Sleepy Surgeons Cause More Errors Than Well-Rested Docs

Hospitals seeking to reduce their operative complication rates should make sure their attending surgeons get at least six hours of sleep between the time they last performed an operation.

That's one of the conclusions from a study by a team at Brigham and Women's Hospital in Boston led by Jeffrey M. Rothschild, MD, of the Division of General Medicine. The study is published in today's Journal of the American Medical Association.

Rothschild's team found a 2.7-fold increase in complications among post-nighttime surgical procedures performed by attending physicians with sleep opportunities of less than six hours compared with those performed by attending surgeons who got more rest the night before.

The study compared 919 surgical and 957 obstetrical post-nighttime procedures with 3,552 and 3,945 control procedures respectively between January 1999 and June of 2008.

They found complications occurred in 6.2% of the post-nighttime procedures when surgeons had sleep opportunities of six hours or less, compared with 3.4% complication rate when surgeons had more than six hours sleep.

"These data suggest that attending physicians, like residents and nurses, may be at increased risk of making errors when sleep deprived or working extended shifts," the authors wrote.

In a media briefing Tuesday, Rothschild said the study findings "raise the importance of professionalism and the need for physicians to step up to the plate. If they feel tired or they find a colleague is tired, to find another way to approach this problem."

Complications measured included surgical site infections, bleeding, organ injury, wound failure, neural damage, and fracture/dislocation.

The study was launched to look into the issue of attending physician and surgeon fatigue. In the past, there have been studies linking resident fatigue with higher incidence of medical errors, including percutaneous needlesticks and lacerations and post-call motor vehicle crashes.

However, the authors wrote, "Less is known about the effects of extended-duration work shifts on the performance of attending physicians." To their surprise, they did not find a higher risk of complications for surgeons and obstetrician/gynecologists who performed procedures the preceding night (procedures that began or ended between midnight and 6 a.m.), compared with surgeons who did not work the preceding night.

The key was in the amount of sleep they got between surgeries, factoring in the time it takes after a surgical procedure to wash up, get dressed, drive home, relax and get to sleep, and then drive back to the hospital to begin a new surgical day.

The authors wrote that because of concerns about their professional development, "attending physicians may be less likely to acknowledge the potentially harmful effects of extended work shifts than trainees. Some attending physicians may also be less inclined than residents to postpone electively scheduled surgical procedures even when they are aware of the possibility of decreased alertness from insufficient overnight sleep.

Rothschild suggested hospitals and surgeons look at five strategies to reduce the times when surgeons go back into the operating room after fewer than six hours sleep.

• If possible, avoid scheduling elective procedures following overnight on-call responsibilities
• Use hospital-based physicians to cover overnight emergencies
• Consider cancelling or postponing elective procedures when the risks are high or when colleagues feel the risks are high
• Use teamwork, including backups, to assist or relieve fatigued physicians
• Consider using caffeine if the surgeon must perform lifesaving procedures