1. Arezou Yaghoubian MD, Amy H. Kaji MD PhD, Brant Putnam MD and Christian de Virgilio MD

2. 1 study: decreased rate of bile duct injury 10 studies: no change in surgical patient outcome 4 studies: worse patient outcomes

3. Trauma Surgery Outcomes: Before and After 80-hr Workweek  de Virgilio et al  Mortality and morbidity unchanged  Salim et al  Mortality unchanged  Increase in the complication rate  Morrison et al  National Trauma Data Bank  Slightly decreased mortality (4.5% vs. 4.6%)

4. CALL No more than Q 3 rd Night 5 hr nap time > 16 hours of work during a 30-hour shift Max 16 hr shift without protected sleep DAYS OFF 5 days/month TIME OFF BETWEEN SHIFTS 10 hours off between day shifts 12 hours off after night shift 14 hours off after 30 hr shift

5.  Effects on surgical training  Eliminates 24 hr+ call  De facto duty hour reduction from 80  56 hr/wk  Increase length of surgical residency  The European experience  58 hours/week  Decreased patient interaction  Loss of continuity of care  Detrimental effect on operative volume

6. To compare outcomes of trauma surgery performed by surgical residents during 1 st 16 hours of shift vs. those performed by residents beyond 16 hr shift

7.  Retrospective review  All urgent/emergent trauma surgery since duty hour restriction (July 2003-2009)  Comparison of two time periods:  6 am-10 pm (daytime) vs. 10 pm- 6 am (nighttime)  Operations after 10 pm performed by residents who began their shift at 6 am and had thus been working 16>hours

8.  Morbidity  Wound infection, pneumonia, DVT, pulmonary embolism and pulmonary insufficiency  Mortality

9.  Urban busy Level I trauma center  High volume penetrating injuries  No night float system  Residents on the Trauma Service take call Q 3 rd night and work 24-hr shifts

10. Daytime 6am – 10pm n = 766 (56.2%) Nighttime 10pm -6am n = 597 (43.8%) P value Male627 (81.9%)521 (87.3%)0.007 Penetrating trauma497 (64.9%)481 (80.6%)<0.0001 Median age (years)2925<0.0001 Median ISS16130.002 Median length of stay (days)870.08 Median POS0.98 0.005

11. Daytime 6am – 10pm n = 766 (56.2%) Nighttime 10pm -6am n = 597 (43.8%) P value Deaths103 (13.5%)63 (10.6%)0.1 Total complications153 (20.0%)93 (15.6%)0.04 Pulmonary embolism3 (0.5%)10 (1.3%)0.1 Pulmonary insufficiency15 (2.5%)39 (5.1%)0.02 DVT4 (0.5%)6 (1%)0.3 Wound infection33 (4.3%)27 (4.5%)0.9 Pneumonia63 (8.2%)27 (4.5%)0.006

12. Multivariable Analysis-Morbidity Odds Ratio 95% Confidence Interval P Time of operation0.970.7-1.30.9 Age11.008-1.0280.0004 ISS11.03-1.04<0.0001

13. Multivariable Analysis-Mortality Odds Ratio 95% Confidence Interval P Time of operation1.020.7-1.60.9 Age1.031.02-1.04<0.0001 ISS1.11.09-1.12<0.0001 Penetrating trauma2.71.6-4.70.0002

14.  Appendectomy  878 daytime, 708 night time (>16 hr shift)  No difference in morbidity, mortality, conversion to open, or length of surgery  Cholecystectomy  2522 daytime, 306 night time (>16 hr shift)  No difference in bile duct injury, overall morbidity, mortality, conversion to open, or length of surgery

15.  Trauma surgery performed at night by residents working >16 hrs have similar favorable outcomes as those performed by more rested residents  Instituting a 5-hour rest period after 16 hrs is unlikely to improve outcomes  When combined with our prior study (appendectomy and cholecystectomy), data even more compelling