Trauma surgery performed by "sleep deprived" residents: are outcomes affected?

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.

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).

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).

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.