Clinical performance of interns after being on call

Impact of extended duty hours on medical trainees

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

Sleep debt and outside employment patterns in helicopter air medical staff working 24-hour shifts

INTRODUCTION

Twenty-four hour availability creates physiological and psychological challenges for air medical teams. The 24-hour shift (24H) is a common staffing pattern in the air medical community. We report sleep dept and pre-duty activity patterns for 24H medical staff members at helicopter air medical transport programs.

METHODS

An anonymous survey collecting self-reported sleep quantities for off-duty, immediate pre-duty, and on-duty periods, along with self-reported outside employment patterns, was distributed to medical team members at cluster sample of 10 rotor wing air medical programs selected by stratified random sample to ensure geographic and operational diversity. Both matched-sample comparisons of sleep quantities in different phases of the duty-cycle and independent-sample comparisons between staff with and without outside employment had 80% power to detect a difference in means of 60 minutes at a 0.05 two-sided significance level using the appropriate t-test. Descriptive statistics are also reported; means are reported with the standard deviation.

RESULTS

A total of 138 surveys were returned (69.0%) and the 133 (66.5%) that were fully completed were utilized for analysis. 24H crewmembers average nearly the same amount of sleep in 24 hour periods on both duty and non-duty days (6.9 +/- 1.3 v. 6.4 +/- 1.8 hours, p = NS, range 3 - 10 for duty days and 4 - 10 for non-duty days). On duty, they average 1.1 +/- 1.3 hours of sleep in the first half of their shifts (range 0 to 5) and 5.3 +/- 1.4 hours in the overnight portion (range 2 - 9). The lowest amount of on-duty sleep reported in the past 30 days ranged from 0 to 6 hours, averaging 1.9 +/- 1.7 hours. The minimum pre-duty sleep reported by 24H crewmembers prior to any shift in the past month averaged 4.6 +/- 1.6 hours (range 0-8), with 3.8% having reported in the past month with no sleep before their 24-hour shift. Outside employment (OE) in addition to the flight position was common for 24H crewmembers (81.1% of respondents). Pre-duty sleep did not differ significantly between 24H crewmembers with and without OE, but 16.3% of surveyed 24H crewmembers with OE had reported for flight duty within eight hours of leaving OE within the past 30 days.

CONCLUSION

In the programs surveyed, 24H crewmembers completed an average duty cycle with little sleep debt and were unlikely to be sleepless prior to reporting for a shift. OE is common for 24H medical staff and some personnel report for flight duty within eight hours of leaving an OE position. As the industry considers the impact of fatigue on operational safety, shift length, on-duty rest, and outside employment will be important considerations.

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.

Safety in training and learning in the intensive care unit

Resident and subspecialty fellow trainees in the intensive care unit (ICU) present risks for patient safety because of their inexperience yet offer opportunities to promote safe patient care because of their around-the-clock presence and their involvement in frontline processes of care. Most trainees approach their ICU experiences without previous education in performance improvement or patient safety. This article reviews the barriers that are faced by residents in providing safe patient care and outlines the nature of a patient safety curriculum that could tap the opportunities that are presented by trainees to promote safer patient care.

Resident duty hours in American neurosurgery

The unexpected death of Libby Zion, at New York Hospital in 1984, led to a series of investigations that recently resulted in profound changes in resident duty hours. On July 1, 2003, the Accreditation Council for Graduate Medical Education (the governing body of all residency programs in the United States) mandated the following work hours rules: no more than 80 hours per week, no more than 24 hours of continuous patient care (with an added 6-hour transition period), 1 day in 7 free of patient care responsibilities, and a minimum of 10 rest hours between duty periods. These rules are based on a considerable body of scientific study indicating that sleep loss affects cognitive performance and, possibly, patient care. The new work hours have stimulated vigorous debate, both pro and con. Those arguments are reviewed.

Effects of limited work hours on surgical training

BACKGROUND

Legal mandates to reduce resident work hours have prompted changes in the structure of surgical training programs. Such changes have included modification of on-call schedules and the adoption of "night float" resident coverage. Little is known about the effects of these changes on surgical resident education and perceptions of quality of patient care.

