Circadian rhythm, shift work, and emergency medicine

Differences in durations, adverse events, and outcomes of in-hospital cardiopulmonary resuscitation between day-time and night-time: An observational cohort study

BACKGROUND

Although patients with out-of-hospital cardiac arrest (OHCA) have a lower survival rate during night-time than during day-time, the cause of this difference remains unclear. We aimed to assess CPR parameters according to time period based on in-hospital cardiopulmonary resuscitation (IHCPR) duration and the frequency of iatrogenic chest injuries among OHCA patients.

METHODS

This two-centre observational cohort study evaluated non-traumatic OHCA patients who were transferred between 2013-2016. These patients were categorised according to whether they received day-time treatment (07:00-22:59) or night-time treatment (23:00-06:59). Differences in IHCPR duration, CPR-related chest injuries, return of spontaneous circulation, and survivals to emergency department and hospital discharge were compared using a generalised estimating equation model adjusted for pre-hospital confounders. Sensitivity analysis was also performed using a propensity score matching method.

RESULTS

Among 1254 patients (day-time: 948, night-time: 306), the night-time patients had a significantly shorter IHCPR duration (27.8 min vs. 23.6 min, adjusted difference: -5.1 min, 95% confidence interval [CI]: -6.7, -3.4), a higher incidence of chest injuries (40.4% vs. 67.0%, adjusted odds ratio [AOR]: 1.27, 95% CI: 1.20, 1.35), and a lower rate of return of spontaneous circulation (38.4% vs. 26.5%, AOR: 0.93, 95% CI: 0.88, 0.98). No significant differences were observed in the rates of survival to emergency department and hospital discharge. The propensity score-matched analysis revealed similar results.

CONCLUSIONS

Patients who underwent night-time treatment for OHCA had an increased risk of CPR-related chest injuries despite their shorter resuscitation duration. Further studies are needed to clarify the underlying mechanism(s).

Night and rotational work exposure within the last 12 months and risk of incident hypertension

Objectives Shift work, such as alternating day and nights, causes chronobiologic disruptions which may cause an increase in hypertension risk. However, the relative contributions of the components of shift work ‒ such as shift type (eg, night work) and rotations (ie, switching of shift times; day to night) ‒ on this association are not clear. To address this question, we constructed novel definitions of night work and rotational work and assessed their associations with risk of incident hypertension. Methods A cohort of 2151 workers at eight aluminum manufacturing facilities previously studied for cardiovascular disease was followed from 2003 through 2013 for incident hypertension, as defined by ICD-9 insurance claims codes. Detailed time-registry data was used to classify each worker's history of rotational and night work. The associations between recent rotational work and night work in the last 12 months and incident hypertension were estimated using adjusted Cox proportional hazards models. Results Elevated hazard ratios (HR) were observed for all levels of recent night work (>0-5, >5-50, >50-95, >95-100%) compared with non-night workers, and among all levels of rotational work (<1, 1-10, >10-20, >20-30, and >30%) compared with those working <1% rotational work. In models for considering the combination of night and rotational work, workers with mostly night work and frequent rotations (≥50% night and ≥10% rotation) had the highest risk of hypertension compared to non-night workers [HR 4.00, 95% confidence interval (CI )1.69-9.52]. Conclusions Our results suggest recent night and rotational work may both be associated with higher rates of incident hypertension.

Targeted synchronization in an externally driven population of mechanical oscillators

We experimentally investigate the synchronization of driven metronomes using a servo motor to impose external control. We show that a driven metronome will only synchronize in a narrow range near its own frequency; when we introduce coupling between metronomes, we can widen the range of frequencies over which a metronome will synchronize to the external input. Using these features, we design a signal to synchronize a population of dissimilar metronomes; separately we design a signal to selectively synchronize a subpopulation of metronomes within a heterogeneous population.

Mantra meditation programme for emergency department staff: a qualitative study

OBJECTIVES

Rates of burnout and stress in healthcare practitioners are steadily increasing. Emergency department (ED) staff are particularly susceptible to such poor outcomes. Mantra meditation (MM) may contribute to increased well-being. The primary aim of this study was to obtain indepth qualitative feedback on ED staff's experience of a MM programme. A secondary objective was to harness staff's perception of the ED working environment.

DESIGN

Qualitative study.

SETTING

ED in St James' Hospital, Dublin, Ireland.

PARTICIPANTS

Doctors, nurses, allied health professionals and administrative staff (n=10, eight women, mean age 35.6 years) working in the ED who attended a MM programme.

METHODS

Semistructured interviews were conducted by a trained independent researcher. Interviews were transcribed and thematically analysed.

RESULTS

Five main themes and six subthemes were identified: work pressure and perceived stress; perceived benefits of meditation (with subthemes of increased attention/awareness, improved emotion regulation and new coping mechanisms, relaxation and sleep quality); conflicting attitudes to practice; barriers to meditation practice (with subthemes of schedule, length of practice and individual differences); and facilitators to practice.

CONCLUSION

ED staff in this study described the demands of their work and voiced a need for a workplace well-being programme. Our findings suggest that MM might represent a viable tool to develop attention and awareness, improve emotion regulation and improve their capacity to cope with stress, which may impact their workplace well-being, wider health service, patient safety and quality of care. Support from the organisation is considered to be integral to embedding of a workplace well-being programme, such as the practice of meditation into their daily lives.

Out-of-hours intensive care unit admission and 90-day mortality: a Danish nationwide cohort study

BACKGROUND

Mortality rates in critically ill adult patients admitted to the intensive care unit (ICU) remains high, and numerous patient- and disease-related adverse prognostic factors have been identified. In recent years, studies in a variety of emergency conditions suggested that outcome is dependent on the time of hospital admission. The importance of out-of-hours admission to the ICU has been sparsely evaluated and with ambiguous findings. We assessed the association between out-of-hours (16:00 to 07:00) and weekend admission to the ICU, respectively, and 90-day mortality in a nationwide cohort.

METHODS

We included all Danish adult patients admitted to the ICU between 1 January 2011 and 30 June 2014, with an ICU stay > 24 h. The crude and adjusted association between out-of-hours and weekend admission and 90-day mortality was assessed (odds ratio (ORs) with 95% confidence intervals (CI)).

RESULTS

A total of 44,797 patients were included, 53.3% were admitted out-of-hours, and 22.6% during weekends. Median age was 67 years (interquartile range (IQR) 55-76), and median SAPS II was 42 (IQR 30-54). Patients admitted in-hours vs. out-of-hours displayed a 90-day mortality rate of 41.0% vs. 44.2%. The adjusted association (OR with 95% CI) between out-of-hours admission and 90-day mortality was 1.07 (1.02-1.11), and the adjusted association (OR with 95% CI) between weekend admission and 90-day mortality was 1.10 (1.05-1.15).

