Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 Infection

BACKGROUND

Obstructive sleep apnea is associated with COVID-19 infection. Less clear is whether obstructive sleep apnea is a risk factor for the development of post-acute sequelae of SARS-CoV-2 infection (PASC).

STUDY DESIGN

Cross-sectional survey of a general population of 24,803 US adults to determine the association of obstructive sleep apnea with PASC.

RESULTS

COVID-19 infection occurred in 10,324 (41.6%) participants. Prevalence of persistent (>3 months post infection) putative PASC-related physical and mental health symptoms ranged from 6.5% (peripheral edema) to 19.6% (nervous/anxious). In logistic regression models, obstructive sleep apnea was associated with all putative PASC-related symptoms with the highest adjusted odds ratios being fever (2.053) and nervous/anxious (1.939). In 4 logistic regression models of overall PASC derived from elastic net regression, obstructive sleep apnea was associated with PASC (range of adjusted odds ratios: 1.934-2.071); this association was mitigated in those with treated obstructive sleep apnea. In the best fitting overall model requiring ≥3 symptoms, PASC prevalence was 21.9%.

CONCLUSION

In a general population sample, obstructive sleep apnea is associated with the development of PASC-related symptoms and a global definition of PASC. Treated obstructive sleep apnea mitigates the latter risk. The presence of 3 or more PASC symptoms may be useful in identifying cases and for future research.

Association of Chronotype and Shiftwork with COVID-19 Infection

OBJECTIVE

This study assesses whether chronotype is related to COVID-19 infection and whether there is an interaction with shift work.

METHODS

Cross-sectional survey of 19,821 U.S. adults.

RESULTS

COVID-19 infection occurred in 40% of participants, 32.6% morning and 17.2% evening chronotypes. After adjusting for demographic and socioeconomic factors, shift/remote work, sleep duration and comorbidities, morning chronotype was associated with a higher (aOR: 1.15, 95% CI 1.10-1.21) and evening chronotype with a lower (aOR: 0.82, 95% CI: 0.78-0.87) prevalence of COVID-19 infection in comparison to an intermediate chronotype. Working exclusively night shifts was not associated with higher prevalence of COVID-19. Morning chronotype and working some evening shifts was associated with the highest prevalence of previous COVID-19 infection (aOR: 1.87, 95% CI: 1.28-2.74).

CONCLUSION

Morning chronotype and working a mixture of shifts increase risk of COVID-19 infection.

Spatiotemporal light exposure modeling for environmental circadian misalignment and solar jetlag

Background

Light exposure is the most powerful resetting signal for circadian rhythms. The objective of this study was to develop and validate a high-resolution geospatial light exposure model that measures environmental circadian misalignment (or solar jetlag) as the mismatch between the social clock and sun clock, which occurs from geographic variation in light exposure leading to delayed circadian phase from relatively less morning light exposure and greater evening light exposure with increasing westward position within a time zone.

Methods

The light exposure model (30 m2 spatial resolution) incorporated geospatial data across the United States on time zones, elevation (using Google Earth Engine), sunrise time, and sunset time to estimate solar jetlag scores (higher values indicate higher environmental circadian misalignment). The validation study compared the light exposure model in 2022, which was linked with geocoded residential addresses of n = 20 participants in Boston, MA (eastern time zone position) and Seattle, WA (western time zone position) using a geographic information system, with illuminance values captured from wearable LYS light sensors and with sun times from the Solar Calculator.

Results

Western versus eastern positions within a time zone were associated with higher solar jetlag scores from the light exposure model (P < 0.01) and relatively larger differences in sunset time measured using light sensors (social clock) and the Solar Calculator (sun clock) (P = 0.04).

Conclusion

We developed and validated a geospatial light exposure model, enabling high spatiotemporal resolution and comprehensive characterization of geographic variation in light exposure potentially impacting circadian phase in epidemiologic studies.

Sleep and mental health among unpaid caregivers of children, adults, and both: United States, 2022

OBJECTIVES

We sought to characterize sleep and mental health, and their relationship, among unpaid caregivers.

METHODS

During March through August 2022, four waves of cross-sectional surveys were administered to US adults using demographic quota sampling and weighting to improve representativeness of the US adult population.

