Category: Hospitals

Categories : COVID HospitalsTags :

How One Hospital Met the COVID Surge Head-on

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Since March of 2020, the COVID pandemic has put an unprecedented strain on hospitals as large surges of intensive care unit patients overwhelmed hospitals. To meet this challenge, Beth Israel Deaconess Medical Center (BIDMC) expanded ICU capacity by 93% and maintained surge conditions during the nine weeks in the first quarter of 2020.

In a pair of papers and a guest editorial published in Dimensions of Critical Care Nursing, a team of nurse-scientists at Beth Israel Deaconess Medical Center (BIDMC) report on almost doubling the hospital’s ICU capacity; identifying, training and redeploying staff; and developing and implementing a proning team to manage patients with acute respiratory distress syndrome during the first COVID surge.

“As COVID was sweeping through the nation, we at BIDMC were preparing for the projected influx of highly infectious, critically ill patients,” said lead author Sharon C. O’Donoghue, DNP, RN, a nurse specialist in the medical intensive care units at BIDMC. “It rapidly became apparent that a plan for the arrival of highly infectious critically ill patients as well as a strategy for adequate staffing protecting employees and assuring the public that this could be managed successfully were needed.”

After setting up a hospital incident command structure to clearly define roles, open up lines of communication and develop surge plans, BIDMC’s leadership began planning for the impending influx of COVID patients in February 2020.

BIDMC – a 673 licensed bed teaching hospital affiliated with Harvard Medical School – has nine specialty ICUs located on two campuses for a total of 77 ICU beds. Informed by an epidemic surge drill conducted at BIDMC in 2012, it was determined that the trigger to open extra ICU space would be when 70 ICU beds were occupied. When this milestone was met on March 31, 2020, departmental personnel had a 12-hour window to convert two 36-bed medical-surgical units into additional ICU space, providing an additional 72 beds.

“Because the medical-surgical environment is not designed to deliver an ICU level of care, many modifications needed to be made and the need for distancing only added to the difficulties,” said senior author Susan DeSanto-Madeya, PhD, RN, FAAN, a Beth Israel Hospital Nurses Alumna Association endowed nurse scientist. “Many of these rooms were originally designed for patient privacy and quiet, but a key safety element in critical care is patient visibility, so we modified the spaces to accommodate ICU workflow.”

Modifications included putting windows in all patient room doors, and repositioning beds and monitors so patients and screens could be easily seen without entering the room. Lines of visibility were augmented with mirrors and baby monitor systems as necessary. Care providers were given two-way radios to decrease the number of staff required to enter a room when hands-on patient care was necessary. Mobile supply carts and workstations helped streamline workflow efficiency.

Besides stockpiling and managing medical equipment including PPE, ventilators and oxygen, increasing ICU capacity also required redeploying 150 staff trained in critical care. The hospital developed a recall list for former ICU nurses, as well as medical-surgical nurses that could care for critically ill patients on teams with veteran ICU nurses.

Education and support was provided from . In-person, socially-distanced workshops were developed for each group, after which nurses were assigned to shadow an ICU nurse to reduce anxiety, practice new skills and gain confidence.

“Staff identified the shadow experience as being most beneficial in preparing them for deployment during the COVID surge,” said O’Donoghue. “Historically, BIDMC has had strong collaborative relationships with staff from different areas and these relationships proved to be vital to the success of all the care teams. The social work department played a major role in fostering teams, especially during difficult situations.”

One of the redeployment teams was the ICU proning team. Proning is known to improve oxygenation in patients with acute respiratory distress syndrome is a complex intervention, takes time and is not without its potential dangers to the patient and staff alike. The coalition maximised resources and facilitated more than 160 interventions between March and May of 2020.

“Although the pandemic was an unprecedented occurrence, it has prepared us for potential future crises requiring the collaboration of multidisciplinary teams to ensure optimal outcomes in an overextended environment,” O’Donoghue said. “BIDMC’s staff rose to the challenge, and many positive lessons were learned from this difficult experience.”

“We must continue to be vigilant in our assessment of what worked and what did not work and look for ways to improve health care delivery in all our systems,” said DeSanto-Madeya, who is also an associate professor at the College of Nursing at the University of Rhode Island. “The memories from this past year and a half cannot be forgotten, and we can move forward confidently knowing we provided the best care possible despite all the hardships.”

