Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine

Residency Wellness: A Historical Narrative Review

INTRODUCTION

The structure of medical residency in the United States has experienced significant changes, paralleling advances in medical science and education. While these changes have enhanced medical training, they have introduced challenges, particularly in resident wellness. The well-being of residents is critical for patient care and the healthcare system. This review aims to provide an overview of the historical trends in medical residency, focusing on the evolution of resident wellness and its associated challenges.

METHODS

A narrative review was conducted, examining the evolution and challenges of medical residency with an emphasis on resident wellness. An exhaustive literature search on January 25, 2024 was conducted across PubMed, Web of Science, and Google Scholar. The search utilized keywords related to medical residency, wellness, and educational reforms. Articles were selected based on relevance and robust evidence, and information was organized into thematic categories for narrative synthesis.

RESULTS

The search yielded 57 publications that met the inclusion criteria. Historical trends revealed a shift from an apprenticeship model to formalized training programs, with each phase bringing unique challenges to resident wellness. The Flexner Report's influence on standardizing medical education, the rise of modern residency programs, and the recognition of burnout as a significant issue were key developments. Policy changes, technological impacts, and the COVID-19 pandemic have further shaped residency training and wellness. Studies highlight the need for interventions addressing burnout and promoting wellness, with varied approaches across specialties and institutions.

CONCLUSION

Residency burnout has been a growing concern since the 1970s, exacerbated by advancements in medicine, technology, and recent global events like the COVID-19 pandemic. Although awareness has increased, the need remains to address burnout and promote wellness during residency. Further research is warranted to develop effective interventions and adapt training to meet the evolving needs of residents.

Exploring sleep duration and clinical reasoning process in resident physicians: a thematic analysis

STUDY OBJECTIVES

Connecting resident physician work hours and sleep deprivation to adverse outcomes has been difficult. Our study explores clinical reasoning rather than outcomes. Diagnostic errors are a leading cause of medical error and may result from deficits in clinical reasoning. We used simulated cases to explore relationships between sleep duration and diagnostic reasoning.

METHODS

Residents were recruited for a 2-month study (inpatient/outpatient). Each participant's sleep was tracked (sleep diary/actigraphy). At the end of each month, residents watched 2 brief simulated clinical encounters and performed "think alouds" of their clinical reasoning. In each session, 1 video was straightforward and the other video contained distracting contextual factors. Sessions were recorded, transcribed, and interpreted. We conducted a thematic analysis using a constant comparative approach. Themes were compared based on sleep duration and contextual factors.

RESULTS

Residents (n = 17) slept more during outpatient compared with inpatient months (450.5 ± 7.13 vs 425.6 ± 10.78 hours, P = .02). We found the following diagnostic reasoning themes: uncertainty, disorganized knowledge, error, semantic incompetence, emotional content, and organized knowledge. Themes reflecting suboptimal clinical reasoning (disorganized knowledge, error, semantic incompetence, uncertainty) were observed more in cases with contextual factors (distractors). "Think alouds" from cases with contextual factors following sleep restriction had a greater number of themes concerning for problematic diagnostic reasoning.

CONCLUSIONS

Residents obtained significantly more sleep during outpatient compared with inpatient months. Several negative clinical reasoning themes emerged with less sleep combined with cases containing contextual distractors. Our findings reinforce the importance of adequate sleep and supervision in house officers, particularly in cases with distracting elements.

CITATION

Collen J, Durning S, Berk J, Mang J, Alcover K, Jung E. Exploring sleep duration and clinical reasoning process in resident physicians: a thematic analysis. J Clin Sleep Med. 2024;20(8):1279-1289.

Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review

BACKGROUND

Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs.

METHODS

The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted.

RESULTS

The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used.

CONCLUSIONS

The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.

Association of sleep quality with duty hours, mental health, and medical errors among Japanese postgraduate residents: a cross-sectional study

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.

baymedr: an R package and web application for the calculation of Bayes factors for superiority, equivalence, and non-inferiority designs

BACKGROUND

Clinical trials often seek to determine the superiority, equivalence, or non-inferiority of an experimental condition (e.g., a new drug) compared to a control condition (e.g., a placebo or an already existing drug). The use of frequentist statistical methods to analyze data for these types of designs is ubiquitous even though they have several limitations. Bayesian inference remedies many of these shortcomings and allows for intuitive interpretations, but are currently difficult to implement for the applied researcher.

RESULTS

We outline the frequentist conceptualization of superiority, equivalence, and non-inferiority designs and discuss its disadvantages. Subsequently, we explain how Bayes factors can be used to compare the relative plausibility of competing hypotheses. We present baymedr, an R package and web application, that provides user-friendly tools for the computation of Bayes factors for superiority, equivalence, and non-inferiority designs. Instructions on how to use baymedr are provided and an example illustrates how existing results can be reanalyzed with baymedr.

CONCLUSIONS

Our baymedr R package and web application enable researchers to conduct Bayesian superiority, equivalence, and non-inferiority tests. baymedr is characterized by a user-friendly implementation, making it convenient for researchers who are not statistical experts. Using baymedr, it is possible to calculate Bayes factors based on raw data and summary statistics.

The effects of resident work hours on well-being, performance, and education: A review from a Japanese perspective

This article examines the impact of working-hour restrictions on the well-being, performance, and education of medical residents in Japan. Despite Japan's plan to introduce new regulations for resident working hours by 2024, there is still an ongoing debate regarding their appropriateness. This review provides a comprehensive overview of the current regulations of resident working hours worldwide, with a specific focus on weekly hours. The varying regulations are highlighted, including the 80-hour-per-week regulation in the United States and the 48-h-per-week regulation in the European Union influencing other regions. The article also discusses the effectiveness of working-hour restrictions on residents' mental health, with shorter working hours having potentially greater benefits. However, the impacts on medical safety and resident education are mixed, and further reduction in working hours must be carefully considered to avoid adverse effects. The planned changes to working-hour limits for residents in Japan offer a unique opportunity to gain new evidence on the impact of such regulations, which will be of interest to policymakers and researchers worldwide.

Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers

BACKGROUND

Shift work is associated with insufficient sleep, which can compromise worker alertness with ultimate effects on occupational health and safety. Adapting shift work schedules may reduce adverse occupational outcomes.

