Monday, December 24, 2012

Saving Lives Through More Sleep

Or, at least, that's the theory.  Ever since the infamous Libby Zion case – surely exemplar of similar occurrences throughout medicine training programs – institutional focus on resident workload and wellness has been emphasized as a surrogate marker for patient safety.  Better-rested residents, working fewer hours, will have fewer misses and derive more substantial benefit from their educational opportunities.

This randomized trial from the University of Pennsylvania evaluating the performance of the new protected sleep time afforded to interns under ACGME rules.  These authors used wrist-based sleep activity monitors to measure the cumulative sleep time on-shift for interns randomized to either traditional 30-hour blocks or blocks with a nap period between 12:30am and 5:30am.  The primary outcome was sleep obtained on shift, with secondary outcomes being total hours of sleep during a call cycle, and post-call scores on the Karolinska Sleepiness Scale.

Well, protected sleep time works – 2.86 vs. 1.98 hours of sleep at the VA hospital, and 3.04 vs. 2.04 at the University hospital, with significantly fewer no-sleep nights as well.  And, the Karolinska Sleepiness Scale means also favored the nap-time group 7.10 vs. 6.65 at the VA and 6.79 vs 5.91 at the University.

But, as I said before, these are surrogate markers for patient safety.  One extra hour of sleep?  Less than a full point on the KSS?  Let's look specifically at the subjective self-reported meaning of the KSS in the range these physicians were reporting:

  • 5 = neither alert nor sleepy
  • 6 = some signs of sleepiness
  • 7 = sleepy, but no effort to keep awake
  • 8 = sleepy, some effort to keep awake

Regardless of intervention group, they're ... pretty much a little sleepy, but not generally struggling to stay awake.  I remain a little skeptical this will account for a substantial improvement in patient safety – at least, at this single-residency experience.

"Effect of a Protected Sleep Period on Hours Slept During Extended Overnight In-hospital Duty Hours Among Medical Interns"

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