Effect on Patient Safety of a Resident Physician Schedule without 24-Hour Shifts.

BACKGROUND: The effects on patient safety of eliminating extended-duration work shifts for resident physicians remain controversial. METHODS: We conducted a multicenter, cluster-randomized, crossover trial comparing two schedules for pediatric resident physicians during their intensive care unit (ICU) rotations: extended-duration work schedules that included shifts of 24 hours or more (control schedules) and schedules that eliminated extended shifts and cycled resident physicians through day and night shifts of 16 hours or less (intervention schedules). The primary outcome was serious medical errors made by resident physicians, assessed by intensive surveillance, including direct observation and chart review. RESULTS: The characteristics of ICU patients during the two work schedules were similar, but resident physician workload, described as the mean (±SD) number of ICU patients per resident physician, was higher during the intervention schedules than during the control schedules (8.8±2.8 vs. 6.7±2.2). Resident physicians made more serious errors during the intervention schedules than during the control schedules (97.1 vs. 79.0 per 1000 patient-days; relative risk, 1.53; 95% confidence interval [CI], 1.37 to 1.72; P<0.001). The number of serious errors unitwide were likewise higher during the intervention schedules (181.3 vs. 131.5 per 1000 patient-days; relative risk, 1.56; 95% CI, 1.43 to 1.71). There was wide variability among sites, however; errors were lower during intervention schedules than during control schedules at one site, rates were similar during the two schedules at two sites, and rates were higher during intervention schedules than during control schedules at three sites. In a secondary analysis that was adjusted for the number of patients per resident physician as a potential confounder, intervention schedules were no longer associated with an increase in errors. CONCLUSIONS: Contrary to our hypothesis, resident physicians who were randomly assigned to schedules that eliminated extended shifts made more serious errors than resident physicians assigned to schedules with extended shifts, although the effect varied by site. The number of ICU patients cared for by each resident physician was higher during schedules that eliminated extended shifts. (Funded by the National Heart, Lung, and Blood Institute; ROSTERS ClinicalTrials.gov number, NCT02134847.).

The Implementation and Acceptability of a Combined Mobile Application with a COVID-19 at-Home Test Kit.

Introduction: Testing facilities for COVID-19 were stood up around the country during the pandemic, but could not handle the demand. This study aimed to combine a mobile application (App) with an at-home test kit to facilitate home-based testing. Methods: After integrating an App with an at-home testing service, we measured the time between sample collection and notification of results. We recruited 92 volunteers to utilize the platform. Results: Sixty-one percent (55/92) responded to the survey. Median sample collection-to-result time was 2.2 days (IQR = 1.3-3.2). Eighty-two percent (45/55) found the self-test kit and App easy to use. Eighty-four percent agreed that the combined solution is an acceptable way to receive health care services. Discussion: Decreasing testing time and providing timely test results improve care access and decrease the risk of infection. Combining a tailored App with an at-home testing service is a feasible solution to reaching that goal.

Associations between sleep disturbances, mental health outcomes and burnout in firefighters, and the mediating role of sleep during overnight work: A cross-sectional study.

This study investigated whether sleep disorder risk and mental health outcomes in firefighters were associated with burnout, particularly emotional exhaustion, and examined the mediating role of sleep at work in these relationships. A secondary aim was to investigate associations between habitual sleep characteristics and burnout. North American firefighters (n = 6,307) completed the Maslach Burnout Inventory (emotional exhaustion, depersonalisation, personal accomplishment), and were screened for sleep disorders and self-reported current mental health conditions and sleep characteristics. Multiple logistic regression analyses examined associations between sleep, mental health outcomes and burnout. Firefighters screening positive for a sleep disorder, particularly insomnia, had increased risk of emotional exhaustion (adjusted odds ratio 3.78, 95% confidence interval 2.97-4.79). Firefighters self-reporting a current mental health condition were at greater risk of emotional exhaustion (adjusted odds ratio 3.45, 95% confidence interval 2.79-4.27). Sleep during overnight work mediated the impact of having a sleep disorder and mental health condition on high burnout. Sleepiness and sleep deficit (difference between required and actual sleep), even in firefighters without sleep disorder risk, were associated with depersonalisation (adjusted odds ratio 1.65, 95% confidence interval 1.34-2.03 and adjusted odds ratio 1.29, 95% confidence interval 1.06-1.57, respectively) and low personal accomplishment (adjusted odds ratio 1.25, 95% confidence interval 1.07-1.47 and adjusted odds ratio 1.17, 95% confidence interval 1.01-1.35, respectively). Sleep and mental health problems were associated with increased risk of burnout in firefighters, and sleep during overnight work mediated these relationships. The results suggest the need to examine the effectiveness of occupational interventions that improve the opportunity for sleep, together with screening for and treating sleep disorders, to reduce burnout risk.

