Rationale and Objectives
To determine if the rate of major discrepancies between resident preliminary reports and faculty final reports increases during the final hours of consecutive 12-hour overnight call shifts.
Materials and methods
Institutional review board exemption status was obtained for this study. All overnight radiology reports interpreted by residents on-call between January 2010 and June 2010 were reviewed by board-certified faculty and categorized as major discrepancies if they contained a change in interpretation with the potential to impact patient management or outcome. Initial determination of a major discrepancy was at the discretion of individual faculty radiologists based on this general definition. Studies categorized as major discrepancies were secondarily reviewed by the residency program director (M.H.S.) to ensure consistent application of the major discrepancy designation. Multiple variables associated with each report were collected and analyzed, including the time of preliminary interpretation, time into shift study was interpreted, volume of studies interpreted during each shift, day of the week, patient location (inpatient or emergency department), block of shift (2-hour blocks for 12-hour shifts), imaging modality, patient age and gender, resident identification, and faculty identification. Univariate risk factor analysis was performed to determine the optimal data format of each variable (ie, continuous versus categorical). A multivariate logistic regression model was then constructed to account for confounding between variables and identify independent risk factors for major discrepancies.
Results
We analyzed 8062 preliminary resident reports with 79 major discrepancies (1.0%). There was a statistically significant increase in major discrepancy rate during the final 2 hours of consecutive 12-hour call shifts. Multivariate analysis confirmed that interpretation during the last 2 hours of 12-hour call shifts (odds ratio (OR) 1.94, 95% confidence interval (CI) 1.18–3.21), cross-sectional imaging modality (OR 5.38, 95% CI 3.22–8.98), and inpatient location (OR 1.81, 95% CI 1.02–3.20) were independent risk factors for major discrepancy.
Conclusions
In a single academic medical center, major discrepancies in resident preliminary reports increased significantly during the final 2 hours of consecutive 12-hour overnight call shifts. This finding could be related to either fatigue or circadian desynchronization. Discrimination of these two potential etiologies requires additional investigation as major discrepancies in resident reports have the potential to negatively impact patient care/outcome. Cross-sectional imaging modalities including computed tomography and ultrasound (versus conventional radiography), as well as inpatient location (versus Emergency Department location), were also associated with significantly higher major discrepancy rates.
The recurring controversy involving resident work hour restrictions was initially driven by an increasing perception of the negative impact of fatigue and medical error on health care quality and patient safety. New York State enacted a health-code regulation in 1989 to restrict resident work hours and increase supervision of physicians in training . In 2003, the Accreditation Council for Graduate Medical Education (ACGME) enacted the first iteration of the common duty hour standards in response to public consumer advocate concerns that excessive resident duty hours may jeopardize quality of care . The New York State regulation and first generation duty hour standards resulted in a litany of both retrospective and prospective studies evaluating the impact work hour restrictions on various performance measures ranging from fine motor coordination, response time, and self-reported sleepiness to sharps-related injuries, medication ordering errors, and morbidity/mortality rates. While many controlled studies convincingly demonstrated that increasing shift length is associated with deterioration in attention and motor and cognitive skills , subsequent restriction of resident work hours has not translated into clear or convincing improvements in patient outcomes. Continued changes to the existing work-hour limitations have prompted physician, government, and patient safety advocate groups to call for more rigorous study of the impact of existing work hour regulations .
Implicit in the movement toward shorter work hours is the assumption that physician cognitive performance deteriorates during the course of a prolonged call shift. Detecting such deficits experimentally, however, can be challenging; structured laboratory cognitive experiments may fail to capture the full complexities of medical practice, while the highly variable clinical environment of most medical specialties does not lend itself well to uniform measurement. In contrast to many clinical specialties, however, there is relatively little variation in the cognitive tasks performed by radiology residents during the course of a call shift. Although particular diagnoses differ between individual cases, the overall process of image interpretation tends to remain constant. Moreover, discrete cognitive decisions (ie, diagnostic impressions) rendered by radiology residents are clearly documented and can be subsequently reviewed in a formalized process by faculty radiologists. These features, along with the relatively constant workload throughout call shifts, make the study of fatigue-related cognitive deterioration particularly attractive in this context. Therefore, we sought to evaluate major discrepancy rates during consecutive 12-hour overnight call shift to determine if there is a decrement in performance during the final hours of these shifts.
Materials and Methods
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Results
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Table 1
Results of Univariate and Multivariate Risk Factor Analyses for Major Discrepancies
Univariate Analysis Major Discrepancy ( n = 79) Concordant ( n = 7983)P ∗ Examination characteristic Hours into shift (median) 6.83 6.53 .176 † <2 5.06% 6.96% .508 2 to <4 15.19% 15.17% .996 4 to <6 16.46% 22.36% .210 6 to <8 15.19% 19.68% .318 8 to <10 15.19% 20.02% .290 10 to <12 29.11% 14.56% <.001 Imaging modality Conventional radiography 29.11% 68.08% <.001 Computed tomography (CT) 59.49% 25.32% <.001 Ultrasound US) 11.39% 6.60% .089 Cross-sectional (CT or US) 70.89% 31.92% <.001 Patient characteristics Age, y (median) 52.08 51.58 .710 † Male gender 43.04% 46.86% .498 Inpatient 21.52% 19.87% .714 Shift characteristics Examinations per shift 50 52 .158 † ≤25 8.86% 4.74% .103 ‡ 26–50 41.77% 42.99% .828 51–75 43.04% 41.29% .753 >75 6.33% 4.82% .281 ‡ Weekend shift 35.44% 34.82% .909
Logistic Regression Regression Coefficient_P_ Odds Ratio (95% Confidence Interval) Exam characteristic Hours 10 to <12 0.665 .009 1.94 (1.18–3.21) Cross-sectional modality 1.682 <.001 5.38 (3.22–8.98) Patient characteristics Age, y −0.00006 .893 1.00 (0.99–1.01) § Male gender −0.044 .849 0.97 (0.61–1.51) Inpatient location 0.593 .042 1.81 (1.02–3.20) Shift characteristics Examinations per shift −0.005 .455 1.00 (0.98–1.01) § Weekend 0.212 .412 1.24 (0.75–2.05)
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Discussion
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