A Pilot Study to Examine the Relationship Between Napping and Fatigue in Nurses Practicing on the Night Shift.

OBJECTIVE: The aim of this study is to explore the relationship of night-shift napping on fatigue. BACKGROUND: Nurses' fatigue, especially at night, interferes with quality of life and job performance and impacts safety and health. METHODS: Night-shift nurses completed the Brief Fatigue Inventory and a demographic information sheet to determine differences in fatigue between nurses who napped during their night shift as compared with nurses who did not nap. RESULTS: No statistically significant differences in global fatigue were found; differences in rotating shift, age, and, gender were identified. Rotating shifts, a 2nd job, and caring for family predicted fatigue. CONCLUSIONS: Based on this pilot study, further investigations of fatigue among night-shift nurses are needed as well as evidence-based support to promote sleep.

Hospital at night: an organizational design that provides safer care at night.

The reduction in the working hours of doctors represents a challenge to the delivery of medical care to acutely sick patients 24 hours a day. Increasing the number of doctors to support multiple specialty rosters is not the solution for economic or organizational reasons. This paper outlines an alternative, economically viable multidisciplinary solution that has been shown to improve patient outcomes and provides organizational consistency. The change requires strong clinical leadership, with organizational commitment to both cultural and structural change. Careful attention to ensuring the teams possess the appropriate competencies, implementing a reliable process to identify the sickest patients and escalate their care, and structuring rotas efficiently are essential features of success.

Nocturnal violence: implications for resident trauma operative experiences.

Trauma centers face novel challenges in resource allocation in an era of cost consciousness and work-hour restrictions. Studies have shown that time of day and day of week affect trauma admission volume; however, these studies were performed in cold climates. Data from 2000 to 2010 at a Level I trauma center were reviewed. Demographic, injury severity, and injury timing from 23,827 trauma patients were analyzed along with their emergency department disposition (operating room, intensive care unit, ward) and final outcome. Nighttime arrivals (NAs) accounted for 56.6 per cent and daytime arrivals accounted for 43.4 per cent of total admissions. The increase in NAs was most pronounced during the period from midnight to 6 am on weekends (P < 0.05). Also, the period from midnight to 6 am on weekends showed a significantly increased proportion of penetrating trauma (P < 0.01). Similarly, there was an increased rate of trauma arrivals needing emergent operative intervention in the period between midnight and 6 am on weekends when compared with any other time period (P < 0.01). In a southern Level I trauma center, patient volume varies nonrandomly with time. Emergent operative intervention is more likely between midnight and 6 am, the peak time for penetrating trauma. Because resident operative experience is maximized at night and on weekends, coverage during these periods should remain a priority for residency programs.

Significant deficiencies in the overnight use of a Standardised Early Warning Scoring system in a teaching hospital.

National Institute for Health and Clinical Excellence guidelines recommend the use of 'Track and Trigger' systems to identify early clinical deterioration. The Standardised Early Warning Score (SEWS) is used in the Royal Infirmary of Edinburgh. Previous work, suggested that the frequency and accuracy of SEWS documentation varied throughout the hospital. A prospective study was performed over a 14-night period looking at SEWS documentation in patients causing clinical concern requiring medical review, or triggering a SEWS of 4 (the 'trigger' score). SEWS charts were examined the following morning. In the ward arc, SEWS documentation was correct in only 21% of cases. The most frequent errors were one or more observations omitted (64%), SEWS total not calculated (55%) or incorrectly calculated (21%). Up to five errors per chart were noted. The observations most frequently omitted were respiratory rate, temperature and neurological status. In contrast, SEWS documentation was correct in 68% of patients in the combined assessment unit (CAU). This study demonstrates significant deficiencies in the overnight use of SEWS, particularly on the ward arc. This is particularly concerning as this study was limited only to patients already causing clinical concern, and highlights that basic observations are often incomplete, and the SEWS chart poorly understood and acted upon. SEWS recording and documentation was significantly better in CAU (P < 0.001, FET), where there is a dedicated, ongoing SEWS education programme for nursing and medical staff. We recommend this is rolled out across the hospital. Alternative methods of improving the use of SEWS are considered.

