EDITORIAL
Sleep Deprivation and the Regulation of Elective Surgical Procedures William C. Lineaweaver, MD
O
ngoing discussions about the regulation of elective procedures by surgeons who have been on call the previous night have proceeded to the level of proposal. A recent issue of the Bulletin of the American College of Surgeons includes an article setting forth guidelines to eradicate ‘‘fatigue related risks to the surgical patient.’’1 The author contends that the issue cannot be left to the ‘‘individual surgeon who may be incapable of making a rational decision.’’ The author further states that a ‘‘systematic approach to the issue of sleep deprivation will provide the best set of safeguards for the surgical patient.’’ First of all, hospitals should provide ‘‘an objective means to evaluate each surgeon’s level of sleep deprivation.’’ The hospital ‘‘should ensure that a surgeon performing elective surgery has had, at a minimum, four hours of uninterrupted sleep before commencing elective surgeryI (and) should establish operational safeguards to prevent a fatigued surgeon from commencing surgeryI.’’ Next, each medical staff should ‘‘establish a limit on surgical work hoursI.’’ Surgical departments should establish guidelines ‘‘regarding taking call the night before an elective surgical schedule.’’ Finally, each surgeon should undergo ‘‘mandatory sleep deprivation training.’’ This complex of regulations is offered not only as a reform of surgical practices to eliminate ‘‘exhaustionI as an unacceptable risk,’’ but also to forestall additional governmental legislation. Setting aside for a moment the extraordinary operational complexities of the proposal, what is the basis for concern about the effects of sleep deprivation on surgical performance? Since 2004, 5 studies have investigated outcomes of elective procedures done by surgeons with or without some defined preexisting sleep deprivation.2Y6 These studies include reviews of 31,430 cases. Specific procedures include cardiac surgery, obstetrical surgery, cholecystectomy, hernia repair, and gastrointestinal procedures. None of the studies identified any significant rate of adverse outcomes with the sleep status of the surgeon. Sleep deprivation status was variously defined, and was based on actual operative activity the night before surgery, total number of self-reported sleep hours, and participation in a nocturnal trauma call shift. Neither the type of sleep deprivation nor any subset of deprivation and surgical procedure yielded a significant difference in the measured performance between sleep-deprived and nonYsleep-deprived surgeons. On the basis of the published studies, regulation of elective cases related to sleep deprivation will have no measurable positive effect on patient outcomes. Regulations may result in such solipsistic outcomes as establishing that protected sleep time results in more sleep.7 Extended experience with the current forms of resident work-hour restrictions has shown no improvements in surgical complications or patient safety measures.8,9 Untoward effects, however, have included decreased operative experience, with one study documenting a combined 31.8% decrease in cases performed by residents in 10 different training programs.10 Similarly, without a foreseeable positive effect on patient outcomes, regulation of postcall elective surgery can result in substantial disruptions in surgical practice and patient care. The administrative acrobatics necessary for developing sleep registries, case cancelling oversights, and work-hour tracking are formidable to contemplate. The effects on patient care will include hardships on cancelled patients who will have to rearrange work schedules, transportation, and child care while extending the duration of their operable diagnoses. The logistics of organizing preoperative preparations, including antibiotics, bowel cleansing, transfusion products, and team procedures will be driven to unpredictable complexities. Surgeons, given the choice of taking call or maintaining their elective practices, may avail themselves of options to leave call schedules, resulting in emergency patients having fewer options for specialized care.11 On the basis of available evidence, sleep-related surgical regulation is a ‘‘drug without a target disease, I a surgical procedure with no measurable outcome.’’12 We should insist that administrative initiatives be subjected to the same evidence-based, outcome-related scrutiny applied to medical and surgical practices. At this time, sleep-related regulation of surgical practice fails any prospect of improved patient care, although it carries great potential for practice disruption and patient hardship. Received January 23, 2014, and accepted for publication, after revision, January 23, 2014. From the 1850 Chadwick Drive, Suite 1427, North Tower, 4 West Jackson, MS 39204. Conflicts of interest and sources of funding: none declared. Reprints: William C. Lineaweaver, MD, JMS Burn and Reconstructive Center, 1850 Chadwick Drive, Suite 1427, North Tower, 4 West Jackson, MS 39204. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7204-0371 DOI: 10.1097/SAP.0000000000000179
Annals of Plastic Surgery
& Volume 72, Number 4, April 2014
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
371
Annals of Plastic Surgery
Editorial
REFERENCES 1. Shearburn EW. Get some rest: minimizing the effects of sleep deprivation on patient care. Bull Am Coll Surg. 2013;98:36Y41. 2. Ellman PI, Law MG, Tach-Leon C, et al. Sleep deprivation does not affect operative results in cardiac surgery. Ann Thorac Surg. 2004;78:906Y911. 3. Rothschild JM, Keohane CA, Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302:1565Y1572. 4. Chu M, Stitt LW, Fox S, et al. Prospective evaluation of consultant sleep deprivation and outcomes in more than 4000 cardiac surgical procedures. Arch Surg. 2011;146:1080Y1085. 5. Sharpe JP, Weinberg JA, Magnotti LJ, et al. Outcomes of operations by attending surgeons after overnight trauma shifts. J Am Coll Surg. 2013;216:791Y799. 6. Vinden C, Nash D, Rangrej J, et al. Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before. JAMA. 2013;210:1838Y1841.
