The effect of fatigue, sleep deprivation and onerous working hours on the physical and mental wellbeing of pre-registration house officers

Developing multiple shortened forms of virtual reality-based color trails test

The Color Trails Test (CTT) is a pencil-and-paper (P&P) neuropsychological test. The CTT is divided into two parts that assess sustained visual attention (Trails A) and divided attention (Trails B). The CTT can also be performed in a virtual reality setting (VR-CTT) introducing a wider spatial range of targets. In cases of multiple assessments, repeating the same CTT configuration can bias the results due to fatigue and learning effects. The aim of this study is to create five different short versions of the VR-CTT. The different forms were created by rotating or flipping the original targets spatial layout on one of the axes and by ending it at ball #13. Healthy young participants (N = 15) performed the shortened VR-CTT forms (in a counterbalanced order), the P&P CTT and the original VR-CTT. We found no difference between the completion times of the five forms (p > 0.2), and a significant difference between Trails A and B across all forms (p < 0.04). Additionally, there was no evidence of a learning effect between trials (p > 0.4). Moreover, the shortened VR-CTT forms showed correlations with the P&P CTT (p < 0.05) and with the original VR-CTT (p < 0.06). These findings suggest that all five forms have an equal level of difficulty and that the different forms managed to mitigate the learning effects reported for repeated testing of the same spatial layout. This opens the possibility of applying the shortened VR-CTT forms for research settings and sets the basis for developing it into a clinical diagnostics tool.

The trail less traveled: Analytical approach for creating shortened versions for virtual reality-based color trails test

The Color Trails Test ("CTT") is among the most popular neuropsychological assessment tests of executive function, targeting sustained visual attention (Trails A), and divided attention (Trails B). During the pen-and-paper (P&P) test, the participant traces 25 consecutive numbered targets marked on a page, and the completion time is recorded. In many cases, multiple assessments are performed on the same individual, either under varying experimental conditions or at several timepoints. However, repeated testing often results in learning and fatigue effects, which confound test outcomes. To mitigate these effects, we set the grounds for developing shorter versions of the CTT (<25 targets), using virtual reality (VR) based CTT (VR-CTT). Our aim was to discover the minimal set of targets that is sufficient for maintaining concurrent validity with the CTT including differentiation between age groups, and the difference between Trails A and B. To this aim, healthy participants in three age groups (total N = 165; young, middle-aged, or older adults) performed both the P&P CTT, and one type of VR-CTT (immersive head-mounted-device VR, large-scale 3D VR, or tablet). A subset of 13 targets was highly correlated with overall task completion times in all age groups and platforms (r > 0.8). We tested construct validity and found that the shortened-CTT preserved differences between Trails A and B (p < 0.001), showed concurrent validity relative to the P&P scores (r > 0.5; p < 0.05), and differentiated between age groups (p < 0.05). These findings open the possibility for shortened "CTT-versions", to be used in repeated-measures experiments or longitudinal studies, with potential implications for shortening neurocognitive assessment protocols.

The effects of dark chocolate on cognitive performance during cognitively demanding tasks: A randomized, single-blinded, crossover, dose-comparison study

Dark chocolate, rich in polyphenols, increases cerebral blood flow and improves cognitive function. This study aimed to determine whether the consumption of chocolate with a high concentration of polyphenols helps to maintain cognitive performance during cognitively demanding tasks. In this randomized, single-blinded, crossover, dose-comparison study, 18 middle-aged adults consumed two types of chocolate (25 g each), one with a high concentration (635.0 mg) and the other with a low concentration (211.7 mg) of cacao polyphenols, and performed a cognitive task requiring response inhibition and selective attention over two time periods (15-30 min and 40-55 min after consumption, respectively). Autonomic nerve function and subjective feelings, such as fatigue and concentration, were measured before food intake and after the second task to assess the participant's state. The results showed that the average reaction time between the first and second sessions was not significantly different for either high- or low-concentration chocolate consumption. However, the percentage of correct responses was similar in the first (96.7 %) and second (96.8 %) sessions for high-concentration chocolate consumption and significantly lower for low-concentration chocolate consumption in the second (96.4 %) session than in the first session (97.3 %). Autonomic nerve function showed a significant increase in sympathetic nerve activity after the second task with high-concentration chocolate consumption, while subjective feelings showed an increase in mental fatigue for both chocolate types but a significant decrease in concentration only after the second task with low-concentration chocolate consumption. These findings suggest that dark chocolate consumption contributes to the maintenance of performance and concentration in continuous and demanding cognitive tasks.

Effects of Serving as a State Functionary on Self-Rated Health: Empirical Evidence From China

Purpose

There is a strong link between occupation and self-rated health. Existing research has revealed the effects of occupation on self-rated health outcomes and the corresponding mechanisms. However, there is a lack of research on the effects of state services on self-rated health in China. Therefore, this study focuses on exploring the effects of serving as a state functionary in China on self-rated health to enrich research in related fields.

Method

Based on the data of 14,138 individuals collected from the 2016 China Labour-Force Dynamics Survey, the logit model was used to investigate the effects of serving as a state functionary on self-rated health and the difference in the effects across different populations.

Results

The results show that (1) serving as a state functionary has a significant positive effect on self-rated health; (2) self-rated health of elderly state functionaries is higher than that of younger state functionaries; (3) self-rated health of state functionaries in non-eastern regions is higher than that of state functionaries in eastern regions; and (4) state functionaries with lower education have higher self-rated health than highly-educated state functionaries; (5) Higher self-rated health of state functionaries is achieved primarily through better work time, better work environment and lower relative deprivation.

Conclusion

Serving as a state functionary in China has a significant positive correlation with self-rated health, with differences across populations of state functionaries. This study expands the current literature on the effects of occupation on self-rated health in the context of China.

