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No quality, patient harm risk from 'graveyard shift' surgeries, study says

Conclusions are at odds with previous research linking sleep deprivation in physicians to reduced performance.

Patients receiving common operations in the daytime fared no worse in the short-term if their attending physician worked a hospital graveyard shift the night before than patients whose doctor did not, according to a new study examining the effects of sleep deprivation on surgeons.

Patients whose physicians worked from midnight to 7 a.m. the night before a daytime operation were as likely to die, be readmitted to the hospital or suffer complications within 30 days of their procedure as other patients who had the same operations in the daytime from physicians who had not worked after midnight, researchers said. Short-term outcomes were compared for patients receiving 12 elective procedures such as knee and hip replacements, hysterectomies and spinal surgeries. The study, conducted in Ontario, Canada by researchers in Toronto, was published Wednesday in the New England Journal of Medicine. It included 38,978 patients and 1,448 physicians.

Its conclusions are at odds with previous research linking sleep deprivation in physicians to reduced performance.

[Also: Leapfrog: 1 in 5 hospitals won't commit to ending medical errors]

In the New England Journal article, researchers said most earlier studies have focused on medical trainees, otherwise known as residents, but not on attending physicians. For example, working surgeons have more experience than trainees, which could compensate for reduced performance, they said. Nancy Baxter, one of the co-authors, said working surgeons have more control over their schedules than residents have and can schedule daytime surgeries with longer breaks between nighttime shifts.

Medical school residents once were expected to work 24- to 36-hour long shifts without scheduled breaks for sleep. New rules implemented in 2003 by the Accreditation Council for Graduate Medical Education, which set standards for medical residencies, capped all residents' schedules at a maximum 80 hours per week or 24 consecutive hours on duty. They should not be on call more than every third night. Under rules set in 2011, first-year residents are limited to 16-hour shifts and require eight hours off between shifts.

But questions about attending surgeons' rest persist.

A small survey study published in 2009 found that only 40 percent of surgeons -- or 55 of 136 -- limited their working time to no more than 30 continuous hours.

David Bates, who has previously researched the relationship between physician medical errors and their lack of sleep, said the new study should be reassuring to patients who get surgery after their doctor has worked overnight. But he cautioned the results do not address the effects of long shifts that last days without rest on patient outcomes.

Such a study would be difficult to conduct in the U.S. because data on attending surgeon hours isn't routinely collected, he said. Canada also has a single-payer system, meaning researchers could cull massive amounts of information from one source. Doing a similar study in the U.S. would be nearly impossible because of the number of insurance companies involved in health care, Bates said.

[Also: AHRQ study: Surgical errors racking up $1.5B annually]

The study reported in the New England Journal dealt only with short-term outcomes on patients, but a physician's performance could have long-term effects on patient health too.

Jeffrey Rothschild, a hospitalist physician at Newton-Wellesley Hospital in Massachusetts, published a study in 2009 finding that post-surgical complications rose when physicians at a single hospital had less than six hours of opportunity for sleep.

More studies should be done looking at long-term effects of sleep deprivation on physicians and at the quantities of sleep to patient outcomes, he said.

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Twitter: @HFNewsTweet

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