impairment remains unclear. In recent years, because of concerns for patient safety, national minimum standards for duty hours have been instituted (2003) and revised (2011). These changes were based on studies of the effects of sleep deprivation on human performance and specifically on the effect of extended shifts on resident performance. These requirements necessitated significant restructuring of resident schedules. Concerns were raised that these changes have impaired continuity of care, resident education and supervision, and patient safety. We review the studies on the effect of extended work hours on resident well-being, education, and patient care as well as those assessing the effect of work hour restrictions. Although many studies support the adverse effects of extended shifts, there are some conflicting results due to factors such as heterogeneity of protocols, schedules, subjects, and environments. Assessment of the effect of work hour restrictions has been even more difficult. Recent data demonstrating that work hour limitations have not been associated with improvement in patient outcomes or resident education and well-being have been interpreted as support for lifting restrictions in some specialties. However, these studies have significant limitations and should be interpreted with caution. Until future research clarifies duty hours that optimize patient outcomes, resident education, and well-being, it is recommended that current regulations be followed.

Association of Resident Duty Hour Restrictions on Mortality of Nervous System Disease and Disorder

BACKGROUND

The impact of the 2003 residency duty hour reform on patient care remains a debated issue.

OBJECTIVE

Determine the association between duty hour limits and mortality in patients with nervous system pathology.

METHODS

Via a retrospective cohort study using the Nationwide Inpatient Sample from 2000-2010, the authors evaluated in-hospital mortality status in those with a primary discharge level diagnosis of disease or disorder of the nervous system. Odds ratios were calculated, and Bonferroni corrected P values and confidence intervals were determined to account for multiple comparisons relating in-hospital mortality with teaching status of the hospital by year.

RESULTS

The pre-reform (2000-2002) and peri-reform (2003) periods revealed no significant difference between teaching and nonteaching hospital mortality (P > .99). The post-reform period (2004-2010) was dominated by years of significantly higher mortality rates in teaching hospitals compared to nonteaching hospitals: 2004 (P < .001); 2006 (P = .043); 2007 (P = .042); and 2010 (P = .003). However, data for 2005 (P ≥ .99), 2008 (P = .80), and 2009 (P = .09) did not show a significant difference in mortality.

CONCLUSIONS

Teaching and nonteaching hospital mortality was similar in patients with nervous system pathology prior to the duty hour reform. While nonteaching institutions demonstrated steadily declining mortality over the decade, teaching hospital mortality spiked in 2004 and declined at a more restricted rate. The timing of these changes could suggest a negative correlation of duty hour restrictions on outcomes of patients with nervous system pathology.

Applying mathematical models to predict resident physician performance and alertness on traditional and novel work schedules

BACKGROUND

In 2011 the U.S. Accreditation Council for Graduate Medical Education began limiting first year resident physicians (interns) to shifts of ≤16 consecutive hours. Controversy persists regarding the effectiveness of this policy for reducing errors and accidents while promoting education and patient care. Using a mathematical model of the effects of circadian rhythms and length of time awake on objective performance and subjective alertness, we quantitatively compared predictions for traditional intern schedules to those that limit work to ≤ 16 consecutive hours.

METHODS

We simulated two traditional schedules and three novel schedules using the mathematical model. The traditional schedules had extended duration work shifts (≥24 h) with overnight work shifts every second shift (including every third night, Q3) or every third shift (including every fourth night, Q4) night; the novel schedules had two different cross-cover (XC) night team schedules (XC-V1 and XC-V2) and a Rapid Cycle Rotation (RCR) schedule. Predicted objective performance and subjective alertness for each work shift were computed for each individual's schedule within a team and then combined for the team as a whole. Our primary outcome was the amount of time within a work shift during which a team's model-predicted objective performance and subjective alertness were lower than that expected after 16 or 24 h of continuous wake in an otherwise rested individual.

RESULTS

The model predicted fewer hours with poor performance and alertness, especially during night-time work hours, for all three novel schedules than for either the traditional Q3 or Q4 schedules.

CONCLUSIONS

Three proposed schedules that eliminate extended shifts may improve performance and alertness compared with traditional Q3 or Q4 schedules. Predicted times of worse performance and alertness were at night, which is also a time when supervision of trainees is lower. Mathematical modeling provides a quantitative comparison approach with potential to aid residency programs in schedule analysis and redesign.

Driving Performance of Residents after Six Consecutive Overnight Work Shifts

Background

Residency training requires work in clinical settings for extended periods of time, resulting in altered sleep patterns, sleep deprivation, and potentially deleterious effects on safe performance of daily activities, including driving a motor vehicle.

Methods

Twenty-nine anesthesiology resident physicians in postgraduate year 2 to 4 drove for 55 min in the Virginia Driving Safety Laboratory using the Driver Guidance System (MBFARR, LLC, USA). Two driving simulator sessions were conducted, one experimental session immediately after the final shift of six consecutive night shifts and one control session at the beginning of a normal day shift (not after call). Both sessions were conducted at 8:00 am. Psychomotor vigilance task testing was employed to evaluate reaction time and lapses in attention.