Central and Peripheral Fatigue in Physical Exercise Explained: A Narrative Review

The study of the origin and implications of fatigue in exercise has been widely investigated, but not completely understood given the complex multifactorial mechanisms involved. Then, it is essential to understand the fatigue mechanism to help trainers and physicians to prescribe an adequate training load. The present narrative review aims to analyze the multifactorial factors of fatigue in physical exercise. To reach this aim, a consensus and critical review were performed using both primary sources, such as scientific articles, and secondary ones, such as bibliographic indexes, web pages, and databases. The main search engines were PubMed, SciELO, and Google Scholar. Central and peripheral fatigue are two unison constructs part of the Integrative Governor theory, in which both psychological and physiological drives and requirements are underpinned by homeostatic principles. The relative activity of each one is regulated by dynamic negative feedback activity, as the fundamental general operational controller. Fatigue is conditioned by factors such as gender, affecting men and women differently. Sleep deprivation or psychological disturbances caused, for example, by stress, can affect neural activation patterns, realigning them and slowing down simple mental operations in the context of fatigue. Then, fatigue can have different origins not only related with physiological factors. Therefore, all these prisms must be considered for future approaches from sport and clinical perspectives.

The workplace and psychosocial experiences of Australian junior doctors during the COVID-19 pandemic

Background

Junior doctors experience high levels of psychological distress and emotional exhaustion. The current Coronavirus disease 2019 (COVID‐19) pandemic has resulted in significant changes to healthcare globally, with quantitative studies demonstrating increased fatigue, depression and burnout in junior doctors. However, there has been limited qualitative research to examine junior doctors' experiences, challenges and beliefs regarding management of future crises.

Aims

To investigate the workplace and psychosocial experiences of Australian junior doctors working during the second wave of the COVID‐19 pandemic.

Methods

Australian healthcare workers were invited to participate in a nationwide, voluntary, anonymous, single time point, online survey between 27 August and 23 October 2020. A qualitative descriptive study of responses to four free‐text questions from 621 junior doctors was undertaken, with responses analysed using inductive content analysis.

Results

Participants were predominantly female (73.2%), aged 31–40 years (48.0%) and most frequently reported working in medical specialties (48.4%), emergency medicine (21.7%) or intensive care medicine (11.4%). Most (51.9%) participants had 0–5 years of clinical experience since medical graduation. Junior doctors described experiences related to four key themes: a hierarchical, difficult workplace culture; challenging working conditions; disrupted training and career trajectories; and broader psychosocial impacts. The COVID‐19 pandemic exacerbated longstanding, workplace issues and stressors for junior doctors and highlighted the threat that crises pose to medical workforce retention. There is an urgent need for authentic, positive workplace cultural interventions to engage, validate and empower junior doctors.

Conclusions

Challenging workplace cultures and conditions, which have worsened during the COVID‐19 pandemic, are associated with poor psychological well‐being in junior doctors. There exists a need for long‐term, widespread improvements in workplace culture and working conditions to ensure junior doctors' well‐being, facilitate workforce retention and enhance the safety and quality of patient care in Australia.

Work fatigue among Lebanese physicians and students during the COVID-19 pandemic: validation of the 3D-Work Fatigue Inventory (3D-WFI) and correlates

Background

Work fatigue is a work-related condition that affects physicians’ health, work attitude safety and performance. Work fatigue affects not only medical workers but can also leave a negative impact on patients. With the burden of the COVID-19 pandemic as well as the economic crisis Lebanese doctors have been facing in the last 2 years, the aim of our study was to validate the 3D-Work Fatigue Inventory (3D-WFI) among Lebanese physicians and assess the rate and correlates of work fatigue (physical, mental and emotional).

Methods

A cross-sectional study was undertaken through an anonymous self-administered questionnaire between October 2020 and January 2021. The SPSS AMOS software v.24 was used to conduct confirmatory factor analysis (CFA). To validate the 3D-WFI, multiple indices of goodness-of-fit were described: the Relative Chi-square (χ2/df) (cut-off values:< 2–5), the Root Mean Square Error of Approximation (RMSEA) (close and acceptable fit are considered for values < 0.05 and < 0.11 respectively), the Tucker Lewis Index (TLI) and the Comparative Fit Index (CFI) (acceptable values are ≥0.90).

Results

A total of 401 responses was collected; 66.1, 64.8 and 65.1% respondents had an intermediate to high level of emotional, mental and physical work fatigue respectively. The fit indices obtained in the CFA of the 3D-WFI items fitted well: CFI =0.98, TLI =0.98, RMSEA = 0.05; 95% CI 0.046–0.063; pclose = 0.20) and χ²(136) = 295.76. The correlation coefficients between the three factors (Factor 1 = Physical work fatigue, Factor 2 = Mental work fatigue, Factor 3 = Emotional work fatigue) were adequate as well: Factor 1-Factor 2 (r = 0.70), Factor 1-Factor 3 (r = 0.52) and Factor 2-Factor 3 (r = 0.65). In addition, feeling pressured by long working hours during the pandemic, having more hours of night duty per month, more stressful events in life, and higher depression were significantly associated with more physical and mental work fatigue. Higher depression and having more stressful events in life were significantly associated with more emotional work fatigue.

Conclusion

Work fatigue in Lebanese physicians seems to be associated with higher level of everyday stress, high work load and depression. Hospitals and local health authorities can use these results for early interventions that aim to reduce work fatigue and ensure the wellbeing of Lebanese physicians.

Cognitive throughput and working memory raw scores consistently differentiate resilient and vulnerable groups to sleep loss

STUDY OBJECTIVES

Substantial individual differences exist in cognitive deficits due to sleep restriction (SR) and total sleep deprivation (TSD), with various methods used to define such neurobehavioral differences. We comprehensively compared numerous methods for defining cognitive throughput and working memory resiliency and vulnerability.

METHODS

41 adults participated in a 13-day experiment: 2 baseline, 5 SR, 4 recovery, and one 36h TSD night. The Digit Symbol Substitution Test (DSST) and Digit Span Test (DS) were administered every 2h. Three approaches (Raw Score [average SR performance], Change from Baseline [average SR minus average baseline performance], and Variance [intraindividual variance of SR performance]), and six thresholds (±1 standard deviation, and the best/worst performing 12.5%, 20%, 25%, 33%, 50%) classified Resilient/Vulnerable groups. Kendall's tau-b correlations compared the group categorizations' concordance within and between DSST number correct and DS total number correct. Bias-corrected and accelerated bootstrapped t-tests compared group performance. .

