ORIGINAL ARTICLE
The Effect of Sleep Deprivation on a Resident’s Situational Awareness in a Trauma Scenario Alexandra Stratton, MD, Andrew Furey, MD, MSc, and Micheal Hogan, MD, MMEd
Objectives: Situational awareness (SA) refers to the perception of elements in one’s environment, the comprehension of their meaning, and the projection of their status in the near future. The SA global assessment technique (SAGAT) is an assessment tool validated for use in a trauma simulation. The goal of this study was to determine the effect of sleep deprivation on residents’ performance in a trauma simulation, evaluated by the SAGAT.
Methods: A power analysis determined that 9 residents would be needed to show a significant difference in SAGAT scores (7%). Therefore, 9 surgical residents on an intensive care unit rotation underwent 2 trauma simulations. One session was performed in the rested condition, and the other was for postcall. The SAGAT was used to evaluate the residents’ performance. The rested and postcall scores were compared. Results: Using a paired t test, the SAGAT scores were analyzed. The average rested score was 80.13% (range, 50%–94%), and the sleep-deprived score was 80.09% (range, 72%–91%). There was no significant difference between the residents’ rested and the postcall SAGAT scores (P = 0.99). Conclusions: From this study, the resident SA in a trauma simulation does not seem to be affected by 1 night of sleep deprivation, as demonstrated by the lack of significant difference in SAGAT scores; however, more research in this area is needed. Key Words: sleep deprivation, resident, duty hours, trauma simulation, situational awareness, simulator
Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. (J Orthop Trauma 2014;28:e160–e163)
BACKGROUND Resident work hours and resulting sleep deprivation have come under close scrutiny over the past 2 decades. In 2003, the Accreditation Council for Graduate Medical Accepted for publication September 11, 2013. From the Memorial University of Newfoundland, Newfoundland and Labrador, Canada. The authors report no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www.jorthotrauma.com). Reprints: Alexandra Stratton, MD, Memorial University of Newfoundland, 4 Carty Place, St. John’s, Newfoundland and Labrador A1A 1M6, Canada (e-mail: [email protected]). Copyright © 2013 by Lippincott Williams & Wilkins
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Education (ACGME) in the United States imposed restrictions on the resident work hours (ACGME 2003). The Institute of Medicine (IOM) published a report in 2008 with further recommendations,1 many of which were approved by the ACGME in September 2010.2,3 There were several published studies contributing to these recommendations, namely, that by Barger et al,4 which demonstrated an increase in the medical errors made by residents working extended-duration shifts (at least 24 hours). The effects of extended periods of wakefulness among residents on many parameters have been researched. Such parameters include clinical performance,5,6 cognitive function,5,7 attention,8 working memory,8,9 psychomotor performance,10 fine motor skills,10,11 medical errors,12 driving simulator performance,13 examination scores,14,15 operative efficiency,16 procedural skills,17–21 and postoperative complications.16,22,23 However, the effect of sleep deprivation on medical residents’ situational awareness (SA) in a trauma scenario has not been studied. Given the complexity of this cognitive construct, we hypothesized that the residents’ SA would decline in a sleep-deprived versus rested state. SA refers to the perception of elements in one’s environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future. Originally used in aviation, Hogan et al24 demonstrated its use in the context of medical education. The Situational Awareness Global Assessment Technique (SAGAT) was designed and validated as a reliable assessment tool for trauma trainees in the dynamic clinical environment created by human patient simulation. It measures the 3 levels of SA as perception, comprehension, and projection. Trauma is the leading cause of mortality between the ages of 1 and 44 years.25 Trauma resuscitation is a dynamic, complex process requiring an experienced team and rapid decision making. Resident physicians are frequently involved in trauma resuscitation in both rested and sleep-deprived states. They are subjected to frequent overnight call and early morning rounds. It is therefore important to ascertain whether residents’ performance in such a critical situation as a trauma scenario declines in the sleep-deprived state. Our study used the SAGAT and human patient simulator (HPS) to evaluate the resident performance and, ultimately, safety in running a trauma resuscitation.
