Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature

Review: psychiatric and medical consequences of disordered sleep

OBJECTIVES

The aim of this article is to draw attention to the clinical importance of disordered sleep in psychiatry and to demonstrate the growing awareness of medical illness as a complication of disordered sleep. As background to these main objectives, some general points are made to illustrate present-day approaches to the common and often serious problem of sleep disturbance.

METHODS

The review is based on a literature search from which key publications were selected to illustrate, in turn, main connections between disordered sleep and psychiatric and medical conditions.

RESULTS

Many such connections are described. Throughout psychiatry, regarding patients whatever their age, these connections have implications for clinical assessment and management. Emphasis is placed on the risk of misdiagnosis of sleep disorders as psychiatric or medical conditions. Examples of this are provided. The growing evidence that disordered sleep can predispose to medical illness is discussed.

CONCLUSION

As the subject of sleep and its disorders is particular relevant in psychiatry, a working knowledge of modern sleep medicine is important in all branches of psychiatric and other medical practice as well as in clinical research.

What effects have resident work-hour changes had on education, quality of life, and safety? A systematic review

BACKGROUND

More than 15 years ago, the Institute of Medicine (IOM) identified medical error as a problem worthy of greater attention; in the wake of the IOM report, numerous changes were made to regulations to limit residents' duty hours. However, the effect of resident work-hour changes remains controversial within the field of orthopaedics.

QUESTIONS/PURPOSES

We performed a systematic review to determine whether work-hour restrictions have measurably influenced quality-of-life measures, operative and technical skill development, resident surgical education, patient care outcomes (including mortality, morbidity, adverse events, sentinel events, complications), and surgeon and resident attitudes (such as perceived effect on learning and training experiences, personal benefit, direct clinical experience, clinical preparedness).

METHODS

We performed a systematic review of PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Google Scholar using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were any English language peer-reviewed articles that analyzed the effect(s) of orthopaedic surgery resident work-hour restrictions on patient safety, resident education, resident/surgeon quality of life, resident technical operative skill development, and resident surgeon attitudes toward work-hour restrictions. Eleven studies met study inclusion criteria. One study was a prospective analysis, whereas 10 studies were of level IV evidence (review of surgical case logs) or survey results.

RESULTS

Within our identified studies, there was some support for improved resident quality of life, improved resident sleep and less fatigue, a perceived negative impact on surgical operative and technical skill, and conflicting evidence on the topic of resident education, patient outcomes, and variable attitudes toward the work-hour changes.

CONCLUSIONS

There is a paucity of high-level or clear evidence evaluating the effect of the changes to resident work hours. Future research in this area should focus on objective measures that include patient safety as a primary outcome.

An innovative on-call system for paediatric residency programs: The alternate night float

BACKGROUND

Night-float systems, in which residents work consecutive nights, have been increasingly adopted in paediatric programs, but may be detrimental to residents' sleep and mood.

OBJECTIVE

To describe the self-reported impact of a novel system consisting of two consecutive weeks of 16 h overnight shifts every second day that was piloted at the Children's Hospital of Eastern Ontario (Ottawa, Ontario).

METHODS

A survey of 28 senior paediatric residents examined their experience with the alternate night-float system in three domains (patient care, resident professional development and well-being) and their comparison of the system with the traditional overnight on-call system.

RESULTS

Twenty-six of 28 residents responded. Nearly all (96%) felt familiar with important details of inpatients and that handover was effective (92%). Results were mixed for professional development, with concerns about the quality of supervisors' feedback and perceived difficulty in attending daytime teaching. All residents believed that the night-float system provided a better learning experience compared with the traditional system. Less than 35% considered fatigue to be a notable problem, although 20% increased use of sleep aids or stimulants beyond their typical use. Ninety-six percent believed their workload was appropriate. All residents felt equally or less fatigued under the night-float system compared with the traditional system. Ninety-six percent recommended that the night-float model continue as the on-call system.

CONCLUSIONS

This novel night-float system is an alternative method of providing paediatric inpatient night coverage because it meets duty hour regulations and has strong resident approval. Studies to examine its impact on residents and patient care in comparison with other systems are warranted.

Shift work and the relationship with metabolic syndrome in Chinese aged workers

BACKGROUND

Shift work is indicated to be associated with adverse metabolic disorders. However, potential effects of shift work on metabolic syndrome (MetS) and its components have not been well established.