OBJECTIVES

To assess the effects of shift schedule adaptation on sleep quality, sleep duration, and sleepiness among shift workers.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, and eight other databases on 13 December 2020, and again on 20 April 2022, applying no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-RCTs, including controlled before-after (CBA) trials, interrupted time series, and cross-over trials. Eligible trials evaluated any of the following shift schedule components. • Permanency of shifts • Regularity of shift changes • Direction of shift rotation • Speed of rotation • Shift duration • Timing of start of shifts • Distribution of shift schedule • Time off between shifts • Split shifts • Protected sleep • Worker participation We included studies that assessed sleep quality off-shift, sleep duration off-shift, or sleepiness during shifts.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of the records recovered by the search, read through the full-text articles of potentially eligible studies, and extracted data. We assessed the risk of bias of included studies using the Cochrane risk of bias tool, with specific additional domains for non-randomised and cluster-randomised studies. For all stages, we resolved any disagreements by consulting a third review author. We presented the results by study design and combined clinically homogeneous studies in meta-analyses using random-effects models. We assessed the certainty of the evidence with GRADE.

MAIN RESULTS

We included 11 studies with a total of 2125 participants. One study was conducted in a laboratory setting and was not considered for drawing conclusions on intervention effects. The included studies investigated different and often multiple changes to shift schedule, and were heterogeneous with respect to outcome measurement. Forward versus backward rotation Three CBA trials (561 participants) investigated the effects of forward rotation versus backward rotation. Only one CBA trial provided sufficient data for the quantitative analysis; it provided very low-certainty evidence that forward rotation compared with backward rotation did not affect sleep quality measured with the Basic Nordic Sleep Questionnaire (BNSQ; mean difference (MD) -0.20 points, 95% confidence interval (CI) -2.28 to 1.89; 62 participants) or sleep duration off-shift (MD -0.21 hours, 95% CI -3.29 to 2.88; 62 participants). However, there was also very low-certainty evidence that forward rotation reduced sleepiness during shifts measured with the BNSQ (MD -1.24 points, 95% CI -2.24 to -0.24; 62 participants). Faster versus slower rotation Two CBA trials and one non-randomised cross-over trial (341 participants) evaluated faster versus slower shift rotation. We were able to meta-analyse data from two studies. There was low-certainty evidence of no difference in sleep quality off-shift (standardised mean difference (SMD) -0.01, 95% CI -0.26 to 0.23) and very low-certainty evidence that faster shift rotation reduced sleep duration off-shift (SMD -0.26, 95% CI -0.51 to -0.01; 2 studies, 282 participants). The SMD for sleep duration translated to an MD of 0.38 hours' less sleep per day (95% CI -0.74 to -0.01). One study provided very low-certainty evidence that faster rotations decreased sleepiness during shifts measured with the BNSQ (MD -1.24 points, 95% CI -2.24 to -0.24; 62 participants). Limited shift duration (16 hours) versus unlimited shift duration Two RCTs (760 participants) evaluated 80-hour workweeks with maximum daily shift duration of 16 hours versus workweeks without any daily shift duration limits. There was low-certainty evidence that the 16-hour limit increased sleep duration off-shift (SMD 0.50, 95% CI 0.21 to 0.78; which translated to an MD of 0.73 hours' more sleep per day, 95% CI 0.30 to 1.13; 2 RCTs, 760 participants) and moderate-certainty evidence that the 16-hour limit reduced sleepiness during shifts, measured with the Karolinska Sleepiness Scale (SMD -0.29, 95% CI -0.44 to -0.14; which translated to an MD of 0.37 fewer points, 95% CI -0.55 to -0.17; 2 RCTs, 716 participants). Shorter versus longer shifts One RCT, one CBA trial, and one non-randomised cross-over trial (692 participants) evaluated shorter shift duration (eight to 10 hours) versus longer shift duration (two to three hours longer). There was very low-certainty evidence of no difference in sleep quality (SMD -0.23, 95% CI -0.61 to 0.15; which translated to an MD of 0.13 points lower on a scale of 1 to 5; 2 studies, 111 participants) or sleep duration off-shift (SMD 0.18, 95% CI -0.17 to 0.54; which translated to an MD of 0.26 hours' less sleep per day; 2 studies, 121 participants). The RCT and the non-randomised cross-over study found that shorter shifts reduced sleepiness during shifts, while the CBA study found no effect on sleepiness. More compressed versus more spread out shift schedules One RCT and one CBA trial (346 participants) evaluated more compressed versus more spread out shift schedules. The CBA trial provided very low-certainty evidence of no difference between the groups in sleep quality off-shift (MD 0.31 points, 95% CI -0.53 to 1.15) and sleep duration off-shift (MD 0.52 hours, 95% CI -0.52 to 1.56).

AUTHORS' CONCLUSIONS

Forward and faster rotation may reduce sleepiness during shifts, and may make no difference to sleep quality, but the evidence is very uncertain. Very low-certainty evidence indicated that sleep duration off-shift decreases with faster rotation. Low-certainty evidence indicated that on-duty workweeks with shift duration limited to 16 hours increases sleep duration, with moderate-certainty evidence for minimal reductions in sleepiness. Changes in shift duration and compression of workweeks had no effect on sleep or sleepiness, but the evidence was of very low-certainty. No evidence is available for other shift schedule changes. There is a need for more high-quality studies (preferably RCTs) for all shift schedule interventions to draw conclusions on the effects of shift schedule adaptations on sleep and sleepiness in shift workers.

Sociotechnical Work System Approach to Occupational Fatigue

INTRODUCTION TO THE PROBLEM

Occupational fatigue is a characteristic of excessive workload and depicts the limited capacity to complete demands. The impact of occupational fatigue has been studied outside of health care in fields such as transportation and heavy industry. Research in health care professionals such as physicians, medical residents, and nurses has demonstrated the potential for occupational fatigue to affect patient, employee, and organizational outcomes. A conceptual framework of occupational fatigue that is informed by a sociotechnical systems approach is needed to (1) describe the multidimensional facets of occupational fatigue, (2) explore individual and work system factors that may affect occupational fatigue, and (3) anticipate downstream implications of occupational fatigue on employee well-being, patient safety, and organizational outcomes.

CONCEPTUAL FRAMEWORK OF OCCUPATIONAL FATIGUE

The health care professional occupational fatigue conceptual framework is outlined following the Systems Engineering Initiative for Patient Safety (SEIPS) model and adapted from the Conceptual Model of Occupational Fatigue in Nursing. Future research may apply this conceptual framework to health care professionals as a tool to describe occupational fatigue, identify the causes, and generate solutions. Interventions to mitigate and resolve occupational fatigue must address the entire sociotechnical system, not just individual or employee changes.

