Hours of work and fatigue-related error: a survey of New Zealand anaesthetists

When is "convenient time" for residents?: a trial of Resident Study Log as asynchronous learning tool for residents

INTRODUCTION

The integration of online learning in health professions education has grown rapidly, offering flexibility to learners worldwide. Asynchronous online learning allows residents to engage with educational content at a time convenient for them, accommodating their demanding schedules. This study aims to reveal how residents approach asynchronous online learning during their residency training.

METHODS

The Resident Study Log, an asynchronous learning tool, was introduced in a teaching hospital in Japan. This tool facilitated residents to share daily reflections on their learning experiences, allowing supervising physicians outside of their regular clinical teams to provide feedback. Posts shared between April 2020 and July 2021 were reviewed. The outcome measured included the frequency and timing of posts as well as residents' satisfaction and perceived burden, which were assessed through anonymous surveys.

RESULTS

A total of 31 residents participated during the study period, posting 599 entries on the Resident Study Log, averaging one post per resident every two days. Participants reported an average satisfaction score of 5.3 out of 6.0 (6-point Likert scale, where 1 indicated 'not satisfied at all' and 6 indicated 'very satisfied'), while the perceived burden averaged 4.0 out of 6.0 (6-point Likert scale, where 1 indicated 'not burdensome at all' and 6 indicated 'very burdensome'). Notably, posting activity peaked at around 23:00, with 17.4% of posts created between midnight and 5:00.

CONCLUSION

The Resident Study Log was a simple, low-cost tool, with high satisfaction levels among residents. However, the late-night posting pattern raises concerns about resident well-being and sleep hygiene. As asynchronous learning is increasingly more prevalent, it is crucial to ensure it does not inadvertently impose hidden burdens on learners' overall well-being.

Examining clinicians' fatigue in a pediatric emergency department

We examined fatigue among emergency department (ED) clinicians. ED clinicians are susceptible to burnout, because of fatigue. Fatigue represents a latent hazard in ED care, being associated with impaired clinician performance, poor patient outcomes, and a negative impact on patient safety. Thirty-five pediatric clinicians were surveyed at the beginning and end of their shifts. The 20-item Swedish Occupational Fatigue Inventory survey was used to evaluate fatigue. Paired t-tests were used to examine whether fatigue scores changed over the course of a shift. The associations between the five fatigue subscales and various factors were modeled with multilevel linear regressions. Surveys (N = 827) were administered over 425 shifts. Clinician fatigue depended on time spent within the shift, shift type, clinician's gender, age, and clinician's role. Analysis showed other individual characteristics and shift factors also may affect fatigue. Clinicians with varying fatigue levels have different needs that should be considered in information technology design and evaluation.

Overtime work of anesthesiologists is associated with increased delirium in older patients admitted to intensive care unit after noncardiac surgery: a secondary analysis

BACKGROUND

Overtime work is common in anesthesiologists due to shortage of manpower. Herein, we analyzed if overtime work of anesthesiologists was associated with delirium development in older patients after surgery.

METHODS

This was a secondary analysis of the database from a randomized trial. Seven hundred older patients (aged ≥ 65 years) who were admitted to the intensive care unit (ICU) after elective noncardiac surgery were enrolled in the underlying trial. Anesthesiologists who worked continuously for more than 8 h by the end of the surgery were marked as "work overtime". Delirium was assessed with the Confusion Assessment Method for the ICU twice daily during the first 7 postoperative days. The association between overtime work of anesthesiologists and development of postoperative delirium was analyzed with multivariable logistic regression models.

RESULTS

All 700 patients (mean age 74.3 years, 39.6% female) were included in this analysis. Anesthesiologists of 281 patients (40.1%) were marked as "work overtime" at the end of surgery. When compared with patients whose anesthesiologists didn't work overtime, patients whose anesthesiologist worked overtime had a higher incidence of delirium within 7 days (20.3% [57/281] vs. 12.9% [54/419], P = 0.009). After correction for confounding factors, both overtime work (OR 1.87, 95% CI 1.19-2.94, P = 0.007) and prolonged continuous working hours of anesthesiologists (OR 1.08, 95% CI 1.01-1.15, P = 0.020) were associated with an increased risk of postoperative delirium.

CONCLUSIONS

Overtime work of anesthesiologists was associated with an increased risk of delirium development in older patients admitted to ICU after major noncardiac surgery.

TRIAL REGISTRATION

The underlying trial was registered with Chinese Clinical Trial Registry ( https://www.chictr.org.cn/showproj.html?proj=8734 ; ChiCTR-TRC-10000802; March 18, 2010).

Examining the impact of sleep deprivation on medical reasoning's performance among anaesthesiology residents and doctors: a prospective study

BACKGROUND

Working long consecutive hours' is common for anaesthesia and critical care physicians. It is associated with impaired medical reasoning's performance of anaesthesiology and serious medical errors. However, no study has yet investigated the impact of working long consecutive hours' on medical reasoning.

OBJECTIVE

The present study evaluated the impact of working long consecutive hours' on the medical reasoning's performance of anaesthesiology and intensive care physicians (residents and seniors).

METHODS

This multicentric, prospective, cross-over study was conducted in 5 public hospitals of Normandy region. Two groups of anaesthesia and critical care physicians were formed. One was in a rest group, RG (after a 48-hours weekend without hospital work) and the other in Sleep Deprivation Group (SDG) after a 24 h-consecutives-shift. Changes in medical reasoning's performance were measured by 69-items script concordance tests (SCT) through to the two tests. Group A completed the first part of the assessment (Set A) after a weekend without work and the second part (Set B) after a 24 h-shift; group B did the same in reverse order. The primary outcome was medical reasoning's performance as measured by SCT in RG and SDG. The secondary outcomes included association between the performance with the demographic data, variation of the KSS (Karolinska sleepiness scale) daytime alertness score, the number of 24 h-shift during the previous 30 days, the vacations during the previous 30 days, the presence of more or less than 4 h consecutives hours slept, the management of a stressful event during the shift, the different resident years, the place where the shift took place (University hospital or general hospitals) and the type of shift (anaesthesia or intensive care).

RESULTS

84 physicians (26 physicians and 58 residents) were included. RG exhibited significantly higher performance scores than SDG (68 ± 8 vs. 65 ± 9, respectively; p = 0.008). We found a negative correlation between the number of 24 h-shifts performed during the previous month and the variation of medical reasoning's performance and no significant variation between professionals who slept 4 h or less and those who slept more than 4 h consecutively during the shift (-4 ± 11 vs. -2 ± 11; p = 0.42).

