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Roizenblatt M, Gehlbach PL, Marin VDG, Roizenblatt A, Saraiva VS, Nakanami MH, Noia LC, Song Watanabe SE, Yasaki ES, Passos RM, Magalhães Junior O, Fernandes RAB, Stefanini FR, Caiado R, Jiramongkolchai K, Farah ME, Belfort Junior R, Maia M. Re: Wubben TJ. A word of caution when interpreting the effect of sleep deprivation on surgical performance (Ophthalmol Retina. 2023;7:937-939). Ophthalmol Retina 2024; 8:e17-e18. [PMID: 38704191 DOI: 10.1016/j.oret.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/14/2024] [Accepted: 01/23/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil; The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Peter L Gehlbach
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vitor D G Marin
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Arnaldo Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vinicius S Saraiva
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mauricio H Nakanami
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luciana C Noia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Sung E Song Watanabe
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Erika S Yasaki
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato M Passos
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Rodrigo A B Fernandes
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Rafael Caiado
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Michel E Farah
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rubens Belfort Junior
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mauricio Maia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
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Nagasaki K, Kobayashi H, Nishizaki Y, Kurihara M, Watari T, Shimizu T, Yamamoto Y, Shikino K, Fukui S, Nishiguchi S, Katayama K, Tokuda Y. Association of sleep quality with duty hours, mental health, and medical errors among Japanese postgraduate residents: a cross-sectional study. Sci Rep 2024; 14:1481. [PMID: 38233476 PMCID: PMC10794685 DOI: 10.1038/s41598-024-51353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/03/2024] [Indexed: 01/19/2024] Open
Abstract
Long duty hours (DH) impair sleep and negatively affect residents' health and medical safety. This cross-sectional study investigated the association among residents' DH, sleep duration, insomnia, sleep impairment, depressive symptoms, and self-reported medical errors among 5579 residents in Japan who completed the General Medicine In-Training Examination (2021) and participated in the training-environment survey. Weekly DH was classified under seven categories. Sleep duration and insomnia symptoms, from the Athens Insomnia Scale, were analysed to determine sleep impairment; depressive symptoms and medical errors were self-reported. Among 5095 residents, 15.5% slept < 5 h/day, and 26.7% had insomnia. In multivariable analysis, compared with ≥ 60 and < 70, DH ≥ 90 h/week associated with shorter sleep duration and worsen insomnia symptoms. Shorter durations of sleep and more intense symptoms of insomnia were associated with increased depressive symptoms. Medical errors increased only among residents with insomnia, but were not associated with sleep duration. DH > 90 h/week could lead to shorter sleep duration, worsen insomnia symptoms, and negatively impact well-being and medical safety. There was no significant association between sleep duration and medical errors; however, insomnia conferred an increased risk of medical errors. Limiting DH for residents to avoid excessive workload can help improve resident sleep, enhance resident well-being, and potentially reduce insomnia-associated medical errors.
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Affiliation(s)
- Kazuya Nagasaki
- Department of Internal Medicine, Mito Kyodo General Hospital, University of Tsukuba, 3-2-7, Miyamachi, Mito, Ibaraki, 310-0015, Japan
| | - Hiroyuki Kobayashi
- Department of Internal Medicine, Mito Kyodo General Hospital, University of Tsukuba, 3-2-7, Miyamachi, Mito, Ibaraki, 310-0015, Japan.
| | - Yuji Nishizaki
- Division of Medical Education, Juntendo University School of Medicine, Tokyo, Japan
| | - Masaru Kurihara
- Department of Patient Safety, Nagoya University Hospital, Aichi, Japan
| | - Takashi Watari
- General Medicine Center, Shimane University Hospital, Shimane, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, Japan
| | - Yu Yamamoto
- Division of General Medicine, Center for Community Medicine, Jichi Medical University, Tochigi, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, Chiba, Japan
| | - Sho Fukui
- Department of Emergency and General Medicine, Kyorin University, Tokyo, Japan
| | - Sho Nishiguchi
- Department of General Internal Medicine, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Kohta Katayama
- Department of General Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
- Department of Clinical Epidemiology, Graduate School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yasuharu Tokuda
- Muribushi Okinawa for Teaching Hospitals, Okinawa, Japan
- Tokyo Foundation for Policy Research, Tokyo, Japan
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Van Dongen HPA, Basner M, Mullington JM, Carlin M. Foreword: Festschrift in honor of David Dinges, scientist and mentor extraordinaire. SLEEP ADVANCES : A JOURNAL OF THE SLEEP RESEARCH SOCIETY 2023; 4:zpad020. [PMID: 38020731 PMCID: PMC10658658 DOI: 10.1093/sleepadvances/zpad020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Affiliation(s)
- Hans P A Van Dongen
- Sleep and Performance Research Center and Department of Translational Medicine and Physiology, Washington State University Health Sciences, Spokane, WA, USA
| | - Mathias Basner
- Unit for Experimental Psychiatry, Division of Sleep and Chronobiology, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, , USA
| | - Janet M Mullington
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Michele Carlin
- Unit for Experimental Psychiatry, Division of Sleep and Chronobiology, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, , USA
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Sephien A, Reljic T, Jordan J, Prida X, Kumar A. Resident duty hours and resident and patient outcomes: Systematic review and meta-analysis. MEDICAL EDUCATION 2023; 57:221-232. [PMID: 36181404 DOI: 10.1111/medu.14943] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 08/18/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES The policies regarding resident physician work hours are constantly being evaluated and changed. However, the results of randomised control trials (RCTs) are mixed. This systematic review of RCTs aims to synthesise the evidence associated with resident duty hour restrictions and its impact on resident- and patient-based outcomes. METHODS A comprehensive search of the Cochrane Library, EMBASE and PubMed was conducted from inception until 31 July 2020. Any RCT evaluating the impact of longer resident physician work hours compared to shorter resident physician work hours on resident- and patient-based outcomes was eligible for inclusion. Two reviewers extracted data independently. The primary outcome was the impact of resident duty hour restrictions on emotional exhaustion, depersonalisation and personal accomplishment, as defined by the Maslach Burnout Inventory. The secondary patient-related outcomes were patient hospital length of stay, serious medical errors and preventable adverse events. Data were pooled using a random-effects model. RESULTS Of the 873 references, nine RCTs met the inclusion criteria. A shorter shift length compared with longer shift length was associated with significantly less emotional exhaustion (standardised mean difference [SMD] = -0.11, 95% CI = -0.21, -0.00) and less dissatisfaction with overall well-being (OR = 0.61, 95% CI 0.38, 0.99) but not with hospital length of stay (SMD = -0.01, 95% CI = -0.05, 0.02, p = 0.45) and serious medical errors per 1000 patient hours (OR = 1.07, 95% CI = 0.52, 2.21; p = 0.86). CONCLUSIONS Shorter resident duty hours is possibly associated with improvement in resident-based outcomes, specifically, emotional exhaustion, dissatisfaction with overall well-being, sleep duration and sleepiness. These findings may inform the policy change in support of reduced shift hours resulting in overall well-being for the residents with possible reduction in burnout without adverse impact on patient-based outcomes.
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Affiliation(s)
- Andrew Sephien
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, Florida, USA
| | - Tea Reljic
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Jeffrey Jordan
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, Florida, USA
| | - Xavier Prida
- Department of Cardiovascular Sciences, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
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Redinger J, Kabil E, Forkin KT, Kleiman AM, Dunn LK. Resting and Recharging: A Narrative Review of Strategies to Improve Sleep During Residency Training. J Grad Med Educ 2022; 14:420-430. [PMID: 35991104 PMCID: PMC9380640 DOI: 10.4300/jgme-d-21-01035.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/21/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Residency involves demanding training with long hours that may cause fatigue and sleep deprivation and adversely impact residents and patients under their care. OBJECTIVE To identify, using a narrative review, evidence-based interventions to reduce the physiologic effects of fatigue and sleep deprivation from overnight and night shift work. METHODS A PubMed literature search was conducted through August 30, 2021, using the terms "resident" and "sleep" in the title or abstract and further narrowed using a third search term. Observational studies, randomized controlled trials, systematic reviews, and meta-analyses of human subjects written and published in English were included. Studies that were not specific to residents or medical interns or did not investigate an intervention were excluded. Additional studies were identified by bibliography review. Due to the heterogeneity of study design and intervention, a narrative review approach was chosen with results categorized into non-pharmacological and pharmacological interventions. RESULTS Initially, 271 articles were identified, which were narrowed to 28 articles with the use of a third search term related to sleep. Bibliography review yielded 4 additional articles. Data on interventions are limited by the heterogeneity of medical specialty, sample size, length of follow-up, and reliance on self-report. Non-pharmacological interventions including strategic scheduling and sleep hygiene may improve sleep and well-being. The available evidence, including randomized controlled trials, to support pharmacological interventions is limited. CONCLUSIONS Non-pharmacological approaches to mitigating fatigue and sleep deprivation have varying effectiveness to improve sleep for residents; however, data for pharmacological interventions is limited.
