Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion

Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work

BACKGROUND

Sleep loss in attending physicians has an unclear effect on patient outcomes. In this study, we examined the effect of medical care provided by physicians after midnight on the outcomes of their scheduled elective procedures performed during the day.

METHODS

We conducted a population-based, retrospective, matched-cohort study in Ontario, Canada. Patients undergoing 1 of 12 elective daytime procedures performed by a physician who had treated patients from midnight to 7 a.m. were matched in a 1:1 ratio to patients undergoing the same procedure by the same physician on a day when the physician had not treated patients after midnight. Outcomes included death, readmission, complications, length of stay, and procedure duration. We used generalized estimating equations to compare outcomes between patient groups.

RESULTS

We included 38,978 patients, treated by 1448 physicians, in the study, of whom 40.6% were treated at an academic center. We found no significant difference in the primary outcome (death, readmission, or complication) between patients who underwent a daytime procedure performed by a physician who had provided patient care after midnight and those who underwent a procedure performed by a physician who had not treated patients after midnight (22.2% and 22.4%, respectively; P=0.66; adjusted odds ratio, 0.99; 95% confidence interval, 0.95 to 1.03). We also found no significant difference in outcomes after stratification for academic versus nonacademic center, physician's age, or type of procedure. Secondary analyses revealed no significant difference between patient groups in length of stay or procedure duration.

CONCLUSIONS

Overall, the risks of adverse outcomes of elective daytime procedures were similar whether or not the physician had provided medical services the previous night. (Funded by the University of Toronto Dean's Fund and others.).

Comparison of Two Watch Schedules for Personnel at the White House Military Office President's Emergency Operations Center

OBJECTIVE

The aim of this study was to assess effectiveness of an alternative, 24-hr-on/72-hr-off watchstanding schedule on sleep and morale of personnel assigned to the President's Emergency Operations Center (PEOC).

BACKGROUND

As part of the White House Military Office, PEOC personnel historically worked a 12-hr "Panama" watch schedule. Personnel reported experiencing chronic insufficient and disrupted sleep patterns and sought advice for improving their watchstanding schedule.

METHOD

Participants (N = 14 active-duty military members, ages 29 to 42 years) completed the Profile of Mood State (POMS) three times: before, during, and after switching to the alternative schedule with 5-hr sleep periods built into their workday. Participants completed a poststudy questionnaire to assess individual schedule preferences. Sleep was measured actigraphically, supplemented by activity logs.

RESULTS

As indicated by POMS scores, mood improved significantly on the new schedule. Although average total sleep amount did not change substantively, the timing of sleep was more consistent on the new schedule, resulting in better sleep hygiene. PEOC personnel overwhelmingly preferred the new schedule, reporting not only that they felt more rested but that the new schedule was more conducive to the demands of family life.

CONCLUSIONS

Demands of family life and time spent commuting were found to be critical factors for acceptance of the alternative schedule. This new schedule will be most effective if personnel adhere to the scheduled rest periods assigned during their 24-hr duty.

APPLICATION

A successful schedule should avoid conflicts between social life and operational demands. Results may lead to changes in the work schedules of other departments with similar 24/7 responsibilities.

Notes From the Field: Changes in the Attentional Capacity and Emotional State of Physicians After Working at Busy Outpatient Clinics

To examine changes in the performance of physicians after working in busy outpatient clinics, we conducted a prospective study, involving full-time clinicians who held morning and afternoon outpatient clinics on the same day. The participants completed three measures of attention, the psychomotor vigilance task, two-back test, and trail-making test, and a measure of emotion, the State-Trait Anger Expression Inventory (STAXI), before and after the two clinic sessions. The physicians saw a mean of 91.3 patients in the two outpatient clinics on the day of testing. Overall, performance in the attention test did not deteriorate after the two successive outpatient sessions. However, we observed an increased STAXI score in 24 (54.3%) participants and saw a significant overall increase in STAXI scores. Our results indicate that busy outpatient sessions may increase physicians' anger although their attentional capacity appears to be maintained.

Sink or Night Float: University of British Columbia Radiology Residents' Experience with Overnight Call

Purpose

In July 2012, in response to residents' concerns regarding the impact of the traditional 24-hour call system on their personal well-being and educational experience, the University of British Columbia Radiology residency program adopted a 12-hour night float system. This shift takes place in the context of increasing concerns, both across Canada and internationally, about resident well-being and the impact of prolonged duty hours on patient care.

Methods

An anonymous survey was distributed to all 25 postgraduate years 2-5 University of British Columbia radiology residents 12 months after the introduction of night float. This study sought to solicit residents' feedback about these changes and to identify potential future changes to optimize the call system.

Results

The response rate was 100%; 96% of residents were in favor of continuing with night float rather than the traditional call system; 72% of residents reported that their judgement was affected secondary to being on night float. Although most residents described varying degrees of impairment, the rate of acute discrepancies between resident preliminary and attending radiologist final reports decreased by more than half, from 2% to less than 1%.

Conclusions

The vast majority of our residents were in favor of maintaining the night float call system. Night float had a beneficial effect on the resident educational experience: by eliminating the pre-call morning and post-call day off rotation, residents gained an additional 24 days per year on other clinical rotations.

Psychomotor impairment detection via finger interactions with a computer keyboard during natural typing

Modern digital devices and appliances are capable of monitoring the timing of button presses, or finger interactions in general, with a sub-millisecond accuracy. However, the massive amount of high resolution temporal information that these devices could collect is currently being discarded. Multiple studies have shown that the act of pressing a button triggers well defined brain areas which are known to be affected by motor-compromised conditions. In this study, we demonstrate that the daily interaction with a computer keyboard can be employed as means to observe and potentially quantify psychomotor impairment. We induced a psychomotor impairment via a sleep inertia paradigm in 14 healthy subjects, which is detected by our classifier with an Area Under the ROC Curve (AUC) of 0.93/0.91. The detection relies on novel features derived from key-hold times acquired on standard computer keyboards during an uncontrolled typing task. These features correlate with the progression to psychomotor impairment (p < 0.001) regardless of the content and language of the text typed, and perform consistently with different keyboards. The ability to acquire longitudinal measurements of subtle motor changes from a digital device without altering its functionality may allow for early screening and follow-up of motor-compromised neurodegenerative conditions, psychological disorders or intoxication at a negligible cost in the general population.

Sleep patterns, sleep instability, and health related quality of life in parents of ventilator-assisted children

STUDY OBJECTIVES

Parents of children with chronic illnesses have poorer health related quality of life (HRQoL), shorter sleep duration, and poorer sleep quality than parents of healthy children. However, night-to-night variability of sleep in parents has not previously been considered. This study compared the sleep patterns of parents of ventilator-assisted children (VENT) and healthy, typically developing children (HEALTHY), and examined the relationship between sleep variability and perceived HRQoL.

