title: Trauma surgery performed by "sleep deprived" residents: are outcomes affected?
abstract: BACKGROUND
  The Institute of Medicine recently recommended further reductions in resident duty hours, including a 5-hour rest time for on-call residents after 16 hours of work, as a way of providing better protection for patients against fatigue-related errors, yet no data are available regarding outcomes of operations performed by surgical trainees working beyond 16 hours in the current 80-hour workweek era.
  
  
  METHODS
  A retrospective review of all trauma patients who required an urgent/emergent operation by the Trauma Surgery service at a Level 1 trauma center between 2003 and 2009. Operations after 10 pm were performed by residents who began their shift at 6 am, and had thus been working 16 hours. A comparison of morbidity and mortality was performed with operations performed between 6 am and 10 pm (daytime) and 10 pm and 6 am (nighttime).
  
  
  RESULTS
  Over the 7-year study period, 1432 trauma patients required an urgent/emergent operation. Eighty-four percent of patients were male and 71% suffered a penetrating injury. The median age for the group was 26 years. The overall complication rate was 18%, with a mortality rate of 12%. On univariate analysis there were a higher proportion of males in the nighttime group versus daytime (87% vs 82%, p = 0.007). The patients in the nighttime group were also younger (25 vs 29 years, p < 0.0001) with a lower injury severity score (ISS) (13 vs 16, p = 0.002) and had a higher proportion of penetrating injuries (81% vs 65%, p < 0.0001). The complication rate was higher in daytime (20% vs 16% for nighttime, p = 0.04), whereas the mortality rates were similar (13.5% for daytime vs 10.6%, p = 0.1). On multivariable analysis, after adjusting for age, male gender, ISS, and penetrating trauma, the time of operation was not a predictor of morbidity (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.7-1.3, p = 0.9) or mortality (odds ratio1.02, 95% confidence interval, 0.7-1.6, p = 0.9).
  
  
  CONCLUSIONS
  Trauma surgery performed at night by residents who have worked longer than 16 hours have similar favorable outcomes compared with those performed during the day. Instituting a 5-hour rest period at night is unlikely to improve outcomes of these commonly performed operations.
authors.affiliation: Department of Surgery, Harbor-UCLA Medical Center, Torrance, California 90509, USA.
authors.forename: Arezou
authors.initials: A
authors.lastname: Yaghoubian
authors.forename: Amy H
authors.initials: AH
authors.lastname: Kaji
authors.forename: Brant
authors.initials: B
authors.lastname: Putnam
authors.forename: Christian
authors.initials: C
authors.lastname: de Virgilio
mesh_terms: D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D002983:Clinical Competence; D016001:Confidence Intervals; D004638:Emergency Treatment; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D015601:Injury Severity Score; D007396:Internship and Residency; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D018570:Risk Assessment; D012892:Sleep Deprivation; D015996:Survival Rate; D013997:Time Factors; D014193:Trauma Centers; D016896:Treatment Outcome; D014940:Work Schedule Tolerance; D016526:Workload; D014947:Wounds and Injuries / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*