RESULTS

The approaches generally did not categorize the same participants into Resilient/Vulnerable groups within or between measures. The Resilient groups categorized by the Raw Score approach had significantly better DSST and DS performance across all thresholds on all study days, while the Resilient groups categorized by the Change from Baseline approach had significantly better DSST and DS performance for several thresholds on most study days. By contrast, the Variance approach showed no significant DSST and DS performance group differences.

CONCLUSION

Various approaches to define cognitive throughput and working memory resilience/vulnerability to sleep loss are not synonymous. The Raw Score approach can be reliably used to differentiate resilient and vulnerable groups using DSST and DS performance during sleep loss.

Working hours, common mental disorder and suicidal ideation among junior doctors in Australia: a cross-sectional survey

OBJECTIVE

Despite concern regarding high rates of mental illness and suicide amongst the medical profession, the link between working hours and doctors' mental health remains unclear. This study examines the relationship between average weekly working hours and junior doctors' (JDs') mental health in Australia.

DESIGN AND PARTICIPANTS

A randomly selected sample of 42 942 Australian doctors were invited to take part in an anonymous Beyondblue National Mental Health Survey in 2013, of whom 12 252 doctors provided valid data (response rate approximately 27%). The sample of interest comprised 2706 full-time graduate medical trainees in various specialties, at either intern, prevocational or vocational training stage. Consultants and retired doctors were excluded.

OUTCOME MEASURES

Main outcomes of interest were caseness of common mental disorder (CMD) (assessed using a cut-off of 4 as a threshold on total General Health Questionnaire-28 score), presence of suicidal ideation (SI) (assessed with a single item) and average weekly working hours. Logistic regression modelling was used to account for the impact of age, gender, stage of training, location of work, specialty, marital status and whether JDs had trained outside Australia.

RESULTS

JDs reported working an average of 50.1 hours per week (SD=13.4). JDs who worked over 55 hours a week were more than twice as likely to report CMD (adjusted OR=2.05; 95% CI 1.62 to 2.59, p<0.001) and SI (adjusted OR=2.00; 95% CI 1.42 to 2.81, p<0.001) compared to those working 40-44 hours per week.

CONCLUSIONS

Our results show that around one in four JDs are currently working hours that are associated with a doubling of their risk of common mental health problems and SI. These findings suggest that management of working hours represents an important focus for workplaces to improve the mental health of medical trainees.

Work-Life Integration and Time Management Strategies

When choosing a career as a surgeon, we knowingly dedicate ourselves to a lifetime of service and education. Our commitment as physicians is but one of many commitments in the larger scheme of life where we function as family members, friends, athletes, and numerous other roles. Work and life are often described as two separate entities diametrically opposed to each other. In reality, personal and professional goals are part of a continuum where work is a major part of our lives and who we are as people and is not necessarily separate from the others. The goal-directed nature with which we approach our responsibilities as surgeons should be applied to all domains of life. As we progress along the training paradigm from intern to attending, control over time allocation increases. Understanding oneself, determining priorities, applying realistic expectations, cultivating a supportive environment, setting personal and professional goals, and being held accountable for progress and completion of these goals will allow us to utilize limited time efficiently to achieve what we individually desire from life.

Associations Between In-Hospital Mortality, Health Care Utilization, and Inpatient Costs With the 2011 Resident Duty Hour Revision

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) has mandated revisions to residents' work hours to improve patient safety and enhance resident education and wellness. The impact on clinical outcomes on a national level is poorly understood.

OBJECTIVE

We examined data from before and after the ACGME 2011 duty hour revision and looked for differences between teaching and nonteaching US hospitals.

METHODS

A retrospective observational study of patients admitted to hospitals in the 2-year periods before and after the 2011 duty hour revision was conducted, utilizing a nationally representative data set. We compared patient and hospital characteristics using standardized differences. With nonteaching hospitals serving as the control group, we used multiple group interrupted time series segmented regression analysis to test for postrevision level and trend changes in mortality, length of stay (LOS), and costs.

RESULTS

We examined more than 117 million hospitalizations. At teaching and nonteaching hospitals, trends in mortality and LOS in prerevision and postrevision periods were not significantly different (all P > .05). A significant monthly reduction in cost per hospitalization was noted postrevision at teaching hospitals (P = .019) but not at nonteaching hospitals (P = .62). In the 2 years following the 2011 revision, there was a monthly reduction in cost per hospitalization (-$52.28; 95% confidence interval -$116.90 to -$12.32; P = .026) at teaching relative to nonteaching hospitals.

CONCLUSIONS

There were no differences in mortality or LOS between teaching and nonteaching hospitals. However, there was a small decrease in cost per hospitalization at teaching hospitals following the 2011 revision.

Assessment of Sleep Quality and its Relationship to Social Media Use Among Medical Students

STUDY OBJECTIVES

This study attempted to assess sleep quality among medical students and examine the relationship between social network use and sleep quality.

METHODS

Descriptive cross-sectional study, enrolling medical students of King Abdulaziz University and Batterjee Medical College. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality.

RESULTS

Of the 702 medical students who responded to our survey (410 females and 292 males), more than 66% suffered from poor sleep quality. Approximately 92.3% of the surveyed students used electronic devices before they fell asleep, and 88.4% used these devices for social networking purposes. Female students were found to suffer more than male students, and they also reported spending more time on social networking sites before sleeping (p = .006).

CONCLUSION

This study suggests that students who reported poor sleep spent an average of 64.38 min on social networking sites before sleeping; this duration was negatively associated with medical students' sleep quality.

The Measurement of Orthopaedic Surgeon Quality and Quantity of Sleep Using a Validated Wearable Device

Introduction:

Recurrent episodes of partial sleep deprivation resulting from shift work or call schedules are commonly seen in physicians. This study measures the quantity and quality of sleep in orthopaedic surgeons and determines the factors that are correlated with decreased quantity and quality of sleep.

Methods:

Orthopaedic surgery residents and attending surgeons at a single institution were prospectively enrolled and provided with a validated wearable device to objectively determine sleep quantity (total hours of sleep) and quality (sleep disturbances; sleep latency; sleep efficiency; and amount of rapid eye movement [REM] sleep, deep sleep, and light sleep). Sleep deprivation was defined as getting less than 7 hours of sleep per day. Bivariate correlations were determined using Spearman rank correlation. Multiple linear regression models were constructed to determine the effect of independent variables (age, attending physician, resident, postgraduate year [PGY] level, sex, number of calls, and total hours worked) and sleep quantity and quality. All P values were reported, and a significance level of α = 0.05 was used (ie, P < 0.05).

