title: Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review.
abstract: The Institute of Medicine (IOM) has called for the elimination of resident work shifts exceeding 16 hours without sleep. We sought to comprehensively evaluate the effects of eliminating or reducing shifts over 16 hours.
  
  
  
  We performed a systematic review of published and unpublished studies (1950-2008) to synthesize data on all intervention studies that have reduced or eliminated U.S. residents' extended shifts. A total of 2,984 citations were identified initially, which were independently reviewed by two authors to determine their eligibility for inclusion. All outcomes relevant to quality of life, education, and safety were collected. Study quality was rated using the U.S. Preventive Services Task Force methodology.
  
  
  
  Twenty-three studies met inclusion criteria (kappa = 0.88 [95% CI, 0.77-0.94] for inclusion decisions). Following reduction or elimination of extended shifts, 8 of 8 studies measuring resident quality of life found improvements. Four of 14 studies that assessed educational outcomes found improvements, 9 found no significant changes, and one found education worsened. Seven of 11 identified statistically significant improvements in patient safety or quality of care; no studies found that safety or care quality worsened.
  
  
  
  In a systematic review, we found that reduction or elimination of resident work shifts exceeding 16 hours did not adversely affect resident education, and was associated with improvements in patient safety and resident quality of life in most studies. Further multi-center studies are needed to substantiate these findings, and definitively measure the effects of eliminating extended shifts on patient outcomes.
authors.affiliation: Harvard Affiliated Emergency Medicine Residency, Department of Emergency Medicine, Brigham and Women's and Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Levine
authors.forename: Josna
authors.initials: J
authors.lastname: Adusumilli
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Landrigan
mesh_terms: D000124:Achievement; D006801:Humans; D007396:Internship and Residency / Q000706:statistics & numerical data*; D011787:Quality of Health Care / Q000706:statistics & numerical data; D011788:Quality of Life / Q000523:psychology; D012449:Safety / Q000706:statistics & numerical data; D014940:Work Schedule Tolerance / Q000523:psychology*
references.citation: Invest Radiol. 1993 Jan;28(1):92-6
references.pmid: 8425860
references.citation: Acad Med. 2006 Dec;81(12):1059-68
references.pmid: 17122470
references.citation: J Am Coll Surg. 2002 Oct;195(4):531-8
references.pmid: 12375759
references.citation: Curr Surg. 2006 Nov-Dec;63(6):435-9; discussion 440
references.pmid: 17084773
references.citation: Curr Surg. 2004 Nov-Dec;61(6):612-5
references.pmid: 15590036
references.citation: Jt Comm J Qual Improv. 1998 Feb;24(2):77-87
references.pmid: 9547682
references.citation: Am J Obstet Gynecol. 2005 Nov;193(5):1823-6
references.pmid: 16260242
references.citation: Arch Intern Med. 1991 Oct;151(10):2065-70
references.pmid: 1929696
references.citation: J Clin Sleep Med. 2009 Jun 15;5(3):191-7
references.pmid: 19960637
references.citation: Obstet Gynecol. 1991 Sep;78(3 Pt 1):468-73
references.pmid: 1876386
references.citation: J Gen Intern Med. 1993 Mar;8(3):146-8
references.pmid: 8455112
references.citation: Chest. 2005 Dec;128(6):3910-5
references.pmid: 16354863
references.citation: Ind Health. 2005 Jan;43(1):20-3
references.pmid: 15732299
references.citation: N Engl J Med. 2009 May 21;360(21):2242-4
references.pmid: 19458371
references.citation: N Engl J Med. 2005 Jan 13;352(2):125-34
references.pmid: 15647575
references.citation: N Engl J Med. 2009 May 21;360(21):2202-15
references.pmid: 19458365
references.citation: Obstet Gynecol. 1989 Oct;74(4):668-72
references.pmid: 2797646
references.citation: Acad Med. 2006 Dec;81(12):1052-8
references.pmid: 17122468
references.citation: Surgery. 1999 Aug;126(2):337-42
references.pmid: 10455903
references.citation: Ann Surg. 2006 Jun;243(6):864-71; discussion 871-5
references.pmid: 16772790
references.citation: Am J Obstet Gynecol. 1994 Jun;170(6):1658-64; discussion 1664-5
references.pmid: 8203423
references.citation: JAMA. 2008 Sep 10;300(10):1197-9
references.pmid: 18780848
references.citation: N Engl J Med. 2004 Oct 28;351(18):1829-37
references.pmid: 15509816
references.citation: J Trauma. 2005 Apr;58(4):758-61; discussion 761-2
references.pmid: 15824652
references.citation: Nature. 1997 Jul 17;388(6639):235
references.pmid: 9230429
references.citation: Sleep. 1992 Oct;15(5):396-9
references.pmid: 1455121
references.citation: Sleep. 2005 Nov;28(11):1392-402
references.pmid: 16335329
references.citation: Laryngoscope. 2006 Jul;116(7):1127-30
references.pmid: 16826046
references.citation: Sleep. 1995 Jun;18(5):346-54
references.pmid: 7676168
references.citation: Am J Prev Med. 2001 Apr;20(3 Suppl):21-35
references.pmid: 11306229
references.citation: Am Surg. 2004 Aug;70(8):687-90
references.pmid: 15328801
references.citation: JAMA. 2005 Sep 7;294(9):1088-100
references.pmid: 16145030
references.citation: JAMA. 2002 Sep 4;288(9):1112-4
references.pmid: 12204081
references.citation: J Med Educ. 1983 May;58(5):382-8
references.pmid: 6343602
references.citation: J Occup Med. 1992 Dec;34(12):1153-60
references.pmid: 1464783
references.citation: Sleep. 1996 May;19(4):318-26
references.pmid: 8776790
references.citation: Ann Intern Med. 1994 Dec 1;121(11):866-72
references.pmid: 7978700
references.citation: Curr Surg. 2004 Mar-Apr;61(2):241-3
references.pmid: 15051273
references.citation: JAMA. 2005 Sep 7;294(9):1025-33
references.pmid: 16145022
references.citation: Am Surg. 2005 Jul;71(7):552-5; discussion 555-6
references.pmid: 16089117
references.citation: Curr Surg. 2004 Sep-Oct;61(5):445-51
references.pmid: 15475093
references.citation: N Engl J Med. 2004 Oct 28;351(18):1838-48
references.pmid: 15509817
references.citation: Curr Surg. 2005 Sep-Oct;62(5):535-8
references.pmid: 16125616
references.citation: JAMA. 2006 Sep 6;296(9):1055-62
references.pmid: 16954484
references.citation: Ann Intern Med. 2007 Jul 17;147(2):97-103
references.pmid: 17548401
references.citation: Chronobiol Int. 1992 Apr;9(2):132-6
references.pmid: 1533178
references.citation: Ann Intern Med. 2004 Dec 7;141(11):851-7
references.pmid: 15583227
references.citation: Am J Med. 2007 Nov;120(11):968-74
references.pmid: 17976424