STUDY DESIGN

The surgical housestaff and faculty at a single institution completed a 21-point Likert survey. Subjects were asked to compare parameters of resident education, patient care, and resident quality of life before and after institution of a strict 80-hour work week resident training schedule. The number of hours worked per week before and after these changes were reported. American Board of Surgery In-Training Examination (ABSITE) scores were compared for the 2 years before and after implementation of this schedule. Total number of surgical cases performed by graduating chief residents were recorded and compared for the 3 years before and after the schedule changes.

RESULTS

Resident work hours reduced significantly after schedule changes were implemented. A majority of surgical residents reported an improvement in quality of life, but residents and faculty perceived changes to have a negative impact on continuity of patient care. Mean ABSITE composite percentile scores significantly improved after the reduction of working hours. ABSITE scores for junior residents improved significantly; no significant differences were noted in scores for senior residents.

CONCLUSIONS

Reduction in resident work hours has salutary effects on perception of quality of life and basic education for surgical residents. These benefits may come at the expense of patient care, particularly continuity of care. This study did not directly assess patient outcomes but the perceptions of caregivers suggest that patient care may be compromised. Further research is needed to assess the longterm effects of changes on both residents and patients.

Sleep deprivation and junior doctors' performance and confidence

PURPOSE OF STUDY

To determine whether sleep deprivation affects not only junior doctors' performance in answering medical questions but whether their ability to judge their own performance is also affected by lack of sleep.

METHODS

A questionnaire based follow up study in two district general hospitals of the Carmarthenshire NHS Trust. Eleven house officers and 15 senior house officers (SHOs) within the medical directorate participating in the on-call rota were recruited between July 1999 and May 2000.

RESULTS

SHOs answered significantly more questions correctly (p=0.04) and were more confident than house officers when they were either correct or incorrect (p<0.001). Length of unbroken or continuous sleep is associated with more correct answers (p=0.03) and higher energy (p=0.09) and confidence (p=0.07) scores self rated by the profile of mood states. Length of continuous sleep was not related to the appropriateness of confidence, as measured by the "within-subject confidence-accuracy correlation" (p=0.919).

CONCLUSIONS

SHOs performed better than house officers even allowing for sleep loss. Sleep deprivation had adverse effects on mood and performance but junior doctors can still monitor their performance and retain insight into their own ability when sleep deprived.

Alterations of host defence system after sleep deprivation are followed by impaired mood and psychosocial functioning

In healthy humans, sleep deprivation (SD) has consistently been demonstrated to impair different parameters of the host defence system and of psychosocial functioning. However, the individual timing of these alterations and their possible association have remained unknown so far. We therefore investigated functional measures of the individual host defence system as well as of subjective well-being and psychosocial performance in 10 healthy male adults before and after SD, as well as after recovery sleep. In detail, we examined the number of leukocytes, granulocytes, monocytes, lymphocytes, B cells, T cells, T helper and cytotoxic T cells, natural killer (NK) cells as well as the interleukin-1 beta (IL-1 beta) release from platelets after serotonin (5-HT) stimulation. Mood and psychosocial performance (excitement, energy, ability to work and timidity) were measured by visual analogue scales. Taken together, SD induced a deterioration of both mood and ability to work, which was most prominent in the evening after SD, while the maximal alterations of the host defence system could be found twelve hours earlier, i.e., already in the morning following SD. Our findings therefore suggest an SD-induced alteration of these psychoimmune response patterns in healthy humans preceding deterioration of mood and psychosocial functioning.

