Prospective Observational Study of Clinical Activities, Education and Sleep During Paediatric Resident On-Call Shifts

Abstract

Background: Long duty hours and fatigue are hallmarks of physician training. Acute and chronic sleep deprivation is associated with reduced performance and increased likelihood of error. Furthermore, the ability to learn is reduced during periods of sleep deprivation. Objectives: To evaluate workload, staff support, education, sleep and physical stress in paediatric residents working within duty-hour regulations. Methods: A prospective observational study was performed in 3 periods: a cohort from 2005 (30 hour shifts), pre-July 2009 (30 hour shifts) and after July 2009 (24 hour) on call shifts. On-call trainees on their paediatric medicine rotations completed surveys describing on call workload, communication with the supervising paediatrician, teaching, learning and the nature of clinical work. Distance walked was measured with pedometers. Results: 179 on-call shifts were studied: 61 in 2005, 55 in May-June 2009, and 63 in July-August 2009. We found differences in patient volumes, workload, distance walked and supervision between the 3 periods (medians reported): of assigned patients (23.5, 27, 22, p=0.002), overnight admissions (4, 3, 2, p<0.0001), pages (27.5, 24, 15.5, p<0.0001), minutes entering orders (70, 105, 65, p=0.003), minutes examining patients (75, 120, 90, p=0.0004), minutes communicating with patients and families (100, 140, 120, p=0.004) and minutes communicating with the staff physician (not measured, 87.5, 30, p<0.0001). Patient emergencies were reported in 9 (15%), 46 (83%) and 15 (24%) shifts (p<0.0001). Trainees reported learning at any stage during 54 (89%), 39 (71%) and 48 (76%) shifts, and specifically overnight during 46 (75%), 14 (25%), 20 (32%) shifts (p<0.0001). Conclusions: We performed a before and after evaluation of the effect of duty hour reductions in a paediatric teaching hospital using prospective self-report. We found significant differences in workload and supervision between periods. The overall proportions of shifts where trainees reported learning was similar, although perceived learning during the night portion of the shift reduced significantly from 2005 to 2009. The inclusion of a remote control group provides additional context in which to frame the shorter term comparisons before and after implementation of the July 2009 duty hour regulations.