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Arezou Yaghoubian MD, Amy H. Kaji MD PhD, Brant Putnam MD and Christian de Virgilio MD
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Surgical Outcomes Pre and Post Duty Hours
• 1 study: decreased rate of bile duct injury
• 10 studies: no change in surgical patient outcome
• 4 studies: worse patient outcomes
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de Virgilio et al Mortality and morbidity unchanged
Salim et al Mortality unchanged Increase in the complication rate
Morrison et al National Trauma Data Bank Slightly decreased mortality (4.5% vs.
4.6%)
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New IOM Recommendations
CALLNo more than Q 3rd Night
5 hr nap time > 16 hours of work during a 30-hour shift
Max 16 hr shift without protected sleepDAYS OFF 5 days/monthTIME OFF BETWEEN SHIFTS 10 hours off between day shifts 12 hours off after night shift 14 hours off after 30 hr shift
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Effects on surgical training Eliminates 24 hr+ call De facto duty hour reduction from
8056 hr/wk Increase length of surgical residency
The European experience 58 hours/week Decreased patient interaction Loss of continuity of care Detrimental effect on operative volume
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To compare outcomes of trauma surgery performed by surgical
residents during 1st 16 hours of shift vs. those performed by residents
beyond 16 hr shift
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Retrospective review All urgent/emergent trauma surgery
since duty hour restriction (July 2003-2009)
Comparison of two time periods: 6 am-10 pm (daytime) vs. 10 pm- 6 am
(nighttime) Operations after 10 pm performed by
residents who began their shift at 6 am and had thus been working 16>hours
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Morbidity Wound infection, pneumonia, DVT,
pulmonary embolism and pulmonary insufficiency
Mortality
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Urban busy Level I trauma centerHigh volume penetrating injuriesNo night float systemResidents on the Trauma Service
take call Q 3rd night and work 24-hr shifts
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Daytime 6am – 10pm
n = 766 (56.2%)
Nighttime 10pm -6am
n = 597 (43.8%)
P value
Male 627 (81.9%) 521 (87.3%) 0.007Penetrating trauma 497 (64.9%) 481 (80.6%) <0.0001Median age (years) 29 25 <0.0001Median ISS 16 13 0.002Median length of stay (days)
8 7 0.08
Median POS 0.98 0.98 0.005
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Daytime 6am – 10pm
n = 766 (56.2%)
Nighttime 10pm -6am
n = 597 (43.8%)
P value
Deaths 103 (13.5%) 63 (10.6%) 0.1Total complications 153 (20.0%) 93 (15.6%) 0.04 Pulmonary embolism 3 (0.5%) 10 (1.3%) 0.1 Pulmonary insufficiency
15 (2.5%) 39 (5.1%) 0.02
DVT 4 (0.5%) 6 (1%) 0.3 Wound infection 33 (4.3%) 27 (4.5%) 0.9 Pneumonia 63 (8.2%) 27 (4.5%) 0.006
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Odds Ratio 95%
Confidence
Interval
P
Time of
operation
0.97 0.7-1.3 0.9
Age 1 1.008-1.028 0.0004
ISS 1 1.03-1.04 <0.0001
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Odds Ratio 95% Confidence
Interval
P
Time of
operation
1.02 0.7-1.6 0.9
Age 1.03 1.02-1.04 <0.0001
ISS 1.1 1.09-1.12 <0.0001
Penetrating
trauma
2.7 1.6-4.7 0.0002
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Prior Studies on Daytime vs Nighttime General Surgery Appendectomy
878 daytime, 708 night time (>16 hr shift) No difference in morbidity, mortality,
conversion to open, or length of surgery Cholecystectomy
2522 daytime, 306 night time (>16 hr shift) No difference in bile duct injury, overall
morbidity, mortality, conversion to open, or length of surgery
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Trauma surgery performed at night by residents working >16 hrs have similar favorable outcomes as those performed by more rested residents
Instituting a 5-hour rest period after 16 hrs is unlikely to improve outcomes
When combined with our prior study (appendectomy and cholecystectomy), data even more compelling