Results:

Of 26 enrolled subjects, 21 (80.8%; 12 residents and 9 attending surgeons, where 15 were men and 6 women, with mean age of 37.2 ± 10.9 years) completed the 4-week duration of the study. Orthopaedic surgeons obtained 6.5 ± 0.8 hours of sleep per night (17.7% REM, 19.4% deep sleep, and 62.6% light sleep; 4.5 ± 1.1 minutes of sleep latency; 4.9 ± 1.7 sleep disturbances; and 89.9% sleep efficiency). Fourteen orthopaedic surgeons (66.7%) of the 21 slept less than the recommended 7 hours of sleep per night. The total hours worked had a moderate negative correlation (r = −0.550; P = 0.010) with total sleep. PGY level had a moderate positive correlation with sleep latency (r = 0.546; P = 0.010).

Discussion:

Diminished sleep quantity is considered sleeping less than 7 hours per night, whereas decreased sleep quality is associated with decreased REM sleep, decreased deep sleep, increased light sleep, decreased sleep latency, decreased sleep efficiency, and increased sleep disturbances. Sleep deprivation in orthopaedic surgeons poses notable health and safety risks for both surgeons and patients.

Conclusion:

Orthopaedic surgeons demonstrate poor sleep quantity and quality which is markedly worse than the general population, with increased work hours markedly correlated with decreased hours of sleep.

Improving the health of psychiatrists

Although the physical health of doctors is largely better than that of the general population, they continue to have high levels of stress, depression and substance misuse. These aspects of mental ill health are particularly elevated in psychiatrists, and in a number of studies psychiatrists have also been found to be those doctors most likely to face disciplinary proceedings. This article explores the individual and organisational causes of these problems and the ways they may interact within the psychiatrist's work role, and suggests a variety of possible interventions to improve the mental health of doctors in psychiatry.

24-hour care: Work and sleep conditions of migrant Filipino live-in caregivers in Los Angeles

INTRODUCTION

Live-in formal caregivers spend consecutive days in patients' homes, raising questions about their ability to secure adequate sleep while on duty. Few studies have examined sleeping conditions and outcomes for this growing workforce.

METHODS

We collected weeklong sleep logs and interview data from 32 Filipino caregivers in Los Angeles who provide live-in services at least 3 consecutive days per week.

RESULTS

Respondents recorded a total average of 6.4 sleep hours during workdays divided over 2.4 sleep periods. Caregivers rated sleep quality as lower while at work; over 40% indicated excessive daytime sleepiness. Female caregivers reported worse sleep outcomes than their male counterparts. Some variations in sleep outcomes were found by employment arrangements.

CONCLUSION

Live-in caregivers experience frequent sleep interruptions at all hours of the day and night to attend to patients' needs. The resulting impacts on sleep quality pose risks for both work-related injury and errors in patient care. Am. J. Ind. Med. 59:1120-1129, 2016. © 2016 Wiley Periodicals, Inc.

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.

Resident duty hour modification affects perceptions in medical education, general wellness, and ability to provide patient care

BACKGROUND

Resident duty hours have recently been under criticism, with concerns for resident and patient well-being. Historically, call shifts have been long, and some residency training programs have now restricted shift lengths. Data and opinions about the effects of such restrictions are conflicting. The Internal Medicine Residency Program at Dalhousie University recently moved from a traditional call structure to a day float/night float system. This study evaluated how this change in duty hours affected resident perceptions in several key domains.

METHODS

Senior residents from an internal medicine training program in Canada responded to an anonymous online survey immediately before and 6 months after the implementation of duty hour reform. The survey contained questions relating to three major domains: resident wellness, ability to deliver quality health care, and medical education experience. Mean pre- and post-intervention scores were compared using the t-test for paired samples.

RESULTS

Twenty-three of 27 (85 %) senior residents completed both pre- and post-reform surveys. Residents perceived significant changes in many domains with duty hour reform. These included improved general wellness, less exposure to personal harm, fewer feelings of isolation, less potential for error, improvement in clinical skills expertise, increased work efficiency, more successful teaching, increased proficiency in medical skills, more successful learning, and fewer rotation disruptions.

CONCLUSIONS

Senior residents in a Canadian internal medicine training program perceived significant benefits in medical education experience, ability to deliver healthcare, and resident wellness after implementation of duty hour reform.

Implications of transitioning to a resident night float system in neurosurgery: mortality, length of stay, and resident experience

OBJECTIVE Many neurosurgical training programs have moved from a 24-hour resident call system to a night float system, but the impact on outcomes is unclear. Here, the authors compare length of stay (LOS) for neurosurgical patients admitted before and after initiation of a night float system at a tertiary care training hospital. METHODS The neurosurgical residency at the University of Alabama at Birmingham transitioned from 24-hour call to a night float resident coverage system in July 2013. In this cohort study, all patients admitted to the neurosurgical service for 1 year before and 1 year after this transition were compared with respect to hospital and ICU LOSs, adjusted for potential confounders. RESULTS A total of 4619 patients were included. In the initial bivariate analysis, night float was associated with increased ICU LOS (p = 0.032) and no change in overall LOS (p = 0.65). However, coincident with the transition to a night float system was an increased frequency of resident service transitions, which were highly associated with hospital LOS (p < 0.01) and ICU LOS (p < 0.01). After adjusting for resident service transitions, initiation of the night float system was associated with decreased hospital LOS (p = 0.047) and no change in ICU LOS (p = 0.35). CONCLUSIONS This study suggests that a dedicated night float resident may improve night-to-night continuity of care and decrease hospital LOS, but caution must be exercised when initiation of night float results in increased resident service transitions.