RESULTS

Among 19,767 respondents, 6260 (31.7%) identified as serving one or more unpaid caregiving roles. Compared to people without caregiving roles, caregivers more commonly reported sleep duration outside the healthy range (7-9 hours), insomnia symptoms, diagnosed sleep disorders, and more commonly screened positive for anxiety, depression, and burnout symptoms. Multivariable analyses adjusted for demographics characteristics revealed unpaid caregivers had several-fold elevated odds of adverse mental health symptoms; associations were attenuated but remained significant after adjusting for impaired and nonoptimal sleep.

CONCLUSIONS

Both sleep and mental health challenges are disproportionately experienced by and commonly co-occur among unpaid caregivers, especially those who care for both children and adults. These populations, which serve critical societal roles, may benefit from enhanced support services to address sleep and mental health.

Public opinion of resident physician work hours in 2022

OBJECTIVE

The purpose of this study was to characterize public awareness and opinion regarding resident physician work hours in the United States.

METHODS

We conducted a nationally representative cross-sectional survey among adults in the United States. Demographic quota-based sampling was conducted by Qualtrics to match 2020 United States Census estimates of age, sex, race, and ethnicity. Descriptive statistics are presented. Hypothesis testing was conducted to identify characteristics associated with agreement with current resident physician work-hour policies.

RESULTS

4763 adults in the United States participated in the study. 97.1% of the public believes that resident physicians should not work 24-hour shifts and 95.6% believe the current 80 hours resident work week is too long. 66.4% of the participants reported that the maximum shift duration should be 12 consecutive hours or fewer, including 22.9% who recommended a maximum shift length of 8 hours. Similarly, 66.4% reported that maximum weekly work hours should be 59 or fewer, including 24.9% who recommended a maximum of 40 weekly work hours.

CONCLUSIONS

Nearly all US adults disagree with current work-hour policies for resident physicians. Public opinion supports limiting shifts to no more than 12 consecutive hours and weekly work to no more than 60 hours, which is in sharp contrast to current regulations that permit of 28 hours shifts and 80 hours of work per week.

The effect of a night shift nap on post-night shift performance, sleepiness, mood, and first recovery sleep: A randomized crossover trial

OBJECTIVES

This study aimed to test the effect of a 30-minute nap versus a 2-hour nap opportunity taken during a simulated night shift on performance, fatigue, sleepiness, mood, and sleep at the end of shift and during post-night shift recovery.

METHODS

We conducted a randomized crossover trial of three nap conditions (30-minute, 2-hour, and no-nap) during 12-hour simulated night shifts. We tested for differences in performance, fatigue, sleepiness, mood, and sleep during in-lab and at-home recovery. Performance was measured with the Brief Psychomotor Vigilance Test (PVT-B). Subjective ratings were assessed with single-item surveys.

RESULTS

Twenty-eight individuals consented to participate [mean age 24.4 (standard deviation 7.2) years; 53.6% female; 85.7% Emergency Medical Services clinicians]. PVT-B false starts at the end of the 12-hour night shift (at 07:00 hours) and at the start of in-lab recovery (08:00 hours) were lower following the 2-hour nap versus other conditions (P<0.05). PVT-B response time at +0 minutes post-recovery nap was poorer compared to pre-recovery nap for the no-nap condition (P=0.003), yet not detected for other nap conditions (P>0.05). Sleepiness, fatigue, and some mood states were lower at most hourly assessments during the in-lab recovery period following the 2-hour nap condition compared to the other conditions. Sleep during recovery did not differ by duration of night shift nap.

CONCLUSIONS

A 2-hour nap opportunity versus a 30-minute or no-nap opportunity is beneficial for performance, alertness, and mood post-night shift. No differences were detected in sleep during recovery.

Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 infection (PASC)

Background

Obstructive sleep apnea (OSA) is associated with COVID-19 infection. Fewer investigations have assessed OSA as a possible risk for the development of Post-Acute Sequelae of SARS-CoV-2 infection (PASC).

Research Question

In a general population, is OSA associated with increased odds of PASC-related symptoms and with an overall definition of PASC?

Study Design

Cross-sectional survey of a general population of 24,803 U.S. adults.

