Call-associated Acute Fatigue in Surgical Residents—Subjective Perception or Objective Fact? A Cross-sectional Observational Study to Examine the Influence of Fatigue on Surgical Performance

Extended-Duration Work Shifts in Surgical Specialties: A Systematic Review

INTRODUCTION

There has been widespread international implementation of duration-hour restrictions to prevent surgical resident burnout and promote patient safety and wellbeing of doctors. A variety of Extended-Duration Work Shifts (EDWS) have been implemented, with a variety of studies examining the effect of shift systems on both surgical performance and the stress response unestablished in the literature.

METHODS

This was a systematic review evaluating the impact of extended working hours on surgical performance, cognitive impairment, and physiological stress responses. The review used PubMed, Ovid Medline, Embase, and Google Scholar search engines between September and October 2021 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Filters including studies carried out after 2002 and published in the English language were applied.

RESULTS

In total, 30 studies were included for analysis. General surgery was the most commonly studied rotation, with Neurosurgical, Orthopedic, and ear, nose and throat specialties also included. The majority of studies found no difference or a significant improvement in post-EDWS on simulated performance. EDWS appeared to have the greatest impact on physiological stress markers in junior surgical trainees.

CONCLUSIONS

Experience appears to confer a protective element in the postcall period, with preservation of skill demonstrated. More experienced clinicians yielded lower levels of physiological markers of stress, although variability in hierarchical workload should be considered. Heterogeneity of findings across physiological, cognitive, and psychomotor assessments highlights the need for robust research on the optimum shift pattern prevents worker burnout and promotes patient safety. Future research to evaluate correlation between stress, on-call workload, and performance in the postcall period is warranted.

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

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

A Polysomnographic Study of Effects of Sleep Deprivation on Novice and Senior Surgeons during Simulated Vitreoretinal Surgery

PURPOSE

To assess the impact of a 3-hour polysomnography (PSG)-recorded night of sleep deprivation on next-morning simulated microsurgical skills among vitreoretinal (VR) surgeons with different levels of surgical experience and associate the sleep parameters obtained by PSG with Eyesi-generated performance.

DESIGN

Self-controlled cohort study.

PARTICIPANTS

Eleven junior VR surgery fellows with < 2 years of surgical experience and 11 senior surgeons with > 10 years of surgical practice.

METHODS

Surgical performance was assessed at 7am after a 3-hour sleep-deprived night using the Eyesi simulator and compared with each subject's baseline performance.

MAIN OUTCOME MEASURES

Changes in Eyesi-generated score (0-700, worst to best), time for task completion (minutes), tremor-specific score (0-100, worst to best), and out-of-tolerance tremor percentage. Polysomnography was recorded during sleep deprivation.

RESULTS

Novice surgeons had worse simulated surgical performance after sleep deprivation compared with self-controlled baseline dexterity in the total score (559.1 ± 39.3 vs. 593.8 ± 31.7; P = 0.041), time for task completion (13.59 ± 3.87 minutes vs. 10.96 ± 1.95 minutes; P = 0.027), tremor-specific score (53.8 ± 19.7 vs. 70.0 ± 15.3; P = 0.031), and out-of-tolerance tremor (37.7% ± 11.9% vs. 28.0% ± 9.2%; P = 0.031), whereas no performance differences were detected in those parameters among the senior surgeons before and after sleep deprivation (P ≥ 0.05). Time for task completion increased by 26% (P = 0.048) in the post-sleep deprivation simulation sessions for all participants with a high apnea-hypopnea index (AHI) and by 37% (P = 0.008) among surgeons with fragmented sleep compared with those with normal AHI and < 10 arousals per hour, respectively. Fragmented sleep was the only polysomnographic parameter associated with a worse Eyesi-generated score, with a 10% (P = 0.005) decrease the following morning.