CONCLUSION

Our study suggests that medical reasoning' performance of anaesthesiologists, measured by the SCT, is reduced after 24 h-shift than after rest period. Working long consecutive hours' and many shifts should be avoided to prevent the occurrence of medical errors.

The prevalence of sleep deprivation and its impact among medical officers in a tertiary hospital, a cross-sectional study from Malaysia

Sleep deprivation (SD), defined as an inability to get a minimum of 7 hours of regular sleep at night is a serious health problem that impacts the performance of medical professionals. This study aims to determine the impact of sleep deprivation on perceived performance among medical officers (MOs). A cross-sectional study design involved 231 MOs from six disciplines in Hospital Tuanku Ja'afar, a tertiary center in the south of Malaysia. A self-administered questionnaire was introduced in the English language. The questionnaire involved the sociodemographic characteristics; job-related factors, and the Sleep Deprivation Impact Scale (SDIS). The SDIS is a 12-question scale, rated on a 5-point Likert scale from strongly disagree to strongly agree. A higher SDIS score reflected a higher impact of sleep deprivation. A total of 206 MOs returned the completed questionnaire yielding a response rate of 89.17%. The mean age of respondents was 31.68 (±3.49) years. Most of the respondents were female, of Malay ethnicity, and married. More than three-quarters (78.64%) reported sleep deprivation. Being less effective in communication and formulating diagnosis (3 (1.01) vs 2.5 (1.15),p = 0.005); taking longer time to do things (3.44 (1.07) vs 2.8 (1.34),p = 0.001); and feeling unsafe while driving (3.56 (1.25) vs 2.93 (1.55),p = 0.006) manifested significantly higher mean among sleep-deprived respondents. In conclusion, sleep deprivation is a prevalent problem; that adversely affects crucial functioning domains that may endanger patients and healthcare providers alike. Radical countermeasures are required to ensure satisfactory sleep duration and address areas jeopardizing MO safety.

Unraveling the interplay between mental workload, occupational fatigue, physiological responses and cognitive performance in office workers

Recently, cognitive demands in workplaces have surged significantly. This study explored the intricate relationship among mental workload (MWL), occupational fatigue, physiological responses, and cognitive performance in office workers by using collective semi-parametric models. One hundred office workers were selected from twenty offices involved in cognitive performance. MWL was assessed through the NASA Task Load Index (NASA-TLX), and occupational fatigue was measured using the Persian version of the Swedish Occupational Fatigue Inventory. Physiological responses, including respiratory rate, the electrical conductivity of the skin (ECS), Heart Rate (HR), and other heart-related parameters, were recorded from the participants during a work shift. Selective and Divided Attention tests were chosen to evaluate workers' cognitive function based on cognitive task analysis. The mean of MWL and occupational fatigue scores were 66.28 ± 11.76 and 1.62 ± 1.07, respectively. There was a significant moderate correlation between two dimensions, mental demand (0.429) and frustration (0.409), with functional fatigue. Also, Significant and, of course, nonlinear relationships were observed between MWL and HR (R2 = 0.44, P-value < 0.001) and ECS (R2 = 0.45, P-value < 0.001) and reaction time in selected (R2 = 0.34, P-value < 0.001) and divided test (R2 = 0.48, P-value < 0.001). Similarly, nonlinear relationships were observed between physiological responses and cognitive performance with fatigue among participants who had experienced higher levels of occupational fatigue. The MWL and fatigue seem to have a significant and non-linear effect on physiological parameters such as HR and ECS and cognitive parameters such as reaction time. Moreover, MWL can influence the dimension of functional fatigue of workers.

European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice

Climate change is a defining issue for our generation. The carbon footprint of clinical practice accounts for 4.7% of European greenhouse gas emissions, with the European Union ranking as the third largest contributor to the global healthcare industry's carbon footprint, after the United States and China. Recognising the importance of urgent action, the European Society of Anaesthesiology and Intensive Care (ESAIC) adopted the Glasgow Declaration on Environmental Sustainability in June 2023. Building on this initiative, the ESAIC Sustainability Committee now presents a consensus document in perioperative sustainability. Acknowledging wider dimensions of sustainability, beyond the environmental one, the document recognizes healthcare professionals as cornerstones for sustainable care, and puts forward recommendations in four main areas: direct emissions, energy, supply chain and waste management, and psychological and self-care of healthcare professionals. Given the urgent need to cut global carbon emissions, and the scarcity of evidence-based literature on perioperative sustainability, our methodology is based on expert opinion recommendations. A total of 90 recommendations were drafted by 13 sustainability experts in anaesthesia in March 2023, then validated by 36 experts from 24 different countries in a two-step Delphi validation process in May and June 2023. To accommodate different possibilities for action in high- versus middle-income countries, an 80% agreement threshold was set to ease implementation of the recommendations Europe-wide. All recommendations surpassed the 80% agreement threshold in the first Delphi round, and 88 recommendations achieved an agreement >90% in the second round. Recommendations include the use of very low fresh gas flow, choice of anaesthetic drug, energy and water preserving measures, "5R" policies including choice of plastics and their disposal, and recommendations to keep a healthy work environment or on the importance of fatigue in clinical practice. Executive summaries of recommendations in areas 1, 2 and 3 are available as cognitive aids that can be made available for quick reference in the operating room.

Fatigue among anaesthesiologists in Europe: Findings from a joint EBA/NASC survey

BACKGROUND

Anaesthesiologists deliver an increasing amount of patient care and often work long hours in operating theatres and intensive care units, with frequent on-calls and insufficient rest in between. In the long term, this will negatively influence mental and physical health and well being. As fatigue becomes more prevalent, this has predictable implications for patient safety and clinical effectiveness. 1.

OBJECTIVE

This study aimed to evaluate the prevalence, severity, causes and implications of work-related fatigue amongst specialist anaesthesiologists.

DESIGN

An online survey of specialist anaesthesiologists.

PARTICIPANTS

The survey was sent to anaesthesiologists in 42 European countries by electronic mail.

MAIN OUTCOME MEASURES

Responses from a 36-item online survey assessed work-related fatigue and its impact on anaesthesiologists in European countries.

RESULTS

Work-related fatigue was experienced in 91.6% of the 1508 respondents from 32 European countries. Fatigue was caused by their working patterns, clinical and nonclinical workloads, staffing issues and excessive work hours. Over 70% reported that work-related fatigue negatively impacted on their physical and mental health, emotional well being and safe commuting. Most respondents did not feel supported by their organisation to maintain good health and well being.