Daytime Sleepiness in Men During Early Fatherhood: Implications for Work Safety

This study measured the daytime sleepiness (DS) and work safety of fathers during the first 12 weeks of their babies' lives (i.e., early fatherhood). A questionnaire was developed using the Epworth Sleepiness Scale (ESS), the Safety Behaviour at Work Scale, a self-reported sleep history, and a work-related incident history. Of the 221 participants, the vast majority reported they experienced less than 6 hours of interrupted sleep per night during the 12 weeks of the study, and an increasing frequency and severity of DS. The study also revealed an inverse correlation between ESS and Safety Behaviour at Work scores; fathers were 14% more likely to report a near-miss accident at work at 12 weeks. This study posits that antenatal classes and assessment of fathers' sleepiness at work by occupational health practitioners could assist fathers in reducing daytime sleepiness and mitigating the risk of workplace incidents.

Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E. Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion

The American Academy of Sleep Medicine and Sleep Research Society recently released a Consensus Statement regarding the recommended amount of sleep to promote optimal health in adults. This paper describes the methodology, background literature, voting process, and voting results for the consensus statement. In addition, we address important assumptions and challenges encountered during the consensus process. Finally, we outline future directions that will advance our understanding of sleep need and place sleep duration in the broader context of sleep health.

Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E. Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion

The American Academy of Sleep Medicine and Sleep Research Society recently released a Consensus Statement regarding the recommended amount of sleep to promote optimal health in adults. This paper describes the methodology, background literature, voting process, and voting results for the consensus statement. In addition, we address important assumptions and challenges encountered during the consensus process. Finally, we outline future directions that will advance our understanding of sleep need and place sleep duration in the broader context of sleep health.

Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform

Object

The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery.

Methods

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

Results

A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55).

Conclusions

The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.

Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions

OBJECT

On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures.

METHODS

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000-2002) and post-reform (2005-2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

RESULTS

A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre- and post-duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11-1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91-1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17).

CONCLUSIONS

The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.

The fatigued anesthesiologist: A threat to patient safety?

Universally, anesthesiologists are expected to be knowledgeable, astutely responding to clinical challenges while maintaining a prolonged vigilance for administration of safe anesthesia and critical care. A fatigued anesthesiologist is the consequence of cumulative acuity, manifesting as decreased motor and cognitive powers. This results in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record keeping. With rising expectations and increased medico-legal claims, anesthesiologists work round the clock to provide efficient and timely services, but are the "sleep provider" in a sleep debt them self? Is it the right time to promptly address these issues so that we prevent silent perpetuation of problems pertinent to anesthesiologist's health and the profession. The implications of sleep debt on patient safety are profound and preventive strategies are quintessential. Anesthesiology governing bodies must ensure requisite laws to prevent the adverse outcomes of sleep debt before patient care is compromised.

Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight

RATIONALE AND OBJECTIVES

To determine if the rate of major discrepancies between resident preliminary reports and faculty final reports increases during the final hours of consecutive 12-hour overnight call shifts.

MATERIALS AND METHODS

Institutional review board exemption status was obtained for this study. All overnight radiology reports interpreted by residents on-call between January 2010 and June 2010 were reviewed by board-certified faculty and categorized as major discrepancies if they contained a change in interpretation with the potential to impact patient management or outcome. Initial determination of a major discrepancy was at the discretion of individual faculty radiologists based on this general definition. Studies categorized as major discrepancies were secondarily reviewed by the residency program director (M.H.S.) to ensure consistent application of the major discrepancy designation. Multiple variables associated with each report were collected and analyzed, including the time of preliminary interpretation, time into shift study was interpreted, volume of studies interpreted during each shift, day of the week, patient location (inpatient or emergency department), block of shift (2-hour blocks for 12-hour shifts), imaging modality, patient age and gender, resident identification, and faculty identification. Univariate risk factor analysis was performed to determine the optimal data format of each variable (ie, continuous versus categorical). A multivariate logistic regression model was then constructed to account for confounding between variables and identify independent risk factors for major discrepancies.

RESULTS

We analyzed 8062 preliminary resident reports with 79 major discrepancies (1.0%). There was a statistically significant increase in major discrepancy rate during the final 2 hours of consecutive 12-hour call shifts. Multivariate analysis confirmed that interpretation during the last 2 hours of 12-hour call shifts (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.18-3.21), cross-sectional imaging modality (OR 5.38, 95% CI 3.22-8.98), and inpatient location (OR 1.81, 95% CI 1.02-3.20) were independent risk factors for major discrepancy.

CONCLUSIONS

In a single academic medical center, major discrepancies in resident preliminary reports increased significantly during the final 2 hours of consecutive 12-hour overnight call shifts. This finding could be related to either fatigue or circadian desynchronization. Discrimination of these two potential etiologies requires additional investigation as major discrepancies in resident reports have the potential to negatively impact patient care/outcome. Cross-sectional imaging modalities including computed tomography and ultrasound (versus conventional radiography), as well as inpatient location (versus Emergency Department location), were also associated with significantly higher major discrepancy rates.

The relationship between thermal comfort and light intensity with sleep quality and eye tiredness in shift work nurses

Environmental conditions such as lighting and thermal comfort are influencing factors on sleep quality and visual tiredness. The purpose of this study was the determination of the relationship between thermal comfort and light intensity with the sleep quality and eye fatigue in shift nurses.

METHOD

This cross-sectional research was conducted on 82 shift-work personnel of 18 nursing workstations in Isfahan Al-Zahra Hospital, Iran, in 2012. Heat stress monitoring (WBGT) and photometer (Hagner Model) were used for measuring the thermal conditions and illumination intensity, respectively. To measure the sleep quality, visual tiredness, and thermal comfort, Pittsburg sleep quality index, eye fatigue questionnaire, and thermal comfort questionnaire were used, respectively. The data were analyzed with descriptive statistics, Student's t-test, and Pearson correlation.

RESULTS

Correlation between thermal comfort which was perceived from the self-reporting of people with eye tiredness was -0.38 (P = 0.002). Pearson correlation between thermal comfort and sleep quality showed a positive and direct relationship (r = 0.241, P = 0.33) but the correlation between thermal comfort, which was perceived from the self-reporting of shift nurses, and WBGT index was a weak relationship (r = 0.019).

CONCLUSION

Based on the obtained findings, it can be concluded that a defect in environmental conditions such as thermal conditions and light intensity and also lack of appropriate managerial plan for night shift-work nurses are destructive and negative factors for the physical and mental health of this group of practitioners.

Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature

Extended work hours, interrupted sleep, and shift work are integral parts of medical training among all specialties. The need for 24-hour patient care coverage and economic factors have resulted in prolonged work hours for resident physicians. This has traditionally been thought to enhance medical educational experience. These long and erratic work hours lead to acute and chronic sleep deprivation and poor sleep quality, resulting in numerous adverse consequences. Impairments may occur in several domains, including attention, cognition, motor skills, and mood. Resident performance, professionalism, safety, and well-being are affected by sleep deprivation, causing potentially adverse implications for patient care. Studies have shown adverse health consequences, motor vehicle accidents, increased alcohol and medication use, and serious medical errors to occur in association with both sleep deprivation and shift work. Resident work hour limitations have been mandated by the Accreditation Council for Graduate Medical Education in response to patient safety concerns. Studies evaluating the impact of these regulations on resident physicians have generated conflicting reports on patient outcomes, demonstrating only a modest increase in sleep duration for resident physicians, along with negative perceptions regarding their education. This literature review summarizes research on the effects of sleep deprivation and shift work, and examines current literature on the impact of recent work hour limitations on resident physicians and patient-related outcomes.

Fatigue-associated alterations of cognitive function and electroencephalographic power densities

Fatigue is a common problem in modern society. We attempted to identify moderate- to long-term fatigue-related alterations in the central nervous system using cognitive tasks and electroencephalography (EEG) measures. The study group consisted of 17 healthy male participants. After saliva samples were collected to measure copy number of human herpesvirus (HHV)-6 DNA to assess the level of moderate- to long-term fatigue, subjects were evaluated using EEG, with their eyes open for 2 min, then closed for 1 min sitting quietly. Thereafter, they completed cognitive task trials to evaluate simple selective attention for 3 min (Task 1) and conflict-controlling selective attention for 6 min (Task 2, which included Stroop trials). The percent error of Task 2 for Stroop trials was positively associated with the copy number of saliva HHV-6 DNA, although the simple selective attention measures in Task 1 did not differ significantly. EEG power densities (especially the alpha power density) during the eye-closed condition were negatively associated with the saliva HHV-6 DNA level. Impaired high-level information processing such as that required for conflict-controlling selective attention in the central nervous system may be a characteristic feature of moderate- to long-term fatigue.

Handover rounds in Irish hospitals

BACKGROUND

With the increasing complexities in medicine and the reduction in working hours, shift work patterns are emerging for hospital doctors and with them the possibility for discontinuity of patient care and negative outcomes for patient safety.

AIMS

The purpose of this study was to evaluate the prevalence, format and structure of formal handover rounds in Irish hospitals in four different specialties.

METHODS

A 26-item questionnaire was sent to 61 participants in 26 hospitals.

RESULTS

Just over a quarter of respondents (28%) reported formal handover rounds. Respondents from Obstetrics and Gynaecology were more likely to report handover rounds (80%). Prominent features of handover include frequent consultant (100%) and post-call staff (73%) attendance.

CONCLUSION

This study confirms that handover rounds are not universal in Irish hospitals. While this does not imply that patient safety is compromised, the need for effective and comprehensive handover is a critical aspect of patient care.

Work safety during early fatherhood

Fathers are increasingly expected to engage in infant care. The early postpartum period has been described as a time when work-family conflict, lack of sleep, and fatigue are prominent themes. Research has demonstrated that these themes can have a deleterious effect on work safety. Lack of sleep and fatigue have been linked to workplace accidents, yet few studies have specifically investigated work-family conflict, sleep, and fatigue among men with infants. The need exists to specifically study and measure work-family conflict, sleep deprivation, and fatigue in relation to early fatherhood. Such research could have a direct effect on occupational health nursing practice.

A further evaluation of the cognitive deficits associated with restless legs syndrome (RLS)

BACKGROUND AND PURPOSE

Restless legs syndrome (RLS) is a common sensorimotor disorder that peaks in severity during the night and comes on with rest. As a result, this condition often results in significant chronic sleep loss, especially for those with severe disease. Chronic partial sleep restriction has been associated with conditions such as depression, anxiety, chronic pain, and decline in cognitive function. Furthermore, studies have found that RLS patients suffer from these conditions more than their unaffected peers. Thus, the morbidity rate associated with RLS has often been attributed to the chronic sleep loss that frequently accompanies this condition. However, no study has specifically compared RLS sufferers to otherwise normal sleep-restricted controls in order to assess disease morbidity independent of its sleep deprivation effects. In this study, we compared the cognitive function of RLS patients who were off treatment to sleep-restricted control subjects.

SUBJECTS AND METHODS

A novel chronic partial sleep-restriction protocol that utilized a 14-day combined inpatient and outpatient design was implemented in order to test the differences in cognitive functioning between RLS patients and sleep-restricted controls. The brief cognitive battery included instruments assessing general intelligence and global executive function in order to control for baseline cognitive function between the groups, and then the effects of sleep loss were assessed using prefrontal lobe-specific tasks. The final sample consisted of 16 RLS (11 male and 5 female) and 13 sleep-restricted control subjects (7 male and 6 female).

RESULTS

In order to examine the differences in cognitive functioning between sleep-restricted controls and RLS subjects, independent samples t-tests were conducted. RLS subjects performed significantly better on both the Letter Fluency (t=2.13, p<0.05) and Category Fluency (t=2.42, p<0.05) than sleep-restricted controls.

CONCLUSIONS

RLS subjects performed better than the sleep-restricted controls on two tasks that are particularly sensitive to sleep loss. Although previous studies suggest that sleep deprivation may impact the cognitive function of those with RLS, our data suggests that RLS subjects may show a relative degree of sleep loss adaptation. Future investigations that more closely match the sleep loss pattern of RLS subjects to controls are warranted in order to explore these potential traits further.

Differences in day and night shift clinical performance in anesthesiology

OBJECTIVE

This study examined whether anesthesia residents (physicians in training) performed clinical duties in the operating room differently during the day versus at night.

BACKGROUND

Fatigue from sleep deprivation and working through the night is common for physicians, particularly during residency training.

METHODS

Using a repeated-measures design, we studied 13 pairs of day-night matched anesthesia cases. Dependent measures included task times, workload ratings, response to an alarm light latency task, and mood.