Doctors' perceptions of the links between stress and lowered clinical care

We know from numerous industrial studies that stress, particularly in the form of tiredness and sleep deprivation, has a detrimental effect upon work performance, though this is not so clear-cut in studies of doctors, despite their stress levels being particularly high. This study explores the doctors' views on this using anonymous questionnaires from a population of 225 hospital doctors and general practitioners, 82 of whom reported recent incidents where they considered that symptoms of stress had negatively affected their patient care. The qualitative accounts they gave were coded for the attribution (type of stress symptom) made, and the effect it had. Half of these effects concerned lowered standards of care; 40% were the expression of irritability or anger; 7% were serious mistakes which still avoided directly leading to death; and two resulted in patient death. The attributions given for these were largely to do with tiredness (57%) and the pressure of overwork (28%), followed by depression or anxiety (8%), and the effects of alcohol (5%). The data are discussed in terms of the links made by the doctors between their fatigue or work pressure and the way they care for patients. It presumes that these incidents had been previously unreported and talks about the effects this secrecy has on the emotional state of the doctors concerned. It offers ways forward for tackling the problem, of interest to the profession, managers and commissioners.

Impact of naps and caffeine on extended nocturnal performance

It was hypothesized that alertness and performance during an extended work period would be improved by an afternoon nap and the subsequent use of caffeine during the night. Twelve young adults received a 4-h afternoon nap and caffeine during the night during one session and four 1-h naps during the night in a second session. After an afternoon nap, subjects had increased objective and subjective alertness, increased oral temperature, and increased performance on complex tasks like logical reasoning and correct additions when compared to the condition that allowed four nighttime naps. It was concluded that the specific scheduling of a nap period in preparation for an all-night work shift where sleep would not be allowed could result in increased alertness and performance as well as a less conflicted work situation.

Internal medicine housestaff and attending physician perceptions of the impact of the New York State Section 405 regulations on working conditions and supervision of residents in two training programs

OBJECTIVES

To assess the attitudes of internal medicine housestaff and their attending physicians regarding the impact of the reduction in on-call working hours and increased supervision mandated in New York by a revision of the State Health Code (Section 405).

DESIGN

Survey of senior medical housestaff and attendings two years after the adoption of the mandated changes.

SETTING

Two independent medicine housestaff training programs of the Albert Einstein College of Medicine in the Bronx, New York.

PARTICIPANTS

Fifty-three percent of third- and fourth-year residents (n = 79) and 60% of voluntary and full-time attendings (n = 266) responded.

MEASUREMENTS

A factor analysis of 13 variables that appeared on both versions of the survey identified two interpretable factors. A multivariate analysis of variance compared responses to each factor by group and by campus, and Bonferroni post-hoc comparisons analyzed the items within factors. Chi-square analyses compared responses of residents and attendings to the open-ended questions.

RESULTS

Significant differences between the housestaff and attendings groups were found for all fixed-response items (minimum p < 0.05 for all analyses), but both groups agreed that the regulations had a positive impact on resident attitudes regarding the demands on their time. Both groups were also uncertain whether the new regulations had a beneficial effect on the choice of internal medicine as a career, the quality of resident supervision, and residents' intellectual interest in challenging medical problems. Whereas residents agreed that the regulations diminished their fatigue, had no impact on their ability to observe the full impact of interventions on patients, and resulted in better patient care, attendings were uncertain or disagreed. While attendings agreed that the regulations had caused a shift-work mentality among residents, housestaff were uncertain.

CONCLUSIONS

Housestaff had more positive attitudes about the impact of the mandated changes in working conditions for residents than did attending physicians in the same institutions. The major benefits seen by residents were less fatigue and more spare time. There was no consensus about whether these changes had a positive impact on internal medicine practice and clinical supervision. There was some concern that a shift-work mentality is developing among residents and that continuity of patient care has suffered. Thus, despite some substantial benefits, Section 405 may not be achieving its goals of improving resident supervision and the quality of patient care by houseofficers.

Call nights and patients care: effects on inpatients at one teaching hospital

OBJECTIVE

To determine whether the timing and number of patients admitted by internal medicine housestaff under a traditional call schedule affect the resource utilization and outcome of care for those patients.

DESIGN

Retrospective cohort study, using existing computerized records.

SETTING

University-affiliated 340-bed city/county teaching hospital.

PATIENTS/PARTICIPANTS

22,112 patients discharged from the internal medicine service who had been admitted by an on-call first-year resident between January 1, 1980, and December 31, 1987.