This is Jeopardy! A flexible coverage-based schedule model to address wellness for pathology training programs

Scheduling rotations for a pathology training program involves balancing educational requirements, service coverage, and paid time off (PTO). Absences can affect training as residents cross-cover, managing multiple services at once. Other specialties utilize a "Jeopardy" based system for covering absences. In this system, residents on outpatient services are "jeopardized" to cover inpatient services for trainee absences. Borrowing this concept, we created a schedule model with a "Jeopardy-Elective" (JE) rotation to support resident absences. Prior to 2018-19, our residency program consisted of a 12 month-long rotation schedule. We adopted a 13 four-week block rotation model system, adding four JE rotations per resident over the course of training. The JE resident covered services during trainee absences and spent the remaining rotation on elective. We then conducted a pre- and post-intervention survey of all residents who trained in both systems. Following the change in schedule model, our results showed a statistically significant increase in resident satisfaction with taking PTO (p = 0.0014), finding coverage (p = 0.0006), and taking a sick day (p = 0.03). The mean number of days covered by the JE resident was 8.5 ± 2.7 workdays (out of 20). PTO usage increased from 16 to 20 days/resident while mean number of sick days decreased from 1.7 to 1.3 days per resident. There was overwhelming support with 82% of residents wanting to retain the new system going forward. Through use of the JE rotation, our program improved service coverage issues and resident satisfaction, with the long-term goal of enhanced resident well-being and enriched resident learning experiences.

The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID-19

BACKGROUND

Burnout has risen across healthcare workers during the pandemic, contributing to workforce turnover. While prior literature has largely focused on physicians and nurses, there is a need to better characterize and identify actionable predictors of burnout and work intentions across healthcare role types.

OBJECTIVE

To characterize the association of work overload with rates of burnout and intent to leave (ITL) the job in a large national sample of healthcare workers.

DESIGN

Cross-sectional survey study conducted between April and December 2020.

SETTING

A total of 206 large healthcare organizations.

PARTICIPANTS

Physicians, nurses, other clinical staff, and non-clinical staff.

MEASURES

Work overload, burnout, and ITL.

RESULTS

The sample of 43,026 respondents (mean response rate 44%) was comprised of 35.2% physicians, 25.7% nurses, 13.3% other clinical staff, and 25.8% non-clinical staff. The overall burnout rate was 49.9% (56.0% in nursing, 54.1% in other clinical staff, 47.3% in physicians, and 45.6% in non-clinical staff; p < 0.001 for difference). ITL was reported by 28.7% of healthcare workers, with nurses most likely to report ITL (41.0%), followed by non-clinical staff (32.6%), other clinical staff (32.1%), and physicians (24.3%) (p < 0.001 for difference). The prevalence of perceived work overload ranged from 37.1% among physicians to 47.4% in other clinical staff. In propensity-weighted models, work overload was significantly associated with burnout (adjusted risk ratio (ARR) 2.21 to 2.90) and intent to leave (ARR 1.73 to 2.10) across role types.

LIMITATIONS

Organizations' participation in the survey was voluntary.

CONCLUSIONS

There are high rates of burnout and intent to leave the job across healthcare roles. Proactively addressing work overload across multiple role types may help with concerning trends across the healthcare workforce. This will require a more granular understanding of sources of work overload across different role types, and a commitment to matching work demands to capacity for all healthcare workers.

Resident duty hours and resident and patient outcomes: Systematic review and meta-analysis

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.

PERCLOS-based technologies for detecting drowsiness: current evidence and future directions

Drowsiness associated with sleep loss and circadian misalignment is a risk factor for accidents and human error. The percentage of time that the eyes are more than 80% closed (PERCLOS) is one of the most validated indices used for the passive detection of drowsiness, which is increased with sleep deprivation, after partial sleep restriction, at nighttime, and by other drowsiness manipulations during vigilance tests, simulated driving, and on-road driving. However, some cases have been reported wherein PERCLOS was not affected by drowsiness manipulations, such as in moderate drowsiness conditions, in older adults, and during aviation-related tasks. Additionally, although PERCLOS is one of the most sensitive indices for detecting drowsiness-related performance impairments during the psychomotor vigilance test or behavioral maintenance of wakefulness test, no single index is currently available as an optimal marker for detecting drowsiness during driving or other real-world situations. Based on the current published evidence, this narrative review suggests that future studies should focus on: (1) standardization to minimize differences in the definition of PERCLOS between studies; (2) extensive validation using a single device that utilizes PERCLOS-based technology; (3) development and validation of technologies that integrate PERCLOS with other behavioral and/or physiological indices, because PERCLOS alone may not be sufficiently sensitive for detecting drowsiness caused by factors other than falling asleep, such as inattention or distraction; and (4) further validation studies and field trials targeting sleep disorders and trials in real-world environments. Through such studies, PERCLOS-based technology may contribute to preventing drowsiness-related accidents and human error.

Electrophysiological Mechanism of Attention of Sleep Deprivation: Evidence From Event-Related Potentials (ERP) Data

INTRODUCTION

The purpose of this study is to investigate the effects of sleep deprivation on individual attentional function and related electrophysiological mechanisms.

METHODS

Twenty healthy men who were deprived of sleep for 24 h were evaluated by selective attention test, persistent attention test, and event-related potentials (ERP) experiment.

RESULTS

After 24 h of sleep deprivation, the subjects' selective attention decreased, mainly manifested as prolonged response time, decreased motion stability, increased rate of neglect error, decreased sustained attention, prolonged latency of P300 at Cz (p=0.001), and decreased amplitude (p=0.000).

CONCLUSION

After 24 h of sleep deprivation, the attentional ability decreased significantly, and behavioral and ERP indicators showed certain changes.

Urology Residents' Perspectives on the In-House On-Call Systems: A Study in an Accredited Academic Center

INTRODUCTION

Medical education and training are crucial in maintaining patients' safety and improving patient care quality. Multiple studies have evaluated the effects of restrictive policies on the resident's quality of life and education. Due to the compiling data and the fact that these trials evaluated programs with a substantial number of residents, it remains uncertain whether these conclusions can be extended to urology programs with a small number of residents. Multiple on-call systems have been adopted in residency programs across the world. This study evaluated the residents' quality of life, clinical experience, and education upon transitioning from 24-hour to 12-hour in-house on-call systems.

METHODS AND MATERIALS

In this observational and questionnaire-based study, the effect of the transition from 24-hour to 12-hour in-house on-call systems was compared in terms of the resident's quality of life and education, surgical case volume, and working hours' rules compliance. Quality of life and education: We adopted a validated survey based on a 5-point Likert scale to assess the residents' perception of the transition to a 12-hour on-call system on their quality of life and education. Surgical case volume: We extracted the number of cases the residents operated on from the operating theater database at our institution. Working hours: compliance and violations: The weekly working hours, compliance, and violations per ACGME-I rules were collected from the MedHub platform.