CONCLUSION

Work-related fatigue is a significant and widespread problem amongst anaesthesiologists. More education and increased awareness of fatigue and its adverse effects on patient safety, staff well being and physical and mental health are needed. Departments should ensure that their rotas and job plans comply with the European Working Time Directive (EWTD) and introduce a fatigue risk management system to mitigate the effects of fatigue.

The effects of resident work hours on well-being, performance, and education: A review from a Japanese perspective

This article examines the impact of working-hour restrictions on the well-being, performance, and education of medical residents in Japan. Despite Japan's plan to introduce new regulations for resident working hours by 2024, there is still an ongoing debate regarding their appropriateness. This review provides a comprehensive overview of the current regulations of resident working hours worldwide, with a specific focus on weekly hours. The varying regulations are highlighted, including the 80-hour-per-week regulation in the United States and the 48-h-per-week regulation in the European Union influencing other regions. The article also discusses the effectiveness of working-hour restrictions on residents' mental health, with shorter working hours having potentially greater benefits. However, the impacts on medical safety and resident education are mixed, and further reduction in working hours must be carefully considered to avoid adverse effects. The planned changes to working-hour limits for residents in Japan offer a unique opportunity to gain new evidence on the impact of such regulations, which will be of interest to policymakers and researchers worldwide.

Nighttime working as perceived by Italian anesthesiologists: a secondary analysis of an international survey

BACKGROUND

No data are available on the working conditions and workload of anesthesiologists during perioperative nighttime work in Italy and on the perceived risks.

RESULTS

We analyzed 1085 responses out of the 5292 from the whole dataset. Most of the responders (76%) declared working a median of 12 consecutive hours during night shifts, with an irregular nightshift schedule (70%). More than half of the responders stated to receive a call 2-4 (40%) or 5 times or more (25%) to perform emergency procedures and/or ICU activities during night shifts. More than 70% of the responders declared having relaxation rooms for nighttime work (74%) but none to be used after a nightshift before going back home (82%) and no free meals, snacks, or beverages (89%). Furthermore, almost all (95%) of the surveyed anesthesiologists declared not having received specifical training or education on how to work at night, and that no institutional program has been held by the hospital to monitor fatigue or stress for night workers (99%). More than half of the responders stated having the possibility, sometimes (38%) or always (45%), to involve another colleague in difficult medical decisions and to feel comfortable, sometimes (31%) or always (35%), to call the on-call colleague. Participants declared that nighttime work affects their quality of life extremely (14%) or significantly (63%), and that sleep deprivation, fatigue, and current working conditions may reduce performance (67%) and increase risk for the patients (74%).

CONCLUSIONS

Italian anesthesiologists declare current nighttime practice to negatively affect their quality of life, and their performance, and are thus concerned for their patients' safety. Proper education on night work, starting from traineeship, and implementing institutional programs to monitor stress and fatigue of operators and to support them during nighttime work could be a mean to improve nighttime work conditions and safety for both patients and healthcare workers.

The burden of peri-operative work at night as perceived by anaesthesiologists: An international survey

BACKGROUND

No international data are available on the night working conditions and workload of anaesthesiologists and their opinions about associated risks.

OBJECTIVE

The aim of this international survey was to describe the peri-operative night working conditions of anaesthesiologists and their perception of the impact these conditions have on patient outcomes and their own quality of life.

DESIGN

Cross-sectional survey.

SETTING

Not applicable.

PARTICIPANTS

Anaesthesiologists providing peri-operative care during night shifts responded to an online survey promoted by the European Society of Anaesthesiology and Intensive Care (ESAIC).

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Twenty-eight closed questions.

RESULTS

Overall 5292 complete responses were analysed. Of these, 920 were from trainees. The median reported monthly number of night shifts was 4 [IQR 3-6]. An irregular weekly night shift schedule was most common (51%). Almost all the respondents (98%) declared that their centres have no relevant institutional programmes to monitor stress or fatigue. Most respondents (90%) had received no training or information regarding performance improvement methods for night work. Most respondents were of the opinion that sleep deprivation affects their professional performance (71%) and that their fatigue during night work may increase the peri-operative risk for their patients (74%). Furthermore, 81% of the respondents agreed or strongly agreed that night work represents an additional risk per se for patient safety, and 77% stated that their night work affects the quality of their daily life significantly or extremely.

CONCLUSION

Anaesthesiologists commonly perform perioperative night work without appropriate training, education or support on this specific condition. They perceive current practice as adversely affecting their professional performance and the safety of their patients. They also report significant effects on their own quality of life. Adequate training and education for night work may ally some of these concerns and programmes to monitor workers' stress and fatigue should be mandated to assess whether these concerns are justified.

TRIAL REGISTRATION

Not applicable.

Protocol for the perioperative outcome risk assessment with computer learning enhancement (Periop ORACLE) randomized study

Background: More than four million people die each year in the month following surgery, and many more experience complications such as acute kidney injury. Some of these outcomes may be prevented through early identification of at-risk patients and through intraoperative risk mitigation. Telemedicine has revolutionized the way at-risk patients are identified in critical care, but intraoperative telemedicine services are not widely used in anesthesiology. Clinicians in telemedicine settings may assist with risk stratification and brainstorm risk mitigation strategies while clinicians in the operating room are busy performing other patient care tasks. Machine learning tools may help clinicians in telemedicine settings leverage the abundant electronic health data available in the perioperative period. The primary hypothesis for this study is that anesthesiology clinicians can predict postoperative complications more accurately with machine learning assistance than without machine learning assistance. Methods: This investigation is a sub-study nested within the TECTONICS randomized clinical trial (NCT03923699). As part of TECTONICS, study team members who are anesthesiology clinicians working in a telemedicine setting are currently reviewing ongoing surgical cases and documenting how likely they feel the patient is to experience 30-day in-hospital death or acute kidney injury. For patients who are included in this sub-study, these case reviews will be randomized to be performed with access to a display showing machine learning predictions for the postoperative complications or without access to the display. The accuracy of the predictions will be compared across these two groups. Conclusion: Successful completion of this study will help define the role of machine learning not only for intraoperative telemedicine, but for other risk assessment tasks before, during, and after surgery. Registration: ORACLE is registered on ClinicalTrials.gov: NCT05042804; registered September 13, 2021.

