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Night Surgery Not a Factor in Transplant Mortality, JHU Study Finds

 |  By John Commins  
   June 02, 2011

Heart and lung transplants that are done at night have no affect on patient survival, despite concerns about surgeon fatigue, a study published in the Journal of the American Medical Association has found.  

"We aren't suggesting that fatigue is good," Ashish S. Shah, MD, an assistant professor of surgery at the Johns Hopkins University School of Medicine and the study's lead author, said in a media release. "But what is important is that, at least in this specialty, it seems we're able to deal with it without subjecting the patient to risk."

The research covers 10 years of heart and lung transplants — more than 27,000 — at medical centers across the country.

"This is one of the first papers to suggest that fatigue, sleep deprivation, and odd hours really don't hurt the patient. It's a surprising finding," Shah said. "While we've felt this, other papers have suggested patients are at risk if they are treated at night. For patients undergoing heart and lung transplants, everything is fine — regardless of the hour, our study shows."

Heart and lung transplants are done whenever organs become available, without regard for the time or how much work a surgeon has already done that day, Shah said.

Previous studies have linked nighttime care with worse outcomes. One study found that nighttime cardiac arrests were associated with lower survival and unfavorable neurological outcomes. Another found that urgent orthopedic surgery at night was linked to a higher rate of unplanned reoperation. A third found that nighttime kidney transplantation was associated with higher risk of graft failure and the need for more emergency reoperation.

Shah said it would not have been surprising to find the same issues with heart and lung transplants. But Shah's research found that the rate of reoperation was the same regardless of operative time of the day. The team also found that hospital length of stay was the same no matter what time the surgery took place.

The Johns Hopkins researchers reviewed United Network of Organ Sharing data on all adult heart and lung transplants in the United States between January 2000 and June 2010. Of the 16,573 who underwent heart transplants, half were done during the day and half at night. After one year, the survival rate for heart transplants was 88% for daytime recipients and 87.7% for those who got their new hearts at night. Researchers categorized daytime operations as those where the critical portion of the surgery took place during the day. Successful heart transplants can take as many as five to 10 hours to complete, said Shah, a cardiac surgeon.

For the 10,545 lung transplants, roughly half were done during the day and half at night. After one year, 83.8% of those who got their organs during the day were still alive, compared to 82.6% of those who had their surgeries at night.

Shah said the success in heart and lung transplant outcomes, no matter the time of day, is a testament to experienced transplant teams who have learned to effectively perform complex surgeries on sick patients, despite fatigue and emotional stress.

He said the new findings show the need for more outcomes research. Without specifically looking at the question of fatigue and medical errors in heart and lung transplants, the assumption would have been that these surgeries are less safe when done at night. "It's worth asking these questions rather than extrapolating the conclusions from other specialties," he said.

Heart and lung transplant teams could serve as a model for others, Shah said, and researchers may learn something from examining why they are so successful and using that knowledge to improve outcomes in other specialties.

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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