RESULTS

Quality of life and education: Residents rated the 12-hour on-call system superior in terms of quality of life, education, and surgical case volume. Surgical case volume: There was a 45% increment in the surgical case volume (p = 0.04) with the 12-hour on-call system. Working hours: compliance and violations There was no significant difference in the mean weekly working hours (p = 0.1). However, the total number of duty hours violations decreased in the 12-hour on-call system.

CONCLUSION

The 12-hour system is a better alternative to the 24-hour system in terms of the resident's quality of life, education, surgical case volume, and compliance with duty hour rules.

Work Organization Factors Associated With Nurses' Stress, Sleep, and Performance: A Pre-pandemic Analysis

Background

The COVID-19 pandemic put extreme stress on an already strained healthcare workforce. Suboptimal work organization, exacerbated by the pandemic, is associated with poor worker, patient, and organizational outcomes. However, there are limited qualitative studies exploring how the interconnections of work organization factors related to shift work, sleep, and work stress influence registered nurses and their work performance in the United States.

Purpose

We sought to understand how nurses perceive work organization factors that impact their performance. Knowledge in this area could direct efforts to implement policies and design tailored interventions to support nurses in the post-pandemic period.

Methods

We used a qualitative descriptive design with the Work, Stress, and Health framework as an overarching guide to understand the interconnectedness of work organization factors, work stress, and outcomes. Participants were randomly assigned to one of two anonymous, asynchronous virtual focus groups (i.e., threaded discussion boards) in 2019. Registered nurses (N = 23) working across the United States were recruited and engaged until data saturation was achieved. Directed content analysis was used to analyze the data.

Results

Findings aligned with the Work, Stress, and Health framework and revealed three themes: (1) "Our Voice Should Matter" (nurses' desire to have their voices heard in staffing policies); (2) "Tired But Wired" (the harmful cycle of work stress, rumination, and poor sleep); and (3) "We're Only Human" (nurses' physical, emotional, and mental exhaustion linked to critical performance impairments).

Conclusion

These findings underscore that high work stress and poor sleep were present before the pandemic and impacted nurses' perceptions of their performance. As leaders look forward to recovery and work redesign efforts, these findings can guide decision-making and resource allocation for optimal nurse, patient, and organization outcomes.

Impact of Extended Duty Hours on Perceptions of Care and Objective Patient Outcomes

OBJECTIVE

In 2017, interns were permitted to work continuously for up to 28 hours at a time, a reversal from the previously mandated 16-hour limit. Our objective was to evaluate perceptions of care and patient outcomes on an extended (28-hour) compared with a limited (16-hour) duty-hour system on identical interdisciplinary teams.

METHODS

Sixty-two interns, 27 residents, 28 attendings, and 449 patients participated. Patients completed surveys assessing their satisfaction. Anonymous weekly surveys were obtained from interns, residents, and attendings evaluating perceptions of intern tiredness, overall satisfaction, and performance. Nursing surveys evaluated intern and medical team performance. Objective outcome measures, including intensive care unit transfers, length of stay, readmissions, mortality, and complications, were assessed through a retrospective, blinded chart review.

RESULTS

Patients reported similar satisfaction in care. Extended duty-hour interns reported significantly decreased familiarity with their patients, decreased ability to conduct physical exams on new patients, increased tiredness, and decreased overall satisfaction. Residents overseeing extended-duty interns reported significantly decreased quality in intern presentations and overall quality of teaching, and increased perception of intern tiredness and increased incorrect orders. Attending physicians reported significantly improved quality of new patient presentations by extended duty-hour interns. No significant differences in patient objective outcome measures were noted.

CONCLUSIONS

Extended intern duty hours do not affect patient's satisfaction with their care. Although interns in the extended duty-hour system reported significantly increased fatigue and decreased overall satisfaction and residents' perceived increases in incorrect intern orders in the extended duty-hour system, there were no detrimental effects on patient safety.

Performance Nutrition for Physician Trainees Working Overnight Shifts: A Randomized Controlled Trial

PURPOSE

To compare acute effects of 2 dietary interventions with usual dietary habits on physician trainees' alertness during overnight shifts.

METHOD

This registered, controlled, block randomized crossover trial (NCT03698123) was conducted between October 2018 and May 2019 at Stanford Medicine. Physician trainees working at least 3 overnight shifts during a 1-week period were recruited. During the first night, participants followed their usual dietary habits. During the intervention nights (low carbohydrate-to-protein ratio and high carbohydrate-to-protein ratio interventions), participants received healthy dinners, snacks, water, and, upon request, caffeinated beverages, at the beginning of their shifts and were instructed to eat meals before 10 pm. The sequence of interventions on the second and third nights were block randomized across study weeks. Outcome measures (a priori) were overnight changes in validated measures of specific neurobehavioral dimensions: psychomotor vigilance, sensory-motor speed, working memory, and risk decision making, as well as self-reported sleepiness and work exhaustion.

RESULTS

Sixty-one physician trainees participated in this study. Compared with usual dietary habits, overnight changes in psychomotor vigilance scores (scale 0-1,000) improved by 51.02 points (95% CI: 12.08, 89.96) and sleepiness (scale 1-7) improved by 0.69 points (95% CI: 0.33, 1.05) under the low carbohydrate-to-protein ratio intervention. Compared with usual dietary habits, overnight changes in sleepiness (scale 1-7) improved by 0.61 points (95% CI: 0.25, 0.96) under the high carbohydrate-to-protein ratio intervention. Neither intervention had beneficial effects relative to usual dietary habits with respect to sensory-motor speed, working memory, risk decision making, or work exhaustion. There were no differences in outcomes between low carbohydrate-to-protein ratio and high carbohydrate-to-protein ratio interventions.

CONCLUSIONS

Dietary interventions may mitigate negative effects of physician trainee sleep deprivation during overnight shifts. Future studies are warranted to further examine the effectiveness of nutritional strategies on physician alertness during overnight shifts.

Long-term impact of overnight shiftwork implementation on pediatric residents' mental wellness: A repeated cross-sectional survey

Objectives

The Japanese government partially enacted the “Work Style Reform Bill” in 2019. The National Center for Child Health and Development (NCCHD) introduced an Overnight Call Shift (OCS) system for pediatrician training. We conducted a follow‐up survey in 2019 to investigate the long‐term effectiveness of the OCS system to improve the pediatric residents' mental wellness at NCCHD.

Methods

We conducted a questionnaire‐based cross‐sectional survey for pediatric residents in 2019 to compare the data with those of the previous survey in 2012. The questionnaire includes demographic data, working conditions data, and mental wellness assessment by the Center for Epidemiologic Studies Depression scale (CES‐D) and the Maslach Burnout Inventory (MBI).