METHODS

Seventy-nine mothers and 33 fathers from 42 VENT families (n = 56) and 40 HEALTHY (n = 56) families completed the SF-36 and wore an actigraph for 2 weeks. Reported bedtime and wake time, along with actigraphic total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE) were examined using both average values and night-tonight instability (mean square successive differences).

RESULTS

VENT parents showed significantly later bedtimes, shorter TST, longer WASO, and lower SE than HEALTHY parents. VENT parents also exhibited greater instability in their reported wake time, WASO, and SE. Adjusting for family type and gender, greater instability of wake times, WASO and SE were related to poorer SF-36 subscale scores, while averaged sleep values were not.

CONCLUSIONS

Many parents of ventilator-assisted children experience deficient sleep and show significant instability in their sleep, which was related to HRQoL. Similar to shift workers, variable sleep schedules that may result from caregiving responsibilities or stress may impact parental caregivers' health and well-being. Additional studies are needed to determine how support and other interventions can reduce sleep disruptions in parental caregivers.

Open fractures and the incidence of infection in the surgical debridement 6 hours after trauma

Objectives:

To determine whether a time delay greater than 6h from injury to surgical debridement influences the infection rate in open fractures.

Methods:

During a period of 18 months, from October 2010 to March 2012, 151 open fractures were available for study in 142 patients in our hospital. The data were collected prospectively and the patients were followed up for 6 weeks. The patients were divided into two groups regarding the time delay from injury to surgical debridement (more or less than 6 hours).

Results:

Surgical debridement was carried out in less than 6h from injury in 90 (59.6%) fractures and after 6 hours from injury in 61 (40.4%) fractures. Infection rates were 12.22% and 13.24%, respectively. The global infection rate was 13.24%.

Conclusion:

A significantly increased infection rate was not observed in patients whose surgical debridement occurred more than 6h after injury. However, in the fractures of high-energy trauma, a statistically significant increase of the rate of infection was observed in those operated 6 hours after trauma. Level of Evidence II, Study Type Comparative and Prospective.

Current Evaluation and Management of Excessive Daytime Sleepiness

Excessive daytime sleepiness has significant impact on neurological function, and has societal implications. Sleepiness is a common feature of many neurological conditions. A careful history will often reveal one of many common causes of excessive daytime sleepiness and suggest appropriate treatment. Neurophysiological testing can provide objective assessment. Behavioural management is an important first step in management. Treatment of common concurrent sleep disorders is also essential. Currently available medications can further symptomatically improve function in many individuals. The strongest evidence base is for the treatment of narcolepsy - a prototype disorder of excessive daytime sleepiness. Currently used medications include modafinil, stimulants, and sodium oxybate amongst others. This review discusses important features in the diagnosis of daytime sleepiness in adults, and outlines a treatment approach. Further evidence-based information about the management of this common problem is essential.

Effects of armodafinil on simulated driving and alertness in shift work disorder

STUDY OBJECTIVES

Forty-one percent of shift workers report dozing while driving. This study tested whether armodafinil improves driving simulator performance in subjects with shift work disorder (SWD). A primary outcome was performance late in the shift when workers are typically driving home.

DESIGN

Randomized, double-blind, crossover. During each 12-h test session (21:30-09:30), subjects were kept awake except for multiple sleep latency testing (MSLT: 01:30, 03:30, 05:30, and 07:30). Subjective sleepiness (Karolinska Sleepiness Scale, KSS), driving performance, and cognitive performance (digit symbol substitution test and creativity on the Remote Associates Test, RAT) were evaluated during the night shift and commute home times.

SETTING

Hospital-based sleep research laboratory.

PARTICIPANTS

Twenty night workers (age: 42.7 ± 8.7 y, 17 F) with excessive sleepiness (≥ 10 on the Epworth Sleepiness Scale), meeting International Classification of Sleep Disorders, Second Edition (ICSD-2) criteria for SWD, and having no other medical conditions.

INTERVENTIONS

Armodafinil (150 mg) or placebo at (23:45 h) on counterbalanced nights separated by 7-14 days.

MEASUREMENT AND RESULTS

Primary endpoints were driving simulator performance (standard deviation of lateral position (SDLP) and off-road deviations) with four sessions starting 3.25 h after drug administration, objective sleepiness (MSLT; 1.75 to 7.75 h post-drug), and creativity (5 h post-drug). Significant effects of drug were observed for each driving measure (P < 0.05). Armodafinil significantly improved SDLP for simulator sessions at 05:30, 07:30, and 09:30, and off-road deviations at 7 h, 15 min and 9 h, 15 min post-drug (P < 0.05). Armodafinil also improved objective sleepiness from 3.7 ± 0.6 min to 9.7 ± 5.2 min (P < 0.001) and RAT score from 8.75 ± 4.9 to 11.25 ± 6.0 (P < 0.005).

CONCLUSIONS

Armodafinil 150 mg early in the night shift improves driving simulator performance in SWD. Effects on sleepiness, cognition, and driving were found up to 9.5 h post-ingestion, during the critical time when many night workers are driving home.

Effects of Fatigue on Driving Safety: A Comparison of Brake Reaction Times in Night Float and Postcall Physicians in Training

BACKGROUND

Concerns about duty hour and resident safety have fostered discussion about postshift fatigue and driving impairment.

OBJECTIVE

We assessed how converting to a night float schedule for overnight coverage affected driving safety for trainees.

METHODS

Brake reaction times were measured for internal medicine and orthopaedic surgery resident volunteers after a traditional 28-hour call shift and after a night float shift. We conducted matched paired t tests of preshift and postshift reaction time means. Participants also completed the Epworth Sleepiness Scale pre- and postshift.

RESULTS

From June to July 2013, we enrolled 58 interns and residents (28 orthopaedic surgery, 30 internal medicine). We included 24 (41%) trainees on night float rotations and 34 (59%) trainees on traditional 28-hour call shifts. For all residents on night float rotations, there was no significant difference pre- and postshift. An increase in reaction times was noted among trainees on 28-hour call rotations. This included no effect on reaction times for internal medicine trainees pre- and postshift, and an increase in reaction times for orthopaedic trainees. For both night float and traditional call groups, there were significant increases in the Epworth Sleepiness Scale.

CONCLUSIONS

Trainees on traditional 28-hour call rotations had significantly worse postshift brake reaction times, whereas trainees on night float rotations had no difference. Orthopaedic trainees had significant differences in brake reaction times after a traditional call shift.