Source: Beth Israel Deaconess Medical Center

Categories : Ethics and Law HospitalsTags :

Violence in the ED: A Critical Issue in Healthcare

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Phot by Mulyadi on Unsplash

A study by the Mayo Clinic found that most healthcare workers experience violence in emergency departments (EDs), but they seldomly report it to anyone.

Over six months prior to being surveyed, 72% of healthcare workers and other ED staff said they had personally experienced violence (71% verbal abuse and 31% physical assault), Sarayna McGuire, MD, chief resident of Mayo Emergency Medicine in Rochester, Minnesota, reported in a series of three studies at the American College of Emergency Physicians annual meeting.

Nurses and clinicians, along with security personnel, bore the brunt of the attacks: 94% of nurses and 90% of clinicians reported experiencing verbal abuse, and 54% of nurses and 36% of clinicians reported instances of physical assault.

“The whole team is impacted by workplace violence,” Dr McGuire said to MedPage Today. “Even people coming in to draw blood are being assaulted physically and verbally abused.”

Despite this prevalent violence and 58% reporting at least moderate awareness of reporting policies, 77% of all respondents said they never or rarely report violence, while only 10% said they often or always do.

A possible explanation could be that only 7% of non-security staff said they were “extremely familiar” with the procedures. And when participants were asked why ED abuse is not usually reported, the top four reasons given were:

  • No physical injury was sustained (53% of respondents)
  • “It comes with the job” (47%)
  • Staff are too busy (47%)
  • Reporting is inconvenient (41%)

The violence is not without consequences; 18% of respondents said they are considering leaving their position due to the violence, and 48% said violence has changed the way they view or interact with patients.

Men and more experienced staff reported feeling significantly better prepared compared with women. When asked which factors staff thought were most responsible for the violence, the following feature in at least 70% of responses: alcohol, illicit drugs, and significant mental illness.

A total of 86% of respondents said they felt at least moderately prepared to handle verbal abuse, while 68% said they felt prepared to handle physical assault.

“Everyone’s feeling right now that violence has increased in healthcare [during the pandemic], and our data have showed that,” Dr McGuire said. “How is this sustainable? …There is a critical issue in healthcare.”

She added that since reporting of violence is so low, true exposure to violence is probably much higher than the study found.

Study co-author Casey M. Clements, MD, PhD, also of Mayo Emergency Medicine, added that “we know this isn’t isolated to emergency departments.”

He explained that while the study encompassed the pandemic era, violence “has been a problem for some time in healthcare” – violence is a major threat to the healthcare workforce, Dr Clements said. He added that another problem is that physicians typically do not receive any training in de-escalation — “we learn this on the job.”

For the study, the researchers sent an anonymous survey to ED staff at 20 EDs. Also included were social workers, management, and security staff. Women made up 73% of the 833 respondents. Nursing staff (31%) made up the largest medical discipline, and 16% were clinicians.

Dr McGuire suggested that a centralised reporting system would help augment reporting of violence.

“We need to change the mindset that it’s anybody’s job to be assaulted at work,” Dr Clements said. “We cannot go on having our emergency department workers being abused and assaulted on a daily basis.”

Source: MedPage Today

Categories : HospitalsTags :

Wits Opens Advanced Surgical Skills Lab

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To help address the critical shortage of expert medical specialists in the country, including surgeons, Wits University opened the Wits Advanced Surgical Skills Lab. It has been estimated that the country needs double the number of surgeons to meet its needs, a situation worsened by losing many surgical experts to the competitive overseas market due to the lack of sufficient highly specialised facilities, infrastructure, and advanced academic training programmes.

“Wits trains more doctors, surgeons, specialists and sub-specialists than any other university in southern Africa. The new R22-million Wits Advanced Surgical Skills Lab will help to enhance the training of surgeons, across disciplines, in a state-of-the-art environment, with the best equipment available,” said Professor Damon Bizos, Head of Wits Surgical Gastroenterology, and the Clinical Head of Surgery at the Wits Donald Gordon Medical Centre. “We need to replenish these specialised skills and replicate them in adequate measure in order to deliver essential services to South Africans and Africans.”