CONCLUSIONS

This study detected impaired simulated surgical dexterity among novice surgeons after acute sleep deprivation, whereas senior surgeons maintained their surgical performance, suggesting that the impact of poor sleep quality on surgical skills is offset by increased experience. When considering the 2 study groups together, sleep fragmentation and AHI were associated with jeopardized surgical performance after sleep deprivation.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Insomnia-A Systematic Review and Comparison of Medical Resident's Average Off-Call Sleep Times

Sleep deprivation is known to have serious consequences, including a decrease in performance, attention and neurocognitive function. It seems common knowledge that medical residents are routinely sleep deprived, yet there is little objective research recording their average sleep times. To discern whether residents may be suffering from the abovementioned side effects, this review aimed to analyze their average sleep times. Thirty papers recording the average sleep time of medical residents were found via a literature search using the key words "resident" and "sleep". An analysis of the mean sleep times cited therein revealed a range of sleep from 4.2 to 8.6 h per night, the median being 6.2 h. A sub-analysis of papers from the USA showed barely any significant differences in sleep time between the specialties, but the mean sleep times were below 7 h. The only significant difference (p = 0.039) was between the mean sleep times of pediatric and urology residents, with the former achieving less sleep. The comparison of methods for data collection showed no significant difference in the sleep times collected. The results of this analysis imply that residents are regularly sleep deprived and may therefore suffer from the abovementioned consequences.

Sleepy Surgeons: A Multi-Method Assessment of Sleep Deprivation and Performance in Surgery

BACKGROUND

Minimum rest is mandated in high stake industries such as aviation. The current system of healthcare provision permits on-call surgeons to work in sleep deprived states when performing procedures. Fatigue has been demonstrated to negatively affect performance. This study aimed to explore measurements of sleep deprivation and their impact on simulated performance.

METHODS

This was a single site study conducted between September 2019 and February 2020. Surgical trainee and consultants were conveniently sampled from a single site. All testing was done between 7 AM and 9 AM. Participants completed electroencephalogram testing using a modified Multiple Sleep Latency Test testing for objective sleep measurement, the Pittsburgh Sleep Quality Index, Chalder Fatigue Scale and Epworth Sleepiness Scale for subjective sleep measurement. The Psychomotor Vigilance Task and the SIMENDO simulated tasks were used for standardized performance assessment.

RESULTS

Surgeons entered sleep in 6 min, on average pre-call. This significantly decreased to an average of 164 s post-call (P = 0.016). Pittsburgh Sleep Quality Index scoring was 5, indicating poor baseline sleep quality. There was higher self-reported fatigue and sleepiness in post-call states. Performance decrements were noted in cognitive performance reaction time and aspects of technical instrument proficiency.

CONCLUSIONS

Surgeons are objectively sleep deprived pre-call according to internationally recognized guidelines. This sleep deprivation increases significantly in post-call states. Tasks with higher cognitive demands showed greater levels of diminished performance compared to those with lower cognitive demands. Current models of provision of surgical on-call are not conducive to optimizing sleep in surgeons. Prioritization of workload in post-call states, focusing on preserving individuals cognitive resources and utilizing lower cognitively demanding aspects of work is likely to have positive impacts on performance outcomes.

The effect of sleep restriction on cognitive performance in elite cognitive performers: a systematic review

STUDY OBJECTIVES

To synthesize original articles exploring the effects of sleep restriction on cognitive performance specifically for Elite Cognitive Performers, i.e. those who engage in cognitively demanding tasks with critical or safety-critical outcomes in their occupation or area of expertise.

METHODS

Backward snowballing techniques, gray literature searches, and traditional database searches (Embase, MEDLINE, Web of Science, Google Scholar, PSYCinfo, and SportDiscus) were used to obtain relevant articles. A quality assessment was performed, and the risk of training effects was considered. Results were narratively synthesized. Fourteen articles fit the criteria. Cognitive outcomes were divided into three categories defined by whether cognitive demands were "low-salience," "high-salience stable," or "high-salience flexible."

RESULTS

Low-salience tests (i.e. psychomotor vigilance tasks & serial reaction tests), mainly requiring vigilance and rudimentary attentional capacities, were sensitive to sleep restriction, however, this did not necessarily translate to significant performance deficits on low-salience occupation-specific task performance. High-salience cognitive outcomes were typically unaffected unless when cognitive flexibility was required.

CONCLUSIONS

Sleep restriction is of particular concern to occupations whereby individuals perform (1) simple, low-salience tasks or (2) high-salience tasks with demands on the flexible allocation of attention and working memory, with critical or safety-critical outcomes.