RESULTS

Residents spent significantly less time on manual tasks and more time on monitoring tasks during the maintenance phase at night than during the day. Residents reported more negative mood at night than during the day, both pre- and postoperation. However, time of day had no effect on the mood change between pre- and postoperation. Workload ratings and the response time to an alarm light latency task were not significantly different between night and day cases.

CONCLUSIONS

Because night shift residents had been awake and working for more than 16 hr, the observed differences in task performance and mood may be attributed to fatigue. The changes in task distribution during night shift work may represent compensatory strategies to maintain patient care quality while keeping perceived workload at a manageable level.

APPLICATIONS

Fatigue effects during night shifts should be considered when designing work-rest schedules for clinicians. This matched-case control scheme can also be applied to study other phenomena associated with patient safety in the actual clinical environment.

Uso de microarrays na busca de perfis de expressão gênica: aplicação no estudo de fenótipos complexos

Com o advento do seqüenciamento de genoma humano, novas tecnologias foram desenvolvidas e despontaram como promissoras ferramentas metodológicas e científicas para o avanço na compreensão dos mecanismos envolvidos em várias doenças complexas. Dentre elas, a técnica de análise em larga escala (conhecida como microarrays ou chips de DNA) é particularmente eficaz em permitir uma visão global na busca de padrões de expressão gênica em amostras biológicas. Por meio da determinação da expressão de milhares de genes simultaneamente, a promissora tecnologia permite que pesquisadores comparem o comportamento molecular de diversos tipos de linhagens celulares e tecidos diferentes, quando expostos a uma determinada condição patológica ou experimental. A aplicação do método pode trazer novas perspectivas de análise de processos fisiológicos e facilitar a identificação de marcadores moleculares para o diagnóstico, prognóstico e para o tratamento farmacológico atual. Nesse artigo, apresentaremos conceitos teóricos e metodológicos que permeiam a tecnologia de microarrays, assim como suas vantagens, perspectivas e direcionamentos futuros. Com o intuito de exemplificar sua aplicabilidade e eficiência no estudo de fenômenos complexos, serão apresentados e também discutidos resultados iniciais sobre padrões de expressão gênica em amostra de cérebros post-mortem de pacientes psiquiátricos e sobre as conseqüências moleculares e funcionais de perturbações no sono, comumente associadas a transtornos psiquiátricos.

Effects of sleep deprivation on neural functioning: an integrative review

Sleep deprivation has a broad variety of effects on human performance and neural functioning that manifest themselves at different levels of description. On a macroscopic level, sleep deprivation mainly affects executive functions, especially in novel tasks. Macroscopic and mesoscopic effects of sleep deprivation on brain activity include reduced cortical responsiveness to incoming stimuli, reflecting reduced attention. On a microscopic level, sleep deprivation is associated with increased levels of adenosine, a neuromodulator that has a general inhibitory effect on neural activity. The inhibition of cholinergic nuclei appears particularly relevant, as the associated decrease in cortical acetylcholine seems to cause effects of sleep deprivation on macroscopic brain activity. In general, however, the relationships between the neural effects of sleep deprivation across observation scales are poorly understood and uncovering these relationships should be a primary target in future research.

Post-call cognitive function and satisfaction in medical students on different call schedules: a prospective observational pilot study

OBJECTIVE

The purpose of this study was to evaluate the effects of 2 different call schedules on post-call cognitive function and satisfaction.

STUDY DESIGN

This is a prospective observational pilot study of 20 third-year medical students. A computerized cognitive function test was administered to students with call every fourth night or a week of 12-hour "night float" shifts. Questionnaires were completed to assess satisfaction on different call schedules.

RESULTS

There was no significant difference in cognitive functioning scores for students on either call schedule. Responses on questionnaires indicate that night float allows students to feel more alert for clinical duties (P = .03).

CONCLUSION

There is no significant impact of sleep deprivation on cognitive scores; however, night float allows students to feel subjectively more alert for clinical duties.

Altered sleep/wake patterns and mental performance

Altered sleep/wake patterns involve, by definition, displaced sleep. The present review concludes that mental performance is strongly influenced by many forms of displaced sleep. Being exposed to the circadian low (during work/activity), extended time awake or reduced duration of sleep will impair performance. The effect is most pronounced in the laboratory setting, however, even if a number of studies have shown effects of for example night work on neuropsychological tests, and simulated work. In real shift work situations performance changes have been less pronounced. No studies have evaluated the effects on production, but accidents and serious mistakes have been clearly established in road transport and there seems to be clear effects also in health care. The effects are similar in connection with flights across several time zones (jet lag) but less data are available. It is suggested that there is a need for establishing the significance of impaired performance due to work hours in white collar and service work. Also the notion of individual differences in performance impairment is an important issue.

Possible broad impacts of long work hours

The paper summarizes research linking long work hours to a wide range of risks to workers, families, employers, and the community. The risks are theorized to stem from less time to recover from work, longer exposure to workplace hazards, and less time to attend to non-work responsibilities. Risks to workers include sleep deprivation, poor recovery from work, decrements in neuro-cognitive and physiological functioning, illnesses, adverse reproductive outcomes, and injuries. Risks to families include delayed marriages and child bearing, and obesity in children. Risks to employers include reduced productivity and increases in workers errors. Mistakes by fatigued workers have broad reaching impacts to the community: medical errors, automobile crashes with other drivers on the road, and industrial disasters that damage the environment.

Introduction of a 14-hour work shift model for housestaff in the medical ICU

STUDY OBJECTIVE

To describe the outcomes of switching housestaff from a traditional model of "long-call" every 4 days to a 14-h work-shift model in a medical ICU (MICU) over a 5-week pilot period.

DESIGN

Retrospective comparison of a 5-week pilot period for a 14-h work-shift model vs a 4-month period for the traditional model.

SETTING

The MICU of a tertiary medical center.

PARTICIPANTS

A total of 626 patients admitted to the MICU and 34 internal medicine residents taking care of them.

INTERVENTIONS

None.

MEASUREMENTS

Severity-adjusted patient outcomes, housestaff performance on end-of-rotation examinations, and scheduled duty hours during the 5-week 14-h work-shift pilot period compared to a 16-week traditional nonpilot work period.