MATERIALS AND METHODS An HPS (Medical Education Technology Incorporated, Sarasota, FL) was used in this study. This life-size mannequin features a palpable pulse, audible heart and breath sounds, eye movement, and pupil reaction. It can display a wide range of J Orthop Trauma Volume 28, Number 7, July 2014
J Orthop Trauma Volume 28, Number 7, July 2014
physiologic abnormalities. In addition, it has a real-time monitor featuring heart rate, blood pressure, and oxygen saturation. For the purpose of our study, 2 separate scenarios were run using the HPS by the simulator staff who were blinded to the participant’s sleep status. Based on the previous results of Hogan et al,24 the clinically significant difference in SAGAT test scores was set at 7% with an alpha of 0.05 and beta of 0.80. Using a paired t test, as the statistic of choice, a power analysis revealed the necessary sample size to be 9 (n = 9). Over a period of 12 months, general surgery, orthopedic, and anesthesia residents performing their intensive care unit rotation in the third year of residency were assessed in trauma response scenarios. Inclusion criteria were the successful completion of the advanced trauma life support (ATLS) course and willingness to participate in the study. Exclusion criteria were refusal to participate, .4 hours of sleep on-call for the postcall session, and not having completed ATLS. One simulation session took place as the resident was beginning an intensive care unit shift. The other simulation session took place when the resident had just completed a night of in-house call (ie, a shift in excess of 24 hours). The residents were asked to fill out a sleep log. If the resident slept longer than 4 consecutive hours during the night on-call, their postcall session was postponed. Each simulation consisted of 1 of 2 scenarios, approximately 20 minutes in length. One scenario involved respiratory compromise and the other significant blood loss and hemodynamic instability. These scenarios were designed to fulfill the primary objectives of ATLS and were of equal difficulty. Residents were randomized to either scenario 1 or 2 for their “rested” session and went through the other scenario for their “postcall” session. The residents were permitted to familiarize themselves with the HPS and equipment before beginning the scenario. A nurse was present to aid the participant with procedures throughout the scenarios. After the first 3 minutes of each scenario, there were 3 random “freezes” during which the SAGAT was performed. The residents were asked questions from the SAGAT while their backs were facing the monitors. The SAGAT questions reflect all 3 levels of SA in a stepwise fashion (see Figure 1, Supplemental Digital Content 1, http://links.lww.com/BOT/A156, a sample SAGAT score sheet). Scenarios and score sheets used in this study were identical to those used and validated in the study by Hogan et al.24 Acceptable answers on quantitative questions were those that fell within 610% of the true value on the monitor. Simulations and SAGAT were supervised by a licensed physician trained in ATLS who was blinded to the participant’s sleep status. The simulations were videotaped and scored by a physician who was also blinded to the sleep status.
RESULTS Nine residents on an intensive care rotation completed both rested and postcall sessions. The average sleep on call was 2.5 hours. The scores are displayed in Table 1. The average SAGAT score rested was 80.13%, and the postcall score was 80.09%. Each resident’s rested score was compared Ó 2013 Lippincott Williams & Wilkins
The Effect of Sleep Deprivation
TABLE 1. Resident SAGAT Scores Rested and Postcall 1 2 3 4 5 6 7 8 9
Sleep on Call (h)
Rested Score (%)
Postcall Score (%)
3 3 2 3.5 1 4 0 2 4
76 81 94 86 91 65 50 92 85
84 79 81 82 78 91 76 76 72
with his/her postcall score using a paired t test. Based on this test, it was determined that there was no statistically significant difference between the 2 groups (P = 0.99).
