Kellogg Adam R, Coute Ryan A, Garra Gregory
J Grad Med Educ. 2015 Mar;7(1):27-31. doi: 10.4300/JGME-D-14-00056.1.
Fatigue and sleepiness contribute to medical errors, although the effect of circadian disruption and fatigue on diagnostic reasoning skills is largely unknown.
To determine whether circadian disruption and fatigue negatively affect the emergency medicine (EM) resident's ability to make important clinical decisions based on electrocardiogram (ECG) interpretation.
Senior EM residents at 2 programs completed a questionnaire consisting of various measures of fatigue followed by an ECG test packet of ST-segment elevation myocardial infarction (STEMI) and STEMI mimics. Participants were asked to examine each ECG and determine whether cardiac catheterization laboratory activation (CLA) was indicated, and to report their confidence in their decision making on an 11-point, numeric rating scale. The primary outcome measured was a pairwise difference in accuracy of CLA between daytime and overnight testing.
A total of 23 residents were enrolled in 2011 and 2012. Subjects demonstrated significant differences in multiple measures of sleepiness and fatigue during overnight periods. The median (interquartile range [IQR]) accuracy of CLA was not significantly different between daytime and overnight (70% [IQR, 50-80] versus 70% [IQR, 60-70], P = .82). There were no significant differences in the median number of overcalls (CLA when not a STEMI) and undercalls (no CLA when a STEMI was present; P = .57 and .37, respectively). Diagnostic confidence and confidence in CLA were not statistically different between daytime and overnight.
Despite a measurable degree of fatigue, senior EM residents experienced no decrease in their ability to accurately make CLA decisions based on ECG interpretation.
疲劳和嗜睡会导致医疗差错，尽管昼夜节律紊乱和疲劳对诊断推理能力的影响在很大程度上尚不清楚。
确定昼夜节律紊乱和疲劳是否会对急诊医学（EM）住院医师基于心电图（ECG）解读做出重要临床决策的能力产生负面影响。
两个项目中的高级EM住院医师完成一份包含各种疲劳测量指标的问卷，随后进行一份关于ST段抬高型心肌梗死（STEMI）及STEMI模拟病例的心电图测试包。要求参与者检查每份心电图，并确定是否需要激活心脏导管实验室（CLA），并在11分制数字评分量表上报告他们对决策的信心。测量的主要结果是白天和夜间测试之间CLA准确性的成对差异。
2011年和2012年共招募了23名住院医师。受试者在夜间的多种嗜睡和疲劳测量指标上表现出显著差异。白天和夜间CLA的中位数（四分位间距[IQR]）准确性无显著差异（分别为70%[IQR，50 - 80]和70%[IQR，60 - 70]，P = 0.82）。过度判断（非STEMI时进行CLA）和漏判（存在STEMI时未进行CLA）的中位数无显著差异（P分别为0.57和0.37）。白天和夜间之间的诊断信心和对CLA的信心在统计学上无差异。
尽管存在可测量程度的疲劳，但高级EM住院医师基于心电图解读准确做出CLA决策的能力并未下降。
