A rational approach to shift work in emergency medicine

Psychosocial working conditions and violence prevention climate in German emergency departments - a cross-sectional study

BACKGROUND

Emergency departments (EDs) are high pressure work environments with several psychosocial job demands, e.g., violence, and job resources, e.g., colleague support. So far, the perceptions of working conditions have been compared between doctors and nurses, but there is limited knowledge regarding their respective supervisors. In addition, the violence prevention climate has not been assessed in German EDs before. Thus, the current study focuses on differences in the perceptions of working conditions and the violence prevention climate between the groups of doctor-supervisors, doctor-employees, nurse-supervisors, and nurse-employees within the ED. Further analyses regarding the association between social relations and pressure for unsafe practices are performed, including the moderating role of belonging to one of the aforementioned groups.

METHODS

A cross-sectional online survey was carried out among N = 370 participants, who were doctors or nurses from German EDs. The Questionnaire for Psychosocial Risk Assessment (QPRA) and the Violence Prevention Climate Scale (VPCS) were applied. Kruskal-Wallis tests were performed for group comparisons, followed by a hierarchical multiple linear regression model and moderation analyses.

RESULTS

Statistically significant differences between the groups were found for eight out of 13 variables. The highest number of significant pairwise comparisons was found between the groups of doctor-supervisors and nurse-employees. High job demands regarding work intensity and work interruptions became apparent across all groups. Nurse-employees reported the highest social and emotional demands as well as the highest pressure for unsafe practices regarding violence prevention, significantly differing from the other groups on these variables. The variables of supervisor support and social stressors were found to be significantly predictive of pressure for unsafe practices. Furthermore, there was no moderating effect of belonging to one of the above-mentioned groups in the relationships between variables of social relations and pressure for unsafe practices.

CONCLUSIONS

Differences found in the current study can help tailor preventive measures according to the needs of distinct professions and positions in order to improve working conditions and the violence prevention climate in EDs. Furthermore, supervisor support should be strengthened while social stressors should be resolved in order to decrease pressure for unsafe practices regarding violence prevention.

Does Long-Term Shift Work Increase the Risk of Dementia? A Systematic Review and Meta-Analysis

Background: Shift work is associated with impaired sleep quality and disrupted circadian rhythms, but the way in which it increases the risk of dementia remains controversial. We conducted a systematic review and meta-analysis to assess the integrated risk of dementia with shift work. Methods: Searching in PubMed, Cochrane Library, and the Web of Science databases, the relative risks of dementia with shift work were extracted from 12 included studies with 3975 dementia cases from 84 492 participants. The subgroup analysis was stratified by age, gender, sample size, dementia cases, shift schedule, occupation, and follow-up time. Heterogeneity analysis and publication bias analysis were conducted for quality control. Results: The pooled risk ratios (RRs) of dementia with shift work were 1.15 (95%CI = 1.02-1.30). The subgroup analysis found that continuous evening shifts reversibly reduced the risk, but continuous night shifts remarkedly increased the risk of dementia. In addition, a larger cohort and longer follow-up significantly increased the risk of dementia with shift work. Conclusion: Shift work shows mild increases in the risk of dementia using meta-analysis.

Chrononutrition in the management of diabetes

Circadian rhythms are 24-h cycles regulated by endogeneous molecular oscillators called the circadian clock. The effects of diet on circadian rhythmicity clearly involves a relationship between factors such as meal timings and nutrients, known as chrononutrition. Chrononutrition is influenced by an individual's "chronotype", whereby "evening chronotypes" or also termed "later chronotype" who are biologically driven to consume foods later in the day. Research in this area has suggested that time of day is indicative of having an influence on the postprandial glucose response to a meal, therefore having a major effect on type 2 diabetes. Cross-sectional and experimental studies have shown the benefits of consuming meals early in the day than in the evening on postprandial glycaemia. Modifying the macronutrient composition of night meals, by increasing protein and fat content, has shown to be a simple strategy to improve postprandial glycaemia. Low glycaemic index (GI) foods eaten in the morning improves glycaemic response to a greater effect than when consumed at night. Timing of fat and protein (including amino acids) co-ingested with carbohydrate foods, such as bread and rice, can reduce glycaemic response. The order of food presentation also has considerable potential in reducing postprandial blood glucose (consuming vegetables first, followed by meat and then lastly rice). These practical recommendations could be considered as strategies to improve glycaemic control, rather than focusing on the nutritional value of a meal alone, to optimize dietary patterns of diabetics. It is necessary to further elucidate this fascinating area of research to understand the circadian system and its implications on nutrition that may ultimately reduce the burden of type 2 diabetes.

