Sleep deprivation in attending physicians not linked to adverse outcomes in elective daytime surgical procedures

1. Night work was not associated with increased risks of adverse outcomes for elective daytime procedures.

2. Broad-based policy shifts in duty hours for attending surgeons may not be necessary at this time. However, investigating the short- or long-term sleep deprivation is needed.

Evidence Rating Level: 2 (Good)

Study Rundown: Lack of sleep can affect mood, cognitive performance, and psychomotor function. Its effects on physician performance and patient outcomes have been explored in a few studies. Each study has provided conflicting results, which has been attributed to the small sample size and few events, resulting in limited statistical power. This study examined whether sleep deprivation, due to overnight clinical work, resulted in differences of elective procedure outcomes compared to the same physicians and procedures but not sleep deprived (control group). There was no significant difference between the rates of death, readmission, or complication in the postmidnight group (22.2%) versus the control group (22.4%). Stratification of outcomes based on academic versus nonacademic centre, physician age, or type of procedure was not significant. This data suggests that short-term sleep deprivation does not affect elective procedure outcomes but studies looking at the effects of profound sleep loss on physicians’ ability to treat patients are warranted.

Click to read the study, published today in NEJM

Relevant Reading: Risks of Complications by Attending Physicians After Performing Nighttime Procedures

In-Depth [retrospective cohort]: This was a population-based, retrospective, matched-cohort study which included all persons in the province of Ontario, Canada, who underwent 1 of the following procedures: cholecystectomy, gastric bypass, colon resection, coronary angioplasty, knee replacement, hip replacement, repair of a hip fracture, hysterectomy, spinal surgery, craniotomy, and lung resection. Patients were divided into a postmidnight group and a control group. The postmidnight group was patients who underwent an elective daytime procedure performed by a physician who had treated patients in the preceding overnight hours (midnight to 7 a.m.). The control group was patients that had not worked clinically in the preceding overnight hours. The two groups were matched in a 1:1 ratio. The primary outcome was death, complications, or readmission (to any hospital in the province) within 30 days. A total of 38,978 patients were included in the study.

There was no significant difference in primary outcomes between the two groups (p=0.66). Furthermore, there were no significant between-group differences in crude rates of death (1.1% in both groups, p=0.92), readmission (6.6% and 7.1% respectively; p = 0.05), or complications (18.1% and 18.2%, respectively; p=0.83). Median length of stay in each group was 3 days (interquartile range, 0–5; p=0.84). There was no significant difference between academic vs. nonacademic hospitals. The adjusted odds ratio for the primary outcome was 1.00 (95% [CI], 0.94–1.07; p=0.97) for academic and 0.98 (95% [CI], 0.92–1.04; p=0.51) for nonacademic institutions. There are limitations associated with the data sources. Billing codes were used as a proxy to define periods and the exact hours when the care was provided is not available. Therefore, the number of hours that a physician had been sleep deprived could not be quantified. Differences in outcomes between daytime procedures performed later in the day versus those performed later in the day could not be established. Lastly, control for other sources of short- or long-term sleep deprivation could not be assessed.

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