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Affiliation(s)
- Joyce Redinger
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Joyce Redinger, MD, is PGY-3 Resident
| | - Emmad Kabil
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Emmad Kabil, MD, is PGY-4 Resident
| | - Katherine T. Forkin
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Katherine T. Forkin, MD, is Associate Professor of Anesthesiology
| | - Amanda M. Kleiman
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Amanda M. Kleiman, MD, is Associate Professor of Anesthesiology
| | - Lauren K. Dunn
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Lauren K. Dunn, MD, PhD, is Associate Professor of Anesthesiology and Neurological Surgery
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Cordoza M, Basner M, Asch DA, Shea JA, Bellini LM, Carlin M, Ecker AJ, Malone SK, Desai SV, Katz JT, Bates DW, Small DS, Volpp KG, Mott CG, Coats S, Mollicone DJ, Dinges DF. Sleep and Alertness Among Interns in Intensive Care Compared to General Medicine Rotations: A Secondary Analysis of the iCOMPARE Trial. J Grad Med Educ 2021; 13:717-721. [PMID: 34721802 PMCID: PMC8527933 DOI: 10.4300/jgme-d-21-00045.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 07/08/2021] [Accepted: 07/22/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Medical interns are at risk for sleep deprivation from long and often rotating work schedules. However, the effects of specific rotations on sleep are less clear. OBJECTIVE To examine differences in sleep duration and alertness among internal medicine interns during inpatient intensive care unit (ICU) compared to general medicine (GM) rotations. METHODS This secondary analysis compared interns during a GM or ICU rotation from a randomized trial (2015-2016) of 12 internal medicine residency programs assigned to different work hour limit policies (standard 16-hour shifts or no shift-length limits). The primary outcome was sleep duration/24-hour using continuous wrist actigraphy over a 13-day period. Secondary outcomes assessed each morning during the concomitant actigraphy period were sleepiness (Karolinska Sleepiness Scale [KSS]), alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses), and self-report of excessive sleepiness over past 24 hours. Linear mixed-effect models with random program intercept determined associations between each outcome by rotation, controlling for age, sex, and work hour policy followed. RESULTS Of 398 interns, 386 were included (n = 261 GM, n = 125 ICU). Average sleep duration was 7.00±0.08h and 6.84±0.10h, and number of PVT lapses were 5.5±0.5 and 5.7±0.7 for GM and ICU, respectively (all P > .05). KSS was 4.8±0.1 for both rotations. Compared to GM, ICU interns reported more days of excessive sleepiness from 12am-6am (2.6 vs 1.7, P < .001) and 6am-12pm (2.6 vs 1.9, P = .013) and had higher percent of days with sleep duration < 6 hours (27.6% vs 23.4%, P < .001). GM interns reported more days with no excessive sleepiness (5.3 vs 3.7, P < .001). CONCLUSIONS Despite ICU interns reporting more excessive sleepiness in morning hours and more days of insufficient sleep (<6 hours), overall sleep duration and alertness did not significantly differ between rotations.
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Affiliation(s)
- Makayla Cordoza
- Makayla Cordoza, PhD, RN, CCRN-K*, is a Lecturer, University of Pennsylvania
| | - Mathias Basner
- Mathias Basner, MD, PhD, MSc*, is a Professor, University of Pennsylvania
| | - David A. Asch
- David A. Asch, MD, MBA, is a Professor, University of Pennsylvania, and Practicing Physician, Corporal Michael J. Crescenz Veterans Affairs Medical Center
| | - Judy A. Shea
- Judy A. Shea, PhD, is a Professor, University of Pennsylvania
| | - Lisa M. Bellini
- Lisa M. Bellini, MD, is a Professor, University of Pennsylvania
| | - Michele Carlin
- Michele Carlin is a Project Manager, University of Pennsylvania
| | - Adrian J. Ecker
- Adrian J. Ecker is a Senior IT Project Leader, University of Pennsylvania
| | - Susan K. Malone
- Susan K. Malone, PhD, RN, is an Assistant Professor, New York University
| | - Sanjay V. Desai
- Sanjay V. Desai, MD, is a Professor, Johns Hopkins University
| | - Joel T. Katz
- Joel T. Katz, MD, is Vice Chair for Education, Brigham and Women's Hospital
| | - David W. Bates
- David W. Bates, MD, MSc, is Division of General Internal Medicine Chief, Brigham and Women's Hospital
| | - Dylan S. Small
- Dylan S. Small, PhD, is a Professor, University of Pennsylvania
| | - Kevin G. Volpp
- Kevin G. Volpp, MD, PhD, is a Professor, University of Pennsylvania, and Practicing Physician, Corporal Michael J. Crescenz Veterans Affairs Medical Center
| | | | - Sara Coats
- Sara Coats, BS, is Lead Project Coordinator, Pulsar Informatics
| | | | - David F. Dinges
- David F. Dinges, PhD, is a Professor, University of Pennsylvania; and iCOMPARE Research Group
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Choshen-Hillel S, Ishqer A, Mahameed F, Reiter J, Gozal D, Gileles-Hillel A, Berger I. Acute and chronic sleep deprivation in residents: Cognition and stress biomarkers. MEDICAL EDUCATION 2021; 55:174-184. [PMID: 32697336 PMCID: PMC7854866 DOI: 10.1111/medu.14296] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 06/29/2020] [Accepted: 07/16/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Insufficient sleep affects circadian hormonal profiles and inflammatory markers and may modulate attention, executive functioning and decision-making. Medical professionals and specifically resident physicians, who are involved in long-term nightshift schedules during their post-graduate training, are prone to acute and chronic sleep deprivation and disruption, putting them at risk for making medical errors. The aim of the study was to evaluate the impact of chronic and acute-on-chronic sleep deprivation and disruption among residents on selected physiological and cognitive measures. METHODS Thirty-three medical and surgical residents were evaluated twice - at baseline and after a 26-hour shift. Eighteen young attending physicians who did not engage in nightshift schedules served as controls and were evaluated once. Measures included morning cortisol and high-sensitivity C-reactive protein (hs-CRP), computerised tests of attention and behaviour, the Behaviour Rating Inventory of Executive Function, a risk-taking questionnaire and the Pittsburgh Sleep Quality Index. RESULTS Residents, but not attendings, reported chronic sleep disruption and deprivation. Residents at baseline exhibited reduced morning cortisol levels and elevated hs-CRP levels, compared to attendings. Residents at baseline had impaired global executive function compared to attendings. A nightshift with acute sleep deprivation further reduced residents' executive function. Residents at baseline and after a nightshift demonstrated increased impulsivity and slower processing time than attendings. Residents and attendings did not differ in risk-taking tendencies which were assessed in a separate cohort. CONCLUSIONS In a real-life setting, resident physicians exhibit increased low-grade systemic inflammation (hs-CRP) and impaired HPA-axis function. Their chronic sleep curtailment is associated with greater impulsivity, slower cognitive processing, and impaired executive function. Future research is warranted to understand how improving working schedule by increasing sleep duration may minimise the short-term and potential long-term risks to physicians in training.