Bad manners in the Emergency Department: Incivility among doctors

Introduction

Negative workplace behaviour, especially negative communication is a recognised problem in many organisations and is known to have serious impact on workplace performance, productivity and personal wellbeing. Emergency Departments (ED) can be high stress environments in which communication and perceptions of respect between physicians and other staff may underlie individual functioning. We conducted a study to estimate the influence of incivility (ICV) among physicians in the ED.

Methods

We developed an online survey to assess workplace incivility in the ED. We focussed on frequency, origin, reasons and situations where ICV was reported. To measure the levels and the potential influence of ICV on psychological safety, social stress and personal wellbeing we correlated our questionnaire to standard psychological scales. Statistical analysis included Students t-test, chi squared distribution and Pearson correlation coefficient.

Results

We invited all seventy-seven ED physicians to participate in our survey. Among those that completed (n = 50, 65%) the survey, 9% of ED physicians reported frequent (1/week) and 38% occasional (1/month) incidents of ICV. 28% of physicians reported experiencing ICV once per quarter and 21% reported a frequency of only once per year, no physician reported ICV on a daily basis. Levels of ICV were significantly higher in interactions with specialists from outside then within the ED (p<0.01).

ICV was perceived particularly during critical situations. Our findings showed a significant correlation between internal (within the ED team) ICV and psychological safety. To ED physicians internal ICV was associated with lower levels of psychological safety (p<0.01). ICV displayed from sources outside the ED team was not associated with psychological safety, but we found a significant influence of external ICV on personal irritability and reduced wellbeing (p<0.01).

Discussion

The incidence of incivility was high among the ED physicians. Although this was a small sample, the association between workplace ICV and psychological safety, personal irritation as well personal comfort suggests that ICV may be an important variable underlying ED team performance. These findings further underscore the need to foster a culture of respect and good communication between departments, as levels of ICV were highest with physicians from outside the ED. Future research would benefit from examining strategies to prevent and reduce ICV and identify reasons for personal variation in perception of ICV. During critical situations and in general collaboration with specialists, awareness of ICV and countermeasures are important to avoid decreased performance and negative impact on staff and patient.

Secondary traumatic stress in emergency medicine clinicians

Previously called Secondary Traumatic Stress (STS), secondary exposure to trauma is now considered a valid DSM-5 Criterion A stressor for posttraumatic stress disorder (PTSD). Previous studies have found high rates of STS in clinicians who treat traumatically injured patients. However, little research has examined STS among Emergency Medicine (EM) physicians and advanced practice providers (APPs). The current study enrolled EM providers (N = 118) working in one of 10 hospitals to examine risk factors, protective factors, and the prevalence of STS in this understudied population. Most of the participants were physicians (72.9%), Caucasian (85.6%), and male (70.3%) with mean age of 39.7 (SD = 8.9). Overall, 12.7% of the sample screened positive for STS with clinical levels of intrusion, arousal, and avoidance symptom clusters, and 33.9% had at least one symptom cluster at clinical levels. Low resilience and a history of personal trauma were positively associated with positive STS screens and STS severity scores. Borderline significance suggested that female gender and spending ≥10% of one's time with trauma patients could be additional risk factors. Findings suggest that resilience-building interventions may be beneficial.

Scheduling in the context of resident duty hour reform

Fuelled by concerns about resident health and patient safety, there is a general trend in many jurisdictions toward limiting the maximum duration of consecutive work to between 14 and 16 hours. The goal of this article is to assist institutions and residency programs to make a smooth transition from the previous 24- to 36-hour call system to this new model. We will first give an overview of the main types of coverage systems and their relative merits when considering various aspects of patient care and resident pedagogy. We will then suggest a practical step-by-step approach to designing, implementing, and monitoring a scheduling system centred on clinical and educational needs in the context of resident duty hour reform. The importance of understanding the impetus for change and of assessing the need for overall workflow restructuring will be explored throughout this process. Finally, as a practical example, we will describe a large, university-based teaching hospital network's transition from a traditional call-based system to a novel schedule that incorporates the new 16-hour duty limit.

Urinary interleukin-8 is a biomarker of stress in emergency physicians, especially with advancing age--the JOBSTRESS* randomized trial

Background

Emergency physicians are exposed to greater stress during a 24-hour shift (24 hS) than a 14-hour night shift (14 hS), with an impact lasting several days. Interleukin-8 (IL-8) is postulated to be a chronic stress biomarker. However, no studies have tracked IL-8 over several shifts or used it for monitoring short-term residual stress. The IL-8 response to the shifts may also increase with age. Conveniently, IL-8 can be measured non-intrusively from urine.

