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Han ER, Chung EK. A qualitative study on the adoption of the new duty hour regulations among medical residents and faculty in Korea. PLoS One 2024; 19:e0301502. [PMID: 38603669 PMCID: PMC11008864 DOI: 10.1371/journal.pone.0301502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/15/2024] [Indexed: 04/13/2024] Open
Abstract
Duty hour regulations (DHRs) were enforced in 2017 in Korea to prevent the detrimental effects of excessively prolonged working hours among medical residents. We investigated the adoption of and implications of the new DHRs among medical residents and faculty members. Semi-structured interviews were conducted with 15 medical residents and 9 faculty members across general surgery, internal medicine, obstetrics-gynecology, and pediatrics departments at Chonnam National University Hospital. Based on the constructivist grounded theory, we developed themes from the data by concurrent coding and analysis with theoretical sampling until data saturation. In addition, respondent validation was used to ensure accuracy, and all authors remained reflexive throughout the study to improve validity. The methods of DHRs adoption among residents and faculty members included the following 4 themes: DHRs improved work schedule, residents have more time to learn on their own, clinical departments have come to distribute work, organization members have strived to improve patient safety. Residents have undertaken initial steps towards creating a balance between personal life and work. Teamwork and shift within the same team are the transitions that minimize discontinuity of patient care considering patient safety. Teaching hospitals, including faculty members, should ensure that residents' work and education are balanced with appropriate clinical experience and competency-based training.
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Affiliation(s)
- Eui-Ryoung Han
- Department of Medical Education, Chonnam National University Medical School, Gwangju, South Korea
| | - Eun-Kyung Chung
- Department of Medical Education, Chonnam National University Medical School, Gwangju, South Korea
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2
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Phillips AJK, St Hilaire MA, Barger LK, O'Brien CS, Rahman SA, Landrigan CP, Lockley SW, Czeisler CA, Klerman EB. Predicting neurobehavioral performance of resident physicians in a Randomized Order Safety Trial Evaluating Resident-Physician Schedules (ROSTERS). Sleep Health 2024; 10:S25-S33. [PMID: 38007304 PMCID: PMC11031327 DOI: 10.1016/j.sleh.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 10/20/2023] [Accepted: 10/27/2023] [Indexed: 11/27/2023]
Abstract
OBJECTIVES Mathematical models of human neurobehavioral performance that include the effects of acute and chronic sleep restriction can be key tools in assessment and comparison of work schedules, allowing quantitative predictions of performance when empirical assessment is impractical. METHODS Using such a model, we tested the hypothesis that resident physicians working an extended duration work roster, including 24-28 hours of continuous duty and up to 88 hours per week averaged over 4weeks, would have worse predicted performance than resident physicians working a rapidly cycling work roster intervention designed to reduce the duration of extended shifts. The performance metric used was attentional failures (ie, Psychomotor Vigilance Task lapses). Model input was 169 actual work and sleep schedules. Outcomes were predicted hours per week during work hours spent at moderate (equivalent to 16-20 hours of continuous wakefulness) or high (equivalent to ≥20 hours of continuous wakefulness) performance impairment. RESULTS The model predicted that resident physicians working an extended duration work roster would spend significantly more time at moderate impairment (p = .02, effect size=0.2) than those working a rapidly cycling work roster; this difference was most pronounced during the circadian night (p < .001). On both schedules, performance was predicted to decline from weeks 1 + 2 to weeks 3 + 4 (p < .001), but the rate of decline was significantly greater on extended duration work roster (p < .01). Predicted performance impairment was inversely related to prior sleep duration (p < .001). CONCLUSIONS These findings demonstrate the utility of a mathematical model to evaluate the predicted performance profile of schedules for resident physicians and others who experience chronic sleep restriction and circadian misalignment.
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Affiliation(s)
- Andrew J K Phillips
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa A St Hilaire
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.
| | - Laura K Barger
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Conor S O'Brien
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Shadab A Rahman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher P Landrigan
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA; Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven W Lockley
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Charles A Czeisler
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth B Klerman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Weaver MD, Sullivan JP, Landrigan CP, Barger LK. Systematic Review of the Impact of Physician Work Schedules on Patient Safety with Meta-Analyses of Mortality Risk. Jt Comm J Qual Patient Saf 2023; 49:634-647. [PMID: 37543449 DOI: 10.1016/j.jcjq.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/07/2023]
Abstract
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.
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Weaver MD, Landrigan CP, Sullivan JP, O'Brien CS, Qadri S, Viyaran N, Czeisler CA, Barger LK. National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies. BMJ Qual Saf 2023; 32:81-89. [PMID: 35537821 PMCID: PMC9887355 DOI: 10.1136/bmjqs-2021-014375] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 04/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy in 2011 that restricted first-year resident physicians in the USA to work no more than 16 consecutive hours. This was rescinded in 2017. METHODS We conducted a nationwide prospective cohort study of resident physicians for 5 academic years (2002-2007) before and for 3 academic years (2014-2017) after implementation of the 16 hours 2011 ACGME work-hour limit. Our analyses compare trends in resident physician-reported medical errors between the two cohorts to evaluate the impact of this policy change. RESULTS 14 796 residents provided data describing 78 101 months of direct patient care. After adjustment for potential confounders, the work-hour policy was associated with a 32% reduced risk of resident physician-reported significant medical errors (rate ratio (RR) 0.68; 95% CI 0.64 to 0.72), a 34% reduced risk of reported preventable adverse events (RR 0.66; 95% CI 0.59 to 0.74) and a 63% reduced risk of reported medical errors resulting in patient death (RR 0.37; 95% CI 0.28 to 0.49). CONCLUSIONS These findings have broad relevance for those who work in and receive care from academic hospitals in the USA. The decision to lift this work hour policy in 2017 may expose patients to preventable harm.
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Affiliation(s)
- Matthew D Weaver
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher P Landrigan
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Medicine, and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason P Sullivan
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
| | - Conor S O'Brien
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
| | - Salim Qadri
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
| | - Natalie Viyaran
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
| | - Charles A Czeisler
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura K Barger
- Brigham and Women's Hospital, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Caruso CC, Arbour MW, Berger AM, Hittle BM, Tucker S, Patrician PA, Trinkoff AM, Rogers AE, Barger LK, Edmonson JC, Landrigan CP, Redeker NS, Chasens ER. Research priorities to reduce risks from work hours and fatigue in the healthcare and social assistance sector. Am J Ind Med 2022; 65:867-877. [PMID: 35596665 PMCID: PMC10165664 DOI: 10.1002/ajim.23363] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 04/03/2022] [Accepted: 04/14/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The services of Healthcare and Social Assistance (HCSA) workers are needed by society around the clock. As a result, these workers are exposed to shift work and long work hours. The combination of demanding work schedules and other hazards in the HCSA work environment increases the health and safety risks to these workers, as well as to their patients/clients and the public. METHODS This paper has three aims: (1) provide an overview of the burden of shift work, long hours, and related sleep and fatigue problems in this sector; (2) suggest research priorities that would improve these; and (3) discuss potential positive impacts of addressing these research priorities for the health and safety of workers and the public. The authors used a modified Delphi approach to anonymously rank-order priorities for improving HCSA worker health and safety and public safety. Input was also obtained from attendees at the 2019 National Institute for Occupational Safety and Health (NIOSH) Work Hours, Sleep, and Fatigue Forum. RESULTS The highest rated research priorities were developing better designs for work schedules, and improving the HCSA culture and leadership approaches to shift work and long work hours. Additional priorities are identified. CONCLUSION Research in these priority areas has the potential to benefit HCSA workers as well as their patients/clients, employers, and society.
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Affiliation(s)
- Claire C. Caruso
- Division of Science Integration, National Institute for Occupational Safety and Health, Cincinnati, Ohio, USA
| | - Megan W. Arbour
- Department of Midwifery, Frontier Nursing University, Versailles, Kentucky, USA
| | - Ann M. Berger
- College of Nursing- Omaha, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Sharon Tucker
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | | | | | - Ann E. Rogers
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Laura K. Barger
- Department of Medicine, Brigham and Women’s Hospital, Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - J. Cole Edmonson
- Department of Administration, AMN Healthcare, Dallas, Texas, USA
| | - Christopher P. Landrigan
- Department of Pediatrics, Boston Children’s Hospital, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Eileen R. Chasens
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Yun JJ, Jane JA. Editorial. Is the grass greener with night float? J Neurosurg 2022; 138:1114-1115. [PMID: 36087326 DOI: 10.3171/2022.6.jns22768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Redinger J, Kabil E, Forkin KT, Kleiman AM, Dunn LK. Resting and Recharging: A Narrative Review of Strategies to Improve Sleep During Residency Training. J Grad Med Educ 2022; 14:420-430. [PMID: 35991104 PMCID: PMC9380640 DOI: 10.4300/jgme-d-21-01035.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/21/2022] [Accepted: 05/31/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Residency involves demanding training with long hours that may cause fatigue and sleep deprivation and adversely impact residents and patients under their care. OBJECTIVE To identify, using a narrative review, evidence-based interventions to reduce the physiologic effects of fatigue and sleep deprivation from overnight and night shift work. METHODS A PubMed literature search was conducted through August 30, 2021, using the terms "resident" and "sleep" in the title or abstract and further narrowed using a third search term. Observational studies, randomized controlled trials, systematic reviews, and meta-analyses of human subjects written and published in English were included. Studies that were not specific to residents or medical interns or did not investigate an intervention were excluded. Additional studies were identified by bibliography review. Due to the heterogeneity of study design and intervention, a narrative review approach was chosen with results categorized into non-pharmacological and pharmacological interventions. RESULTS Initially, 271 articles were identified, which were narrowed to 28 articles with the use of a third search term related to sleep. Bibliography review yielded 4 additional articles. Data on interventions are limited by the heterogeneity of medical specialty, sample size, length of follow-up, and reliance on self-report. Non-pharmacological interventions including strategic scheduling and sleep hygiene may improve sleep and well-being. The available evidence, including randomized controlled trials, to support pharmacological interventions is limited. CONCLUSIONS Non-pharmacological approaches to mitigating fatigue and sleep deprivation have varying effectiveness to improve sleep for residents; however, data for pharmacological interventions is limited.