DISCUSSION Much debate exists surrounding the issue of resident work hours and sleep deprivation leading to medical error. The ACGME has taken a firm stance on the issue, mandating in 2003 that resident duty hours be restricted to 80 h/wk averaged over 4 weeks.26 The IOM released further recommendations in 2008, which focused on increasing the opportunity for sleep in addition to limiting hours worked.1 Reaction to these recommendations has been mixed. The Orthopedic Trauma Association stated that should the recommendations be implemented, “the result would be detrimental to the care of patients with trauma and the training of orthopedic residents in the United States.”27 The Association for Program Directors in Surgery also disagreed with the further restrictions suggested by the IOM, stating that the restrictions are incongruent with the experience necessary to adequately train a surgical resident.28 Likewise, the American Board of Surgery published a comment on the report that strongly discouraged the ACGME from implementing the latest recommendations.29 Although there are many studies supporting both the sides of the debate, as discussed below, the effects of sleep deprivation on resident performance in a trauma scenario had not been studied. Studies on the effect of sleep deprivation on memory and cognition generally show deterioration postcall, but are somewhat contradictory in their results. Gohar et al9 found that working memory was adversely affected by the lack of sleep in internal medicine residents and suggested that this decrease in the working memory might impair clinical judgment. Halbach et al7 noted a decline in cognitive function test scores in obstetrics and gynecology residents and medical students after oncall duty. Reaction time was tested by Bartel et al8 as a measure of working memory and attention in anesthesia residents. After night duty, the reaction time was significantly prolonged, and the accuracy was less affected. In 2005, Arnedt et al30 compared the neurobehavioral performance of residents postcall with their performance after alcohol ingestion. They found the impairment from a heavy call rotation to be similar to that associated with an elevated blood alcohol level. Contrarily, Reimann et al31 did not find a difference in the cognitive performance of sleep-deprived neurology residents versus that of www.jorthotrauma.com |
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a control group. Furthermore, Deaconson et al’s10 results from 1988 showed no difference between the cognitive and the motor performance of residents rested and sleep deprived. Another method used to evaluate the cognitive function in the sleep-deprived state has been resident performance on in-training examinations. Stone et al14 found the differences on the American Board of Surgery In-Training Examination to be related to the level of training and not to the call status. The same examination was studied at a different institution over 8 years by Minion et al,15 and they reported that being on-call the night before the examination did not significantly affect resident performance. Simulator studies have been performed to test residents’ vigilance and clinical performance. Ware et al13 demonstrated using a driving simulator that residents, particularly men, are at risk driving after a night of call. A simulated anesthetic monitoring task was used by Denisco et al20 to show that when fatigued, residents are less likely than when rested to detect important changes in monitored variables. Sharpe et al6 investigated the clinical performance of medical residents in the management of a simulated critically ill patient. They found that residents committed more errors as the duration of wakefulness was prolonged. Surgical simulators provide a practical means by which to study the effects of sleep deprivation on residents. In general, there does not seem to be a deterioration postcall. Lehmann et al11 used a virtual surgery simulator to show that typical surgery skills do not decline with sleep loss in surgery residents. The effects of sleep deprivation on simulated endoscopic sinus surgery were tested by Jakubowicz et al.32 Although they found no significant change in the number of errors, time to completion, or overall performance between the precall and postcall groups of surgery residents, there was a trend noted toward increased speed at the expense of accuracy postcall. In DeMaria et al’s18 study, the residents’ performance at tasks similar to laparoscopic cholecystectomy were evaluated using the minimally invasive surgical trainer virtual reality. Most parameters actually showed improvement postcall. In 2003, Jensen et al17 noted that residents after short-term sleep deficits performed similarly on a laparoscopic simulator when compared with their non–sleep deprived colleagues. Finally, in contrast to the above-mentioned studies, Eastridge et al19 demonstrated increased technical errors in the performance of simulated laparoscopic surgical skills. Our study endeavored to determine if 1 night of sleep deprivation adversely affects resident performance in a trauma scenario, as measured by the SA. We did this by having 9 residents perform 2 trauma simulations, 1 rested, and 1 postcall. The residents’ performance was evaluated using the SAGAT. The results demonstrated no significant difference in the SA in the trauma scenarios sleep deprived versus rested. This study is limited in size and to 1 center; however, it was adequately powered to answer the research question. Our results add to the body of conflicting evidence on the effects of resident sleep deprivation on various parameters. However, it is evident that 1 night of sleep deprivation does not adversely affect residents’ SA in a simulated trauma resuscitation. Further work using trauma simulation is required.