Located on the ninth floor of the Faculty of Health Sciences building in Parktown, the Wits Advanced Surgical Skills Lab officially opened on Tuesday, 12 October 2021. The state-of-the-art facility is designed in line with international best standards. along with teaching facilities that make the Wits surgical training programme one of the best in the world.

“If we fail to replenish the pool of surgeons in South Africa, both the training of all South African doctors and the delivery of healthcare for all will be compromised. The loss of these skills will result in the loss of services in both the private and public sectors,” said Professor Zeblon Vilakazi, Wits Vice-Chancellor and Principal. “South Africa needs to retain highly skilled and specialised surgeons. By creating opportunities for doctors to undergo highly specialised training locally, rather than abroad, the likelihood of losing these doctors to other countries is lessened.”

The Wits Advanced Surgical Skills Lab will be able to provide the interdisciplinary training needs of surgical disciplines including general surgery; orthopaedics; gynaecology; ear, nose and throat; cardiothoracic; urology; maxillofacial; ophthalmologic; neuro; and plastic surgery. It will also include the training of specialists, doctors, nurses and other allied health practitioners.

“The basic and intermediate courses will help inculcate basic surgical competence and skills development, whilst advanced courses will ensure that experienced practitioners remain at the forefront of advances in the field,” added Prof Bizos. “We will offer access to in-house training as well as industry-sponsored surgical training courses and symposia. Train-the-trainer programmes and research into skills training will also be integral.”

The Wits Advanced Surgical Skills Laboratory boasts a large ‘wet lab’ with eight stations; laparoscopic towers and endoscopy (upper endoscopy and colonoscopy); has facilities available for training on cadavers; lead-lined walls to accommodate imaging; a new lecture room for 35 participants; and full audiovisual and videoconferencing facilities.

“Access to safe, high-quality surgery care remains an ongoing challenge in South Africa and beyond. There is a well-defined unmet need, and the training of surgeons and surgical care providers is an essential component of the strategy to improve surgical care and address the unmet need. Modern day approaches to training require that we must address both the technical competency and non-technical skills of the surgeon. This must be achieved in a standardised and measurable way. To do so has meant that we, as the trainers of the next generation of practitioners, must embrace new technologies and training opportunities,” said Professor Martin Smith, the Head of the Department of Surgery in the Faculty of Health Sciences at Wits University. “We are very grateful that through the support of the University and the contributions of a number of donors we have been able to establish a facility to enhance and improve this training.”

Source: Wits University

Categories : HospitalsTags :

Equivalent Hip Surgery Outcomes for Spinal vs General Anaesthesia

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Research comparing general versus spinal anaesthesia for hip fracture surgery shows similar outcomes for patients, challenging the common thinking that patients receiving spinal anaesthesia fare better. 

Led by researchers from the Perelman School of Medicine at the University of Pennsylvania, the study was published in the New England Journal of Medicine and presented at Anesthesiology 2021, the annual meeting of the American Society of Anesthesiologists (ASA).

“Available evidence has not definitively addressed the question of whether spinal anaesthesia is safer than general anaesthesia for hip fracture surgery, an important question to clinicians, patients, and families. Our study argues that, in many cases, either form of anaesthesia appears to be safe,” said lead investigator Mark D. Neuman, MD, MSc, an associate professor of Anesthesiology and Critical Care. “This is important because it suggests that choices can be guided by patient preference rather than anticipated differences in outcomes in many cases.”

While most of the 250 000 annual hip fracture patients in the US undergo general anaesthesia, spinal anaesthesia increased by 50% between 2007 and 2017, while in the United Kingdom and other countries, spinal anaesthesia is used in over 50% of hip fracture cases. [PDF]

Most recent comparisons of general anaesthesia versus spinal anaesthesia come from non-randomised studies, some indicating fewer cognitive and medical complications with spinal. Some patients may choose spinal anaesthesia for lower complications, while those choosing general may have a fear of spinal injection or insufficient anaesthesia. 

The study enrolled 1600 patients, all at least 50 years old, who had broken a hip. Among older populations, hip fractures are particularly worrisome as they can lead to a loss of mobility, linked to a doubling or even tripling the risk of near-term death. The patients were randomised into two groups, a major advantage for the study.