Changes in medical errors after implementation of a handoff program

BACKGROUND

Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking.

METHODS

We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events.

RESULTS

In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time.

CONCLUSIONS

Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

The cost of after-hours operative debridement of open tibia fractures

OBJECTIVES

The aim of this study was to evaluate the additional cost associated with performing after-hours operative debridement of open fractures within 6 hours of injury.

DATA SOURCES

The economic model is based on population estimates obtained from the National Trauma Database and the National Inpatient Sample on the number of open tibia fractures that occur annually in the United States and the number that present after-hours (between 6 PM and 2 AM) that undergo operative debridement within 6 hours. This model estimates incremental cost for after-hours surgery based on overtime wages for on-call personnel (nurses and surgical technicians) required to staff after-hours cases as published by the US Department of Labor and data from our own institution. As many level 1 hospitals are capable of performing after-hours cases without additional cost, a sensitivity analysis was performed to determine the effect of designated level of care of the trauma hospital.

DATA EXTRACTION AND SYNTHESIS

A total of 17,414 open tibia fractures were recorded in the National Inpatient Sample for 2009, and an estimated 7485 open tibia fractures presented after-hours, 4242 of which underwent operative debridement within 6 hours of presentation. Based on wage statistics from the US Department of Labor and our own institution, the estimated total additional cost for after-hours operative debridement of open tibia fractures within 6 hours is from $2,210,895 to $4,046,648 annually, respectively. For level 2 hospitals and below, the cost of performing after-hours operative debridement of open tibia fractures is calculated as from $1,532,980 to $2,805,846 annually.

CONCLUSIONS

The data indicated an increased overall financial cost of performing after-hours operative debridement of open tibia fractures. Given that there is minimal documented benefit to this practice, and with increased pressure to practice cost containment, elective delay of operative debridement of open fractures and/or transfer to a higher level of care trauma hospital may be an acceptable way to address these issues.

LEVEL OF EVIDENCE

Economic analysis level III. See instructions for authors for a complete description of levels of evidence.

Effect of non-alcoholic beer on Subjective Sleep Quality in a university stressed population

Sleep deprivation affects the homeostasis of the physiological functions in the human organism. Beer is the only beverage that contains hops, a plant which has a sedative effect. Our objective is to determine the improvement of subjective sleep quality using the Pittsburgh Sleep Quality Index (PSQI). The sample was conducted among a population of 30 university students. The study took place during a period of 3 weeks, the first 7 days were used for the Control, and during the following 14 days the students ingested beer (were asked to drink non-alcoholic beer) while having dinner. The results revealed that Subjective Sleep Quality improved in the case of those students who drank one beer during dinner compared to the Control, this is corroborated by the fact that Sleep Latency decreased (p < 0.05) compared to their Control. The overall rating Global Score of Quality of Sleep also improved significantly (p < 0.05). These results confirm that the consumption of non-alcoholic beer at dinner time helps to improve the quality of sleep at night.

Morbidity, mortality, and health care costs for patients undergoing spine surgery following the ACGME resident duty-hour reform

Object

The Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty-hour restrictions on July 1, 2003, in concern for patient and resident safety. Whereas studies have shown that duty-hour restrictions have increased resident quality of life, there have been mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay (LOS), and charges in patients who underwent spine surgery.

Methods

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, LOS, and charges by comparing the prereform (2000–2002) and postreform (2005–2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

Results

A total of 693,058 patients were included in the study. The overall complication rate was 8.6%, with patients in the postreform era having a significantly higher rate than those in the pre–duty-hour restriction era (8.7% vs 8.4%, p < 0.0001). Examination of hospital teaching status revealed complication rates to decrease in nonteaching hospitals (8.2% vs 7.6%, p < 0.0001) while increasing in teaching institutions (8.6% vs 9.6%, p < 0.0001) in the duty-hour reform era. The DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching institutions to had a significantly greater increase in complications during the postreform era (p = 0.0002). The overall mortality rate was 0.37%, with no significant difference between the pre– and post–duty-hour eras (0.39% vs 0.36%, p = 0.12). However, the mortality rate significantly decreased in nonteaching hospitals in the postreform era (0.30% vs 0.23%, p = 0.0008), while remaining the same in teaching institutions (0.46% vs 0.46%, p = 0.75). The DID analysis to compare the changes in mortality between groups revealed that the difference between the effects approached significance (p = 0.069). The mean LOS for all patients was 4.2 days, with hospital stay decreasing in nonteaching hospitals (3.7 vs 3.5 days, p < 0.0001) while significantly increasing in teaching institutions (4.7 vs 4.8 days, p < 0.0001). The DID analysis did not demonstrate the magnitude of change for each group to differ significantly (p = 0.26). Total patient charges were seen to rise significantly in the post–duty-hour reform era, increasing from $40,000 in the prereform era to $69,000 in the postreform era. The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.55).

Conclusions

The implementation of duty-hour restrictions was associated with an increased risk of postoperative complications for patients undergoing spine surgery. Therefore, contrary to its intended purpose, duty-hour reform may have resulted in worse patient outcomes. Additional studies are needed to evaluate strategies to mitigate these effects and assist in the development of future health care policy.

The effects of a split sleep-wake schedule on neurobehavioural performance and predictions of performance under conditions of forced desynchrony

Extended wakefulness, sleep loss, and circadian misalignment are factors associated with an increased accident risk in shiftwork. Splitting shifts into multiple shorter periods per day may mitigate these risks by alleviating prior wake. However, the effect of splitting the sleep-wake schedule on the homeostatic and circadian contributions to neurobehavioural performance and subjective assessments of one's ability to perform are not known. Twenty-nine male participants lived in a time isolation laboratory for 13 d, assigned to one of two 28-h forced desynchrony (FD) schedules. Depending on the assigned schedule, participants were provided the same total time in bed (TIB) each FD cycle, either consolidated into a single period (9.33 h TIB) or split into two equal halves (2 × 4.67 h TIB). Neurobehavioural performance was regularly assessed with a psychomotor vigilance task (PVT) and subjectively-assessed ability was measured with a prediction of performance on a visual analogue scale. Polysomnography was used to assess sleep, and core body temperature was recorded to assess circadian phase. On average, participants obtained the same amount of sleep in both schedules, but those in the split schedule obtained more slow wave sleep (SWS) on FD days. Mixed-effects ANOVAs indicated no overall difference between the standard and split schedules in neurobehavioural performance or predictions of performance. Main effects of circadian phase and prior wake were present for both schedules, such that performance and subjective ratings of ability were best around the circadian acrophase, worst around the nadir, and declined with increasing prior wake. There was a schedule by circadian phase interaction for all neurobehavioural performance metrics such that performance was better in the split schedule than the standard schedule around the nadir. There was no such interaction for predictions of performance. Performance during the standard schedule was significantly better than the split schedule at 2 h of prior wake, but declined at a steeper rate such that the schedules converged by 4.5-7 h of prior wake. Overall, the results indicate that when the total opportunity for sleep per day is satisfactory, a split sleep-wake schedule is not detrimental to sleep or performance. Indeed, though not reflected in subjective assessments of performance capacity, splitting the schedule may be of some benefit, given its reduction of neurobehavioural impairment at night and its association with increased SWS. Therefore, for some industries that require operations to be sustained around the clock, implementing a split work-rest schedule may be of assistance.