Why Are Patients Unhappy with Their Healthcare? A Romanian Physicians’ Perspective

Background: Medical professional liability complaints are not triggered by a single factor, but rather by multiple factors, each having more or less implications, such as the characteristics of the physician, the medical system, the patients, the complexity of their pathology, and the inherent limits of medicine. Knowledge about the factors that initiate the complaint procedure is essential to identify the targeted measures to limit their prevalence and impact. The purpose of this study was to identify the reasons behind the malpractice complaints and the factors that may influence the initiation of complaints by the patients. Material and Methods: This study was conducted using an online questionnaire, addressed to Romanian doctors, with questions about the reasons for patient dissatisfaction and complaints, the factors that predispose a physician to being complained against, and the protective factors against patient complaints. Results: The study group included 1684 physicians, of whom 16.1% were themselves involved in a complaint, and 52.5% knew of a colleague who was complained against. The opinions of the participants regarding the reasons for the complaints, the predisposing factors to complaints, and the factors that contributed to the reported incident showed a strong link between professional liability complaints and the physician–patient/patient’s family relationship. The relationship between fellow physicians is additional to this. Conclusion: This study reveals that the improvement in the relational aspects of medical practice (physician–patient relationship and relationship between physicians) has the highest potential to decrease the number of malpractice complaints. Its practical relevance is related to the need for training physicians in the relational aspects of medical practice during academic years and throughout their career.

Coping strategies adopted by medical residents in dealing with work-related stress: a mixed-methods study

BACKGROUND

This study was carried out to identify and explore the difference in coping strategies for dealing with stress; adopted by medical residents in surgical and nonsurgical specialties.

METHODS

A mixed methods approach, was chosen for this study. In phase one (quantitative); data were collected by a web-based survey, using a structured questionnaire. This survey was carried out in five major teaching hospitals of Rawalpindi & Muzaffarabad in 2020. Purposive sampling was done and data were analysed using SPSS, recording frequencies and major trends. In phase two (qualitative); six focus group discussions were carried out with 24 participants, using semi-structured questions and prompts. Convenient sampling was done from the cohort of phase 1. These focus group discussions, explored the various coping strategies adopted by medical residents. Later, the data were analysed manually for development of codes, sub-themes and themes.

RESULTS

Out of 250 (100%) participants, 146 (58%) participants responded to the online survey. Surgical residents had a higher response rate (60%, n = 87) than nonsurgical residents. Moreover, female participation (54%, n = 79) was greater than male participation (46%, n = 67). The Mann-Whitney U test was statistically significant only for seeking medical advice to cope with stress (P = .029). There was no statistically significant difference found between the coping strategies, employed by medical residents. In focus group discussions, female involvement was more (58% n = 14) than their counterparts. Four main themes were developed after data analysis: self-regulation, tailor-made strategies, educational focus and support system. Finally, minor differences were obtained qualitatively; like, socializing is preferred by surgical residents whereas, spiritualism is chosen by nonsurgical residents.

CONCLUSION

Quantitatively, no significant differences were found between the coping strategies of medical residents, against work-related stress. However, minor differences were obtained qualitatively due to difference in job demands and level of burnout between these two specialities.

Socio-Demographic, Professional and Institutional Characteristics That Make Romanian Doctors More Prone to Malpractice Complaints

Background and objectives: Medical malpractice is a phenomenon that shadows current medical practice, the number of complaints following an upward trend worldwide. The background for complaints is related both to the doctor and medical practice in general, as well as to the patient. The aim of this study was to identify a profile of the Romanian doctors who are more prone to receiving complaints, by analyzing the socio-demographic, professional and institutional characteristics. Materials and Methods: We conducted a quantitative, prospective research, the data being collected using a newly developed questionnaire. Data analysis was performed with the IBM Statistical Package for Social Sciences (SPSS, version 24). We used counts, percentages, means and standard deviation, and comparative and correlational analyses. A logistic regression model was applied to select a statistically best-fit model to identify independent predictors for receiving complaints; a Hosmer–Lemeshow test was used to check the performance of the prediction model. Results: The study group consisted of 1684 doctors, of which 16.1% had been involved in a malpractice complaint. Results showed that men, senior doctors from surgical specialties who perform a greater number of on-call shifts, those who work in regional or county hospitals, those who have greater fear of receiving complaints and those whose life partner is a doctor with the same specialty are more prone to receiving complaints. Conclusions: The profile identified by the present research underlines the main characteristics that could be targeted with specific measures in order to prevent the ongoing increase of malpractice complaints in Romania.

Current Status of Clinical Engineer Anesthesia Assistants and Their Effect on Labor Task Shifting in Japan: A Prospective Observational Study in a Single Institute

Introduction:

Anesthesiologists are in short supply across the world, resulting in perpetually long working hours. To reduce the burden on anesthesiologists, tasks that can be performed by non-physicians must be shifted to other medical staff. In hospitals, clinical engineers can work as anesthesia assistants and perform some of the duties of anesthesiologists. This study aimed to evaluate the effect of task shift performed by clinical engineer anesthesia assistants (CEAAs).

Methods:

This was a 1-month prospective observational study that included 33 anesthesiologists (11 fellows and 22 certified anesthesiologists) and 11 CEAAs. The total activity and anesthesia times were extracted from the attendance record as indices of the anesthesiologists' work status. The CEAAs recorded the duration of work performed on behalf of the anesthesiologists as task shift time. The task shift rate was evaluated as follows: task shift time/(task shift time + total activity time) and task shift time/(task shift time) + (total anesthesia time).

Results:

The study period consisted of 19 weekdays. The average daily activity time of the anesthesiologists was 10.1 h, and the average anesthesia time was 8.5 h. The CEAAs performed a total of 546.8 h of task shift. The defined task shift rate was 20.1% when the total activity time was the denominator and 23.1% when the anesthesia time was the denominator.

Conclusions:

CEAAs might be effective in reducing the working hours of anesthesiologists through task shift. Their taking over a portion of the anesthesiologists' duties may allow the anesthesiologists to work more efficiently.

