Extended-duration Shifts Research Articles

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

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

Should public safety shift workers be allowed to nap while on duty?

Fatigue and sleep deficiency among public safety personnel are threats to wellness, public and personal safety, and workforce retention. Napping strategies may reduce work‐related fatigue, improve safety and health, yet in some public safety organizations it is discouraged or prohibited. Our aim with this commentary is to define intra‐shift napping, summarize arguments for and against it, and to outline potential applications of this important fatigue mitigation strategy supported by evidence. We focus our discussion on emergency medical services (EMS); a key component of the public safety system, which is comprised of police, fire, and EMS. The personnel who work in EMS stand to benefit from intra‐shift napping due to frequent use of extended duration shifts, a high prevalence of personnel working multiple jobs, and evidence showing that greater than half of EMS personnel report severe fatigue, poor sleep quality, inadequate inter‐shift recovery, and excessive daytime sleepiness. The benefits of intra‐shift napping include decreased sleepiness and fatigue, improved recovery between shifts, decreased anxiety, and reduced feelings of burnout. Intra‐shift napping also mitigates alterations in clinician blood pressure associated with disturbed sleep and shift work. The negative consequences of napping include negative public perception, acute performance deficits stemming from sleep inertia, and the potential costs associated with reduced performance. While there are valid arguments against intra‐shift napping, we believe that the available scientific evidence favors it as a key component of fatigue mitigation and workplace wellness. We further believe that these arguments extend beyond EMS to all sectors of public safety.

The Association Between Resident Physician Work-Hour Regulations and Physician Safety and Health

BackgroundIn 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted a 16-h limit on consecutive hours for first-year resident physicians. We sought to examine the effect of these work-hour regulations on physician safety. MethodsAll medical students matched to a US residency program from 2002 to 2007 and 2014 to 2017 were invited to participate in prospective cohort studies. Each month participants reported hours of work, extended duration shifts, and adverse safety outcomes, including motor vehicle crashes, percutaneous injuries, and attentional failures. The incidence of each outcome was compared before and after the 2011 ACGME work-hour limit. Hypotheses were tested using generalized linear models adjusted for potential confounders. ResultsOf all first-year resident physicians nationwide, 13% participated in the study, with 80,266 monthly reports completed by 15,276 first-year resident physicians. Following implementation of the 16-h 2011 ACGME work-hour limit, the mean number of extended duration (≥24-h) shifts per month decreased from 3.9 to 0.2. The risk of motor vehicle crash decreased 24% (relative risk [RR] 0.76; 0.67-0.85), percutaneous injury risk decreased more than 40% (relative risk 0.54; 0.48-0.61), and the rate of attentional failures was reduced 18% (incidence rate ratio [IRR] 0.82; 0.78-0.86). Extended duration shifts and prolonged weekly work hours were associated with an increased risk of adverse safety outcomes independent of cohort. ConclusionsThe 2011 ACGME work-hour limit was associated with meaningful improvements in physician safety and health. Surveillance is needed to monitor the ongoing impact of work hours on physician safety, health, and well-being.

0970 Resident Physician Work Hours Decreased and Sleep Duration Increased Following Elimination of Scheduled Extended Duration Shifts

0970 Resident Physician Work Hours Decreased and Sleep Duration Increased Following Elimination of Scheduled Extended Duration Shifts

Fatigue mitigation with SleepTrackTXT2 in air medical emergency care systems: study protocol for a randomized controlled trial

