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Patient Safety Tip
of the Week
August 25,
2020
The Off-Hours Effect in
Radiology
Weve done multiple
columns on the weekend effect and the after hours effect, in which patient outcomes tend to
be worse than for those during normal daytime hours. And, weve
done even more columns on the impact of fatigue or derangements of normal
circadian cycles on performance.
Physicians,
nurses, and really all healthcare workers tend to have drop-offs in performance
when fatigued. In our April 2018 What's New in the Patient Safety World column Radiologists
Get Fatigued, Too we
highlighted a study looking at the effect of overnight shifts on performance of
radiologists (Hanna 2018). The researchers used a tool for measuring
fatigue and advance eye tracking technology to assess the performance of radiologists
(both attendings and residents).
During
each session, radiologists viewed 20 bone radiographs consisting of normal and
abnormal findings. The Swedish Occupational Fatigue Inventory results
demonstrated worsening in all five variables (lack of energy, physical
exertion, physical discomfort, lack of motivation, and sleepiness) after
overnight shifts. Not surprisingly, participants demonstrated worse diagnostic
performance in the fatigued versus not-fatigued state. Viewing time per case
was significantly prolonged when the radiologists were fatigued. Mean total
fixations generated during the search increased by 60% during fatigued
sessions. Mean time to first fixate on bone fractures increased by 34% during
fatigued sessions. Moreover, dwell times associated with true- and
false-positive decisions increased, whereas those with false negatives
decreased. Effects of fatigue were more pronounced in residents.
The
authors concluded that further research is needed to address and reverse the
impact of such fatigue-related changes. They speculate that environmental
changes (eg. lighting) and activity changes (eg. periodic breaks, moving around, etc.) might help
mitigate the adverse effects of fatigue on performance.
There
have actually been several studies on the impact of
fatigue on radiologist performance, but most have focused primarily on
radiology residents. Now a new study has looked at the performance of radiology
fellows who have completed full radiology residencies (all of whom successfully
completed the American Board of Radiology board certification following their
fellowship year), comparing CT scan reading error rates during daytime or night
shifts (Patel
2020).
Fellows
working off-hours interpreted in-patient and emergency department examinations.
The following day, attending radiologists read the studies that had been
interpreted by the fellows. All fellows had at least 11 hours off prior to any off-hours assignment, and fellows took no more than 5
consecutive off-hours assignments before having at least 48 hours off work.
During
the study period, off-hour day assignments on weekends and holidays were from
7:00 AM to 5:59 PM; the off-hour night assignments on weekends, holidays, and
Fridays were from 6:00 PM to 6:59 AM. Off-hour night assignments on Monday to
Thursday were from 8:00 PM to 6:59 AM.
Over 10,000 body CT studies were interpreted
by 32 radiology fellows. Nighttime studies had error rates of 3%, compared to
2% for daytime studies, and 69% of the radiology fellows had higher error rates
for night cases. Moreover, there were significantly more errors during the last
half of night assignments (3.7%) compared with the first half (2.5%).
Diagnostic error rates
were also lower in the first half of the day assignment from 7:00 AM to 11:59 AM
compared with the second half from 12:00 PM to 5:59 PM (1.1% vs. 2.6%), but that
difference was not statistically significant. Though not statistically
significant, we would tend not to ignore that trend. In our May 3, 2011 Patient
Safety Tip of the Week Its All in the Timing we noted that detection rates for polyps or
adenomas during colonoscopy fell off during colonoscopies done later in a shift.
And in our June 2019 What's New in the
Patient Safety World column More
on the Time of Day we noted your chance of
getting an influenza vaccination or one of several preventive screening
procedures also falls off when you are seen late in the day.
The authors state: The error rate was higher
despite lower work intensity during night assignments and despite having work
schedules exceeding Accreditation Council for Graduate Medical Education guidelines
to promote rest. The error rate was highest during the latter half of night
assignments. These findings have implications for patient care and quality assurance
efforts, and for designing processes to deliver the highest quality of care at lowest
cost.
Of course, there may be factors other than fatigue
that contribute to more errors occurring toward the end of the night shift (or
toward the end of the day shift). It may be that the attention of the
healthcare professional is directed toward what will happen once the shift has
ended. While the Patel paper notes that all the fellows had at least 11 hours
off prior to their off-hour shifts, it does not state whether they sometimes had
to work during the day following the off-hour shift. Or it might be that the radiologist
is rushed to finish up all work before the shift ends (eg.
making sure that all dictations were done). It might even be that the time
required for a safe handoff at the end of a shift leads to rushing the
interpretation of the imaging study.