Methods

We conducted a shifts-randomized trial comparing 17 emergency physicians’ urinary IL-8 levels during a 24 hS, a 14 hS, and a control day (clerical work on return from leave). Mean levels of IL-8 were compared using a Wilcoxon matched-pairs test. Independent associations of key factors including shifts, stress, and age with IL-8 levels were further assessed in a multivariable generalized estimating equations model.

Results

Mean urinary IL-8 levels almost doubled during and after a 24 hS compared with a 14 hS or a control day. Furthermore, IL-8 levels failed to return to control values at the end of the third day after the shift despite a rest day following the 24 hS. In the multivariable model, engaging in a 24 hS, self-reported stress, and age were independently associated with higher IL-8 levels. A 24 hS significantly increased IL-8 levels by 1.9 ng (p = .007). Similarly, for every unit increase in self-reported stress, there was a 0.11 ng increase in IL-8 levels (p = .003); and for every one year advance in age of physicians, IL-8 levels also increased by 0.11 ng (p = .018).

Conclusion

The 24 hS generated a prolonged response of the immune system. Urinary IL-8 was a strong biomarker of stress under intensive and prolonged demands, both acutely and over time. Because elevated IL-8 levels are associated with cardiovascular disease and negative psychological consequences, we suggest that emergency physicians limit their exposure to 24 hS, especially with advancing age.

Trial of shift scheduling with standardized sign-out to improve continuity of care in intensive care units

BACKGROUND

Since 2003, the Accreditation Council for Graduate Medical Education requires residency programs to restrict to 80 hrs/wk, averaged over 4 wks to improve patient safety. These restrictions force training programs with night call responsibilities to either maintain a traditional program with alternative night float schedules or adopt a "shift" model, both with increased handoffs.

OBJECTIVE

To assess whether a 65 hrs/wk shift-work schedule combined with structured sign-out curriculum is equivalent to a 65 hrs/wk traditional day coverage with night call schedule, as measured by multiple assessments.

DESIGN

Eight-month trial of shift-work schedule with structured sign-out curriculum (intervention) vs. traditional call schedule without curriculum (control) in alternating 1-2 month periods.

SETTING

A mixed medical-surgical intensive care unit at a tertiary care academic center.

SUBJECTS

Primary subjects: 19 fellows in a Multidisciplinary Critical Care Training Program; Secondary subjects: intensive care unit nurses and attending physicians, families of intensive care unit patients.

INTERVENTIONS

Implementation of shift-work schedule, combined with structured sign-out curriculum.

MEASUREMENTS

Workplace perception assessment through Continuity of Care Survey evaluation by faculty, fellows, and nurses through structured surveys; family assessment by the Critical Care Family Needs Index survey; clinical assessment through intensive care unit mortality, intensive care unit length of stay, and intensive care unit readmission within 48 hrs; and educational impact assessment by rate of fellow didactic lecture attendance.

MAIN RESULTS

There were no statistically significant differences in surveyed perceptions of continuity of care, intensive care unit mortality (8.5% vs. 6.0%, p = .20), lecture attendance (43% vs. 42%), or family satisfaction (Critical Care Family Needs Index score 24 vs. 22) between control and intervention periods. There was a significant decrease in intensive care unit length of stay (8.4 vs. 5.7 days, p = .04) with the shift model. Readmissions within 48 hrs were not different (3.6% vs. 4.9%, p = .39). Nurses preferred the intervention period (7% control vs. 73% intervention, n = 30, p = .00), and attending faculty preferred the intervention period and felt continuity of care was maintained (15% control vs. 54% intervention, n = 11, p = .15).

CONCLUSIONS

A shift-work schedule with structured sign-out curriculum is a viable alternative to traditional work schedules for the intensive care unit in training programs.

Shiftwork and emergency medical practice

Shiftwork has numerous negative effects on workers, but it is an essential component of the demanding 24/7 practice of emergency medicine. We conducted a systematic literature review to characterize the effects of shiftwork on physician health, well-being and practice, and to describe rational strategies to mitigate its impact on Canadian emergency physicians.

Effect of working consecutive night shifts on sleep time, prior wakefulness, perceived levels of fatigue and performance on a psychometric test in emergency registrars

OBJECTIVE

To evaluate the effect of working consecutive night shifts on sleep time, prior wakefulness, perceived levels of fatigue and psychomotor performance in a group of Australian emergency registrars.

METHODS

A prospective observational study with a repeated within-subjects component was conducted. Sleep time was determined using sleep diaries and activity monitors. Subjective fatigue levels and reciprocal reaction times were evaluated before and after day and night shifts.

RESULTS

A total of 11 registrars participated in the study with 120 shifts analysed. Sleep time was found to be similar during consecutive night and day shifts. The mean number of hours spent awake before the end of a night shift was 14.33. Subjective fatigue scores were worst at the end of a night shift. There was no difference in reciprocal reaction time between the end of night shift and the start of day shift.