Opposite effects of sleep deprivation on the continuous reaction times in patients with liver cirrhosis and normal persons

The continuous reaction times (CRT) method describes arousal functions. Reaction time instability in a patient with liver disease indicates covert hepatic encephalopathy (cHE). The effects of sleep deprivation are unknown although cirrhosis patients frequently suffer from sleep disorders. The aim of this study was to determine if sleep deprivation influences the CRT test. Eighteen cirrhosis patients and 27 healthy persons were tested when rested and after one night's sleep deprivation. The patients filled out validated sleep quality questionnaires. Seven patients (38%) had unstable reaction times (a CRTindex < 1.9) compatible with cHE. In these patients, the wakefulness improved or normalized their reaction speed and CRTindex (p = 0.01). There was no change in the other patients' reaction speed or stability. Seven patients (38%) reported poor sleep that was not related to their CRT tests before or after the sleep deprivation. In the healthy participants, the sleep deprivation slowed their reaction times by 11% (p < 0.0001) and in 7 persons (25%) destabilized them. The acute sleep deprivation normalized or improved the reaction time stability of the patients with a CRTindex below 1.9 and had no effect in the patients with a CRTindex above 1.9. There was no relation between reported sleep quality and reaction time results. Thus, in cirrhosis patients, sleep disturbances do not lead to 'falsely' slowed and unstable reaction times. In contrast, the acute sleep deprivation slowed and destabilized the reaction times of the healthy participants. This may have negative consequences for decision-making.

ACGME Duty Hour Requirements: Perceptions and Impact on Resident Training and Patient Care

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) created national guidelines for resident work hours to promote safe care and high-quality learning. However, some reports suggested that the 2003 rules did not reduce resident fatigue or improve patient care. Since July 2011, further restrictions have been in effect. The changes have been the source of much controversy regarding their impact on resident education and patient safety. We reviewed existing literature on the effects of the new and old rules, with a focus on the field of orthopaedics. In addition, we conducted a national survey of orthopaedic residents and residency directors to assess the general opinions of the orthopaedic community. Overall, only 19.7% of all respondents were satisfied with the new 2011 regulations, whereas 58.9% believe the 80-hour work week averaged over 4 weeks is appropriate. The results will inform discussions and decisions related to changing residency education in the future.

Half of the family members of critically ill patients experience excessive daytime sleepiness

BACKGROUND

Sleepiness and fatigue are commonly reported by family members of intensive care unit (ICU) patients. Sleep deprivation may result in cognitive deficits. Sleep deprivation and cognitive blunting have not been quantitatively assessed in this population. We sought to determine the proportion of family members of ICU patients that experience excessive daytime sleepiness, sleep-associated functional impairment, and cognitive blunting.

METHODS

Multicenter, cross-sectional survey of family members of patients admitted to ICUs at the University of Maryland Medical Center, Johns Hopkins University Hospital, and Christiana Hospital. Family members of ICU patients were evaluated using the Epworth Sleepiness Scale, a validated survey assessing sleepiness in everyday situations (normal, less than 10); the Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10), a questionnaire quantifying the impact of sleepiness on daily activities (normal, at least 17.9); and psychomotor vigilance testing, a test of cognitive function, in relation to sleep deprivation (normal mean reaction time less than 500 ms).

RESULTS

A total of 225 family members were assessed. Of these, 50.2 % (113/225) had Epworth scores consistent with excessive daytime sleepiness. Those with sleepiness experienced greater impairment in performing daily activities by FOSQ-10 (15.6 ± 3.0 vs 17.4 ± 2.2, p < 0.001). Cognitive blunting was found in 13.3 % (30/225) of family members and 15.1 % (14/93) of surrogate decision-makers. Similar rates of cognitive blunting as reported by mean reaction time of at least 500 ms were found among family members whether or not they reported sleepiness (15.0 % (17/113) vs. 11.6 % (13/112), p = 0.45).

CONCLUSIONS

Half of the family members of ICU patients suffer from excessive daytime sleepiness. This sleepiness is associated with functional impairment, but not cognitive blunting.

The effect of sleep deprivation on a resident's situational awareness in a trauma scenario

OBJECTIVES

Situational awareness (SA) refers to the perception of elements in one's environment, the comprehension of their meaning, and the projection of their status in the near future. The SA global assessment technique (SAGAT) is an assessment tool validated for use in a trauma simulation. The goal of this study was to determine the effect of sleep deprivation on residents' performance in a trauma simulation, evaluated by the SAGAT.

METHODS

A power analysis determined that 9 residents would be needed to show a significant difference in SAGAT scores (7%). Therefore, 9 surgical residents on an intensive care unit rotation underwent 2 trauma simulations. One session was performed in the rested condition, and the other was for postcall. The SAGAT was used to evaluate the residents' performance. The rested and postcall scores were compared.

RESULTS

Using a paired t test, the SAGAT scores were analyzed. The average rested score was 80.13% (range, 50%-94%), and the sleep-deprived score was 80.09% (range, 72%-91%). There was no significant difference between the residents' rested and the postcall SAGAT scores (P = 0.99).

CONCLUSIONS

From this study, the resident SA in a trauma simulation does not seem to be affected by 1 night of sleep deprivation, as demonstrated by the lack of significant difference in SAGAT scores; however, more research in this area is needed.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions

OBJECT

On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures.

METHODS

The Nationwide Inpatient Sample was used to evaluate the effect of duty-hour restrictions on complications, mortality, length of stay, and charges by comparing the pre-reform (2000-2002) and post-reform (2005-2008) periods. Outcomes were compared between nonteaching and teaching hospitals using a difference-in-differences (DID) method.