Evaluation of cognitive and psychomotor functional changes in anesthesiology residents after 12 hours of continuous work in operation theater: An observational study

Background:

Aims:

Settings and Design:

Methods:

Statistical Analysis:

Results:

Conclusion:

Difficult and failed intubation in the first 4000 incidents reported on webAIRS

A review of the first 4000 reports to the webAIRS anaesthesia incident reporting database was performed to analyse cases reported as difficult or failed intubation. Patient, task, caregiver and system factors were evaluated. Among the 4000 reports, there were 170 incidents of difficult or failed intubation. Difficult or failed intubation incidents were most common in the 40-59 years age group. More than half of cases were not predicted. A total of 40% involved patients with a body mass index >30 kg/m² and 41% involved emergency cases. A third of the reports described multiple intubation attempts. Of the reports, 18% mentioned equipment problems including endotracheal tube cuff rupture, laryngoscope light failure, dysfunctional capnography and delays with availability of additional equipment to assist with intubation. Immediate outcomes included 40 cases of oxygen desaturation below 85%; of these cases, four required cardiopulmonary resuscitation. The majority of the incidents resulted in no harm or minor harm (45%). However, 12% suffered moderate harm, 3.5% severe harm and there were three deaths (although only one related to the airway incident). Despite advances and significant developments in airway management strategies, difficult and failed intubation still occurs. Although not all incidents are predictable, nor are all preventable, the information provided by this analysis might assist with future planning, preparation and management of difficult intubation.

Excessive Daytime Sleepiness and Safety Performance: Comparing Proactive and Reactive Approaches

BACKGROUND

Sleep disorders and excessive daytime sleepiness negatively affect employees' safety performance.

OBJECTIVE

To investigate the relationship between excessive daytime sleepiness with obstructive sleep apnea and safety performance at an oil construction company in Iran.

METHODS

661 employees consented to participate in this study. Excessive daytime sleepiness was measured with the STOP-BANG questionnaire and Epworth Sleepiness Scale (ESS). To determine how sleepiness would affect the studied occupational incidents, accidents causing injury and near misses, both reactive data and proactive safety performance indices were measured. Demographic and predictor variables were analyzed with hierarchical multiple linear regression.

RESULTS

Employees who met the criteria of excessive daytime sleepiness and obstructive sleep apnea had significantly poorer safety performance indicators. STOP-BANG and ESS were significant predictors of safety compliance (β 0.228 and 0.370, respectively), safety participation (β 0.210 and 0.144, respectively), and overall safety behavior (β 0.332 and 0.213, respectively). Further, occupational incidents were 2.5 times higher in workers with indicators of excessive daytime sleepiness and 2 times higher in those with obstructive sleep apnea compared with those without.

CONCLUSION

These findings confirmed that excessive daytime sleepiness is a serious safety hazard, and that both reactive and proactive measures are important to understand the relative contribution of predictor variables.

Development and evaluation of a matrix for assessing fatigue-related risk, derived from a national survey of nurses' work patterns

BACKGROUND

Multiple aspects of nurses' rosters interact to affect the quality of patient care they can provide and their own health, safety and wellbeing.

OBJECTIVES

(1) Develop and test a matrix incorporating multiple aspects of rosters and recovery sleep that are individually associated with three fatigue-related outcomes - fatigue-related clinical errors, excessive sleepiness and sleepy driving; and (2) evaluate whether the matrix also predicts nurses' ratings of the effects of rosters on aspects of life outside work.

DESIGN

Develop and test the matrix using data from a national survey of nurses' fatigue and work patterns in six hospital-based practice areas with high fatigue risk.

METHODS

Survey data included demographics, work patterns (previous 14 days), choice about shifts, and the extent to which work patterns cause problems with social life, home life, personal relationships, and other commitments (rated 1 = not at all to 5 = very much). Matrix variables were selected based on univariate associations with the fatigue-related outcomes, limits in the collective employment contract, and previous research. Each variable was categorised as lower (score 0), significant (score 1), or higher risk (score 2). Logistic multiple regression modelling tested the independent predictive power of matrix scores against models including all the (uncategorised) work pattern and recovery sleep variables with significant univariate associations with each outcome variable. Model fit was measured using Akaike and Bayesian Information Criterion statistics.

RESULTS

Data were included from 2358 nurses who averaged at least 30 h/week in the previous fortnight in one of the target practice areas. Final matrix variables were: total hours worked; number of shift extensions >30 min, night shifts; breaks < 9 h; breaks ≥ 24 h; nights with sleep 11pm to 7am; days waking fully rested; and roster change. After controlling for gender, ethnicity, years of nursing experience, and the extent of shift choice, the matrix score was a significant independent predictor of each of the three fatigue-related outcomes, and for all four aspects of life outside work. For all outcome variables, the model including the matrix score was a better fit to the data than the equivalent model including all the (uncategorised) work pattern variables.

CONCLUSIONS

A matrix that predicts the likelihood of nurses reporting fatigue-related safety outcomes can be used to compare the impact of rosters both at work and outside work. It can be used for roster design and management, and to guide nurses' choices about the shifts they work.

"Breaking" the Emergency Department: Does the Culture of Emergency Medicine Present a Barrier to Self-Care?

INTRODUCTION

Our goal was to critically examine emergency physician's (EP) beliefs about taking breaks for self-care on shift. Our operational definition of a break for self-care included time not engaging in direct patient care, eating, drinking, using the bathroom, or leaving a clinical area for a mental break. Using focus groups, the study aimed to accomplish the following: 1) identify barriers to why residents and faculty at our academic center may not take breaks in the emergency department; 2) generate hypotheses for empirical testing; and 3) generate solutions to include in a departmental breaks initiative.

METHODS

We convened eight focus groups comprised separately of resident and faculty physicians. Group discussion was guided by eight questions representing a priori themes. The groups were recorded for transcription and subjected to a "cut-and-sort" process. Six themes were identified by consensus after independent review by three of the co-authors, which were confirmed by participant validation.

RESULTS

We identified six themes that represented the pooled outcomes of both resident and faculty focus groups: 1) Physiological needs affect clinical performance, 2) EPs share beliefs around taking breaks that center on productivity, patient safety and the dichotomy of strength/weakness, 3) when taking breaks EPs fear worst-case scenarios, 4) breaking is a learned skill, 5) culture change is needed to allow EPs to engage in self-care; and 6) a flexible, individualized approach to breaking is necessary. Our central finding was that productivity and patient safety are of key importance to EPs when considering whether to take a break for self-care. We identified a dichotomy with the concept of strength related to productivity/patient safety, and the concept of weakness related to self-care.

CONCLUSION

The current practice culture of emergency medicine and the organization of our unique work environment may present barriers to physicians attempting to engage in self-care.

Fatigue and nurses' work patterns: An online questionnaire survey

BACKGROUND

Fatigue resulting from shift work and extended hours can compromise patient care and the safety and health of nurses, as well as increasing nursing turnover and health care costs.