CONCLUSIONS

Registrars sleep a similar amount of time surrounding night and day shifts. Despite reporting the highest levels of fatigue at the end of a night shift, there is no significant difference in reaction times at the end of night shift compared with the beginning of day shift. This correlates with the finding that at the end of night shift the registrars have been awake for less than 16 h, which is the point at which psychomotor performance is expected to decline.

Strategies for coping with stress in emergency medicine: Early education is vital

INTRODUCTION

Physician burnout has received considerable attention in the literature and impacts a large number of emergency medicine physicians, but there is no standardized curriculum for wellness in resident education. A culture change is needed to educate about wellness, adopt a preventative and proactive approach, and focus on resiliency.

DISCUSSION

We describe a novel approach to wellness education by focusing on resiliency rather than the unintended endpoint of physician burnout. One barrier to adoption of wellness education has been establishing legitimacy among emergency medicine (EM) residents and educators. We discuss a change in the language of wellness education and provide several specific topics to facilitate the incorporation of these topics in resident education.

CONCLUSION

Wellness education and a culture of training that promotes well-being will benefit EM residents. Demonstrating the impact of several factors that positively affect emergency physicians may help to facilitate alert residents to the importance of practicing activities that will result in wellness. A change in culture and focus on resiliency is needed to adequately address and optimize physician self-care.

Obesity and shift work: chronobiological aspects

The present review has the objective of summarising chronobiological aspects of shift work and obesity. There was a systematic search in PubMed databases, using the following descriptors: shift work; obesity; biological clock. Shift work is extremely frequent in several services and industries, in order to systematise the needs for flexibility of the workforce, necessary to optimise productivity and business competitiveness. In developing countries, this population represents a considerable contingent workforce. Recently, studies showed that overweight and obesity are more prevalent in shift workers than day workers. In addition, the literature shows that shift workers seem to gain weight more often than those workers submitted to a usual work day. In conclusion, there is considerable epidemiological evidence that shift work is associated with increased risk for obesity, diabetes and CVD, perhaps as a result of physiological maladaptation to chronically sleeping and eating at abnormal circadian times. The impact of shift work on metabolism supports a possible pathway to the development of obesity and its co-morbities. The present review demonstrated the adverse cardiometabolic implications of circadian misalignment, as occurs chronically with shift workers.

Optimal shift duration and sequence: recommended approach for short-term emergency response activations for public health and emergency management

Since September 11, 2001, and the consequent restructuring of the US preparedness and response activities, public health workers are increasingly called on to activate a temporary round-the-clock staffing schedule. These workers may have to make key decisions that could significantly impact the health and safety of the public. The unique physiological demands of rotational shift work and night shift work have the potential to negatively impact decisionmaking ability. A responsible, evidence-based approach to scheduling applies the principles of circadian physiology, as well as unique individual physiologies and preferences. Optimal scheduling would use a clockwise (morning-afternoon-night) rotational schedule: limiting night shifts to blocks of 3, limiting shift duration to 8 hours, and allowing 3 days of recuperation after night shifts.

Sleep loss and fatigue in healthcare professionals

Sleep loss and impairments related to resultant fatigue are common among professionals working in healthcare settings. Long continuous duty hours, reduced opportunities for sleep with minimal recuperation time, and shift work all contribute significantly to impairments in physical, cognitive, and emotional functioning. Detrimental effects include those on personal health and well-being, patient health and safety, performance of job-related tasks, and professionalism. Many challenges exist to implementing effective personal and systemwide strategies to manage the impact of sleep loss. Therefore, adopting fatigue management strategies that have been successful in other occupational settings and developing specific interventions that are appropriate for the hospital setting are key. The following review outlines the causes and consequences of sleep loss and fatigue in healthcare professionals, and provides an empirically based framework for developing strategies to recognize, address, and manage sleep loss and fatigue.

The rhythm of rest and excess

There is a stark contrast between our attitudes to sleep and those of the pre-industrial age. In Shakespeare's Julius Caesar we are told to "Enjoy the honey-heavy dew of slumber". There seems little chance of this today, as we crave more, work more and expect more, and, in the process, abandon sleep. Our occupation of the night is having unanticipated costs for both our physical and mental health, which, if continued, might condemn whole sectors of our society to a dismal future.

The effects of consecutive night shifts on neuropsychological performance of interns in the emergency department: a pilot study

STUDY OBJECTIVE

We obtain preliminary information on the neuropsychological performance of house officers at the beginning and end of a shift while they worked consecutive night shifts in the emergency department.

