The Effect of New ACGME Work Hour Rules on Resident Exhaustion: Prospective Study in a Community Teaching Hospital

1. The Effect of New ACGME Work Hour Rules on Resident Exhaustion: Prospective Study in a Community Teaching Hospital Tovy Haber Kamine, MD John D. Galbraith, MD Frederick Millham, MD Janet Larson, MD

2. Background: The New Work Hours • A 16 hour schedule decreased attention failures and increased wakefulness over a q3 schedule. • Interns started new ACGME work hours: July, 2011 • 80 hours per week • No more than 16 hours straight per shift Lockley et al., Effect of Reducing Interns’ Weekly Work Hours on Sleep and AttentionalFailures. NEJM. 2004. 351(18):1829-37

3. Background: Nightfloat Risks • Decrease in education • Deterioration in laparoscopic skills • Decreased perception of quality of education • Increased sleepiness • Increased risk of car accidents • Hormonal abnormalities • Increased risk of metabolic syndrome • Increased risk of stroke • Increased risk of breast cancer • Decreased mood

4. Methods: Surveys • NWH Transitional Year Interns and rotating MGH Anesthesia, Medicine, Psychiatry and Surgery interns filled out surveys • From 2/9/2011 until 5/20/2011, interns on the Surgical, Medical, and MICU services filled out weekly surveys including: • demographic data • Questions from the Beck Depression Inventory • Epworth Sleepiness Scale • The Surgical service switched to an ACGME compliant on 3/3/2011

5. Methods: Statistical Analysis • Data dichotomized for analysis • ESS scores dichotomized to <10 or 10+ • Hours dichotomized to <80, 80+ • Days of depression and self-reported error data dichotomized to 0 or 1+ in the past week • All other data dichotomized about the median • Comparison of absolute ESS scores performed using an unpaired T-Test • All other comparisons and relative risks calculated using a chi square test • Surgical data were used to evaluate the effects of workhours change • All data (including medicine data) were used to evaluate the effects of working >80 hours

6. Results: Surveys • 97 total surveys filled out by 44 interns over the study period • 30 surveys were filled out by 14 interns on the surgical service

7. Results-Effects of Working >80 hours per week

8. Results: Work Hours Schedule

9. Results-Work Hours Schedule * P=0.01

10. Discussion-Hours • Interns working >80 hours were more tired than those working <80 hours • In addition, they reported more depression and trended to more self-reported errors • This is consistent with Lockley, et al 2004, where “intervention group” residents averaged 65 hours compared to 85 hours in the Q3 call group • All interns in this cohort abided by the ACGME rules, i.e. they did not work more than 80 hours per week, averaged over 4 weeks • However, these data suggest that residents should not work more than 80 hours in any week.

11. Discussion-Work Hours Schedule • Interns on the AGCME-compliant work hours schedule were significantly more tired than those on a Q4 schedule. • Residents' average ESS on the ACGME-compliant schedule was identical to previously published data from before the 80 hour work week was implemented

12. Discussion-Work Hours Schedule • Increased sleepiness may be due to: • Lack of a post-call day to recuperate from decreased sleep • Up to 12 days accumulation of sleep debt, rather than 4 • Previous data have correlated ESS scores with medical errors. • Our data did not show increased self-reported medical errors in the ACGME compliant group, though they were more tired-this may be due to insignificant power of our study to detect this. • More study is needed on the real world effects of the new ACGME work hours

13. Conclusions • The new ACGME work hours cause interns to be as tired as they were before implementation of the 80-hour work week • The schedule of work may be more important than the total number of hours worked • Interns who work more than 80 hours in a week are more tired, more likely to be depressed, and trend to more self-reported errors

14. Acknowledgements • Marie Williams • Rebecca Barron, MD, MPH • Agnes Lesicka, MD • Interns of NWH

15. Questions?

16. Additional References Volpp, et al., Mortality Among Hospitalized Medicare Beneficiaries in the First 2 Years Following ACGME Resident Duty Hour Reform, JAMA. 2007;298(9):975-983 de Virgilio, et al., The 80-Hour Resident Workweek Does Not Adversely Affect Patient Outcomes or Resident Education, Current Surgery, 2006; 63(6):435-9 Mcelearney, et al., Effect of the 80-Hour Work Week on Cases Performed by General Surgery Residents, Am Surgeon, 2005;71(7):552-556 Leibrandt, et al., Has the 80-Hour Work Week Had an Impact on Voluntary Attrition in General Surgery Residency Programs?, JACS. 2006;202(2):340-344 Carlin, et al., Effect of the 80-hour work week on resident operative experience in general surgery, Am J Surg A. 2007;193(3):326-330 Gordon, et al., Does Simulator-Based Clinical Performance Correlate With Actual Hospital Behavior? The Effect of Extended Work Hours on Patient Care Provided by Medical Interns, Academic Med. 2010;85(10):1583-1588 Schenarts, et al., The effect of a rotating night-float coverage scheme on preventable and potentially preventable morbidity at a level 1 trauma center. Am J Surg. 2005; 190(1):147-152 Leff, et al., Laparoscopic Skills Suffer on The First Shift of Sequential Night Shifts: Program Directors Beware and Residents Prepare, Ann Surg 2008 247(3) 530-539 Pietroiusti et al., Incidence of metabolic syndrome among night-shift healthcare workers, Occup Environ Med 2010;67:54-57 Brown, et al., Rotating Night Shift Work and the Risk of Ischemic Stroke, Am. J. Epidemiol. (2009) 169 (11): 1370-1377 Hansen, Risk of Breast Cancer After Night- and Shift Work: Current Evidence and Ongoing Studies in Denmark, Cancer causes control (2006) 17:531-53 Crowley et al., Complete or partial circadian re-entrainment improves performance, alertness, and mood during night-shift work. Sleep. 2004;27(6):1077-87 Touitou , et al., Effect of shift work on the night-time secretory patterns of melatonin, prolactin, cortisol and testosterone. Eur J App Physiol, 1990;60(4):288-92 Åkerstedt, et al., Impaired alertness and performance driving home from the night shift: a driving simulator study. J Sleep Research, 2005;14(1):17-20 Gold, et al., Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. Am J Pub Health 1992;82(7):1011-1014 Cavallo, et al., Impact of Night-Float Rotation on Sleep, Mood, and Alertness: The Resident’s Perception. Chronobiology International; 2002;19(5):893-902 Son, et al., Effects of long working hours and the night shift on severe sleepiness among workers with 12-hour shift systems for 5 to 7 consecutive days in the automobile factories of Korea. J Sleep Research; 2008;17(4):385-94 McCoy, et al., Effect of 16-Hour Duty Periods on Patient Care and Resident Education. Mayo Clinic Proc 2011;86(3):192-196 Papp, et al., The Effects of Sleep Loss and Fatigue on Resident–Physicians: A Multi-Institutional, Mixed-Method Study, Acad. Med. 2004. 79 (5);394-406