RESULTS

There were no statistically significant differences in patients' adjusted mortality rates, hospital lengths of stay, or housestaff performance on end-of-rotation knowledge assessment examinations between the pilot and nonpilot periods. During the pilot period, each resident was scheduled to work for an average of 61.3 h weekly, and each fellow for 65.3 h weekly. In comparison, each resident and fellow was scheduled to work for an average of 73.3 h weekly during the nonpilot period.

CONCLUSIONS

The 14-h work shift is a feasible option for housestaff rotation in the MICU. Although the power of our study to detect significant differences in mortality, length of stay, and educational outcomes was low, there was no evidence of compromised patient care or housestaff education associated with the 14-h shift model over the course of this 5-week pilot study.

Sleep deprivation does not affect operative results in cardiac surgery

BACKGROUND

There has been an increasing trend towards the mandatory reduction in work hours for physicians because of the fear that sleep-deprived (SD) surgeons are more prone to make mistakes. We hypothesized that sleep deprivation would not be associated with increased morbidity or mortality in cardiac operations.

METHODS

A retrospective review was done of all cases performed by all attending cardiac surgeons from January 1994 to April 2003. Complication rates of cases performed by SD surgeons were compared with cases done when the surgeons were not sleep-deprived (NSD). A surgeon was deemed sleep deprived if he or she performed a case the previous evening that started between 10:00 pm and 5:00 am, or ended between the hours of 11:00 pm and 7:30 am.

RESULTS

A total of 6,751 cases were recorded in the Society of Thoracic Surgeons database over the 9-year period examined. Of these, 339 cases (5%) were performed by SD surgeons, and 6,412 (95%) cases were performed by NSD surgeons. Mortality rates for coronary artery bypass operations showed no significant differences (1.7% [SD = 4/223] vs 3.1% [NSD = 133/4206)] p = 0.34). Operative (p = 0.47), pulmonary (p = 0.60), renal (p = 0.93), neurologic (p = 0.11), and infectious (p = 0.87) complications of all cases also failed to show any statistically significant differences in any group. Perfusion times, cross-clamp times, and the use of blood products were also similar between groups.

CONCLUSIONS

Sleep deprivation does not affect operative morbidity or mortality in cardiac surgical operations. These data do not support a need for work hour restrictions on surgeons.

Acute Sleep Deprivation in the Thoracic Surgical Resident Does Not Affect Operative Outcomes

BACKGROUND

There is an increasing trend toward work hour restrictions for doctors world wide. These reforms have been inspired, in part, by the assertion by some that the fatigued physician is more prone to making errors. Interestingly, there is very little in the way of objective data with regard to the effects of sleep deprivation on patient outcomes. We have recently studied this in attending surgeons. The present study focused on thoracic surgical residents. Our hypothesis was that acute sleep deprivation would not lead to an increase in operative times or complications.

METHODS

A retrospective review of all cases performed by thoracic surgical residents at the University of Virginia from January 1994 to March of 2004 was done. Complication rates of cases performed by "sleep deprived" (SD) residents were compared with cases done when the residents were "not sleep deprived" (NSD). A resident was deemed sleep deprived if he or she performed a case the previous evening that started between 10 pm and 5 am or ended between the hours of 11 pm and 7:30 am.

RESULTS

A total of 7,323 cases were recorded in the STS database over the 10-year period examined. Two hundred and twenty-nine of these cases (3%) were performed by SD residents. Mortality rates for coronary artery bypass operations showed no significant differences (2.1% [SD = 3 of 141 patients] vs 3.1% (NSD = 143 of 4452 patients), p = 0.63). A comparison of operative, neurologic, renal, infectious, and pulmonary complications as well as cardiopulmonary bypass times, cross-clamp times, the use of blood products, and length of stay also demonstrated no significant differences between groups.

CONCLUSIONS

Acute sleep deprivation in thoracic surgical residents does not affect operative efficiency, morbidity, or mortality in cardiac surgical operations.

Balancing continuity of care with residents' limited work hours: defining the implications

The impact of the new resident work-hours rules on all aspects of patient care and education must be considered. While physician fatigue has taken center stage as the primary motivation behind this movement, the effect of these rules on the continuity of care for hospitalized patients needs to be critically analyzed from the perspectives of patients, physicians, and the health care system. The authors describe a conceptual framework that places continuity at the center and then considers the benefits and drawbacks of preserving continuity from the perspectives of the major stakeholders. They describe the categories of outcomes related to residents' fatigue and sleep deprivation that have been studied. Only a few studies have addressed patient outcomes, while most address resident outcomes. The authors discuss some of the possible solutions, including night float and the British system of shift work, and suggest that these solutions have different effects on each group of stakeholders, including both intended and unintended benefits and harms. Finally, the research agenda that arises from this framework is described. It includes taking into account multiple perspectives, identifying important outcomes, and considering unintended consequences. Using this framework, medical educators may better evaluate previous studies and consider remaining questions.

The impact of sustained wakefulness and time-of-day on OSPAT performance

Fatigue associated with shiftwork is a key contributor to human error in the workplace. One way to prevent fatigue-related errors from occurring is to identify fatigue in employees using fitness-for-duty measures. The Occupational Safety Performance Assessment Test (OSPAT), an unpredictable tracking task that measures hand-eye coordination, is currently being used as a fitness-for-duty measure in a variety of industries, but has not yet been validated as a test sensitive to the effects of fatigue. Consequently, the aim of this study was to systematically examine the impact of sustained wakefulness and time-of-day on OSPAT performance. Twenty individuals (10 male, 10 female), aged between 18-25 yr (M=20.90, SD=2.29) participated in the study, which was conducted in Australia. The study had a repeated measures design, whereby participants completed the OSPAT and measures of sustained attention (i.e., the psychomotor vigilance task: PVT), and subjective alertness (i.e., the Visual Analog Scale: VAS) every 2 h during 24 h of sustained wakefulness, beginning at 07:00 h. Results revealed that VAS ratings of alertness, PVT performance, and OSPAT performance declined significantly as hours of wakefulness increased during the night-time (all p<.01). Furthermore, a positive correlation between OSPAT and PVT performance was observed (r=0.40, p<.01). Overall, these findings suggest that OSPAT is sensitive to sustained wakefulness during the night-time, and builds the case for OSPAT being a suitable measure for determining fitness-for-duty in workplace environments.