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Affiliation(s)
- Joyce Redinger
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Joyce Redinger, MD, is PGY-3 Resident
| | - Emmad Kabil
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Emmad Kabil, MD, is PGY-4 Resident
| | - Katherine T. Forkin
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Katherine T. Forkin, MD, is Associate Professor of Anesthesiology
| | - Amanda M. Kleiman
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Amanda M. Kleiman, MD, is Associate Professor of Anesthesiology
| | - Lauren K. Dunn
- All authors are with the University of Virginia Health System, Department of Anesthesiology
- Lauren K. Dunn, MD, PhD, is Associate Professor of Anesthesiology and Neurological Surgery
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Aggarwal S, Wisely CE, Gross A, Challa P. Transition to a Night Float System in Ophthalmology Residency: Perceptions of Resident Wellness and Performance. JOURNAL OF ACADEMIC OPHTHALMOLOGY 2022. [DOI: 10.1055/s-0042-1747969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract
Purpose The purpose of this study is to characterize the influence of a new night float rotation on resident wellness and performance in the Duke University Eye Center Ophthalmology Residency Program.
Methods We analyzed three classes of ophthalmology residents: one class (n = 4) utilized the new night float rotation with no daytime clinical duties, while two senior classes (n = 12) utilized the traditional call system wherein they had daytime and nighttime responsibilities. Residents completed a questionnaire regarding their perceptions of the night float rotation. Supervising attendings (n = 15) were also surveyed about their perceptions of the new rotation.
Results Zero of the four residents on the night float rotation reported burnout compared with 6 of 11 residents in the traditional call system. Most residents supported the adoption of the night float rotation, but this trend was less apparent among fellows and attendings.Most respondents believed the new night float rotation reduced burnout, fatigue, and work hours while increasing time for nonclinical activities. Perceived skills gained while on call were felt to be similar between the two call systems. Fellows and attendings believed residents in the night float system performed similarly or better than residents in the traditional system in indicators such as knowledge and enthusiasm. There was no significant difference in the average number of patient encounters (290.8 ± 30.5 vs. 310.7 ± 25.4, p = 0.163), phone encounters (430.8 ± 20.2 vs. 357.1 ± 90.0, p = 0.068), or average hours worked per week (57.3 ± 4.6 vs. 58.0 ± 5.7 p = 0.797) per resident between night float residents and traditional call residents.
Conclusions This study shows resident support for a night float rotation in ophthalmology residency at Duke, with reductions in burnout and more time for nonclinical activities without affecting perceived clinical performance. We hope this study serves as an impetus for other ophthalmology programs considering a transition to a night float system.
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Affiliation(s)
| | | | - Andrew Gross
- Duke University Eye Center, Durham, North Carolina
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Peck JA, Porter TH. Pandemics and the Impact on Physician Mental Health: A Systematic Review. Med Care Res Rev 2022; 79:772-788. [PMID: 35549938 DOI: 10.1177/10775587221091772] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Physician mental health is a major area of concern with physician burnout on the rise, while at the same time pandemics are becoming more frequent and serious in nature. This combination of physician burnout and pandemics has the potential for serious negative implications for physicians, patients, and health care organizations. Thus, we conduct a systematic review that examines the effect of pandemics on physician mental health using the burnout cascade as a framework. We identified 30 quantitative studies for inclusion. We find that Stages 4 and 5 of the burnout cascade are particularly troublesome with physicians experiencing high levels of anxiety and depression. Furthermore, we find in the degradation phase that physicians experience stigma which may intensify other negative effects. Physicians who are women, younger, and have less training are more susceptible to the negative effects of pandemics. We discuss overall implications and recommendations for future research.
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Resident physicians' advice seeking and error making: A social networks approach. Health Care Manage Rev 2022; 47:E41-E49. [PMID: 35499396 DOI: 10.1097/hmr.0000000000000333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resident physicians are especially at risk of being involved in medical errors because they bear tremendous responsibility for patient care yet are still in the process of learning and mastering their profession. To increase knowledge and gain information, they create a professional-instrumental network, that is, the deliberate initiation of advice ties with senior physicians. PURPOSE We aim to explore whether and how residents' networking with senior physicians is associated with their error rates. Specifically, we aim to identify whether the centralities of residents (advice seekers) and senior physicians (advice givers) in the social network are associated with residents' error rates. METHODOLOGY We surveyed 142 resident physicians working in 22 wards in two general hospitals about whom and how frequently they consult using a sociometric technique. Information about errors made in a 3-month period was collected independently. RESULTS Residents made less errors when they sought advice from few senior physicians but consulted more frequently with focal senior physicians (those whom many other advice seekers frequently consult). However, when residents sought advice from many senior physicians, their frequency of consultation with focal senior physicians was not associated with their number of errors. These effects were more pronounced for residents at the beginning of their residency period. CONCLUSIONS Results of this study provide evidence of a specific association between resident physicians' consultation patterns and their error rates. PRACTICE IMPLICATIONS Results inform ward managers about ways to leverage opportunities and remove constraints for residents to ask for advice and for focal physicians to provide it.
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Nakao H, Nomura O, Kubota M, Ishiguro A. Long-term impact of overnight shiftwork implementation on pediatric residents' mental wellness: A repeated cross-sectional survey. J Occup Health 2022; 64:e12349. [PMID: 35906714 PMCID: PMC9338226 DOI: 10.1002/1348-9585.12349] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/25/2022] [Accepted: 07/21/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Hiro Nakao
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Setagaya-ku, Japan.,Center for Postgraduate Education and Training, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Osamu Nomura
- Center for Postgraduate Education and Training, National Center for Child Health and Development, Setagaya-ku, Japan.,Department of Emergency and Disaster Medicine, Hirosaki University, Hirosaki, Japan
| | - Mitsuru Kubota
- Department of General Pediatrics and Interdisciplinary Medicine, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Akira Ishiguro
- Center for Postgraduate Education and Training, National Center for Child Health and Development, Setagaya-ku, Japan
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Abstract
PURPOSE OF REVIEW This review addresses the importance of some of the human factors for intraoperative patient safety with particular focus on the active failures. These are the mishaps or sentinel events related to decisons taken and actions performed by the individual at the delivery end of a system. Such sentinel events may greatly affect intraoperative patient safety. RECENT FINDINGS Intimidating, aggressive and disruptive communication is a cause of adverse staff interaction, which may then represent an important patient safety threat. Also, anaesthesiologist's physical and mental state and limitations may interfere with patient safety. SUMMARY The concept of physician well being is multidimensional and includes factors related to each physician as an individual as well as to the working environment. Creating optimal safe conditions for patients, therefore, requires actions at both the personal level and the working conditions. Also, initiatives to ban rude and dismissive communication should be implemented in order to further improve intraoperative patient safety.
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Affiliation(s)
- Stefan De Hert
- Department of Anesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
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Schwartz LP, Hursh SR, Boyle L, Davis JE, Smith M, Fitzgibbons SC. Fatigue in surgical residents an analysis of duty-hours and the effect of hypothetical naps on predicted performance. Am J Surg 2021; 221:866-871. [DOI: 10.1016/j.amjsurg.2020.08.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/10/2020] [Accepted: 08/16/2020] [Indexed: 11/25/2022]
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Cygler J, Page AV, Ginsburg S. Life on Call: Perspectives of Junior and Senior Internal Medicine Residents. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:744-750. [PMID: 33060400 DOI: 10.1097/acm.0000000000003803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Models of daytime and nighttime on-call responsibilities for residents vary across internal medicine training programs, but there are few data regarding residents' perceptions of their on-call experiences. The authors sought to understand what residents perceive as the benefits and detriments of 24-hour, in-house call, a perspective instrumental to informing change. METHOD The authors conducted in-depth individual interviews and focus groups between December 2018 and March 2019 with 17 internal medicine residents from postgraduate years 1, 2, and 3 at the University of Toronto about their on-call experiences. Using constructivist grounded theory, the authors developed a framework to understand the residents' perceived benefits and drawbacks of 24-hour in-house call. RESULTS Residents' experiences on call were grouped into 7 themes regarding negative and positive aspects of call. Participants reported multidimensional fatigue related to call, including decision fatigue, emotional fragility and lability, and loss of empathy, and also reported that call adversely affected their personal lives. Residents expressed conflicting opinions as to whether prolonged duty hours affected patient outcomes. In contrast, residents also expressed benefits to call, including that overnight call led to increased autonomy and decision-making skills and provided preparation for future careers as independent internists. They described developing camaraderie and a sense of belonging to a team with coresidents overnight. Lastly, residents described occupying different roles during regular duty hours and while on call-daytime roles revolved around follow-up of previously admitted patients and administrative tasks, while overnight duties centered on initial workup and medical stabilization of referred patients. CONCLUSIONS Understanding the nuanced phenomenon of being on call from the perspective of those who live through it is a critical step in creating evidence-based educational policies. New call models should emphasize resident autonomy and decision making and should include a consideration of residents' perceived differences between daytime and on-call roles.
