Limiting On-Call Hours Improves Resident-Physicians’ Neurobehavioral Performance

1. A large, multicenter clinical trial found that resident-physicians who worked ≤ 16 consecutive hours for a majority of their shifts over a four-week period had fewer attentional failures, faster reaction time, and lower subjective sleepiness than participants who worked shifts of ≥ 24 hours every 3-4 shifts. 

2. These neurobehavioral metrics, along with the correlative reduction in serious medical errors, contribute significantly to the conversation about the value of reducing resident-physician on-call hours.

Evidence Rating Level: 2 (Good)

Study Rundown: To date, the deleterious effects of extended-duration work rosters (EDWRs; shifts lasting greater than 24 hours) as compared to rapid cycling work rosters (RCWRs; shifts capped at 16 hours) remain controversial. On the basis of a number of past conflicting studies, the Accreditation Council for Graduate Medical Education (ACGME) has alternatingly limited, then extended, the maximum allowable length of on-call duration. This study found that compared to a control group (EWDRs), residents who were limited to shifts of no longer than 16 hours’ duration (RCWRs) had significantly lower sleepiness ratings, faster mean reaction times, fewer attentional failures, better slowest 10% reaction times, and fewer serious medical events, according to data collected from Psychomotor Vigilance Tasks (PVT), participant’s sleep diaries, and observer data. After adjustment for resident workload, fewer serious medical errors occurred in the RCWR group. This study improved on previous studies by including a much larger cohort of resident-physicians in the study (n=312) and utilizing multiple clinical sites. The study was limited by the fact that the experimental RCWR was not uniform across clinical sites and workload was variable between programs and residents. Results of this study may call into question the current position of the ACGME allowing 28-hour continuous call.

Click to read the study in Pediatrics

Click to read an accompanying editorial in Pediatrics

Relevant Reading: Effects of reducing or eliminating resident work shifts over 16 hours: A systematic review

In-Depth [randomized controlled trial]: The Randomized Order Safety Trial Evaluating Resident-Physician Schedules (ROSTERS) study was a multicenter cluster-randomized crossover clinical trial taking place at 6 PICUs in the United States. It compared resident-physician cognitive performance and medical outcomes between traditional extended shifts (24-28 hours) and the intervention group working no more than 16 hours a shift. Only PGY-2 and PGY-3 residents were eligible for this 4-week study. Participants were randomized to EDWR or RCWR groups. Neurobehavioral performance was assessed using 10-minute Psychomotor Vigilance Task (PVT) assessments taken every 5 hours through a shift (mean attentional failures, mean reaction time, and mean of the slowest 10% of responses). Subjective sleepiness was measured using the Karolinska Sleepiness Scale (KSS) and daily electronic sleep and work logs. Medical error data was tracked and synthesized from direct observation of residents, review of unit charts by trained research nurses, voluntary reports from unit staff, and formal hospital incident reports. Significant improvement in every metric of neurocognitive performance was observed in the RCWR groups, with fewer attentional failures (mean ± SE, 2.9 ± 0.7 vs 6.8 ± 1.0; P = .01), faster mean reaction time (283.7 ± 6.3 vs 336.2 ± 7.2; P < .0001), slowest 10% reaction time (509.9 ± 24.6 vs 683.8 ± 31.8; P < .0001), and lower sleepiness ratings (4.4 ± 0.1 vs 4.8 ± 0.1; P < .0001).

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Quick Take: Intimate Partner Homicide of Adolescents