Results

The collection rate for the 2019 survey was 94.5% (37 participants/39 eligible). Compared to 2012, there were no significant changes in demographic data and working hours, a significant increase by about 30% in residents who took daytime off after night work, about 10% decrease in residents who scored 16 and above on the CES‐D, and a significant decrease in the mean score for depersonalization (DP) in the MBI. Multiple regression analyses showed that daytime off after night work was the decreasing factor for CES‐D and Emotional exhaustion (EE).

Conclusions

The overnight shiftwork system shortened the pediatric residents' duty hours somewhat, and imposed an impact on the pediatric residents' mental wellness.

Working hours, on-call shifts, and risk of occupational injuries among hospital physicians: A case-crossover study

OBJECTIVE

To investigate the association of hospital physicians' working hours and on-call shifts with the risk of occupational injuries.

METHODS

In this nested cohort study of 556 Finnish hospital physicians, we linked electronic records from working-hour and on-call duty payroll data to occupational injury data obtained from the Finnish Workers' Compensation Center for the period 2005-2019. We used a case-crossover design with matched intervals for a 7-day 'case window' immediately prior to occupational injury and a 'control window' 7 days prior to the beginning of the case window, and analyzed their associations using conditional logistic regression models.

RESULTS

We noted 556 occupational injuries, 281 at the workplace and 275 while commuting. Having three to four long (>12 h) work shifts on the preceding 7 days was associated with a higher probability of an occupational injury (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.11, 4.09), and the OR for three to four on-call shifts was 3.54 (95%CI 2.11, 5.92) in comparison to having none of these work shift types. A higher number of several consecutive working days was associated with a higher probability of injury in a dose-response manner. Moreover, increasing weekly working hours was associated with an increased likelihood of injury (OR 1.03, 95%CI 1.01, 1.04), whereas the number of normal (≤12 h) work shifts reduced this likelihood (OR 0.79, 95%CI 0.64, 0.98).

CONCLUSIONS

Our findings suggest that accumulated working-hour load, as opposed to single, very long (>24 h) work shifts, may increase the risk of occupational injury among hospital physicians.

Objective Assessment of Sleep Patterns among Night-Shift Workers: A Scoping Review

In this scoping review of the literature, we identified the types and the parameters of objective measurements to assess sleep patterns among night-shift workers. We conducted a literature search using electronic databases for studies published from 1991 to 2020 and charted and summarized key information. We included 32 studies in the review. Polysomnography was used in 6 studies and wearable sleep detection devices were utilized in 26 studies. The duration of sleep assessment using the wearable devices ranged from 1 day to ≥4 weeks, and more than half of the studies collected data for >2 weeks. The majority of the studies used subjective questionnaires, such as the Karolinska Sleepiness Scale, Epworth Sleepiness Scale, and Pittsburgh Sleep Quality Index, in addition to objective sleep measurements. Total sleep time was the most common parameter, followed by sleep efficiency, sleep onset latency, and time or frequency of being awake. As the utilization of wearable devices to assess the sleep patterns of night-shift workers is expected to increase, further evaluation of device accuracy and precision, optimal data collection period, and key parameters is warranted.

Sleep and Alertness Among Interns in Intensive Care Compared to General Medicine Rotations: A Secondary Analysis of the iCOMPARE Trial

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.

Effect of Intraoperative Dexmedetomidine on Recovery of Gastrointestinal Function After Abdominal Surgery in Older Adults: A Randomized Clinical Trial

IMPORTANCE

Postoperative ileus is common after abdominal surgery, and small clinical studies have reported that intraoperative administration of dexmedetomidine may be associated with improvements in postoperative gastrointestinal function. However, findings have been inconsistent and study samples have been small. Further examination of the effects of intraoperative dexmedetomidine on postoperative gastrointestinal function is needed.

OBJECTIVE

To evaluate the effects of intraoperative intravenous dexmedetomidine vs placebo on postoperative gastrointestinal function among older patients undergoing abdominal surgery.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, double-blind, placebo-controlled randomized clinical trial was conducted at the First Affiliated Hospital of Anhui Medical University in Hefei, China (lead site), and 12 other tertiary hospitals in Anhui Province, China. A total of 808 participants aged 60 years or older who were scheduled to receive abdominal surgery with an expected surgical duration of 1 to 6 hours were enrolled. The study was conducted from August 21, 2018, to December 9, 2019.

INTERVENTIONS

Dexmedetomidine infusion (a loading dose of 0.5 μg/kg over 15 minutes followed by a maintenance dose of 0.2 μg/kg per hour) or placebo infusion (normal saline) during surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to first flatus. Secondary outcomes were postoperative gastrointestinal function measured by the I-FEED (intake, feeling nauseated, emesis, physical examination, and duration of symptoms) scoring system, time to first feces, time to first oral feeding, incidence of delirium, pain scores, sleep quality, postoperative nausea and vomiting, hospital costs, and hospital length of stay.

RESULTS

Among 808 patients enrolled, 404 were randomized to receive intraoperative dexmedetomidine, and 404 were randomized to receive placebo. In total, 133 patients (60 in the dexmedetomidine group and 73 in the placebo group) were excluded because of protocol deviations, and 675 patients (344 in the dexmedetomidine group and 331 in the placebo group; mean [SD] age, 70.2 [6.1] years; 445 men [65.9%]) were included in the per-protocol analysis. The dexmedetomidine group had a significantly shorter time to first flatus (median, 65 hours [IQR, 48-78 hours] vs 78 hours [62-93 hours], respectively; P < .001), time to first feces (median, 85 hours [IQR, 68-115 hours] vs 98 hours [IQR, 74-121 hours]; P = .001), and hospital length of stay (median, 13 days [IQR, 10-17 days] vs 15 days [IQR, 11-18 days]; P = .005) than the control group. Postoperative gastrointestinal function (as measured by the I-FEED score) and delirium incidence were similar in the dexmedetomidine and control groups (eg, 248 patients [72.1%] vs 254 patients [76.7%], respectively, had I-FEED scores indicating normal postoperative gastrointestinal function; 18 patients [5.2%] vs 12 patients [3.6%] had delirium on postoperative day 3).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the administration of intraoperative dexmedetomidine reduced the time to first flatus, time to first feces, and length of stay after abdominal surgery. These results suggest that this therapy may be a viable strategy to enhance postoperative recovery of gastrointestinal function among older adults.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR1800017232.

