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

Surgical Outcomes Pre and Post Duty Hours

• 1 study: decreased rate of bile duct injury

• 10 studies: no change in surgical patient outcome

• 4 studies: worse patient outcomes

de Virgilio et al Mortality and morbidity unchanged

Salim et al Mortality unchanged Increase in the complication rate

Morrison et al National Trauma Data Bank Slightly decreased mortality (4.5% vs.

4.6%)

New IOM Recommendations

CALLNo 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 training Eliminates 24 hr+ call De facto duty hour reduction from

8056 hr/wk Increase length of surgical residency

The European experience 58 hours/week Decreased patient interaction Loss of continuity of care Detrimental 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 review All 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

Morbidity Wound infection, pneumonia, DVT,

pulmonary embolism and pulmonary insufficiency

Mortality

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%) <0.0001Median age (years) 29 25 <0.0001Median ISS 16 13 0.002Median length of stay (days)

8 7 0.08

Median POS 0.98 0.98 0.005

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 complications 153 (20.0%) 93 (15.6%) 0.04 Pulmonary embolism 3 (0.5%) 10 (1.3%) 0.1 Pulmonary insufficiency

15 (2.5%) 39 (5.1%) 0.02

DVT 4 (0.5%) 6 (1%) 0.3 Wound infection 33 (4.3%) 27 (4.5%) 0.9 Pneumonia 63 (8.2%) 27 (4.5%) 0.006

Odds Ratio 95%

Confidence

Interval

P

Time of

operation

0.97 0.7-1.3 0.9

Age 1 1.008-1.028 0.0004

ISS 1 1.03-1.04 <0.0001

Odds Ratio 95% Confidence

Interval

P

Time of

operation

1.02 0.7-1.6 0.9

Age 1.03 1.02-1.04 <0.0001

ISS 1.1 1.09-1.12 <0.0001

Penetrating

trauma

2.7 1.6-4.7 0.0002

Prior Studies on Daytime vs Nighttime General Surgery Appendectomy

878 daytime, 708 night time (>16 hr shift) No difference in morbidity, mortality,

conversion to open, or length of surgery Cholecystectomy

2522 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 residents

Instituting 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