OBJECTIVES

This research aimed to identify aspects of nurses' work patterns associated with increased risk of reporting fatigue-related outcomes.

DESIGN

A national survey of work patterns and fatigue-related outcomes in 6 practice areas expected to have high fatigue risk (child health including neonatology, cardiac care/intensive care, emergency and trauma, in-patient mental health, medical, and surgical nursing).

METHODS

The 5-page online questionnaire included questions addressing: demographics, usual work patterns, work in the previous two weeks, choice about shifts, and four fatigue-related outcomes - having a sleep problem for at least 6 months, sleepiness (Epworth Sleepiness Scale), recalling a fatigue-related error in clinical practice in the last 6 months, and feeling close to falling asleep at the wheel in the last 12 months. The target population was all registered and enrolled nurses employed to work in public hospitals at least 30 h/week in one of the 6 practice areas. Participation was voluntary and anonymous.

RESULTS

Respondents (n = 3133) were 89.8% women and 8% Māori (indigenous New Zealanders), median age 40 years, range 21-71 years (response rate 42.6%). Nurses were more likely than New Zealand adults in general to report chronic sleep problems (37.73% vs 25.09%, p < 0.0001) and excessive sleepiness (33.75% vs 14.9%, p < 0.0001). Fatigue-related error(s) in the last 6 months were recalled by 30.80% and 64.50% reported having felt sleepy at the wheel in the last 12 months. Logistic regression analyses indicated that fatigue-related outcomes were most consistently associated with shift timing and sleep. Risk increased with more night shifts and decreased with more nights with sleep between 11 p.m. and 7 a.m. and on which nurses had enough sleep to feel fully rested. Risk also increased with roster changes and more shift extensions greater than 30 min and decreased with more choice about shifts. Comparisons between intensive care/cardiac care and in-patient mental health nursing highlight that fatigue has different causes and consequences in different practice areas.

CONCLUSIONS

Findings confirm the need for a more comprehensive and adaptable approach to managing fatigue. We advocate an approach that integrates safety management and scientific principles with nursing and management expertise. It should be data-driven, risk-focused, adaptable, and resilient in the face of changes in the services required, the resources available, and the overall goals of the healthcare system.

[An introduction to human factors: From aeronautic to obstetrics]

The theme of human factors is becoming more and more prominent in the healthcare field. Indeed, despite their expertise, healthcare providers display the same limits, those of any human being working in a team, in a system that requires high-reliability. Error is inherent in all human activity. Therefore, the study of human factors makes a perfect sense. The aim of our article is to provide to readers general and recent information on the concept of human factors, and to introduce other related notions such as "error", "fault", non-punishment of error, leadership, crew resource management, situation awareness. Indeed, in some teams, a lack of situation awareness, a poor communication, or an inadequate leadership may lead to a deteriorated clinical situation, leading to a significant and unbearable risk to our pregnant patients. We have a lot to learn from other professional systems that require high-reliability such as aeronautic, military and nuclear field for example. Thus, understanding a teamwork running and the genesis of the errors, developing some notions as illustrated by non-punishment of the error occurrence, debriefings, maintenance of regular staffs, high-fidelity simulation may allow the teams to evolve in a safer system for our pregnant patients.

Fatigue Risk Management: The Impact of Anesthesiology Residents' Work Schedules on Job Performance and a Review of Potential Countermeasures

Long duty periods and overnight call shifts impair physicians' performance on measures of vigilance, psychomotor functioning, alertness, and mood. Anesthesiology residents typically work between 64 and 70 hours per week and are often required to work 24 hours or overnight shifts, sometimes taking call every third night. Mitigating the effects of sleep loss, circadian misalignment, and sleep inertia requires an understanding of the relationship among work schedules, fatigue, and job performance. This article reviews the current Accreditation Council for Graduate Medical Education guidelines for resident duty hours, examines how anesthesiologists' work schedules can affect job performance, and discusses the ramifications of overnight and prolonged duty hours on patient safety and resident well-being. We then propose countermeasures that have been implemented to mitigate the effects of fatigue and describe how training programs or practice groups who must work overnight can adapt these strategies for use in a hospital setting. Countermeasures include the use of scheduling interventions, strategic naps, microbreaks, caffeine use during overnight and extended shifts, and the use of bright lights in the clinical setting when possible or personal blue light devices when the room lights must be turned off. Although this review focuses primarily on anesthesiology residents in training, many of the mitigation strategies described here can be used effectively by physicians in practice.

Healthy working time arrangements for healthcare personnel and patients: a systematic literature review

BACKGROUND

A number of working time arrangements have been linked to negative consequences for both health personnel and their patients. A common hypothesis put forth to explain these findings suggests that certain working time arrangements lead to negative patient consequences due to the adverse impact they have on employee health. The purpose of this study is to use systematic reviews to investigate whether employee health explains the relationship between working time arrangements and patient safety.

METHODS

A systematic literature review was performed including published reviews and original studies from MEDLINE, PsycINFO, Cinahl and Web of Science investigating working time arrangements for healthcare personnel, employee health and patient safety. In addition, we screened reference lists of identified reviews. Two reviewers independently identified relevant publications according to inclusion criteria, extracted findings and assessed quality.

RESULTS

Six thousand nine hundred thirty papers were identified, of which 52 studies met our criteria. Articles were categorized into five groups according to how they approached the research question: 1) independent analyses of relationship between working time arrangements and employee health, and of working time arrangements and patient safety (5 studies); 2) relationship between working time arrangements on both employee health and patient safety (21 studies); 3) working time arrangements and employee health as two explanatory variables for patient safety (8 studies); 4) combinations of the above analyses (7 studies); 5) other relevant studies (5 studies). Studies that find that working time is detrimental to employee health, generally also find detrimental results for patient safety. This is particularly shown through increases in errors by health personnel. When controlling for employee health, the relationship between working time arrangements and patient safety is reduced, but still significant.

CONCLUSIONS

Results suggest that employee health partially (but not completely) mediates the relationship between working time arrangements and patient safety. However, there is a lack of studies directly investigating employee health as a mediator between working time arrangements and patient safety. Future studies should address this research gap.