Bellagio II Report: Terrestrial Applications of Space Medicine Research

AbstractINTRODUCTION: For over 50 yr, investigators have studied the physiological adaptations of the human system during short- and long-duration spaceflight exposures. Much of the knowledge gained in developing health countermeasures for astronauts onboard the International Space Station demonstrate terrestrial applications. To date, a systematic process for translating these space applications to terrestrial human health has yet to be defined.METHODS: In the summer of 2017, a team of 38 international scientists launched the Bellagio ll Summit Initiative. The goals of the Summit were: 1) To identify space medicine findings and countermeasures with highest probability for future terrestrial applications; and 2) To develop a roadmap for translation of these countermeasures to future terrestrial application. The team reviewed public domain literature, NASA databases, and evidence books within the framework of the five-stage National Institutes of Health (NIH) translation science model, and the NASA two-stage translation model. Teams then analyzed and discussed interdisciplinary findings to determine the most significant evidence-based countermeasures sufficiently developed for terrestrial application.RESULTS: Teams identified published human spaceflight research and applied translational science models to define mature products for terrestrial clinical practice.CONCLUSIONS: The Bellagio ll Summit identified a snapshot of space medicine research and mature science with the highest probability of translation and developed a Roadmap of terrestrial application from space medicine-derived countermeasures. These evidence-based findings can provide guidance regarding the terrestrial applications of best practices, countermeasures, and clinical protocols currently used in spaceflight.Sides MB, Johnston SL III, Sirek A, Lee PH, Blue RS, Antonsen EL, Basner M, Douglas GL, Epstein A, Flynn-Evans EE, Gallagher MB, Hayes J, Lee SMC, Lockley SW, Monseur B, Nelson NG, Sargsyan A, Smith SM, Stenger MB, Stepanek J, Zwart SR; Bellagio II Team. Bellagio II report: terrestrial applications of space medicine research. Aerosp Med Hum Perform. 2021; 92(8):650669.

Neurobiology and Neuroprotective Benefits of Sleep

PURPOSE OF REVIEW

This article outlines the neurocircuitry underlying sleep-wake and circadian physiology with a focus on the fundamental roles that sleep and circadian health play in optimal neurologic function.

RECENT FINDINGS

The foundation of sleep and wake promotion is laid primarily by the "fast-acting" neurotransmitters: γ-aminobutyric acid (GABA) for sleep and glutamate for wake. External to these primary systems are a host of modulatory systems that are characterized by two flip-flop switches of mutually inhibitory neurotransmitter systems that facilitate transitions between wake and sleep as well as non-rapid eye movement (non-REM) and REM sleep. Additional mechanisms are in place to help coordinate the sleep-wake states with environmental, metabolic, and behavioral demands. The complexity of the evolutionarily preserved sleep-wake and circadian systems, the proportion of the day dedicated to the natural sleeping period, as well as the neurocognitive dysfunction and neurodegeneration caused by deficient sleep highlight the importance of defining, assessing, and optimizing the sleep health of our patients and ourselves.

SUMMARY

Exciting discoveries continue to elucidate the underlying mechanisms of sleep and wake state coordination, reinforcing fundamental healthy practices and paving the way for new interventions that preserve and promote optimal neurologic health.

Hilaire MA, O’Brien CS, Stone KL, Phillips AJ, Klerman EB, Qadri S, Wright KP, Halbower AC, Segar JL, McGuire JK, Vitiello MV, de la Iglesia HO, Poynter SE, Yu PL, Sanderson AL, Zee PC, Landrigan CP, Czeisler CA, Lockley SW. Extended Work Shifts and Neurobehavioral Performance in Resident-Physicians

OBJECTIVES

Extended-duration work rosters (EDWRs) with shifts of 24+ hours impair performance compared with rapid cycling work rosters (RCWRs) that limit shifts to 16 hours in postgraduate year (PGY) 1 resident-physicians. We examined the impact of a RCWR on PGY 2 and PGY 3 resident-physicians.

METHODS

Data from 294 resident-physicians were analyzed from a multicenter clinical trial of 6 US PICUs. Resident-physicians worked 4-week EDWRs with shifts of 24+ hours every third or fourth shift, or an RCWR in which most shifts were ≤16 consecutive hours. Participants completed a daily sleep and work log and the 10-minute Psychomotor Vigilance Task and Karolinska Sleepiness Scale 2 to 5 times per shift approximately once per week as operational demands allowed.

RESULTS

Overall, the mean (± SE) number of attentional failures was significantly higher (P =.01) on the EDWR (6.8 ± 1.0) compared with RCWR (2.9 ± 0.7). Reaction time and subjective alertness were also significantly higher, by ∼18% and ∼9%, respectively (both P <.0001). These differences were sustained across the 4-week rotation. Moreover, attentional failures were associated with resident-physician-related serious medical errors (SMEs) (P =.04). Although a higher rate of SMEs was observed under the RCWR, after adjusting for workload, RCWR had a protective effect on the rate of SMEs (rate ratio 0.48 [95% confidence interval: 0.30-0.77]).

CONCLUSIONS

Performance impairment due to EDWR is improved by limiting shift duration. These data and their correlation with SME rates highlight the impairment of neurobehavioral performance due to extended-duration shifts and have important implications for patient safety.

Day-to-day variability in sleep parameters and depression risk: a prospective cohort study of training physicians

While 24-h total sleep time (TST) is established as a critical driver of major depression, the relationships between sleep timing and regularity and mental health remain poorly characterized because most studies have relied on either self-report assessments or traditional objective sleep measurements restricted to cross-sectional time frames and small cohorts. To address this gap, we assessed sleep with a wearable device, daily mood with a smartphone application and depression through the 9-item Patient Health Questionnaire (PHQ-9) over the demanding first year of physician training (internship). In 2115 interns, reduced TST (b = -0.11, p < 0.001), later bedtime (b = 0.068, p = 0.015), along with increased variability in TST (b = 0.4, p = 0.0012) and in wake time (b = 0.081, p = 0.005) were associated with more depressive symptoms. Overall, the aggregated impact of sleep variability parameters and of mean sleep parameters on PHQ-9 were similar in magnitude (both r² = 0.01). Within individuals, increased TST (b = 0.06, p < 0.001), later wake time (b = 0.09, p < 0.001), earlier bedtime (b = - 0.07, p < 0.001), as well as lower day-to-day shifts in TST (b = -0.011, p < 0.001) and in wake time (b = -0.004, p < 0.001) were associated with improved next-day mood. Variability in sleep parameters substantially impacted mood and depression, similar in magnitude to the mean levels of sleep parameters. Interventions that target sleep consistency, along with sleep duration, hold promise to improve mental health.

