Tired Doctors More Prone to Errors
TUESDAY Oct. 13, 2009 -- Attending surgeons and obstetricians/gynecologists who get fewer than six hours of sleep between procedures risk increasing the rate of surgical complications, according to Harvard researchers.
A lot of attention has been paid to the long hours that residents and interns work and the increase in medical errors brought on by their fatigue, but the new study found the same problems among practicing physicians.
"Attending surgeons and obstetricians/gynecologists, like resident physicians and nurses, are vulnerable to the effects of fatigue and extended work shifts on performance and patient care," said Dr. Jeffrey M. Rothschild, a physician at Brigham and Women's Hospital in Boston and the lead researcher on the study.
"The risk of performing post-nighttime cases without sufficient rest may be especially important in hospitals without backup support or house staff physicians to assist a fatigued attending physician," he added.
The report is published in the Oct. 14 issue of the Journal of the American Medical Association.
For the study, Rothschild's group assessed how working at night and sleep affected the rate of surgical complications in procedures done the next day. Specifically, they looked at the 919 surgical and 957 obstetrical procedures done the day after a doctor had worked at night and compared them with 3,552 surgical and 3,945 obstetrical procedures done without preceding night work.
When doctors worked overnight but still had sufficient sleep, there was not a significantly increased risk for complications on procedures performed the next day, Rothschild said.
"However, if the opportunity for sleep prior to the post-nighttime procedure was less than six hours, there was a 2.7-fold greater risk of procedural complications, such as infection, wound failure and bleeding," he said. The study also found a higher rate of complications when procedures were performed after a doctor had worked a shift of more than 12 hours, although Rothschild said the rate increase was not statistically significant.
Complications occurred in 5.4 percent of procedures done the day after the doctor had worked at night, compared with 4.9 percent of procedures done without having worked the previous night, the study found.
For doctors who got six or fewer hours of sleep, the complication rate rose to 6.2 percent, compared with 3.4 percent for procedures done by doctors who got more than six hours of sleep. The rate of complications was 6.5 percent for doctors who'd worked more than 12 hours before a procedure, compared with 4.3 percent for those who'd worked fewer than 12 hours.
Rothschild said that attending physicians should consider several approaches to reduce the risks of unsafe levels of fatigue during procedures. These include having large physician groups avoid scheduling elective procedures for doctors who have overnight on-call responsibilities and using hospital-based physicians to cover nighttime emergencies, he said.
"Adequate backup personnel should be available during the day to relieve or assist physicians whose fatigue may impair performance," Rothschild said. "For emergency situations where it is necessary to perform life-saving procedures following overnight work, the appropriate use of caffeine should be considered."
"In addition, attending physicians should try to avoid or cancel or postpone elective procedures if, when following overnight emergency cases, they do not get sufficient rest before the scheduled elective case," he added.
Dr. David A. Lubarsky, a professor, chairman of anesthesiology and senior associate dean for quality safety and risk prevention at the University of Miami Miller School of Medicine, agrees that attending physicians -- not just residents and interns -- should have their hours limited.
"I have eliminated all 24-hour shifts for anesthesiologists," Lubarsky said. "It did increase staffing costs, but I do believe it decreased our error rates."
Lubarsky noted, though, that working long hours is part of the medical culture.
"It takes years of training to get to where you are going to be able to practice," he said. "And people who are unable to function on little sleep -- and there are many -- they just don't make it through the program. You've got to have that level of dedication and intestinal fortitude."
However, Lubarsky said, good doctors are better doctors when they have had enough sleep.
Nonetheless, many doctors believe they can function just as well on little rest.
Doctors are trained to "think they are critical to the care of the patient, and they don't like handing that off," Lubarsky said. "To get where we need to be, we have to get more of a team-based approach to the provision of care. We're just not there yet."
The U.S. Agency for Healthcare Research and Quality has more on improving patient safety.
Posted: October 2009
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