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Affiliation(s)
- Jeremy Cygler
- J. Cygler is a resident physician, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrea V Page
- A.V. Page is assistant professor, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shiphra Ginsburg
- S. Ginsburg is professor, Department of Medicine, University of Toronto, scientist, Wilson Centre for Education, University of Toronto, Toronto, Ontario, Canada, and Canada Research Chair in Health Professions Education; ORCID: http://orcid.org/0000-0002-4595-6650
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Dunbar-Yaffe R, Wu RC, Oza A, Lee-Kim V, Cram P. Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study. CMAJ Open 2021; 9:E667-E672. [PMID: 34145049 PMCID: PMC8248558 DOI: 10.9778/cmajo.20200167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Nocturnists (overnight hospitalists) are commonly implemented in US teaching hospitals to adhere to per-resident patient caps and improve care but are rare in Canada, where patient caps and duty hours are comparatively flexible. Our objective was to assess the impact of a newly implemented nocturnist program on perceived quality of care, code status documentation and patient outcomes. METHODS Nocturnists were phased in between June 2018 and December 2019 at Toronto General Hospital, a large academic teaching hospital in Toronto, Ontario. We performed a quality-improvement study comparing rates of code status entry into the electronic health record at admission, in-hospital mortality, the 30-day readmission rate and hospital length of stay for patients with cancer admitted by nocturnists and by residents. Surveys were administered in June 2019 to general internal medicine faculty and residents to assess their perceptions of the impact of the nocturnist program. RESULTS From July 2018 to June 2019, 30 nocturnists were on duty for 241/364 nights (66.5%), reducing the mean maximum overnight per-resident patient census from 40 (standard deviation [SD] 4) to 25 (SD 5) (p < 0.001). The rate of admission code status entry was 35.3% among patients admitted by residents (n = 133) and 54.9% among those admitted by nocturnists (n = 339) (p < 0.001). The mortality rate was 10.5% among patients admitted by residents and 5.6% among those admitted by nocturnists (p = 0.06), the 30-day readmission rate was 8.3% and 5.9%, respectively (p = 0.4), and the mean acute length of stay was 7.2 (SD 7.0) days and 6.4 (SD 7.8) days, respectively (p = 0.3). Surveys were completed by 15/24 faculty (response rate 62%), who perceived improvements in patient safety, efficiency and trainee education; however, only 30/102 residents (response rate 29.4%) completed the survey. INTERPRETATION Although implementation of a nocturnist program did not affect patient outcomes, it reduced residents' overnight patient census, and improved faculty perceptions of quality of care and education, as well as documentation of code status. Our results support nocturnist implementation in Canadian teaching hospitals.
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Affiliation(s)
- Richard Dunbar-Yaffe
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont.
| | - Robert C Wu
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
| | - Amit Oza
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
| | - Victoria Lee-Kim
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
| | - Peter Cram
- Division of General Internal Medicine and Geriatrics (Dunbar-Yaffe, Wu, Cram), Sinai Health System and University Health Network; Division of General Internal Medicine (Dunbar-Yaffe, Wu, Cram), Department of Medicine, University of Toronto; Division of Medical Oncology and Hematology (Oza), University Health Network, Toronto, Ont.; School of Medicine (Lee-Kim), Queen's University, Kingston, Ont
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Dairo Oguntebi A, Rosenbluth G. Doctors Also Need Sleep: Is It Time to Take Another Look at Our ROSTERS? Pediatrics 2021; 147:peds.2020-034017. [PMID: 33619045 DOI: 10.1542/peds.2020-034017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Abimbola Dairo Oguntebi
- Department of Pediatric Hospital Medicine, Santa Clara Medical Center, Kaiser Permanente, Santa Clara, California; and
| | - Glenn Rosenbluth
- Division of Hospital Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California
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Rahman SA, Sullivan JP, Barger LK, St. 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. Pediatrics 2021; 147:peds.2020-009936. [PMID: 33619044 PMCID: PMC7919117 DOI: 10.1542/peds.2020-009936] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2020] [Indexed: 01/31/2023] Open
Abstract
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.
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Affiliation(s)
- Shadab A. Rahman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts;,Division of Sleep Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jason P. Sullivan
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Laura K. Barger
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts;,Division of Sleep Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Melissa A. St. Hilaire
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts;,Division of Sleep Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Conor S. O’Brien
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Katie L. Stone
- California Pacific Medical Center Research Institute, San Francisco, California
| | - Andrew J.K. Phillips
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts;,Division of Sleep Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts;,Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
| | - Elizabeth B. Klerman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts;,Division of Sleep Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Salim Qadri
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Kenneth P. Wright
- Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado
| | - Ann C. Halbower
- Department of Pediatrics, Children’s Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Jeffrey L. Segar
- University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa
| | | | | | | | - Sue E. Poynter
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Pearl L. Yu
- University of Virginia Children’s Hospital, Charlottesville, Virginia
| | - Amy L. Sanderson
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine and
| | - Phyllis C. Zee
- Center for Circadian and Sleep Medicine, Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christopher P. Landrigan
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts;,Division of Sleep Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts;,Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts; and
| | - Charles A. Czeisler
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts;,Division of Sleep Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Steven W. Lockley
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts;,Division of Sleep Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
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Kotze K, van der Westhuizen HM, van Loggerenberg E, Jawitz F, Ehrlich R. Doctors' Extended Shifts as Risk to Practitioner and Patient: South Africa as a Case Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165853. [PMID: 32806723 PMCID: PMC7459929 DOI: 10.3390/ijerph17165853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/16/2022]
Abstract
Extended shifts are common in medical practice. This is when doctors are required to work continuously for more than 16 h, with little or no rest, often without a maximum limit. These shifts have been a part of medical practice for more than a century. Research on the impact of fatigue presents compelling evidence that extended shifts increase the risk of harm to patients and practitioners. However, where the number of doctors is limited and their workloads are not easily reduced, there are numerous barriers to reform. Some of these include a perceived lack of safer alternatives, concerns about continuity of care, trainee education, and doctors’ preferences. As such, working hour reorganisation has been contentious globally. South Africa, a middle-income country where extended shifts are unregulated for most doctors, offers a useful case study of reform efforts. The South African Safe Working Hours campaign has promoted working hour reorganization through multi-level advocacy efforts, although extended shifts remain common. We propose that extended shifts should be regarded as an occupational hazard under health and safety legislation. We suggest options for managing the risks of extended shifts by adapting the hierarchy of controls for occupational hazards. Despite the challenges reform pose, the practice of unregulated extended shifts should not continue.
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Affiliation(s)
- Koot Kotze
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford OX2 6GG, UK;
- Correspondence:
| | - Helene-Mari van der Westhuizen
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, University of Oxford, Oxford OX2 6GG, UK;
| | | | - Farah Jawitz
- Saïd Business School, University of Oxford, Oxford OX1 1HP, UK;
| | - Rodney Ehrlich
- Division of Occupational Medicine, School of Public Health and Family Medicine, University of Cape Town, Observatory, Cape Town 8001, South Africa;
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19
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Landrigan CP, Rahman SA, Sullivan JP, Vittinghoff E, Barger LK, Sanderson AL, Wright KP, O'Brien CS, Qadri S, St Hilaire MA, Halbower AC, Segar JL, McGuire JK, Vitiello MV, de la Iglesia HO, Poynter SE, Yu PL, Zee PC, Lockley SW, Stone KL, Czeisler CA. Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts. N Engl J Med 2020; 382:2514-2523. [PMID: 32579812 PMCID: PMC7405505 DOI: 10.1056/nejmoa1900669] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effects on patient safety of eliminating extended-duration work shifts for resident physicians remain controversial. METHODS We conducted a multicenter, cluster-randomized, crossover trial comparing two schedules for pediatric resident physicians during their intensive care unit (ICU) rotations: extended-duration work schedules that included shifts of 24 hours or more (control schedules) and schedules that eliminated extended shifts and cycled resident physicians through day and night shifts of 16 hours or less (intervention schedules). The primary outcome was serious medical errors made by resident physicians, assessed by intensive surveillance, including direct observation and chart review. RESULTS The characteristics of ICU patients during the two work schedules were similar, but resident physician workload, described as the mean (±SD) number of ICU patients per resident physician, was higher during the intervention schedules than during the control schedules (8.8±2.8 vs. 6.7±2.2). Resident physicians made more serious errors during the intervention schedules than during the control schedules (97.1 vs. 79.0 per 1000 patient-days; relative risk, 1.53; 95% confidence interval [CI], 1.37 to 1.72; P<0.001). The number of serious errors unitwide were likewise higher during the intervention schedules (181.3 vs. 131.5 per 1000 patient-days; relative risk, 1.56; 95% CI, 1.43 to 1.71). There was wide variability among sites, however; errors were lower during intervention schedules than during control schedules at one site, rates were similar during the two schedules at two sites, and rates were higher during intervention schedules than during control schedules at three sites. In a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors. CONCLUSIONS Contrary to our hypothesis, resident physicians who were randomly assigned to schedules that eliminated extended shifts made more serious errors than resident physicians assigned to schedules with extended shifts, although the effect varied by site. The number of ICU patients cared for by each resident physician was higher during schedules that eliminated extended shifts. (Funded by the National Heart, Lung, and Blood Institute; ROSTERS ClinicalTrials.gov number, NCT02134847.).
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Affiliation(s)
- Christopher P Landrigan
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Shadab A Rahman
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Jason P Sullivan
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Eric Vittinghoff
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Laura K Barger
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Amy L Sanderson
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Kenneth P Wright
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Conor S O'Brien
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Salim Qadri
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Melissa A St Hilaire
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Ann C Halbower
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Jeffrey L Segar
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - John K McGuire
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Michael V Vitiello
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Horacio O de la Iglesia
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Sue E Poynter
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Pearl L Yu
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Phyllis C Zee
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Steven W Lockley
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Katie L Stone
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
| | - Charles A Czeisler
- From the Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital (C.P.L., S.A.R., J.P.S., L.K.B., C.S.O., S.Q., M.A.S.H., S.W.L., C.A.C.), the Division of Sleep Medicine, Harvard Medical School (C.P.L., S.A.R., L.K.B., M.A.S.H., S.W.L., C.A.C.), and the Division of General Pediatrics, Department of Pediatrics (C.P.L.), and the Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine (A.L.S.), Boston Children's Hospital - all in Boston; the University of California, San Francisco (E.V., K.L.S.), and California Pacific Medical Center Research Institute (K.L.S.), San Francisco; the Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado Boulder, Boulder (K.P.W.), and Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (A.C.H.); the University of Iowa Stead Family Children's Hospital, Iowa City (J.L.S.); Seattle Children's Hospital (J.K.M.) and the University of Washington (M.V.V., H.O.I.), Seattle; Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati (S.E.P.); University of Virginia Children's Hospital, Charlottesville (P.L.Y.); and the Department of Neurology and Center for Circadian and Sleep Medicine, Northwestern University, Feinberg School of Medicine, Chicago (P.C.Z.)