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REFERENCES 1. Ulmer C, Miller Wolman D, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, National Research Council. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press; 2009. 2. Iglehart JK. Revisiting duty-hour limits—IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359: 2633–2635. 3. ACGME Board of Directors approved new requirements for residency programs—Institute of medicine [internet]. [Cited January 6, 2012]; Available at: http://www.iom.edu/Reports/2008/Resident-Duty-HoursEnhancing-Sleep-Supervision-and-Safety/ACGME-Board-of-DirectorsApproved-New-Requirements-for-Residency-Programs.aspx. 4. Barger LK, Ayas NT, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med. 2006;3:e487. 5. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep. 2005;28:1392–1402. 6. Sharpe R, Koval V, Ronco JJ, et al. The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study. Crit Care Med. 2010;38:766–770. 7. Halbach MM, Spann CO, Egan G. Effect of sleep deprivation on medical resident and student cognitive function: a prospective study. Am J Obstet Gynecol. 2003;188:1198–1201. 8. Bartel P, Offermeier W, Smith F, et al. Attention and working memory in resident anaesthetists after night duty: group and individual effects. Occup Environ Med. 2004;61:167–170. 9. Gohar A, Adams A, Gertner E, et al. Working memory capacity is decreased in sleep-deprived internal medicine residents. J Clin Sleep Med. 2009;5:191–197. 10. Deaconson TF, O’Hair DP, Levy MF, et al. Sleep deprivation and resident performance. JAMA. 1988;260:1721–1727. 11. Lehmann KS, Martus P, Little-Elk S, et al. Impact of sleep deprivation on medium-term psychomotor and cognitive performance of surgeons: prospective cross-over study with a virtual surgery simulator and psychometric tests. Surgery. 2010;147:246–254. 12. Kramer M. Sleep loss in resident physicians: the cause of medical errors? Front Neurol. 2010;1:128. 13. Ware JC, Risser MR, Manser T, et al. Medical resident driving simulator performance following a night on call. Behav Sleep Med. 2006;4:1–12. 14. Stone MD, Doyle J, Bosch RJ, et al. Effect of resident call status on ABSITE performance. American Board of Surgery In-Training Examination. Surgery. 2000;128:465–471. 15. Minion D, Plymale M, Donnelly M, et al. The effect of prior night call status on the American Board of Surgery in-training examination scores: eight years of data from a single institution. J Surg Educ. 2007;64:416–419. 16. Ellman PI, Kron IL, Alvis JS, et al. Acute sleep deprivation in the thoracic surgical resident does not affect operative outcomes. Ann Thorac Surg. 2005;80:60–64; discussion 64–65. 17. Jensen A, Milner R, Fisher C, et al. Short-term sleep deficits do not adversely affect acquisition of laparoscopic skills in a laboratory setting. Surg Endosc. 2004;18:948–953. 18. DeMaria EJ, McBride CL, Broderick TJ, et al. Night call does not impair learning of laparoscopic skills. Surg Innov. 2005;12:145–149. 19. Eastridge BJ, Hamilton EC, O’Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg. 2003;186:169–174. 20. Denisco RA, Drummond JN, Gravenstein JS. The effect of fatigue on the performance of a simulated anesthetic monitoring task. J Clin Monit. 1987;3:22–24. 21. Hayter MA, Friedman Z, Katznelson R, et al. Effect of sleep deprivation on labour epidural catheter placement. Br J Anaesth. 2010;104: 619–627. 22. Yaghoubian A, Kaji AH, Ishaque B, et al. Acute care surgery performed by sleep deprived residents: are outcomes affected? J Surg Res. 2010; 163:192–196. 23. Haynes DF, Schwedler M, Dyslin DC, et al. Are postoperative complications related to resident sleep deprivation? South Med J. 1995;88: 283–289.
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J Orthop Trauma Volume 28, Number 7, July 2014 24. Hogan MP, Pace DE, Hapgood J, et al. Use of human patient simulation and the situation awareness global assessment technique in practical trauma skills assessment. J Trauma. 2006;61:1047–1052. 25. CDC. Ten leading causes of death and injury—PDFs [internet]. [Cited March 23, 2012]; Available at: http://www.cdc.gov/injury/wisqars/ LeadingCauses.html. 26. Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288:1112–1114. 27. Anglen JO, Bosse MJ, Bray TJ, et al. The Institute of Medicine report on resident duty hours. Part I: The Orthopaedic Trauma Association response to the report. J Bone Joint Surg Am. 2009;91:720–722. 28. Borman KR, Fuhrman GM. “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”: response of the Association of Program Directors in Surgery to the December 2008 Report of the Institute of Medicine. Surgery. 2009;146:420–427.
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The Effect of Sleep Deprivation 29. Lewis FR. Comment of the American Board of Surgery on the recommendations of the Institute of Medicine Report, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.” Surgery. 2009; 146:410–419. 30. Arnedt JT, Owens J, Crouch M, et al. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 2005; 294:1025–1033. 31. Reimann M, Manz R, Prieur S, et al. Education research: cognitive performance is preserved in sleep-deprived neurology residents. Neurology. 2009;73:e99–e103. 32. Jakubowicz DM, Price EM, Glassman HJ, et al. Effects of a twentyfour hour call period on resident performance during simulated endoscopic sinus surgery in an accreditation council for graduate medical education-compliant training program. Laryngoscope. 2005;115: 143–146.
