At the 11th Hour
We have all felt it. The fatigue. The hunger. The hazy fog that ensues 11 hours into our shift. How does the average physician react in times of mental exhaustion? Do we order more tests? Do we miss critical diagnoses? Do we administer inappropriate medications? Let's take a look.
Concentration and Alertness
While there is a bounty of data regarding the health hazards of night shifts and long work hours,1,2,3,4 few studies have focused on the potential for inappropriate care specifically at the end of a long shift. One 2014 study looked at physician concentration and performance after 24-hour on-call duty versus a routine work day and found that concentration-endurance test scores were significantly lower after on-call duty.5 This same study demonstrated subjectively worse moods after on-call duty, which could extrapolate to hindered ability to think clearly.
It is also possible that physicians have an overall decreased level of alertness just prior to leaving the hospital. In a prospective nationwide survey of interns, every extended work shift (>24 hours) that was scheduled in a month increased the risk of a crash during the commute from work by 16.2%. In months when interns worked 5 or more extended shifts, the risk that they would fall asleep while driving doubled.6
Even shorter shifts have been associated with decreased alertness. A study with nurses showed they were more likely to nearly fall asleep driving home when working 12-hour shifts as opposed to 8-hour shifts.7 While clinical outcomes related to length of shift have not been formally studied in any meaningful trials, one could argue that decreased alertness on the drive home would indicate decreased alertness and concentration when making critical decisions just prior to leaving work.
There is a decent amount of literature supporting the fact that decision-making, regardless of profession, varies by how far removed one is from the start of their day. The best known and most cited evidence comes from Israel. These studies show that rulings in Israeli courts are drastically altered by how close the decision is made to a break in the judge's day. Specifically, this study of 1,112 judicial rulings concluded that the most favorable rulings on prisoners occurred early in the morning and just after lunch breaks. Significant drops in favorable rulings correlated with length of time from each break.8
Several interesting studies on the effect of timing as it relates to medication choice have been published. One study in the primary care setting evaluated appropriate antibiotic prescription in a primary care clinic, compared to the physician's proximity to either lunch break or the end of their day. The conclusion was that physicians in this primary care clinic setting were roughly 25% more likely to give antibiotics when they were not necessarily indicated in the hour just before lunch and just before the end of the day.9
Similarly, anesthesiologists in New Zealand had more medication errors when they were pushed beyond their own preset continuous work hour goals.10 Additional data from radiology has shown that radiologists make significantly more errors in the last 2 hours of their 12-hour shift compared to their first 10.11 Still more data shows that longer shifts increase the risk of medication errors among nurses in the ICU setting.12
To complete the circle back to the acute care setting, fatigued EMS providers committed significantly more errors and errors that resulted in adverse events compared to their non-fatigued colleagues.13
As a community, we now must decide how to address these concerns. To start, as more residency programs become aware of these realities, there could be a push for fewer 12-hour shifts.
In reality, a change like that is not easily executed. Instead, one wonders if mandatory breaks, rather than reduced hours, would be helpful. Napping during shift has shown to improve subjective tiredness and some key performance indicators, though not totally negate fatigue.14-16 These findings are again demonstrated in nurses, in a study that found a 40-minute break during shifts leads to fewer performance lapses, increased vigor, and a trend toward faster IV insertion.17 While these results are promising, existing work environment/cultural barriers may prevent these practices being adopted.
Another creative solution can be borrowed from the EMS world. Pilot studies are in place to see if outcomes are affected if provider fatigue is assessed in the middle of the shift, with small interventions as appropriate.18 A similar strategy could be done in the emergency department either in person or via cellular phones.
Tired doctors are bad doctors. Some physicians have chosen to acknowledge this as reality and openly err on the side of caution towards the end of shift. They believe patients deserve a physician's best, and we simply cannot provide that at the end of 12 consecutive hours without a break.
Overall, we likely are more dangerous to our patients and to ourselves when working these extended hours. As the future leaders of emergency medicine, we need to not only pick our work schedule carefully, but also help shape the departments in which we work.
- Akerstedt T, Knutsson A. Cardiovascular disease and shift work. Scand J Environ Health. 1997;23(4):241-2.
- Harma M, Sallinen M, Ranta R, Mutanen P, Muller K. The effect of an irregular shift system on sleepiness at work in train drivers and railway traffic controllers. J Sleep Res. 2002 Jun;11(2):141-51.
- Knutsson A, Alfredsson L, Karlsson B, et al. Breast cancer among shift workers: results of the WOLF longitudinal cohort study. Scand J Work Environ Health. 2013;39(2):170-77.
- Baldwin DC Jr, Daugherty SR. Sleep deprivation and fatigue in residency training: results of a national survey of first-and second-year residents. Sleep. 2004;27(2):217–23.
- Ernst F, Rauchenzauner M, Zoller H, et al. Effects of 24 h working on-call on psychoneuroendocrine nad oculomotor function: a randomized cross-over trial. Psychoneuroendocrinology. 2014;47:221-31.
- Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352(2):125-134.
- Dean GE, Scott LD, Rogers AE, et al. The majority of nurses report difficulties with drowsiness driving home after work [abstract]. Sleep. 2006;29(Suppl):A151–52.
- Danziger S, Levav J, Avnaim-Pesso L. Extraneous factors in judicial decisions. Proc Natl Acad Sci U S A. 2011;108(17):6889:92.
- Linder JA, Doctor JN, Friedberg MW, et al. Time of day and the decision to prescribe antibiotics. JAMA Intern Med.2014;174(12):2029-31.
- Gander PH, Merry A, Millar MM, Weller J. Hours of work and fatigue-related error: a survey of New Zealand anaesthetists. Anaesth Intensive Care. 2000;28(2):178-83.
- Ruutiainen AT, Durand DJ, Scanlon MH, Itri JN. Increased error rates in preliminary reports issued by radiology residents working more than 10 consecutive hours overnight. Acad Radiol. 2013;20(3):305-11.
- Scott L, Rogers A, Hwang WT, et al. The effects of critical care nurse work hours on vigilance and patient safety. J Crit Care Nurs. 2006;15(4):30–7.
- Patterson PD, Weaver MD, Frank RC, et al. Assocation between poor sleep, fatigue, and safety outcomes in emergency medical providers. Prehosp Emerg Care. 2012;16(1):86-97.
- Mitra B, Cameron PA, Mele G, Archer P. Rest during shift work in the emergency department. Aust Health Rev. 2008;32(2):246-51.
- Cheng YH, Roach GD, Petrilli RM. Current and future directions in clinical fatigue management: An update for emergency medicine practitioners. Emerg Med Australas. 2014;26(6):640-4.
- Smith-Coggins R, Howard SK, Mac DT, et al. Improving alertness and performance in emergency department physicians and nurses: the use of planned naps. Ann Emerg Med. 2006;48(5):596-604.
- Fallis WM, McMillan DE, Edwards MP. Napping during night shift: practices, preferences, and perceptions of critical care and emergency department nurses. Crit Care Nurse. 2011;31(2):e1-11.
- Patterson PD, Moore CG, Weaver MD, et al. Mobile phone text messaging intervention to improve alertness and reduce sleepiness and fatigue during shiftwork among emergency medicine clinicians: study protocol for the SleepTrackTXT pilot randomized controlled trial. Trials. 2014;15:244.