Results

COVID-19 infection occurred in 10,324 (41.6%) participants. Prevalence rates for a wide variety of persistent (> 3 months post infection) putative PASC-related physical and mental health symptoms ranged from 6.5% (peripheral edema) to 19.6% (nervous/anxious). In logistic regression models adjusted for demographic, anthropometric, comorbid medical and socioeconomic factors, OSA was associated with all putative PASC-related symptoms with the highest adjusted odds ratios (aOR) being fever (2.053) and nervous/anxious (1.939) respectively. Elastic net regression identified the 13 of 37 symptoms most strongly associated with COVID-19 infection. Four definitions of PASC were developed using these symptoms either weighted equally or proportionally by their regression coefficients. In all 4 logistic regression models using these definitions, OSA was associated with PASC (range of aORs: 1.934-2.071); this association was mitigated in those with treated OSA. In the best fitting overall model requiring ≥3 symptoms, PASC prevalence was 21.9%.

Conclusion

In a general population sample, OSA is associated with the development of PASC-related symptoms and a global definition of PASC. A PASC definition requiring the presence of 3 or more symptoms may be useful in identifying cases and for future research.

The importance of sleep regularity: a consensus statement of the National Sleep Foundation sleep timing and variability panel

OBJECTIVE

To develop and present consensus findings of the National Sleep Foundation sleep timing and variability panel regarding the impact of sleep timing variability on health and performance.

METHODS

The National Sleep Foundation assembled a panel of sleep and circadian experts to evaluate the scientific evidence and conduct a formal consensus and voting procedure. A systematic literature review was conducted using the NIH National Library of Medicine PubMed database, and panelists voted on the appropriateness of 3 questions using a modified Delphi RAND/UCLA Appropriateness Method with 2 rounds of voting.

RESULTS

The literature search and panel review identified 63 full text publications to inform consensus voting. Panelists achieved consensus on each question: (1) is daily regularity in sleep timing important for (a) health or (b) performance? and (2) when sleep is of insufficient duration during the week (or work days), is catch-up sleep on weekends (or non-work days) important for health? Based on the evidence currently available, panelists agreed to an affirmative response to all 3 questions.

CONCLUSIONS

Consistency of sleep onset and offset timing is important for health, safety, and performance. Nonetheless, when insufficient sleep is obtained during the week/work days, weekend/non-work day catch-up sleep may be beneficial.

Systematic Review of the Impact of Physician Work Schedules on Patient Safety with Meta-Analyses of Mortality Risk

Resident physician work hour limits continue to be controversial. Numerous trials have come to conflicting conclusions about the impact on patient safety of eliminating extended duration work shifts. We conducted meta-analyses to evaluate the impact of work hour policies and work schedules on patient safety. After identifying 8,362 potentially relevant studies and reviewing 688 full-text articles, 132 studies were retained and graded on quality of evidence. Of these, 68 studies provided enough information for consideration in meta-analyses. We found that patient safety improved following implementation of the Accreditation Council for Graduate Medical Education's 2003 and 2011 resident physicians work hour guidelines. Limiting all resident physicians to 80-hour work weeks and 28-hour shifts in 2003 was associated with an 11% reduction in mortality (p < 0.001). Limited shift durations and shorter work weeks were also associated with improved patient safety in clinical trials and observational studies not specifically tied to policy changes. Given the preponderance of evidence showing that patient and physician safety is negatively affected by long work hours, efforts to improve physician schedules should be prioritized. Policies that enable extended-duration shifts and long work weeks should be reexamined. Further research should expand beyond resident physicians to additional study populations, including attending physicians and other health care workers.

Are Short Duration Naps Better than Long Duration Naps for Mitigating Sleep Inertia? Brief Report of a Randomized Crossover Trial of Simulated Night Shift Work

OBJECTIVE

We sought to test the effects of different duration naps on post-nap cognitive performance during simulated night shifts.