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& Volume 72, Number 4, April 2014
7. Volpp KG, Shea JA, Small DS, et al. Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns. JAMA. 2012;308:2208Y2217. 8. Naylor RA, Rege RV, Valentine RJ. Do resident duty hour restrictions reduce technical complications of emergency laparoscopic cholecystectomy? J Am Coll Surg 2005;201:724Y731. 9. Poulose BK, Ray W, Arbogast PG, et al. Resident work hours and patient safety. Ann Surg. 2005;241:164Y177. 10. Schwartz SI, Galante J, Kaji A, et al. Effect of the 16 hour work limit on general surgery intern operative case volume. JAMA Surg. 2013:148: 829Y833. 11. Hallock GG. Fatigue, work hours, and other fossils. Ann Plast Surg. 2011; 66:323. 12. Lineaweaver W. Sleepy surgeons and patient safety. Ann Plast Surg. 2011;67: 203Y204.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Sleep Deprivation and the Regulation of Elective Surgical Procedures William C. Lineaweaver, MD
O
ngoing discussions about the regulation of elective procedures by surgeons who have been on call the previous night have proceeded to the level of proposal. A recent issue of the Bulletin of the American College of Surgeons includes an article setting forth guidelines to eradicate ‘‘fatigue related risks to the surgical patient.’’1 The author contends that the issue cannot be left to the ‘‘individual surgeon who may be incapable of making a rational decision.’’ The author further states that a ‘‘systematic approach to the issue of sleep deprivation will provide the best set of safeguards for the surgical patient.’’ First of all, hospitals should provide ‘‘an objective means to evaluate each surgeon’s level of sleep deprivation.’’ The hospital ‘‘should ensure that a surgeon performing elective surgery has had, at a minimum, four hours of uninterrupted sleep before commencing elective surgeryI (and) should establish operational safeguards to prevent a fatigued surgeon from commencing surgeryI.’’ Next, each medical staff should ‘‘establish a limit on surgical work hoursI.’’ Surgical departments should establish guidelines ‘‘regarding taking call the night before an elective surgical schedule.’’ Finally, each surgeon should undergo ‘‘mandatory sleep deprivation training.’’ This complex of regulations is offered not only as a reform of surgical practices to eliminate ‘‘exhaustionI as an unacceptable risk,’’ but also to forestall additional governmental legislation. Setting aside for a moment the extraordinary operational complexities of the proposal, what is the basis for concern about the effects of sleep deprivation on surgical performance? Since 2004, 5 studies have investigated outcomes of elective procedures done by surgeons with or without some defined preexisting sleep deprivation.2Y6 These studies include reviews of 31,430 cases. Specific procedures include cardiac surgery, obstetrical surgery, cholecystectomy, hernia repair, and gastrointestinal procedures. None of the studies identified any significant rate of adverse outcomes with the sleep status of the surgeon. Sleep deprivation status was variously defined, and was based on actual operative activity the night before surgery, total number of self-reported sleep hours, and participation in a nocturnal trauma call shift. Neither the type of sleep deprivation nor any subset of deprivation and surgical procedure yielded a significant difference in the measured performance between sleep-deprived and nonYsleep-deprived surgeons. On the basis of the published studies, regulation of elective cases related to sleep deprivation will have no measurable positive effect on patient outcomes. Regulations may result in such solipsistic outcomes as establishing that protected sleep time results in more sleep.7 Extended experience with the current forms of resident work-hour restrictions has shown no improvements in surgical complications or patient safety measures.8,9 Untoward effects, however, have included decreased operative experience, with