High risk of near-crash driving events following night-shift work.

Night-shift workers are at high risk of drowsiness-related motor vehicle crashes as a result of circadian disruption and sleep restriction. However, the impact of actual night-shift work on measures of drowsiness and driving performance while operating a real motor vehicle remains unknown. Sixteen night-shift workers completed two 2-h daytime driving sessions on a closed driving track at the Liberty Mutual Research Institute for Safety: (i) a postsleep baseline driving session after an average of 7.6 ± 2.4 h sleep the previous night with no night-shift work, and (ii) a postnight-shift driving session following night-shift work. Physiological measures of drowsiness were collected, including infrared reflectance oculography, electroencephalography, and electrooculography. Driving performance measures included lane excursions, near-crash events, and drives terminated because of failure to maintain control of the vehicle. Eleven near-crashes occurred in 6 of 16 postnight-shift drives (37.5%), and 7 of 16 postnight-shift drives (43.8%) were terminated early for safety reasons, compared with zero near-crashes or early drive terminations during 16 postsleep drives (Fishers exact: P = 0.0088 and P = 0.0034, respectively). Participants had a significantly higher rate of lane excursions, average Johns Drowsiness Scale, blink duration, and number of slow eye movements during postnight-shift drives compared with postsleep drives (3.09/min vs. 1.49/min; 1.71 vs. 0.97; 125 ms vs. 100 ms; 35.8 vs. 19.1; respectively, P < 0.05 for all). Night-shift work increases driver drowsiness, degrading driving performance and increasing the risk of near-crash drive events. With more than 9.5 million Americans working overnight or rotating shifts and one-third of United States commutes exceeding 30 min, these results have implications for traffic and occupational safety.

Sleep disorders, depression and anxiety are associated with adverse safety outcomes in healthcare workers: A prospective cohort study.

The objective of the study was to determine if sleep disorder, depression or anxiety screening status was associated with safety outcomes in a diverse population of hospital workers. A sample of shift workers at four hospitals participated in a prospective cohort study. Participants were screened for five sleep disorders, depression and anxiety at baseline, then completed prospective monthly surveys for the next 6 months to capture motor vehicle crashes, near-miss crashes, occupational exposures and medical errors. We tested the associations between sleep disorders, depression and anxiety and adverse safety outcomes using incidence rate ratios adjusted for potentially confounding factors in a multivariable negative binomial regression model. Of the 416 hospital workers who participated, two in five (40.9%) screened positive for a sleep disorder and 21.6% screened positive for depression or anxiety. After multivariable adjustment, screening positive for a sleep disorder was associated with 83% increased incidence of adverse safety outcomes. Screening positive for depression or anxiety increased the risk by 63%. Sleep disorders and mood disorders were independently associated with adverse outcomes and contributed additively to risk. Our findings suggest that screening for sleep disorders and mental health screening can help identify individuals who are vulnerable to adverse safety outcomes. Future research should evaluate sleep and mental health screening, evaluation and treatment programmes that may improve safety.

Interspecific variation in Rx1 expression controls opsin expression and causes visual system diversity in African cichlid fishes.