METHODS

We used a randomized laboratory-based crossover trial design with simulated 12-hr night shifts and each participant completing three conditions of 72 hrs each (Clinicaltrials.gov; registration # NCT04469803). The three conditions tested included no-nap, a 30-min nap opportunity, and a 2-hr nap opportunity. Naps occurred at 02:00 hrs. Cognitive performance was assessed with the Brief 3-min Psychomotor Vigilance Test (PVT-B). Four PVT-B measures include: reaction time (RT in milliseconds (ms)), lapses (RT > 355 ms), false starts (reactions before stimulus or RT <100 ms), and speed (1,000/RT). The PVT-B was performed at the start of the simulated night shift (19:00), end of shift (07:00), pre-nap (02:00), and at 0 mins, 10 mins, 20 mins, and 30 mins following the 30-min and 2-hr nap conditions. Simultaneously, participants reported subjective ratings of fatigue and other constructs.

RESULTS

Twenty-eight (15 female), mostly certified emergency medical technicians or paramedics, consented to participate. For all three conditions, looking within condition, PVT-B lapse performance at the end of the 12-hr simulated night shift (at 07:00) was poorer compared to shift start (p < 0.05). Performance on PVT-B speed, RT, and false starts were poorer at shift end than shift start for the no-nap and 30-min nap conditions (p < 0.05), but not for the 2-hr nap condition (p > 0.05). Compared to pre-nap measures, performance on the PVT-B assessed at 0 mins post-nap showed significant performance declines for lapses and speed for both the 30-min and 2-hr nap conditions (p < 0.05), but not at 10, 20, or 30 mins post-nap. After waking from the 2-hr on-shift nap opportunity (at 0 mins), participants rated sleepiness, difficulty with concentration, and alertness poorer than pre-nap (p < 0.05). Participants in the 30-min nap condition rated alertness poorer immediately after the nap (at 0 mins) compared to pre-nap (p < 0.05).

CONCLUSIONS

While sleep inertia was detectable immediately following short 30-min and long 2-hr nap opportunities during simulated night shift work, deficits in cognitive performance and subjective ratings quickly dissipated and were not detectable at 10-30 mins post-nap.

Effect of Short versus Long Duration Naps on Blood Pressure during Simulated Night Shift Work: A Randomized Crossover Trial

OBJECTIVE

Blunting of the sleep-related dip in blood pressure (BP) has been linked to numerous cardiovascular outcomes including myocardial infarction. Blunting of BP dipping occurs during night shift work and previous research suggest that a 60-min or longer on-shift nap is needed to restore normal/healthy BP dipping. We sought to determine the effect of different durations of napping on BP during and following simulated night shifts. We hypothesized that the greatest benefit in terms of restoration of normal BP dipping during night shift work would be observed during a longer duration nap versus a shorter nap opportunity.

METHODS

We used a randomized crossover laboratory-based study design. Participants consented to complete three separate 72-hr conditions that included a 12-hr simulated night shift. Nap conditions included a 30-min and 2-hr nap compared to a no-nap condition. Ambulatory BP monitoring was assessed hourly and every 10-30 mins during in-lab naps. Blunted BP dipping during in-lab naps was the primary outcome. Goal enrollment of 25 (35 with attrition) provided 80% power to detect a mean difference of 5 mmHg in BP between nap conditions.

RESULTS

Of the 58 screened, 28 were consented, and 26 completed all three 72-hr conditions. More than half (53.6%) were female. Mean age was 24.4 years (SD7.2). Most (85.7%) were certified as emergency medical technicians or paramedics. The mean percentage dip in systolic BP (SBP) and diastolic BP (DBP) did not differ between the 30-min and 2-hr nap conditions (p > 0.05), yet a greater proportion of participants experienced a 10-20% dip in SBP or DBP during the 2-hr nap versus the 30-min nap (p < 0.05). For every additional minute of total sleep during the 30-min nap, the percentage of SBP dip improved by 0.60%, and the percentage of DBP dip improved by 0.68% (p < 0.05). These improvements approximate to a 6% per minute relative advancement toward normal/healthy BP dipping.

CONCLUSIONS

Restoration of a normal/healthy dip in BP is achievable during short and long duration nap opportunities during simulated night shift work. Our findings support the hypothesis that BP dipping is more common during longer 2-hr versus shorter 30-min naps.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04469803. Registered on 9 July 2020.

Association of Chronotype and Shiftwork with COVID-19 Infection

Objective

This study assesses whether chronotype is related to COVID-19 infection and whether there is an interaction with shift work.

Methods

Cross-sectional survey of 19,821 U.S. adults.