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Affiliation(s)
- Shoham Choshen-Hillel
- School of Business Administration and the Federmann Center for the Study of Rationality, Hebrew University of Jerusalem
| | - Ahmad Ishqer
- Pediatric Pulmonary & Sleep Unit, Hadassah-Hebrew University Medical Center
| | - Fadi Mahameed
- Pediatric Pulmonary & Sleep Unit, Hadassah-Hebrew University Medical Center
| | - Joel Reiter
- Pediatric Pulmonary & Sleep Unit, Hadassah-Hebrew University Medical Center
| | - David Gozal
- Department of Child Health, MU Women’s and Children’s Hospital, University of Missouri School of Medicine
| | - Alex Gileles-Hillel
- Pediatric Pulmonary & Sleep Unit, Hadassah-Hebrew University Medical Center
- The Wohl Institute for Translational Medicine, Hadassah-Hebrew University Medical Center
| | - Itai Berger
- Pediatric Neurology; Department of Pediatrics, Assuta-Ashdod University Medical Center
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva
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Rotenberg L, Silva-Costa A, Griep RH. On-shift naps are associated with systolic and diastolic blood pressure level among night working nursing professionals. Chronobiol Int 2020; 37:1365-1372. [DOI: 10.1080/07420528.2020.1819114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Lucia Rotenberg
- Laboratory of Health and Environmental Education, Oswaldo Cruz Institute - Fiocruz, Rio de Janeiro, RJ, Brazil
| | - Aline Silva-Costa
- Department of Collective Health, Federal University of Triangulo Mineiro - Uberaba, MG, Brazil
| | - Rosane Härter Griep
- Laboratory of Health and Environmental Education, Oswaldo Cruz Institute - Fiocruz, Rio de Janeiro, RJ, Brazil
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St Hilaire MA, Anderson C, Anwar J, Sullivan JP, Cade BE, Flynn-Evans EE, Czeisler CA, Lockley SW. Brief (<4 hr) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts. Sleep 2020; 42:5362587. [PMID: 30794317 DOI: 10.1093/sleep/zsz041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 01/15/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES The Accreditation Council for Graduate Medical Education (ACGME) recently reinstated extended-duration (24-28 hr) work shifts (EDWS) for postgraduate year 1 (PGY-1) resident physicians. This study examined the relationship between overnight sleep duration during EDWS and subsequent "post-call" performance in PGY-1 resident physicians. METHODS Thirty-four PGY-1 resident physicians (23 males; 24-32 years) were studied between 2002 and 2004 during 3-week Q3 "on-call" rotation schedules in the Medical and Cardiac Intensive Care Units at Brigham and Women's Hospital in Boston. Daily sleep logs (validated by ambulatory polysomnography) were collected and the 10 min psychomotor vigilance task (PVT) was administered every ~6 hr during each EDWS. Generalized estimating equations were used to examine the relationship between overnight sleep duration and PVT performance "post-call" (0500-1900 hr). Postcall performance during EDWS was compared with sessions matched for time-of-day and weeks-into-schedule in the same resident physician during an intervention schedule that eliminated EDWS. RESULTS Resident physicians obtained an average of 1.6 ± 1.5 hr cumulative sleep overnight during EDWS (<4 hr on 92% of nights). PVT attentional failures were significantly reduced only after >4 hr sleep (p = 0.027 versus no sleep). Despite this apparent improvement, the odds of incurring >1 attentional failure were 2.72 times higher during postcall following >4 hr sleep compared with matched sessions during non-EDWS. CONCLUSIONS Even with >4 hr sleep overnight (8% of EDWS), performance remained significantly impaired. These findings suggest that even "strategic napping," a recommendation recently removed from ACGME guidelines, is insufficient to mitigate severe performance impairment introduced by extending duty beyond 16 hr.
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Affiliation(s)
- Melissa A St Hilaire
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Clare Anderson
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Junnat Anwar
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA
| | - Jason P Sullivan
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Brian E Cade
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Erin E Flynn-Evans
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Charles A Czeisler
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Steven W Lockley
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
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Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing. Crit Care Med 2020; 47:894-902. [PMID: 30985450 DOI: 10.1097/ccm.0000000000003773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model. DESIGN Prospective observational study. SETTING Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing. PATIENTS Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012. INTERVENTIONS As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily. MEASUREMENTS AND MAIN RESULTS Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model. CONCLUSIONS Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.
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St Hilaire MA, Kristal BS, Rahman SA, Sullivan JP, Quackenbush J, Duffy JF, Barger LK, Gooley JJ, Czeisler CA, Lockley SW. Using a Single Daytime Performance Test to Identify Most Individuals at High-Risk for Performance Impairment during Extended Wake. Sci Rep 2019; 9:16681. [PMID: 31723161 PMCID: PMC6853981 DOI: 10.1038/s41598-019-52930-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/25/2019] [Indexed: 12/20/2022] Open
Abstract
We explored the predictive value of a neurobehavioral performance assessment under rested baseline conditions (evaluated at 8 hours awake following 8 hours of sleep) on neurobehavioral response to moderate sleep loss (evaluated at 20 hours awake two days later) in 151 healthy young participants (18-30 years). We defined each participant's response-to-sleep-loss phenotype based on the number of attentional failures on a 10-min visual psychomotor vigilance task taken at 20 hours awake (resilient: less than 6 attentional failures, n = 26 participants; non-resilient: 6 or more attentional failures, n = 125 participants). We observed that 97% of rested participants with 2 or more attentional failures (n = 73 of 151) and 100% of rested participants with 3 or more attentional failures (n = 57 of 151) were non-resilient after moderate sleep loss. Our approach can accurately identify a significant proportion of individuals who are at high risk for neurobehavioral performance impairment from staying up late with a single neurobehavioral performance assessment conducted during rested conditions. Additional methods are needed to predict the future performance of individuals who are not identified as high risk during baseline.
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Affiliation(s)
- Melissa A St Hilaire
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA.
- Division of Sleep Medicine, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA.
| | - Bruce S Kristal
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Division of Sleep Medicine, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Shadab A Rahman
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Division of Sleep Medicine, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Jason P Sullivan
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - John Quackenbush
- Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Jeanne F Duffy
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Division of Sleep Medicine, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Laura K Barger
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Division of Sleep Medicine, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Joshua J Gooley
- Programme in Neuroscience and Behavioural Disorders, Duke-National University of Singapore Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Charles A Czeisler
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Division of Sleep Medicine, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Steven W Lockley
- Division of Sleep and Circadian Disorders, Brigham & Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
- Division of Sleep Medicine, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
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12
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Wong LR, Flynn-Evans E, Ruskin KJ. Fatigue Risk Management: The Impact of Anesthesiology Residents' Work Schedules on Job Performance and a Review of Potential Countermeasures. Anesth Analg 2019; 126:1340-1348. [PMID: 29049076 DOI: 10.1213/ane.0000000000002548] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Long duty periods and overnight call shifts impair physicians' performance on measures of vigilance, psychomotor functioning, alertness, and mood. Anesthesiology residents typically work between 64 and 70 hours per week and are often required to work 24 hours or overnight shifts, sometimes taking call every third night. Mitigating the effects of sleep loss, circadian misalignment, and sleep inertia requires an understanding of the relationship among work schedules, fatigue, and job performance. This article reviews the current Accreditation Council for Graduate Medical Education guidelines for resident duty hours, examines how anesthesiologists' work schedules can affect job performance, and discusses the ramifications of overnight and prolonged duty hours on patient safety and resident well-being. We then propose countermeasures that have been implemented to mitigate the effects of fatigue and describe how training programs or practice groups who must work overnight can adapt these strategies for use in a hospital setting. Countermeasures include the use of scheduling interventions, strategic naps, microbreaks, caffeine use during overnight and extended shifts, and the use of bright lights in the clinical setting when possible or personal blue light devices when the room lights must be turned off. Although this review focuses primarily on anesthesiology residents in training, many of the mitigation strategies described here can be used effectively by physicians in practice.