RESULTS

A total of 90,648 patients were included in the analysis. The overall complication rate was 11.7%, with the rates not significantly differing between the pre- and post-duty hour eras (p = 0.26). Examination of hospital teaching status revealed that complication rates decreased in nonteaching hospitals (12.1% vs 10.4%, p = 0.0004) and remained stable in teaching institutions (11.8% vs 11.9%, p = 0.73) in the post-reform era. Multivariate analysis demonstrated a significantly higher complication risk in teaching institutions (OR 1.33 [95% CI 1.11-1.59], p = 0.0022), with no significant change in nonteaching hospitals (OR 1.11 [95% CI 0.91-1.37], p = 0.31). A DID analysis to compare the magnitude in change between teaching and nonteaching institutions revealed that teaching hospitals had a significantly greater increase in complications during the post-reform era than nonteaching hospitals (p = 0.040). The overall mortality rate was 3.0%, with a significant decrease occurring in the post-reform era in both nonteaching (5.0% vs 3.2%, p < 0.0001) and teaching (3.2% vs 2.3%, p < 0.0001) hospitals. DID analysis to compare the changes in mortality between groups did not reveal a significant difference (p = 0.40). The mean length of stay for all patients was 8.7 days, with hospital stay decreasing from 9.2 days to 8.3 days in the post-reform era (p < 0.0001). The DID analysis revealed a greater length of stay decrease in nonteaching hospitals than teaching institutions, which approached significance (p = 0.055). Patient charges significantly increased in the post-reform era for all patients, increasing from $70,900 to $96,100 (p < 0.0001). The DID analysis did not reveal a significant difference between the changes in charges between teaching and nonteaching hospitals (p = 0.17).

CONCLUSIONS

The implementation of duty-hour restrictions correlated with an increased risk of postoperative complications for patients undergoing brain tumor and cerebrovascular neurosurgical procedures. Duty-hour reform may therefore be associated with worse patient outcomes, contrary to its intended purpose. Due to the critical condition of many neurosurgical patients, this patient population is most sensitive and likely to be negatively affected by proposed future increased restrictions.

The science of medical decision making: neurosurgery, errors, and personal cognitive strategies for improving quality of care

During the last 2 decades, there has been a shift in the U.S. health care system towards improving the quality of health care provided by enhancing patient safety and reducing medical errors. Unfortunately, surgical complications, patient harm events, and malpractice claims remain common in the field of neurosurgery. Many of these events are potentially avoidable. There are an increasing number of publications in the medical literature in which authors address cognitive errors in diagnosis and treatment and strategies for reducing such errors, but these are for the most part absent in the neurosurgical literature. The purpose of this article is to highlight the complexities of medical decision making to a neurosurgical audience, with the hope of providing insight into the biases that lead us towards error and strategies to overcome our innate cognitive deficiencies. To accomplish this goal, we review the current literature on medical errors and just culture, explain the dual process theory of cognition, identify common cognitive errors affecting neurosurgeons in practice, review cognitive debiasing strategies, and finally provide simple methods that can be easily assimilated into neurosurgical practice to improve clinical decision making.

Absence of central circadian pacemaker abnormalities in humans with loss of function mutation in prokineticin 2

CONTEXT

Loss of prokineticin 2 (PROK2) signaling in mice disrupts circadian rhythms, but the role of PROK2 signaling in the regulation of circadian rhythms in humans is undetermined.

OBJECTIVE

The aim of the study was to examine the circadian rhythms of humans with a complete loss-of-function PROK2 mutation using an inpatient constant routine (CR) protocol.

DESIGN AND SETTING

We conducted a case study in an academic medical center.

SUBJECTS AND METHODS

Two siblings (one male and one female, ages 67 and 62 y, respectively) with isolated GnRH deficiency (IGD) due to a biallelic loss-of-function PROK2 mutation were studied using an inpatient CR protocol. Historical data from inpatient CR protocols conducted in healthy controls (ages 65-81 y) were used for comparison.

MAIN OUTCOME MEASURES

We measured circadian phase markers (melatonin, cortisol, and core body temperature) and neurobehavioral performance (psychomotor vigilance task [PVT] and subjective alertness scale).

RESULTS

Circadian waveforms of melatonin and cortisol did not differ between the IGD participants with PROK2 mutation and controls. In both IGD participants, neurobehavioral testing with PVT showed disproportionate worsening of PVT lapses and median reaction time in the second half of the CR.

CONCLUSIONS

Humans with loss of PROK2 signaling lack abnormalities in circadian phase markers, indicating intact central circadian pacemaker activity in these patients. These results suggest that PROK2 signaling in humans is not required for central circadian pacemaker function. However, impaired PVT in the PROK2-null participants despite preserved endocrine rhythms suggests that PROK2 may transmit circadian timing information to some neurobehavioral neural networks.

Cognitive effects of hospital calls in anaesthesiologists

BACKGROUND

The work hours of Norwegian physicians are under scrutiny because of an increased public focus on patient safety. Ample international research indicate harmful effects of doctor fatigue based on studies on physicians working long weeks and on-call shifts of more than 30 consecutive hours. There is a lack of research on effects relevant for short or intermediate length of work weeks and call shifts. This study intended to study cognitive effects of short or intermediate duration in-hospital calls.

METHODS

Eighteen anaesthesiology residents working on-call at an operation ward or an intensive care unit at Haukeland University Hospital were invited to participate. Schedules were adapted to allow for two additional experimental shifts. Participants were subjected to Cambridge Neuropsychological Test Automated Battery cognitive testing in a rested state and on three occasions after call. Amount of sleep and self-assessed sleepiness were recorded.

RESULTS

Ten residents completed all four tests during 10 months. Reaction time was longer post-call. It was significantly increased only after the 18 h night call, by 21.1 and 20.5 ms for simple and five-choice reaction time, respectively. Executive function was not significantly altered post-call. Visual memory was improved post-call. Karolinska Sleepiness Score was increased by 3.3 (long day), 2.1 (short night) and 2.5 (long night) points post-call.

CONCLUSION

Reaction times were increased after 18 h night calls and non-significant increases in reaction times were apparent after the other on-call shifts. Self reported sleepiness was increased post-call. We were not able to conclude whether executive function or memory was negatively affected post-call.

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.

Resident duty hours in Canada: a survey and national statement

Physicians in general, and residents in particular, are adapting to duty schedules in which they have fewer continuous work hours; however, there are no Canadian guidelines on duty hours restrictions. To better inform resident duty hour policy in Canada, we set out to prepare a set of recommendations that would draw upon evidence reported in the literature and reflect the experiences of resident members of the Canadian Association of Internes and Residents (CAIR). A survey was prepared and distributed electronically to all resident members of CAIR. A total of 1796 eligible residents participated in the survey. Of those who responded, 38% (601) reported that they felt they could safely provide care for up to 16 continuous hours, and 20% (315) said that 12 continuous hours was the maximum period during which they could safely provide care (n=1592). Eighty-two percent (1316) reported their perception that the quality of care they had provided suffered because of the number of consecutive hours worked (n=1598). Only 52% (830) had received training in handover (n=1594); those who had received such training reported that it was commonly provided through informal modelling. On the basis of these data and the existing literature, CAIR recommends that resident duty hours be managed in a way that does not endanger the health of residents or patients; does not impair education; is flexible; and does not violate ethical or legal standards. Further, residents should be formally trained in handover skills and alternative duty hour models.