METHODS

We prospectively studied interns working 12-hour consecutive night shifts in an urban Level I trauma center ED. All consecutive non-emergency medicine interns rotating for 1 month were eligible except those older than 40 years and those with sleep disorders or depression (identified by using the Profile of Mood Scale, Sleep Diagnostic Questionnaire). We tested research subjects at the beginning of a day shift and at the beginning and end of night shifts 1 and 3 of 4 consecutive night shifts at times of estimated baseline wakefulness (10 PM) and maximum fatigue (3 AM). We used 3 standardized neuropsychological tests: (1) Delayed Recognition Span Test (visual memory capacity); (2) Continuous Performance Test (attentional function, vigilance); and (3) Santa Ana Form Board Test (psychomotor speed, coordination). We analyzed data with mixed-model analysis, with research subject as a random effect.

RESULTS

Thirteen interns were eligible, and 1 declined. Twelve interns (6 men and 6 women; age range 25 to 35 years) were enrolled. The Delayed Recognition Span Test (number correct before first error) revealed significant deterioration from the beginning of the shift to the end of the shift (mean difference -2.2; 95% confidence interval -3.1 to -1.3). This represents an 18.5% decrease in visual memory capacity. There were no significant differences found for the other tests.

CONCLUSION

Interns working nights demonstrated a significant reduction in visual memory capacity across the night shift. Research involving neuropsychological performance during night shifts in the ED is important. It might provide valuable insights into ways to improve our performance during night shifts.

How healthy are our emergency departments?

OBJECTIVE

To demonstrate a comprehensive workplace health survey is able to identify indicators that contribute to staff workplace welfare.

METHODS

Analysis of a VicHealth workplace health survey distributed to seven suburban emergency departments. Respondents rated multiple workplace health indicators in terms of perceived importance and perceived performance. A satisfaction rating and performance gap for each indicator was calculated.

RESULTS

There was a 64% response rate to 500 surveys. Staff rated a safe environment, professional standards, and staff morale the most important factors for workplace health. They were most satisfied with the flexibility of work arrangements (85.6%) and leadership (79.9%), and were least satisfied with the performance management of staff (68.5%) and job satisfaction and morale (67.2%). The largest gaps between perceived importance and performance were in the provision of safe well-lit parking, staff morale, and the use of reward and recognition systems.

CONCLUSION

The VicHealth survey was an effective tool in identifying indicators that contribute to staff workplace health. Quantifiable findings allowed interdepartmental comparison and may be useful in focusing on improvements in organizational structure.

Sleep loss and fatigue in medical training

The effects of sleep loss and fatigue in the context of medical training is a topic that has generated considerable interest, as well as controversy, over the past two decades. The sleep deprived state in medical trainees potentially impacts on a variety of domains relevant to medical care, including performance on neurobehavioral and work-related tasks, mood and affect, learning, risk for and commission of medical errors, and the health and well-being of medical students and residents. The following review provides a summary of research conducted on this topic in the past decade, including the relation of sleep loss and fatigue to medical errors and the quality of patient care. Those few studies that have analyzed the use of operational alertness management strategies, countermeasures, and educational interventions to address and mitigate the effects of sleep loss and fatigue are also reviewed. There is clearly a need for additional research to further explore the complex interaction between sleep and fatigue and medical care, and to support the development and implementation of regulatory policies based on sound science.

Circadian rhythm, shift work, and emergency medicine

Human beings, like other living organisms, have physiologic systems that are cyclic in nature. Many of these systems have a circadian length. This provides for internal stability while at the same time enabling the organism to interact with the external environment and respond to changes in that environment. These physiologic systems, including those with a circadian length, can change timing as a result of environmental cues, such as the light-dark cycle or seasonal variations, but this takes time. When people engage in rotating or night shift work, the circadian rhythms are unable to quickly adapt to a rapidly changing activity schedule. This results in desynchronosis of many physiologic systems, including those with circadian timing. Because many emergency physicians engage in shift work, they are subject to the effects of circadian rhythm disruption. Research on the effect of desynchronosis on emergency physicians is sparse but has demonstrated negative effects. This article reviews the effect of desynchronosis on the health and productivity of physicians engaged in shift work.

Promoting patient safety and preventing medical error in emergency departments

An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are, individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system-level efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the likelihood of reduction of error in EM practice.

Emergency medicine residents' shiftwork tolerance and preference

OBJECTIVES

To determine the shift lengths currently worked by emergency medicine (EM) residents and their shift length preferences, and to determine factors associated with EM residents' subjective tolerance of shiftwork.

METHODS

A survey was sent to EM-2 through EM-4 allopathic EM residents in May 1996. This questionnaire assessed the residents' shift length worked, shift length preferences, night shift schedules, and self-reported ability to overcome drowsiness, sleep flexibility, and morningness-eveningness tendencies. When providing shift length preferences, the residents were asked to assume a constant total number of hours scheduled per month.