Assessment of Patient and Occupational Safety Culture in Hospitals: Development of a Questionnaire with Comparable Dimensions and Results of a Feasibility Study in a German University Hospital

(1) Background: Both patient and occupational safety cultures should be considered when promoting safety culture. To our knowledge, there are no studies that capture patient safety culture (PSC) and occupational safety culture (OSC) in hospitals while using a common questionnaire. The aim of this feasibility study in a German university hospital was to develop a questionnaire to assess both issues analogously. In addition to feasibility outcomes, we report results of PSC-OSC comparisons. (2) Methods: To assess PSC, we used the existing Hospital Survey on Patient Safety Culture (HSPSC) questionnaire. Developing new OSC "twin items" for certain parts of the HSPSC was supported by a previous literature review. Additionally, we developed multiple choice questions to examine knowledge and competencies regarding specific PS/OS aspects. (3) Results: Developing and implementing a combined PSC and OSC assessment instrument was feasible. The overall response rate was 33% (407 nurses, 140 physicians). In general, the statistical reliability of almost all scales was sufficient. Positive PSC perceptions (agreement rates 46⁻87%) were found in 16 out of 18 scales. Of the four twin scales, the PSC values were significantly better. Individual PS- and OS-related knowledge and competencies were lower than expected. (4) Conclusion: The comparative investigation of patient and occupational safety in a large hospital is a promising approach and can be recommended for further studies. We used our experiences that are presented here in an ongoing bicentric study on the associations between working conditions, occupational safety culture, patient safety culture, and patient safety outcomes (WorkSafeMed).

Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors

OBJECTIVE

To evaluate physician burnout, well-being, and work unit safety grades in relationship to perceived major medical errors.

PARTICIPANTS AND METHODS

From August 28, 2014, to October 6, 2014, we conducted a population-based survey of US physicians in active practice regarding burnout, fatigue, suicidal ideation, work unit safety grade, and recent medical errors. Multivariate logistic regression and mixed-effects hierarchical models evaluated the associations among burnout, well-being measures, work unit safety grades, and medical errors.

RESULTS

Of 6695 responding physicians in active practice, 6586 provided information on the areas of interest: 3574 (54.3%) reported symptoms of burnout, 2163 (32.8%) reported excessive fatigue, and 427 (6.5%) reported recent suicidal ideation, with 255 of 6563 (3.9%) reporting a poor or failing patient safety grade in their primary work area and 691 of 6586 (10.5%) reporting a major medical error in the prior 3 months. Physicians reporting errors were more likely to have symptoms of burnout (77.6% vs 51.5%; P<.001), fatigue (46.6% vs 31.2%; P<.001), and recent suicidal ideation (12.7% vs 5.8%; P<.001). In multivariate modeling, perceived errors were independently more likely to be reported by physicians with burnout (odds ratio [OR], 2.22; 95% CI, 1.79-2.76) or fatigue (OR, 1.38; 95% CI, 1.15-1.65) and those with incrementally worse work unit safety grades (OR, 1.70; 95% CI, 1.36-2.12; OR, 1.92; 95% CI, 1.48-2.49; OR, 3.12; 95% CI, 2.13-4.58; and OR, 4.37; 95% CI, 2.06-9.28 for grades of B, C, D, and F, respectively), adjusted for demographic and clinical characteristics.

CONCLUSION

In this large national study, physician burnout, fatigue, and work unit safety grades were independently associated with major medical errors. Interventions to reduce rates of medical errors must address both physician well-being and work unit safety.

Impact of fatigue and insufficient sleep on physician and patient outcomes: a systematic review

OBJECTIVES

For physicians in independent practice, we synthesised evidence on the (1) impacts of insufficient sleep and fatigue on health and performance, and patient safety and (2) effectiveness of interventions targeting insufficient sleep and fatigue.

DESIGN

We systematically reviewed online literature. After piloting, one reviewer selected studies by title and abstract; full texts were then reviewed in duplicate. One reviewer extracted data; another verified a random 10% sample. Two reviewers assessed risk of bias. We pooled findings via meta-analysis when appropriate or narratively.

DATA SOURCES

We searched Medline, Embase, PsycINFO, CINAHL and PubMed for published studies in April 2016; Medline was updated in November 2017. We searched Embase for conference proceedings, and hand-searched meeting abstracts, association and foundation websites.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

English or French language primary research studies published from 2000 to 2017 examining the effect of fatigue-related or sleep-related exposures or interventions on any outcome among physicians in independent practice and their patients.

RESULTS

Of 16 154 records identified, we included 47 quantitative studies of variable quality. 28 studies showed associations between fatigue or insufficient sleep and physician health and well-being outcomes. 21 studies showed no association with surgical performance, and mixed findings for psychomotor performance, work performance and medical errors. We pooled data from six cohort studies for patient outcomes. For sleep deprived versus non-sleep deprived surgeons, we found no difference in patient mortality (n=60 436, relative risk (RR) 0.98, 95% CI 0.84 to 1.15, I²=0% (p=0.87)) nor postoperative complications (n=60 201, RR 0.99, 95% CI 0.95 to 1.03, I²=0% (p=0.45)). The findings for intraoperative complications and length of stay were considerably heterogeneous.

CONCLUSIONS

Fatigue and insufficient sleep may be associated with negative physician health outcomes. Current evidence is inadequate to inform practice recommendations.

Survey of occupational fatigue in anaesthetists in Australia and New Zealand

Occupational fatigue in anaesthetists is recognised as a patient safety risk. Better understanding of the issues surrounding their fatigue is needed. This study aimed to ascertain the sources and effects of occupational fatigue amongst anaesthetists in Australia and New Zealand. An anonymous online survey was sent to 979 anaesthetists. The response rate was 38.0%. Most participants reported regularly working over 40 hours per week; men reported five more hours per week than women. Stated contributors to fatigue included long work hours, mental strain at work, and personal and family demands. Fatigue-related behaviour was reported more by men (OR [odds ratio]=2.6) and less by respondents reporting eight or more hours of sleep before work (OR=0.6). Reporting at least one instance of less than five hours off between shifts was predictive of falling asleep while administering an anaesthetic (OR=1.6). More data are required to support practices and policies that promote more time off between work periods and increased time for sleep to reduce risk of fatigue.

Associations of Shift Work and Its Duration with Work-Related Injury among Electronics Factory Workers in South Korea

This study aimed to explore the association between shift work and work-related injuries. We collected data on workers from an electronics factory. This cross-sectional study included 13,610 subjects, who were assessed based on a self-reported questionnaire about their shift work experiences, work-related injuries, and other covariates. Multiple logistic regression models were used to evaluate the associations between shift work and work-related injuries and were estimated using the odds ratio. We found that the current and past shift workers, compared to non-shift workers, were associated with a 2.7- and 1.7-fold higher risk of work-related injury. There was a dose-response relationship between shift work duration and work-related injury among current female shift workers. Shift work increased the risk of work-related injuries, and the impact could be different depending on gender.