CONCLUSION

This nationwide study suggests that critically ill adult patients admitted to the ICU during weekends and out-of-hours, and with an ICU stay > 24 h are at slightly increased risk of mortality.

Sleep and Exercise in Emergency Medicine Residents: An Observational Pilot Study Exploring the Utility of Wearable Activity Monitors for Monitoring Wellness

Introduction

Burnout is well-documented in residents and emergency physicians. Wellness initiatives are becoming increasingly prevalent, but there is a lack of data supporting their efficacy. In some populations, a relationship between sleep, exercise, and wellness has been documented; however, this relationship has not been established in emergency medicine (EM) residents or physicians. We aim to determine whether a wearable activity monitor is a feasible method of evaluating exercise and sleep quality and quantity in emergency medicine residents and if these assessments are associated with greater perceived wellness.

Methods

Twenty EM residents from two training sites wore a wearable activity monitor (Fitbit ChargeTM, Fitbit, Inc., San Francisco, CA, USA) during a four-week EM rotation. The Fitbit recorded data on sleep quantity (minutes sleeping) and quality (sleep disruptions), as well as exercise quantity and quality (daily step count, daily active minutes performing activity of 3 - 6, and > 6 metabolic equivalents). Participants completed an end-of-rotation Perceived Wellness Survey (PWS), which provided information on six domains of personal wellness (psychological, emotional, social, physical, spiritual, and intellectual). PWS levels were compared between groups of subjects with higher or lower levels of activity and sleep (i.e., above and below the median subject-averaged values) using the Mann-Whitney U test. Other subject characteristics were similarly assessed for their association with PWS. When a possible confounding effect was seen, the data was stratified and reviewed using a scatterplot.

Results

Of the 28 eligible residents, 23 agreed to participate. Of these, 20 and 16 wore the device for at least 50% of the respective days and nights during the observation period. Two devices were lost. One PWS was not completed. There was no statistically significant correlation between resident perceived wellness survey scores, sleep interruptions, average daily sleep minutes, daily step count, or average daily active minutes for the sample overall. However, first-year residents and residents from years two to five reported different median PWS scores of 13.9 and 17.1, respectively. Further exploration by the training group suggested that step counts may correlate with wellness in participants in their first year of residency, while the quantity of sleep may have an association with wellness in participants in years two through five of their residency.

Conclusion

Using wearable activity monitor devices to capture sleep and exercise data among residents does not seem to be an effective approach. Our data does not support our hypothesis that overall resident wellness was associated with exercise and sleep quality and quantity as measured by such a device. These results are counterintuitive and may be complicated by several measurement-related limitations and the possibility that benefits depend on the stage of training.

Emergency Medicine Resident Shift Work Preferences: A Comparison of Resident Scheduling Preferences and Recommended Schedule Design for Shift Workers

BACKGROUND

Shift work can negatively impact an individual's health, wellness, and quality of work. Optimal schedule design can mitigate some of these effects. The American College of Emergency Physicians has published schedule design guidelines to increase wellness and longevity in the field, but these guidelines are difficult to apply to emergency medicine (EM) residents given their high shift burdens and other scheduling constraints. Little is known is known about EM resident scheduling preferences or ideal schedule design in the context of residency training.

OBJECTIVES

The objectives were to determine whether EM resident schedule design preferences are consistent with current scheduling guidelines for shift workers and to gather information on scheduling practices that are important to residents.

METHODS

We surveyed residents at four allopathic EM residency programs and assessed residents' preferences on various schedule design features including shift length, circadian scheduling, night shift scheduling, and impact of schedule design on personal wellness.

RESULTS

Of the 144 residents surveyed, 98% of residents felt that their shift schedule was a key factor in their overall wellness. Residents agreed with shift work guidelines regarding the importance of circadian scheduling (65% favorable), although rated the ability to request a day off and have a full weekend off as more important (84 and 78% favorable responses, respectively). Recommended guidelines promote shorter shifts, but only 24% of residents preferred 8-hour shifts compared to 57, 71, and 43% of residents preferring 9-, 10-, and 12-hour shifts, respectively. Sixty-seven percent of residents preferred their nights to be scheduled in one sequence per 4-week period, a night scheduling strategy most at odds with recommended guidelines.

CONCLUSIONS

Emergency medicine resident scheduling preferences are not universally consistent with shift work guidelines, likely due to the distinct circumstances of residency training. Residents identify schedule design as a significant factor in their overall wellness.

Effects of night shift on the cognitive load of physicians and urinary steroid hormone profiles - a randomized crossover trial

Mental and physical stress is common in physicians during night shifts. Neurocognitive effects of sleep deprivation as well as alterations in hormonal and metabolic parameters have previously been described. The aim of this crossover study was to evaluate the effects of night-shift work with partial sleep deprivation on steroid hormone excretion and possible associations with mood, sleep characteristics and cognitive functions in physicians. In total, 34 physicians (mean age 42 ± 8.5 years, 76.5% male) from different departments of the General Hospital of Vienna, Austria, were randomly assigned to two conditions: a regular day shift (8 h on duty, condition 1) and a continuous day-night shift (24 h on duty, condition 2). In both conditions, physicians collected a 24 h urine sample for steroid hormone concentration analysis and further completed psychological tests, including the sleep questionnaire (SF-A), the questionnaire for mental state (MDBF) and the computer-assisted visual memory test (FVW) before and at the end of their shifts, respectively. Although mean sleep deprivation during night shift was relatively small (~1.5 h) the impairment in participants' mental state was high in all three dimensions (mood, vigilance and agitation, p ≤ 0.001). Sleep quality (SQ), feeling of being recovered after sleep and mental balance decreased (p ≤ 0.001), whereas mental exhaustion increased (p < 0.05). Moreover, we could show a nearly linear relationship between most of these self-rating items. Testing visual memory participants made significantly more mistakes after night shift (p = 0.011), however, mostly in incorrectly identified items and not in correctly identified ones (FVW). SQ and false identified items were negatively correlated, whereas SQ and time of reaction were positively associated. It is assumed that after night shift, a tendency exists to make faster wrong decisions. SQ did not influence correctly identified items in FVW. In contrast to previous investigations, we found that only excretion rates for pregnanetriol and androsterone/etiocholanolone ratios (p < 0.05, respectively) were slightly reduced in 24-h urine samples after night shift. A considerable stimulation of the adrenocortical axis could not be affirmed. In general, dehydroepiandrosteron (DHEA) was negatively associated with the sense of recreation after sleep and with the time of reaction and positively correlated with correctly identified items in the FVW test. These results, on the one hand, are in line with previous findings indicating that stress and sleep deprivation suppress gonadal steroids, but, on the other hand, do not imply significant adrenocortical-axis stimulation (e.g. an increase of cortisol) during the day-night shift.