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Affiliation(s)
- Lily R Wong
- From the San Jose State University Research Foundation, San Jose, California.,Human Factors Research Division, NASA Ames Research Center, Moffett Field, California
| | - Erin Flynn-Evans
- Human Factors Research Division, NASA Ames Research Center, Moffett Field, California
| | - Keith J Ruskin
- Department of Anesthesia and Critical Care, University of Chicago School of Medicine, Chicago, Illinois
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13
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Basner M, Asch DA, Shea JA, Bellini LM, Carlin M, Ecker AJ, Malone SK, Desai SV, Sternberg AL, Tonascia J, Shade DM, Katz JT, Bates DW, Even-Shoshan O, Silber JH, Small DS, Volpp KG, Mott CG, Coats S, Mollicone DJ, Dinges DF. Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine. N Engl J Med 2019; 380:915-923. [PMID: 30855741 PMCID: PMC6457111 DOI: 10.1056/nejmoa1810641] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A purpose of duty-hour regulations is to reduce sleep deprivation in medical trainees, but their effects on sleep, sleepiness, and alertness are largely unknown. METHODS We randomly assigned 63 internal-medicine residency programs in the United States to follow either standard 2011 duty-hour policies or flexible policies that maintained an 80-hour workweek without limits on shift length or mandatory time off between shifts. Sleep duration and morning sleepiness and alertness were compared between the two groups by means of a noninferiority design, with outcome measures including sleep duration measured with actigraphy, the Karolinska Sleepiness Scale (with scores ranging from 1 [extremely alert] to 9 [extremely sleepy, fighting sleep]), and a brief computerized Psychomotor Vigilance Test (PVT-B), with long response times (lapses) indicating reduced alertness. RESULTS Data were obtained over a period of 14 days for 205 interns at six flexible programs and 193 interns at six standard programs. The average sleep time per 24 hours was 6.85 hours (95% confidence interval [CI], 6.61 to 7.10) among those in flexible programs and 7.03 hours (95% CI, 6.78 to 7.27) among those in standard programs. Sleep duration in flexible programs was noninferior to that in standard programs (between-group difference, -0.17 hours per 24 hours; one-sided lower limit of the 95% confidence interval, -0.45 hours; noninferiority margin, -0.5 hours; P = 0.02 for noninferiority), as was the score on the Karolinska Sleepiness Scale (between-group difference, 0.12 points; one-sided upper limit of the 95% confidence interval, 0.31 points; noninferiority margin, 1 point; P<0.001). Noninferiority was not established for alertness according to the PVT-B (between-group difference, -0.3 lapses; one-sided upper limit of the 95% confidence interval, 1.6 lapses; noninferiority margin, 1 lapse; P = 0.10). CONCLUSIONS This noninferiority trial showed no more chronic sleep loss or sleepiness across trial days among interns in flexible programs than among those in standard programs. Noninferiority of the flexible group for alertness was not established. (Funded by the National Heart, Lung, and Blood Institute and American Council for Graduate Medical Education; ClinicalTrials.gov number, NCT02274818.).
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Affiliation(s)
- Mathias Basner
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David A Asch
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Judy A Shea
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Lisa M Bellini
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Michele Carlin
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Adrian J Ecker
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Susan K Malone
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Sanjay V Desai
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Alice L Sternberg
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - James Tonascia
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David M Shade
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Joel T Katz
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David W Bates
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Orit Even-Shoshan
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Jeffrey H Silber
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Dylan S Small
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Kevin G Volpp
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Christopher G Mott
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Sara Coats
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Daniel J Mollicone
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David F Dinges
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
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14
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Shea JA, Silber JH, Desai SV, Dinges DF, Bellini LM, Tonascia J, Sternberg AL, Small DS, Shade DM, Katz JT, Basner M, Chaiyachati KH, Even-Shoshan O, Bates DW, Volpp KG, Asch DA. Development of the individualised Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education (iCOMPARE) trial: a protocol summary of a national cluster-randomised trial of resident duty hour policies in internal medicine. BMJ Open 2018; 8:e021711. [PMID: 30244209 PMCID: PMC6157525 DOI: 10.1136/bmjopen-2018-021711] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Medical trainees' duty hours have received attention globally; restrictions in Europe, New Zealand and some Canadian provinces are much lower than the 80 hours per week enforced in USA. In USA, resident duty hours have been implemented without evidence simultaneously reflecting competing concerns about patient safety and physician education. The objective is to prospectively evaluate the implications of alternative resident duty hour rules for patient safety, trainee education and intern sleep and alertness. METHODS AND ANALYSIS 63 US internal medicine training programmes were randomly assigned 1:1 to the 2011 Accreditation Council for Graduate Medical Education resident duty hour rules or to rules more flexible in intern shift length and number of hours off between shifts for academic year 2015-2016. The primary outcome is calculated for each programme as the difference in 30-day mortality rate among Medicare beneficiaries with any of several prespecified principal diagnoses in the intervention year minus 30-day mortality in the preintervention year among Medicare beneficiaries with any of several prespecified principal diagnoses. Additional safety outcomes include readmission rates, prolonged length of stay and costs. Measures derived from trainees' and faculty responses to surveys and from time-motion studies of interns compare the educational experiences of residents. Measures derived from wrist actigraphy, subjective ratings and psychomotor vigilance testing compare the sleep and alertness of interns. Differences between duty hour groups in outcomes will be assessed by intention-to-treat analyses. ETHICS AND DISSEMINATION The University of Pennsylvania Institutional Review Board (IRB) approved the protocol and served as the IRB of record for 40 programmes that agreed to sign an Institutional Affiliation Agreement. Twenty-three programmes opted for a local review process. TRIAL REGISTRATION NUMBER NCT02274818; Pre-results.
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Affiliation(s)
- Judy A Shea
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey H Silber
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sanjay V Desai
- Department of Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
| | - David F Dinges
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lisa M Bellini
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James Tonascia
- Department of Biostatistics, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Alice L Sternberg
- Department of Epidemiology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Dylan S Small
- Wharton Statistics Department, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David M Shade
- Department of Epidemiology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Joel Thorp Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mathias Basner
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Krisda H Chaiyachati
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Orit Even-Shoshan
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David Westfall Bates
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin G Volpp
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medical Ethics and Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David A Asch
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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15
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Cheval B, Mongin D, Cullati S, Winz C, von Arx M, Schmidt RE, Agoritsas T, Chopard P, Courvoisier DS. Reciprocal relations between care-related emotional burden and sleep problems in healthcare professionals: a multicentre international cohort study. Occup Environ Med 2018; 75:647-653. [PMID: 30026283 DOI: 10.1136/oemed-2018-105096] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/18/2018] [Accepted: 07/06/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine whether there are reciprocal relations between care-related regret and insomnia severity among healthcare professionals, and whether the use of different coping strategies influences these associations. METHODS This is a multicentre international cohort study of 151 healthcare professionals working in acute care hospitals and clinics (87.4% female; mean age=30.4±8.0 years, 27.2% physicians, 48.3% nurses and 24.5% other professions) between 2014 and 2017. Weekly measures of regret intensity, number of regrets, and use of coping strategies (Regret Coping Scale) and sleep problems (Insomnia Severity Index) were assessed using a web survey. RESULTS The associations between regret and insomnia severity were bidirectional. In a given week, regret intensity (bregret intensity→sleep=0.26, 95% credible interval (CI) (0.14 to 0.40)) and number of regrets (bnumber of regrets→sleep=0.43, 95% CI (0.07 to 0.53)) were significantly associated with increased insomnia severity the following week. Conversely, insomnia severity in a given week was significantly associated with higher regret intensity (bsleep→regret intensity=0.14, 95% CI (0.11 to 0.30)) and more regrets (bsleep→number of regrets=0.04, 95% CI (0.02 to 0.06)) the week after. The effects of regret on insomnia severity were much stronger than those in the opposite direction. The use of coping strategies, especially if they were maladaptive, modified the strength of these cross-lagged associations. CONCLUSIONS The present study showed that care-related regret and sleep problems are closely intertwined among healthcare professionals. Given the high prevalence of these issues, our findings call for the implementation of interventions that are specifically designed to help healthcare professionals to reduce their use of maladaptive coping strategies.