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St Hilaire MA, Anderson C, Anwar J, Sullivan JP, Cade BE, Flynn-Evans EE, Czeisler CA, Lockley SW. Brief (<4 hr) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended-duration work shifts. Sleep 2020; 42:5362587. [PMID: 30794317 DOI: 10.1093/sleep/zsz041] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 01/15/2019] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES The Accreditation Council for Graduate Medical Education (ACGME) recently reinstated extended-duration (24-28 hr) work shifts (EDWS) for postgraduate year 1 (PGY-1) resident physicians. This study examined the relationship between overnight sleep duration during EDWS and subsequent "post-call" performance in PGY-1 resident physicians. METHODS Thirty-four PGY-1 resident physicians (23 males; 24-32 years) were studied between 2002 and 2004 during 3-week Q3 "on-call" rotation schedules in the Medical and Cardiac Intensive Care Units at Brigham and Women's Hospital in Boston. Daily sleep logs (validated by ambulatory polysomnography) were collected and the 10 min psychomotor vigilance task (PVT) was administered every ~6 hr during each EDWS. Generalized estimating equations were used to examine the relationship between overnight sleep duration and PVT performance "post-call" (0500-1900 hr). Postcall performance during EDWS was compared with sessions matched for time-of-day and weeks-into-schedule in the same resident physician during an intervention schedule that eliminated EDWS. RESULTS Resident physicians obtained an average of 1.6 ± 1.5 hr cumulative sleep overnight during EDWS (<4 hr on 92% of nights). PVT attentional failures were significantly reduced only after >4 hr sleep (p = 0.027 versus no sleep). Despite this apparent improvement, the odds of incurring >1 attentional failure were 2.72 times higher during postcall following >4 hr sleep compared with matched sessions during non-EDWS. CONCLUSIONS Even with >4 hr sleep overnight (8% of EDWS), performance remained significantly impaired. These findings suggest that even "strategic napping," a recommendation recently removed from ACGME guidelines, is insufficient to mitigate severe performance impairment introduced by extending duty beyond 16 hr.
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Affiliation(s)
- Melissa A St Hilaire
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Clare Anderson
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Junnat Anwar
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA
| | - Jason P Sullivan
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Brian E Cade
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Erin E Flynn-Evans
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Charles A Czeisler
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Steven W Lockley
- Departments of Medicine and Neurology, Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
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Cardiac Autonomic Modulation during on-Call Duty under Working Hours Restriction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17031118. [PMID: 32050580 PMCID: PMC7038185 DOI: 10.3390/ijerph17031118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/05/2020] [Accepted: 02/07/2020] [Indexed: 12/20/2022]
Abstract
Background: Medical residency is a time of high stress and long working hours, which increase the risk of cardiovascular disease. This study aimed to investigate the autonomic modulation of resident physicians throughout the on-call duty cycle. Methods: Spectral analysis of heart rate variability (HRV) was used to compute cardiac parasympathetic modulation (high-frequency power, HF) and cardiac sympathetic modulation (normalized low-frequency power, LF%, and the ratio of LF and HF, LF/HF) of 18 residents for a consecutive 4-day cycle. Results: Male residents show reduced cardiac sympathetic modulation (i.e., higher LF/HF and LF%) than the female interns. Medical residents’ cardiac parasympathetic modulation (i.e., HF) significantly increased on the first and the second post-call day compared with the pre-call day. In contrast, LF% was significantly decreased on the first and the second post-call day compared with the pre-call day. Similarly, LF/HF was significantly decreased on the second post-call day compared with the pre-call day. LF/HF significantly decreased on the first post-call day and on the second post-call day from on-call duty. Conclusion: The guideline that limits workweeks to 80 h and shifts to 28 h resulted in reduced sympathetic modulation and increased parasympathetic modulation during the two days following on-call duty.
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Work shift duration for emergency physicians – the shorter, the better: the French Experience. Eur J Emerg Med 2019; 26:396-397. [DOI: 10.1097/mej.0000000000000639] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yang AD, Quinn CM, Hewitt DB, Chung JW, Zembower TR, Jones A, Buyske J, Hoyt DB, Nasca TJ, Bilimoria KY. National Evaluation of Needlestick Events and Reporting Among Surgical Residents. J Am Coll Surg 2019; 229:609-620. [PMID: 31541698 DOI: 10.1016/j.jamcollsurg.2019.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 09/03/2019] [Accepted: 09/03/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Needlestick injuries pose significant health hazards; however, the nationwide frequency of needlesticks and reporting practices among surgical residents are unknown. The objectives of this study were to examine the rate and circumstances of self-reported needlestick events in US surgery residents, assess factors associated with needlestick injuries, evaluate reporting practices, and identify reporting barriers. STUDY DESIGN A survey administered after the American Board of Surgery In-Training Examination (January 2017) asked surgical residents how many times they experienced a needlestick during the last 6 months, circumstances of the most recent event, and reporting practices and barriers. Factors associated with needlestick events were examined using multivariable hierarchical regression models. RESULTS Among 7,395 resident survey respondents from all 260 US general surgery residency programs (99.3% response rate), 27.7% (n = 2,051) noted experiencing a needlestick event in the last 6 months. Most events occurred in the operating room (77.5%) and involved residents sticking themselves (76.2%), mostly with solid needles (84.7%). Self-reported factors underlying needlestick events included residents' own carelessness (48.8%) and feeling rushed (31.3%). Resident-level factors associated with self-reported needlestick events included senior residents (PGY5 29.9% vs PGY1 22.4%; odds ratio 1.66; 95% CI 1.41 to 1.96), female sex (31.9% vs male 25.2%; odds ratio 1.31; 95% CI 1.18 to 1.46), or frequently working more than 80 hours per week (odds ratio 1.42; 95% CI 1.20 to 1.68). More than one-fourth (28.7%) of residents did not report the needlestick event to employee health. CONCLUSIONS In this comprehensive national survey of surgical residents, needlesticks occurred frequently. Many needlestick events were not reported and numerous reporting barriers exist. These findings offer guidance in identifying opportunities to reduce needlesticks and encourage reporting of these potentially preventable injuries among trainees.
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Affiliation(s)
- Anthony D Yang
- Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern Medicine, Chicago, IL.
| | - Christopher M Quinn
- Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern Medicine, Chicago, IL
| | - D Brock Hewitt
- Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern Medicine, Chicago, IL; Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jeanette W Chung
- Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern Medicine, Chicago, IL
| | - Teresa R Zembower
- Division of Infectious Diseases, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | - Jo Buyske
- American Board of Surgery, Philadelphia, PA
| | | | - Thomas J Nasca
- Accreditation Council for Graduate Medical Education, Chicago, IL
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center, Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern Medicine, Chicago, IL
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Basner M, Asch DA, Shea JA, Bellini LM, Carlin M, Ecker AJ, Malone SK, Desai SV, Sternberg AL, Tonascia J, Shade DM, Katz JT, Bates DW, Even-Shoshan O, Silber JH, Small DS, Volpp KG, Mott CG, Coats S, Mollicone DJ, Dinges DF. Sleep and Alertness in a Duty-Hour Flexibility Trial in Internal Medicine. N Engl J Med 2019; 380:915-923. [PMID: 30855741 PMCID: PMC6457111 DOI: 10.1056/nejmoa1810641] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND A purpose of duty-hour regulations is to reduce sleep deprivation in medical trainees, but their effects on sleep, sleepiness, and alertness are largely unknown. METHODS We randomly assigned 63 internal-medicine residency programs in the United States to follow either standard 2011 duty-hour policies or flexible policies that maintained an 80-hour workweek without limits on shift length or mandatory time off between shifts. Sleep duration and morning sleepiness and alertness were compared between the two groups by means of a noninferiority design, with outcome measures including sleep duration measured with actigraphy, the Karolinska Sleepiness Scale (with scores ranging from 1 [extremely alert] to 9 [extremely sleepy, fighting sleep]), and a brief computerized Psychomotor Vigilance Test (PVT-B), with long response times (lapses) indicating reduced alertness. RESULTS Data were obtained over a period of 14 days for 205 interns at six flexible programs and 193 interns at six standard programs. The average sleep time per 24 hours was 6.85 hours (95% confidence interval [CI], 6.61 to 7.10) among those in flexible programs and 7.03 hours (95% CI, 6.78 to 7.27) among those in standard programs. Sleep duration in flexible programs was noninferior to that in standard programs (between-group difference, -0.17 hours per 24 hours; one-sided lower limit of the 95% confidence interval, -0.45 hours; noninferiority margin, -0.5 hours; P = 0.02 for noninferiority), as was the score on the Karolinska Sleepiness Scale (between-group difference, 0.12 points; one-sided upper limit of the 95% confidence interval, 0.31 points; noninferiority margin, 1 point; P<0.001). Noninferiority was not established for alertness according to the PVT-B (between-group difference, -0.3 lapses; one-sided upper limit of the 95% confidence interval, 1.6 lapses; noninferiority margin, 1 lapse; P = 0.10). CONCLUSIONS This noninferiority trial showed no more chronic sleep loss or sleepiness across trial days among interns in flexible programs than among those in standard programs. Noninferiority of the flexible group for alertness was not established. (Funded by the National Heart, Lung, and Blood Institute and American Council for Graduate Medical Education; ClinicalTrials.gov number, NCT02274818.).
