trauma surgery performed by “sleep deprived” residents: are outcomes affected?
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Trauma Surgery Performed by “Sleep Deprived” Residents: Are Outcomes Affected?. Arezou Yaghoubian MD, Amy H. Kaji MD PhD, Brant Putnam MD and Christian de Virgilio MD. Surgical Outcomes Pre and Post Duty Hours. 1 study: decreased rate of bile duct injury - PowerPoint PPT PresentationTRANSCRIPT
Arezou Yaghoubian MD, Amy H. Kaji MD PhD, Brant Putnam MD and Christian de Virgilio MD
Surgical Outcomes Pre and Post Duty Hours
• 1 study: decreased rate of bile duct injury
• 10 studies: no change in surgical patient outcome
• 4 studies: worse patient outcomes
de Virgilio et al Mortality and morbidity unchanged
Salim et al Mortality unchanged Increase in the complication rate
Morrison et al National Trauma Data Bank Slightly decreased mortality (4.5% vs.
4.6%)
New IOM Recommendations
CALLNo more than Q 3rd Night
5 hr nap time > 16 hours of work during a 30-hour shift
Max 16 hr shift without protected sleepDAYS OFF 5 days/monthTIME OFF BETWEEN SHIFTS 10 hours off between day shifts 12 hours off after night shift 14 hours off after 30 hr shift
Effects on surgical training Eliminates 24 hr+ call De facto duty hour reduction from
8056 hr/wk Increase length of surgical residency
The European experience 58 hours/week Decreased patient interaction Loss of continuity of care Detrimental effect on operative volume
To compare outcomes of trauma surgery performed by surgical
residents during 1st 16 hours of shift vs. those performed by residents
beyond 16 hr shift
Retrospective review All urgent/emergent trauma surgery
since duty hour restriction (July 2003-2009)
Comparison of two time periods: 6 am-10 pm (daytime) vs. 10 pm- 6 am
(nighttime) Operations after 10 pm performed by
residents who began their shift at 6 am and had thus been working 16>hours
Morbidity Wound infection, pneumonia, DVT,
pulmonary embolism and pulmonary insufficiency
Mortality
Urban busy Level I trauma centerHigh volume penetrating injuriesNo night float systemResidents on the Trauma Service
take call Q 3rd night and work 24-hr shifts
Daytime 6am – 10pm
n = 766 (56.2%)
Nighttime 10pm -6am
n = 597 (43.8%)
P value
Male 627 (81.9%) 521 (87.3%) 0.007Penetrating trauma 497 (64.9%) 481 (80.6%) <0.0001Median age (years) 29 25 <0.0001Median ISS 16 13 0.002Median length of stay (days)
8 7 0.08
Median POS 0.98 0.98 0.005
Daytime 6am – 10pm
n = 766 (56.2%)
Nighttime 10pm -6am
n = 597 (43.8%)
P value
Deaths 103 (13.5%) 63 (10.6%) 0.1Total complications 153 (20.0%) 93 (15.6%) 0.04 Pulmonary embolism 3 (0.5%) 10 (1.3%) 0.1 Pulmonary insufficiency
15 (2.5%) 39 (5.1%) 0.02
DVT 4 (0.5%) 6 (1%) 0.3 Wound infection 33 (4.3%) 27 (4.5%) 0.9 Pneumonia 63 (8.2%) 27 (4.5%) 0.006
Odds Ratio 95%
Confidence
Interval
P
Time of
operation
0.97 0.7-1.3 0.9
Age 1 1.008-1.028 0.0004
ISS 1 1.03-1.04 <0.0001
Odds Ratio 95% Confidence
Interval
P
Time of
operation
1.02 0.7-1.6 0.9
Age 1.03 1.02-1.04 <0.0001
ISS 1.1 1.09-1.12 <0.0001
Penetrating
trauma
2.7 1.6-4.7 0.0002
Prior Studies on Daytime vs Nighttime General Surgery Appendectomy
878 daytime, 708 night time (>16 hr shift) No difference in morbidity, mortality,
conversion to open, or length of surgery Cholecystectomy
2522 daytime, 306 night time (>16 hr shift) No difference in bile duct injury, overall
morbidity, mortality, conversion to open, or length of surgery
Trauma surgery performed at night by residents working >16 hrs have similar favorable outcomes as those performed by more rested residents
Instituting a 5-hour rest period after 16 hrs is unlikely to improve outcomes
When combined with our prior study (appendectomy and cholecystectomy), data even more compelling