Limiting On-Call Hours Improves Resident-Physicians’ Neurobehavioral Performance
1. A large, multicenter clinical trial found that resident-physicians who worked ≤ 16 consecutive hours for a majority of their shifts over a four-week period had fewer attentional failures, faster reaction time, and lower subjective sleepiness than participants who worked shifts of ≥ 24 hours every 3-4 shifts.
2. These neurobehavioral metrics, along with the correlative reduction in serious medical errors, contribute significantly to the conversation about the value of reducing resident-physician on-call hours.
Evidence Rating Level: 2 (Good)
Study Rundown: To date, the deleterious effects of extended-duration work rosters (EDWRs; shifts lasting greater than 24 hours) as compared to rapid cycling work rosters (RCWRs; shifts capped at 16 hours) remain controversial. On the basis of a number of past conflicting studies, the Accreditation Council for Graduate Medical Education (ACGME) has alternatingly limited, then extended, the maximum allowable length of on-call duration. This study found that compared to a control group (EWDRs), residents who were limited to shifts of no longer than 16 hours’ duration (RCWRs) had significantly lower sleepiness ratings, faster mean reaction times, fewer attentional failures, better slowest 10% reaction times, and fewer serious medical events, according to data collected from Psychomotor Vigilance Tasks (PVT), participant’s sleep diaries, and observer data. After adjustment for resident workload, fewer serious medical errors occurred in the RCWR group. This study improved on previous studies by including a much larger cohort of resident-physicians in the study (n=312) and utilizing multiple clinical sites. The study was limited by the fact that the experimental RCWR was not uniform across clinical sites and workload was variable between programs and residents. Results of this study may call into question the current position of the ACGME allowing 28-hour continuous call.
Click to read the study in Pediatrics
Click to read an accompanying editorial in Pediatrics
Relevant Reading: Effects of reducing or eliminating resident work shifts over 16 hours: A systematic review
In-Depth [randomized controlled trial]: The Randomized Order Safety Trial Evaluating Resident-Physician Schedules (ROSTERS) study was a multicenter cluster-randomized crossover clinical trial taking place at 6 PICUs in the United States. It compared resident-physician cognitive performance and medical outcomes between traditional extended shifts (24-28 hours) and the intervention group working no more than 16 hours a shift. Only PGY-2 and PGY-3 residents were eligible for this 4-week study. Participants were randomized to EDWR or RCWR groups. Neurobehavioral performance was assessed using 10-minute Psychomotor Vigilance Task (PVT) assessments taken every 5 hours through a shift (mean attentional failures, mean reaction time, and mean of the slowest 10% of responses). Subjective sleepiness was measured using the Karolinska Sleepiness Scale (KSS) and daily electronic sleep and work logs. Medical error data was tracked and synthesized from direct observation of residents, review of unit charts by trained research nurses, voluntary reports from unit staff, and formal hospital incident reports. Significant improvement in every metric of neurocognitive performance was observed in the RCWR groups, with fewer attentional failures (mean ± SE, 2.9 ± 0.7 vs 6.8 ± 1.0; P = .01), faster mean reaction time (283.7 ± 6.3 vs 336.2 ± 7.2; P < .0001), slowest 10% reaction time (509.9 ± 24.6 vs 683.8 ± 31.8; P < .0001), and lower sleepiness ratings (4.4 ± 0.1 vs 4.8 ± 0.1; P < .0001).
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