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Whats New in the
Patient Safety World
July 2022
Outcomes OK When
Surgeon Operated the Night Before
The role of fatigue in causing errors in healthcare or any industry is well established. But there is one glaring example that seems to defy this concept. In our September 2015 What's New in the Patient Safety World column Surgery Previous Night Does Not Impact Attending Surgeon Next Day we discussed a Canadian study (Govindarajan 2015) that showed outcomes for the next day case do not seem to be adversely impacted by the surgeons previous night procedures.
Now a new study (Sun 2022) from more than 50 hospitals across 18 states and 2 countries (US and the Netherlands) confirms the results seen in the Canadian study. Sun et al. looked at outcomes of almost 500,000 surgeries, of which 2.6% involved an attending surgeon who operated the night before.
After adjusting for operation type, surgeon fixed effects (indicator variables for each surgeon), and patient characteristics such as age and comorbidities, the incidence of in-hospital death or major complications was 5.89% among daytime operations when the attending surgeon operated the night before compared with 5.87% among daytime operations when the same surgeon did not. There was also no difference in several secondary outcomes studied except for a slight decrease in the length of daytime operations.
Several sensitivity analyses also suggested no difference between overnight work and the primary outcome. There was no statistically significant difference in the incidence of death or major complication for daytime procedures based on procedure length. Each additional hour worked the previous night was associated with a statistically nonsignificant decrease in the probability of death or a major complication for daytime procedures.
The authors conclude that, combined with previous studies, their results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform procedures the following morning. They state their results do not establish that this practice is always safe or that fatigue does not affect outcomes, but that the potential risk was managed well enough to avoid patient harm in this sample of
surgeons. They do note that these cases were done mostly at academic institutions and that the results may not be generalizable to other settings.
Again, this is a
very different question from one we have addressed on numerous occasions. Several
of our columns have questioned whether surgery should be done after hours,
particularly for procedures that may not be true emergency ones (see our Whats
New in the Patient Safety World columns for September 2009 After-Hours Surgery Is
There a Downside?, October
2014 What Time of Day Do You Want
Your Surgery?, December
2014 Another Procedure to Avoid
Late in the Day or on Weekends and January 2015 Emergency Surgery Also Very
Costly).
In those columns we
have pointed out that such surgeries and procedures involve considerations far
beyond just the surgeon. Why should after hours surgery be more prone to
adverse outcomes than regularly scheduled elective surgery? There are many
reasons aside from the fact that patients needing emergency and after hours surgery are generally sicker. You are operating
with a team that is likely different from your daytime team. All members of
that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the
same level of expertise as your regular daytime team and the team dynamics
between members is likely to be different. The post-surgery recovery unit is
likely to be staffed much differently after-hours as well. The staff may be
more likely to be unfamiliar with things like location of equipment. And some
of the other hospital support services (eg. radiology, laboratory) may have lesser staffing after-hours. Just as
importantly, many or all of the on-call staff that make up the after-hours
surgical team have likely worked a full daytime shift that day
so fatigue enters as a potential contributory factor. And there are always time
pressures after hours as well. In addition, one of the most compelling reasons surgery is done at night rather than deferred to the next
morning is the schedule of the surgeon or other physician for that next morning
(either in surgery or the cath lab or his/her office). Because the surgeon
does not want to disrupt that next day schedule, he/she often prefers to go
ahead with the current case at night. Similarly, many hospitals run very tight
OR schedules and adding a case from the previous night can disrupt the schedule
of many other cases.
It is reassuring, however, that both the studies by Sun et al. and Govindarajan et al. seem to indicate that surgeons operating the day following a night procedure have managed potential risk well enough to avoid patient harm.
Some of our other columns on the role of fatigue in
Patient Safety:
November 9, 2010 12-Hour Nursing Shifts and Patient Safety
April 26, 2011 Sleeping Air Traffic Controllers: What About
Healthcare?
February 2011 Update on 12-hour Nursing Shifts
September 2011 Shiftwork and Patient Safety
November 2011 Restricted Housestaff
Work Hours and Patient Handoffs
January 2012 Joint Commission Sentinel Event Alert:
Healthcare Worker Fatigue and Patient Safety
January 3, 2012 Unintended Consequences of Restricted Housestaff Hours
June 2012 June 2012 Surgeon Fatigue
November 2012 The Mid-Day Nap
November 13, 2012 The 12-Hour Nursing Shift: More Downsides
July 29, 2014 The 12-Hour Nursing Shift: Debate Continues
October 2014 Another Rap on the 12-Hour Nursing Shift
December 2, 2014 ANA Position Statement on Nurse Fatigue
August 2015 Surgical Resident Duty Reform and
Postoperative Outcomes
September 2015 Surgery Previous Night Does Not Impact
Attending Surgeon Next Day
September 29, 2015 More on the 12-Hour Nursing Shift
September 6, 2016 Napping
Debate Rekindled
April 18, 2017 Alarm
Response and Nurse Shift Duration
July 11, 2017 The
12-Hour Shift Takes More Hits
February 13, 2018 Interruptions
in the ED
April 2018 Radiologists
Get Fatigued, Too
August 2018 Burnout
and Medical Errors
September 4, 2018 The
12-Hour Nursing Shift: Another Nail in the Coffin
August 2020 New Twist on Resident Work Hours and Patient Safety
August 25, 2020 The Off-Hours Effect in Radiology
September 2020 Daylight Savings Time Impacts Patient Safety?
January 19, 2021 Technology to Identify Fatigue?
October 12, 2021 FDA Approval of Concussion Tool Why Not a Fatigue Detection Tool?
February 2022 Does Time of Day Matter?
Some of our previous columns on after-hours surgery:
· September 2009 After-Hours Surgery Is There a Downside?
·
October
2014 What Time of Day Do You Want Your Surgery?
·
January
2015 Emergency Surgery Also Very Costly
·
September
2015 Surgery Previous Night Does Not Impact
Attending Surgeon Next Day
·
October
4, 2016 More
on After-Hours Surgery
·
August
15, 2017 Delayed
Emergency Surgery and Mortality Risk
·
October
24, 2017 Neurosurgery
and Time of Day
·
December
2019 Surgeon
On-Call Shifts
·
October
13, 2020 Night-Time Surgery
References:
Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work. N Engl J Med 2015; 373: 845-853
https://www.nejm.org/doi/full/10.1056/NEJMsa1415994
Sun EC, Mello MM, Vaughn MT, et al. Assessment of Perioperative Outcomes Among Surgeons Who Operated the Night Before. JAMA Intern Med 2022; Published online May 23, 2022
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2792088
(Sun 2022)
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