Results

COVID-19 infection occurred in 40% of participants, 32.6% morning and 17.2% evening chronotypes. After adjusting for demographic and socioeconomic factors, shift work, sleep duration and comorbidities, morning chronotype was associated with a higher (aOR: 1.15, 95% CI 1.10-1.21) and evening chronotype with a lower (aOR: 0.82, 95% CI: 0.78-0.87) prevalence of COVID-19 infection in comparison to an intermediate chronotype. Working exclusively night shifts was not associated with higher prevalence of COVID-19. Morning chronotype and working some evening shifts was associated with the highest prevalence of previous COVID-19 infection (aOR: 1.87, 95% CI: 1.28-2.74).

Conclusion

Morning chronotype and working a mixture of shifts increase risk of COVID-19 infection.

Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among US adults

STUDY OBJECTIVES

Medical comorbidities increase the risk of severe COVID-19 infection. In some studies, obstructive sleep apnea (OSA) has been identified as a comorbid condition that is associated with an increased prevalence of COVID-19 infection and hospitalization, but few have investigated this association in a general population. This study aimed to answer the following research question: In a general population, is OSA associated with increased odds of COVID-19 infection and hospitalization and are these altered with COVID-19 vaccination?

METHODS

This was a cross-sectional survey of a diverse sample of 15,057 US adults.

RESULTS

COVID-19 infection and hospitalization rates in the cohort were 38.9% and 2.9%, respectively. OSA or OSA symptoms were reported in 19.4%. In logistic regression models adjusted for demographic, socioeconomic, and comorbid medical conditions, OSA was positively associated with COVID-19 infection (adjusted odds ratio: 1.58, 95% CI: 1.39-1.79) and COVID-19 hospitalization (adjusted odds ratio: 1.55, 95% CI: 1.17-2.05). In fully adjusted models, boosted vaccination status was protective against both infection and hospitalization. Boosted vaccination status attenuated the association between OSA and COVID-19 related hospitalization but not infection. Participants with untreated or symptomatic OSA were at greater risk for COVID-19 infection; those with untreated but not symptomatic OSA were more likely to be hospitalized.

CONCLUSIONS

In a general population sample, OSA is associated with a greater likelihood of having had a COVID-19 infection and a COVID-19 hospitalization with the greatest impact observed among persons experiencing OSA symptoms or who were untreated for their OSA. Boosted vaccination status attenuated the association between OSA and COVID-19-related hospitalization.

CITATION

Quan SF, Weaver MD, Czeisler MÉ, et al. Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among U.S. adults. J Clin Sleep Med. 2023;19(7):1303-1311.

Examining understandability, information quality, and presence of misinformation in popular YouTube videos on sleep compared to expert-led videos

The Internet is a common source of sleep information but may be subject to commercial bias and misinformation. We compared the understandability, information quality, and presence of misinformation of popular YouTube videos on sleep to videos with credible experts. We identified the most popular YouTube videos on sleep/insomnia and 5 videos from experts. Videos were assessed for understanding and clarity using validated instruments. Misinformation and commercial bias were identified by consensus of sleep medicine experts. The most popular videos received, on average, 8.2 (± 2.2) million views; the expert-led videos received, on average, 0.3 (± 0.2) million views. Commercial bias was identified in 66.7% of popular videos and 0% of expert videos (P < .012). The popular videos featured more misinformation than expert videos (P < .001). The popular videos about sleep/insomnia on YouTube featured misinformation and commercial bias. Future research may explore methods for disseminating evidence-based sleep information.

CITATION

Robbins R, Epstein LJ, Iyer JM, et al. Examining understandability, information quality, and presence of misinformation in popular YouTube videos on sleep compared to expert-led videos. J Clin Sleep Med. 2023;19(5):991-994.

Insomnia, Poor Sleep Quality and Sleep Duration and Risk for COVID-19 Infection and Hospitalization

BACKGROUND

Medical comorbidities increase the risk of severe acute COVID-19 illness. Although sleep problems are common after COVID-19 infection, it is unclear whether insomnia, poor sleep quality and extremely long or short sleep increase risk of developing COVID-19 infection or hospitalization.