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The Effect of Sleep Deprivation on a Resident’s Situational Awareness in a Trauma Scenario Alexandra Stratton, MD, Andrew Furey, MD, MSc, and Micheal Hogan, MD, MMEd
Objectives: Situational awareness (SA) refers to the perception of elements in one’s environment, the comprehension of their meaning, and the projection of their status in the near future. The SA global assessment technique (SAGAT) is an assessment tool validated for use in a trauma simulation. The goal of this study was to determine the effect of sleep deprivation on residents’ performance in a trauma simulation, evaluated by the SAGAT.
Methods: A power analysis determined that 9 residents would be needed to show a significant difference in SAGAT scores (7%). Therefore, 9 surgical residents on an intensive care unit rotation underwent 2 trauma simulations. One session was performed in the rested condition, and the other was for postcall. The SAGAT was used to evaluate the residents’ performance. The rested and postcall scores were compared. Results: Using a paired t test, the SAGAT scores were analyzed. The average rested score was 80.13% (range, 50%–94%), and the sleep-deprived score was 80.09% (range, 72%–91%). There was no significant difference between the residents’ rested and the postcall SAGAT scores (P = 0.99). Conclusions: From this study, the resident SA in a trauma simulation does not seem to be affected by 1 night of sleep deprivation, as demonstrated by the lack of significant difference in SAGAT scores; however, more research in this area is needed. Key Words: sleep deprivation, resident, duty hours, trauma simulation, situational awareness, simulator
Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. (J Orthop Trauma 2014;28:e160–e163)
BACKGROUND Resident work hours and resulting sleep deprivation have come under close scrutiny over the past 2 decades. In 2003, the Accreditation Council for Graduate Medical Accepted for publication September 11, 2013. From the Memorial University of Newfoundland, Newfoundland and Labrador, Canada. The authors report no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions this article on the journal’s Web site (www.jorthotrauma.com). Reprints: Alexandra Stratton, MD, Memorial University of Newfoundland, 4 Carty Place, St. John’s, Newfoundland and Labrador A1A 1M6, Canada (e-mail: [email protected]). Copyright © 2013 by Lippincott Williams & Wilkins
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Education (ACGME) in the United States imposed restrictions on the resident work hours (ACGME 2003). The Institute of Medicine (IOM) published a report in 2008 with further recommendations,1 many of which were approved by the ACGME in September 2010.2,3 There were several published studies contributing to these recommendations, namely, that by Barger et al,4 which demonstrated an increase in the medical errors made by residents working extended-duration shifts (at least 24 hours). The effects of extended periods of wakefulness among residents on many parameters have been researched. Such parameters include clinical performance,5,6 cognitive function,5,7 attention,8 working memory,8,9 psychomotor performance,10 fine motor skills,10,11 medical errors,12 driving simulator performance,13 examination scores,14,15 operative efficiency,16 procedural skills,17–21 and postoperative complications.16,22,23 However, the effect of sleep deprivation on medical residents’ situational awareness (SA) in a trauma scenario has not been studied. Given the complexity of this cognitive construct, we hypothesized that the residents’ SA would decline in a sleep-deprived versus rested state. SA refers to the perception of elements in one’s environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future. Originally used in aviation, Hogan et al24 demonstrated its use in the context of medical education. The Situational Awareness Global Assessment Technique (SAGAT) was designed and validated as a reliable assessment tool for trauma trainees in the dynamic clinical environment created by human patient simulation. It measures the 3 levels of SA as perception, comprehension, and projection. Trauma is the leading cause of mortality between the ages of 1 and 44 years.25 Trauma resuscitation is a dynamic, complex process requiring an experienced team and rapid decision making. Resident physicians are frequently involved in trauma resuscitation in both rested and sleep-deprived states. They are subjected to frequent overnight call and early morning rounds. It is therefore important to ascertain whether residents’ performance in such a critical situation as a trauma scenario declines in the sleep-deprived state. Our study used the SAGAT and human patient simulator (HPS) to evaluate the resident performance and, ultimately, safety in running a trauma resuscitation.
