A study designed to assess the effect of disrupted sleep on surgeons finds that surgical complications did not increase when surgeons who operated on emergency cases during the midnight to 7 AM shift operated on scheduled patients later in the day.
Surgeons with disrupted sleep, who operated on patients between midnight and 7 AM., and on different patients undergoing elective gallbladder surgeries after 7AM, did not demonstrate higher rates of complications in the second set of patients.
That's the finding from a first-of-its kind study in Tuesday's JAMA that looked at outcomes from 2,078 elective laparoscopic cholecystectomies performed by 331 Canadian general surgeons. All of the surgeons had operated on different patients who needed emergency surgery between midnight and 7 AM.
The at-risk surgeries, defined as daytime procedures performed by surgeons who had operated hours earlier, were matched with four other procedures performed by the same doctors who had not been operating hours earlier.
"There was no evidence that operating the night before was associated with conversion to open cholecystectomy, the risk of iatrogenic complications, or death from elective laparoscopic surgery performed the next day," the authors wrote.
Poor outcomes also did not increase when surgeons had midnight to 7 AM shifts on the trauma service and operated on scheduled patients the next day, but had similar rates of complications as surgeons who had not operated the night before.
The study was performed at 102 non-academic hospitals by Christopher Vinden, MD, and colleagues at the Western University in London, in the province of Ontario.
The authors said they focused on laparoscopic gall bladder operations because they are commonplace, and because "errors attributable to disrupted sleep occur in common and routine tasks."
A Legal Challenge
The study has implications for 80-hour per week duty hour limits in medical training and hospital regulations that were established in U.S. medical teaching programs in 2003, 20 years after an incident, in which an 18-year-old college freshman, Libby Zion, died at New York Hospital.
The patient's father, attorney Sidney Zion, alleged that administration of drugs with fatal interactions and use of restraints that contributed to his daughter's death were due to the hospital residents' long-working hours.
The authors of the Ontario study conclude that "policies limiting attending surgeon work hours are controversial. Critics suggest such policies reduce continuity in care, increase communication errors, and introduce the potential for a bystander effect (in which one surgeon may expect another to bear the burden for authority and responsibility)," they wrote.
Also, the authors wrote, policies preventing surgeons who operated on the night shift from operating hours later "would have important cost, staffing, and resource implications," possibly increasing costs by more than $1 million per life saved. In rural areas, they wrote, establishing work hour limits "may not be possible without making care unavailable."
Conflicting Study Results
In an accompanying editorial, Michael Zinner, MD, of Brigham and Women's Hospital in Boston, and Julie Ann Fresichlag, MD, of Johns Hopkins Medical Institute in Baltimore, noted that a basis for arguments in favor of duty hour limits lie in a 2009 study.
Data presented in that report "demonstrated higher complication rates among attending surgeons who had worked the night before and performed elective operations the following day."
Zinner and Fresichlag wrote that even though there was no difference in complication rates, "a subgroup analysis revealed more complications among cases in which the surgeon had operated at night within six hours before performing the elective operation… compared with when the nighttime operation occurred more than six hours before the elective operation."
And they cautioned that while routine monotonous tasks can be adversely affected by limited amounts of sleep before the task, "Pilots do not fall asleep during takeoff and landing, truck drivers do not fall asleep during loading and unloading, and astronauts do not fall asleep during atmospheric reentry."
Recommendation: Self-Assess
Zinner and Fresichlag acknowledged that the study by Vinden and colleagues verifies that surgeons can safely perform elective procedures when they operated hours earlier.
"However, just as each patient undergoing an operation requires an individualized assessment and operative plan, each surgeon must objectively self-assess fatigue level and honestly determine" whether—if he or she operated all night—he can operate with the same level of skill as he or she would with a good night's sleep. Patient safety and surgeon well-being deserve no less."