Impact of night shifts on emergency medicine resident resuscitation performance

AIM

Emergency medicine (EM) trainees often work nightshifts. We sought to measure how this circadian disruption affects EM resident performance during simulated resuscitations.

METHODS

This retrospective cohort study enrolled EM residents at a single Canadian academic centre over a six-year period. Residents completed twice-annual simulation-based resuscitation-focused objective structured clinical examinations (OSCEs) with assessment in four domains (primary assessment, diagnostic actions, therapeutic actions and communication), and a global assessment score (GAS). Primary and secondary exposures of interest were the presence of a nightshift (late-evening shifts ending between midnight and 03h00 or overnight shifts ending after 06h00) the day before or within three days before an OSCE. A random effects linear regression model was used to quantify the association between nightshifts and OSCE scores.

RESULTS

From 57 residents, 136 OSCE scores were collected. Working a nightshift the day before an OSCE did not affect male trainee scores but was associated with a significant absolute decrease in mean total scores (-6% [95% CI -12% to 0%]), GAS (-7% [-13% to 0%]), and communication (-9% [-16% to -2%]) scores among women. Working any nightshift within three days before an OSCE lowered absolute mean total scores by 4% [-7% to 0%] and communication scores by 5% [-5% to 0%] irrespective of gender.

CONCLUSION

Our results suggest that shift work may impact EM resident resuscitation performance, particularly in the communication domain. This impact may be more significant in women than men, suggesting a need for further investigation.

Influence of Shift Duration on Cognitive Performance of Emergency Physicians: A Prospective Cross-Sectional Study

STUDY OBJECTIVE

The relationship between tiredness and medical errors is now commonly accepted. The main objective of this study is to evaluate the cognitive performance of emergency physicians after a night shift of 14 hours (H14) and after a work shift of 24 hours (H24) and to compare it with tests performed after a rest night at home (H0).

METHODS

Forty emergency physicians (19 staff physicians and 21 residents) were randomly evaluated at H0, H14, and H24. Four cognitive abilities (processing speed, working memory capacity, perceptual reasoning, and cognitive flexibility) were tested according to the Wechsler Adult Intelligence Scale and the Wisconsin Card Sorting Test.

RESULTS

No cognitive ability was significantly altered after H14 compared with H0. Three of 4 cognitive abilities were impaired at H24 compared with H0: processing speed (11.2 [SD 2.7] versus 12.4 [SD 3.2]; mean difference=-1.2 [95% confidence interval -1.9 to -0.5]), working memory capacity (10.1 [SD 2.9] versus 11.6 [SD 3.0]; mean difference=-1.5 [95% confidence interval -2.2 to -0.8]), and perceptual reasoning (8.4 [SD 2.7] versus 10.6 [SD 2.8]; mean difference=-2.2 [95% confidence interval -3.4 to -1.0]). Cognitive abilities were not different between residents and staff physicians (except for perceptual reasoning) and were not affected by the amount of sleep during the night shift.

CONCLUSION

The cognitive abilities of emergency physicians were significantly altered after a 24-hour shift, whereas they were not significantly different from the rested condition after a 14-hour night shift. Limiting 24-hour shift work for emergency physicians should be considered and further evaluated.

Time of Admission to the PICU and Mortality

OBJECTIVES

To evaluate for any association between time of admission to the PICU and mortality.

DESIGN

Retrospective cohort study of admissions to PICUs in the Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database from 2009 to 2014.

SETTING

One hundred and twenty-nine PICUs in the United States.

PATIENTS

Patients less than 18 years old admitted to participating PICUs; excluding those post cardiac bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 391,779 admissions were included with an observed PICU mortality of 2.31%. Overall mortality was highest for patients admitted from 07:00 to 07:59 (3.32%) and lowest for patients admitted from 14:00 to 14:59 (1.99%). The highest mortality on weekdays occurred for admissions from 08:00 to 08:59 (3.30%) and on weekends for admissions from 09:00 to 09:59 (4.66%). In multivariable regression, admission during the morning 06:00-09:59 and midday 10:00-13:59 were independently associated with PICU death when compared with the afternoon time period 14:00-17:59 (morning odds ratio, 1.15; 95% CI, 1.04-1.26; p = 0.006 and midday odds ratio, 1.09; 95% CI; 1.01-1.18; p = 0.03). When separated into weekday versus weekend admissions, only morning admissions were associated with increased odds of death on weekdays (odds ratio, 1.13; 95% CI, 1.01-1.27; p = 0.03), whereas weekend admissions during the morning (odds ratio, 1.33; 95% CI, 1.14-1.55; p = 0.004), midday (odds ratio, 1.27; 95% CI, 1.11-1.45; p = 0.0006), and afternoon (odds ratio, 1.17; 95% CI, 1.03-1.32; p = 0.01) were associated with increased risk of death when compared with weekday afternoons.

CONCLUSIONS

Admission to the PICU during the morning period from 06:00 to 09:59 on weekdays and admission throughout the day on weekends (06:00-17:59) were independently associated with PICU death as compared to admission during weekday afternoons. Potential contributing factors deserving further study include handoffs of care, rounds, delays related to resource availability, or unrecognized patient deterioration prior to transfer.

Job stress and behavioral characteristics in relation to coronary heart disease risk among Japanese police officers

This study examined the association between job-related behavioral characteristics and the risk of coronary heart diseases (CHD) in Japanese male police officers. Compared to office clerks, police officers exhibited greater age-related increases of the prevalence of CHD risk factors, and a clustering number of CHD risk factors was significantly higher in the group of those over 45 yr of age. Among the police officers, coronary-prone behavior was more frequent than that seen in office clerks. The police officers with coronary-prone behavior tended to engage in shift work and to work overtime more; yet they were less likely to perceive job stress and to express the relevant physical and psychological symptoms than those without coronary-prone behavior. The subjects with such behavioral characteristics had a significantly greater number of CHD risk factors. In a multiple regression analysis, coronary-prone behavior together with age, social support, walking hours per day, and amount of alcohol consumption were selected as significant determinants of a cluster of CHD risk factors. These results suggest that coronary-prone behavior may contribute to the higher prevalence of CHD risk factors in police officers via leading the long working hours and the work-related unfavorable lifestyles, such as alcohol drinking and physical inactivity.