MATERIALS AND METHODS An HPS (Medical Education Technology Incorporated, Sarasota, FL) was used in this study. This life-size mannequin features a palpable pulse, audible heart and breath sounds, eye movement, and pupil reaction. It can display a wide range of J Orthop Trauma Volume 28, Number 7, July 2014
J Orthop Trauma Volume 28, Number 7, July 2014
physiologic abnormalities. In addition, it has a real-time monitor featuring heart rate, blood pressure, and oxygen saturation. For the purpose of our study, 2 separate scenarios were run using the HPS by the simulator staff who were blinded to the participant’s sleep status. Based on the previous results of Hogan et al,24 the clinically significant difference in SAGAT test scores was set at 7% with an alpha of 0.05 and beta of 0.80. Using a paired t test, as the statistic of choice, a power analysis revealed the necessary sample size to be 9 (n = 9). Over a period of 12 months, general surgery, orthopedic, and anesthesia residents performing their intensive care unit rotation in the third year of residency were assessed in trauma response scenarios. Inclusion criteria were the successful completion of the advanced trauma life support (ATLS) course and willingness to participate in the study. Exclusion criteria were refusal to participate, .4 hours of sleep on-call for the postcall session, and not having completed ATLS. One simulation session took place as the resident was beginning an intensive care unit shift. The other simulation session took place when the resident had just completed a night of in-house call (ie, a shift in excess of 24 hours). The residents were asked to fill out a sleep log. If the resident slept longer than 4 consecutive hours during the night on-call, their postcall session was postponed. Each simulation consisted of 1 of 2 scenarios, approximately 20 minutes in length. One scenario involved respiratory compromise and the other significant blood loss and hemodynamic instability. These scenarios were designed to fulfill the primary objectives of ATLS and were of equal difficulty. Residents were randomized to either scenario 1 or 2 for their “rested” session and went through the other scenario for their “postcall” session. The residents were permitted to familiarize themselves with the HPS and equipment before beginning the scenario. A nurse was present to aid the participant with procedures throughout the scenarios. After the first 3 minutes of each scenario, there were 3 random “freezes” during which the SAGAT was performed. The residents were asked questions from the SAGAT while their backs were facing the monitors. The SAGAT questions reflect all 3 levels of SA in a stepwise fashion (see Figure 1, Supplemental Digital Content 1, http://links.lww.com/BOT/A156, a sample SAGAT score sheet). Scenarios and score sheets used in this study were identical to those used and validated in the study by Hogan et al.24 Acceptable answers on quantitative questions were those that fell within 610% of the true value on the monitor. Simulations and SAGAT were supervised by a licensed physician trained in ATLS who was blinded to the participant’s sleep status. The simulations were videotaped and scored by a physician who was also blinded to the sleep status.
RESULTS Nine residents on an intensive care rotation completed both rested and postcall sessions. The average sleep on call was 2.5 hours. The scores are displayed in Table 1. The average SAGAT score rested was 80.13%, and the postcall score was 80.09%. Each resident’s rested score was compared Ó 2013 Lippincott Williams & Wilkins
The Effect of Sleep Deprivation
TABLE 1. Resident SAGAT Scores Rested and Postcall 1 2 3 4 5 6 7 8 9
Sleep on Call (h)
Rested Score (%)
Postcall Score (%)
3 3 2 3.5 1 4 0 2 4
76 81 94 86 91 65 50 92 85
84 79 81 82 78 91 76 76 72
with his/her postcall score using a paired t test. Based on this test, it was determined that there was no statistically significant difference between the 2 groups (P = 0.99).
DISCUSSION Much debate exists surrounding the issue of resident work hours and sleep deprivation leading to medical error. The ACGME has taken a firm stance on the issue, mandating in 2003 that resident duty hours be restricted to 80 h/wk averaged over 4 weeks.26 The IOM released further recommendations in 2008, which focused on increasing the opportunity for sleep in addition to limiting hours worked.1 Reaction to these recommendations has been mixed. The Orthopedic Trauma Association stated that should the recommendations be implemented, “the result would be detrimental to the care of patients with trauma and the training of orthopedic residents in the United States.”27 The Association for Program Directors in Surgery also disagreed with the further restrictions suggested by the IOM, stating that the restrictions are incongruent with the experience necessary to adequately train a surgical resident.28 Likewise, the American Board of Surgery published a comment on the report that strongly discouraged the ACGME from implementing the latest recommendations.29 Although there are many studies supporting both the sides of the debate, as discussed below, the effects of sleep deprivation on resident performance