The mechanisms underlying natural phenotypic diversity are key to understanding evolution and speciation. Cichlid fishes are among the most speciose vertebrates and an ideal model for identifying genes controlling species differences. Cichlids have diverse visual sensitivities that result from species expressing subsets of seven cichlid cone opsin genes. We previously identified a quantitative trait locus (QTL) that tunes visual sensitivity by varying SWS2A (short wavelength sensitive 2A) opsin expression in a genetic cross between two Lake Malawi cichlid species. Here, we identify Rx1 (retinal and anterior neural fold homeobox) as the causative gene for the QTL using fine mapping and RNAseq in retinal transcriptomes. Rx1 is differentially expressed between the parental species and correlated with SWS2A expression in the F2 progeny. Expression of Rx1 and SWS2A is also correlated in a panel of 16 Lake Malawi cichlid species. Association mapping in this panel identified a 413-bp deletion located 2.5-kb upstream of the Rx1 translation start site that is correlated with decreased Rx1 expression. This deletion explains 62% of the variance in SWS2A expression across 53 cichlid species in 29 genera. The deletion occurs in both the sand and rock-dwelling cichlid clades, suggesting that it is an ancestral polymorphism. Our finding supports the hypothesis that mixing and matching of ancestral polymorphisms can explain the diversity of present day cichlid phenotypes.

Predicting neurobehavioral performance of resident physicians in a Randomized Order Safety Trial Evaluating Resident-Physician Schedules (ROSTERS).

OBJECTIVES: Mathematical models of human neurobehavioral performance that include the effects of acute and chronic sleep restriction can be key tools in assessment and comparison of work schedules, allowing quantitative predictions of performance when empirical assessment is impractical. METHODS: Using such a model, we tested the hypothesis that resident physicians working an extended duration work roster, including 24-28 hours of continuous duty and up to 88 hours per week averaged over 4weeks, would have worse predicted performance than resident physicians working a rapidly cycling work roster intervention designed to reduce the duration of extended shifts. The performance metric used was attentional failures (ie, Psychomotor Vigilance Task lapses). Model input was 169 actual work and sleep schedules. Outcomes were predicted hours per week during work hours spent at moderate (equivalent to 16-20 hours of continuous wakefulness) or high (equivalent to ≥20 hours of continuous wakefulness) performance impairment. RESULTS: The model predicted that resident physicians working an extended duration work roster would spend significantly more time at moderate impairment (p = .02, effect size=0.2) than those working a rapidly cycling work roster; this difference was most pronounced during the circadian night (p < .001). On both schedules, performance was predicted to decline from weeks 1 + 2 to weeks 3 + 4 (p < .001), but the rate of decline was significantly greater on extended duration work roster (p < .01). Predicted performance impairment was inversely related to prior sleep duration (p < .001). CONCLUSIONS: These findings demonstrate the utility of a mathematical model to evaluate the predicted performance profile of schedules for resident physicians and others who experience chronic sleep restriction and circadian misalignment.

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy in 2011 that restricted first-year resident physicians in the USA to work no more than 16 consecutive hours. This was rescinded in 2017. METHODS: We conducted a nationwide prospective cohort study of resident physicians for 5 academic years (2002-2007) before and for 3 academic years (2014-2017) after implementation of the 16 hours 2011 ACGME work-hour limit. Our analyses compare trends in resident physician-reported medical errors between the two cohorts to evaluate the impact of this policy change. RESULTS: 14 796 residents provided data describing 78 101 months of direct patient care. After adjustment for potential confounders, the work-hour policy was associated with a 32% reduced risk of resident physician-reported significant medical errors (rate ratio (RR) 0.68; 95% CI 0.64 to 0.72), a 34% reduced risk of reported preventable adverse events (RR 0.66; 95% CI 0.59 to 0.74) and a 63% reduced risk of reported medical errors resulting in patient death (RR 0.37; 95% CI 0.28 to 0.49). CONCLUSIONS: These findings have broad relevance for those who work in and receive care from academic hospitals in the USA. The decision to lift this work hour policy in 2017 may expose patients to preventable harm.

Feeling sleepy? stop driving-awareness of fall asleep crashes.

