Department of Surgery, Harbor-UCLA Medical Center, Torrance, California 90509, USA.
J Surg Educ. 2010 Nov-Dec;67(6):449-51. doi: 10.1016/j.jsurg.2010.09.003. Epub 2010 Nov 7.
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.
美国国家医学院最近建议进一步减少住院医师的工作时间，包括在工作 16 小时后给值夜班的住院医师 5 小时的休息时间，以此为患者提供更好的保护，防止因疲劳而导致错误，然而，在目前的 80 小时工作周时代，还没有关于外科住院医师在工作 16 小时后进行手术的结果的数据。
对 2003 年至 2009 年期间在 1 级创伤中心创伤外科服务需要紧急/紧急手术的所有创伤患者进行回顾性分析。晚上 10 点以后的手术由早上 6 点开始轮班的住院医师进行，因此工作了 16 小时。对晚上 10 点到早上 6 点（夜间）和早上 6 点到晚上 10 点（白天）之间进行的手术的发病率和死亡率进行了比较。
在 7 年的研究期间，1432 名创伤患者需要紧急/紧急手术。84%的患者为男性，71%的患者为穿透性损伤。该组的中位年龄为 26 岁。总体并发症发生率为 18%，死亡率为 12%。单因素分析显示，夜间组男性比例高于白天组（87%比 82%，p=0.007）。夜间组患者也更年轻（25 岁比 29 岁，p<0.0001），损伤严重程度评分（ISS）较低（13 比 16，p=0.002），穿透伤比例较高（81%比 65%，p<0.0001）。白天的并发症发生率更高（20%比夜间的 16%，p=0.04），而死亡率相似（白天的 13.5%比夜间的 10.6%，p=0.1）。多变量分析显示，在校正年龄、男性、ISS 和穿透性创伤后，手术时间不是发病率的预测因素（比值比[OR]0.97；95%置信区间[CI]0.7-1.3，p=0.9）或死亡率（OR1.02，95%CI0.7-1.6，p=0.9）。
夜间由工作时间超过 16 小时的住院医师进行的创伤手术与白天进行的手术相比，结果相似。夜间实施 5 小时休息时间不太可能改善这些常见手术的结果。