Results

After six consecutive night shifts, residents experienced significantly impaired control of all the driving variables including speed, lane position, throttle, and steering. They were also more likely to be involved in collisions. After six consecutive night shifts, residents had a significant increase in reaction times (281.1 vs. 298.5 ms; P = 0.001) and had a significant increase in the number of both minor (0.85 vs. 1.88; P = 0.01) and major lapses (0.00 vs. 0.31; P = 0.008) in attention.

Conclusions

Resident physicians have greater difficulty controlling speed and driving performance in the driving simulator after six consecutive night shifts. Reaction times are also increased with emphasis on increases in minor and major lapses in attention after six consecutive night shifts.

Principles of fatigue in residency education: a qualitative study

BACKGROUND

Proposals to implement fatigue-management strategies in residency education assume that medicine shares the view of other risk-adverse industries that fatigue is hazardous. This view is an essential underpinning of fatigue-management strategies that other industries have embedded as part of their workplace occupational health and safety programs. We sought to explore how residents understand fatigue in the context of their training environment.

METHODS

We interviewed 21 residents in 7 surgical and nonsurgical programs at Western University in 2014. All participants met the inclusion criteria of routinely working 24-hour call shifts while enrolled in their training program. Data collection and analysis occurred iteratively in keeping with constructivist grounded theory methodology and informed theoretical sampling to sufficiency.

RESULTS

Four predominant principles of fatigue captured how the social learning environment shaped residents' perceptions of fatigue. These included the conceptualization of fatigue as (a) inescapable and therefore accepted, (b) manageable through experience, (c) necessary for future practice and (d) surmountable when required.

INTERPRETATION

This study elaborates our understanding of how principles of fatigue are constructed and reinforced by the training environment. Whereas fatigue is seen as a collective hazard in other industries, our data showed that, in residency training, fatigue may be seen as a personal challenge. Consequently, fatigue-management strategies that conceptualize fatigue as an occupational threat may have a limited impact on resident behaviour and patient safety.

Recovery of Sleep or Recovery of Self? A Grounded Theory Study of Residents' Decision Making Regarding How to Spend Their Nonclinical Postcall Time

PURPOSE

As resident work hours policies evolve, residents' off-duty time remains poorly understood. Despite assumptions about how residents should be using their postcall, off-duty time, there is little research on how residents actually use this time and the reasoning underpinning their activities. This study sought to understand residents' nonclinical postcall activities when they leave the hospital, their decision-making processes, and their perspectives on the relationship between these activities and their well-being or recovery.

METHOD

The study took place at a Liaison Committee on Medical Education-accredited Canadian medical school from 2012 to 2014. The authors recruited a purposive and convenience sample of postgraduate year 1-5 residents from six surgical and nonsurgical specialties at three hospitals affiliated with the medical school. Using a constructivist grounded theory approach, semistructured interviews were conducted, audio-taped, transcribed, anonymized, and combined with field notes. The authors analyzed interview transcripts using constant comparative analysis and performed post hoc member checking.

RESULTS

Twenty-four residents participated. Residents characterized their predominant approach to postcall decision making as one of making trade-offs between multiple, competing, seemingly incompatible, but equally valuable, activities. Participants exhibited two different trade-off orientations: being oriented toward maintaining a normal life or toward mitigating fatigue.

CONCLUSIONS

The authors' findings on residents' trade-off orientations suggest a dual recovery model with postcall trade-offs motivated by the recovery of sleep or of self. This model challenges the dominant viewpoint in the current duty hours literature and suggests that the duty hours discussion must be broadened to include other recovery processes.

Use of a Night Float System to Comply With Resident Duty Hours Restrictions: Perceptions of Workplace Changes and Their Effects on Professionalism

PURPOSE

Although some evidence suggests that resident duty hours reforms can lead to shift-worker mentality and loss of patient ownership, other evidence links long hours and fatigue to poor work performance and loss of empathy, suggesting the restrictions could positively affect professionalism. The authors explored perceived impacts of a 16-hour duty restriction, achieved using a night float (NF) system, on the workplace and professionalism.

METHOD

In 2013, the authors conducted semistructured interviews with 18 residents, 9 staff physicians, and 3 residency program directors in the McGill University core internal medicine residency program regarding their perceptions of the program's 12-hour shift-based NF system. Interviews were transcribed and coded for common themes. The authors used a descriptive qualitative methodology.

RESULTS

Participants viewed implementation of the NF system as leading to decreased physical and mental exhaustion, more consistent interaction with patients, and more stable team structure within shifts compared with the previous 24-hour call system. These workplace changes were felt to improve teamwork and patient ownership within shifts, quality of work performed, and empathy. Across shifts, however, more frequent sign-overs, stricter application of shift time boundaries, and loose integration between daytime and NF teams were perceived as leading to emergence of shift-worker mentality around sign-over. Perceptions of optimal patient ownership changed from the traditional single-physician-24/7 model to team-based shared ownership.