Welfare of anaesthesia trainees survey

This study was designed to investigate levels of stress, anxiety or depression and to identify factors compounding or relieving stress in anaesthesia trainees within the Australian and New Zealand College of Anaesthetists (ANZCA) training scheme. An electronic survey was sent to 999 randomly selected trainees and 428 responses were received. In addition to demographics, psychological wellbeing was assessed using the Kessler Psychological Distress Scale (K10) and questions were asked about depression and anxiety, exacerbating factors, personal healthcare and strategies used to manage stress. The majority of respondents (73%) reported being satisfied or very satisfied with their job and training. However, 28% of respondents had K10 scores indicating high or very high distress levels. Eleven percent reported being currently on treatment for anxiety and/or depression. Twenty-two percent reported having experienced bullying and 14% sexism. Twenty-eight percent reported that they did not have a regular general practitioner (GP), and 41% reported having not visited their GP in the previous year. Forty-seven percent of trainees reported that they self-prescribe medications. Major stressors reported were exams, critical clinical events and fear of making errors. Two stressors previously not identified in similar studies were concern about job prospects in 71% of respondents and workplace-based assessments in 51%. This survey demonstrates significant psychological impairment and poor personal healthcare amongst many trainees. Education, careful continuing assessment of trainees' welfare and a review of current support and remedial measures may be required.

A national survey of the effects of fatigue on trainees in anaesthesia in the UK

Long daytime and overnight shifts remain a major feature of working life for trainees in anaesthesia. Over the past 10 years, there has been an increase in awareness and understanding of the potential effects of fatigue on both the doctor and the patient. The Working Time Regulations (1998) implemented the European Working Time Directive into UK law, and in August 2009 it was applied to junior doctors, reducing the maximum hours worked from an average of 56 per week to 48. Despite this, there is evidence that problems with inadequate rest and fatigue persist. There is no official guidance regarding provision of a minimum standard of rest facilities for doctors in the National Health Service, and the way in which rest is achieved by trainee anaesthetists during their on-call shift depends on rota staffing and workload. We conducted a national survey to assess the incidence and effects of fatigue among the 3772 anaesthetists in training within the UK. We achieved a response rate of 59% (2231/3772 responses), with data from 100% of NHS trusts. Fatigue remains prevalent among junior anaesthetists, with reports that it has effects on physical health (73.6% [95%CI 71.8-75.5]), psychological wellbeing (71.2% [69.2-73.1]) and personal relationships (67.9% [65.9-70.0]). The most problematic factor remains night shift work, with many respondents commenting on the absence of breaks, inadequate rest facilities and 57.0% (55.0-59.1) stating they had experienced an accident or near-miss when travelling home from night shifts. We discuss potential explanations for the results, and present a plan to address the issues raised by this survey, aiming to change the culture around fatigue for the better.

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.

Current and future directions in clinical fatigue management: An update for emergency medicine practitioners

Physicians worldwide are working round the clock to meet the demands of healthcare systems, especially in acute medical settings such as EDs. Demanding shift work schedules cause fatigue and thus deterioration in mood and motor performance. This article explores the effects of sleep deprivation, focusing on cognition, executive decision-making and the implications for clinical care. Humans are capable of functioning and even adapting to sleep restriction; however, clinicians should be aware of pitfalls and absolute minimums for sleep. Fatigue management training shows promise in enhancing safety in aviation and might have a role in medical shift work. Strategic napping improves performance during night shift in the ED, but does not fully negate fatigue. Drugs offer limited benefit for performance under sleep-deprived conditions, and whenever possible, sleep and/or strategic napping takes precedence.

The Impact of the Australian and New Zealand College of Anaesthetists’ Specialist Examinations on Trainee Learning and Wellbeing: A Qualitative Study

Assessment is an essential component of any medical specialist training program and should motivate trainees to acquire and retain the knowledge and skills essential for specialist practice, and to develop effective approaches to learning, essential for continuous professional development. Ideally, this should be achieved without creating an unreasonable burden of assessment. In this qualitative study we sought to investigate the underlying processes involved in trainees’ preparation for Australian and New Zealand College of Anaesthetists’ examinations, focusing on how the examinations helped trainees to learn the Australian and New Zealand College of Anaesthetists’ curriculum, and to identify any potential areas for improvement. We also explored the effect the examinations had on trainees’ lives, to identify if the examinations were a potential threat to their wellbeing. Using a phenomenological approach and purposive sampling, we conducted semi-structured interviews with post-fellowship trainees (n=20) selected from three different regions, with sampling continuing to achieve data saturation. We undertook a thematic analysis of the transcribed interview data utilising a general inductive approach. Our preliminary data suggest that, while the examinations are an important extrinsic motivator to learn and important for professional development, interviewees described many test-driven learning strategies, including rote learning and memorising past examination questions. A strong theme was the considerable impact on participants’ relationships and social activities for prolonged periods. Our findings support further research in this area and, in particular, into alternative testing strategies that might increase the proportion of time spent in useful study while decreasing less useful study time.

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.

Fifteen-hour day shifts have little effect on the performance of taskwork by anaesthesia trainees during uncomplicated clinical simulation

Shiftwork and work-hour limits for junior doctors are now well established in hospital work patterns. In order to ensure that trainees have adequate exposure to daytime elective surgical procedures, there is a tendency to have long shifts that include an after-hours component. However, long shifts can cause performance decrement due to time-on-task fatigue. In addition, shifts that encroach upon sleep time result in sleep loss. Using a high-fidelity patient simulation environment, we undertook a randomised, controlled trial to examine fatigue effects. A within-subjects comparison was used to evaluate the effect of 15-hour day shifts on the performance of 12 anaesthesia registrars. Preoperative assessment, machine check and taskwork using 42 task categories were evaluated. In both conditions, there was failure to meet current guidelines for preoperative evaluation or machine check, and when fatigued there was a 'trend' (P=0.06) to a reduction in the number of items in the machine check. With increase in time awake, there was an increase in time taken for explanation to the patient, an increase in mean duration of explanation to the patient, more time looking at the intravenous line or fluids when multi-tasking but less time adjusting the intravenous fluid. These effects are minor during routine uncomplicated induction of anaesthesia, but further investigation is needed to examine fatigue effects during non-routine circumstances.