The researchers combined subsequent patient death rates and whether they regained the ability to walk, even with a walker. By 60 days post-surgery, 18.5% of patients assigned to spinal anaesthesia had either died or become newly unable to walk versus 18% of patients who received general anaesthesia. Mortality at this point was 3.9% of patients who received spinal anaesthesia died versus 4.1% who got general anaesthesia.

Additionally, to examine how the different forms of anaesthesia factored into potential cognitive complications, the researchers also examined post-operative delirium. Delirium was experienced in 21% of spinal anaesthesia patients versus 20% for general anaesthesia.

“What our study offers is reassurance that general anaesthesia can represent a safe option for hip fracture surgery for many patients,” said Prof Neuman. “This is information that patients, families, and clinicians can use together to make the right choice for each patient’s personalised care.”

Source: Perelman School of Medicine at the University of Pennsylvania 

Categories : HospitalsTags :

Physician Anaesthesiologist-led Teams Reduce Cardiac Arrests and Deaths

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Rapid response teams led by physician anaesthesiologists resulted in a significant decrease in cardiac arrest and death, after a transition from nurse-only rapid response teams, according to a study presented at the ANESTHESIOLOGY® 2021 annual meeting.

“As anaesthesiologists, we care for the entire spectrum of a patient’s life from in utero to end of life,” said lead author Faith Factora, MD, medical director, Surgical Intensive Care Unit, Cleveland Clinic. “Our training gives us experience performing practical skills like resuscitation and CPR, in addition to more subtle skills like implementing quality improvement projects and developing safety processes for patient care. Our specialty affects entire patient populations of hospital care and this study represents an example of the care we provide across the spectrum of our patients’ lives and our health care institutions.”

Analysing 458 233 patient hospitalisations, the study found 103 103 patients who were cared for by the original nurse-led rapid response team and 355 130 patients were cared for by the physician anaesthesiologist-led rapid response team. Patients of the physician-led team had a 50% less chance of experiencing cardiac arrest and a 27% less chance of death, compared to the original nurse-led rapid response team.

Rapid response teams address early clinical deterioration, initiating critical care interventions before an emergency or intubation occurs outside of the intensive care unit. By implementing a hospital-wide system led by anaesthesiologists, using principles of monitoring and patient safety that guide the specialty, the physician-led team showed a decrease in cardiac arrests and deaths. The system included early warning systems, including regular monitoring of patients’ conditions and vital sign checks on a regular basis that triggered alerts if critical criteria were met. Examples of conditions that triggered alerts were low blood pressure or high heart rates.

Physician anaesthesiologists are champions of patient safety, uniquely educated and trained for critical moments in health care, with an ability to navigate life-and-death moments in patient care unmatched by other professions. Their education and training is extensive, with up to 14 years of education, including medical school, and 12 000 to 16 000 hours of clinical training.

Source: American Society of Anesthesiologists

Categories : COVID HospitalsTags :

ECG Readings Can Predict Worsening and Mortality in COVID and Influenza

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Specific and dynamic changes on electrocardiograms (ECGs) of hospitalised COVID patients with COVID or influenza can help predict a timeframe for worsening health and death, according to a new Mount Sinai study.

Published in the American Journal of Cardiology, the study shows that shrinking waveforms on these tests can be used to help better identify high-risk patients and provide them more aggressive monitoring and treatment.  

“Our study shows diminished waveforms on ECGs over the course of COVID illness can be an important tool for health care workers caring for these patients, allowing them to catch rapid clinical changes over their hospital stay and intervene more quickly. […] ECGs may be helpful for hospitals to use when caring for these patients before their condition gets dramatically worse,” said senior author Joshua Lampert, MD, Cardiac Electrophysiology fellow at The Mount Sinai Hospital. “This is particularly useful in overwhelmed systems, as there is no wait for blood work to return and this test can be performed by the majority of health care personnel. Additionally, the ECG can be done at the time of other bedside patient care, eliminating the potential exposure of another health care worker to COVID.”