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Affiliation(s)
- Boris Cheval
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland.,Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland.,Swiss NCCR 'LIVES: Overcoming Vulnerability: Life Course Perspectives', University of Geneva, Geneva, Switzerland
| | - Denis Mongin
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland.,Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland.,Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland.,Swiss NCCR 'LIVES: Overcoming Vulnerability: Life Course Perspectives', University of Geneva, Geneva, Switzerland.,Institute of Sociological Research, University of Geneva, Geneva, Switzerland
| | - Carole Winz
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Martina von Arx
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland.,Swiss NCCR 'LIVES: Overcoming Vulnerability: Life Course Perspectives', University of Geneva, Geneva, Switzerland
| | | | - Thomas Agoritsas
- Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland.,Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland.,Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Pierre Chopard
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland.,Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland
| | - Delphine Sophie Courvoisier
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland.,Department of General Internal Medicine, Rehabilitation and Geriatrics, University of Geneva, Geneva, Switzerland
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16
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Davy J, Göbel M. The effects of extended nap periods on cognitive, physiological and subjective responses under simulated night shift conditions. Chronobiol Int 2017; 35:169-187. [PMID: 29144168 DOI: 10.1080/07420528.2017.1391277] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Extended nap opportunities have been effective in maintaining alertness in the context of extended night shifts (+12 h). However, there is limited evidence of their efficacy during 8-h shifts. Thus, this study explored the effects of extended naps on cognitive, physiological and perceptual responses during four simulated, 8-h night shifts. In a laboratory setting, 32 participants were allocated to one of three conditions. All participants completed four consecutive, 8-h night shifts, with the arrangements differing by condition. The fixed night condition worked from 22h00 to 06h00, while the nap early group worked from 20h00 to 08h00 and napped between 00h00 and 03h20. The nap late group worked from 00h00 to 12h00 and napped between 04h00 and 07h20. Nap length was limited to 3 hours and 20 minutes. Participants performed a simple beading task during each shift, while also completing six to eight test batteries roughly every 2 h. During each shift, six test batteries were completed, in which the following measures were taken. Performance indicators included beading output, eye accommodation time, choice reaction time, visual vigilance, simple reaction time, processing speed and object recognition, working memory, motor response time and tracking performance. Physiological measures included heart rate and tympanic temperature, whereas subjective sleepiness and reported sleep length and quality while outside the laboratory constituted the self reported measures. Both naps reduced subjective sleepiness but did not alter the circadian and homeostatic-related changes in cognitive and physiological measures, relative to the fixed night condition. Additionally, there was evidence of sleep inertia following each nap, which resulted in transient reductions in certain perceptual cognitive performance measures. The present study suggested that there were some benefits associated with including an extended nap during 8-h night shifts. However, the effects of sleep inertia need to be effectively managed to ensure that post-nap alertness and performance is maintained.
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Affiliation(s)
- Jonathan Davy
- a Department of Human Kinetics and Ergonomics , Rhodes University , Grahamstown , South Africa
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17
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Basner M, Hermosillo E, Nasrini J, McGuire S, Saxena S, Moore TM, Gur RC, Dinges DF. Repeated Administration Effects on Psychomotor Vigilance Test Performance. Sleep 2017; 41:4605253. [DOI: 10.1093/sleep/zsx187] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Tang NKY, Fiecas M, Afolalu EF, Wolke D. Changes in Sleep Duration, Quality, and Medication Use Are Prospectively Associated With Health and Well-being: Analysis of the UK Household Longitudinal Study. Sleep 2017; 40:2845958. [PMID: 28364423 DOI: 10.1093/sleep/zsw079] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Introduction Sleep is a plausible target for public health promotion. We examined the association of changes in sleep with subsequent health and well-being in the general population. Aims and Methods We analyzed data from the UK Household Longitudinal Survey, involving 30594 people (aged > 16) who provided data on sleep and health and well-being at both Wave 1 (2009-2011) and Wave 4 (2012-2014) assessments. Predicting variables were changes in sleep quantity, sleep quality, and sleep medication use over the 4-year period. Outcome variables were the General Health Questionnaire (GHQ-12) and the 12-Item Short-Form Health Survey (SF-12) mental (MCS) and physical (PCS) component scores at Wave 4. Linear regression on each outcome was fully adjusted for potential confounders and baseline values of the relevant predicting and outcome variables. Results Better outcomes were associated with an increase in sleep duration (GHQ: β = 1.031 [95% confidence interval {CI}: -1.328, -0.734]; MCS: 1.531 [1.006, 2.055]; PCS: -0.071 [-0.419, 0.56]), sleep quality (GHQ: β = -2.031 [95% CI: -2.218, -1.844]; MCS: 3.027 [2.692, 3.361]; PCS: 0.924 [0.604, 1.245]), and a reduction in sleep medication use (GHQ: β = -1.929 [95% CI: -2.400, -1.459]; MCS: 3.106 [2.279, 3.933]; PCS: 2.633 [1.860, 3.406]). Poorer outcomes were on the other hand associated with a reduction in sleep duration, a decrease in sleep quality, and an increase in sleep medication use. Changes in sleep quality yielded the largest effects on the health and well-being outcomes. Conclusions Changes in sleep were temporally associated with subsequent health and well-being. Initiatives that aim to protect a critical amount of sleep, promote sleep quality, and reduce sleep medication use may have public health values.
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Affiliation(s)
- Nicole K Y Tang
- Department of Psychology, University of Warwick, Coventry, UK
| | - Mark Fiecas
- Department of Statistics, University of Warwick, Coventry, UK
| | | | - Dieter Wolke
- Department of Psychology, University of Warwick, Coventry, UK
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19
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Basner M, Dinges DF, Shea JA, Small DS, Zhu J, Norton L, Ecker AJ, Novak C, Bellini LM, Volpp KG. Sleep and Alertness in Medical Interns and Residents: An Observational Study on the Role of Extended Shifts. Sleep 2017; 40:3045870. [PMID: 28329124 PMCID: PMC5806581 DOI: 10.1093/sleep/zsx027] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Study Objectives Fatigue from sleep loss is a risk to physician and patient safety, but objective data on physician sleep and alertness on different duty hour schedules is scarce. This study objectively quantified differences in sleep duration and alertness between medical interns working extended overnight shifts and residents not or rarely working extended overnight shifts. Methods Sleep-wake activity of 137 interns and 87 PGY-2/3 residents on 2-week Internal Medicine and Oncology rotations was assessed with wrist-actigraphy. Alertness was assessed daily with a brief Psychomotor Vigilance Test (PVT) and the Karolinska Sleepiness Scale. Results Interns averaged 6.93 hours (95% confidence interval [CI] 6.84-7.03 hours) sleep per 24 hours across shifts, significantly less than residents not working overnight shifts (7.18 hours, 95% CI 7.06-7.30 hours, p = .007). Interns obtained on average 2.19 hours (95% CI 2.02-2.36 hours) sleep during on-call nights (17.5% obtained no sleep). Alertness was significantly lower on mornings after on-call nights compared to regular shifts (p < .001). Naps between 9 am and 6 pm on the first day post-call were frequent (90.8%) and averaged 2.84 hours (95% CI 2.69-3.00 hours), but interns still slept 1.66 hours less per 24 hours (95% CI 1.56-1.76 hours) compared to regular shift days (p < .001). Sleep inertia significantly affected alertness in the 60 minutes after waking on-call. Conclusions Extended overnight shifts increase the likelihood of chronic sleep restriction in interns. Reduced levels of alertness after on-call nights need to be mitigated. A systematic comparison of sleep, alertness, and safety outcomes under current and past duty hour rules is encouraged.