STUDY OBJECTIVES: To examine whether drivers are aware of sleepiness and associated symptoms, and how subjective reports predict driving impairment and physiological drowsiness. METHODS: Sixteen shift workers (19-65 years; 9 women) drove an instrumented vehicle for 2 hours on a closed-loop track after a night of sleep and a night of work. Subjective sleepiness/symptoms were rated every 15 minutes. Severe and moderate driving impairment was defined by emergency brake maneuvers and lane deviations, respectively. Physiological drowsiness was defined by eye closures (Johns drowsiness scores) and EEG-based microsleep events. RESULTS: All subjective ratings increased post night-shift (p < 0.001). No severe drive events occurred without noticeable symptoms beforehand. All subjective sleepiness ratings, and specific symptoms, predicted a severe (emergency brake) driving event occurring in the next 15 minutes (OR: 1.76-2.4, AUC > 0.81, p < 0.009), except "head dropping down". Karolinska Sleepiness Scale (KSS), ocular symptoms, difficulty keeping to center of the road, and nodding off to sleep, were associated with a lane deviation in the next 15 minutes (OR: 1.17-1.24, p<0.029), although accuracy was only "fair" (AUC 0.59-0.65). All sleepiness ratings predicted severe ocular-based drowsiness (OR: 1.30-2.81, p < 0.001), with very good-to-excellent accuracy (AUC > 0.8), while moderate ocular-based drowsiness was predicted with fair-to-good accuracy (AUC > 0.62). KSS, likelihood of falling asleep, ocular symptoms, and "nodding off" predicted microsleep events, with fair-to-good accuracy (AUC 0.65-0.73). CONCLUSIONS: Drivers are aware of sleepiness, and many self-reported sleepiness symptoms predicted subsequent driving impairment/physiological drowsiness. Drivers should self-assess a wide range of sleepiness symptoms and stop driving when these occur to reduce the escalating risk of road crashes due to drowsiness.

Conservation of the photoperiodic neuroendocrine axis among vertebrates: evidence from the teleost fish, Gasterosteus aculeatus.

Photoperiod, or length of day, has a predictable annual cycle, making it an important cue for the timing of seasonal behavior and development in many organisms. Photoperiod is widely used among temperate and polar animals to regulate the timing of sexual maturation. The proper sensing and interpretation of photoperiod can be tightly tied to an organism's overall fitness. In photoperiodic mammals and birds the thyroid hormone pathway initiates sexual maturation, but the degree to which this pathway is conserved across other vertebrates is not well known. We use the threespine stickleback Gasterosteus aculeatus, as a representative teleost to quantify the photoperiodic response of key genes in the thyroid hormone pathway under controlled laboratory conditions. We find that the photoperiodic responses of the hormones are largely consistent amongst multiple populations, although differences suggest physiological adaptation to various climates. We conclude that the thyroid hormone pathway initiates sexual maturation in response to photoperiod in G. aculeatus, and our results show that more components of this pathway are conserved among mammals, birds, and teleost fish than was previously known. However, additional endocrinology, cell biology and molecular research will be required to define precisely which aspects of the pathway are conserved across vertebrates.

Sleep disorders, health, and safety in police officers.

CONTEXT: Sleep disorders often remain undiagnosed. Untreated sleep disorders among police officers may adversely affect their health and safety and pose a risk to the public. OBJECTIVE: To quantify associations between sleep disorder risk and self-reported health, safety, and performance outcomes in police officers. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional and prospective cohort study of North American police officers participating in either an online or an on-site screening (n=4957) and monthly follow-up surveys (n=3545 officers representing 15,735 person-months) between July 2005 and December 2007. A total of 3693 officers in the United States and Canada participated in the online screening survey, and 1264 officers from a municipal police department and a state police department participated in the on-site survey. MAIN OUTCOME MEASURES: Comorbid health conditions (cross-sectional); performance and safety outcomes (prospective). RESULTS: Of the 4957 participants, 40.4% screened positive for at least 1 sleep disorder, most of whom had not been diagnosed previously. Of the total cohort, 1666 (33.6%) screened positive for obstructive sleep apnea, 281 (6.5%) for moderate to severe insomnia, 269 (5.4%) for shift work disorder (14.5% of those who worked the night shift). Of the 4608 participants who completed the sleepiness scale, 1312 (28.5%) reported excessive sleepiness. Of the total cohort, 1294 (26.1%) reported falling asleep while driving at least 1 time a month. Respondents who screened positive for obstructive sleep apnea or any sleep disorder had an increased prevalence of reported physical and mental health conditions, including diabetes, depression, and cardiovascular disease. An analysis of up to 2 years of monthly follow-up surveys showed that those respondents who screened positive for a sleep disorder vs those who did not had a higher rate of reporting that they had made a serious administrative error (17.9% vs 12.7%; adjusted odds ratio [OR], 1.43 [95% CI, 1.23-1.67]); of falling asleep while driving (14.4% vs 9.2%; adjusted OR, 1.51 [95% CI, 1.20-1.90]); of making an error or safety violation attributed to fatigue (23.7% vs 15.5%; adjusted OR, 1.63 [95% CI, 1.43-1.85]); and of exhibiting other adverse work-related outcomes including uncontrolled anger toward suspects (34.1% vs 28.5%; adjusted OR, 1.25 [95% CI, 1.09-1.43]), absenteeism (26.0% vs 20.9%; adjusted OR, 1.23 [95% CI, 1.08-1.40]), and falling asleep during meetings (14.1% vs 7.0%; adjusted OR, 1.95 [95% CI, 1.52-2.52]). CONCLUSION: Among a group of North American police officers, sleep disorders were common and were significantly associated with increased risk of self-reported adverse health, performance, and safety outcomes.

