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There's the rub: The risk of sleepy surgeons
Expert: No elective surgery after a night of call
Just as hospitals are set to comply with new restrictions on medical resident hours to reduce fatigue, a leading sleep expert is questioning the schedules that could lead to sleep deprivation among practicing surgeons.
A surgeon who has been awake 22 of the past 24 hours due to on-call duty should re-schedule elective surgery or at least inform patients and allow them to decide whether to continue with the elective surgery, says Charles Czeisler, PhD, MD, director of the Division of Sleep Medicine at Harvard School of Medicine in Boston. Czeisler and two colleagues presented this perspective in a recent article in the New England Journal of Medicine.1
Preferably, hospitals should not permit the scheduling of elective surgery during the day after a surgeon has had nighttime call duty, he says.
"In those instances where the institution does not implement safer policies regarding surgeon's work schedules prior to operations, at least patients have a right to know," he says. "That is certainly not the ideal situation because it creates a burden on patients and inefficiencies for hospitals. The far more sensible thing is to implement a program where this does not happen."
Czeisler has been a proponent of greater restrictions on work hours of medical residents to allow more time for sleep. As of July 1, new rules of the Accreditation Council for Graduate Medical Education limit the work hours of first-year residents to 16-hour shifts. First-year and "intermediate-level" residents must have at least eight hours off between shifts.2
Those restrictions still fall short of what Czeisler, other sleep experts and advocates for medical residents say is necessary to reduce the risk of error due to fatigue. (See HEH, November 2010, p.127.) In its 2009 report, "Resident Duty Hours: Enhancing Sleep, Supervision and Safety," an Institute of Medicine panel cited gaps in compliance with the ACGME standard that left residents "susceptible to acute and chronic sleep deprivation."3
Some have argued that residents need long shifts, especially in specialties such as surgery, to allow them adequate opportunities for training and for continuity of care of patients. But there's no imperative for a surgeon to perform an elective procedure while sleep-deprived, says Czeisler.
A retrospective study of surgical and obstetrical procedures found an 83% increase in the risk of complications in patients who had elective procedures performed by surgeons who had less than six hours of opportunity for sleep the night before because of on-call duty.4
"It came to our attention that it was routine practice for surgeons to schedule elective procedures even when they're on call the night before," Czeisler says. "This had to do with the fact that the on-call schedules were established often completely independently of the scheduling of elective procedures."
Some hospitals already prohibit that practice, he says. "There are some institutions where this routinely happens and some where it very rarely happens," he says.
In a letter to the same issue the New England journal, the American College of Surgeons said surgeons should be educated about the impact of fatigue on performance and should make the decision about whether to inform patients, reschedule surgeries or request assistance.
1. Nurok M, Czeisler CA, Lehmann LS. Sleep deprivation, elective surgical procedures, and informed consent. N Engl J Med 2010; 363:2577-2579.
2. Pellegrini CA, Britt LD, Hoyt DB. Sleep deprivation and elective surgery. N Engl J Med 2010; 363:2672–2673.
3. Institute of Medicine. Resident duty hours: Enhancing sleep, supervision, and safety. National Academies Press, Washington, D.C., 2009.
4. Rothschild JM, Keohane CA, Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA 2009; 302:1565-1572.