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Affiliation(s)
- Mathias Basner
- Unit for Experimental Psychiatry, Division of Sleep and Chronobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David F Dinges
- Unit for Experimental Psychiatry, Division of Sleep and Chronobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Judy A Shea
- Center for Health Equity Research and Promotion, Philadelphia Corporal Michael J. Cresencz Veterans Affairs Medical Center, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Dylan S Small
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Jingsan Zhu
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Laurie Norton
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Adrian J Ecker
- Unit for Experimental Psychiatry, Division of Sleep and Chronobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cristina Novak
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Lisa M Bellini
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kevin G Volpp
- Center for Health Equity Research and Promotion, Philadelphia Corporal Michael J. Cresencz Veterans Affairs Medical Center, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia PA
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20
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Weiss P, Kryger M, Knauert M. Impact of extended duty hours on medical trainees. Sleep Health 2016; 2:309-315. [PMID: 29073389 DOI: 10.1016/j.sleh.2016.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/11/2016] [Accepted: 08/17/2016] [Indexed: 01/02/2023]
Abstract
Many studies on resident physicians have demonstrated that extended work hours are associated with a negative impact on well-being, education, and patient care. However, the relationship between the work schedule and the degree of impairment remains unclear. In recent years, because of concerns for patient safety, national minimum standards for duty hours have been instituted (2003) and revised (2011). These changes were based on studies of the effects of sleep deprivation on human performance and specifically on the effect of extended shifts on resident performance. These requirements necessitated significant restructuring of resident schedules. Concerns were raised that these changes have impaired continuity of care, resident education and supervision, and patient safety. We review the studies on the effect of extended work hours on resident well-being, education, and patient care as well as those assessing the effect of work hour restrictions. Although many studies support the adverse effects of extended shifts, there are some conflicting results due to factors such as heterogeneity of protocols, schedules, subjects, and environments. Assessment of the effect of work hour restrictions has been even more difficult. Recent data demonstrating that work hour limitations have not been associated with improvement in patient outcomes or resident education and well-being have been interpreted as support for lifting restrictions in some specialties. However, these studies have significant limitations and should be interpreted with caution. Until future research clarifies duty hours that optimize patient outcomes, resident education, and well-being, it is recommended that current regulations be followed.
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Affiliation(s)
- Pnina Weiss
- Section of Pediatric Respiratory Medicine and Medical Education, Yale University School of Medicine, 333 Cedar St, PO Box 208064, New Haven, CT 06520-8064.
| | - Meir Kryger
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 333 Cedar St, PO Box 208057, New Haven, CT 06520-8057
| | - Melissa Knauert
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 333 Cedar St, PO Box 208057, New Haven, CT 06520-8057
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21
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Yarnell CJ, Shadowitz S, Redelmeier DA. Hospital Readmissions Following Physician Call System Change: A Comparison of Concentrated and Distributed Schedules. Am J Med 2016; 129:706-714.e2. [PMID: 26976386 DOI: 10.1016/j.amjmed.2016.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Physician call schedules are a critical element for medical practice and hospital efficiency. We compared readmission rates prior to and after a change in physician call system at Sunnybrook Health Sciences Centre. METHODS We studied patients discharged over a decade (2004 through 2013) and identified whether or not each patient was readmitted within the subsequent 28 days. We excluded patients discharged for a surgical, obstetrical, or psychiatric diagnosis. We used time-to-event analysis and time-series analysis to compare rates of readmission prior to and after the physician call system change (January 1, 2009). RESULTS A total of 89,697 patients were discharged, of whom 10,001 (11%) were subsequently readmitted and 4280 died. The risk of readmission was increased by about 26% following physician call system change (9.7% vs 12.2%, P <.001). Time-series analysis confirmed a 26% increase in the readmission rate after call system change (95% confidence interval, 22%-31%; P <.001). The increase in readmission rate after call system change persisted across patients with diverse ages, estimated readmission risks, and medical diagnoses. The net effect was equal to 7240 additional patient days in the hospital following call system change. A modest increase was observed at a nearby acute care hospital that did not change physician call system, and no increase in risk of death was observed with increased hospital readmissions. CONCLUSION We suggest that changes in physician call systems sometimes increase subsequent hospital readmission rates. Further reductions in readmissions may instead require additional resources or ingenuity.
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Affiliation(s)
- Christopher J Yarnell
- Department of Medicine, University of Toronto, Ont., Canada; Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ont., Canada
| | - Steven Shadowitz
- Department of Medicine, University of Toronto, Ont., Canada; Division of General Internal Medicine, University of Toronto, Ont., Canada
| | - Donald A Redelmeier
- Department of Medicine, University of Toronto, Ont., Canada; Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ont., Canada; Division of General Internal Medicine, University of Toronto, Ont., Canada; Institute of Clinical Evaluative Sciences (ICES) in Ontario, Toronto, Canada; Institute for Health Policy Management and Evaluation, Toronto, Ont., Canada.
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22
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Lin H, Lin E, Auditore S, Fanning J. A Narrative Review of High-Quality Literature on the Effects of Resident Duty Hours Reforms. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2016; 91:140-50. [PMID: 26445081 DOI: 10.1097/acm.0000000000000937] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE To summarize current high-quality studies evaluating the effect and efficacy of resident duty hours reforms (DHRs) on patient safety and resident education and well-being. METHOD The authors searched PubMed and Medline in August 2012 and again in May 2013 for literature (1987-2013) about the effects of DHRs. They assessed the quality of articles using the Medical Education Research Study Quality Instrument (MERSQI) scoring system. They considered randomized controlled trials (RCTs), partial RCTs, and all studies with a MERSQI score ≥ 14 to be "high-quality" methodology studies. RESULTS A total of 72 high-quality studies met inclusion criteria. Most studies showed no change or slight improvement in mortality and complication rates after DHRs. Resident well-being was generally improved, but there was a perceived negative impact on education (knowledge acquisition, skills, and cognitive performance) following DHRs. Eleven high-quality studies assessed the impact of DHR interventions; all reported a neutral to positive impact. Seven high-quality studies assessed costs associated with DHRs and demonstrated an increase in hospital costs. CONCLUSIONS The results of most studies that allow enough time for DHR interventions to take effect suggest a benefit to patient safety and resident well-being, but the effect on the quality of training remains unknown. Additional methodologically sound studies on the impact of DHRs are necessary. Priorities for future research include approaches to optimizing education and clinical proficiency and studies on the effect of intervention strategies on both education and patient safety. Such studies will provide additional information to help improve duty hours policies.
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Affiliation(s)
- Henry Lin
- H. Lin is a pediatric gastroenterologist, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. E. Lin is a gastroenterology fellow, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin. S. Auditore is market segment development manager, American Medical Association, Chicago, Illinois. J. Fanning is chief of membership and resident fellow member-early career psychiatrist officer, American Psychiatric Association, Arlington, Virginia
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Bolster L, Rourke L. The Effect of Restricting Residents' Duty Hours on Patient Safety, Resident Well-Being, and Resident Education: An Updated Systematic Review. J Grad Med Educ 2015; 7:349-63. [PMID: 26457139 PMCID: PMC4597944 DOI: 10.4300/jgme-d-14-00612.1] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Despite 25 years of implementation and a sizable amount of research, the impact of resident duty hour restrictions on patients and residents still is unclear. Advocates interpret the research as necessitating immediate change; opponents draw competing conclusions. OBJECTIVE This study updates a systematic review of the literature on duty hour restrictions conducted 1 year prior to the implementation of the Accreditation Council for Graduate Medical Education's 2011 regulations. METHODS The review draws on reports catalogued in MEDLINE and PreMEDLINE from 2010 to 2013. Interventions that dealt with the duty hour restrictions included night float, shortened shifts, and protected time for sleep. Outcomes were patient care, resident well-being, and resident education. Studies were excluded if they were not conducted in patient care settings. RESULTS Twenty-seven studies met the inclusion criteria. Most frequently, the studies concluded that the restrictions had no impact on patient care (50%) or resident wellness (47%), and had a negative impact on resident education (64%). Night float was the most frequent means of implementing duty hour restrictions, yet it yielded the highest proportion of unfavorable findings. CONCLUSIONS This updated review, including 27 recent applicable studies, demonstrates that focusing on duty hours alone has not resulted in improvements in patient care or resident well-being. The added duty hour restrictions implemented in 2011 appear to have had an unintended negative impact on resident education. New approaches to the issue of physician fatigue and its relationship to patient care and resident education are needed.