METHODS

Cross-sectional survey of a diverse sample of 19,926 U.S. adults RESULTS: COVID-19 infection and hospitalization prevalence rates were 40.1% and 2.9% respectively. Insomnia and poor sleep quality were reported in 19.8% and 40.1% respectively. In logistic regression models adjusted for comorbid medical conditions and sleep duration but excluding participants who reported COVID-19 associated sleep problems, poor sleep quality but not insomnia was associated with COVID-19 infection (aOR: 1.16, 95%CI: 1.07-1.26) and COVID-19 hospitalization (aOR: 1.50, 95% CI: 1.18-1.91). In comparison to habitual sleep duration of 7-8 hours, sleep durations less than 7 hours (aOR: 1.14, 95% CI: 1.06-1.23) and sleep duration of 12 hours (aOR: 1.61, 95% CI: 1.12-2.31) were associated with increased odds of COVID-19 infection. Overall, the relationship between COVID-19 infection and hours of sleep followed a quadratic (U shaped) pattern. No association between sleep duration and COVID-19 hospitalization was observed.

CONCLUSION

In a general population sample, poor sleep quality and extremes of sleep duration are associated with greater odds of having had a COVID-19 infection; poor sleep quality was associated with an increased requirement of hospitalization for severe COVID-19 illness. These observations suggest that inclusion of healthy sleep practices in public health messaging may reduce the impact of the COVID-19 pandemic.

Impact of sleep deficiency on surgical performance: a prospective assessment

STUDY OBJECTIVES

Sleep deficiency can adversely affect the performance of resident physicians, resulting in greater medical errors. However, the impact of sleep deficiency on surgical outcomes, particularly among attending surgeons, is less clear.

METHODS

Sixty attending surgeons from academic and community departments of surgery or obstetrics and gynecology were studied prospectively using direct observation and self-report to explore the effect of sleep deprivation on patient safety, operating room communication, medical errors, and adverse events while operating under 2 conditions, post-call (defined as > 2 hours of nighttime clinical duties) and non-post-call.

RESULTS

Each surgeon contributed up to 5 surgical procedures post-call and non-post-call, yielding 362 cases total (150 post-call and 210 non-post-call). Most common were caesarian section and herniorrhaphy. Hours of sleep on the night before the operative procedure were significantly less post-call (4.98 ± 1.41) vs non-post-call (6.68 ± 0.88, P < .01). Errors were infrequent and not related to hours of sleep or post-call status. However, Non-Technical Skills for Surgeons ratings demonstrated poorer performance while post-call for situational awareness, decision-making, and communication/teamwork. Fewer hours of sleep also were related to lower ratings for situational awareness and decision-making. Decreased self-reported alertness was observed to be associated with increased procedure time.

CONCLUSIONS

Sleep deficiency in attending surgeons was not associated with greater errors during procedures performed during the next day. However, procedure time was increased, suggesting that surgeons were able to compensate for sleep loss by working more slowly. Ratings on nontechnical surgical skills were adversely affected by sleep deficiency.

CITATION

Quan SF, Landrigan CP, Barger LK, et al. Impact of sleep deficiency on surgical performance: a prospective assessment. J Clin Sleep Med. 2023;19(4):673-683.

Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study

Objective

To determine whether long weekly work hours and shifts of extended duration (≥24 hours) are associated with adverse patient and physician safety outcomes in more senior resident physicians (postgraduate year 2 and above; PGY2+).

Design

Nationwide, prospective cohort study.

Setting

United States, conducted over eight academic years (2002-07, 2014-17).

Participants

4826 PGY2+ resident physicians who completed 38 702 monthly web based reports of their work hours and patient and resident safety outcomes.

Main outcome measures

Patient safety outcomes included medical errors, preventable adverse events, and fatal preventable adverse events. Resident physician health and safety outcomes included motor vehicle crashes, near miss crashes, occupational exposures to potentially contaminated blood or other bodily fluids, percutaneous injuries, and attentional failures. Data were analysed with mixed effects regression models that accounted for dependence of repeated measures and controlled for potential confounders.