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Affiliation(s)
- Mathias Basner
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David A Asch
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Judy A Shea
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Lisa M Bellini
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Michele Carlin
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Adrian J Ecker
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Susan K Malone
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Sanjay V Desai
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Alice L Sternberg
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - James Tonascia
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David M Shade
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Joel T Katz
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David W Bates
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Orit Even-Shoshan
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Jeffrey H Silber
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Dylan S Small
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Kevin G Volpp
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Christopher G Mott
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Sara Coats
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - Daniel J Mollicone
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
| | - David F Dinges
- From the University of Pennsylvania (M.B., D.A.A., J.A.S., L.M.B., M.C., A.J.E., S.K.M., D.S.S., K.G.V., D.F.D.), Corporal Michael J. Crescenz Veterans Affairs Medical Center (D.A.A., K.G.V.), Children's Hospital of Philadelphia (O.E.-S., J.H.S.), and Pulsar Informatics (C.G.M., S.C., D.J.M.) - all in Philadelphia; Johns Hopkins University, Baltimore (S.V.D., A.L.S., J.T., D.M.S.); and Brigham and Women's Hospital, Boston (J.T.K., D.W.B.)
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Azmand S, Ebrahimi S, Iman M, Asemani O. Learning professionalism through hidden curriculum: Iranian medical students' perspective. J Med Ethics Hist Med 2018; 11:10. [PMID: 31346387 PMCID: PMC6642446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 06/12/2018] [Indexed: 11/06/2022] Open
Abstract
Learning professionalism is a central topic in medical education. While many factors could affect the educational process of professionalism, hidden curriculum is considered one of the most important ones. As the working components of a hidden curriculum might be specific to the settings, this study explored its components in terms of professionalism and ethical conduct from the viewpoint of Iranian undergraduate medical trainees. Semi-structured and in-depth interviews were used to collect medical students' experiences and viewpoints, which were then analyzed through simple content analysis and the codes and categories were extracted. Finally, themes were derived as the central organizing concepts. Saturation occurred after 17 interviews. Seven main themes were extracted as the working components of hidden curriculum regarding professionalism in the setting: 'convenient patients', 'evaluate me', 'trust as the base of team interactions', 'perceiving encouragement', 'relationship satisfaction and authenticity', 'workload and students' well-being' and 'role modeling at the heart of professionalism'. Students' perception and experiences are a rich source of gaining a deeper understanding of the working hidden curriculum. In this study, two groups of human-related and environment-related elements were extracted. They were effective in the formation of the current 'ethical climate', which shaped the professional and ethical identity of medical trainees. Moreover, specific plans regarding the condition of the settings may provide opportunities for medical educators to enhance professionalism in their institutions.
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Affiliation(s)
- Sajjad Azmand
- PhD Candidate of Medical Ethics, Department of Medical Ethics, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Sedigheh Ebrahimi
- Associate Professor, Department of Medical Ethics, Shiraz University of Medical Sciences, Shiraz, Iran.,Corresponding Author: Sedigheh Ebrahimi Address: Block No.2, Department of Medical Ethics and Philosophy of Health, School of Medicine, Zand Ave., Imam Hosein Sq., Shiraz, Fars, Iran. Tel: (+98) 917 1129908. Fax: (+98) 713 2348980.
| | | | - Omid Asemani
- Assistant Professor, Department of Medical Ethics, Shiraz University of Medical Sciences, Shiraz, Iran.
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Assessing the 16 hour intern shift limit: Results of a multi-center, mixed-methods study of residents and faculty in general surgery. Am J Surg 2018; 215:326-330. [DOI: 10.1016/j.amjsurg.2017.08.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/06/2017] [Accepted: 08/22/2017] [Indexed: 11/21/2022]
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Patterson PD, Runyon MS, Higgins JS, Weaver MD, Teasley EM, Kroemer AJ, Matthews ME, Curtis BR, Flickinger KL, Xun X, Bizhanova Z, Weiss PM, Condle JP, Renn ML, Sequeira DJ, Coppler PJ, Lang ES, Martin-Gill C. Shorter Versus Longer Shift Durations to Mitigate Fatigue and Fatigue-Related Risks in Emergency Medical Services Personnel and Related Shift Workers: A Systematic Review. PREHOSP EMERG CARE 2018; 22:28-36. [PMID: 29324079 DOI: 10.1080/10903127.2017.1376135] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study comprehensively reviewed the literature on the impact of shorter versus longer shifts on critical and important outcomes for Emergency Medical Services (EMS) personnel and related shift worker groups. METHODS Six databases (e.g., PubMed/MEDLINE) were searched, including one website. This search was guided by a research question developed by an expert panel a priori and registered with the PROSPERO database of systematic reviews (2016:CRD42016040099). The critical outcomes of interest were patient safety and personnel safety. The important outcomes of interest were personnel performance, acute fatigue, sleep and sleep quality, retention/turnover, long-term health, burnout/stress, and cost to system. Screeners worked independently and full-text articles were assessed for relevance. Data abstracted from the retained literature were categorized as favorable, unfavorable, mixed/inconclusive, or no impact toward the shorter shift duration. This research characterized the evidence as very low, low, moderate, or high quality according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. RESULTS The searched yielded n = 21,674 records. Of the 480 full-text articles reviewed, 100 reported comparisons of outcomes of interest by shift duration. We identified 24 different shift duration comparisons, most commonly 8 hours versus 12 hours. No one study reported findings for all 9 outcomes. Two studies reported findings linked to both critical outcomes of patient and personnel safety, 34 reported findings for one of two critical outcomes, and 64 did not report findings for critical outcomes. Fifteen studies were grouped to compare shifts <24 hours versus shifts ≥24 hours. None of the findings for the critical outcomes of patient and personnel safety were categorized as unfavorable toward shorter duration shifts (<24 hours). Nine studies were favorable toward shifts <24 hours for at least one of the 7 important outcomes, while findings from one study were categorized as unfavorable. Evidence quality was low or very low. CONCLUSIONS The quality of existing evidence on the impact of shift duration on fatigue and fatigue-related risks is low or very low. Despite these limitations, this systematic review suggests that for outcomes considered critical or important to EMS personnel, shifts <24 hours in duration are more favorable than shifts ≥24 hours.
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Burchiel KJ, Zetterman RK, Ludmerer KM, Philibert I, Brigham TP, Malloy K, Arrighi JA, Ashley SW, Bienstock JL, Carek PJ, Correa R, Forstein DA, Gaiser RR, Gold JP, Keepers GA, Kennedy BC, Kirk LM, Kothari A, Langdale LA, Shayne PH, Stain SC, Woods SK, Wyatt-Johnson C, Nasca TJ. The 2017 ACGME Common Work Hour Standards: Promoting Physician Learning and Professional Development in a Safe, Humane Environment. J Grad Med Educ 2017; 9:692-696. [PMID: 29270256 PMCID: PMC5734321 DOI: 10.4300/jgme-d-17-00317.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Sayyah-Melli M, Nikravan Mofrad M, Amini A, Piri Z, Ghojazadeh M, Rahmani V. The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences. J Caring Sci 2017; 6:281-292. [PMID: 28971078 PMCID: PMC5618952 DOI: 10.15171/jcs.2017.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 01/22/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction: Medical records contain valuable information
about a patient's medical history and treatment. Patient safety is one of the most
important dimensions of health care quality assurance and performance improvement.
Completing the process of documentation is necessary to continue patient care and
continuous quality improvement of basic services. The aim of the present study was to
evaluate the effect of medical recording education on the quantity and quality of
recording in gynecology residents of Tabriz University of Medical Sciences. Methods: This study is a quasi-experimental study and was
conducted at Al-Zahra Teaching Hospital, Tabriz, Iran, in 2016. Thirty-two second through
fourth year gynecologic residents of Tabriz University of Medical Sciences who were
willing to participate in the study were included by census sampling and participated in
training workshop. Three evaluators reviewed the residents’ records before and after
training course by a checklist. Statistical analyses were performed using SPSS 13
software. P-values less than 0.05 were considered statistically significant. Results: The results showed that before the intervention,
there were significant differences in the quantity of information status among the
evaluators and no significant difference was observed in the recording of qualitative
status. After the workshop, among the 3 evaluators, there were also significant
differences in the quantity of data recording status; however, no significant change was
observed in recording of qualitative status. Conclusion: The study findings revealed that a sectional
training course of correct and standardized medical records has no effect on reforming the
process of recording.
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Affiliation(s)
- Manizheh Sayyah-Melli
- Departement of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, School of Medical Education, Tehran, Iran.,Research Center of Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Malahat Nikravan Mofrad
- Departement of Nursing, School of Nursing & Midwifery, School of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abolghasem Amini
- Department and Center for Educational Research and Development (EDC), Tabriz University of Medical Science, Tabriz, Iran
| | - Zakieh Piri
- Department of Medical Records, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Ghojazadeh
- Research Center of Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vahideh Rahmani
- Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Basner M, Dinges DF, Shea JA, Small DS, Zhu J, Norton L, Ecker AJ, Novak C, Bellini LM, Volpp KG. Sleep and Alertness in Medical Interns and Residents: An Observational Study on the Role of Extended Shifts. Sleep 2017; 40:3045870. [PMID: 28329124 PMCID: PMC5806581 DOI: 10.1093/sleep/zsx027] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Study Objectives Fatigue from sleep loss is a risk to physician and patient safety, but objective data on physician sleep and alertness on different duty hour schedules is scarce. This study objectively quantified differences in sleep duration and alertness between medical interns working extended overnight shifts and residents not or rarely working extended overnight shifts. Methods Sleep-wake activity of 137 interns and 87 PGY-2/3 residents on 2-week Internal Medicine and Oncology rotations was assessed with wrist-actigraphy. Alertness was assessed daily with a brief Psychomotor Vigilance Test (PVT) and the Karolinska Sleepiness Scale. Results Interns averaged 6.93 hours (95% confidence interval [CI] 6.84-7.03 hours) sleep per 24 hours across shifts, significantly less than residents not working overnight shifts (7.18 hours, 95% CI 7.06-7.30 hours, p = .007). Interns obtained on average 2.19 hours (95% CI 2.02-2.36 hours) sleep during on-call nights (17.5% obtained no sleep). Alertness was significantly lower on mornings after on-call nights compared to regular shifts (p < .001). Naps between 9 am and 6 pm on the first day post-call were frequent (90.8%) and averaged 2.84 hours (95% CI 2.69-3.00 hours), but interns still slept 1.66 hours less per 24 hours (95% CI 1.56-1.76 hours) compared to regular shift days (p < .001). Sleep inertia significantly affected alertness in the 60 minutes after waking on-call. Conclusions Extended overnight shifts increase the likelihood of chronic sleep restriction in interns. Reduced levels of alertness after on-call nights need to be mitigated. A systematic comparison of sleep, alertness, and safety outcomes under current and past duty hour rules is encouraged.