Researchers did a retrospective analysis of ECGs on 140 hospitalised COVID patients across the Mount Sinai Health System in New York City, and compared them with 281 ECGs from patients with laboratory-confirmed influenza A or B admitted to The Mount Sinai Hospital.  
For each patient, the researchers compared three ECG time points: a baseline scan done within a year prior to COVID or influenza hospitalisation, a scan taken at hospital admission, and follow-up ECGs performed during hospitalisation.

They manually measured QRS waveform height on all electrocardiograms – changes in this electrical activity can indicate failing ventricles. The researchers analysed follow-up ECGs after hospital admission and analysed changes in the waveforms according to a set of criteria they designed  called LoQRS amplitude (LoQRS) to identify a reduced signal. LoQRS was defined by QRS amplitude of less than 5mm measured from the arms and legs or less than 10mm when measured on the chest wall as well as a relative reduction in waveform height in either location by at least 50%.

Fifty-two COVID patients in the study did not survive, and 74% of those had LoQRS. Their ECG QRS waveforms reduced approximately 5.3 days into their hospital admission and they died approximately two days after the first abnormal ECG was observed.

Out of the 281 influenza patients studied, LoQRS was identified in 11 percent of them. Seventeen influenza patients died, and 39% had LoQRS present. Influenza patients met LoQRS criteria a median of 55 days into their hospital admission, and the median time to death was six days from when LoQRS was identified. Overall, these results show influenza patients followed a less virulent course of illness when compared to COVID patients.

“When it comes to caring for COVID patients, our findings suggest it may be beneficial not only for health care providers to check an EKG when the patient first arrives at the hospital, but also follow-up ECGs during their hospital stay to assess for LoQRS, particularly if the patient has not made profound clinical progress. If LoQRS is present, the team may want to consider escalating medical therapy or transferring the patient to a highly monitored setting such as an intensive care unit (ICU) in anticipation of declining health,” added Dr Lampert.

Source: The Mount Sinai Hospital / Mount Sinai School of Medicine

Categories : COVID HospitalsTags :

Prone Positioning Reduces Need for Mechanical Ventilation

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A ‘meta-trial’ of 1100 hospitalised COVID patients requiring high-flow nasal cannula oxygen therapy suggests that prone positioning soon after admission can significantly reduce the need for mechanical ventilation.

While acute respiratory distress syndrome patients have been placed prone for years by critical care specialists, this study provides clinical evidence needed to support the use of prone positioning for patients with COVID requiring high-flow nasal cannula oxygen therapy.

The findings, published today in the Lancet Respiratory Medicine, were conducted on severely ill COVID patients between April 2020 and January 2021.

“Breathing in the prone position helps the lungs work more efficiently,” explained the study’s lead author Dr. Jie Li, associate professor and respiratory therapist at Rush University Medical Center. “When people with severe oxygenation issues are laying on their stomachs, it results in better matching of the blood flow and ventilation in the lungs which improves blood oxygen levels.”

Prof Li noted that several interventions are available to improve oxygenation in critically ill patients, but that there was little outcomes-focused clinical evidence to show that prone positioning prior to mechanical ventilation is beneficial.

Adult patients with COVID needing respiratory support from a high-flow nasal cannula agreed to participate in this clinical trial, and were randomly assigned to the supine or prone positioning groups. They were asked to stay in that position for as long as they could tolerate. Both positioning groups received high-flow oxygen therapy and standard medical management.

Patients were continually monitored to determine if mechanical ventilation was needed. This study’s data showed that patients in the prone positioning group were significantly less likely to require mechanical ventilation (33% in the awake prone positioning group vs 40% in the supine group).

Another study lead author, Stephan Ehrmann, MD, PhD, said that “for the clinical implications of our study, awake prone positioning is a safe intervention that reduces the risk of treatment failure in acute severe hypoxemic respiratory failure due to COVID-19. Our findings support the routine implementation of awake prone positioning in critically ill patients with COVID19 requiring high flow nasal cannula oxygen therapy. It appears important that clinicians improve patient comfort during prone positioning, so the patient can stay in the position for at least 8 hours a day.”

Reducing the need for mechanical ventilation cuts down on resources needed. “Ventilators can indeed save the lives of people who are no longer able to breathe on their own. That said, we now have strategies to keep patients off the ventilator, saving those devices for the sickest patients who truly need them.” Prof Li added.