Nighttime noise issues that interrupt sleep after cardiac surgery.

Patients' perceptions of noise events that prevent/interrupt nighttime sleep after cardiac surgery and sleep promotion aids were studied for associations with patient characteristics. Overhead paging, equipment, and loud communication prevented/interrupted nighttime sleep; however, most patient characteristics were not associated with the presence or absence of these noise events. Patients selected pain medication to promote sleep. Other sleep aids were used infrequently. Behavioral and structural noise reduction interventions are needed to minimize sleep interruptions.

What is the safety of nonemergent operative procedures performed at night? A study of 10,426 operations at an academic tertiary care hospital using the American College of Surgeons national surgical quality program improvement database.

BACKGROUND: Ever-increasing numbers of in-house acute care surgeons and competition for operating room time during normal daytime business hours have led to an increased frequency of nonemergent general and vascular surgery procedures occurring at night when there are fewer residents, consultants, nurses, and support staff available for assistance. This investigation tests the hypothesis that patients undergoing such procedures after hours are at increased risk for postoperative morbidity and mortality. METHODS: Clinical data for 10,426 operative procedures performed over a 5-year period at a single academic tertiary care hospital were obtained from the American College of Surgeons National Surgical Quality Improvement Program Database. The prevalence of preoperative comorbid conditions, postoperative length of stay, morbidity, and mortality was compared between two cohorts of patients: one who underwent nonemergent operative procedures at night and other who underwent similar procedures during the day. Subsequent statistical comparisons utilized chi tests for comparisons of categorical variables and F-tests for continuous variables. RESULTS: Patients undergoing procedures at night had a greater prevalence of serious preoperative comorbid conditions. Procedure complexity as measured by relative value unit did not differ between groups, but length of stay was longer after night procedures (7.8 days vs. 4.3 days, p < 0.0001). CONCLUSIONS: Patients undergoing nonemergent general and vascular surgery procedures at night in an academic medical center do not seem to be at increased risk for postoperative morbidity or mortality. Performing nonemergent procedures at night seems to be a safe solution for daytime overcrowding of operating rooms.

The effect of a rotating night-float coverage scheme on preventable and potentially preventable morbidity at a level 1 trauma center.

BACKGROUND: The effect of resident work-hour restriction on patient outcome remains controversial. METHODS: Demographic data, mechanism of injury, length of hospital stay length of intensive care unit (ICU) stay, ventilator days, mortality, and complication data were prospectively collected for 11 months before and 11 months after institution of a rotating night-float system. Seven attending surgeons reviewed all complications and categorized each as preventable, potentially preventable, or nonpreventable. RESULTS: Both study periods were comparable with respect to demographic data, mean Injury Severity Score, mechanism of injury, and admissions. Limitation of resident work hours had no effect on length of hospital or ICU stay, ventilator days, or mortality. Work-hour restrictions did not increase or decrease the total number of complications nor did it alter the distribution of those determined to be preventable or potentially preventable. CONCLUSIONS: Resident work-hour restrictions were not associated with significant improvement or deterioration in patient outcome.

[Influence of nocturnal surgery on mortality and complications in patients with hip fractures]. / Auswirkungen von in der Nacht durchgeführten Stabilisierungsoperationen bei hüftnahen Femurfrakturen auf Mortalitätsrate und Komplikationen.