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Affiliation(s)
- Mathias Basner
- Unit for Experimental Psychiatry, Division of Sleep and Chronobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David F Dinges
- Unit for Experimental Psychiatry, Division of Sleep and Chronobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Judy A Shea
- Center for Health Equity Research and Promotion, Philadelphia Corporal Michael J. Cresencz Veterans Affairs Medical Center, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Dylan S Small
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Jingsan Zhu
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Laurie Norton
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Adrian J Ecker
- Unit for Experimental Psychiatry, Division of Sleep and Chronobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cristina Novak
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Lisa M Bellini
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kevin G Volpp
- Center for Health Equity Research and Promotion, Philadelphia Corporal Michael J. Cresencz Veterans Affairs Medical Center, Philadelphia, PA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia PA
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Philibert I. What Is Known: Examining the Empirical Literature in Resident Work Hours Using 30 Influential Articles. J Grad Med Educ 2016; 8:795-805. [PMID: 28018556 PMCID: PMC5180546 DOI: 10.4300/jgme-d-16-00642.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Examining influential, highly cited articles can show the advancement of knowledge about the effect of resident physicians' long work hours, as well as the benefits and drawbacks of work hour limits. OBJECTIVE A narrative review of 30 articles, selected for their contribution to the literature, explored outcomes of interest in the research on work hours-including patient safety, learning, and resident well-being. METHODS Articles were selected from a comprehensive review. Citation volume, quality, and contribution to the evolving thinking on work hours and to the Accreditation Council for Graduate Medical Education standards were assessed. RESULTS Duty hour limits are supported by the scientific literature, particularly limits on weekly hours and reducing the frequency of overnight call. The literature shows declining hours and call frequency over 4 decades of study, although the impact on patient safety, learning, and resident well-being is not clear. The review highlighted limitations of the scientific literature on resident hours, including small samples and reduced generalizability for intervention studies, and the inability to rule out confounders in large studies using administrative data. Key areas remain underinvestigated, and accepted methodology is challenged when assessing the impact of interventions on the multiple outcomes of interest. CONCLUSIONS The influential literature, while showing the beneficial effect of work hour limits, does not answer all questions of interest in determining optimal limits on resident hours. Future research should use methods that permit a broader, collective examination of the multiple, often competing attributes of the learning environment that collectively promote patient safety and resident learning and well-being.
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Affiliation(s)
- Ingrid Philibert
- Corresponding author: Ingrid Philibert, PhD, MBA, Accreditation Council for Graduate Medical Education, 401 N Michigan Avenue, Suite 2000, Chicago, IL 60611, 312.755.5003,
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Weiss P, Kryger M, Knauert M. Impact of extended duty hours on medical trainees. Sleep Health 2016; 2:309-315. [PMID: 29073389 DOI: 10.1016/j.sleh.2016.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/11/2016] [Accepted: 08/17/2016] [Indexed: 01/02/2023]
Abstract
Many studies on resident physicians have demonstrated that extended work hours are associated with a negative impact on well-being, education, and patient care. However, the relationship between the work schedule and the degree of impairment remains unclear. In recent years, because of concerns for patient safety, national minimum standards for duty hours have been instituted (2003) and revised (2011). These changes were based on studies of the effects of sleep deprivation on human performance and specifically on the effect of extended shifts on resident performance. These requirements necessitated significant restructuring of resident schedules. Concerns were raised that these changes have impaired continuity of care, resident education and supervision, and patient safety. We review the studies on the effect of extended work hours on resident well-being, education, and patient care as well as those assessing the effect of work hour restrictions. Although many studies support the adverse effects of extended shifts, there are some conflicting results due to factors such as heterogeneity of protocols, schedules, subjects, and environments. Assessment of the effect of work hour restrictions has been even more difficult. Recent data demonstrating that work hour limitations have not been associated with improvement in patient outcomes or resident education and well-being have been interpreted as support for lifting restrictions in some specialties. However, these studies have significant limitations and should be interpreted with caution. Until future research clarifies duty hours that optimize patient outcomes, resident education, and well-being, it is recommended that current regulations be followed.
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Affiliation(s)
- Pnina Weiss
- Section of Pediatric Respiratory Medicine and Medical Education, Yale University School of Medicine, 333 Cedar St, PO Box 208064, New Haven, CT 06520-8064.
| | - Meir Kryger
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 333 Cedar St, PO Box 208057, New Haven, CT 06520-8057
| | - Melissa Knauert
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale University School of Medicine, 333 Cedar St, PO Box 208057, New Haven, CT 06520-8057
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Klerman EB, Beckett SA, Landrigan CP. Applying mathematical models to predict resident physician performance and alertness on traditional and novel work schedules. BMC MEDICAL EDUCATION 2016; 16:239. [PMID: 27623842 PMCID: PMC5022151 DOI: 10.1186/s12909-016-0751-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/19/2016] [Indexed: 05/31/2023]
Abstract
BACKGROUND In 2011 the U.S. Accreditation Council for Graduate Medical Education began limiting first year resident physicians (interns) to shifts of ≤16 consecutive hours. Controversy persists regarding the effectiveness of this policy for reducing errors and accidents while promoting education and patient care. Using a mathematical model of the effects of circadian rhythms and length of time awake on objective performance and subjective alertness, we quantitatively compared predictions for traditional intern schedules to those that limit work to ≤ 16 consecutive hours. METHODS We simulated two traditional schedules and three novel schedules using the mathematical model. The traditional schedules had extended duration work shifts (≥24 h) with overnight work shifts every second shift (including every third night, Q3) or every third shift (including every fourth night, Q4) night; the novel schedules had two different cross-cover (XC) night team schedules (XC-V1 and XC-V2) and a Rapid Cycle Rotation (RCR) schedule. Predicted objective performance and subjective alertness for each work shift were computed for each individual's schedule within a team and then combined for the team as a whole. Our primary outcome was the amount of time within a work shift during which a team's model-predicted objective performance and subjective alertness were lower than that expected after 16 or 24 h of continuous wake in an otherwise rested individual. RESULTS The model predicted fewer hours with poor performance and alertness, especially during night-time work hours, for all three novel schedules than for either the traditional Q3 or Q4 schedules. CONCLUSIONS Three proposed schedules that eliminate extended shifts may improve performance and alertness compared with traditional Q3 or Q4 schedules. Predicted times of worse performance and alertness were at night, which is also a time when supervision of trainees is lower. Mathematical modeling provides a quantitative comparison approach with potential to aid residency programs in schedule analysis and redesign.
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Affiliation(s)
- Elizabeth B. Klerman
- Division of Sleep and Circadian Disorders, Departments of Neurology and Medicine, Brigham and Women’s Hospital, Boston, MA 02115 USA
- Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, MA 02115 USA
| | - Scott A. Beckett
- Division of Sleep and Circadian Disorders, Departments of Neurology and Medicine, Brigham and Women’s Hospital, Boston, MA 02115 USA
| | - Christopher P. Landrigan
- Division of Sleep and Circadian Disorders, Departments of Neurology and Medicine, Brigham and Women’s Hospital, Boston, MA 02115 USA
- Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, MA 02115 USA
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, MA 02115 USA
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Jaeger CB, Acree-Hamann C, Zurmehly J, Buck J, Patrick T. Assessment of Neonatal Nurse Practitioner Workload in a Level IV Neonatal Intensive Care Unit: Satisfaction. ACTA ACUST UNITED AC 2016. [DOI: 10.1053/j.nainr.2016.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Vukkadala N, Auerbach A, Maselli JH, Rosenbluth G. Association between ordering patterns and shift-based care in general pediatrics inpatients. J Hosp Med 2016; 11:210-4. [PMID: 26559789 DOI: 10.1002/jhm.2507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 09/19/2015] [Accepted: 10/15/2015] [Indexed: 11/06/2022]
Abstract
Duty-hour restrictions have forced changes in care models for inpatient services, including an increase in shift work. In this study we aimed to determine whether a shift model compliant with 2011 Accreditation Council for Graduate Medical Education duty-hour standards was associated with more active patient care management. Residents caring for pediatric patients changed from a schedule with extended duty shifts and cross-coverage to one based on day/night shifts, limiting interns to 16 consecutive duty hours. We conducted a retrospective review of orders written under each model. After the intervention, there was a significant increase in the mean number of orders written within the first 12 hours (pre: 0.58 orders vs post: 1.12, P = 0.009) and 24 hours (pre: 1.52 vs post: 2.38, P = 0.004) following admission (not including admission orders), but we did not detect a significantly higher percentage of orders written at night. This shift-based coverage system was associated with a greater number of orders written early in the hospitalization, indicating more active management of clinical problems.