Approximately 43 million adults in the US are affected by intimate partner violence (IPV). Data from the 2017 national Youth Risk Behavior Survey indicated that among high school students who dated, 6.9% experienced sexual violence, and 8.0% experienced physical violence by someone they were dating or going out with in the past year. The National Survey on Teen Relationships and Intimate Violence also showed that over 60% of adolescents in a current or past-year dating relationship have experienced some form of IPV, which includes physical, sexual, and/or psychological abuse. Intimate partner homicide (IPH) is the most extreme form of IPV, with most existing literature on IPH focusing on the adult population. In this multistate study of homicides of 2188 individuals age 11 to 18 years captured in the National Violent Death Reporting System (2003-2016), investigators aimed to determine the proportion of adolescent homicides perpetrated by intimate partners, to describe the victims, perpetrators, and incident characteristics of IPH in this population. Researchers found that of adolescent homicides, 6.9% were classified as IPH. Of these, 90% were female (mean age 16.8 years, SD 1.3 years). In terms of perpetrators, 77.9% were age 18 years and older (mean 20.6 years, SD 5.0 years). A total of 62.7% were current intimate partners of the victim, 26.7% were former intimate partners, and the relationship status at the time of death was unspecified for the remaining 10.7%. Compared with IPHs of young adults aged 19 to 24 years, perpetrators of adolescent victims were younger and less likely to be a current intimate partner. Firearms were the most common mechanism of injury (61.2%), followed by sharp or blunt instruments (25.2%). Based on available narrative information from the coroner/medical examiner and law enforcement reports, IPH was most often related to broken/desired relationship or jealousy (27.3%) and altercation (24.7%), followed by reckless firearm behavior (8.0%), and pregnancy (6.7%). This study therefore shows that adolescent victims of IPH are largely female and that the circumstances leading to IPH are commonly due to broken/desired relationship or jealousy and altercation, where perpetrators have access to firearms. This has important implications in informing prevention and intervention efforts tailored to adolescents at high risk of IPV/IPH.

Click to read the study in JAMA Pediatrics

Image: PD

©2019 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.

 

Less than half of mothers place sleeping infants supine

1. Fewer than 50% of mothers surveyed both intended to and actually did exclusively choose the supine position for their sleeping infants.

2. Only slightly over half of mothers reported getting advice from their doctors that was consistent with that from the American Academy of Pediatrics (AAP) regarding sleeping position.

Evidence Level: 2 (Good)

Study Rundown: For more than one decade, the AAP has recommended that infants only be placed in a supine position to sleep. However, sudden infant death syndrome (SIDS) continues to be the number one cause of death among post-neonatal infants. Authors of this study surveyed mothers of infants regarding sleeping position practices they intended to follow versus what they actually practiced, as well as factors influencing their decisions. Results showed that in actual practice, a little over half of mothers indicated that they intended to use the supine sleeping position, while a little over 40% both intended to and were actually adherent to the AAP recommendations at all times. Slightly more than half of mothers surveyed received advice from a health care provider that was consistent with the AAP guidelines for sleeping position. White mothers were more likely than both Hispanic and non-Hispanic African American mothers to intend to place their infants prone while sleeping. Responses in this survey are limited by self-report bias. Nonetheless, these findings suggest that improving physician counseling practices and parental education regarding recommended sleeping practices may improve both intentions and actual practices.

Click to read the study, published today in Pediatrics

Relevant reading: SIDS and other sleep related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment.

In-depth [prospective cohort]: Study investigators surveyed 3297 mothers (25% Hispanic, 25% non-Hispanic African American) with infants aged 2 to 6 months from 32 hospitals across the United States regarding their intended practices over the next 2 weeks and their actual practices over the past 2 weeks. To illicit factors related to maternal decisions, surveys also included questions about their attitudes, perceived control, and subjective social norms regarding infant sleeping position. Results showed that 57.6% of mothers intended to put their infants in the supine position while 43.7% of those who intended to do so actually did. 14.9% of mothers reported they intended to have their infants sleep prone at least some of the time. White mothers were more likely to intend to use the prone position than both Hispanic and non-Hispanic African American mothers (aOR = 2.5, 95% CI 1.57-3.85 vs. aOR = 1.5, 95% CI 0.58-3.30 and aOR = 1.5, 95% CI 0.80-2.65, respectively). Mothers who completed high school were more likely to intend to use the supine position compared to non-graduates (aOR = 2.1, 95% CI 1.16-3.73). Mothers who thought the prone position would be healthy, pleasant, or safer for their infant were much more likely to use that position (aOR = 130, 95% CI 7.18-236). Those who received advice consistent with the AAP guidelines were more likely to choose the prone position than those who did not (aOR = 0.6, 95% 0.39-0.93 vs. aOR = 2.6, 95% CI 1.52-4.47, respectively).

Image: CC

©2017 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.