Source: Medical Xpress

Categories : Hospitals Medical Research & TechnologyTags :

New Medical Device Slashes Surgery Risk

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A new electromedical device provides important data about possible cardiovascular and pulmonary risks before an operation.

Before any operation, it is important to properly assess the individual risk: Are there perhaps circulatory or pulmonary problems that need special consideration? To what extent can special risks be taken into account when planning the anaesthesia? Previously, clinicians have had to rely on rather subjective empirical values or carry out more elaborate examinations when in doubt. To address this, a novel device has been developed by TU Wien and MedUni Wien to objectively measure the cardiovascular and pulmonary system fitness of patients.

Pre-op interviews are important—but subjective
Complications often occur after surgical interventions. In addition to blood loss and sepsis, perioperative cardiovascular and pulmonary problems are among the most common causes of death in the first 30 days after surgery.

To minimise this risk, anesthesiologists routinely talk to patients before surgery, in addition to measuring their blood pressure, performing an electrocardiogram, or conducting more laborious examinations. But assessing responses can be highly individualised. “There are also objectively measurable parameters by which one could easily identify possible risks,” said Prof Eugenijus Kaniusas (TU Wien, Faculty of Electrical Engineering and Information Technology). “So far, however, they have not been routinely measured.”

Just hold your breath
This new device uses multiple sensors to determine key metrics in a completely non-invasive way. All the patient has to do is hold their breath for a short time to slightly outbalance their body, which responds reflexively with various biosignals. “Holding your breath is a mild stress for the body, but that is already enough to observe changes in the regulatory cardiovascular and pulmonary systems,” explained Eugenijus Kaniusas. “Oxygen saturation in the blood, heart rate variability, certain characteristics of the pulse waveform—these are dynamic parameters that we can measure in a simple way, and from them we could ideally infer individual fitness in general, especially before surgery.”

Since the device is non-invasive, medical training is not needed to operate it, and has no side effects. The result is easy to read: A rough assessment according to the three-color traffic light system or a score between 0 and 100 is displayed. The measurement can also be carried out at the bedside without any problems for people with limited mobility.

“Our laboratory prototype is being tested at MedUni Wien in cooperation with Prof. Klaus Klein from the University Department of Anesthesia, General Intensive Care Medicine and Pain Therapy. We hope to bring the device to market in the next 5 years with the help of research and transfer support,” said Eugenijus Kaniusas.

Source: Vienna University of Technology

Categories : Cancer HospitalsTags :

Cancer Surgery Patients Have a Reduced Hospital Stay with ‘Prehabilitation’

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A new approach to improve their fitness for surgery reduced the length of hospital stay for cancer patients, according to a new study.

Termed ‘prehabilitation’, the study’s approach includes exercise, nutrition and psychological and social interventions to bolster physical and mental health before surgery.

The study, published in the Annals of Surgery, found that prehabilitation interventions of between one and four weeks reduced cancer patients’ stay in hospital by 1.8 days compared with usual care.

Study author Dr Chris Gaffney from Lancaster Medical School said: “Surgery is like a marathon in terms of stressing the body, and you wouldn’t run a marathon without training.”

The researchers found that as little as one week can still benefit patient outcomes, indicating that prehabilitation should be recommended to accelerate recovery from cancer surgery, as shown by a reduced hospital length of stay.

Study author Dr Joel Lambert, now a postgraduate student at Lancaster Medical School and a surgeon at East Lancashire Teaching Hospitals NHS Trust, said: “We think that it may also confer a survival advantage for cancer patients as they can get to follow up treatments like chemotherapy more quickly.

“We think that the patient groups most likely to benefit are the ones with lower levels of fitness at baseline. In the Northwest we have some of the most socioeconomically deprived populations in the UK. This subset tend to have more co-morbid conditions hence less fit.”  

The patients studied were those with liver, colorectal, and upper gastrointestinal cancer, and who are often less fit than other cancer patients.

The study interventions were grouped into three types

  • Multimodal prehabilitation: exercise, which included both nutrition and psychosocial support,
  • Bimodal prehabilitation: exercise and nutrition or psychosocial support
  • Unimodal prehabilitation: exercise or nutrition alone

The exercise interventions included aerobic, resistance, and both aerobic and resistance exercises at all levels of intensity, some supervised by a kinesiologist or physiotherapist, while others were home-based exercise regimes. These ranged from one to four weeks and all interventions were within the current NHS surgery targets for cancer surgery.

