Are Procedural Complications Related to Sleep Pattern the Night Before?
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: The complication rate for procedures performed by attending surgeons and obstetricians was not greater among those who worked overnight.
Source: Rothschild JM, et al. Risks of complications by attending physicians after performing nighttime procedures, JAMA 2009;302:1565-1572.
Conducted in a 700+ bed tertiary care, urban academic teaching hospital with a trauma center and referral center for high-risk obstetrics, this retrospective cohort study involved the procedures of 86 surgeons and 134 OB/GYNs between 1999 and 2008. Cases performed between midnight and 6 am were considered "overnight" and "sleep opportunity" was defined as the time between the end of the overnight procedure and the start of the first scheduled morning procedure. The study was conducted to see if sleep opportunities correlated with surgical complications among attending surgeons and OB/GYNs. The complication rates among post-nighttime procedures were compared with those of controls. Also, complication rates in post-nighttime procedures performed by physicians with more than 6-hour sleep opportunities were compared to those performed by physicians who had sleep opportunities of 6 hours or less. Nearly a thousand obstetrical and more than 900 surgical cases were identified as post-nighttime, and these were compared to almost 4000 obstetrical and more than 3500 surgical control cases.
There were complications in 101 post-nighttime cases (5.4%) and 365 control procedures (4.9%; odds ratio [OR], 1.09; 98% confidence interval [CI], 0.84-1.41). Among the post-nighttime complications, they occurred in 6.2% of cases in which the sleep opportunity was 6 hours or less compared to 3.4% of cases where the sleep opportunity exceeded 6 hours (OR, 1.72; 95% CI, 1.02-2.89). In addition, complication rates in post-nighttime procedures performed after working more than 12 hours was higher, but not significantly, than after working 12 hours or less (6.5% vs 4.3%; OR, 1.47; 95% CI, 0.96-2.27).
The conclusions of this article, from one single study site, are that there were not higher complication rates for surgeons and gynecologic surgeons who had worked overnight, although the complication rates were slightly higher among the post-nighttime procedures done if sleep opportunities were less than 6 hours. Surgeons did have a higher complication rate if sleep opportunities were limited, though the rate was not increased for OB/GYN attendings.
Is that reassuring? It can be, particularly if you're one of those surgeons who works inconsistent and unpredictable hours. Throughout our training, the issue of long hours and sleep deprivation has always been there, particularly with the implied concern that daytime activity could be adversely affected by nighttime emergencies/unscheduled procedures. On the other hand, if you are someone looking to debunk these data, one can simply (and correctly) point out that this was only one study site, it was retrospective in nature, and the outcome measures were not defined appropriately. It was also done at a tertiary care facility, which certainly could be very different from community hospitals that most people utilize in their respective practices. Nevertheless, there is not a statistical difference in the surgical complication rates whether or not the surgeon had done other procedures the night before.
Likewise, much more study is needed for anyone to be able to determine the critical amount of rest/sleep that a surgeon needs to avoid increasing the complication rates after a nighttime procedure. Prospective data are needed. There may not, in fact, be a specific number of hours of rest that is needed. That is unlikely to stop boards, commissions, governmental agencies, etc., from declaring that certain guidelines must be in place to protect the welfare of patients. In fact, who can argue with regulations that protect the patient? We're all practicing this business called medicine for that primary reason, i.e., the patient. The controversy arises when the good intentions of those making the rules run into the good intentions of those trying to render quality health care.
The results of the 2003 ACGME decision to limit resident duty hours to 80 hours per week have yet to be fully appreciated. Since that time, further tweaking has occurred, with more refinements to defining how those hours may be counted. Even greater reductions are in play, with first year residents being limited differently than upper level trainees. On the other hand, the topic of hours of attending physicians has not been addressed, with this article being one attempt to take part in that discussion. I raise the topic of resident duty hours because it is germane to practitioners as they look at their newly graduated younger colleagues and how they practice. Some may adapt well to an unregulated practice pattern with unlimited practice hours. Others may either choose not to adapt or find that the rigors of such a schedule are stressful and/or difficult to manage.
Of greater importance are patient safety topics that we can all do something about. First, we can all have back-up plans for what we currently do. Self-awareness of fatigue also plays a critical role. It's OK to be tired and admit to it. It has been reported that fatigue played a role in up to 16% of preventable adverse events in one study.1 Another study came to different conclusions for cardiac surgeons who performed procedures within a 24-hour period after an overnight case. In that study, there was no difference between surgeons who were or were not sleep-deprived.2
Perhaps a series of questions could stimulate each of us to determine how we fit into this controversy:
- Are older, more experienced physicians more or less susceptible than residents to the effects of fatigue?
- Are we taking full advantage of "hospitalists" to minimize the risk of overnight emergency procedures adversely affecting the surgeon the next morning?
- Does the practice routinely avoid scheduling elective surgery the day after someone has been on call the night before?
- Do we have back-up providers available to step in should surgeons find that fatigue is affecting them?
- Have we adequately educated ourselves on the topics related to sleep deprivation?
- Do we use caffeine appropriately (as opposed to inappropriately) as a stimulant to combat fatigue?
- Is the possibility of delaying elective surgery appropriately utilized (recognizing the inconvenience and stress on the patient and families)?
- Do attending physicians factor in monetary reward (i.e., surgical fees) as they decide if an elective procedure should be rescheduled?
The topic of patient safety in the operating room would not be complete without touching on a couple of other topics. What effect has the surgical "time out" made? You can be your own judge. Maybe it's not a bad thing, even if it seems as though it shouldn't be necessary.
What about patient safety elsewhere? I'd like for each of you to think about your practice. Answer these questions to see how things stack up within an environment that you, as the practitioner, have a greater degree of control:
- Do we have a fool-proof tracking mechanisms for all lab tests drawn?
- Do we have a system to notify patient of all abnormal results?
- Are providers responsible for signing off on all test results?
- Are phone calls logged and answered in a timely fashion?
- Does the office have appropriate protocols in place in case of cardiac arrest or adverse patient outcomes?
- If procedures such as hysteroscopy or LEEP are done in the office, are the same safety measures taken in the hospital operating rooms utilized in the office?
What we do in our respective daily activities should be based on good medicine first, but with a healthy dose of patient safety in mind at every turn. Let's lead the way and show the government, insurers, and anyone who wants to watch us that physicians take this topic seriously.
- Gawande AA, et al. Analysis of errors reported by surgeons at three teaching hospitals. Surgery 2003;133:614-621.
- Ellman PI et al. Sleep deprivation does not affect operative results in cardiac surgery. Ann Thorac Surg 2004;78:906-911.