Arezou Yaghoubian MD, Amy H. Kaji MD PhD, Brant Putnam MD and Christian de Virgilio MD.

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  • Arezou Yaghoubian MD, Amy H. Kaji MD PhD, Brant Putnam MD and Christian de Virgilio MD

  • Surgical Outcomes Pre and Post Duty Hours1 study: decreased rate of bile duct injury

    10 studies: no change in surgical patient outcome

    4 studies: worse patient outcomes

  • de Virgilio et alMortality and morbidity unchangedSalim et alMortality unchangedIncrease in the complication rateMorrison et al National Trauma Data BankSlightly decreased mortality (4.5% vs. 4.6%)

  • New IOM RecommendationsCALLNo more than Q 3rd Night 5 hr nap time > 16 hours of work during a 30-hour shift Max 16 hr shift without protected sleepDAYS OFF 5 days/monthTIME OFF BETWEEN SHIFTS 10 hours off between day shifts 12 hours off after night shift 14 hours off after 30 hr shift

  • Effects on surgical trainingEliminates 24 hr+ callDe facto duty hour reduction from 8056 hr/wkIncrease length of surgical residencyThe European experience58 hours/week Decreased patient interactionLoss of continuity of careDetrimental effect on operative volume

  • To compare outcomes of trauma surgery performed by surgical residents during 1st 16 hours of shift vs. those performed by residents beyond 16 hr shift

  • Retrospective reviewAll urgent/emergent trauma surgery since duty hour restriction (July 2003-2009) Comparison of two time periods:6 am-10 pm (daytime) vs. 10 pm- 6 am (nighttime)Operations after 10 pm performed by residents who began their shift at 6 am and had thus been working 16>hours

  • MorbidityWound infection, pneumonia, DVT, pulmonary embolism and pulmonary insufficiencyMortality

  • Urban busy Level I trauma centerHigh volume penetrating injuriesNo night float systemResidents on the Trauma Service take call Q 3rd night and work 24-hr shifts

  • Daytime 6am 10pm n = 766 (56.2%) Nighttime 10pm -6am n = 597 (43.8%) P value Male 627 (81.9%)521 (87.3%)0.007Penetrating trauma 497 (64.9%)481 (80.6%)

  • Daytime 6am 10pm n = 766 (56.2%) Nighttime 10pm -6am n = 597 (43.8%) P value Deaths 103 (13.5%)63 (10.6%)0.1Total complications153 (20.0%)93 (15.6%)0.04 Pulmonary embolism3 (0.5%)10 (1.3%)0.1 Pulmonary insufficiency15 (2.5%)39 (5.1%)0.02 DVT4 (0.5%)6 (1%)0.3 Wound infection33 (4.3%)27 (4.5%)0.9 Pneumonia63 (8.2%)27 (4.5%)0.006

  • Odds Ratio95% Confidence IntervalPTime of operation0.970.7-1.30.9Age11.008-1.0280.0004ISS11.03-1.04

  • Odds Ratio95% Confidence IntervalPTime of operation1.020.7-1.60.9Age1.031.02-1.04

  • Prior Studies on Daytime vs Nighttime General SurgeryAppendectomy878 daytime, 708 night time (>16 hr shift)No difference in morbidity, mortality, conversion to open, or length of surgeryCholecystectomy2522 daytime, 306 night time (>16 hr shift)No difference in bile duct injury, overall morbidity, mortality, conversion to open, or length of surgery

  • Trauma surgery performed at night by residents working >16 hrs have similar favorable outcomes as those performed by more rested residentsInstituting a 5-hour rest period after 16 hrs is unlikely to improve outcomes When combined with our prior study (appendectomy and cholecystectomy), data even more compelling