Extended Work Shifts and Neurobehavioral Performance in Resident-Physicians.

OBJECTIVES: Extended-duration work rosters (EDWRs) with shifts of 24+ hours impair performance compared with rapid cycling work rosters (RCWRs) that limit shifts to 16 hours in postgraduate year (PGY) 1 resident-physicians. We examined the impact of a RCWR on PGY 2 and PGY 3 resident-physicians. METHODS: Data from 294 resident-physicians were analyzed from a multicenter clinical trial of 6 US PICUs. Resident-physicians worked 4-week EDWRs with shifts of 24+ hours every third or fourth shift, or an RCWR in which most shifts were ≤16 consecutive hours. Participants completed a daily sleep and work log and the 10-minute Psychomotor Vigilance Task and Karolinska Sleepiness Scale 2 to 5 times per shift approximately once per week as operational demands allowed. RESULTS: Overall, the mean (± SE) number of attentional failures was significantly higher (P =.01) on the EDWR (6.8 ± 1.0) compared with RCWR (2.9 ± 0.7). Reaction time and subjective alertness were also significantly higher, by ∼18% and ∼9%, respectively (both P <.0001). These differences were sustained across the 4-week rotation. Moreover, attentional failures were associated with resident-physician-related serious medical errors (SMEs) (P =.04). Although a higher rate of SMEs was observed under the RCWR, after adjusting for workload, RCWR had a protective effect on the rate of SMEs (rate ratio 0.48 [95% confidence interval: 0.30-0.77]). CONCLUSIONS: Performance impairment due to EDWR is improved by limiting shift duration. These data and their correlation with SME rates highlight the impairment of neurobehavioral performance due to extended-duration shifts and have important implications for patient safety.

The Association Between Resident Physician Work-Hour Regulations and Physician Safety and Health.

BACKGROUND: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted a 16-h limit on consecutive hours for first-year resident physicians. We sought to examine the effect of these work-hour regulations on physician safety. METHODS: All medical students matched to a US residency program from 2002 to 2007 and 2014 to 2017 were invited to participate in prospective cohort studies. Each month participants reported hours of work, extended duration shifts, and adverse safety outcomes, including motor vehicle crashes, percutaneous injuries, and attentional failures. The incidence of each outcome was compared before and after the 2011 ACGME work-hour limit. Hypotheses were tested using generalized linear models adjusted for potential confounders. RESULTS: Of all first-year resident physicians nationwide, 13% participated in the study, with 80,266 monthly reports completed by 15,276 first-year resident physicians. Following implementation of the 16-h 2011 ACGME work-hour limit, the mean number of extended duration (≥24-h) shifts per month decreased from 3.9 to 0.2. The risk of motor vehicle crash decreased 24% (relative risk [RR] 0.76; 0.67-0.85), percutaneous injury risk decreased more than 40% (relative risk 0.54; 0.48-0.61), and the rate of attentional failures was reduced 18% (incidence rate ratio [IRR] 0.82; 0.78-0.86). Extended duration shifts and prolonged weekly work hours were associated with an increased risk of adverse safety outcomes independent of cohort. CONCLUSIONS: The 2011 ACGME work-hour limit was associated with meaningful improvements in physician safety and health. Surveillance is needed to monitor the ongoing impact of work hours on physician safety, health, and well-being.

