Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing

Abstract

Objectives: To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model.

Design: Prospective observational study.

Setting: Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing.

Patients: Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012.

Interventions: As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily.

Measurements and main results: Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model.

Conclusions: Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.

Trial registration: ClinicalTrials.gov NCT01434823.

Figures

Figure 1:

1A) Sample Fellow Actigraphy:The first week depicted here is a standard staffing week, and the second is an intervention week. The vertical black bars depict activity level and the yellow line indicates degree of light exposure. The light blue shades indicate times of rest (lighter blue) and times of sleep (medium-shade blue), and times where the actigraph has been taken off (dark blue). As can be seen, the first week shows that that fellow’s sleep is highly interrupted, with multiple prolonged awakenings. The fellow was off clinical duties (had a “day off”) on Sunday. He/she had Satuday night off, slept in on Sunday morning, napped on Sunday in the early afternoon, and had Sunday night off. Beginning Monday of the second week, he/she had an intervention staffing model with a nighttime intensivist in-hospital, meaning that the fellow did not have on-call responsibilities that week. 1B) Sample Faculty Actigraphy:The first week depicted is a standard staffing week. As can be seen, there are interruptions of sleep most nights. The second week is an intervention week, with a nighttime intensivist in-hospital, meaning that the faculty member depicted here had no on-call responsibilities that week.

Figure 1:

1A) Sample Fellow Actigraphy:The first week depicted here is a standard staffing week, and the second is an intervention week. The vertical black bars depict activity level and the yellow line indicates degree of light exposure. The light blue shades indicate times of rest (lighter blue) and times of sleep (medium-shade blue), and times where the actigraph has been taken off (dark blue). As can be seen, the first week shows that that fellow’s sleep is highly interrupted, with multiple prolonged awakenings. The fellow was off clinical duties (had a “day off”) on Sunday. He/she had Satuday night off, slept in on Sunday morning, napped on Sunday in the early afternoon, and had Sunday night off. Beginning Monday of the second week, he/she had an intervention staffing model with a nighttime intensivist in-hospital, meaning that the fellow did not have on-call responsibilities that week. 1B) Sample Faculty Actigraphy:The first week depicted is a standard staffing week. As can be seen, there are interruptions of sleep most nights. The second week is an intervention week, with a nighttime intensivist in-hospital, meaning that the faculty member depicted here had no on-call responsibilities that week.