Mental fatigue measurement using eye metrics: A systematic literature review

Mental fatigue measurement techniques utilize one or a combination of the cognitive, affective, and behavioral responses of the body. Eye-tracking and electrooculography, which are used to compute eye-based features, have gained momentum with increases in accuracy and robustness of the lightweight equipment emerging in the markets and can be used for objective and continuous assessment of mental fatigue. The main goal of this systematic review was to summarize the various eye-based features that have been used to measure mental fatigue and explore the relation of eye-based features to mental fatigue. The review process, following the preferred reporting items for systematic reviews and meta-analyses, used the electronic databases Web of Science, Scopus, ACM digital library, IEEE Xplore, and PubMed. Of the 1,385 retrieved documents, 34 studies met the inclusion criteria, resulting in 21 useful eye-based features. Categorizing these into eight groups revealed saccades as the most promising category, with saccade mean and peak velocity providing quick access to the cognitive states within 30 min of fatiguing activity. Complex brain networks involving sympathetic and parasympathetic nervous systems control the relation of mental fatigue to tonic pupil size and have the potential to indicate mental fatigue in controlled experimental conditions. Other categories, like blinks, are derived from the field of sleep research and should be used with caution. Several limitations emerged in the analysis, including varied experimental methods, use of dim lighting during the experiment (that could possibly also induce sleepiness), and use of unclear data analysis techniques, thereby complicating comparisons between studies.

Effects of exogenous factors on spatial accuracy in neurosurgery

The study aimed to assess the effect of exogenous factors such as surgeon posture, surgical instrument length, fatigue after a night shift, exercise and caffeine consumption on the spatial accuracy of neurosurgical manipulations. For the evaluation and simulation of neurosurgical manipulations, a testing device developed by the authors was used. The experimental results were compared using nonparametric analysis (Wilcoxon test) and multivariate analysis, which was performed using mixed models. The results were considered statistically significant at p < 0.05. The study included 11 first-year neurosurgery residents who met the inclusion criteria. Hand support in the sitting position (Wilcoxon test p value = 0.0033), caffeine consumption (p = 0.0058) and the length of the microsurgical instrument (p = 0.0032) had statistically significant influences on the spatial accuracy of surgical manipulations (univariate analysis). The spatial accuracy did not significantly depend on the type of standing position (Wilcoxon test p value = 0.2860), whether the surgeon was standing/sitting (p = 0.1029), fatigue following a night shift (p = 0.3281), or physical exertion prior to surgery (p = 0.2845). When conducting the multivariate analysis, the spatial accuracy significantly depended on the test subject (p < 0.0001), the use of support during the test (p = 0.0001), and the length of the microsurgical instrument (p = 0.0397). To increase the spatial accuracy of microsurgical manipulations, hand support and shorter tools should be used. Caffeine consumption in high doses should also be avoided prior to surgery.

Nighttime Appendectomy is Safe and has Similar Outcomes as Daytime Appendectomy: A Study of 1198 Appendectomies

Introduction:

Although it is controversial whether appendectomy can be safely delayed, it is often unnecessary to postpone operation as a shorter delay may increase patient comfort, enables quicker recovery, and decreases costs. In this study, we sought to study whether the time of day influences the outcomes among patients operated on for acute appendicitis.

Materials and Methods:

Consecutive patients undergoing appendectomy at Tampere University Hospital between 1 September 2014 and 30 April 2017 for acute appendicitis were included. Primary outcome measures were postoperative morbidity, mortality, length of hospital stay, and amount of intraoperative bleeding. Appendectomies were divided into daytime and nighttime operations.

Results:

A total of 1198 patients underwent appendectomy, of which 65% were operated during daytime and 35% during nighttime. Patient and disease-related characteristics were similar in both groups. The overall morbidity and mortality rates were 4.8% and 0.2%, respectively. No time categories were associated with risk of complications or complication severity. Neither was there difference in operation time and clinically significant difference in intraoperative bleeding. Patients undergoing surgery during night hours had a shorter hospital stay. In multivariate analysis, only complicated appendicitis was associated with worse outcomes.

Discussion:

We have shown that nighttime appendectomy is associated with similar outcomes than daytime appendectomy. Subsequently, appendectomy should be planned for the next available slot, minimizing delay whenever possible.