RESULTS

Seventy-eight programs participated, and 62% of 1,554 eligible residents returned usable surveys. Current shift lengths worked were 8 hours (12%), 10 hours (13%), 12 hours (37%), combinations of 8-hour, 10-hour, or 12-hour (34%) shifts, and other combinations (4%). Seventy-three percent of the respondents indicated that they preferred to work 8-hour or 10-hour shifts, and only 21% preferred a 12-hour shift. Shiftwork tolerance was recorded as: not well at all (2%), not very well (14%), fairly well (70%), and very well (14%). The EM residents' eveningness preference, ability to overcome drowsiness, sleep flexibility, younger age, and having no children at home were all associated with greater shiftwork tolerance.

CONCLUSIONS

Emergency medicine residents generally tolerate shiftwork well and prefer 8-hour or 10-hour shift lengths compared with 12-hour shift lengths. Emergency medicine residencies with 12-hour shifts should consider changing residents' shifts to shorter shifts.

The occupational hazards of emergency physicians

Emergency physicians are exposed to a variety of occupational hazards. Among these are infectious diseases, such the human immunodeficiency virus, hepatitis B and C viruses, and tuberculosis. Hepatitis G virus is transmissible but may not be a cause of illness. The likelihood of being exposed to these agents appears to be higher in the ED than other medical settings but estimates of the prevalence of these diseases in the ED vary, depending on the patient population served. Estimates of risk for contracting these infections are reviewed. Measures to prevent these exposures can reduce risk, but compliance is low, particularly for those involving changes in the behavior of emergency physicians (such as not recapping needles). Latex allergy is a hazard of health care workers. Its prevalence is reported to be quite high, but these findings are difficult to interpret in the absence of a universally accepted definition of the condition. Its prevalence in emergency physicians is not known. Other noninfectious hazards include workplace violence and exposure to nitrous oxide. The health effects of rotating shift work may put emergency physicians at increased risk of coronary artery disease and impaired reproductive health. Emotional stress is another hazard of emergency physicians, and may lead to burnout.

Randomized clinical trial of melatonin after night-shift work: efficacy and neuropsychologic effects

OBJECTIVE

Melatonin has received considerable publicity for its sleep-promoting properties; however, there is little scientific evidence of its efficacy. The objective of this study is to determine whether there are measurable beneficial effects from exogenous melatonin in emergency physicians after intermittent night-shift duty.

METHODS

This randomized, placebo-controlled, double-blind, crossover trial was conducted in the emergency department of an urban tertiary care hospital. Fifteen emergency physicians were given melatonin 5 mg or placebo for 3 consecutive nights after night-shift duty with crossover to the opposite agent after a subsequent block of night shifts. The primary outcome measure was the global assessment of recovery measured by a visual analog scale. Secondary outcome measures included sleep quality, duration, and tiredness. In addition, the Profile of Mood States questionnaire and neuropsychologic testing were performed.

RESULTS

There was no difference between melatonin and placebo in the global assessment of recovery (60.4+/-16.9 and 58.9+/-14.5, respectively; P=.29). There were no differences in sleep quality, duration or tiredness scores, sleep latency, hours of sleep obtained per night, and night or early awakening at any measurement point. Profile of Mood States and neuropsychologic test performances were similar.

CONCLUSION

We found no beneficial effect of melatonin on sleep quality, tiredness, or cognitive function in emergency physicians after night-shift duty. Our results suggest that exogenous melatonin is of limited value in recovery from night-shift work in emergency physicians.

Ambulatory blood pressure and Holter monitoring of emergency physicians before, during, and after a night shift

BACKGROUND

Occupational stress may affect measured hemodynamic and electrocardiographic variables. Data describing the physiologic effects of work on the emergency physician (EP) are sparse.

OBJECTIVE

To determine whether blood pressure (BP) and heart rate variability (HRV) of the EP are affected during a night shift in the ED.

METHODS

This prospective study evaluated BP and HRV in attending EPs at an urban academic medical center for a 24-hour period during which a night shift was scheduled. Participants were fitted with an oscillometric ambulatory BP device and a Holter monitor at 1500 hours on the day of a night shift. The monitors were worn continuously before, during, and after a night shift (2300-0700) in the ED and were removed at 1500. Systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), heart rate (HR), measures of HRV, and occurrence of cardiac dysrhythmias were evaluated. Comparisons were made for ED and non-ED awake periods and non-ED sleep periods.