Effects of Sleep Deprivation on the Cognitive Performance of Nurses Working in Shift

INTRODUCTION

Sleep deprivation and altered circadian rhythm affects the cognitive performance of an individual. Quality of sleep is compromised in those who are frequently involved in extended working hours and shift work which is found to be more common among nurses. Cognitive impairment leads to fatigability, decline in attention and efficiency in their workplace which puts their health and patients' health at risk.

AIM

To find out the prevalence of sleep deprivation and its impact on cognition among shift working nurses.

MATERIALS AND METHODS

Sleep deprivation among 97 female and three male healthy nurses of age 20-50 years was assessed by Epworth sleepiness scale (ESS). Cognition was assessed by Montreal Cognitive Assessment (MoCA) questionnaire. Mobile applications were used to test their vigilance, reaction time, photographic memory and numerical cognition. The above said parameters were assessed during end of day shift and 3-4 days after start of night shift.

RESULTS

Poor sleep quality was observed among 69% of shift working nurses according to ESS scores. The cognitive performance was analysed using Wilcoxon signed rank test. The MoCA score was found to be lesser among 66% of nurses during night (25.72) than day (26.81). During the night, 32% made more mathematical errors. It was also found that, 71%, 83% and 68% of the nurses scored lesser during night in the Stroop's colour test, vigilance test and memory tests respectively. Thus, impairment in cognitive performance was statistically significant (p<0.001) among shift working nurses.

CONCLUSION

Cognitive performance was found to be impaired among shift working nurses, due to poor sleep quality and decreased alertness during wake state. Thus, shift work poses significant cognitive risks in work performance of nurses.

Survival Rates Following Pediatric In-Hospital Cardiac Arrests During Nights and Weekends

IMPORTANCE

Nearly 6000 hospitalized children in the United States receive cardiopulmonary resuscitation (CPR) annually. Little is known about whether the survival of these children is influenced by the time of the event (eg, nighttime or weekends). Differences in survival could have important implications for hospital staffing, training, and resource allocation.

OBJECTIVE

To determine whether outcomes after pediatric in-hospital cardiac arrests differ during nights and weekends compared with days/evenings and weekdays.

DESIGN, SETTING, AND PARTICIPANTS

This study included a total of 354 hospitals participating in the American Heart Association's Get With the Guidelines-Resuscitation registry from January 1, 2000, to December 12, 2012. Index cases (12 404 children) from all children younger than 18 years of age receiving CPR for at least 2 minutes were included. Data analysis was performed in December 2014 and June 2016. We aggregated hourly blocks of time, using previously defined time intervals of day/evening and night, as well as weekend. Multivariable logistic regression models were used to examine the effect of independent variables on survival to hospital discharge. We used a combination of a priori variables based on previous literature (including age, first documented rhythm, location of event in hospital, extracorporeal CPR, and hypotension as the cause of arrest), as well as variables that were identified in bivariate generalized estimating equation models, and maintained significance of P ≤ .15 in the final multivariable models.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was survival to hospital discharge, and secondary outcomes included return of circulation lasting more than 20 minutes and 24-hour survival.

RESULTS

Of 12 404 children (56.0% were male), 8731 (70.4%) experienced a return of circulation lasting more than 20 minutes, 7248 (58.4%) survived for 24 hours, and 4488 (36.2%) survived to hospital discharge. After adjusting for potential confounders, we found that the rate of survival to hospital discharge was lower during nights than during days/evenings (adjusted odds ratio, 0.88 [95% CI, 0.80-0.97]; P = .007) but was not different between weekends and weekdays (adjusted odds ratio, 0.92 [95% CI, 0.84-1.01]; P = .09).

CONCLUSIONS AND RELEVANCE

The rate of survival to hospital discharge was lower for pediatric CPR events occurring at night than for CPR events occurring during daytime and evening hours, even after adjusting for many potentially confounding patient-, event-, and hospital-related factors.

Exploring a New Simulation Approach to Improve Clinical Reasoning Teaching and Assessment: Randomized Trial Protocol

BACKGROUND

Helping trainees develop appropriate clinical reasoning abilities is a challenging goal in an environment where clinical situations are marked by high levels of complexity and unpredictability. The benefit of simulation-based education to assess clinical reasoning skills has rarely been reported. More specifically, it is unclear if clinical reasoning is better acquired if the instructor's input occurs entirely after or is integrated during the scenario. Based on educational principles of the dual-process theory of clinical reasoning, a new simulation approach called simulation with iterative discussions (SID) is introduced. The instructor interrupts the flow of the scenario at three key moments of the reasoning process (data gathering, integration, and confirmation). After each stop, the scenario is continued where it was interrupted. Finally, a brief general debriefing ends the session. System-1 process of clinical reasoning is assessed by verbalization during management of the case, and System-2 during the iterative discussions without providing feedback.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of Simulation with Iterative Discussions versus the classical approach of simulation in developing reasoning skills of General Pediatrics and Neonatal-Perinatal Medicine residents.

METHODS

This will be a prospective exploratory, randomized study conducted at Sainte-Justine hospital in Montreal, Qc, between January and March 2016. All post-graduate year (PGY) 1 to 6 residents will be invited to complete one SID or classical simulation 30 minutes audio video-recorded complex high-fidelity simulations covering a similar neonatology topic. Pre- and post-simulation questionnaires will be completed and a semistructured interview will be conducted after each simulation. Data analyses will use SPSS and NVivo softwares.

RESULTS

This study is in its preliminary stages and the results are expected to be made available by April, 2016.

CONCLUSIONS

This will be the first study to explore a new simulation approach designed to enhance clinical reasoning. By assessing more closely reasoning processes throughout a simulation session, we believe that Simulation with Iterative Discussions will be an interesting and more effective approach for students. The findings of the study will benefit medical educators, education programs, and medical students.

Are there high-risk groups among physicians that are more vulnerable to on-call work?

BACKGROUND

Work done in the emergency departments is one stressful aspect of physicians' work. Numerous previous studies have highlighted the stressfulness of on-call work and especially of night on call. In addition, previous studies suggest that there may be individual differences in adjusting to changes in circadian rhythms and on-call work.

OBJECTIVE

The objective of this study was to examine whether physicians' on-call work is associated with perceived work-related stress factors and job resources and whether there are groups that are more vulnerable to on-call work according to sex, age, and specialization status.

METHODS

This was a cross-sectional questionnaire study among 3230 Finnish physicians (61.5% women). The analyses were conducted using analyses of covariance adjusted for sex, age, specialization status, and employment sector.