METHODS

In total, 26,382 workers from Dongfeng-Tongji Cohort were included in this study. Information on shift work history was gathered through questionnaires and metabolic traits were measured. Logistic regression models were used to calculate the odds ratio (OR) and 95% confidence interval (CI) for long-term shift work related with MetS and each component, respectively. Further stratification analysis was performed to detect the differences on MetS between female and male shift workers.

RESULTS

Long-term shift work was associated with MetS without adjusting for any confounders. Compared with the group of non-shift work, the multivariate-adjusted ORs (95%CI) of MetS associated with 1-10, 11-20, and ≥20y of shift work were 1.05 (0.95-1.16), 1.14 (1.03-1.26), 1.16 (1.01-1.31), respectively. In female workers, we found a dose-response relationship that every 10 years increase in shift work was associated with a 10% (95% CI: 1%-20%) elevated OR of MetS, while no significant dose-response trend was found among male workers. Furthermore, shift work duration was significantly associated with ORs of high blood pressure (1.07, 1.01-1.13), long waist circumference (1.10, 1.01-1.20) and high glucose levels (1.09, 1.04-1.15). No significant association was observed between shift work and low HDL cholesterol) and raised triglyceride levels.

CONCLUSIONS

Long-term shift work was associated with metabolic syndrome and the association might differ by gender in retired workers. Applicable intervention strategies are needed for prevention of metabolic disorders for shift workers.

Health-related quality of life and happiness within an internal medicine residency training program: a longitudinal follow-up study

PURPOSE

While undergoing a hospital residency training program, residents often suffer anxiety and stress. This study aims to evaluate the change in health-related quality of life and happiness among internal medicine residents, and identify prognostic factors.

METHODS

Thirty-eight residents in the Ramathibodi Hospital internal medicine training program completed the World Health Organization Quality of Life-BREF and happiness Measures questionnaires at three time points: commencement, day 100, and the end of the second year of training. Confidence, expectations, anxiety, and general health were rated. Analyses were performed with mixed linear regression.

RESULTS

Financial problems were reported for 16 residents (42.1%). At baseline, most residents had moderate-to-very high confidence, expectations, and general health but also moderate-to-very high anxiety. The health-related quality of life score was highest in the social domain followed by the environmental, psychological, and physical domains. Their psychological, physical, social, and environmental scores significantly decreased after enrollment. Their happiness and general health scores were significantly reduced after enrollment. The training program duration was negatively associated with all domains. Residents with greater confidence had higher health-related quality of life scores in the physical, psychological, and environmental domains. Moreover, their general health was positively associated with the social and environmental domains.

CONCLUSION

A reduction in health-related quality of life and happiness under the internal medicine residency program is reported. High confidence and good physical health may counterbalance the decline in health-related quality of life and happiness.

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.

Achievement of take-home dose privileges is associated with better-perceived sleep and with cognitive status among methadone maintenance treatment patients

OBJECTIVES

Methadone maintenance treatment (MMT) patients may achieve up to a 2-week privilege of methadone take-home doses (THD), which is associated with considerable responsibility. MMT patients are characterized as having poor sleep quality and low cognitive states. We studied sleep indices and cognitive status with respect to THD privileges.

METHODS

A sample of 123 MMT patients stratified by THD groups was studied. Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and the cognitive Clock Drawing Test (CDT) were performed.

RESULTS

Thirty-one of 123 patients never had any THD and 92 did (25 had the maximum of 2 weeks). The never THD had history of longer duration of opiate usage and a shorter period in MMT. They had the highest rates of poor sleep (80.6%, PSQI > 5), daily sleepiness ("fall asleep while talking") (41.9%), and impaired cognitive status (58.1%, CDT < 3), while those who had 2-week privileges had the lowest (56, 8, and 28%, respectively). Logistic regression characterized THD patients as no-benzodiazepine and no-cocaine, short opiate usage duration, low ADHD scores, and no cognitive impairment (CDT = 3) and its interaction with treatment duration.

CONCLUSION

Privileges that reflect patients' abstinence and rehabilitation were also expanded to be associated with better cognitive states. These finding confirm the THD dispensing performance. Including CDT as part of the decision for dispensing THD may be considered.