CONCLUSIONS

Duty hours restrictions, as exemplified by an NF system, have both positive and negative impacts on professionalism. Interventions and training toward effective team-based care are needed to curb emergence of shift-worker mentality.

A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms

PURPOSE

To summarize current high-quality studies evaluating the effect and efficacy of resident duty hours reforms (DHRs) on patient safety and resident education and well-being.

METHOD

The authors searched PubMed and Medline in August 2012 and again in May 2013 for literature (1987-2013) about the effects of DHRs. They assessed the quality of articles using the Medical Education Research Study Quality Instrument (MERSQI) scoring system. They considered randomized controlled trials (RCTs), partial RCTs, and all studies with a MERSQI score ≥ 14 to be "high-quality" methodology studies.

RESULTS

A total of 72 high-quality studies met inclusion criteria. Most studies showed no change or slight improvement in mortality and complication rates after DHRs. Resident well-being was generally improved, but there was a perceived negative impact on education (knowledge acquisition, skills, and cognitive performance) following DHRs. Eleven high-quality studies assessed the impact of DHR interventions; all reported a neutral to positive impact. Seven high-quality studies assessed costs associated with DHRs and demonstrated an increase in hospital costs.

CONCLUSIONS

The results of most studies that allow enough time for DHR interventions to take effect suggest a benefit to patient safety and resident well-being, but the effect on the quality of training remains unknown. Additional methodologically sound studies on the impact of DHRs are necessary. Priorities for future research include approaches to optimizing education and clinical proficiency and studies on the effect of intervention strategies on both education and patient safety. Such studies will provide additional information to help improve duty hours policies.

Sleep Quality and Vigilance Differ Among Inpatient Nurses Based on the Unit Setting and Shift Worked

OBJECTIVES

Sleepiness in nurses has been shown to impact patient care and safety. The objectives of this study are to measure sleep quality, sleepiness, fatigue, and vigilance in inpatient nurses and to assess how setting (intensive care unit versus the general floor) and shift worked (day versus night) affect these measures.

METHODS

Nurses from both the ICU and floor were included in the study. Participants completed questionnaires assessing self-reported sleep quality (Pittsburgh Sleep Quality Index, PSQI), sleepiness (Stanford Sleepiness Scale and Epworth Sleepiness Scale, ESS), and fatigue (Fatigue Severity Scale, FSS). Vigilance was measured by means of the psychomotor vigilance test (PVT), before and after a 12-hour duty shift.

RESULTS

The ESS was abnormal in 22% of all nurses, the FSS was abnormal in 33%, and the global PSQI was abnormal in 63%. More ICU nurses than floor nurses reported abnormal sleep quality (component 5) on the PSQI. Sleep medication use (PSQI component 6) was higher in night shift nurses. The FSS was greater in night shift nurses. On preshift PVT testing, day-shift nurses overall provided faster mean reaction time (RT) than night-shift nurses. ICU nurses working the day shift made more than twice as many total errors and false starts than day shift floor nurses. Floor nurses demonstrated a significant decrease from preshift to postshift in the mean of the fastest 10% RT.

CONCLUSIONS

Our data indicate that a significant number of inpatient nurses have impaired sleep quality, excessive sleepiness, and abnormal fatigue, which may place them at a greater risk of making medical errors and harming patients; these problems are especially pronounced in night shift workers. PVT results were inconsistent, but floor and day shift nurses performed better on some tasks than ICU and night shift nurses.

The Relationship of On-Call Work with Fatigue, Work-Home Interference, and Perceived Performance Difficulties

OBJECTIVES

This study examined the relationship between on-call duty exposure (active and total on-call hours a month, number of calls per duty) and employees' experiences of being on-call (stress due to unpredictability, ability to relax during inactive on-call periods, restrictions during on-call duties, on-call work demands, and satisfaction with compensation for on-call duties) on the one hand and fatigue, strain-based and time-based work-home interference (WHI), and perceived on-call performance difficulties (PPD) on the other hand.

METHODS

Cross-sectional survey data were collected among a large heterogeneous sample of Dutch employees (N = 5437). The final sample consisted of 157 on-call workers (23-69 years, 71% males). Data were analyzed by means of hierarchical regression analyses (controlling for age and job characteristics).

RESULTS

Differences in on-call work exposure were not systematically related to fatigue, WHI, and PPD (all p's >0.50). The experience of being on-call explained a medium proportion of the variation in fatigue and strain-based WHI and a medium to large proportion of the variation in time-based WHI and PPD over and above the control variables.

CONCLUSIONS

Our results suggest that it is employees' experience of being on-call, especially the experience of stress due to the unpredictability, rather than the amount of exposure, that is related to fatigue, WHI, and perceived on-call performance difficulties.