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Affiliation(s)
- Lauren Bolster
- Corresponding author: Lauren Bolster, MD, University of Alberta, Department of Medicine, 13-103 Clinical Sciences Building, 11350-83 Avenue, Edmonton, AB T6G 2P4 Canada, 780.407.1584,
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Knauss M, Bonner CL, Patka J, Abraham P. Evaluation of pharmacy resident alertness in an overnight on-call program. Am J Health Syst Pharm 2015; 72:1215-20. [DOI: 10.2146/ajhp140338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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25
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Parshuram CS, Amaral ACKB, Ferguson ND, Baker GR, Etchells EE, Flintoft V, Granton J, Lingard L, Kirpalani H, Mehta S, Moldofsky H, Scales DC, Stewart TE, Willan AR, Friedrich JO. Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. CMAJ 2015; 187:321-9. [PMID: 25667258 DOI: 10.1503/cmaj.140752] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care. METHODS Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents' physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed. RESULTS We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents' sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents' somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents' knowledge and decision-making worst with the 16-hour schedule. INTERPRETATION Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents' symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT00679809.
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Affiliation(s)
- Christopher S Parshuram
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont.
| | - Andre C K B Amaral
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Niall D Ferguson
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - G Ross Baker
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Edward E Etchells
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Virginia Flintoft
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - John Granton
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Lorelei Lingard
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Haresh Kirpalani
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Sangeeta Mehta
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Harvey Moldofsky
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Damon C Scales
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Thomas E Stewart
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Andrew R Willan
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
| | - Jan O Friedrich
- Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont
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Garg M, Drolet BC, Tammaro D, Fischer SA. Resident duty hours: a survey of internal medicine program directors. J Gen Intern Med 2014; 29:1349-54. [PMID: 24913004 PMCID: PMC4175662 DOI: 10.1007/s11606-014-2912-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 02/02/2014] [Accepted: 05/14/2014] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In 2011, the Accreditation Council for Graduate Medical Education (ACGME) implemented new Common Program Requirements to regulate duty hours of resident physicians, with three goals: improved patient safety, quality of resident education and quality of life for trainees. We sought to assess Internal Medicine program director (IMPD) perceptions of the 2011 Common Program Requirements in July 2012, one year following implementation of the new standards. METHODS A cross-sectional study of all IMPDs at ACGME-accredited programs in the United States (N = 381) was performed using a 32-question, self-administered survey. Contact information was identified for 323 IMPDs. Three individualized emails were sent to each director over a 6-week period, requesting participation in the survey. Outcomes measured included approval of duty hours regulations, as well as perceptions of changes in graduate medical education and patient care resulting from the revised ACGME standards. RESULTS A total of 237 surveys were returned (73% response rate). More than half of the IMPDs (52%) reported "overall" approval of the 2011 duty hour regulations, with greater than 70% approval of all individual regulations except senior resident daily duty periods (49% approval) and 16-hour intern shifts (17% approval). Although a majority feel resident quality of life has improved (55%), most IMPDs believe that resident education (60%) is worse. A minority report that quality (8%) or safety (11%) of patient care has improved. CONCLUSION One year after implementation of new ACGME duty hour requirements, IMPDs report overall approval of the standards, but strong disapproval of 16-hour shift limits for interns. Few program directors perceive that the duty hour restrictions have resulted in better care for patients or education of residents. Although resident quality of life seems improved, most IMPDs report that their own workload has increased. Based on these results, the intended benefits of duty hour regulations may not yet have been realized.
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Affiliation(s)
- Megha Garg
- Department of Medicine, The Warren Alpert Medical School of Brown University and Rhode Island Hospital, 593 Eddy St, JB 0100, Providence, RI, 02903, USA,
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Allen-Dicker J, Herzig SJ, Mukamal KJ, Tess A. ACGME Duty Hour Revisions and Self-Reported Intern ICU Sleep Schedules. J Grad Med Educ 2014; 6:561-6. [PMID: 26279785 PMCID: PMC4535224 DOI: 10.4300/jgme-d-13-00263.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 12/02/2013] [Accepted: 05/05/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education duty hour standards restrict continuous duty for postgraduate year (PGY)-1 residents to 16 hours. OBJECTIVE We aimed to assess the relationship between a duty hour-compliant schedule and resident sleep. METHODS To comply with 2011 duty hour limits, Beth Israel Deaconess Medical Center restructured its intensive care unit call model for internal medicine PGY-1 residents from a traditional shift model to an overlapping shorter-duration shift model with preserved educational periods. Before and after schedule changes, we used daily surveys of PGY-1 residents to collect self-reported data on quantity and quality of sleep and quality of education. RESULTS A total of 1162 surveys were sent to 43 interns before scheduling changes, and 1305 were sent to 41 interns after the changes. Response rate was 31.2% (362 of 1161) before and 22.2% (290 of 1305) after. Before changes, 57.7% (209 of 362) reported receiving 6 hours or more of sleep in a 24-hour period compared to 72.4% (210 of 290) after the changes (adjusted relative risk, 1.33; 95% CI, 1.15-1.53), with an adjusted difference of 0.83 hours of sleep per 24 hours (95% CI, 0.28-1.38). After the intervention, on a 5-point Likert scale, residents reported higher quality of sleep (odds ratio [OR], 1.62; 95% CI, 1.01-2.60) and greater satisfaction with their education (OR, 2.59; 95% CI, 1.40-4.81). CONCLUSIONS Following conversion to a duty hour-compliant model with preserved didactic time, PGY-1 residents reported minor increases in quantity and quality of sleep per 24-hour period, and increased satisfaction with the educational experience.
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Affiliation(s)
- Reena Pattani
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Pattani, Wu, Dhalla), University of Toronto, Toronto, Ont.; Department of Medicine (Wu), Toronto General Hospital, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont.
| | - Peter E Wu
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Pattani, Wu, Dhalla), University of Toronto, Toronto, Ont.; Department of Medicine (Wu), Toronto General Hospital, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
| | - Irfan A Dhalla
- Department of Medicine (Pattani, Dhalla), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Pattani, Wu, Dhalla), University of Toronto, Toronto, Ont.; Department of Medicine (Wu), Toronto General Hospital, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Dhalla), University of Toronto, Toronto, Ont
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Amirian I, Andersen LT, Rosenberg J, Gögenur I. Laparoscopic skills and cognitive function are not affected in surgeons during a night shift. JOURNAL OF SURGICAL EDUCATION 2014; 71:543-550. [PMID: 24813717 DOI: 10.1016/j.jsurg.2013.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 11/24/2013] [Accepted: 12/20/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To monitor surgeons' performance and cognition during night shifts. DESIGN Surgeons were monitored before call and on call (17-hour shift). Psychomotor performance was assessed by laparoscopic simulation and cognition by the d2 test of attention. The surgeons performed the laparoscopic simulation and the d2 test of attention at 8 a.m. before call and at 4 a.m. on call. Sleep was measured by wrist actigraphy and sleepiness by the Karolinska sleepiness scale. SETTING Department of Surgery at Herlev Hospital, Denmark. PARTICIPANTS Overall, 30 interns, residents, and attending surgeons were included and completed the study. One participant was subsequently excluded owing to myxedema. RESULTS The surgeons slept significantly less on call than before call. There was increasing sleepiness on call; however, no significant differences were found in the precall laparoscopic simulation values compared with on-call values. The d2 test of attention showed significantly improved values on call compared with before call. CONCLUSION Sleep deprivation during a 17-hour night shift did not impair surgeons' psychomotor or cognitive performance.
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Affiliation(s)
- Ilda Amirian
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark.
| | - Lærke T Andersen
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Jacob Rosenberg
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | - Ismail Gögenur
- Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
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Shea JA, Bellini LM, Dinges DF, Curtis ML, Tao Y, Zhu J, Small DS, Basner M, Norton L, Novak C, Dine CJ, Rosen IM, Volpp KG. Impact of protected sleep period for internal medicine interns on overnight call on depression, burnout, and empathy. J Grad Med Educ 2014; 6:256-63. [PMID: 24949128 PMCID: PMC4054723 DOI: 10.4300/jgme-d-13-00241.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 10/11/2013] [Accepted: 10/21/2013] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patient safety and sleep experts advocate a protected sleep period for residents. OBJECTIVE We examined whether interns scheduled for a protected sleep period during overnight call would have better end-of-rotation assessments of burnout, depression, and empathy scores compared with interns without protected sleep periods and whether the amount of sleep obtained during on call predicted end-of-rotation assessments. METHODS We conducted a randomized, controlled trial with internal medicine interns at the Philadelphia Veterans Affairs Medical Center (PVAMC) and the Hospital of the University of Pennsylvania (HUP) in academic year 2009-2010. Four-week blocks were randomly assigned to either overnight call permitted under the 2003 duty hour standards or a protected sleep period from 12:30 am to 5:30 am. Participants wore wrist actigraphs. At the beginning and end of the rotations, they completed the Beck Depression Inventory (BDI-II), Maslach Burnout Inventory (MBI-HSS), and Interpersonal Reactivity Index (IRI). RESULTS A total of 106 interns participated. There were no significant differences between groups in end-of-rotation BDI-II, MBI-HSS, or IRI scores at either location (P > .05). Amount of sleep while on call significantly predicted lower MBI-Emotional Exhaustion (P < .003), MBI-Depersonalization (P < .003), and IRI-Personal Distress (P < .006) at PVAMC, and higher IRI-Perspective Taking (P < .008) at HUP. CONCLUSIONS A protected sleep period produced few consistent improvements in depression, burnout, or empathy, although depression was already low at baseline. Possibly the amount of protected time was too small to affect these emotional states or sleep may not be directly related to these scores.