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Affiliation(s)
- Neelaysh Vukkadala
- University of California, San Francisco, School of Medicine, San Francisco, California
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Judith H Maselli
- Division of Hospital Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Glenn Rosenbluth
- Division of Pediatric Hospital Medicine, University of California, San Francisco, Benioff Children's Hospital, San Francisco, California
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Lifestyle and Depression among Hong Kong Nurses. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13010135. [PMID: 26784216 PMCID: PMC4730526 DOI: 10.3390/ijerph13010135] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/12/2016] [Accepted: 01/13/2016] [Indexed: 01/18/2023]
Abstract
Recent longitudinal data suggest a close association between depression and lifestyle. Little work to date has estimated the prevalence of depression in the nursing workforce in China, nor considered what lifestyle factors might be correlated with it—a gap filled by the present study. The study’s web-based cross-sectional survey solicited data from qualified nurses aged between 21 and 65 registered with the Hong Kong Nursing Council. The Depression, Anxiety and Stress Scale 21 was used to measure 850 nurses for depression, anxiety and symptoms of stress; a generalized linear regression model examined associations between lifestyle factors and depression. Mean depression symptom scores show a downward linear trend for male and female participants. Gender and age, however, did not emerge as significant predictors of depression. Three lifestyles factors (sleep, entertainment and hobbies) showed a significant association with depression. Nurses should make therapeutic lifestyle changes to improve their work-life balance and safeguard their functioning at work and personal well-being.
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Mahoney B, Holck G, Cappiello E, Liu X, Tsen L. Chronotropic variation in the incidence of unintentional dural puncture in parturients undergoing epidural placement. Int J Obstet Anesth 2015; 24:192-3. [DOI: 10.1016/j.ijoa.2015.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 12/30/2014] [Accepted: 01/03/2015] [Indexed: 11/24/2022]
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Tucker P, Bejerot E, Kecklund G, Aronsson G, Åkerstedt T. The impact of work time control on physicians' sleep and well-being. APPLIED ERGONOMICS 2015; 47:109-116. [PMID: 25479980 DOI: 10.1016/j.apergo.2014.09.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 08/20/2014] [Accepted: 09/08/2014] [Indexed: 06/04/2023]
Abstract
Physicians' work schedules are an important determinant of their own wellbeing and that of their patients. This study considers whether allowing physicians control over their work hours ameliorates the effects of demanding work schedules. A questionnaire was completed by hospital physicians regarding their work hours (exposure to long shifts, short inter-shift intervals, weekend duties, night duties, unpaid overtime; and work time control), sleep (quantity and disturbance) and wellbeing (burnout, stress and fatigue). Work time control moderated the negative impact that frequent night working had upon sleep quantity and sleep disturbance. For participants who never worked long shifts, work time control was associated with fewer short sleeps, but this was not the case for those who did work long shifts. Optimizing the balance between schedule flexibility and patient needs could enhance physicians' sleep when working the night shift, thereby reducing their levels of fatigue and enhancing patient care.
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Affiliation(s)
- P Tucker
- Stress Research Institute, Stockholm University, 106 91 Stockholm, Sweden; Department of Psychology, Swansea University, Swansea SA2 8PP, United Kingdom.
| | - E Bejerot
- Department of Psychology, Stockholm University, 106 91 Stockholm, Sweden
| | - G Kecklund
- Stress Research Institute, Stockholm University, 106 91 Stockholm, Sweden; Behavioral Science Institute, Radboud University, 6500 HE Nijmegen, The Netherlands
| | - G Aronsson
- Department of Psychology, Stockholm University, 106 91 Stockholm, Sweden
| | - T Åkerstedt
- Stress Research Institute, Stockholm University, 106 91 Stockholm, Sweden
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Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, Noble EL, Tse LL, Dalal AK, Keohane CA, Lipsitz SR, Rothschild JM, Wien MF, Yoon CS, Zigmont KR, Wilson KM, O'Toole JK, Solan LG, Aylor M, Bismilla Z, Coffey M, Mahant S, Blankenburg RL, Destino LA, Everhart JL, Patel SJ, Bale JF, Spackman JB, Stevenson AT, Calaman S, Cole FS, Balmer DF, Hepps JH, Lopreiato JO, Yu CE, Sectish TC, Landrigan CP. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014; 371:1803-12. [PMID: 25372088 DOI: 10.1056/nejmsa1405556] [Citation(s) in RCA: 553] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. METHODS We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. RESULTS In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. CONCLUSIONS Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).
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Affiliation(s)
- Amy J Starmer
- From the Department of Medicine, Division of General Pediatrics, Boston Children's Hospital (A.J.S., T.C.S., C.P.L., A.D.A., E.L.N., L.L.T.), Harvard Medical School (A.J.S., A.K.D., S.R.L., J.M.R., T.C.S., C.P.L.), Center for Patient Safety Research, Division of General Medicine (A.K.D., C.A.K., J.M.R., S.R.L., M.F.W., C.S.Y., K.R.Z.) and Division of Sleep Medicine (C.P.L.), Brigham and Women's Hospital, and CRICO/Risk Management Foundation (C.A.K.) - all in Boston; the Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health and Science University, Portland (A.J.S., M.A.); the Department of Pediatrics, Section of General Pediatrics (N.D.S.) and Section of Critical Care (S.C.), St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia; the Departments of Pediatrics (R.S., J.B.S., A.T.S.) and Neurology (J.F.B.), Primary Children's Hospital, Intermountain Healthcare, University of Utah School of Medicine, and Institute for Health Care Delivery Research, Intermountain Healthcare (R.S.), Salt Lake City; the Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco (D.C.W., G.R.), and the Department of Pediatrics, Division of General Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto (R.L.B., L.A.D., J.L.E., S.J.P.) - both in California; the Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (K.M.W.); the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati (J.K.O., L.G.S.); the Department of Paediatrics (Z.B., M.C., S.M.), Centre for Quality Improvement and Patient Safety (M.C.), and Institute for Health Policy, Management and Evaluation (S.M.), Hospital for Sick Children and University of Toronto, Toronto; the Department of Pediatrics, Division of General Pediatrics, Kapi'olani Medical Center for W
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Oshimura JM, Sperring J, Bauer BD, Carroll AE, Rauch DA. Changes in inpatient staffing following implementation of new residency work hours. J Hosp Med 2014; 9:640-5. [PMID: 25078706 DOI: 10.1002/jhm.2242] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 07/03/2014] [Accepted: 07/08/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND In 2011, the Accreditation Council for Graduate Medical Education added additional resident work-hour restrictions that limited the number of hours residents could work, with increased emphasis on attending supervision. OBJECTIVE Our objective was to determine how residency programs have responded to residency work hours, specifically assessing residency night float systems and in-house attending physicians. DESIGN In May 2012, an electronic survey was sent to all US pediatric residency training programs via the Association of Pediatric Program Directors listserv with e-mail reminders to nonresponding programs. We analyzed data to assess the use of resident night float systems, admission caps, and attending physicians in-house at night. RESULTS Out of 198 programs contacted, 152 programs responded (77% response rate). Residency programs utilizing a night float system increased from 43% to 71% after new work hours were implemented. Overall use of resident admission caps did not change significantly. Twenty-three percent of programs increased the number of attending physicians in-house at night; 57% of those programs increased the number of pediatric hospitalist attendings, whereas 37% increased the number of pediatric intensivists. There is a trend toward increased pediatric hospitalist attending in-house 24/7 coverage. Of programs without 24/7 coverage, 26% plan to add coverage within 5 years. Only 12% of programs have no in-house attending coverage at night. CONCLUSIONS Although programs vary in their response to changes in residency work restrictions, they most commonly utilize night float systems and increased the amount of in-house attending coverage at night, especially pediatric hospitalist attendings. Many programs plan to add 24/7 pediatric hospitalist coverage within 5 years.
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Affiliation(s)
- Jennifer M Oshimura
- Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
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Merry AF, Weller J, Mitchell SJ. Improving the Quality and Safety of Patient Care in Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2014; 28:1341-51. [DOI: 10.1053/j.jvca.2014.02.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Indexed: 01/17/2023]
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Abstract
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.
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Hauer KE, Ten Cate O, Boscardin C, Irby DM, Iobst W, O'Sullivan PS. Understanding trust as an essential element of trainee supervision and learning in the workplace. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2014; 19:435-456. [PMID: 23892689 DOI: 10.1007/s10459-013-9474-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 06/28/2013] [Indexed: 06/02/2023]
Abstract
Clinical supervision requires that supervisors make decisions about how much independence to allow their trainees for patient care tasks. The simultaneous goals of ensuring quality patient care and affording trainees appropriate and progressively greater responsibility require that the supervising physician trusts the trainee. Trust allows the trainee to experience increasing levels of participation and responsibility in the workplace in a way that builds competence for future practice. The factors influencing a supervisor's trust in a trainee are related to the supervisor, trainee, the supervisor-trainee relationship, task, and context. This literature-based overview of these five factors informs design principles for clinical education that support the granting of entrustment. Entrustable professional activities offer promise as an example of a novel supervision and assessment strategy based on trust. Informed by the design principles offered here, entrustment can support supervisors' accountability for the outcomes of training by maintaining focus on future patient care outcomes.