Delta: The Value That Matters in Fatigue Risk Management

INTRODUCTION: Noninferiority or equivalence testing are often used when comparing a novel pharmaceutical, operation, or procedure to the current standard designated as safe. Noninferiority and equivalence testing require estimates of a metric called delta: the margin of meaningful difference. Inappropriate delta margins can lead to invalid conclusions, thereby creating uncertainty about a studys scientific credibility. We recommend that a working group be convened with the following goals: 1) to evaluate delta values currently in use in aviation; 2) to determine if it is possible to develop a systematic, evidence-based, and replicable process to derive delta values based on statistical properties from population data, rather than a mixture of evidence- and opinion-based processes; and 3) based on the findings of the second goal, update the current delta values in use in aviation. This working group should include, at a minimum, government agencies and other key stakeholders using these values within operational settings.Lamp ACM, Rempe MJ, Belenky GL. Delta: the value that matters in fatigue risk management. Aerosp Med Hum Perform. 2021; 92(2):127128.

Non-Pharmacological Interventions to Improve Chronic Disease Risk Factors and Sleep in Shift Workers: A Systematic Review and Meta-Analysis

Shift work is associated with adverse chronic health outcomes. Addressing chronic disease risk factors including biomedical risk factors, behavioural risk factors, as well as sleep and perceived health status, affords an opportunity to improve health outcomes in shift workers. The present study aimed to conduct a systematic review, qualitative synthesis, and meta-analysis of non-pharmacological interventions targeting chronic disease risk factors, including sleep, in shift workers. A total of 8465 records were retrieved; 65 publications were eligible for inclusion in qualitative analysis. Random-effects meta-analysis were conducted for eight eligible health outcomes, including a total of thirty-nine studies. Interventions resulted in increased objective sleep duration (Hedges' g = 0.73; CI: 0.36, 1.10, k = 16), improved objective sleep efficiency (Hedges' g = 0.48; CI: 0.20, 0.76, k = 10) and a small increase in both subjective sleep duration (Hedges' g = 0.11; CI: -0.04, 0.27, k = 19) and sleep quality (Hedges' g = 0.11; CI: -0.11, 0.33, k = 21). Interventions also improved perceived health status (Hedges' g = 0.20; CI: -0.05, 0.46, k = 8), decreased systolic (Hedges' g = 0.26; CI: -0.54, 0.02, k = 7) and diastolic (Hedges' g = 0.06; CI: -0.23, 0.36, k = 7) blood pressure, and reduced body mass index (Hedges' g = -0.04; CI: -0.37, 0.29, k = 9). The current study suggests interventions may improve chronic disease risk factors and sleep in shift workers; however, this could only be objectively assessed for a limited number of risk factor endpoints. Future interventions could explore the impact of non-pharmacological interventions on a broader range of chronic disease risk factors to better characterise targets for improved health outcomes in shift workers.

Characterizing Glycemic Control and Sleep in Adults with Long-Standing Type 1 Diabetes and Hypoglycemia Unawareness Initiating Hybrid Closed Loop Insulin Delivery

Nocturnal hypoglycemia is life threatening for individuals with type 1 diabetes (T1D) due to loss of hypoglycemia symptom recognition (hypoglycemia unawareness) and impaired glucose counter regulation. These individuals also show disturbed sleep, which may result from glycemic dysregulation. Whether use of a hybrid closed loop (HCL) insulin delivery system with integrated continuous glucose monitoring (CGM) designed for improving glycemic control, relates to better sleep across time in this population remains unknown. The purpose of this study was to describe long-term changes in glycemic control and objective sleep after initiating hybrid closed loop (HCL) insulin delivery in adults with type 1 diabetes and hypoglycemia unawareness. To accomplish this, six adults (median age = 58 y) participated in an 18-month ongoing trial assessing HCL effectiveness. Glycemic control and sleep were measured using continuous glucose monitoring and wrist accelerometers every 3 months. Paired sample t-tests and Cohen's d effect sizes modeled glycemic and sleep changes and the magnitude of these changes from baseline to 9 months. Reduced hypoglycemia (d = 0.47-0.79), reduced basal insulin requirements (d = 0.48), and a smaller glucose coefficient of variation (d = 0.47) occurred with medium-large effect sizes from baseline to 9 months. Hypoglycemia awareness improved from baseline to 6 months with medium-large effect sizes (Clarke score (d = 0.60), lability index (d = 0.50), HYPO score (d = 1.06)). Shorter sleep onset latency (d = 1.53; p < 0.01), shorter sleep duration (d = 0.79), fewer total activity counts (d = 1.32), shorter average awakening length (d = 0.46), and delays in sleep onset (d = 1.06) and sleep midpoint (d = 0.72) occurred with medium-large effect sizes from baseline to 9 months. HCL led to clinically significant reductions in hypoglycemia and improved hypoglycemia awareness. Sleep showed a delayed onset, reduced awakening length and onset latency, and maintenance of high sleep efficiency after initiating HCL. Our findings add to the limited evidence on the relationships between diabetes therapeutic technologies and sleep health. This trial is registered with ClinicalTrials.gov (NCT03215914).

Learner Preference of Schedule Type Improves Engagement of Pediatric Residents: Results of a Mixed-Methods Analysis

OBJECTIVE

Determine whether a call or shift schedule is better for acquiring optimal knowledge and professionalism, while limiting fatigue for pediatric residents during the pediatric intensive care unit (PICU) rotation in a small residency program.

METHODS

This was a prospective, randomized, crossover, mixed-methods study in which pediatric residents were randomized to either a call or shift schedule during their PICU rotation. Attentiveness, bedside care, perceived knowledge, and professionalism were assessed by the resident participants, attending physicians, and nursing staff. Epworth Sleepiness Scale determined the level of resident fatigue. Statistical analysis utilized a t test of unequal variances. Two focus groups were conducted of resident non-participants and participants. Graduated resident participants and non-participants were surveyed via anonymous e-mail responses.

RESULTS

Thirty residents participated in the study and twenty residents were surveyed and participated in a focus group. No major differences were detected between each participating group, whether assigned to a call or shift schedule in regard to perceived knowledge, professionalism, or fatigue. Overall themes from qualitative analysis identified advantages and disadvantages for both work schedules. Participants recognized a learner preference for schedule type depending on level of training, suggesting a shift schedule for junior residents and a call schedule for senior residents.

CONCLUSIONS

There is no difference between the call or shift schedule in regard to residents' perceived knowledge, professionalism, and fatigue. Participants expressed learner preferences for one schedule over the other, recommending the shift schedule during the PGY-2 year and the call schedule during the PGY-3 year.

Gradually Increased Interhemispheric Functional Connectivity During One Night of Sleep Deprivation

BACKGROUND

It is well known that circadian rhythms and sleep homeostasis contribute to a pronounced trough in sleepiness and behavioral performance at night. However, the underlying neuroimaging mechanisms remain unclear. How brain-function connectivity is modulated during sleep deprivation (SD) has been rarely examined.