BackgroundMost air medical Emergency Medical Services (EMS) clinicians work extended duration shifts, and more than 50% report inadequate sleep, poor sleep quality, and/or poor recovery between shifts. The SleepTrackTXT pilot trial (ClinicalTrials.gov, NCT02063737) showed that use of mobile phone text messages could impact EMS clinician self-reported fatigue and sleepiness during long duration shifts. The purpose of the SleepTrackTXT2 trial is to leverage lessons learned from the first SleepTrackTXT study and test an enhanced intervention targeting air medical EMS clinicians.Methods/designWe will conduct a multi-site randomized trial with a sample of adult EMS clinicians recruited from four air medical EMS systems located in the midwest, northeastern, and southern USA. Participants will be allocated to one of two possible arms for a 4-month (120-day) study period. The intervention arm will involve text-message assessments of sleepiness, fatigue, and difficulty concentrating at the beginning, every 4 hours during, and at the end of scheduled shifts. Participants reporting high levels of sleepiness, fatigue, or difficulty with concentration will receive one of nine randomly selected intervention messages to promote behavior change during shift work to improve alertness. Intervention participants will receive a text-message report on Friday of each week that shows their sleep debt over the previous 7 days followed by a text message to promote paying back sleep debt recovery when feasible. Participants in the control group receive text messages that only include assessments. Both arms will receive text-message assessments of perceived recovery since last shift, sleepiness, fatigue, or difficulty with concentration at noon (1200 hours) on days between scheduled shifts (off-duty days). We have two aims for this study: (1) to determine the short-term impact of the enhanced SleepTrackTXT2 intervention on air medical clinician fatigue reported in real time during and at the end of shift work, and (2) to determine the long-term impact of the SleepTrackTXT2 intervention on sleep quality and sleep health indicators including hours of sleep and recovery between shift work.DiscussionThe SleepTrackTXT2 trial may provide evidence of real-world effectiveness that would support widespread expansion of fatigue mitigation interventions in emergency care clinician shift workers. The trial may specifically support use of real-time assessments and interventions delivered via mobile technology such as text messaging.Trial registrationClinicalTrials.gov, NCT02783027. Registered on 23 May 2016.

Sleep and cognitive function of crewmembers and mission controllers working 24-h shifts during a simulated 105-day spaceflight mission

The success of long-duration space missions depends on the ability of crewmembers and mission support specialists to be alert and maintain high levels of cognitive function while operating complex, technical equipment. We examined sleep, nocturnal melatonin levels and cognitive function of crewmembers and the sleep and cognitive function of mission controllers who participated in a high-fidelity 105-day simulated spaceflight mission at the Institute of Biomedical Problems (Moscow). Crewmembers were required to perform daily mission duties and work one 24-h extended duration work shift every sixth day. Mission controllers nominally worked 24-h extended duration shifts. Supplemental lighting was provided to crewmembers and mission controllers. Participants' sleep was estimated by wrist-actigraphy recordings. Overall, results show that crewmembers and mission controllers obtained inadequate sleep and exhibited impaired cognitive function, despite countermeasure use, while working extended duration shifts. Crewmembers averaged 7.04±0.92h (mean±SD) and 6.94±1.08h (mean±SD) in the two workdays prior to the extended duration shifts, 1.88±0.40h (mean±SD) during the 24-h work shift, and then slept 10.18±0.96h (mean±SD) the day after the night shift. Although supplemental light was provided, crewmembers’ average nocturnal melatonin levels remained elevated during extended 24-h work shifts. Naps and caffeine use were reported by crewmembers during ∼86% and 45% of extended night work shifts, respectively. Even with reported use of wake-promoting countermeasures, significant impairments in cognitive function were observed. Mission controllers slept 5.63±0.95h (mean±SD) the night prior to their extended duration work shift. On an average, 89% of night shifts included naps with mission controllers sleeping an average of 3.4±1.0h (mean±SD) during the 24-h extended duration work shift. Mission controllers also showed impaired cognitive function during extended duration work shifts.These findings indicate that extended duration work shifts present a significant challenge to crewmembers and mission support specialists during long-duration space mission operations. Future research is needed to evaluate the efficacy of alternative work schedules and the development and implementation of more effective countermeasures will be required to maintain high levels of performance.

Neurobehavioral, health, and safety consequences associated with shift work in safety-sensitive professions

Almost 15% of the full-time workers in the United States are shift workers. We review the physiologic challenges inherent not only in traditional night or rotating shifts but also in extended-duration shifts and other nonstandard hours. The challenging schedules of those in particularly safety-sensitive professions such as police officers, firefighters, and health care providers are highlighted. Recent findings describing the neurobehavioral, health, and safety outcomes associated with shift work also are reviewed. Comprehensive fatigue management programs that include education, screening for common sleep disorders, and appropriate interventions need to be developed to minimize these negative consequences associated with shift work.

Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures

BackgroundA recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (≥24 h) reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States.Methods and FindingsWe conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3–3.7) and 7.5 (95% CI, 7.2–7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4–22) and 7.0 (95% CI, 4.3–11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality.ConclusionsIn our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education.