RESULTS

Physicians with on-call duties had more time pressure and stress related to team work and patient information systems compared with those who did not have on-call duties. In addition, they had less job control opportunities and experienced organization as less fair and team climate as worse. Older physicians and specialists seemed to be especially vulnerable to on-call work regarding stress factors, whereas younger and specialist trainees seemed vulnerable to on-call work regarding job resources.

CONCLUSIONS

Focusing on team issues and resources is important for younger physicians and trainees having on-call duties, whereas for older and specialists, attention should be focused on actual work load and time pressure.

Off-hours admission to pediatric intensive care and mortality

BACKGROUND

Critically ill patients are admitted to the pediatric ICU at all times, while staffing and other factors may vary by day of the week or time of day. The purpose of this study was to evaluate whether admission during off-hours is independently associated with mortality in PICUs.

METHODS

A retrospective cohort study of admissions of patients <18 years of age to PICUs was performed using the Virtual PICU Systems (VPS, LLC) database. "Off-hours" was defined as nighttime (7:00 pm to 6:59 am) or weekend (Saturday or Sunday any time). Mixed-effects multivariable regression was performed by using Pediatric Index of Mortality 2 (PIM2) to adjust for severity of illness. Primary outcome was death in the pediatric ICU.

RESULTS

Data from 234,192 admissions to 99 PICUs from January 2009 to September 2012 were included. When compared with regular weekday admissions, off-hours admissions were less likely to be elective, had a higher risk for mortality by PIM2, and had a higher observed ICU mortality (off-hours 2.7% vs weekdays 2.2%; P < .001). Multivariable regression revealed that, after adjustment for other significant factors, off-hours admission was associated with lower odds of mortality (odds ratio, 0.91; 95% confidence interval, 0.85-0.97; P = .004). Post hoc multivariable analysis revealed that admission during the morning period 6:00 am to 10:59 am was independently associated with death (odds ratio, 1.27; 95% confidence interval, 1.16-1.39; P < .0001).

CONCLUSIONS

Off-hours admission does not independently increase odds of death in the PICU. Admission from 6:00 am to 10:59 am is associated with increased risk for death and warrants further investigation in the PICU population.

On-call work and physicians' well-being: testing the potential mediators

BACKGROUND

On-call duties have been rated to be among the most stressful aspects of physicians' work. On-call work has been associated, for example, with medical errors, injuries and lower well-being. Thus, because it is not possible to remove on-call duties, measures to decrease the negative ramifications of on-call work are needed.

AIMS

To examine whether working on-call would predict psychological distress, job satisfaction and work ability in a 4-year follow-up and whether sleeping problems or work interference with family (WIF) would act as mechanisms in these associations.

METHODS

Questionnaires in 2006 and 2010 among physicians in Finland. The mediation analyses were conducted using methods suggested by Preacher and Hayes to examine direct and indirect effects with multiple mediators.

RESULTS

There were 1541 respondents (60% women) of whom 52% had on-call duties. Sleeping problems and WIF acted as mechanisms in the association of existence of on-call duties with high distress, low job satisfaction and low work ability. On-call work was associated with higher levels of sleeping problems and WIF, and the number of active on-call hours was associated with higher levels of WIF, but not with sleeping problems.

CONCLUSIONS

According to our results, one way to attenuate on-call work's negative ramifications is to make it easier for on-call physicians to connect work and family lives and develop work arrangements to promote better sleep and protected sleep time.

Delinking resident duty hours from patient safety

Patient safety is a powerful motivating force for change in modern medicine, and is often cited as a rationale for reducing resident duty hours. However, current data suggest that resident duty hours are not significantly linked to important patient outcomes. We performed a narrative review and identified four potential explanations for these findings. First, we question the relevance of resident fatigue in the creation of harmful errors. Second, we discuss factors, including workload, experience, and individual characteristics, that may be more important determinants of resident fatigue than are duty hours. Third, we describe potential adverse effects that may arise from--and, therefore, counterbalance any potential benefits of--duty hour reductions. Fourth, we explore factors that may mitigate any risks to patient safety associated with using the services of resident trainees. In summary, it may be inappropriate to justify a reduction in working hours on the grounds of a presumed linkage between patient safety and resident duty hours. Better understanding of resident-related factors associated with patient safety will be essential if improvements in important patient safety outcomes are to be realized through resident-focused strategies.

Neurocognitive effects following an overnight call shift on faculty anesthesiologists

BACKGROUND

The impact of sleep deprivation on neurocognitive performance is a significant concern to both the health of patients and to the physicians caring for them, as demonstrated by the Accreditation Council for Graduate Medical Education enforced resident work hours. This study examined the effects of an overnight call at a level 1 trauma hospital on neurocognitive performance of faculty anesthesiologists.

METHODS

Eleven faculty anesthesiologists completed a series of computerized tests that were designed to evaluate different areas of neurocognition, such as working memory, verbal learning, and concentration. The anesthesiologists completed the tests following an overnight call in the morning at 6:30 and again following a normal night's rest at 6:30 on a different date.

RESULTS

Within-subjects, repeated measures analysis of variance revealed a significant difference on post-call vs. control performance on measures of learning and memory (P = 0.04). However, there were no significant differences on performance on measures of working memory or sustained attention and vigilance. Pre-call vs. control performances were also evaluated, but no significant differences were detected.

CONCLUSIONS

Following a night call shift, performance on learning and memory was significantly reduced. Other areas were not significantly affected, which may have been due to certain possibilities, such as practice effect or variability in the call shifts. The real-world relevance of the decline in performance on these measures remains unclear.

Chronic phase advance alters circadian physiological rhythms and peripheral molecular clocks

Shifting the onset of light, acutely or chronically, can profoundly affect responses to infection, tumor progression, development of metabolic disease, and mortality in mammals. To date, the majority of phase-shifting studies have focused on acute exposure to a shift in the timing of the light cycle, whereas the consequences of chronic phase shifts alone on molecular rhythms in peripheral tissues such as skeletal muscle have not been studied. In this study, we tested the effect of chronic phase advance on the molecular clock mechanism in two phenotypically different skeletal muscles. The phase advance protocol (CPA) involved 6-h phase advances (earlier light onset) every 4 days for 8 wk. Analysis of the molecular clock, via bioluminescence recording, in the soleus and flexor digitorum brevis (FDB) muscles and lung demonstrated that CPA advanced the phase of the rhythm when studied immediately after CPA. However, if the mice were placed into free-running conditions (DD) for 2 wk after CPA, the molecular clock was not phase shifted in the two muscles but was still shifted in the lung. Wheel running behavior remained rhythmic in CPA mice; however, the endogenous period length of the free-running rhythm was significantly shorter than that of control mice. Core body temperature, cage activity, and heart rate remained rhythmic throughout the experiment, although the onset of the rhythms was significantly delayed with CPA. These results provide clues that lifestyles associated with chronic environmental desynchrony, such as shift work, can have disruptive effects on the molecular clock mechanism in peripheral tissues, including both types of skeletal muscle. Whether this can contribute, long term, to increased incidence of insulin resistance/metabolic disease requires further study.