Changes in inpatient staffing following implementation of new residency work hours

BACKGROUND

In 2011, the Accreditation Council for Graduate Medical Education added additional resident work-hour restrictions that limited the number of hours residents could work, with increased emphasis on attending supervision.

OBJECTIVE

Our objective was to determine how residency programs have responded to residency work hours, specifically assessing residency night float systems and in-house attending physicians.

DESIGN

In May 2012, an electronic survey was sent to all US pediatric residency training programs via the Association of Pediatric Program Directors listserv with e-mail reminders to nonresponding programs. We analyzed data to assess the use of resident night float systems, admission caps, and attending physicians in-house at night.

RESULTS

Out of 198 programs contacted, 152 programs responded (77% response rate). Residency programs utilizing a night float system increased from 43% to 71% after new work hours were implemented. Overall use of resident admission caps did not change significantly. Twenty-three percent of programs increased the number of attending physicians in-house at night; 57% of those programs increased the number of pediatric hospitalist attendings, whereas 37% increased the number of pediatric intensivists. There is a trend toward increased pediatric hospitalist attending in-house 24/7 coverage. Of programs without 24/7 coverage, 26% plan to add coverage within 5 years. Only 12% of programs have no in-house attending coverage at night.

CONCLUSIONS

Although programs vary in their response to changes in residency work restrictions, they most commonly utilize night float systems and increased the amount of in-house attending coverage at night, especially pediatric hospitalist attendings. Many programs plan to add 24/7 pediatric hospitalist coverage within 5 years.

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.

The effects of shift work on sleeping quality, hypertension and diabetes in retired workers

BACKGROUND

Shift work has been associated with adverse health effects by disturbing circadian rhythms. However,its potential long-term health effects and the persistent effects after leaving shifts have not been well established.

METHODS AND RESULTS

We studied 26,463 workers from Tongji-Dongfeng Cohort in China. All the participants are retired employees of Dongfeng Motor Company. Information on demographics, occupational history and medical history were gathered through questionnaires. After adjusting potential confounders in the logistic regression models, shift work was associated with poor sleeping quality, diabetes and hypertension independently. We observed significant effects of shift work on poor sleeping quality, diabetes and hypertension; the ORs (95%CI) are 1.18 (1.09-1.27), 1.10 (1.03-1.17) and 1.05 (1.01-1.09) respectively. In the further analysis, we found elevated ORs (95%CI) for participants with poor sleeping quality, the ORs (95%CI) are 1.34 (1.08-1.60), 1.13 (1.05-1.21), 1.05 (1.03-1.07) and 1.05 (1.01-1.09) for 1-4, 5-9, 10-19, ≥20 years of shift work respectively. However, with the extension of leaving shift work duration, the effects of shift work on sleep quality gradually reduced.

CONCLUSIONS

Shift work may be an independent risk factor for sleeping quality, diabetes and hypertension even in retired workers. Applicable intervention strategies are needed for prevention of sleep loss, diabetes, and hypertension for shift workers.

On-call duty effects on sleep-state physiological stability in male medical interns

Background

On-call duty among medical interns is characterized by sleep deprivation and stressful working conditions, both of which alter cardiac autonomic modulation. We hypothesized that sleep stability decreased in medical interns during on-call duty. We used cardiopulmonary-coupling (CPC) analysis to test our hypothesis.

Methods

We used electrocardiogram (ECG)-based CPC analysis to quantify physiological parameters of sleep stability in 13 medical interns during on-call and on-call duty-free periods. There were ten 33.5-h on-call duty shifts per month for interns, each followed by 2 on-call duty-free days, over 3 months. Measurements during sleep were collected before, during, and after an on-call shift. Measurements were repeated 3 months later during an on-call duty-free period.

Results

The medical interns had significantly reduced stable sleep, and displayed increased latency to the first epoch of stable sleep during the on-call night shift, compared to the pre-call and on-call duty-free nights. Interns also had significantly increased rapid-eye-movement (REM) sleep during the on-call night shift, compared to the pre-call and on-call duty-free nights.

Conclusion

Medical interns suffer disrupted sleep stability and continuity during on-call night shifts. The ECG-based CPC analysis provides a straightforward means to quantify sleep quality and stability in medical staff performing shift work under stressful conditions.