Negative impacts of shiftwork and long work hours

PURPOSE

Healthcare organizations often have to provide patient care around the clock. Shift work (any shift outside of 7 a.m. to 6 p.m) and long work hours increase the risk for short sleep duration and sleep disturbances. Thirty-two percent of healthcare workers report they do not get enough sleep. The purpose of the article is to give an overview of the wide range of risks to nurses, patients, and employers that are linked to shift work, long work hours, and poor sleep from other sources.

FINDINGS

Shift work and long work hours increase the risk for reduced performance on the job, obesity, injuries, and a wide range of chronic diseases. In addition, fatigue-related errors could harm patients. Fatigued nurses also endanger others during their commute to and from work.

CONCLUSION AND CLINICAL RELEVANCE

The key strategy to reduce these risks is making sleep a priority in the employer's systems for organizing work and in the nurse's personal life.

Effect of the introduction of an emergency general surgery service on outcomes from appendicectomy

Background

Appendicectomy is a common general surgical emergency procedure and may be used as a surrogate marker to evaluate quality in surgical management. The aim of this study was to assess the outcomes of appendicectomy before and after the introduction of a consultant-led emergency general surgery (EGS) service at a large metropolitan tertiary referral centre.

Methods

A retrospective historical control study was performed that included all adult patients undergoing appendicectomy during two 18-month periods, before and after the introduction of the EGS service. Data collected included patient demographics, use of radiological investigations, time to surgery, length of hospital stay and histopathology findings. Outcome measures were time to surgery, hospital length of stay, use of radiological investigations, negative appendicectomy rate and perforation rate.

Results

A total of 675 patients were identified of whom 276 had an appendicectomy before the EGS service was introduced (2008–2009) and 399 after its introduction (2011–2012). The EGS service resulted in an increase in time to surgery (15 versus 18 h; P &lt; 0·001) with no increase in length of hospital stay (3 days for both periods; P = 0·424). An increase in the rate of appendicectomies performed within office hours was seen (54·3 versus 64·4 per cent; P &lt; 0·001), with no significant increase in negative appendicectomy (13·0 versus 15·8 per cent; P = 0·322) or perforation (8·3 versus 5·5 per cent; P = 0·149) rates. The use of preoperative computed tomography reduced from 38·4 to 26·6 per cent (P = 0·001).

Conclusion

The introduction of a consultant-led EGS service resulted in a decrease in the use of computed tomography and a greater proportion of appendicectomies performed within office hours, with no increase in length of stay. Overall negative appendicectomy and perforation rates did not change.

Self-perceived sleepiness in emergency training physicians: prevalence and relationship with quality of life

Introduction

Sleep deprivation among training physicians is of growing concern; training physicians are susceptible due to their prolonged work hours and rotating work schedules. The aim of this study was to determine the prevalence of self-perceived sleepiness in emergency training physicians, and to establish a relationship between self-perceived sleepiness, and quality of life.

Methods

Prospective survey in Ibn Sina University hospital Center in Morocco from January to April 2011 was conducted. Questionnaires pertaining to socio-demographic, general, and sleep characteristics were completed by training physician who ensured emergency service during the month preceding the survey. They completed the Epworth sleepiness scale (ESS) which assessed the self-perceived sleepiness, and the EuroQol-5 dimensions (EQ-5D) scale which assessed the general quality of life.

Results

Total 81 subjects (49 men and 32 women) were enrolled with mean age of 26.1 ± 3.4 years. No sleepiness was found in 24.7% (n = 20), excessive sleepiness 39.5% (n = 32), and severe sleepiness in 35.8% (n = 29) of training physicians. After adjusting for multiple confounding variables, four independent variables were associated with poorer quality of life index in training physician; unmarried (ß −0.2, 95% CI −0.36 to −0.02; P = 0.02), no physic exercise (ß −0.2, 95% CI −0.39 to 0.006; P = 0.04), shift-off sleep hour less than 6 hours (ß −0.13, 95% CI −0.24 to −0.02; P = 0.01), and severe sleep deprivation(ß −0.2, 95% CI −0.38 to −0.2; P = 0.02).

Conclusion

Nearly two third of training physicians had suffered from sleepiness. There is an association between poor quality of life and severe sleepiness in unmarried physicians, sleeping less than 6 hours in shift-off day, and doing no physical activity.

Overweight physicians during residency: a cross-sectional and longitudinal study

BACKGROUND

Resident physicians are at risk for increasing weight status given their changes in environment, resources, and stress level.

OBJECTIVE

To describe body mass index (BMI), blood pressure, eating habits, and physical activity during postgraduate training and to compare the findings to data for nationally matched controls.

METHODS

This was a combined cross-sectional study and longitudinal cohort, with a comparison to matched controls in 2 academic hospital centers in the eastern and western United States. BMI and blood pressure were objectively measured, and an eating and exercise habits recall was obtained for 375 enrolled medical and surgical residents (93 longitudinally) at the onset of each postgraduate year (PGY) in 2006, 2007, and 2008.

RESULTS

Nearly half (43%) of overweight residents described themselves as normal weight. Residents were more likely to be overweight (BMI ≥25) at the beginning of PGY-3 than at the beginning of PGY-1 (49% versus 30%; odds ratio 2.26; 95% confidence interval 1.19-4.28). The average BMI of residents at PGY-1 was lower than that of their matched controls, but the magnitude of this difference decreased with increasing PGY (P  =  .02).

CONCLUSIONS

Overweight status is underacknowledged by overweight residents and increases by PGY of training. These changes differ significantly from that of controls and may affect overweight physicians' long-term health.

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.

Evaluation of potential distractors in the urology operating room

BACKGROUND AND PURPOSE

Surgical outcomes depend on patient and disease-related factors, as well as the technical skill of the surgeon. Various distractions in the operating room (OR) environment have been shown to negatively impact a surgeon's performance. A survey was conducted with the objective to evaluate and characterize distractions during urologic surgery.

METHODS

An Internet-based survey was distributed to 2057 international urologists via email between April and October 2011; questions focused on a variety of disruptive factors postulated to have a negative impact on surgical performance.

