Extended Work Shifts and Neurobehavioral Performance in Resident-Physicians

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.

Trial registration: ClinicalTrials.gov NCT02134847.

Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: All authors have completed the International Committee of Medical Journal Editors uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare the following: no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, and no other relationships or activities that could appear to have influenced the submitted work.

Copyright © 2021 by the American Academy of Pediatrics.

Figures

FIGURE 1

Consolidated Standards of Reporting Trials diagram.

FIGURE 2

Objective performance and subjective sleepiness ratings during the traditional EDWR and intervention RCWR schedules. The box and whisker plots depict the median (solid horizontal line), 25th and 75th percentiles (box limits), 10th and 90th percentiles (whiskers), and fifth and 95th percentiles (black circle) along with the predicted values (± SE) of each outcome estimated from the regression analyses shown next to each box and whisker plot under the EDWR (white triangles) and RCWR (black triangles) schedules for attentional failures (A) (lapses, reaction time >500 milliseconds), reaction time (B), slowest 10% reaction time (C), and subjective sleepiness ratings (D).

FIGURE 3

Objective performance measures and subjective sleepiness ratings during the traditional EDWR and intervention RCWR schedules during the day and night. Least-square means (± SE) are estimated from the mixed-effects model under the EDWR (white triangles) and RCWR (black triangles) schedules during the day (top row) and night (bottom row) for attentional failures (A and B) (lapses, reaction time >500 milliseconds), reaction time(C and D), slowest 10% reaction time (E and F), and subjective sleepiness ratings (G and H) plotted across the day. Note that under the day shift interval of 5:00 am to 2:59 pm, Cincinnati started at ∼5:00 am, and all others started at ∼6:00 am. *P < .05, significant differences between conditions at each time point with Tukey-Kramer adjusted post hoc analysis. Shift*CT, interaction between the fixed effects shift and clock time.

FIGURE 4

Objective performance measures and subjective sleepiness ratings during the traditional EDWR and intervention RCWR schedules across the 4-week study. Least-square means (± SE) are estimated from the mixed-effects model under the EDWR (white triangles) and RCWR (black triangles) schedules for attentional failures (A) (lapses, reaction time >500 milliseconds), reaction time (B), slowest 10% reaction time (C), and subjective sleepiness ratings (D) plotted across the 4-week rotation. *P < .05, significant differences between conditions at each time point with Tukey-Kramer adjusted post hoc analysis. Sched*Week, interaction between the fixed effects schedule and week.

FIGURE 5

Objective performance during the traditional EDWR and intervention RCWR schedules during the day and night across the 4-week study. Least-square means (± SE) are estimated from the mixed-effects model under the EDWR (white triangles) and RCWR (black triangles) schedules during the day (top row) and night (bottom row) for attentional failures (lapses, reaction time >500 milliseconds) plotted across the 4 weeks. Note that under the day shift interval of 5:00 am to 2:59 pm, Cincinnati started at ∼5:00 am, and all others started at ∼6:00 am. *P < .05, significant differences between conditions at each time point with Tukey-Kramer adjusted post hoc analysis. Shift*CT*Week, interaction between the fixed effects shift, clock time, and week.

FIGURE 6

Association between resident-physician–related SMEs and workload. Resident-physician–related SMEs increased with resident-physician workload (IPRP). The best fit regression line is shown with 95% CI as a gray shaded band.