Associations between shift work characteristics, shift work schedules, sleep and burnout in North American police officers: a cross-sectional study.

OBJECTIVES: To examine associations between shift work characteristics and schedules on burnout in police and whether sleep duration and sleepiness were associated with burnout. METHODS: Police officers (n=3140) completed the Maslach Burnout Inventory (emotional exhaustion, depersonalisation, personal accomplishment) and self-reported shift schedules (irregular, rotating, fixed), shift characteristics (night, duration, frequency, work hours), sleep duration and sleepiness. RESULTS: Irregular schedules, long shifts (≥11 hours), mandatory overtime, short sleep and sleepiness were associated with increased risk of overall burnout in police. Police working a greater frequency of long shifts were more likely to have emotional exhaustion (adjusted OR 1.91, 95% CI 1.35 to 2.72) than those not working long shifts. Night shifts were associated with depersonalisation (1.32, 1.05 to 1.66) compared with not working nights. Police working mandatory overtime had increased risk of emotional exhaustion (1.37, 1.14 to 1.65) than those who did not. Compared with fixed schedules, irregular schedules were associated with emotional exhaustion and depersonalisation (1.91, 1.44 to 2.54 and 1.39, 1.02 to 1.89, respectively). Police sleeping <6 hours were more likely to have emotional exhaustion (1.60, 1.33 to 1.93) than those sleeping longer, and excessive sleepiness was associated with emotional exhaustion (1.81, 1.50 to 2.18). CONCLUSIONS: Irregular schedules and increased night shifts, sleep disturbances and work hours were related to higher burnout risk in police. Future research should evaluate work schedules in law enforcement that optimise shift duration and frequency, and increase consistency in scheduling and control over work hours to limit burnout in police.

Prediction of drowsiness events in night shift workers during morning driving.

The morning commute home is an especially vulnerable time for workers engaged in night shift work due to the heightened risk of experiencing drowsy driving. One strategy to manage this risk is to monitor the driver's state in real time using an in vehicle monitoring system and to alert drivers when they are becoming sleepy. The primary objective of this study is to build and evaluate predictive models for drowsiness events occurring in morning drives using a variety of physiological and performance data gathered under a real driving scenario. We used data collected from 16 night shift workers who drove an instrumented vehicle for approximately two hours on a test track on two occasions: after a night shift and after a night of rest. Drowsiness was defined by two outcome events: performance degradation (Lane-Crossing models) and electroencephalogram (EEG) characterized sleep episodes (Microsleep Models). For each outcome, we assessed the accuracy of sets of predictors, including or not including a driver factor, eyelid measures, and driving performance measures. We also compared the predictions using different time intervals relative to the events (e.g., 1-min prior to the event through 10-min prior). By examining the Area Under the receiver operating characteristic Curve (AUC), accuracy, sensitivity, and specificity of the predictive models, the results showed that the inclusion of an individual driver factor improved AUC and prediction accuracy for both outcomes. Eyelid measures improved the prediction for the Lane-Crossing models, but not for Microsleep models. Prediction performance was not changed by adding driving performance predictors or by increasing the time to the event for either outcome. The best models for both measures of drowsiness were those considering driver individual differences and eyelid measures, suggesting that these indicators should be strongly considered when predicting drowsiness events. The results of this paper can benefit the development of real-time drowsiness detection and help to manage drowsiness to avoid related motor-vehicle crashes and loss.

Design and recruitment of the randomized order safety trial evaluating resident-physician schedules (ROSTERS) study.

