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24-Hour ER Shifts Linked to Cognitive Impairment in Physicians

Analysis  |  By Christopher Cheney  
   August 13, 2018

Daylong shifts in the emergency room pose a threat to physician health and patient safety, researchers say.

Recently published research shows the cognitive abilities of emergency room physicians were significantly impaired after working a 24-hour shift.

The researchers, who published their work in this month's edition of the Annals of Emergency Medicine, gauged the cognitive function of 40 ER physicians after a night of rest at home, after a 14-hour shift, and after a 24-hour shift.  

While there was no difference in cognitive function after a night of rest at home compared to working a 14-hour shift, the researchers found ER physicians posted lower scores for three out of four cognitive functions after working a 24-hour shift.

"The cognitive abilities of emergency physicians were significantly altered after a 24-hour shift, whereas they were not significantly different from the rested condition after a 14-hour night shift," the researchers wrote.

While the research suggests that a 14-hour night shift could be a more optimal schedule for ER doctors, the primary conclusion of the Annals of Emergency Medicine article is that 24-hour shifts should be discontinued.

"Our results mainly suggest that emergency physicians should not continue to work 24 consecutive hours," the researchers wrote.

The risks associated with physician fatigue have been published in earlier research, they wrote. "Chronic tiredness related to long working hours is common among physicians. It has also been clearly established that chronic tiredness negatively affects patient safety."

In their study, the Annals of Emergency Medicine researchers found that ER physicians underestimated the level of their cognitive impairment.

"The lack of correlation that we found between the self-evaluation of tiredness and cognitive performance suggests that emergency physicians were not able to accurately evaluate their tiredness and attention capacity. This could lead to increased risks to their own health and patient safety," the researchers wrote.

Assessing cognition

The researchers assessed four measures of cognitive function: processing speed, working memory capacity, cognitive flexibility, and perceptual reasoning.

Processing speed is important for multitasking. Working memory capacity features short-term memory, which enables decision algorithms and helps determine the level of an emergency. Cognitive flexibility supports strategic capacity and executive functions. Perceptual reasoning, enables understanding of abstract concepts and rules.

ER physicians underwent a three-part assessment:

  • A questionnaire collected demographic and lifestyle data as well as highlights of the previous night shift
  • Participants conducted a self-assessment of tiredness, sleep deprivation, and degradation of attention and mood
  • An examiner evaluated participants' cognitive abilities

The researchers found that ER physicians who work 24-hour shifts experienced decreased functionality in processing speed, working memory capacity and perceptual reasoning. When compared to cognitive abilities after resting at home, decreased performance ranged from 10% to 21%.

The researchers say these decreases in cognitive function likely have negative impacts on emergency departments. "Because these cognitive abilities are involved in the practice of emergency medicine, their decrease is likely to affect abilities such as using a decision algorithm, making a diagnosis, prioritizing emergencies, or multitasking."


Earlier research and the Annals of Emergency Medicine article suggest several methods to avoid sleep deprivation among ER physicians:

  • Napping and strict sleep hygiene have been proposed
  • For residents, the Accreditation Council for Graduate Medical Education Task Force recommends strategic napping for residents
  • The Annals of Emergency Medicine say conscious effort is required to achieve strategic napping because of demanding workloads and busy periods in the ER setting

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.

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