RESULTS

Of the 523 (25%) respondents, 58% practiced in North America, 42% were from an academic institution, and 68% had completed a clinical fellowship. In an average year, 83% reported having operated at least once while sleep deprived, 84% when significantly ill, 55% with a musculoskeletal injury, and 65% under significant social stress. Up to 38% reported that on at least one occasion, such "internal distractions" had significantly affected surgical performance and 14% perceived that at least one surgical complication was caused mainly by an internal distraction. Less than 50% had ever cancelled surgery because of an internal distraction. Music was routinely played in the OR by 57% of respondents, >67% reported answering pages and discussing consults while operating, and 25% reported "commonly" working with scrub nurses/techs that were unfamiliar with the procedure and/or instruments. Only 44% had consistent individual(s) assisting, and 27% reported that the scrub nurse/tech would "commonly" scrub out during a critical portion of the procedure. Overall, 14.5% reported that at least one complication had occurred mainly because of such "external" or "interactive" distractions.

CONCLUSIONS

Urologists face various distractions in the OR that can negatively impact surgical performance, potentially compromising patient outcomes and safety. Further studies are needed to elucidate the true impact of such distractions and to develop strategies to mitigate their effects.

Postpartum mothers' napping and improved cognitive growth fostering of infants: results from a pilot study

Little is known about how maternal sleep disturbances in the postpartum period affect mother-infant interaction. The study was designed to assess if less maternal sleep disturbance and less fatigue were associated with more positive mother-child interaction, independent of maternal depression symptoms. Twenty-three mothers completed 1 week of actigraphy and self-report measures of fatigue and depression symptoms. To determine the quality of mother-infant interaction, mothers and infants were then observed in a structured, video-recorded teaching episode. Greater maternal napping frequency was associated with better cognitive growth fostering of the infant (r s = .44, p < .05), a subscale of the interaction assessment. Maternal napping, not the quality or quantity of nocturnal sleep, appears to be associated with improvements in mother-infant interactions.

Fatigue optimization scheduling in graduate medical education: reducing fatigue and improving patient safety

BACKGROUND

Medical error is a major cause of preventable morbidity and mortality. Resident fatigue is likely to be a significant contributor.

OBJECTIVES

We calculated and compared predicted fatigue impairment in surgical residents on varying schedules by using the validated Sleep, Activity, Fatigue, and Task Effectiveness model and Fatigue Avoidance Scheduling Tool; we identified specific times of day and rotations during which residents were most affected, instituted countermeasures, and measured the predicted response.

METHODS

We compared 4 scheduling patterns: day shift, trauma shift, night shift, and prework hour restriction Q3 call (or every-third-night call). The dependent variables were mean daily effectiveness while at work and the percentage of time residents worked with critical fatigue impairment (defined as an effectiveness score of less than 70 correlated with an increased risk for error and a blood alcohol content of 0.08). Fatigue countermeasures (ie, a 30-minute nap, eliminating 24-hour shifts) were applied to rotations with significant impairment to determine impairment plasticity.

RESULTS

CALCULATED MEAN EFFECTIVENESS SCORES AND PERCENTAGE OF TIME SPENT IMPAIRED AT WORK WERE AS FOLLOWS: day shift, 90.3, 0%; trauma shift, 82.0, 7.5%; prework hour restriction Q3 call shift, 80.7, 23%; and night shift, 68.0, 50% (P < .001). Fatigue optimization countermeasures for night shift rotation improved mean daily effectiveness to 87.1 with only 1.9% of time working while impaired (P < .001).

CONCLUSIONS

There is a significant potential for fatigue impairment in residents, with work schedule a significant factor. Once targeted, fatigue impairment may be minimized with specific countermeasures. Fatigue optimization tools provide data for targeted scheduling interventions, which reduce fatigue and may mitigate medical error.

Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight

RATIONALE AND OBJECTIVES

To determine if the rate of major discrepancies between resident preliminary reports and faculty final reports increases during the final hours of consecutive 12-hour overnight call shifts.

MATERIALS AND METHODS

Institutional review board exemption status was obtained for this study. All overnight radiology reports interpreted by residents on-call between January 2010 and June 2010 were reviewed by board-certified faculty and categorized as major discrepancies if they contained a change in interpretation with the potential to impact patient management or outcome. Initial determination of a major discrepancy was at the discretion of individual faculty radiologists based on this general definition. Studies categorized as major discrepancies were secondarily reviewed by the residency program director (M.H.S.) to ensure consistent application of the major discrepancy designation. Multiple variables associated with each report were collected and analyzed, including the time of preliminary interpretation, time into shift study was interpreted, volume of studies interpreted during each shift, day of the week, patient location (inpatient or emergency department), block of shift (2-hour blocks for 12-hour shifts), imaging modality, patient age and gender, resident identification, and faculty identification. Univariate risk factor analysis was performed to determine the optimal data format of each variable (ie, continuous versus categorical). A multivariate logistic regression model was then constructed to account for confounding between variables and identify independent risk factors for major discrepancies.

RESULTS

We analyzed 8062 preliminary resident reports with 79 major discrepancies (1.0%). There was a statistically significant increase in major discrepancy rate during the final 2 hours of consecutive 12-hour call shifts. Multivariate analysis confirmed that interpretation during the last 2 hours of 12-hour call shifts (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.18-3.21), cross-sectional imaging modality (OR 5.38, 95% CI 3.22-8.98), and inpatient location (OR 1.81, 95% CI 1.02-3.20) were independent risk factors for major discrepancy.

CONCLUSIONS

In a single academic medical center, major discrepancies in resident preliminary reports increased significantly during the final 2 hours of consecutive 12-hour overnight call shifts. This finding could be related to either fatigue or circadian desynchronization. Discrimination of these two potential etiologies requires additional investigation as major discrepancies in resident reports have the potential to negatively impact patient care/outcome. Cross-sectional imaging modalities including computed tomography and ultrasound (versus conventional radiography), as well as inpatient location (versus Emergency Department location), were also associated with significantly higher major discrepancy rates.

Classifying performance impairment in response to sleep loss using pattern recognition algorithms on single session testing

There is currently no "gold standard" marker of cognitive performance impairment resulting from sleep loss. We utilized pattern recognition algorithms to determine which features of data collected under controlled laboratory conditions could most reliably identify cognitive performance impairment in response to sleep loss using data from only one testing session, such as would occur in the "real world" or field conditions. A training set for testing the pattern recognition algorithms was developed using objective Psychomotor Vigilance Task (PVT) and subjective Karolinska Sleepiness Scale (KSS) data collected from laboratory studies during which subjects were sleep deprived for 26-52h. The algorithm was then tested in data from both laboratory and field experiments. The pattern recognition algorithm was able to identify performance impairment with a single testing session in individuals studied under laboratory conditions using PVT, KSS, length of time awake and time of day information with sensitivity and specificity as high as 82%. When this algorithm was tested on data collected under real-world conditions from individuals whose data were not in the training set, accuracy of predictions for individuals categorized with low performance impairment were as high as 98%. Predictions for medium and severe performance impairment were less accurate. We conclude that pattern recognition algorithms may be a promising method for identifying performance impairment in individuals using only current information about the individual's behavior. Single testing features (e.g., number of PVT lapses) with high correlation with performance impairment in the laboratory setting may not be the best indicators of performance impairment under real-world conditions. Pattern recognition algorithms should be further tested for their ability to be used in conjunction with other assessments of sleepiness in real-world conditions to quantify performance impairment in response to sleep loss.