INTRODUCTION: While the Accreditation Council for Graduate Medical Education limited first year resident-physicians to 16 consecutive work hours from 2011 to 2017, resident-physicians in their second year or higher were permitted to work up to 28 h consecutively. This paper describes the Randomized Order Safety Trial Evaluating Resident-physician Schedules (ROSTERS) study, a clustered-randomized crossover clinical trial designed to evaluate the effectiveness of eliminating traditional shifts of 24 h or longer for second year or higher resident-physicians in pediatric intensive care units (PICUs). METHODS: ROSTERS was a multi-center non-blinded trial in 6 PICUs at US academic medical centers. The primary aim was to compare patient safety between the extended duration work roster (EDWR), which included shifts ≥24 h, and a rapidly cycling work roster (RCWR), where shifts were limited to a maximum of 16 h. Information on potential medical errors was gathered and used for classification by centrally trained physician reviewers who were blinded to the study arm. Secondary aims were to assess the relationship of the study arm to resident-physician sleep duration, work hours and neurobehavioral performance. RESULTS: The study involved 6577 patients with a total of 38,821 patient days (n = 18,749 EDWR, n = 20,072 RCWR). There were 413 resident-physician rotations included in the study (n = 203 EDWR, n = 210 RCWR). Resident-physician questionnaire data were over 95% complete. CONCLUSIONS: Results from data collected in the ROSTERS study will be evaluated for the impact of resident-physician schedule roster on patient safety outcomes in PICUs, and will allow for examination of a number of secondary outcome measures. ClinicalTrials.gov Identifier: NCT02134847.

Effects on resident work hours, sleep duration, and work experience in a randomized order safety trial evaluating resident-physician schedules (ROSTERS).

STUDY OBJECTIVES: We compared resident physician work hours and sleep in a multicenter clustered-randomized crossover clinical trial that randomized resident physicians to an Extended Duration Work Roster (EDWR) with extended-duration (≥24 hr) shifts or a Rapidly Cycling Work Roster (RCWR), in which scheduled shift lengths were limited to 16 or fewer consecutive hours. METHODS: Three hundred two resident physicians were enrolled and completed 370 1 month pediatric intensive care unit rotations in six US academic medical centers. Sleep was objectively estimated with wrist-worn actigraphs. Work hours and subjective sleep data were collected via daily electronic diary. RESULTS: Resident physicians worked fewer total hours per week during the RCWR compared with the EDWR (61.9 ± 4.8 versus 68.4 ± 7.4, respectively; p < 0.0001). During the RCWR, 73% of work hours occurred within shifts of ≤16 consecutive hours. In contrast, during the EDWR, 38% of work hours occurred on shifts of ≤16 consecutive hours. Resident physicians obtained significantly more sleep per week on the RCWR (52.9 ± 6.0 hr) compared with the EDWR (49.1 ± 5.8 hr, p < 0.0001). The percentage of 24 hr intervals with less than 4 hr of actigraphically measured sleep was 9% on the RCWR and 25% on the EDWR (p < 0.0001). CONCLUSIONS: RCWRs were effective in reducing weekly work hours and the occurrence of >16 consecutive hour shifts, and improving sleep duration of resident physicians. Although inclusion of the six operational healthcare sites increases the generalizability of these findings, there was heterogeneity in schedule implementation. Additional research is needed to optimize scheduling practices allowing for sufficient sleep prior to all work shifts.Clinical Trial: Multicenter Clinical Trial of Limiting Resident Work Hours on ICU Patient Safety (ROSTERS), https://clinicaltrials.gov/ct2/show/NCT02134847.

Cross-sectional analysis of sleep-promoting and wake-promoting drug use on health, fatigue-related error, and near-crashes in police officers.