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Ahmed N, Devitt KS, Keshet I, Spicer J, Imrie K, Feldman L, Cools-Lartigue J, Kayssi A, Lipsman N, Elmi M, Kulkarni AV, Parshuram C, Mainprize T, Warren RJ, Fata P, Gorman MS, Feinberg S, Rutka J. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg 2014; 259:1041-53. [PMID: 24662409 PMCID: PMC4047317 DOI: 10.1097/sla.0000000000000595] [Citation(s) in RCA: 325] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour resident duty limits. In 2011 the ACGME mandated 16-hour duty maximums for PGY1 (post graduate year) residents. The stated goals were to improve patient safety, resident well-being, and education. A systematic review and meta-analysis were performed to evaluate the impact of resident duty hours (RDH) on clinical and educational outcomes in surgery. METHODS A systematic review (1980-2013) was executed on CINAHL, Cochrane Database, Embase, Medline, and Scopus. Quality of articles was assessed using the GRADE guidelines. Sixteen-hour shifts and night float systems were analyzed separately. Articles that examined mortality data were combined in a random-effects meta-analysis to evaluate the impact of RDH on patient mortality. RESULTS A total of 135 articles met the inclusion criteria. Among these, 42% (N = 57) were considered moderate-high quality. There was no overall improvement in patient outcomes as a result of RDH; however, some studies suggest increased complication rates in high-acuity patients. There was no improvement in education related to RDH restrictions, and performance on certification examinations has declined in some specialties. Survey studies revealed a perception of worsened education and patient safety. There were improvements in resident wellness after the 80-hour workweek, but there was little improvement or negative effects on wellness after 16-hour duty maximums were implemented. CONCLUSIONS Recent RDH changes are not consistently associated with improvements in resident well-being, and have negative impacts on patient outcomes and performance on certification examinations. Greater flexibility to accommodate resident training needs is required. Further erosion of training time should be considered with great caution.
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Affiliation(s)
- Najma Ahmed
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Itay Keshet
- Department of Internal Medicine, Mount Sinai Hospital, New York City, NY
| | - Jonathan Spicer
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Kevin Imrie
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Liane Feldman
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Ahmed Kayssi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nir Lipsman
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Maryam Elmi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Chris Parshuram
- Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Todd Mainprize
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Richard J. Warren
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paola Fata
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - M. Sean Gorman
- Department of Surgery, Royal Inland Hospital, Kamloops, British Columbia, Canada
| | - Stan Feinberg
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - James Rutka
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Shea JA, Dinges DF, Small DS, Basner M, Zhu J, Norton L, Ecker AJ, Novak C, Bellini LM, Dine CJ, Mollicone DJ, Volpp KG. A randomized trial of a three-hour protected nap period in a medicine training program: sleep, alertness, and patient outcomes. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:452-459. [PMID: 24448046 DOI: 10.1097/acm.0000000000000144] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE Protected sleep periods for internal medicine interns have previously resulted in increased amount slept and improved cognitive alertness but required supplemental personnel. The authors evaluated intern and patient outcomes associated with protected nocturnal nap periods of three hours that are personnel neutral. METHOD Randomized trial at Philadelphia Veterans Affairs Medical Center (PVAMC) Medical Service and Hospital of the University of Pennsylvania (HUP) Oncology Unit. During 2010-2011, four-week blocks were randomly assigned to a standard intern schedule (extended duty overnight shifts of up to 30 hours), or sequential protected sleep periods (phone sign-out midnight to 3:00 AM [early shift] intern 1; 3:00 to 6:00 AM [late shift] intern 2). Participants wore wrist Actiwatches, completed sleep diaries, and performed daily assessments of behavioral alertness. Between-group comparisons of means and proportions controlled for within-person correlations. RESULTS HUP interns had significantly longer sleep durations during both early (2.40 hours) and late (2.44 hours) protected periods compared with controls (1.55 hours, P < .0001). At PVAMC sleep duration was longer only for the late shift group (2.40 versus 1.90 hours, P < .036). Interns assigned to either protected period were significantly less likely to have call nights with no sleep and had fewer attentional lapses on the Psychomotor Vigilance Test. Differences in patient outcomes between standard schedule months versus intervention months were not observed. CONCLUSIONS Protected sleep periods of three hours resulted in more sleep during call and reductions in periods of prolonged wakefulness, providing a plausible alternative to 16-hour shifts.
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Affiliation(s)
- Judy A Shea
- Dr. Shea is professor of medicine-clinician educator and associate dean of medical education research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Dinges is professor of psychology in psychiatry and chief of the division of sleep and chronobiology, department of psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Small is associate professor, department of statistics, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Basner is assistant professor of sleep and chronobiology in psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Mr. Zhu is assistant director of data analytics, LDI Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Ms. Norton is research project manager, CHERP, Philadelphia VA Medical Center, and CHIBE, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Mr. Ecker is a senior information technology project leader, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Ms. Novak was research coordinator, CHERP, Philadelphia VA Medical Center, and CHIBE, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, at the time this study was conducted. Currently she is a second-year medical student, Temple University School of Medicine, Philadelphia, Pennsylvania. Dr. Bellini is professor of medicine, and vice chair for education, department of medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Dine is assistant professor of medicine, division of pulmonary and critical care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. Dr. Mollicone is president and CEO of Pulsar Informatics, Inc., Philadelphia, Pennsylvania. Dr. Volpp is staff ph
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McDonald J, Potyk D, Fischer D, Parmenter B, Lillis T, Tompkins L, Bowen A, Grant D, Lamp A, Belenky G. Napping on the Night Shift: A Study of Sleep, Performance, and Learning in Physicians-in-Training. J Grad Med Educ 2013; 5:634-8. [PMID: 24455014 PMCID: PMC3886464 DOI: 10.4300/jgme-d-12-00324.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 03/22/2013] [Accepted: 05/22/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Physicians in training experience fatigue from sleep loss, high workload, and working at an adverse phase of the circadian rhythm, which collectively degrades task performance and the ability to learn and remember. To minimize fatigue and sustain performance, learning, and memory, humans generally need 7 to 8 hours of sleep in every 24-hour period. METHODS In a naturalistic, within-subjects design, we studied 17 first- and second-year internal medicine residents working in a tertiary care medical center, rotating between day shift and night float every 4 weeks. We studied each resident for 2 weeks while he/she worked the day shift and for 2 weeks while he/she worked the night float, objectively measuring sleep by wrist actigraphy, vigilance by the Psychomotor Vigilance Task test, and visual-spatial and verbal learning and memory by the Brief Visuospatial Memory Test-Revised and the Rey Auditory-Verbal Learning Test. RESULTS Residents, whether working day shift or night float, slept approximately 7 hours in every 24-hour period. Residents, when working day shift, consolidated their sleep into 1 main sleep period at night. Residents working night float split their sleep, supplementing their truncated daytime sleep with nighttime on-duty naps. There was no difference in vigilance or learning and memory, whether residents worked day shift or night float. CONCLUSIONS Off-duty sleep supplemented with naps while on duty appears to be an effective strategy for sustaining vigilance, learning, and memory when working night float.
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