After-hours on-call: the effect on paediatricians' spouses and families

AIM

The after-hours or on-call component of a paediatrician's work has implications for their spouse and family. Little is known about the specifics and extent of this impact. We aimed to understand the potential positive and negative impacts of this important aspect of a paediatrician's work.

METHODS

The spouses (nine female and one male) of 10 practising paediatricians, who are providing care in a variety of hospital settings within New Zealand, were interviewed using an open-questioning technique. Interviews were analysed by a qualitative line-by-line thematic method in order to categorise the perceived impact of their spouses' on-call work on themselves and their families.

RESULTS

Participants reported multiple effects of after-hours on-call on themselves, their paediatrician partners and their families. Negative themes included sleep deprivation, restrictions on life-style and living location (specifically home proximity to hospital), spousal sacrifice, intimacy and communication challenges, and diminished quality time with children. Positive themes highlighted professional rewards, financial security and adaptability. Themes were consistent across age, length of relationship, spousal occupation and the presence of children. The intensity of these impacts for our participants appeared to vary depending on the degree of marital support and frequency of on-call.

CONCLUSION

After-hours on-call has a generally negative impact on paediatricians' spouses and families.

A national survey of academic emergency medicine leaders on the physician workforce and institutional workforce and aging policies

PURPOSE

To describe the policies, practices, and attitudes of academic emergency medicine (EM) leaders regarding workforce issues, shift work, and accommodating the academic and personal needs of aging physicians.

METHOD

In 2009, the authors and the Society for Academic Emergency Medicine's Aging and Generational Issues taskforce developed, pilot tested, and deployed a survey of academic leaders at EM residency programs in the United States. They used descriptive statistics to analyze the results and chi-square or Fisher exact test for additional comparisons.

RESULTS

Seventy-eight of 146 (53%) invited EM leaders completed the survey. Forty-four of those 78 (56%) respondents reported formal or informal policies at their institutions for accommodating aging faculty, and 55 (71%) reported policies for accommodating faculty for reasons not related to age. Fifty-six (73%) reported employing physicians who work primarily overnight shifts, whereas only 23 (30%) reported employing physicians who work primarily weekend shifts. Fifty-five (71%) supported considering age in assigning shift type (overnight, weekend, etc.), but only 26 (33%) supported considering age in determining number of shifts. Sixty-six (86%) supported considering a faculty member's academic role in determining number of shifts. Only 26 (34%) supported considering a faculty member's academic rank in determining number of shifts, and 15 (20%) supported considering rank in assigning shift type.

CONCLUSIONS

EM leaders have considered the implications of issues related to clinical shift work and aging physicians. The findings of this report indicate some of the ways that leaders have begun to adapt their programs to ensure the field's future success.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

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

SUBJECTS

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

INTERVENTIONS

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

MEASUREMENTS

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

MAIN RESULTS

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

CONCLUSIONS

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

Associations of long-term shift work with waking salivary cortisol concentration and patterns among police officers

The objective of this study was to evaluate whether long-term shift work is associated with both the total hormonal secretion after awakening and the pattern of the cortisol levels during the first hour following awakening, among 65 randomly selected police officers who represent a high stress occupation. Dominant shift (Day, Afternoon, or Midnight) was ascertained using daily payroll records of each participant's work activities during the 6-8 yrs prior to saliva sampling. Four salivary samples were collected at 15 min intervals upon first awakening. After accounting for potential confounders, salivary cortisol concentrations averaged across all four time points and total area under the curve differed significantly across shift with midnight shift workers showing suppressed awakening cortisol response relative to the afternoon and day shift. The percent of hours worked on midnight shift was inversely correlated with total awakening cortisol output. In contrast, the pattern of cortisol secretion during the first hour following waking appeared not to be affected as no significant interaction effect was found between time since awakening and shift work. The results show that long-term midnight shift work is associated with decreased absolute mean level and total volume of cortisol released over the waking period.

The effect of shift length on fatigue and cognitive performance in air medical providers

OBJECTIVE

To employ a battery of previously validated surveys and neuropsychological tests to compare changes in fatigue and cognitive abilities of air medical providers after 12- and 24-hour shifts.

METHODS

A convenience sample of 34 flight nurses and flight paramedics employed by one air medical service completed the Pittsburgh Sleep Quality Index (PSQI) and the Chalder Fatigue Questionnaire (CFQ) to determine fatigue before and after 12-hour (n = 16) and 24-hour (n = 19) shifts. A battery of neuropsychological tests, including the University of Southern California Repeatable Episodic Memory Test (USC-REMT), Paced Auditory Serial Addition Test (PASAT), Trail Making Test (TMT), and Stroop Color-Word Test were administered before and after the shift to measure changes in cognition. We compared the change in scores stratified by shift length using t-tests, Wilcoxon signed-rank test, and Fisher's exact test.

RESULTS

Participants in the 12- and 24-hour shift groups were aged 36 ± 8 years (12-hour shifts) and 39 ± 6 years (24-hour shifts) (mean ± standard deviation) and were preponderantly male (62% 12-hour shifts; 63%, 24 hour shifts). The PSQI scores identified 50% of both 12-hour and 24-hour shift subjects as having poor sleep quality. Preshift fatigue was described as a median 2/10 (interquartile range [IQR] = 2-4) and fatigue declined by the end of the shift to a median 1/10 [IQR = 1-2], p = 0.006. Providers averaged 6.8 hours of sleep during 24-hour shifts and 1 hour of sleep during 12-hour shifts. Changes in cognitive scores did not differ between groups.

CONCLUSIONS

This study identified no changes in cognitive performance following 12- and 24-hour shifts in air medical providers. This suggests that 24-hour shifts in an air medical service with low to moderate utilization do not have a detrimental effect on cognition as measured by this test battery, and are comparable to 12-hour shifts in terms of impact on cognitive function.

The relationship between shift work, sleep, and cognition in career emergency physicians

OBJECTIVES

The 24-hour physician coverage of the emergency department (ED) requires shift work, which can result in desynchronosis and cognitive decline. We measured changes in cognition and sleep disturbance in attending emergency physicians (EPs) before and after day and overnight shifts.