OBJECTIVES: To examine sleep-promoting and wake-promoting drug use in police officers and associations between their use and health (excessive sleepiness, stress and burnout), performance (fatigue-related errors) and safety (near-crashes) outcomes, both alone and in combination with night-shift work. DESIGN: Cross-sectional survey. SETTING: Police officers from North America completed the survey either online or via paper/pencil at a police station. PARTICIPANTS: 4957 police participated, 3693 online (91.9%, participation rate) and 1264 onsite (cooperation rate 63.1%). MAIN OUTCOME MEASURES: Sleep-promoting and wake-promoting drug use, excessive sleepiness, near-crash motor vehicle crashes, dozing while driving, fatigue errors, stress and burnout. RESULTS: Over the past month, 20% of police officers reported using sleep-promoting drugs and drugs causing sleepiness, while wake-promoting agents were used by 28% of police (5% used wake-promoting drugs, 23% used high levels of caffeine and 4% smoked to stay awake). Use of sleep-promoting drugs was associated with increased near-crashes (OR=1.61; 95% CI 1.21 to 2.13), fatigue-related errors (OR=1.75; 95% CI 1.32 to 2.79), higher stress (OR=1.41; 95% CI 1.10 to 1.82), and higher burnout (OR=1.83; 95% CI 1.40 to 2.38). Wake-promoting drug use, high caffeine and smoking to stay awake were associated with increased odds of a fatigue-related error, stress and burnout (ORs ranging from 1.68 to 2.56). Caffeine consumption was common, and while smoking was not, of those participants who did smoke, one-in-three did so to remain awake. Night-shift work was associated with independent increases in excessive sleepiness, near-crashes and fatigue-related errors. Interactions between night-shift work and wake-promoting drug use were also found for excessive sleepiness. CONCLUSIONS: Police who use sleep-promoting and wake-promoting drugs, especially when working night shifts, are most vulnerable to adverse health, performance and safety outcomes. Future research should examine temporal relationships between shift work, drug use and adverse outcomes, in order to develop optimal alertness management strategies.

Irregular sleep/wake patterns are associated with poorer academic performance and delayed circadian and sleep/wake timing.

The association of irregular sleep schedules with circadian timing and academic performance has not been systematically examined. We studied 61 undergraduates for 30 days using sleep diaries, and quantified sleep regularity using a novel metric, the sleep regularity index (SRI). In the most and least regular quintiles, circadian phase and light exposure were assessed using salivary dim-light melatonin onset (DLMO) and wrist-worn photometry, respectively. DLMO occurred later (00:08 ± 1:54 vs. 21:32 ± 1:48; p < 0.003); the daily sleep propensity rhythm peaked later (06:33 ± 0:19 vs. 04:45 ± 0:11; p < 0.005); and light rhythms had lower amplitude (102 ± 19 lux vs. 179 ± 29 lux; p < 0.005) in Irregular compared to Regular sleepers. A mathematical model of the circadian pacemaker and its response to light was used to demonstrate that Irregular vs. Regular group differences in circadian timing were likely primarily due to their different patterns of light exposure. A positive correlation (r = 0.37; p < 0.004) between academic performance and SRI was observed. These findings show that irregular sleep and light exposure patterns in college students are associated with delayed circadian rhythms and lower academic performance. Moreover, the modeling results reveal that light-based interventions may be therapeutically effective in improving sleep regularity in this population.

Randomized, Prospective Study of the Impact of a Sleep Health Program on Firefighter Injury and Disability.

Study Objectives: Firefighters' schedules include extended shifts and long work weeks which cause sleep deficiency and circadian rhythm disruption. Many firefighters also suffer from undiagnosed sleep disorders, exacerbating fatigue. We tested the hypothesis that a workplace-based Sleep Health Program (SHP) incorporating sleep health education and sleep disorders screening would improve firefighter health and safety compared to standard practice. Design: Prospective station-level randomized, field-based intervention. Setting: US fire department. Participants: 1189 firefighters. Interventions: Sleep health education, questionnaire-based sleep disorders screening, and sleep clinic referrals for respondents who screened positive for a sleep disorder. Measurements and Results: Firefighters were randomized by station. Using departmental records, in an intention-to-treat analysis, firefighters assigned to intervention stations which participated in education sessions and had the opportunity to complete sleep disorders screening reported 46% fewer disability days than those assigned to control stations (1.4 ± 5.9 vs. 2.6 ± 8.5 days/firefighter, respectively; p = .003). There were no significant differences in departmental injury or motor vehicle crash rates between the groups. In post hoc analysis accounting for intervention exposure, firefighters who attended education sessions were 24% less likely to file at least one injury report during the study than those who did not attend, regardless of randomization (OR [95% CI] 0.76 [0.60, 0.98]; χ2 = 4.56; p = .033). There were no significant changes pre- versus post-study in self-reported sleep or sleepiness in those who participated in the intervention. Conclusions: A firefighter workplace-based SHP providing sleep health education and sleep disorders screening opportunity can reduce injuries and work loss due to disability in firefighters.