Parshuram Christopher S, Amaral Andre C K B, Ferguson Niall D, Baker G Ross, Etchells Edward E, Flintoft Virginia, Granton John, Lingard Lorelei, Kirpalani Haresh, Mehta Sangeeta, Moldofsky Harvey, Scales Damon C, Stewart Thomas E, Willan Andrew R, Friedrich Jan O
Department of Critical Care Medicine (Parshuram) and The Center for Safety Research at Child Health Evaluative Sciences (Parshuram, Willan), The Hospital for Sick Children, Toronto, Ont.; Interdepartmental Division of Critical Care Medicine (Parshuram, Amaral, Ferguson, Granton, Mehta, Scales, Friedrich,), Institute for Health Policy, Management and Evaluation (Baker, Flintoft), Department of Medicine (Etchells, Granton, Stewart), Department of Anaesthesia (Stewart) and Dalla Lana School of Public Health (Willan), University of Toronto, Toronto, Ont.; Department of Critical Care (Friedrich) and Li Ka Shing Knowledge Institute (Friedrich), St. Michael's Hospital, Toronto, Ont.; Sunnybrook Research Institute (Amaral, Scales), Department of Critical Care Medicine (Amaral, Scales) and Division of General Internal Medicine (Etchells), Sunnybrook Health Sciences Centre, Toronto, Ont.; Critical Care Medicine (Granton), University Health Network, Toronto, Ont.; Centre for Education Research and Innovation (Lingard) and Department of Medicine and Dentistry (Lingard), Western University, London, Ont.; Perelman School of Medicine (Kirpalani), University of Pennsylvania, Philadelphia, Pa.; Neonatology (Kirpalani), The Children's Hospital of Philadelphia, Philadelphia, Pa.; Department of Medicine, Division of Respirology and Critical Care Program (Ferguson, Mehta), Mount Sinai Hospital and University Health Network, Toronto, Ont.; Department of Medicine, (Mehta) Mount Sinai Hospital, Toronto, Ont.; Sleep Disorders Clinic of the Centre for Sleep and Chronobiology (Moldofsky), Toronto, Ont.; Department of Clinical Epidemiology and Biostatistics (Willan), McMaster University, Hamilton, Ont.; Research Institute (Ferguson), Toronto General Hospital, Toronto, Ont.
CMAJ. 2015 Mar 17;187(5):321-9. doi: 10.1503/cmaj.140752. Epub 2015 Feb 9.
Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care.
Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents' physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed.
We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents' sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents' somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents' knowledge and decision-making worst with the 16-hour schedule.
Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents' symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change.
ClinicalTrials.gov, no. NCT00679809.
为提高患者安全和医生的健康状况，越来越多地规定缩短住院医生的值班时间。然而，与连续性相关的错误增加可能会抵消减少疲劳带来的预期益处。我们评估了重症监护病房（ICU）的三种住院医生排班方式对患者安全、住院医生健康状况和医疗连续性的影响。
两所大学附属医院ICU的住院医生被随机分配（在2009年1月至6月为期2个月的轮班中）为24小时、16小时或12小时的院内通宵排班。主要患者结局是不良事件。主要住院医生结局是嗜睡程度，通过7分制的斯坦福嗜睡量表进行测量。次要结局包括患者死亡、可预防的不良事件以及住院医生的身体症状和职业倦怠。还评估了医疗连续性以及ICU工作人员的看法。
我们评估了49名住院医生中的47名（96%）、所有971例入院患者、5894个患者日以及452份工作人员调查问卷。我们发现排班方式（24小时、16小时或12小时轮班）对不良事件（每1000个患者日分别为81.3、76.3和至律8.2起事件；p = 0.7）、住院医生白天的嗜睡程度（平均评分分别为2.33、2.61和至律0；p = 0.3）或夜间的嗜睡程度（平均评分分别为3.06、2.73和2.42；p = 0.2）均无影响。8起可预防的不良事件中有7起发生在12小时排班时（p = 0.1）。三种排班方式的死亡率相似。24小时排班时住院医生的躯体症状更严重且更频繁（p = 0.04）；然而，各组的职业倦怠情况相似。ICU工作人员对16小时排班的住院医生的知识和决策能力评价最差。
我们的研究结果不支持缩短值班时间的所谓优势。它们还凸显了住院医生症状与多种患者安全次要指标之间的权衡。在广泛进行系统变革之前，需要进一步明确这一新兴信号。
ClinicalTrials.gov，编号NCT00679809 。