METHODS

By increasing the number of scanning sessions during SD, the current study used voxel-mirrored homotopic connectivity (VMHC) to investigate dynamic changes in interhemispheric communication during one night of SD. Every 2 hours from 10 pm to 06 am (session 1, 10 pm; session 2, 12 am; session 3, 2 am; session 4, 4 am; session 5, 6 am), functional magnetic resonance-imaging data and Stanford Sleepiness Scale (SSS) scores were collected from 36 healthy participants with intermediate chronotype. Dynamic changes in SSS scores and VMHC were determined using one-way repeated-measure ANOVA with the false discovery-rate method to correct for multiple comparisons.

RESULTS

Significant time effects for VMHC were found mainly in the bilateral thalamus, bilateral superior temporal gyrus, and bilateral precentral gyrus. SSS scores and VMHC in these areas were both found to be monotonously increased during SD. Furthermore, significant positive associations were found between SSS valu and VMHC values in the left superior temporal and right superior gyri.

CONCLUSION

These findings might represent the dynamic modulation of circadian rhythm merely or the interaction effects of both circadian rhythm and sleep homeostasis on interhemispheric connectivity within the thalamus, default-mode network, and sensorimotor network. Our study provides more comprehensive information on how SD regulates brain connectivity between hemispheres and adds new evidence of neuroimaging correlates of increased sleepiness after SD.

The impact of aircraft noise on vascular and cardiac function in relation to noise event number: a randomized trial

Aims

Nighttime aircraft noise exposure has been associated with increased risk of hypertension and myocardial infarction, mechanistically linked to sleep disturbance, stress, and endothelial dysfunction. It is unclear, whether the most widely used metric to determine noise exposure, equivalent continuous sound level (L_eq), is an adequate indicator of the cardiovascular impact induced by different noise patterns.

Methods and results

In a randomized crossover study, we exposed 70 individuals with established cardiovascular disease or increased cardiovascular risk to two aircraft noise scenarios and one control scenario. Polygraphic recordings, echocardiography, and flow-mediated dilation (FMD) were determined for three study nights. The noise patterns consisted of 60 (Noise60) and 120 (Noise120) noise events, respectively, but with comparable L_eq, corresponding to a mean value of 45 dB. Mean value of noise during control nights was 37 dB. During the control night, FMD was 10.02 ± 3.75%, compared to 7.27 ± 3.21% for Noise60 nights and 7.21 ± 3.58% for Noise120 nights (P < 0.001). Sleep quality was impaired after noise exposure in both noise scenario nights (P < 0.001). Serial echocardiographic assessment demonstrated an increase in the E/E′ ratio, a measure of diastolic function, within the three exposure nights, with a ratio of 6.83 ± 2.26 for the control night, 7.21 ± 2.33 for Noise60 and 7.83 ± 3.07 for Noise120 (P = 0.043).

Conclusions

Nighttime exposure to aircraft noise with similar L_eq, but different number of noise events, results in a comparable worsening of vascular function. Adverse effects of nighttime aircraft noise exposure on cardiac function (diastolic dysfunction) seemed stronger the higher number of noise events.

Testing Alertness of Emergency Physicians: A Novel Quantitative Measure of Alertness and Implications for Worker and Patient Care

BACKGROUND

Establishing practical solutions to manage fatigue in health care settings could reduce errors. Predictive Safety SRP Inc.'s AlertMeter is a 2-min cognitive assessment tool currently used in high-hazard industries to identify fatigued staff.

OBJECTIVE

No prior study has attempted to address fatigue in emergency medicine (EM). We objectively assessed provider alertness to determine potential application of software-based fatigue recognition for risk reduction.

METHODS

In a double-blind, prospective evaluation from July 1 to September 30, 2016, we applied the AlertMeter to EM residents at an academic level I trauma center. The tool was applied before and after shifts to evaluate alertness in three types of shifts: day, evening, and night. All residents were invited to participate-27 of 30 enrolled. Analysis of covariance (ANCOVA) was implemented to examine shift and completion effects on alertness score using baseline score as a covariate. Additionally, three separate ANCOVAs were conducted to examine alertness score differences between portion (start vs. end) and type of shift (day, evening, or night).

RESULTS

Residents were significantly less alert at the completion of the evening shift. Scores at the end of the night shift were significantly lower than the start of the night shift.

CONCLUSIONS

Alertness software can be reliably integrated into the emergency department. Alertness was lower at the end of the evening shift and end of the night shift. This work could have positive implications on shift and task scheduling and potentially reduce errors in patient care by quantifying providers' fatigue and identifying areas for countermeasures.

Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules

BACKGROUND

Concern persists that extended shifts in medical residency programs may adversely affect patient safety.

METHODS

We conducted a cluster-randomized noninferiority trial in 63 internal-medicine residency programs during the 2015-2016 academic year. Programs underwent randomization to a group with standard duty hours, as adopted by the Accreditation Council for Graduate Medical Education (ACGME) in July 2011, or to a group with more flexible duty-hour rules that did not specify limits on shift length or mandatory time off between shifts. The primary outcome for each program was the change in unadjusted 30-day mortality from the pretrial year to the trial year, as ascertained from Medicare claims. We hypothesized that the change in 30-day mortality in the flexible programs would not be worse than the change in the standard programs (difference-in-difference analysis) by more than 1 percentage point (noninferiority margin). Secondary outcomes were changes in five other patient safety measures and risk-adjusted outcomes for all measures.

RESULTS

The change in 30-day mortality (primary outcome) among the patients in the flexible programs (12.5% in the trial year vs. 12.6% in the pretrial year) was noninferior to that in the standard programs (12.2% in the trial year vs. 12.7% in the pretrial year). The test for noninferiority was significant (P = 0.03), with an estimate of the upper limit of the one-sided 95% confidence interval (0.93%) for a between-group difference in the change in mortality that was less than the prespecified noninferiority margin of 1 percentage point. Differences in changes between the flexible programs and the standard programs in the unadjusted rate of readmission at 7 days, patient safety indicators, and Medicare payments were also below 1 percentage point; the noninferiority criterion was not met for 30-day readmissions or prolonged length of hospital stay. Risk-adjusted measures generally showed similar findings.

CONCLUSIONS

Allowing program directors flexibility in adjusting duty-hour schedules for trainees did not adversely affect 30-day mortality or several other measured outcomes of patient safety. (Funded by the National Heart, Lung, and Blood Institute and Accreditation Council for Graduate Medical Education; iCOMPARE ClinicalTrials.gov number, NCT02274818.).