Sleep science, schedules, and safety in hospitals: challenges and solutions for pediatric providers

Sleep deprivation is common among resident physicians and clinical fellows. Current evidence about sleep science, performance, shift work, and medical errors consistently demonstrates positive impact from reduction of excessive duty hours, particularly when shift length is shortened. This article provides an overview of this literature, highlighting research on diminished physician cognitive performance due to sleep deprivation and the increase in the number of medical errors that is seen under these conditions. Accreditation Council on Graduate Medical Education trainee duty hour guidelines are reviewed. Practical approaches to evidence-based scheduling of shift-work are also discussed, with attention to improving patient safety.

Does sleep deprivation impair orthopaedic surgeons' cognitive and psychomotor performance?

BACKGROUND

Sleep deprivation may slow reaction time, cloud judgment, and impair the ability to think. Our purpose was to study the cognitive and psychomotor performances of orthopaedic trauma surgeons on the basis of the amount of sleep that they obtained.

METHODS

We prospectively studied the performances of thirty-two orthopaedic trauma surgeons (residents, fellows, and attending surgeons) over two four-week periods at an urban academic trauma center. Testing sessions used handheld computers to administer validated cognitive and psychomotor function tests. We conducted a multivariate analysis to examine the independent association between test performance and multiple covariates, including the amount of sleep the night before testing.

RESULTS

Our analysis demonstrated that orthopaedic surgeons who had slept four hours or less the night before the test had 1.43 times the odds (95% confidence interval, 1.04 to 1.95; p = 0.03) of committing at least one error on an individual test compared with orthopaedic surgeons who had slept more than four hours the previous night. The Running Memory test, which assesses sustained attention, concentration, and working memory, was most sensitive to deterioration in performance in participants who had had four hours of sleep or less; when controlling for other covariates, the test demonstrated a 72% increase in the odds of making at least one error (odds ratio, 1.72 [95% confidence interval, 1.02 to 2.90]; p = 0.04). No significant decrease in performance with sleep deprivation was shown with the other three tests.

CONCLUSIONS

Orthopaedic trauma surgeons showed deterioration in performance on a validated cognitive task when they had slept four hours or less the previous night. It is unknown how performance on this test relates to surgical performance.

New shift models for doctors in a large German University Neurosurgery Department: how they comply with the European Working Time Directive 3 years after implementation

BACKGROUND

Due to the European Working Time Directive (EWTD) and a new collective agreement for doctors working at University hospitals in 2006 new shift models had to be designed in the Department of Neurosurgery of the University Hospital Tübingen, Germany. The aim of the study was to show the fit of the models regarding the average weekly working time limits (aWTL), the daily maximum of 10-h working time (10-h dWT), and the staff expenditures 3 years after implementation.

METHODS

The new shift model was implemented in 2008, and hence planning and documentation were done electronically. Adherence to the work schedules was measured, and aWTL adherence rates were compared. The relative number of 10-h dWT violations in 2009 and 2010 was analysed. Staff costs relative to performance before and after implementation were calculated and tested using analysis of variance (ANOVA). Four other departments without alteration of shift models served as a control group in cost trend analysis.

RESULTS

In 2010 all doctors in the Department of Neurosurgery were able to stay within the limit of 54 h/week; one doctor without opt-out exceeded the 48 h/week limit (50.1 h/week). The median per capita rate of 10-h dWT violations in 2009 was 20.3 % of all eligible working days and further declined to 10.7 % in 2010 (p < 0.001). Staff costs per case-weight point did not change significantly (2007: 339.88€, 2009: 307.99€, 2010: 322.54€; p = 0.22) in neurosurgery or in the control group (2007: 633.72€, 2009: 637.06€, 2010: 690.30€; p = 0.67).

CONCLUSIONS

After implementation of the new shift model, current monitoring and properly matching modifications led to long-term stability in complying with the EWTD regulations without increasing costs for staff expenditures.

Call-associated acute fatigue in surgical residents--subjective perception or objective fact? A cross-sectional observational study to examine the influence of fatigue on surgical performance

BACKGROUND

The effect of acute partial sleep deprivation on surgical proficiency is still controversially discussed. The present study correlated physiological parameters of fatigue with objective technical and cognitive skills, as well as subjective sleepiness of surgical residents. The aim of the study was to assess the effect of acute partial sleep deprivation on surgical performance.

METHODS

Thirty-eight surgeons were interviewed on three consecutive mornings: prior to a 24 h call, post-call, and after 24 h of rest. Reported hours of sleep were recorded. Subjective alertness was assessed with the standardized Stanford-Sleepiness-Scale (SSS). Saliva cortisol concentrations and pupillary activity were measured by standardized ELISA and pupillography. The virtual reality (VR)-simulator LapSim was used to assess technical skills through low-fidelity VR-tasks ("cutting," "clip applying") and cognitive skills through high-fidelity VR-tasks ("intracorporeal suturing," "VR-cholecystectomy"). Objective alertness was measured by the standardized d2-Paper-Pencil Test.

RESULTS

Recorded hours of sleep (p = 0.001) and subjective alertness (SSS) decreased (p = 0.001) significantly post-call. None of the three factors studied-saliva cortisol concentration (p = 0.313), pupillary activity (p = 0.998), or VR-performance of low-fidelity VR-tasks-differed significantly between assessments. Surprisingly, VR-performance of high-fidelity VR-tasks (error-score p = 0.044, time to complete task p = 0.0001, economy of instrument motion p = 0.0001) and objective alertness (d2-Paper-Pencil Test p = 0.027) significantly improved in the post-call setting.

CONCLUSIONS

Acute call-associated fatigue seems to be a predominantly subjective perception. Physiological factors seem to outbalance an anticipated fatigue-associated impairment of technical performances within low-fidelity VR-tasks. In surgical residents, acute partial sleep deprivation seems to have a positive short-term effect on cognitive skills, leading to enhanced technical performance and increased objective alertness within complex tasks.