RESULTS

Twelve participants completed the study. Eight (67%) subjects were men and 4 (33%) were women. Age ranged from 28 to 40 years (mean 34.1+/-4.1). Results were analyzed using repeated-measures ANOVA. An elevation of mean DBP (5.5 mm Hg+/-4.37; p < 0.05; 95% CI 1-10) during night shift activity was seen. A trend toward elevation of SBP, MAP, and HR was discernible. HRV measures indicated a significant relative increase in sympathetic vs parasympathetic tone and an increase in HR of prework and work compared with postwork. Dysrhythmias observed included sinus tachycardia, sinus bradycardia, sinus pause, atrial premature beats, atrial couplets and triplets, supraventricular tachycardia, and premature ventricular contractions.

CONCLUSIONS

The elevation of DBP during a night shift suggests that these patterns of BP variability are activity- or stress-related rather than a result of a true diurnal variation. HRV analysis suggests that sympathetic tone is heightened both before work and during work. The implications of such findings to the health of the EP warrant further investigation.

Can melatonin improve adaptation to night shift?

This study was undertaken to determine whether melatonin (N-acetyl-5 methoxytryptamine) is effective in helping emergency medical services (EMS) personnel who work rotating night shifts reset their biological clocks and minimize circadian rhythm disruption. A double-blinded, randomized, crossover study was performed using 22 volunteers. Participants were working a span of consecutive night (2300 to 0700 hours) shifts and received either a melatonin capsule (6 mg) or placebo to be taken before each of the consecutive day sleeps. Each participant completed a total of 4 spans of consecutive night shifts (2 melatonin, 2 placebo). Collected data included daily sleep diaries, quantification of alcohol/caffeine consumed, and drug side effects. Assessment of sleep quality, posttreatment mood, and workload ratings were measured daily by 10-cm visual analog scale (VAS). Analysis of sleep diaries found no significant difference (P > .05) between the two treatments with respect to mean sleep latency, duration, and efficiency, and subjectively rated sleep quality. Similarly, no significant benefits were noted between the median VAS scores for daily posttreatment mood or workload ratings. Adverse effects were rare; one patient taking melatonin reported a prolonged sedative effect. Despite recent interest in melatonin for treatment of circadian-based sleep disorders, no clinical benefits were noted in EMS personnel working rotating night shifts.

Does exogenous melatonin improve day sleep or night alertness in emergency physicians working night shifts?

STUDY OBJECTIVE

To determine whether exogenous melatonin improves day sleep or night alertness in emergency physicians working night shifts.

METHODS

In a double-blind, placebo-controlled crossover trial, emergency physicians were given 10 mg sublingual melatonin or placebo each morning during one string of nights and the other substance during another string of nights of equal duration. During day-sleep periods, subjective sleep data were recorded. During night shifts, alertness was assessed with the use of the Stanford Sleepiness Scale. Key outcome comparisons were visual analog scale scores for gestalt night alertness and for gestalt day sleep for the entire string of nights.

RESULTS

We analyzed data from 18 subjects. Melatonin improved gestalt day sleep (P = .3) and gestalt night alertness (P = .03) but in neither case was the improvement statistically significant. Of 13 secondary comparisons, 9 showed a benefit of melatonin over placebo; none showed a benefit of placebo over melatonin.

CONCLUSION

Exogenous melatonin may be of modest benefit to emergency physicians working night shifts.

The work of the American emergency physician

The organisation of the American emergency health care system has changed rapidly during recent years, but it remains very different to the system in the United Kingdom. American emergency departments are organised around an attending physician based service, rather than a consultant led service. As a result, the work of the American emergency physician differs considerably from that of the United Kingdom A&E consultant. The problems associated with working in an attending physician based service include antisocial hours of work, sleep deprivation, decreased job satisfaction, and "burn out," all in the context of a relatively hostile medicolegal climate. Although there appear to be no easy answers to some of these problems, the A&E specialist should be aware of the potential future difficulties for A&E medicine as it develops within the United Kingdom.

Rotating shiftwork schedules: can we enhance physician adaptation to night shifts?

OBJECTIVES

To evaluate the effectiveness of a broad, literature-based night shiftwork intervention for enhancement of emergency physicians' (EPs') adaptation to night rotations.

METHODS

A prospective, double-blind, active placebo-controlled study was conducted on 6 attending physicians in a university hospital ED. Three data sets were collected under the following conditions: baseline, after active placebo intervention, and after experimental intervention. In each condition, data were collected when the physicians worked both night and day shifts. Measurements included ambulatory polysomnographic recordings of the main sleep periods, objective performance tests administered several times during the subjects' shifts, and daily subjective ratings of the subjects' sleep, moods, and intervention use.