in a trauma scenario had not been studied. Studies on the effect of sleep deprivation on memory and cognition generally show deterioration postcall, but are somewhat contradictory in their results. Gohar et al9 found that working memory was adversely affected by the lack of sleep in internal medicine residents and suggested that this decrease in the working memory might impair clinical judgment. Halbach et al7 noted a decline in cognitive function test scores in obstetrics and gynecology residents and medical students after oncall duty. Reaction time was tested by Bartel et al8 as a measure of working memory and attention in anesthesia residents. After night duty, the reaction time was significantly prolonged, and the accuracy was less affected. In 2005, Arnedt et al30 compared the neurobehavioral performance of residents postcall with their performance after alcohol ingestion. They found the impairment from a heavy call rotation to be similar to that associated with an elevated blood alcohol level. Contrarily, Reimann et al31 did not find a difference in the cognitive performance of sleep-deprived neurology residents versus that of www.jorthotrauma.com |
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a control group. Furthermore, Deaconson et al’s10 results from 1988 showed no difference between the cognitive and the motor performance of residents rested and sleep deprived. Another method used to evaluate the cognitive function in the sleep-deprived state has been resident performance on in-training examinations. Stone et al14 found the differences on the American Board of Surgery In-Training Examination to be related to the level of training and not to the call status. The same examination was studied at a different institution over 8 years by Minion et al,15 and they reported that being on-call the night before the examination did not significantly affect resident performance. Simulator studies have been performed to test residents’ vigilance and clinical performance. Ware et al13 demonstrated using a driving simulator that residents, particularly men, are at risk driving after a night of call. A simulated anesthetic monitoring task was used by Denisco et al20 to show that when fatigued, residents are less likely than when rested to detect important changes in monitored variables. Sharpe et al6 investigated the clinical performance of medical residents in the management of a simulated critically ill patient. They found that residents committed more errors as the duration of wakefulness was prolonged. Surgical simulators provide a practical means by which to study the effects of sleep deprivation on residents. In general, there does not seem to be a deterioration postcall. Lehmann et al11 used a virtual surgery simulator to show that typical surgery skills do not decline with sleep loss in surgery residents. The effects of sleep deprivation on simulated endoscopic sinus surgery were tested by Jakubowicz et al.32 Although they found no significant change in the number of errors, time to completion, or overall performance between the precall and postcall groups of surgery residents, there was a trend noted toward increased speed at the expense of accuracy postcall. In DeMaria et al’s18 study, the residents’ performance at tasks similar to laparoscopic cholecystectomy were evaluated using the minimally invasive surgical trainer virtual reality. Most parameters actually showed improvement postcall. In 2003, Jensen et al17 noted that residents after short-term sleep deficits performed similarly on a laparoscopic simulator when compared with their non–sleep deprived colleagues. Finally, in contrast to the above-mentioned studies, Eastridge et al19 demonstrated increased technical errors in the performance of simulated laparoscopic surgical skills. Our study endeavored to determine if 1 night of sleep deprivation adversely affects resident performance in a trauma scenario, as measured by the SA. We did this by having 9 residents perform 2 trauma simulations, 1 rested, and 1 postcall. The residents’ performance was evaluated using the SAGAT. The results demonstrated no significant difference in the SA in the trauma scenarios sleep deprived versus rested. This study is limited in size and to 1 center; however, it was adequately powered to answer the research question. Our results add to the body of conflicting evidence on the effects of resident sleep deprivation on various parameters. However, it is evident that 1 night of sleep deprivation does not adversely affect residents’ SA in a simulated trauma resuscitation. Further work using trauma simulation is required.
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J Orthop Trauma Volume 28, Number 7, July 2014