UNLABELLED: SUBJECT OF INVESTIGATION: The appropriate time of day for surgery of hip fractures and the question of whether surgery should be performed at night are controversial. We therefore investigated the influence of the time of day on mortality and complication rates in surgery for hip fractures. METHOD: A total of 170 persons were included in the study with 128 operations being performed during the day and 42 at night, after 9 p.m. All patients were operated as early as possible. Patients were randomly assigned to groups. The recorded data were mainly demographic, perioperative and those concerning the patient's history. Mortality and complication rates 6 months after surgery were compared. RESULTS: The two groups were largely homogeneous. Patients operated on at night had a non-significantly higher mortality rate. Mortality was highest in those operated on between 9 and 10 p.m. Of those who underwent surgery after midnight, no patient died. No differences were registered with regard to complications. The team of surgeons and anesthetists was equally qualified in both groups. CONCLUSIONS: Given a medical team with equal qualifications and size, we consider nocturnal surgery for hip fractures to be as appropriate as surgery during the day.

Nighttime child care: inadequate sudden infant death syndrome risk factor knowledge, practice, and policies.

BACKGROUND: Millions of children in the US have parents who work alternative shifts. As a result, extended-hour and nighttime child care centers have increased in number to meet the needs of parents working nonstandard hours. Recognizing that 20% of sudden infant death syndrome (SIDS) occurs in child care settings and that child care providers may place infants prone, it is important to determine sleep position practices in nighttime child care centers. OBJECTIVE: To determine if nighttime child care centers 1) follow Back to Sleep recommendations; 2) are aware of the need for a safe sleep environment; and 3) have written policies directing proper SIDS risk reduction practices. DESIGN: A descriptive, cross-sectional survey of licensed child care centers in the US offering evening and nighttime care. All nighttime centers caring for infants <6 months old were recruited for the study. RESULTS: Out of 153 eligible centers, 110 centers in 27 states completed the survey. Infants were placed prone in 20% of centers, although only 1 center placed infants exclusively prone. Infants slept in cribs in 53.6% of centers, but slept in uncluttered sleep environments in only 18.2% of centers. Smoking was prohibited in 86.4% of centers. The most commonly cited reason for avoiding prone altogether was SIDS risk reduction; however, 10 centers that cited SIDS risk reduction continued to place infants prone at least some of the time, because of parental request or concerns about infant comfort. Over half (59%) of the centers had written policies; however, presence of written policy was not associated with avoidance of prone position. In over one third of centers with written policies, providers were unaware of the content of the policy. CONCLUSIONS: Twenty percent of nighttime child care centers place infants prone at least some of the time. Most providers who place infants prone do so because of lack of awareness or misinformation about safe sleep environment. Although the Back to Sleep campaign has been effective in communicating the risks of sleeping prone, nonprone positioning is not universal among nighttime child care providers. Additional educational efforts toward child care providers remain necessary. In addition, parents as advocates for their own infants need to be proactive in assuring that safe sleep practices are implemented in child care settings.

Relating palliative care principles to the promotion of undisturbed sleep in a hospice setting.

Nurses working at night have a specific role in supporting sleep and promoting rest and comfort. Sometimes the role of the night duty nurse in promoting sleep and comfort is taken for granted. One author's experience of working as a night duty nurse led to reflection on her responsibilities in improving practice and addressing the sleep-related needs of patients in a palliative care setting. Following a literature review, it was clear that there are very few publications on sleep disturbance in palliative care. Using the four principles of palliative care (Aranda, 1998a), the authors construct a series of strategies to prevent and manage sleep issues.

Effect of an administrative intervention on rates of screening for domestic violence in an urban emergency department.

OBJECTIVES: This study measured the effects of an administrative intervention on health care provider compliance with universal domestic violence screening protocols. METHODS: We used a simple, interrupted-time-series design in a stratified random sample of female emergency department patients 18 years or older (n = 1638 preintervention, n = 1617 postintervention). The intervention was a 4-tiered hospital-approved disciplinary action, and the primary outcome was screening compliance. RESULTS: Preintervention and postintervention screening rates were 29.5% and 72.8%, respectively. Before the intervention, screening was worse on the night shift (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.31, 0.68) and with psychiatric patients (OR = 0.34, 95% CI = 0.14, 0.85); after the intervention, no previous screening barriers remained significant. CONCLUSIONS: An administrative intervention significantly enhanced compliance with universal domestic violence screening.