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Affiliation(s)
- Karen E Hauer
- Department of Medicine, School of Medicine, University of California at San Francisco, 505 Parnassus Ave, M1078, Box 0120, San Francisco, CA, 94143-0120, USA,
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Auger KA, Jerardi KE, Sucharew HJ, Yau C, Unaka N, Simmons JM. Effects of the 2011 duty hour restrictions on resident education and learning from patient admissions. Hosp Pediatr 2014; 4:222-227. [PMID: 24986991 DOI: 10.1542/hpeds.2014-0004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE In July 2011, new duty hour limits for resident physicians were instituted to address concerns about the effects of sleep deprivation on patient care and trainee experience. We sought to evaluate potential educational impacts of these duty hour changes with regard to learning and frequency of attending interactions during patient admissions. METHODS Forty-nine residents on general pediatric teams participated in a prospective observational cohort study. Intervention residents (n = 23) worked a shift-based schedule compliant with new requirements. Control residents (n = 26) were on call every fourth night and compliant with 2003 work hour limits. Faculty members were present 16 hours daily. Resident surveys assessed learning from admissions (frequency of attending interaction and perceived learning during admissions). Data were analyzed with generalized linear mixed models to account for multiple responses from each resident. RESULTS Intervention interns and seniors were less likely to present admissions to faculty during morning rounds, but there were no differences between intervention and control groups in percentage of admissions discussed with faculty at any time. Perceived learning from admissions was not different between the 2 groups. CONCLUSIONS Faculty-resident interaction decreased during morning rounds; however, overall attending contact did not, suggesting inpatient teaching approaches must adapt to meet learners' needs throughout the workday.
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Affiliation(s)
- Katherine A Auger
- Division of Hospital Medicine James M. Anderson Center for Health Systems Excellence, and
| | | | - Heidi J Sucharew
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Connie Yau
- School of Public Health, University of Michigan, Ann Arbor, Michigan
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Block L, Jarlenski M, Wu AW, Feldman L, Conigliaro J, Swann J, Desai SV. Inpatient safety outcomes following the 2011 residency work-hour reform. J Hosp Med 2014; 9:347-52. [PMID: 24677678 DOI: 10.1002/jhm.2171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 01/22/2014] [Accepted: 01/24/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND The impact of the 2011 residency work-hour reforms on patient safety is not known. OBJECTIVE To evaluate the association between implementation of the 2011 reforms and patient safety outcomes at a large academic medical center. DESIGN Observational study using difference-in-differences estimation strategy to evaluate whether safety outcomes improved among patients discharged from resident and hospitalist (nonresident) services before (2008-2011) and after (2011-2012) residency work-hour changes. PATIENTS All adult patients discharged from general medicine services from July 2008 through June 2012. MEASUREMENTS Outcomes evaluated included length of stay, 30-day readmission, intensive care unit (ICU) admission, inpatient mortality, and presence of Maryland Hospital Acquired Conditions. Independent variables included time period (pre- vs postreform), resident versus hospitalist service, patient age at admission, race, gender, and case mix index. RESULTS Patients discharged from the resident services in the postreform period had higher likelihood of an ICU stay (5.7% vs 4.5%, difference 1.4%; 95% confidence interval [CI]: 0.5% to 2.2%), and lower likelihood of 30-day readmission (17.2% vs 20.1%, difference 2.8%; 95 % CI: 1.3 to 4.3%) than patients discharged from the resident services in the prereform period. Comparing pre- and postreform periods on the resident and hospitalist services, there were no significant differences in patient safety outcomes. CONCLUSIONS In the first year after implementation of the 2011 work-hour reforms relative to prior years, we found no change in patient safety outcomes in patients treated by residents compared with patients treated by hospitalists. Further study of the long-term impact of residency work-hour reforms is indicated to ensure improvement in patient safety.
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Affiliation(s)
- Lauren Block
- Division of General Internal Medicine, Hofstra North Shore-LIJ School of Medicine, Lake Success, New York; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Affiliation(s)
- Lee Ann Riesenberg
- Lee Ann Riesenberg is director of medical education outcomes and research in the department of anesthesiology and associate professor of anesthesiology at the University of Alabama at Birmingham. Ellen M. Justice is a community health librarian at Christiana Care Health System in Newark, Del
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Robertson ER, Morgan L, Bird S, Catchpole K, McCulloch P. Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf 2014; 23:600-7. [PMID: 24811239 DOI: 10.1136/bmjqs-2013-002309] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Modern medical care requires numerous patient handovers/handoffs. Handover error is recognised as a potential hazard in patient care, and the information error rate has been estimated at 13%. While accurate, reliable handover is essential to high quality care, uncertainty exists as to how intrahospital handover can be improved. This systematic review aims to evaluate the effectiveness of interventions aimed at improving the quality and/or safety of the intrahospital handover process. METHODS We searched for articles on handover improvement interventions in EMBASE, MEDLINE, HMIC and CINAHL between January 2002 and July 2012. We considered studies of: staff knowledge and skills, staff behavioural change, process change or patient outcomes. RESULTS 631 potentially relevant papers were identified from which 29 papers were selected for inclusion (two randomised controlled trials and 27 uncontrolled studies). Most studies addressed shift-change handover and used a median of three outcome measures, but there was no outcome measure common to all. Poor study design and inconsistent reporting methods made it difficult to reach definite conclusions. Information transfer was improved in most relevant studies, while clinical outcome improvement was reported in only two of 10 studies. No difference was noted in the likelihood of success across four types of intervention. CONCLUSIONS The current literature does not confirm that any methodology reliably improves the outcomes of clinical handover, although information transfer may be increased. Better study designs and consistency of the terminology used to describe handover and its improvement are urgently required.
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Affiliation(s)
- Eleanor R Robertson
- Quality, Reliability, Safety and Teamwork Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Lauren Morgan
- Quality, Reliability, Safety and Teamwork Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Sarah Bird
- University of Oxford Medical School, John Radcliffe Hospital, Oxford, UK
| | - Ken Catchpole
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California USA
| | - Peter McCulloch
- Quality, Reliability, Safety and Teamwork Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Kevat DAS, Cameron PA, Davies AR, Landrigan CP, Rajaratnam SW. Safer hours for doctors and improved safety for patients. Med J Aust 2014; 200:396-8. [DOI: 10.5694/mja13.10412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 12/16/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Dev A S Kevat
- Monash University, Melbourne, VIC
- Royal Brisbane and Women's Hospital, Brisbane, QLD
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Wu PE, Stroud L, McDonald-Blumer H, Wong BM. Understanding the effect of resident duty hour reform: a qualitative study. CMAJ Open 2014; 2:E115-20. [PMID: 25077127 PMCID: PMC4084747 DOI: 10.9778/cmajo.20130049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Concern surrounding the effect of resident fatigue on patient care recently led the National Steering Committee on Resident Duty Hours to publish Canadian recommendations suggesting that duty periods of 24 or more consecutive hours without restorative sleep should be avoided. We sought to characterize how different training programs are preparing for the effect of such changes on education, patient care and provider well-being. METHODS Using constructivist grounded theory methodology, we conducted 18 one-on-one semistructured interviews with program directors, division directors and department chiefs from 11 residency programs affiliated with one Canadian medical school. We gathered and analyzed data iteratively until we reached theoretical saturation. RESULTS The key theme articulated by our participants was that changes in resident duty hours would potentially lead to gaps in the provision of clinical care. These changes affect acute care specialties based primarily in the inpatient setting (e.g., medicine, surgery) more than primarily ambulatory (e.g., family medicine) or shift-model based (e.g., emergency) specialties. Potential strategies to address gaps in clinical care include resident-based solutions, faculty-based solutions and solutions based on other providers (e.g., nonacademic physicians, physician extenders). Each solution has unique advantages and disadvantages in terms of education, continuity of care, preparedness for practice and provider well-being. INTERPRETATION Our data-driven framework serves as a guide for programs to anticipate challenges of satisfying clinical care needs in the face of changes to resident duty hours, while balancing education, care continuity, preparedness for practice and provider well-being. Our findings challenge the "one-size-fits-all" approach to changes to resident duty hours and endorse flexibility in enacting duty hour regulations based on specialty-specific factors.
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Affiliation(s)
- Peter E Wu
- Department of Medicine, University of Toronto, Toronto, Ont. ; Department of Medicine, Toronto General Hospital, Toronto, Ont
| | - Lynfa Stroud
- Department of Medicine, University of Toronto, Toronto, Ont. ; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ont
| | | | - Brian M Wong
- Department of Medicine, University of Toronto, Toronto, Ont. ; Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ont. ; Centre for Quality Improvement & Patient Safety, University of Toronto, Toronto, Ont
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HUSBY T, TORGERSEN J, FLAATTEN H. Cognitive effects of hospital calls in anaesthesiologists. Acta Anaesthesiol Scand 2014; 58:177-84. [PMID: 24192076 DOI: 10.1111/aas.12220] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The work hours of Norwegian physicians are under scrutiny because of an increased public focus on patient safety. Ample international research indicate harmful effects of doctor fatigue based on studies on physicians working long weeks and on-call shifts of more than 30 consecutive hours. There is a lack of research on effects relevant for short or intermediate length of work weeks and call shifts. This study intended to study cognitive effects of short or intermediate duration in-hospital calls. METHODS Eighteen anaesthesiology residents working on-call at an operation ward or an intensive care unit at Haukeland University Hospital were invited to participate. Schedules were adapted to allow for two additional experimental shifts. Participants were subjected to Cambridge Neuropsychological Test Automated Battery cognitive testing in a rested state and on three occasions after call. Amount of sleep and self-assessed sleepiness were recorded. RESULTS Ten residents completed all four tests during 10 months. Reaction time was longer post-call. It was significantly increased only after the 18 h night call, by 21.1 and 20.5 ms for simple and five-choice reaction time, respectively. Executive function was not significantly altered post-call. Visual memory was improved post-call. Karolinska Sleepiness Score was increased by 3.3 (long day), 2.1 (short night) and 2.5 (long night) points post-call. CONCLUSION Reaction times were increased after 18 h night calls and non-significant increases in reaction times were apparent after the other on-call shifts. Self reported sleepiness was increased post-call. We were not able to conclude whether executive function or memory was negatively affected post-call.
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Affiliation(s)
- T. HUSBY
- Department of Anaesthesiology and Intensive Care Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - J. TORGERSEN
- The Norwegian Junior Doctors Association; The Norwegian Medical Association; Oslo Norway
| | - H. FLAATTEN
- Department of Anaesthesiology and Intensive Care Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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