METHODS

Thirteen EPs were tested before and after day and overnight shifts using the Paced Auditory Serial Addition Test (PASAT), the University of Southern California Repeatable Episodic Memory Test (REMT), the Trail Making Test (TMT), and the Stroop Color-Word Test. Sleep quality and fatigue were assessed using the Pittsburgh Sleep Quality Index (PSQI) and Chalder Fatigue Questionnaire (CFQ). Saliva samples were collected from each physician immediately before and after day shifts and night shifts for neurohormonal assays.

RESULTS

Significantly fewer words were recalled on the REMT after both day (-2.4, 95% confidence interval [CI] = -4.4 to -0.4) and overnight shifts (-4.6, 95% CI = -6.4 to -2.8). There was a significant postshift increase in words recalled from the last third of the REMT list after overnight shifts (6.6, 95% CI = 2.8 to 10.4). Sleep quality was worse in EPs (mean PSQI = 4.8, SD ± 2.5) compared to the normal population, with 31% of subjects reporting poor sleep quality. Postshift fatigue was correlated with the perceived difficulty of the shift. Salivary cortisol and melatonin demonstrated diurnal variation consistent with normal circadian rhythms. Morning cortisol peak was decreased or delayed in samples from physicians after a night shift.

CONCLUSIONS

These data indicate that short-term memory appears to decline after day and overnight shifts and confirms the high incidence of disturbed sleep in this population.

Effective models of periodically driven networks

Circadian rhythms are governed by a highly coupled, complex network of genes. Due to feedback within the network, any modification of the system's state requires coherent changes in several nodes. A model of the underlying network is necessary to compute these modifications. We use an effective modeling approach for this task. Rather than inferred biochemical interactions, our method utilizes microarray data from a group of mutants for its construction. With simulated data, we develop an effective model for a circadian network in a peripheral tissue, subject to driving by the suprachiasmatic nucleus, the mammalian pacemaker. The effective network can predict time-dependent gene expression levels in other mutants.

Emergency medicine residents' use of psychostimulants and sedatives to aid in shift work

OBJECTIVES

We evaluated the frequency that emergency medicine house staff report use of stimulants and sedatives to aid in shift work and circadian transitions.

METHODS

We surveyed residents from 12 regional emergency medicine programs inviting them to complete a voluntary, anonymous electronic questionnaire regarding their use of stimulants and sedatives.

RESULTS

Out of 485 eligible residents invited to participate in the survey, 226 responded (47% response frequency). The reported use of prescription stimulants for shift work is uncommon (3.1% of respondents.) In contrast, 201 residents (89%) report use of caffeine during night shifts, including 118 residents (52%) who use this substance every night shift. Eighty-six residents (38%) reported using sedative agents to sleep following shift work with the most common agents being anti-histamines (31%), nonbenzodiazepine hypnotics such as zolpidem (14%), melatonin (10%), and benzodiazepines (9%).

CONCLUSION

Emergency medicine residents report substantial use of several classes of hypnotics to aid in shift work. Despite anecdotal reports, use of prescription stimulants appears rare, and is notably less common than use of sedatives and non-prescription stimulants.

Circadian melatonin profiles during single 24-h shifts in anesthetists

PURPOSE

It has been shown that shift work constitutes a great health hazard, particularly when chronodisruption is involved. Anesthetists are used to working for a certain number of 24-h shifts every month. The work-related lack of sleep in combination with light exposure is suspected to alter melatonin courses. The main aim of the present study was to analyze circadian melatonin profiles before, during, and after a 24-h shift in anesthetists and medical students (controls). Furthermore, we evaluated possible differences in melatonin profiles between the groups. Interactions between specific parameters were calculated.

METHODS

Over three consecutive days, including a 24-h shift, urine samples were collected daily at five time points. 6-Sulfateoxymelatonin (aMT6-s) courses were assayed using a commercially available competitive immunoassay kit.

RESULTS

Ten anesthetists aged between 29 and 35 years and ten medical students aged between 25 and 31 years were included in the study. aMT6-s fluctuated between nocturnal values of (mean [range]) 2.2 (1.4; 3.0) pg/ml and morning values of 25.5 (12.1; 39.0) pg/ml. A marked circadian rhythm of aMT6-s courses was observed in both groups. Analyses of variance showed an effect of the factor "time" on aMT6-s concentrations but not of the factor "anesthetists versus students". Correlations between aMT6-s, the amount of sleep, and the time since the last extended duration shift could be found.

CONCLUSIONS

The results show no evidence for a single 24-h shift having a great impact on circadian disruption as evidenced by a similar melatonin profile for both groups over the study phase.

Hospital mortality is associated with ICU admission time

Introduction

Previous studies have shown that patients admitted to the intensive care unit (ICU) after “office hours” are more likely to die. However these results have been challenged by numerous other studies. We therefore analysed this possible relationship between ICU admission time and in-hospital mortality in The Netherlands.

Methods

This article relates time of ICU admission to hospital mortality for all patients who were included in the Dutch national ICU registry (National Intensive Care Evaluation, NICE) from 2002 to 2008. We defined office hours as 08:00–22:00 hours during weekdays and 09:00–18:00 hours during weekend days. The weekend was defined as from Saturday 00:00 hours until Sunday 24:00 hours. We corrected hospital mortality for illness severity at admission using Acute Physiology and Chronic Health Evaluation II (APACHE II) score, reason for admission, admission type, age and gender.

Results

A total of 149,894 patients were included in this analysis. The relative risk (RR) for mortality outside office hours was 1.059 (1.031–1.088). Mortality varied with time but was consistently higher than expected during “off hours” and lower during office hours. There was no significant difference in mortality between different weekdays of Monday to Thursday, but mortality increased slightly on Friday (RR 1.046; 1.001–1.092). During the weekend the RR was 1.103 (1.071–1.136) in comparison with the rest of the week.

Conclusions

Hospital mortality in The Netherlands appears to be increased outside office hours and during the weekends, even when corrected for illness severity at admission. However, incomplete adjustment for certain confounders might still play an important role. Further research is needed to fully explain this difference.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-010-1918-1) contains supplementary material, which is available to authorized users.

Sleep quality and fatigue among prehospital providers

BACKGROUND

Fatigue is common among medical professionals and has been linked to poor performance and medical error. Objective. To characterize sleep quality and its association with severe fatigue in emergency medical services (EMS) providers.