A systematic review of sleep deprivation and technical skill in surgery

BACKGROUND

It is uncertain if sleep deprivation impacts sleepy surgeons' technical skills. Lapses in surgical performance could increase morbidity and mortality. This review concludes if sleep deprivation impacts on technical skill performance in simulated environments.

OBJECTIVE

Primary: 1. To identify if sleep deprivation has an impact on technical skill proficiency in surgeons. Secondary: a. To identify if the level of surgical experience, quality of sleep, or quantity of sleep influences technical skill proficiency in sleep deprived surgeons.

METHODS

The review was conducted according to PRISMA guidelines utilising the databases Journals Ovid. Validation followed with two independent reviewers utilising an adapted version of BEME.

RESULTS

Thirty-three heterogeneous studies were included. Sleep deprivation likely negatively impacts technical performance between 11.9 and 32% decrement in performance. No strong evidence exists with regards to influence of experience, sleep type, or sleep length on technical proficiency.

CONCLUSION

Sleepy surgeons' technical skills are, on balance, between 11.9 and 32% negatively impacted in a standardised simulated environment. This is likely to have clinical implications for patient safety.

Endogenous and Exogenous Factors Affecting the Surgical Technique (Review)

In this review, we analyzed essential factors affecting precise manual movements in microsurgery described in the medical literature. The search for publications in English and Russian languages was conducted in the PubMed database without limitation by the date of publication. The search was carried out according to the following descriptors: surgical procedures, dexterity, microsurgery, caffeine, alcohol, nicotine, physical exercise, sleep deprivation, posture. Only randomized and cohort studies involving doctors and students with surgical specialties were included in the analysis. We did not include papers in which only psychological (non-motor) aspects were studied.

Due to the limited number of publications meeting the inclusion criteria and conflicting results in some of them, the presented review does not allow us to formulate unambiguous conclusions and recommendations. Further studies (deep and fundamental) of endogenous and exogenous factors affecting the microsurgical technique are needed.

Does sleep deprivation alter virtual reality-based robotic surgical skills?

Introduction

Robotic surgery is widely used in many surgical specialities, and there has been no study to assess the impact of sleep deprivation on the complex environment of robotic surgery.

Aim

To compare specific metrics of selected robotic simulator exercises on sleep-deprived and non-sleep-deprived surgical residents.

Material and methods

We enrolled 20 volunteers, residents in surgery, evaluated before and after an 18-hour overnight shift, regarding their results on virtual robotic surgery simulator – the sleep deprivation (SD) group. As a control group, the same subjects were evaluated 5–7 days after the post-shift evaluation, without having a shift overnight and at least 7 h of sleep the previous night – the non-sleep-deprivation (nSD) group.

Results

A statistically significant difference between the pre-shift and post-shift overall results for all exercises in the SD group and no statistical differences for the nSD group were observed. As the difficulty of the exercises increased, statistical differences were observed on specific metrics for all exercises between the pre-shift and post-shift as well as between the post-shift and the morning after a normal sleep period overnight. In a subgroup analysis, the overall results revealed a stronger statistical difference between pre-shift and post-shift for residents with more intense sleep deprivation (< 3 h of sleep vs. > 3 h of sleep).

Conclusions

Sleep deprivation leads to impairment of surgical skills assessed by robotic virtual simulator. The more complex and skill demanding the exercise, the higher the difference between sleep deprived and non-deprived residents.

Effects of Sleep Deprivation on Surgeons Dexterity

Sleep deprivation is an ordinary aspect in the global society and its prevalence is increasing. Chronic and acute sleep deprivation have been linked to diabetes and heart diseases as well as depression and enhanced impulsive behaviors. Surgeons are often exposed to long hour on call and few hours of sleep in the previous days. Nevertheless, few studies have focused their attention on the effects of sleep deprivation on surgeons and more specifically on the effects of sleep deprivation on surgical dexterity, often relying on virtual surgical simulators. A better understanding of the consequences of sleep loss on the key surgical skill of dexterity can shed light on the possible risks associated to a sleepy surgeon. In this paper, the authors aim to provide a comprehensive review of the relationship between sleep deprivation and surgical dexterity.