The researchers concluded: “Future studies should focus on identifying patients who would benefit most from prehabilitation and the mechanistic underpinning of any improvement in clinical outcomes. Studies should closely monitor nutrition intake to determine if the response to exercise prehabilitation is dependent upon nutritional status. Lastly, mortality should be monitored for 12 months post surgery to determine if prehabilitation has any effect beyond 30 or 90 days.”

Source: Lancaster University

Categories : HospitalsTags :

Sleep Deprivation Common in Surgeons, Impacting Performance

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New research has found that surgeons were sleep deprived prior to on-call shifts and afterwards even more so, and crucially, that sleep deprivation impacted surgical performance. 

The study is the first to focus on Irish surgeons and is published in the Journal of Surgical Research. A separate study found that short naps of 30 to 60 minutes do little to reduce sleep deprivation.

Focussing on the effects of being ‘on-call’, a frequent state for surgeons, the study explored subjective and objective metrics around sleep and performance using ‘on-call’ as a particular influencer for increased fatigue.

Surgeons frequently work 24 straight hours (or more) resulting in unavoidable sleep disturbance. This is partly due to historical associations of the Halstedian Era of Surgery to ‘reside’ in the hospital in order to properly learn, but also current staffing levels mandating surgeons to complete regular on-call work.

Participants were hooked up to electroencephalogram (EEG) machines and a validated modified Multiple Sleep Latency Test testing was used to objectively measure sleep on the morning of their on-call shift. The researchers also record other validated tests for subjective sleep and fatigue measurement. ‘Sleep latency’ refers to the time it takes to go from being fully awake to sleeping and is often an indicator of sleepiness. The surgeons in the study had early onset sleep latency before on-call, which was exacerbated further in post-call settings.

Performance was measured with standardised and validated tools. Technical performance of surgeons was assessed using the validated Simendo © surgical simulator, while cognitive performance was measured using the Psychomotor Vigilance Task (PVT) to assess objective alertness and reaction time, a known aspect of cognitive performance.

The study is the first to attempt to control for a series of confounding variables such as experience, quality and quantity of sleep, the influence of caffeine and circadian rhythm influences.

The study found that:

  • Surgeons had poor baseline sleep quality and were objectively sleep-deprived, even pre-call, when they should be in a ‘rested state’.
  • In all study participants, early onset sleep latency was seen in pre-call settings and worsened in post-call settings.
  • Early onset sleep latency was worse in trainees compared to consultants, though both groups experienced early onset sleep latency post-call.
  • As sleep-deprivation increased, diminished performance was seen in cognitive tasks and surgical tasks with greater cognitive components.
  • Higher levels of self-reported fatigue and daytime sleepiness were recorded post-call.

Technical skill performance was relatively preserved in acutely sleep deprived states but may be influenced by learning curve effects and experience in surgical tasks.

Existing models of surgical on-call were not conducive to optimising sleep for surgeons, the research found. But making changes for better sleep has challenges, such as loss of continuity of patient care, loss of trainee exposure, and reduced service delivery.

Dale Whelehan, PhD researcher in Behaviour Science at the School of Medicine and lead researcher commented: “The findings of this study tell us that current provision of on-call models preclude the opportunity for surgeons to get enough rest. Similarly, surgeons are sleep deprived before going on-call which further perpetuates the issue. The implications for performance suggest aspects of surgeons performance is diminished, particularly tasks which might be more cognitively demanding. 

“We need meaningful engagement from all stakeholders in the process, working towards the common goal of optimising performance in surgeons. This involves looking at the multifactorial causes and effects of fatigue. Part of that discussion involves consideration around how current models of on-call influence sleep levels in healthcare staff, and how it creates barriers to fatigue management in staff.”

Professor Paul Ridgway, Department of Surgery at Trinity, who supervised the study, said: “Our study is further evidence that the way we deliver emergency work alongside normal work in Ireland has to change. We need to learn from our colleagues in aviation who have mandatory rest periods before flights.”

Source: Trinity College Dublin