Results

Working more than 48 hours per week was associated with an increased risk of self-reported medical errors, preventable adverse events, and fatal preventable adverse events as well as near miss crashes, occupational exposures, percutaneous injuries, and attentional failures (all P<0.001). Working between 60 and 70 hours per week was associated with a more than twice the risk of a medical error (odds ratio 2.36, 95% confidence interval 2.01 to 2.78) and almost three times the risk of preventable adverse events (2.93, 2.04 to 4.23) and fatal preventable adverse events (2.75, 1.23 to 6.12). Working one or more shifts of extended duration in a month while averaging no more than 80 weekly work hours was associated with an 84% increased risk of medical errors (1.84, 1.66 to 2.03), a 51% increased risk of preventable adverse events (1.51, 1.20 to 1.90), and an 85% increased risk of fatal preventable adverse events (1.85, 1.05 to 3.26). Similarly, working one or more shifts of extended duration in a month while averaging no more than 80 weekly work hours also increased the risk of near miss crashes (1.47, 1.32 to 1.63) and occupational exposures (1.17, 1.02 to 1.33).

Conclusions

These results indicate that exceeding 48 weekly work hours or working shifts of extended duration endangers even experienced (ie, PGY2+) resident physicians and their patients. These data suggest that regulatory bodies in the US and elsewhere should consider lowering weekly work hour limits, as the European Union has done, and eliminating shifts of extended duration to protect the more than 150 000 physicians training in the US and their patients.

The Emergency Medical Services Sleep Health Study: A cluster-randomized trial

BACKGROUND

Greater than half of emergency medical services (EMS) clinician shift workers report poor sleep, fatigue, and inadequate recovery between shifts. We hypothesized that EMS clinicians randomized to receive tailored sleep health education would have improved sleep quality and less fatigue compared to wait-list controls after 3 months.

METHODS

We used a cluster-randomized, 2-arm, wait-list control study design (clinicaltrials.gov identifier: NCT04218279). Recruitment of EMS agencies (clusters) was nationwide. Our study was powered at 88% to detect a 0.4 standard deviation difference in sleep quality with 20 agencies per arm and a minimum of 10 individuals per agency. The primary outcome was measured using the Pittsburgh Sleep Quality Index (PSQI) at 3-month follow-up. Our intervention was accessible in an online, asynchronous format and comprised of 10 brief education modules that address fatigue mitigation topics prescribed by the American College of Occupational Environmental Medicine.

RESULTS

In total, 36 EMS agencies and 678 individuals enrolled. Attrition at 3 months did not differ by study group (Intervention = 17.4% vs. Wait-list control = 18.2%; p = .37). Intention-to-treat analyses detected no differences in PSQI and fatigue scores at 3 months. Per protocol analyses showed the greater the number of education modules viewed, the greater the improvement in sleep quality and the greater the reduction in fatigue (p < .05).

CONCLUSIONS

While intention-to-treat analyses revealed no differences in sleep quality or fatigue at 3 months, per protocol findings identified select groups of EMS clinician shift workers who may benefit from sleep health education. Our findings may inform fatigue risk management programs.

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy in 2011 that restricted first-year resident physicians in the USA to work no more than 16 consecutive hours. This was rescinded in 2017.

METHODS

We conducted a nationwide prospective cohort study of resident physicians for 5 academic years (2002-2007) before and for 3 academic years (2014-2017) after implementation of the 16 hours 2011 ACGME work-hour limit. Our analyses compare trends in resident physician-reported medical errors between the two cohorts to evaluate the impact of this policy change.

RESULTS

14 796 residents provided data describing 78 101 months of direct patient care. After adjustment for potential confounders, the work-hour policy was associated with a 32% reduced risk of resident physician-reported significant medical errors (rate ratio (RR) 0.68; 95% CI 0.64 to 0.72), a 34% reduced risk of reported preventable adverse events (RR 0.66; 95% CI 0.59 to 0.74) and a 63% reduced risk of reported medical errors resulting in patient death (RR 0.37; 95% CI 0.28 to 0.49).

CONCLUSIONS

These findings have broad relevance for those who work in and receive care from academic hospitals in the USA. The decision to lift this work hour policy in 2017 may expose patients to preventable harm.

