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Systematic Review: Association of Shift Length, Protected Sleep Time, and Night Float With Patient Care, Residents' Health, and Education

Darcy A. Reed, MD, MPH; Kathlyn E. Fletcher, MD, MA; and Vineet M. Arora, MD, MA
[+] Article and Author Information

From the Mayo Clinic College of Medicine, Rochester, Minnesota; Milwaukee Veteran Affairs Medical Center, Medical College of Wisconsin, Milwaukee, Wisconsin; and University of Chicago, Pritzker School of Medicine, Chicago, Illinois.


Acknowledgment: The authors thank Lisa Bellini, MD, at the University of Pennsylvania for expert review of the reference list. They also thank Jessica Schmidt and Andrea Bruckbauer at the Milwaukee Veterans Affairs Medical Center; Alexis Dye, MS, and Mark Oium at the Medical College of Wisconsin; Katya Papatla at Duke University; Patricia Erwin, MLS, and Kate Featherstone at the Mayo Clinic College of Medicine; Meryl Prochaska, BA, and Diane Daviera, BS, at the University of Chicago; and Emily Chiu at the University of Michigan for their excellent research assistance. Finally, they thank Jack Littrell, MS, for his assistance with database creation and management and DeWitt Baldwin, MD, at the ACGME for his assistance with obtaining funding.

Grant Support: By the Accreditation Council for Graduate Medical Education.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1582.

Requests for Single Reprints: Darcy A. Reed, MD, MPH, Division of Primary Care Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Current Author Addresses: Dr. Reed: Division of Primary Care Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Dr. Fletcher: Department of Medicine, Milwaukee Veterans Affairs Medical Center, Primary Care Division, 5000 West National Avenue, Milwaukee, WI 53295.

Dr. Arora: Department of Medicine, University of Chicago, 5841 South Maryland Avenue, MC 2007 AMB W216, Chicago, IL 60637.

Author Contributions: Conception and design: D.A. Reed, K.E. Fletcher, V.M. Arora.

Analysis and interpretation of the data: D.A. Reed, K.E. Fletcher, V.M. Arora.

Drafting of the article: D.A. Reed.

Critical revision of the article for important intellectual content: K.E. Fletcher.

Final approval of the article: D.A. Reed, K.E. Fletcher, V.M. Arora.

Provision of study materials or patients: V.M. Arora.

Statistical expertise: V.M. Arora.

Obtaining of funding: D.A. Reed, K.E. Fletcher, V.M. Arora.

Administrative, technical, or logistic support: V.M. Arora.

Collection and assembly of data: D.A. Reed, K.E. Fletcher, V.M. Arora.


Ann Intern Med. 2010;153(12):829-842. doi:10.7326/0003-4819-153-12-201012210-00010
Text Size: A A A

Background: The Accreditation Council for Graduate Medical Education's new duty-hour standards limit interns' shifts to 16 hours and night float to 6 consecutive nights. Protected sleep time (that is, “nap”) is strongly encouraged. As duty-hour reforms are implemented, examination of the quality and outcomes of the relevant literature is important.

Purpose: To systematically review the literature examining shift length, protected sleep time, and night float.

Data Sources: MEDLINE, PREMEDLINE, and EMBASE from January 1989 through May 2010.

Study Selection: Studies examined the associations of shift length, protected sleep time, or night float with patient care, resident health, and education outcomes among residents in practice settings.

Data Extraction: Study quality was measured by using the validated Medical Education Research Study Quality Instrument and the U.S. Preventive Services Task Force criteria. Two investigators independently rated study quality, and interrater agreement was calculated.

Data Synthesis: Sixty-four studies met inclusion criteria. Most studies used single-group cross-sectional (19 studies [29.7%]) or pre–post (41 studies [64.1%]) designs, and 4 (6.3%) were randomized, controlled trials. Five studies (7.8%) were multi-institutional. Twenty-four of 33 (72.7%) studies examining shift length reported that shorter shifts were associated with decreased medical errors, motor vehicle crashes, and percutaneous injuries. Only 2 studies assessed protected sleep time and reported that residents' adherence to naps was poor. Night floats described in 33 studies involved 5 to 7 consecutive nights.

Limitations: Most studies used single-institution, observational designs. Publication bias is likely but difficult to assess in this methodologically weak and heterogeneous body of evidence.

Conclusion: For the limited outcomes measured, most studies supported reducing shift length but did not adequately address the optimal shift duration. Studies had numerous methodological limitations and unclear generalizability for most outcomes. Specific recommendations about shift length, protected sleep time, and night float should acknowledge the limitations of this evidence.

Primary Funding Source: Accreditation Council for Graduate Medical Education.

Figures

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Figure 1.
Summary of evidence search and selection.
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Figure 2.
Methodological quality of 64 studies examining shift length, protected sleep time, and night float.

The percentage of studies fulfilling quality criteria from the Medical Education Research Study Quality Instrument are shown. Criteria fully satisfied = proportion of studies that received maximum points for each quality criterion; criteria partially satisfied = proportion of studies that received less than the maximum but more than 0 points for each quality criterion; criteria not satisfied = proportion of studies that received 0 points for each quality criterion; criteria not applicable = proportion of studies for which each quality criterion did not apply.

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Figure 3.
Quality and effect size of studies examining associations between shift length and patient care.

The MERSQI scores and study effect sizes (odds ratios and 95% CIs) are shown for 10 studies examining shift length and patient care. Each study is labeled with the primary outcome and reference number. MERSQI = Medical Education Research Study Quality Instrument.

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