1. The Effect of New ACGME Work Hour Rules on Resident Exhaustion: Prospective Study in a Community Teaching Hospital Tovy Haber Kamine, MD John D. Galbraith, MD Frederick Millham, MD Janet Larson, MD

2. Background: The New Work Hours A 16 hour schedule decreased attention failures and increased wakefulness over a q3 schedule. Interns started new ACGME work hours: July, 2011 ▫80 hours per week ▫No more than 16 hours straight per shift Lockley et al., Effect of Reducing Interns’ Weekly Work Hours on Sleep and Attentional Failures. NEJM. 2004. 351(18):1829-37

3. Background: Nightfloat Risks Decrease in education ▫Deterioration in laparoscopic skills ▫Decreased perception of quality of education Increased sleepiness ▫Increased risk of car accidents Hormonal abnormalities ▫Increased risk of metabolic syndrome ▫Increased risk of stroke ▫Increased risk of breast cancer ▫Decreased mood

4. Methods: Surveys NWH Transitional Year Interns and rotating MGH Anesthesia, Medicine, Psychiatry and Surgery interns filled out surveys From 2/9/2011 until 5/20/2011, interns on the Surgical, Medical, and MICU services filled out weekly surveys including: ▫demographic data ▫Questions from the Beck Depression Inventory ▫Epworth Sleepiness Scale The Surgical service switched to an ACGME compliant on 3/3/2011

5. Methods: Statistical Analysis Data dichotomized for analysis ▫ESS scores dichotomized to <10 or 10+ ▫Hours dichotomized to <80, 80+ ▫Days of depression and self-reported error data dichotomized to 0 or 1+ in the past week ▫All other data dichotomized about the median Comparison of absolute ESS scores performed using an unpaired T-Test All other comparisons and relative risks calculated using a chi square test Surgical data were used to evaluate the effects of workhours change All data (including medicine data) were used to evaluate the effects of working >80 hours

6. Results: Surveys 97 total surveys filled out by 44 interns over the study period 30 surveys were filled out by 14 interns on the surgical service

7. Results-Effects of Working >80 hours per week Factor RR of working >80 hours in the previous week 95% CIP value ESS≥101.341.10-1.640.019 Depression1.391.11-1.740.005 Self Reported Errors 1.460.91-2.350.074

8. Results: Work Hours Schedule Factor RR of ACGME complaint v. Q4 95% CIP value ESS≥102.861.17-6.970.029 Depression0.240.1-1.40.093 Work>80hrs1.370.46-4.140.561

9. Results-Work Hours Schedule P=0.01 *

10. Discussion-Hours Interns working >80 hours were more tired than those working <80 hours ▫In addition, they reported more depression and trended to more self-reported errors This is consistent with Lockley, et al 2004, where “intervention group” residents averaged 65 hours compared to 85 hours in the Q3 call group All interns in this cohort abided by the ACGME rules, i.e. they did not work more than 80 hours per week, averaged over 4 weeks ▫However, these data suggest that residents should not work more than 80 hours in any week.

11. Discussion-Work Hours Schedule Interns on the AGCME-compliant work hours schedule were significantly more tired than those on a Q4 schedule. Residents' average ESS on the ACGME- compliant schedule was identical to previously published data from before the 80 hour work week was implemented

12. Discussion-Work Hours Schedule Increased sleepiness may be due to: ▫Lack of a post-call day to recuperate from decreased sleep ▫Up to 12 days accumulation of sleep debt, rather than 4 Previous data have correlated ESS scores with medical errors. Our data did not show increased self-reported medical errors in the ACGME compliant group, though they were more tired- this may be due to insignificant power of our study to detect this. More study is needed on the real world effects of the new ACGME work hours

13. Conclusions The new ACGME work hours cause interns to be as tired as they were before implementation of the 80-hour work week ▫The schedule of work may be more important than the total number of hours worked Interns who work more than 80 hours in a week are more tired, more likely to be depressed, and trend to more self-reported errors

14. Acknowledgements Marie Williams Rebecca Barron, MD, MPH Agnes Lesicka, MD Interns of NWH

15. Questions?

16. Additional References Volpp, et al., Mortality Among Hospitalized Medicare Beneficiaries in the First 2 Years Following ACGME Resident Duty Hour Reform, JAMA. 2007;298(9):975-983 de Virgilio, et al., The 80-Hour Resident Workweek Does Not Adversely Affect Patient Outcomes or Resident Education, Current Surgery, 2006; 63(6):435-9 Mcelearney, et al., Effect of the 80-Hour Work Week on Cases Performed by General Surgery Residents, Am Surgeon, 2005;71(7):552- 556 Leibrandt, et al., Has the 80-Hour Work Week Had an Impact on Voluntary Attrition in General Surgery Residency Programs?, JACS. 2006;202(2):340-344 Carlin, et al., Effect of the 80-hour work week on resident operative experience in general surgery, Am J Surg A. 2007;193(3):326-330 Gordon, et al., Does Simulator-Based Clinical Performance Correlate With Actual Hospital Behavior? The Effect of Extended Work Hours on Patient Care Provided by Medical Interns, Academic Med. 2010;85(10):1583-1588 Schenarts, et al., The effect of a rotating night-float coverage scheme on preventable and potentially preventable morbidity at a level 1 trauma center. Am J Surg. 2005; 190(1):147-152 Leff, et al., Laparoscopic Skills Suffer on The First Shift of Sequential Night Shifts: Program Directors Beware and Residents Prepare, Ann Surg 2008 247(3) 530-539 Pietroiusti et al., Incidence of metabolic syndrome among night-shift healthcare workers, Occup Environ Med 2010;67:54-57 Brown, et al., Rotating Night Shift Work and the Risk of Ischemic Stroke, Am. J. Epidemiol. (2009) 169 (11): 1370-1377 Hansen, Risk of Breast Cancer After Night- and Shift Work: Current Evidence and Ongoing Studies in Denmark, Cancer causes control (2006) 17:531-53 Crowley et al., Complete or partial circadian re-entrainment improves performance, alertness, and mood during night-shift work. Sleep. 2004;27(6):1077-87 Touitou, et al., Effect of shift work on the night-time secretory patterns of melatonin, prolactin, cortisol and testosterone. Eur J App Physiol, 1990;60(4):288-92 Åkerstedt, et al., Impaired alertness and performance driving home from the night shift: a driving simulator study. J Sleep Research, 2005;14(1):17-20 Gold, et al., Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. Am J Pub Health 1992;82(7):1011-1014 Cavallo, et al., Impact of Night-Float Rotation on Sleep, Mood, and Alertness: The Resident’s Perception. Chronobiology International; 2002;19(5):893-902 Son, et al., Effects of long working hours and the night shift on severe sleepiness among workers with 12-hour shift systems for 5 to 7 consecutive days in the automobile factories of Korea. J Sleep Research; 2008;17(4):385-94 McCoy, et al., Effect of 16-Hour Duty Periods on Patient Care and Resident Education. Mayo Clinic Proc 2011;86(3):192-196 Papp, et al., The Effects of Sleep Loss and Fatigue on Resident–Physicians: A Multi-Institutional, Mixed-Method Study, Acad. Med. 2004. 79 (5);394-406