Perception of Local COVID-19 Transmission and Use of Preventive Behaviors Among Adults with Recent SARS-CoV-2 Infection - Illinois and Michigan, June 1-July 31, 2022

During the early stages of the COVID-19 pandemic, use of preventive behaviors was associated with perceived risk for contracting SARS-CoV-2 infection (1,2). Over time, perceived risk has declined along with waning COVID-19-related media coverage (3,4). The extent to which communities continue to be aware of local COVID-19 transmission levels and are implementing recommended preventive behaviors is unknown. During June 1-July 31, 2022, health departments in DuPage County, Illinois and metropolitan Detroit, Michigan surveyed a combined total of 4,934 adults who had received a positive test result for SARS-CoV-2 during the preceding 3 weeks. The association between awareness of local COVID-19 transmission and use of preventive behaviors and practices was assessed, both in response to perceived local COVID-19 transmission levels and specifically during the 2 weeks preceding SARS-CoV-2 testing. Both areas had experienced sustained high COVID-19 transmission during the study interval as categorized by CDC COVID-19 transmission levels.* Overall, 702 (14%) respondents perceived local COVID-19 transmission levels as high, 987 (20%) as substantial, 1,902 (39%) as moderate, and 581 (12%) as low; 789 (16%) reported they did not know. Adjusting for geographic area, age, gender identity, and combined race and ethnicity, respondents who perceived local COVID-19 transmission levels as high were more likely to report having made behavioral changes because of the level of COVID-19 transmission in their area, including wearing a mask in public, limiting travel, and avoiding crowded places or events. Continued monitoring of public perceptions of local COVID-19 levels and developing a better understanding of their influence on the use of preventive behaviors can guide COVID-19 communication strategies and policy making during and beyond the pandemic.

Evaluating the impact of a sleep health education and a personalised smartphone application on sleep, productivity and healthcare utilisation among employees: results of a randomised clinical trial

OBJECTIVES

We evaluated an online Sleep Health and Wellness (SHAW) programme paired with dayzz, a personalised sleep training programme deployed via smartphone application (dayzz app) that promotes healthy sleep and treatment for sleep disorders, among employees at a large healthcare organisation.

DESIGN

Open-label, randomised, parallel-group controlled trial.

SETTING

A healthcare employer in the USA.

PARTICIPANTS

1355 daytime workers.

INTERVENTION

Participants were randomised to intervention (n=794) or control (n=561) on consent. Intervention participants received the SHAW educational programme at baseline plus access to the personalised dayzz app for up to 9 months. The control condition received the intervention at month 10.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome measures were sleep-related behavioural changes (eg, consistent sleep schedule); sleep behaviour tracked on an electronic sleep diary and sleep quality. Our secondary outcome measures included employee absenteeism, performance and productivity; stress, mood, alertness and energy; and adverse health and safety outcomes (eg, accidents).

RESULTS

At follow-up, employees in the intervention condition were more likely to report increased sleep duration on work (7.20 vs 6.99, p=0.01) and on free (8.26 vs 8.04, p=0.03) nights. At follow-up, the prevalence of poor sleep quality was lower in the intervention (n=160 of 321, 50%) compared with control (n=184 of 327, 56%) (p=0.04). The mean total dollars lost per person per month due to reduced workplace performance (presenteeism) was less in the intervention condition (US$1090 vs US$1321, p=0.001). Employees in the intervention reported fewer mental health visits (RR 0.72, 95% CI 0.56 to 0.94, p=0.01) and lower healthcare utilisation over the study interval (RR 0.81, 95% CI 0.67 to 0.98, p=0.03). We did not observe differences in stress (4.7 (95% CI 4.6 to 4.8) vs 4.7 (95% CI 4.6 to 4.8)), mood (4.5 (95% CI 4.4 to 4.6) vs 4.6 (95% CI 4.5 to 4.7)), alertness (4.9 (95% CI 4.8 to 5.0) vs 5.0 (95% CI 4.9 to 5.1)) or adverse health and safety outcomes (motor vehicle crashes: OR 0.82 (95% CI 0.34 to 1.9); near-miss crashes: OR=0.89 (95% CI 0.5 to 1.5) and injuries: 0.9 (95% CI 0.6 to 1.3)); energy was higher at follow-up in the intervention group (4.3 vs 4.5; p=0.03).

CONCLUSIONS

Results from this trial demonstrate that a SHAW programme followed by access to the digital dayzz app can be beneficial to both the employee and employer.

TRIAL REGISTRATION NUMBER

NCT04224285.