REFERENCES 1. Ulmer C, Miller Wolman D, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, National Research Council. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press; 2009. 2. Iglehart JK. Revisiting duty-hour limits—IOM recommendations for patient safety and resident education. N Engl J Med. 2008;359: 2633–2635. 3. ACGME Board of Directors approved new requirements for residency programs—Institute of medicine [internet]. [Cited January 6, 2012]; Available at: http://www.iom.edu/Reports/2008/Resident-Duty-HoursEnhancing-Sleep-Supervision-and-Safety/ACGME-Board-of-DirectorsApproved-New-Requirements-for-Residency-Programs.aspx. 4. Barger LK, Ayas NT, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med. 2006;3:e487. 5. Philibert I. Sleep loss and performance in residents and nonphysicians: a meta-analytic examination. Sleep. 2005;28:1392–1402. 6. Sharpe R, Koval V, Ronco JJ, et al. The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study. Crit Care Med. 2010;38:766–770. 7. Halbach MM, Spann CO, Egan G. Effect of sleep deprivation on medical resident and student cognitive function: a prospective study. Am J Obstet Gynecol. 2003;188:1198–1201. 8. Bartel P, Offermeier W, Smith F, et al. Attention and working memory in resident anaesthetists after night duty: group and individual effects. Occup Environ Med. 2004;61:167–170. 9. Gohar A, Adams A, Gertner E, et al. Working memory capacity is decreased in sleep-deprived internal medicine residents. J Clin Sleep Med. 2009;5:191–197. 10. Deaconson TF, O’Hair DP, Levy MF, et al. Sleep deprivation and resident performance. JAMA. 1988;260:1721–1727. 11. Lehmann KS, Martus P, Little-Elk S, et al. Impact of sleep deprivation on medium-term psychomotor and cognitive performance of surgeons: prospective cross-over study with a virtual surgery simulator and psychometric tests. Surgery. 2010;147:246–254. 12. Kramer M. Sleep loss in resident physicians: the cause of medical errors? Front Neurol. 2010;1:128. 13. Ware JC, Risser MR, Manser T, et al. Medical resident driving simulator performance following a night on call. Behav Sleep Med. 2006;4:1–12. 14. Stone MD, Doyle J, Bosch RJ, et al. Effect of resident call status on ABSITE performance. American Board of Surgery In-Training Examination. Surgery. 2000;128:465–471. 15. Minion D, Plymale M, Donnelly M, et al. The effect of prior night call status on the American Board of Surgery in-training examination scores: eight years of data from a single institution. J Surg Educ. 2007;64:416–419. 16. Ellman PI, Kron IL, Alvis JS, et al. Acute sleep deprivation in the thoracic surgical resident does not affect operative outcomes. Ann Thorac Surg. 2005;80:60–64; discussion 64–65. 17. Jensen A, Milner R, Fisher C, et al. Short-term sleep deficits do not adversely affect acquisition of laparoscopic skills in a laboratory setting. Surg Endosc. 2004;18:948–953. 18. DeMaria EJ, McBride CL, Broderick TJ, et al. Night call does not impair learning of laparoscopic skills. Surg Innov. 2005;12:145–149. 19. Eastridge BJ, Hamilton EC, O’Keefe GE, et al. Effect of sleep deprivation on the performance of simulated laparoscopic surgical skill. Am J Surg. 2003;186:169–174. 20. Denisco RA, Drummond JN, Gravenstein JS. The effect of fatigue on the performance of a simulated anesthetic monitoring task. J Clin Monit. 1987;3:22–24. 21. Hayter MA, Friedman Z, Katznelson R, et al. Effect of sleep deprivation on labour epidural catheter placement. Br J Anaesth. 2010;104: 619–627. 22. Yaghoubian A, Kaji AH, Ishaque B, et al. Acute care surgery performed by sleep deprived residents: are outcomes affected? J Surg Res. 2010; 163:192–196. 23. Haynes DF, Schwedler M, Dyslin DC, et al. Are postoperative complications related to resident sleep deprivation? South Med J. 1995;88: 283–289.
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J Orthop Trauma Volume 28, Number 7, July 2014 24. Hogan MP, Pace DE, Hapgood J, et al. Use of human patient simulation and the situation awareness global assessment technique in practical trauma skills assessment. J Trauma. 2006;61:1047–1052. 25. CDC. Ten leading causes of death and injury—PDFs [internet]. [Cited March 23, 2012]; Available at: http://www.cdc.gov/injury/wisqars/ LeadingCauses.html. 26. Philibert I, Friedmann P, Williams WT. New requirements for resident duty hours. JAMA. 2002;288:1112–1114. 27. Anglen JO, Bosse MJ, Bray TJ, et al. The Institute of Medicine report on resident duty hours. Part I: The Orthopaedic Trauma Association response to the report. J Bone Joint Surg Am. 2009;91:720–722. 28. Borman KR, Fuhrman GM. “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”: response of the Association of Program Directors in Surgery to the December 2008 Report of the Institute of Medicine. Surgery. 2009;146:420–427.
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The Effect of Sleep Deprivation 29. Lewis FR. Comment of the American Board of Surgery on the recommendations of the Institute of Medicine Report, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.” Surgery. 2009; 146:410–419. 30. Arnedt JT, Owens J, Crouch M, et al. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. JAMA. 2005; 294:1025–1033. 31. Reimann M, Manz R, Prieur S, et al. Education research: cognitive performance is preserved in sleep-deprived neurology residents. Neurology. 2009;73:e99–e103. 32. Jakubowicz DM, Price EM, Glassman HJ, et al. Effects of a twentyfour hour call period on resident performance during simulated endoscopic sinus surgery in an accreditation council for graduate medical education-compliant training program. Laryngoscope. 2005;115: 143–146.
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