Worse outcomes for patients undergoing brain tumor and cerebrovascular procedures following the ACGME resident duty-hour restrictions

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Abstract

On July 1, 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented duty-hour restrictions for resident physicians due to concerns for patient and resident safety. Though duty-hour restrictions have increased resident quality of life, studies have shown mixed results with respect to patient outcomes. In this study, the authors have evaluated the effect of duty-hour restrictions on morbidity, mortality, length of stay, and charges in patients who underwent brain tumor and cerebrovascular procedures.

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Extended work duration and the risk of self-reported percutaneous injuries in interns.

Najib T Ayas, Laura K Barger, Brian E Cade … (2006)

In their first year of postgraduate training, interns commonly work shifts that are longer than 24 hours. Extended-duration work shifts are associated with increased risks of automobile crash, particularly during a commute from work. Interns may be at risk for other occupation-related injuries. To assess the relationship between extended work duration and rates of percutaneous injuries in a diverse population of interns in the United States. National prospective cohort study of 2737 of the estimated 18,447 interns in US postgraduate residency programs from July 2002 through May 2003. Each month, comprehensive Web-based surveys that asked about work schedules and the occurrence of percutaneous injuries in the previous month were sent to all participants. Case-crossover within-subjects analyses were performed. Comparisons of rates of percutaneous injuries during day work (6:30 am to 5:30 pm) after working overnight (extended work) vs day work that was not preceded by working overnight (nonextended work). We also compared injuries during the nighttime (11:30 pm to 7:30 am) vs the daytime (7:30 am to 3:30 pm). From a total of 17,003 monthly surveys, 498 percutaneous injuries were reported (0.029/intern-month). In 448 injuries, at least 1 contributing factor was reported. Lapse in concentration and fatigue were the 2 most commonly reported contributing factors (64% and 31% of injuries, respectively). Percutaneous injuries were more frequent during extended work compared with nonextended work (1.31/1000 opportunities vs 0.76/1000 opportunities, respectively; odds ratio [OR], 1.61; 95% confidence interval [CI], 1.46-1.78). Extended work injuries occurred after a mean of 29.1 consecutive work hours; nonextended work injuries occurred after a mean of 6.1 consecutive work hours. Injuries were more frequent during the nighttime than during the daytime (1.48/1000 opportunities vs 0.70/1000 opportunities, respectively; OR, 2.04; 95% CI, 1.98-2.11). Extended work duration and night work were associated with an increased risk of percutaneous injuries in this study population of physicians during their first year of clinical training.

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Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion.

J Arnedt, Judith Owens, Megan Crouch … (2005)

Concern exists about the effect of extended resident work hours; however, no study has evaluated training-related performance impairments against an accepted standard of functional impairment. To compare post-call performance during a heavy call rotation (every fourth or fifth night) to performance with a blood alcohol concentration of 0.04 to 0.05 g% (per 100 mL of blood) during a light call rotation, and to evaluate the association between self-assessed and actual performance. A prospective 2-session within-subject study of 34 pediatric residents (18 women and 16 men; mean age, 28.7 years) in an academic medical center conducted between October 2001 and August 2003, who were tested under 4 conditions: light call, light call with alcohol, heavy call, and heavy call with placebo. Residents attended a test session during the final week of a light call rotation (non-post-call) and during the final week of a heavy call rotation (post-call). At each session, they underwent a 60-minute test battery (light and heavy call conditions), ingested either alcohol (light call with alcohol condition) or placebo (heavy call with placebo condition), and repeated the test battery. Performance self-evaluations followed each test. Sustained attention, vigilance, and simulated driving performance measures; and self-report sleepiness, performance, and effort measures. Participants achieved the target blood alcohol concentration. Compared with light call, heavy call reaction times were 7% slower (242.5 vs 225.9 milliseconds, P<.001); commission errors were 40% higher (38.2% vs 27.2%, P<.001); and lane variability (7.0 vs 5.5 ft, P<.001) and speed variability (4.1 vs 2.4 mph, P<.001) on the driving simulator were 27% and 71% greater, respectively. Speed variability was 29% greater in heavy call with placebo than light call with alcohol (4.2 vs 3.2 mph, P = .01), and reaction time, lapses, omission errors, and off-roads were not different. Correlation between self-assessed and actual performance under heavy call was significant for commission errors (r = -0.45, P = .01), lane variability (r = -0.76, P<.001), and speed variability (r = -0.71, P<.001), but not for reaction time. Post-call performance impairment during a heavy call rotation is comparable with impairment associated with a 0.04 to 0.05 g% blood alcohol concentration during a light call rotation, as measured by sustained attention, vigilance, and simulated driving tasks. Residents' ability to judge this impairment may be limited and task-specific.

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Sleep loss and performance in residents and nonphysicians: a meta-analytic examination.

Ingrid Philibert (2005)

To explore the effect of sleep loss on cognitive function, memory, and vigilance in resident physicians and nonphysicians and on residents' clinical performance. Meta-analysis of 60 studies on the effect of sleep deprivation, with a total sample of 959 physicians and 1,028 nonphysicians and 5,295 individual effect indexes. Cognitive performance and performance on clinical tasks under acute and partial chronic sleep deprivation. Additional analyses stratified the data by physician/nonphysician, type of performance, and length and type of sleep loss and assessed the combined effect of several of these factors. Sleep loss of less than 30 hours reduced physicians' overall performance by nearly 1 standard deviation and clinical performance by more than 1.5 standard deviations. The effect of sleep deprivation was larger in nonphysicians than in physicians (corrected d value -.995 vs -.880), with these smaller effects likely resulting from "study factors," primarily variation in the hours without sleep prior and chronically reduced sleep in the "rested" controls in physician studies. The weekly hours and continuous wakefulness permitted under the current national minimum standards for residents may not completely guard against the negative effect of sleep loss on cognitive and clinical performance. Research is needed to explore the effect of continuous duty periods and chronic partial sleep loss in residents and to assess the clinical and educational consequences of sleep loss. The goal should be to combine scientifically based duty-hour limits with broader efforts to enhance patient safety and resident learning.