one study documenting a combined 31.8% decrease in cases performed by residents in 10 different training programs.10 Similarly, without a foreseeable positive effect on patient outcomes, regulation of postcall elective surgery can result in substantial disruptions in surgical practice and patient care. The administrative acrobatics necessary for developing sleep registries, case cancelling oversights, and work-hour tracking are formidable to contemplate. The effects on patient care will include hardships on cancelled patients who will have to rearrange work schedules, transportation, and child care while extending the duration of their operable diagnoses. The logistics of organizing preoperative preparations, including antibiotics, bowel cleansing, transfusion products, and team procedures will be driven to unpredictable complexities. Surgeons, given the choice of taking call or maintaining their elective practices, may avail themselves of options to leave call schedules, resulting in emergency patients having fewer options for specialized care.11 On the basis of available evidence, sleep-related surgical regulation is a ‘‘drug without a target disease, I a surgical procedure with no measurable outcome.’’12 We should insist that administrative initiatives be subjected to the same evidence-based, outcome-related scrutiny applied to medical and surgical practices. At this time, sleep-related regulation of surgical practice fails any prospect of improved patient care, although it carries great potential for practice disruption and patient hardship. Received January 23, 2014, and accepted for publication, after revision, January 23, 2014. From the 1850 Chadwick Drive, Suite 1427, North Tower, 4 West Jackson, MS 39204. Conflicts of interest and sources of funding: none declared. Reprints: William C. Lineaweaver, MD, JMS Burn and Reconstructive Center, 1850 Chadwick Drive, Suite 1427, North Tower, 4 West Jackson, MS 39204. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7204-0371 DOI: 10.1097/SAP.0000000000000179
Annals of Plastic Surgery
& Volume 72, Number 4, April 2014
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
371
Annals of Plastic Surgery
Editorial
REFERENCES 1. Shearburn EW. Get some rest: minimizing the effects of sleep deprivation on patient care. Bull Am Coll Surg. 2013;98:36Y41. 2. Ellman PI, Law MG, Tach-Leon C, et al. Sleep deprivation does not affect operative results in cardiac surgery. Ann Thorac Surg. 2004;78:906Y911. 3. Rothschild JM, Keohane CA, Rogers S, et al. Risks of complications by attending physicians after performing nighttime procedures. JAMA. 2009;302:1565Y1572. 4. Chu M, Stitt LW, Fox S, et al. Prospective evaluation of consultant sleep deprivation and outcomes in more than 4000 cardiac surgical procedures. Arch Surg. 2011;146:1080Y1085. 5. Sharpe JP, Weinberg JA, Magnotti LJ, et al. Outcomes of operations by attending surgeons after overnight trauma shifts. J Am Coll Surg. 2013;216:791Y799. 6. Vinden C, Nash D, Rangrej J, et al. Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before. JAMA. 2013;210:1838Y1841.
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www.annalsplasticsurgery.com
& Volume 72, Number 4, April 2014
7. Volpp KG, Shea JA, Small DS, et al. Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns. JAMA. 2012;308:2208Y2217. 8. Naylor RA, Rege RV, Valentine RJ. Do resident duty hour restrictions reduce technical complications of emergency laparoscopic cholecystectomy? J Am Coll Surg 2005;201:724Y731. 9. Poulose BK, Ray W, Arbogast PG, et al. Resident work hours and patient safety. Ann Surg. 2005;241:164Y177. 10. Schwartz SI, Galante J, Kaji A, et al. Effect of the 16 hour work limit on general surgery intern operative case volume. JAMA Surg. 2013:148: 829Y833. 11. Hallock GG. Fatigue, work hours, and other fossils. Ann Plast Surg. 2011; 66:323. 12. Lineaweaver W. Sleepy surgeons and patient safety. Ann Plast Surg. 2011;67: 203Y204.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