METHODS

We studied a convenience sample of EMS providers who completed three surveys: the Pittsburgh Sleep Quality Index (PSQI), the Chalder Fatigue Questionnaire (CFQ), and a demographic survey. We used established measures to examine survey psychometrics and performed t-tests, analysis of variance (ANOVA), and chi-square tests to identify differences in PSQI and CFQ scores.

RESULTS

One hundred nineteen surveys were completed. The eight-hour shift was most commonly reported (35.4%). A majority of subjects were overweight (41.9%) or obese (42.7%), and 59.6% had been diagnosed with one or more health conditions (e.g., diabetes). Results from psychometric tests were positive. The mean (+/- standard deviation) PSQI score was 9.2 (+/- 3.7). A CFQ score > or =4, indicating severe mental and physical fatigue, was present in 44.5% of the subjects. The mean PSQI score was higher among those reporting severe fatigue (11.3 +/- 3.2) than among those not reporting fatigue (7.5 +/- 3.0, p < 0.0001).

CONCLUSIONS

The results from this study suggest that the sleep quality and fatigue status of EMS workers are at unhealthy levels. The health and safety of the EMS worker and patient population should be considered in light of these results.

Factors associated with longer emergency department length of stay for children with bronchiolitis : a prospective multicenter study

OBJECTIVES

Emergency department (ED) length of stay (LOS) is a quality of care measure and, when prolonged, contributes to ED crowding. Bronchiolitis, a common seasonal illness of infants, provides an opportunity to examine factors affecting ED LOS.

METHODS

We analyzed data from a 30-center prospective cohort study of ED patients younger than 2 years with an attending physician diagnosis of bronchiolitis to determine what factors affect LOS. Researchers conducted a structured interview and chart review.

RESULTS

Among 1459 children enrolled, ED LOS was available for 1416 children (97%). The median ED LOS was 3.3 hours (interquartile range, 2.3-4.8 hours). Multivariate analysis demonstrated that factors significantly (P < 0.05) associated with ED LOS were larger annual ED visit volume (reference, lowest tertile [< 44,134 visits], 44,134-62,420 [β = 0.74], and ≥ 62,421 [β = 0.63]), Hispanic race/ethnicity (reference, white race, β = 1.43), lack of primary care provider (β = 1.28), duration of symptoms of 4 to 7 days (reference, < 1 day; β = 0.58), presentation of midnight to 7 AM (reference, 4:00-11:59 PM; β = 1.07), decreasing lowest oxygen saturation in ED (β = 0.07), fewer number of A-agonists during the first hour (β = 0.74), unknown oral intake (reference, adequate; β = 0.69), performance of chest x-ray (β = 0.62), and hospital admission (β = 1.11).

CONCLUSIONS

In this prospective multicenter study of children younger than 2 years with bronchiolitis, multiple factors were associated with longer ED LOS. These factors suggest the following steps to help shorten ED LOS: optimizing translation services, improving primary care provider rates, enhancing overnight patient flow, forgoing chest x-rays, and developing evidence-based admission criteria.

Quantifying the volume of documented clinical information in critical illness

OBJECTIVES

The purpose of this study is to describe the volume of clinical information documented in critical illness, its relationship to the use of intensive care unit (ICU) technology, and changes over time.

METHODS

We performed a 6-year retrospective cohort study. Eligible patients were admitted to a university-affiliated pediatric ICU for at least 24 hours during the years 2000 to 2005. For each complete 24-hour period (midnight-midnight) that each patient was admitted to the ICU, we extracted the total number of items of documented clinical information and the use of 5 ICU technologies. For each day of the study, we calculated the total volume of documented information available to inform the daily ward round. A 2-level hierarchical linear model was used to analyze the primary outcome variable.

MAIN MEASUREMENTS AND RESULTS

There were 5623 admissions and 41202 complete patient-days studied. The median number of items of documented clinical data for each complete 24-hour period was 1348 (interquartile range, 1018-1664; mean, 1341). Significantly, more clinical information was documented about children who were ventilated with conventional ventilation (1483), children on inotropes or vasoactive medications (1685) and high-frequency oscillation (1726), and children receiving extracorporeal membrane oxygenation therapy (2354) or hemodialysis (1889) than children not in these categories (all P < .0001). The number of items documented per patient-day increased by 26% from 1165 in 2000 to 1471 items in 2005 (P < .0001). This finding was independent of ICU technology use.

CONCLUSIONS

A large and increasing volume of information was documented during the course of critical illness. More information was documented in patients receiving ICU technologies, suggesting that the volume of documented information is a marker of therapeutic intensity. It is also a source of workload and provides opportunity for error. Our findings underscore the importance of effective information management and communication strategies. Additional work is needed to evaluate the implications of current documentation practices for workload and quality of care.

Rapid phase adjustment of melatonin and core body temperature rhythms following a 6-h advance of the light/dark cycle in the horse

Background

Rapid displacement across multiple time zones results in a conflict between the new cycle of light and dark and the previously entrained program of the internal circadian clock, a phenomenon known as jet lag. In humans, jet lag is often characterized by malaise, appetite loss, fatigue, disturbed sleep and performance deficit, the consequences of which are of particular concern to athletes hoping to perform optimally at an international destination. As a species renowned for its capacity for athletic performance, the consequences of jet lag are also relevant for the horse. However, the duration and severity of jet lag related circadian disruption is presently unknown in this species. We investigated the rates of re-entrainment of serum melatonin and core body temperature (BT) rhythms following an abrupt 6-h phase advance of the LD cycle in the horse.

Methods

Six healthy, 2 yr old mares entrained to a 12 h light/12 h dark (LD 12:12) natural photoperiod were housed in a light-proofed barn under a lighting schedule that mimicked the external LD cycle. Following baseline sampling on Day 0, an advance shift of the LD cycle was accomplished by ending the subsequent dark period 6 h early. Blood sampling for serum melatonin analysis and BT readings were taken at 3-h intervals for 24 h on alternate days for 11 days. Disturbances to the subsequent melatonin and BT 24-h rhythms were assessed using repeated measures ANOVA and analysis of Cosine curve fitting parameters.

Results

We demonstrate that the equine melatonin rhythm re-entrains rapidly to a 6-h phase advance of an LD12:12 photocycle. The phase shift in melatonin was fully complete on the first day of the new schedule and rhythm phase and waveform were stable thereafter. In comparison, the advance in the BT rhythm was achieved by the third day, however BT rhythm waveform, especially its mesor, was altered for many days following the LD shift.

Conclusion

Aside from the temperature rhythm disruption, rapid resynchronization of the melatonin rhythm suggests that the central circadian pacemaker of the horse may possess a particularly robust entrainment response. The consequences for athletic performance remain unknown.