RESULTS

The subjects slept an average of 5 hr 42 min across all conditions. After night shifts, the subjects slept significantly less than they did after day shifts (5 hr 13 min vs 6 hr 20 min; p < 0.05). The physicians' vigilance reaction times and times for intubation of a mannequin were significantly slower during night shifts than they were during day shifts (p = 0.007 and p < 0.04, respectively), but performances on ECG analysis did not significantly differ between night and day shifts. Mood ratings were significantly more negative during night shifts than they were during day shifts (more sluggish p < 0.04, less motivated p < 0.03, and less clear thinking p < 0.04). The strategies in the experimental intervention were used 85% of the time according to logbook entries. The experimental and active placebo interventions did not significantly improve the physician's performance, or mood on the night shift, although the subjects slept more after both interventions.

CONCLUSIONS

Although the experimental intervention was successfully implemented, it failed to significantly improve attending physicians' sleep, performance, or mood on night shifts. A decrease in speed of intubation, vigilance reaction times, and subjective alertness was evident each time the physicians rotated through the night shift. These findings plus the limited sleep across all conditions and shifts suggest that circadian-mediated disruptions of waking neurobehavioral functions and sleep deprivation are problems in EPs.

Emergency medicine residency faculty scheduling: current practice and recent changes

STUDY OBJECTIVE

To assess current emergency medicine faculty scheduling practices, preferences, and recent changes.

DESIGN

Mail survey.

PARTICIPANTS

All emergency medicine residency program directors and full-time faculty.

INTERVENTIONS

Questions were asked about current faculty scheduling practices, preferences, and recent changes.

RESULTS

Eighty-five percent (79 of 93) of the programs and 63% (606 of 961) of the full-time faculty responded. Faculty most commonly worked a combination of 8- and 12-hour shifts. Seventy-five percent of full-time faculty stated that they would prefer to work 8-hour shifts. Eighty-three percent of those who work some or all 8-hour shifts preferred 8-hour shifts; 21% of those working 12-hour shifts preferred the same (P < .0005; test of proportions difference, 62%; 95% confidence interval, 55% to 69%). Over the past 5 years, 40% of programs had shortened shift lengths, and the number of night shifts worked per month and/or the number of nights in a row worked per faculty decreased for 34%.

CONCLUSION

Residency faculty prefer and have moved toward working shorter shifts. They are also working fewer night shifts per month and fewer night shifts in a row.

Resident service hours in emergency medicine. SAEM Education Committee

OBJECTIVE

The number of hours worked by residents in all specialties has become a controversial issue. Residents often are expected to competently conduct patient care activities and to take educational advantage of clinical experiences in spite of frequent fatigue and sleep deprivation. This survey of residency directors was designed to assess the scheduled clinical time for emergency medicine (EM) residents.

METHODS

A 13-question survey dealing with time commitments of EM residents was sent to the residency directors of all accredited EM residency programs in the United States in the fall of 1991. Residency directors were asked to indicate the number of shifts, hours, and days off per week; and the number of night shifts and weekend days off per month for each postgraduate year of residency training (PGY1-PGY4). Directors also were asked whether shifts were scheduled randomly or predictably with progression from days to nights with time off after nights.

RESULTS

Seventy of 71 (98.6% response rate) residency directors responded. Residents were scheduled for an average of 49.1 hours per week. Scheduled hours decreased from an average of 51.9 at the PGY1 level to an average of 44.5 at the PGY4 level. A similar progression with year of training was noted for scheduled night shifts/month, days off/week, and weekend days off/month. A PGY1 trainee averaged 7.0 night shifts/month, 1.9 days off/week, and 3.0 weekend days off/month; while a PGY4 trainee averaged 5.3, 2.4, and 3.2, respectively. Only 40% of the directors reported predictable scheduling progressing from days to nights.

CONCLUSION

Emergency medicine resident schedules, as reported by residency directors, fall well within current specialty-specific requirements and compare favorably with the reported numbers for other specialties. However, because large ranges in scheduling parameters were reported, the data may be of value to residency directors, residents, and prospective residents. Most programs did not report a predictable schedule progression of shifts.

Floating nights: a 5-year experience with an innovative ED schedule

An academic emergency group was surveyed to determine if scheduling night shifts in blocks ("floats") improved attitudes and functioning. Seven physicians worked most of their nights as floats. Another four chose only isolated nights. Float physicians were surveyed for isolated and block nights. Faculty in the float group had poorer attitudes compared with the nonfloat group when both worked isolated nights (P = .0053). Working night floats eliminated these differences. Float physicians had more difficulty with sleep regardless of their schedule. They took longer to recover from an isolated night shift, drank more coffee, and used more postcall sedatives than their colleagues (P = .0108). The ideal night float was 2 to 4 weeks with shifts less than 10 hours, but careful attention to sleep hygiene remained essential. Physicians have different adaptability to night work. For some, concentrating night shifts is a useful strategy for improving shift work. This would require shorter shifts and larger groups than are now commonplace.