A review of current approaches for evaluating impaired performance in around-the-clock medical professionals

The need for data to study the relationship between fatigued healthcare professionals and performance outcomes is evident, however, it is unclear which methodology is most appropriate to provide these insights. To address this issue, we performed a systematic review of relevant articles by searching the MEDLINE, EMBASE, Cochrane, Web of Science, and CINAHL databases. The literature search identified 2960 unique references, of which 82 were identified eligible. The impact on performance was studied on clinical outcomes, medical simulation, neurocognitive performance, sleep quantification and subjective assessment. In general results on performance are conflicting; impairment, no effect, and improvement were found. This review outlines the various methods currently available for assessing fatigue-impaired performance. The contrasting outcomes can be attributed to three main factors: differences in the operationalisation of fatigue, incomplete control data, and the wide variety in the methods used. We recommend the implementation of a clinically applicable tool that can provide uniform data. Until these data become available, caution should be used when developing regulations that can have implications for physicians, education, manpower planning, and ‒ ultimately ‒ patient care.

Systematic Review of Factors Influencing Surgical Performance: Practical Recommendations for Microsurgical Procedures in Neurosurgery

BACKGROUND

Microneurosurgical techniques involve complex manual skills and hand-eye coordination that require substantial training. Many factors affect microneurosurgical skills. The goal of this study was to use a systematic evidence-based approach to analyze the quality of evidence for intrinsic and extrinsic factors that influence microneurosurgical performance and to make weighted practical recommendations.

METHODS

A literature search of factors that may affect microsurgical performance was conducted using PubMed and Embase. The criteria for inclusion were established in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) statement.

RESULTS

Forty-eight studies were included in the analysis. Most of the studies used surgeons as participants. Most used endoscopic surgery simulators to assess skills, and only 12 studies focused on microsurgery. This review provides 18 practical recommendations based on a systematic literature analysis of the following 8 domains: 1) listening to music before and during microsurgery, 2) caffeine consumption, 3) β-blocker use, 4) physical exercise, 5) sleep deprivation, 6) alcohol consumption before performing surgery, 7) duration of the operation, and 8) the ergonomic position of the surgeon.

CONCLUSIONS

Despite the clear value of determining the effects of various factors on surgical performance, the available body of literature is limited, and it is not possible to determine standards for each surgical field. These recommendations may be used by neurosurgical trainees and practicing neurosurgeons to improve microsurgical performance and acquisition of microsurgical skills. Randomized studies assessing the factors that influence microsurgical performance are required.

Influence of previous night call and sleep deprivation on screening colonoscopy quality

OBJECTIVES

There are few studies evaluating the influence of sleep deprivation on endoscopic outcomes. To evaluate the effect of a previous night call on the quality of screening colonoscopies performed the following day.

METHODS

Average-risk patients undergoing screening colonoscopies were included. Quality metrics were retrospectively compared between two groups of post-call colonoscopies and colonoscopies performed by the same individuals not on call the night before: those performed by gastroenterologists who were only on call the night prior and those performed by gastroenterologists who performed emergent on-call procedures the night prior.

RESULTS

Between 1 July 2010 and 31 March 2012, 447 colonoscopies were performed by gastroenterologists who were on call only the night prior, 126 colonoscopies were performed by gastroenterologists who had completed on-call emergent procedures the night prior, and 8,734 control colonoscopies were completed. There was a lower percent of patients who were screened with adenomas detected in procedures performed by endoscopists who had performed emergent on-call procedures the night prior compared with the controls (30 vs. 39%, respectively; P=0.043). The mean withdrawal time for these colonoscopies was significantly longer than that for the control procedures (15.5 vs. 14.0 min; P=0.025). For the colonoscopies performed by endoscopists who were on call only the night prior, there was no significant difference in the percent of patients screened with adenomas detected compared with controls (42 vs. 39%, respectively; P=0.136).

CONCLUSIONS

(1) Despite longer withdrawal times, being on call the night prior and performing an emergent procedure lead to a significant 24% decrease in the adenoma detection rates. (2) It is imperative for screening physicians to be aware of the influence of sleep deprivation on procedural outcomes and to consider altering their practice accordingly.

Laparoscopic skills and cognitive function are not affected in surgeons during a night shift

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.

A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes

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.