MEASUREMENTS AND MAIN RESULTS

Admission after 5:00 PM was associated with decreased hospital length of stay (8.1%, p less than 0.0001), but increased total charges (3.1%, p = 0.007). The relative risk of inpatient mortality for patients admitted at night was 1.21 (p = 0.03). Patients of busier housestaff, as indicated by a larger number of on-call admissions, had lower total charges (1.7% decreased per admission) and no change in risk of inpatient mortality. While no linear relation was found between number of admissions and length of stay, analysis of nonlinear effects revealed that length of stay first rises, then falls as interns receive more on-call admissions.

CONCLUSIONS

The number and timing of admissions by on-call internal medicine housestaff are significantly related to length of hospital stay, total charges, and likelihood of inpatient mortality at one teaching hospital. These variations should be considered in planning the reform of residency training programs.

Does the current use of junior doctors in the United Kingdom affect the quality of medical care?

Current proposals in the U.K. envisage a reduction in both junior staff numbers and the hours which they work. The proponents of change argue that this will improve patient care, although there are also opposing arguments, based mainly on the need to maintain continuity of care and ensure juniors gain sufficient clinical experience. By means of a literature review and interviews with junior doctors, this paper examines the effect of the existing system of hospital medical staffing on quality of care. There is evidence that the existing system reduces the quality of care, principally through mistakes associated with inadequate supervision, and lowered humanity of care due to tiredness. The training value of night-time and weekend work is low, and many doctors find it unsatisfying. In contrast, many doctors value providing continuity of care and a few appreciate the opportunity to gain unsupervised experience. Overall, the disadvantages of the existing system outweight the advantages, and change is required to improve the quality of care. There are, however, several obstacles to change, and there are doubts about the extent to which the current proposals will be implemented.

The impact of the night float system on internal medicine residency programs

OBJECTIVE

To study the design, method of implementation, perceived benefits, and problems associated with a night float system.

DESIGN

Self-administered questionnaire completed by program directors, which included both structured and open-ended questions. The answers reflect resident and student opinions as well as those of the program directors, since program directors regularly obtain feedback from these groups.

SETTING/PARTICIPANTS

The 442 accredited internal medicine residency programs listed in the 1988-89 Directory of Graduate Medical Education Programs.

RESULTS

Of the 442 programs, 79% responded, and 30% had experience with a night float system. The most frequent methods for initiating a night float system included: decreasing elective time (42.3%), hiring more residents (26.9%), creating a non-teaching service (12.5%), and reallocating housestaff time (9.6%). Positive effects cited include decreased fatigue, improved housestaff morale, improved recruiting, and better attitude toward internal medicine training. The quality of medical care was considered the same or better by most programs using it. The most commonly cited problems were decreased continuity of care, inadequate teaching of the night float team, and miscommunication.

CONCLUSION

Residency programs using a night float system usually observe a positive effect on housestaff morale, recruitment, and working hours and no detrimental effect on the quality of patient care. Miscommunication and inadequate learning experience for the night float team are important potential problems. This survey suggests that the night float represents one solution to reducing resident working hours.

An evaluation of mood states among first-year residents

To examine the need for preventive and treatment interventions, a prevalence study was conducted to ascertain the rate of depressive symptomatology and other negative mood states among 112 first-year residents. The participation rate was 54%. Subjects (N = 61) were administered the Beck Depression Inventory and Profile of Mood States in personal interview sessions. The Profile measures five negative mood states, namely, "tension-anxiety," "depression-dejection," "anger-hostility," "fatigue-inertia," "confusion-bewilderment," and one positive state, "vigor-activity." A 15.5% rate of depression was found, which is lower than a rate of 23.5%, also measured by Beck's inventory, among a sample of university undergraduates and 19.9% among an adult sample from the general population. No differences were observed among residency programs or sex on Beck's scale; however, significantly higher scores were found for women on the "depression-dejection" dimension of the Profile. The mean scores on all negative mood dimensions of the Profile were below the mean for university undergraduate norms. Neither sleep nor hours worked over the past week were associated with increased Beck scores. These results indicate that sleep deprivation and long work hours did not contribute to depression among the subjects who participated in the study. Female interns, however, appear to be at increased risk of depression, and adequate support systems need to be provided.