Protected sleep periods improve intern alertness and sleep duration

Key study points:

1. For internal medicine interns working shifts 16 hours or longer, 5-hour protected sleep periods are shown to improve alertness and sleep duration.

Primer: Medical interns and residents are known to work prolonged shifts, at times upwards of 24 hours. Such extended periods of wakefulness have been shown to have detrimental effects on psychomotor alertness and increase the incidence of performance errors. In 2011 the Accreditation Council for Graduate Medical Education mandated that interns are no longer allowed to work more than 16 hours per shift. However, residents continue to work up to 24 hours with minimal sleep. While strategies to cope with extended shifts, such as “strategic napping,” have been suggested there is a dearth of research into what is feasible for interns and residents. The researchers in this study set out to determine whether the recommended 5 hour protected sleep periods are both feasible and effective for increasing the amount sleep interns receive.

Background reading:

1. The New Recommendations on Duty Hours from the ACGME Task Force.
2. Effect of Reducing Interns’ Work Hours on Serious Medical Errors in Intensive Care Units.

This [randomized control trial] enrolled a total of 106 senior medical students and postgraduate year 1 interns at the Philadelphia VA Medical Center and the Hospital of the University of Pennsylvania. The participants were followed for twelve 4-week rotations.

The primary outcome measured was sleep time during the 5-hour protected sleep period, set at 12:30am-5:30am. Participants were fitted with wrist actigraphs to monitor periods of sleep and activity.

Mean sleep time was increased by 1 hour at the university hospital and 0.7 hours at the VA when interns were allowed the 5-hour protected sleep period. At both sites the mean psychomotor vigilance test responses, which measure alertness based on reaction time, were quicker in the protected sleep period group than in the control group (95% CI, P=.02)

In sum: The authors of this study demonstrated protected sleep periods result in increased morning alertness, increased amount of sleep, and decreased sleepiness. Further, it was shown such sleep periods are feasible as 98.3% of the time the interns relinquished their phones prior to sleeping.

A major strength of this study is its use of subjective sleep diaries strengthened by objective wrist actigraph data. However, there are several limitations to this study. The authors were not able to reliably assess small clinical changes in patient outcomes. Additionally, as the study was conducted in only two hospitals, there is a lack of generalizability to interns of other medical institutions. Finally, the interns and study staff were fully aware of the goals of the study during the trial. Future directions for this research include testing the influence of the 5-hour protected sleep period on patient outcomes. While the long hours of interns and residents are entrenched in tradition, research is beginning to illustrate how sleeplessness can negatively affect both intern and patient alike.

Click to read the study in JAMA

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