There is also one area in which we would like
to have seen more data. The fellows often worked multiple consecutive night
shifts (as many as five consecutive night shifts). In several of our columns weve discussed data that shows the number of performance errors
in other industries increases with each consecutive night shift. For example,
our November 9, 2010 Patient Safety Tip of the Week 12-Hour Nursing Shifts and
Patient Safety cited a study on shift workers in fields
other than healthcare (Folkard 2003)
which showed that the risk of incidents increased each consecutive day worked.
For example, on average for night shifts risk was 6% higher on the second
night, 17% higher on the third night, and 36% higher on the fourth night (for
morning/day shifts the corresponding risks were 2%, 7% and 17%). It would have
been very interesting to see in the current Patel
study whether the radiology fellows made more errors on the fourth or fifth
consecutive off-hours shift compared to the first or second.
Patel et al. note that dtouble
reading is an established strategy used to mitigate radiology errors. But
they go on to discuss of the downsides of double reading. One of those is
ensuring that the result of the second reading gets back to the appropriate
clinician at a time when intervention can be done. Both a patient and an
emergency physician may have left the emergency department long before the
result of that second reading is posted, potentially leading to falling
through the cracks. Therefore, it is important to encourage real-time
readings. They also discuss more demand for more in-house attending
radiologist coverage. But we suspect those attendings would also likely be
subject to the very same factors that led to more errors in all these studies.
There is another
option: teleradiology. We once worked with a small, rural hospital that
had a unique relationship with a radiology group. The group consisted of mostly
top-notch Israeli radiologists, all licensed in the US and appropriately
credentialed at the hospital. There was always one radiologist on-site at the
US hospital during daytime hours. But at night the readings were done via teleradiology
by one of the radiologists in Israel, where it was daytime. Clinicians at the
US hospital still had the opportunity to talk with the remote radiologist and
go over the imaging studies over the phone. Many hospitals in the US do use
similar nighthawk services. With telemedicine, in general, now opening up in the COVID-19 era, it is conceivable that
much radiology that is night-time in one location could be daytime in
another.
In an editorial accompanying the Patel study, Bruno (Bruno 2020) notes that many academic centers have already been using in-house radiology attendings along with residents, so that all interpretations are final in real-time. He also notes that many medical centers and hospitals are relying on nighthawk services, akin to the teleradiology services we allude to above. Bruno notes that the key take-home message of the Patel study is that even attending-level radiologists are prone to more errors when working a night shift.
Regardless
of which solutions might be put in place, it is important that hospitals and
medical centers actually measure error rates to ensure
that their solutions actually achieved the desired effects.
Some
of our previous columns on the weekend
effect:
·
February 26, 2008 Nightmares
.The
Hospital at Night
·
December 15, 2009 The
Weekend Effect
·
July 20, 2010 More
on the Weekend Effect/After-Hours Effect
·
October 2008 Hospital
at Night Project
·
September 2009 After-Hours
Surgery Is There a Downside?
·
December
21, 2010 More Bad News About Off-Hours Care
·
June
2011 Another Study on Dangers of Weekend
Admissions
·
September
2011 Add COPD to Perilous Weekends
·
August
2012 More on the Weekend Effect
·
June
2013 Oh No! Not Fridays Too!
·
November
2013 The Weekend Effect: Not One Simple Answer
·
August
2014 The Weekend Effect in Pediatric Surgery
·
October
2014 What Time of Day Do You Want Your Surgery?
·
December
2014 Another Procedure to Avoid Late in the Day or
on Weekends
·
January
2015 Emergency Surgery Also Very Costly
·
May 2015
HACs and the Weekend Effect
·
August
2015 More Stats on the Weekend Effect
·
September
2015 Surgery Previous Night Does Not Impact
Attending Surgeon Next Day
·
February
23, 2016 Weekend
Effect Solutions?
·
June 2016
Weekend
Effect Challenged
·
October 4,
2016 More
on After-Hours Surgery
·
July 25,
2017 Can
We Influence the Weekend Effect?
·
August
15, 2017 Delayed
Emergency Surgery and Mortality Risk
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
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
References:
Hanna TN, Zygmont ME,
Peterson R, et al. The effects of fatigue from overnight
shifts on radiology search patterns and
diagnostic performance. J Am Coll Radiol 2018; 15(12):
1709-1716
https://www.jacr.org/article/S1546-1440(17)31661-7/fulltext
Patel AG, Pizzitola
VJ, Johnson CD, et al. Radiologists Make More Errors Interpreting Off-Hours
Body CT Studies during Overnight Assignments as Compared with Daytime
Assignments. Radiology 2020; Published Online: Aug 18
2020
https://pubs.rsna.org/doi/10.1148/radiol.2020201558
Folkard S, Tucker
P. Shift work, safety and productivity. Occupational
Medicine 2003; 53: 95-101
Bruno MA. Radiology Errors across the Diurnal
Cycle. Radiology 2020; Published Online: Aug 18 2020
https://pubs.rsna.org/doi/full/10.1148/radiol.2020202902
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