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Study ObjectivesWe compared resident physician work hours and sleep in a multicenter clustered-randomized crossover clinical trial that randomized resident physicians to an Extended Duration Work Roster (EDWR) with extended-duration (≥24 hr) shifts or a Rapidly Cycling Work Roster (RCWR), in which scheduled shift lengths were limited to 16 or fewer consecutive hours.MethodsThree hundred two resident physicians were enrolled and completed 370 1 month pediatric intensive care unit rotations in six US academic medical centers. Sleep was objectively estimated with wrist-worn actigraphs. Work hours and subjective sleep data were collected via daily electronic diary.ResultsResident physicians worked fewer total hours per week during the RCWR compared with the EDWR (61.9 ± 4.8 versus 68.4 ± 7.4, respectively; p < 0.0001). During the RCWR, 73% of work hours occurred within shifts of ≤16 consecutive hours. In contrast, during the EDWR, 38% of work hours occurred on shifts of ≤16 consecutive hours. Resident physicians obtained significantly more sleep per week on the RCWR (52.9 ± 6.0 hr) compared with the EDWR (49.1 ± 5.8 hr, p < 0.0001). The percentage of 24 hr intervals with less than 4 hr of actigraphically measured sleep was 9% on the RCWR and 25% on the EDWR (p < 0.0001).ConclusionsRCWRs were effective in reducing weekly work hours and the occurrence of >16 consecutive hour shifts, and improving sleep duration of resident physicians. Although inclusion of the six operational healthcare sites increases the generalizability of these findings, there was heterogeneity in schedule implementation. Additional research is needed to optimize scheduling practices allowing for sufficient sleep prior to all work shifts.Clinical Trial: Multicenter Clinical Trial of Limiting Resident Work Hours on ICU Patient Safety (ROSTERS), https://clinicaltrials.gov/ct2/show/NCT02134847

SEVEN YEARS HAVE PASSED SINCE THE ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION (ACGME) ESTABLISHED DUTY HOUR LIMITS for physicians-in-training. Prior to that time, few high quality studies existed regarding the effects on safety of residents' traditional work schedules.1,2 In the past few years, however, a growing body of literature has emerged regarding the hazards of prolonged sleep deprivation and of one particular aspect of residents' traditional schedules: the extended duty (> 16 h) shift.3–10 Data on extended shifts have previously prompted calls for action from the federal government and professional organizations.11–14 Last year, the Institute of Medicine (IOM) published a comprehensive report on resident duty hours,15 in which it recommended that residents should work no more than 16 consecutive hours without sleep. This recommendation has been the subject of considerable controversy. While numerous studies demonstrate the adverse consequences of sleep deprivation in industrial and laboratory settings,15 critics have suggested that insufficient data have been generated from clinical intervention studies to support the call for a change in traditional resident scheduling practices.16 Concerns raised include both the potential for “unintended consequences” of reducing work hours on patient safety—due to concerns about inadequate handovers of care—as well as the effects of work hour reduction on resident education. In addition, data have emerged suggesting that implementation of the IOM's recommendations could cost up to $1.6 billion dollars, while yielding uncertain benefits.17 The ACGME is currently reviewing the IOM recommendations to determine whether to make changes to current duty hour standards.18 Remarkably, in the face of international reductions in resident-physicians' extended shifts and calls for change in the U.S., there has not been a systematic evaluation of the IOM's key recommendation regarding extended shifts. Prior systematic reviews have been conducted of the relationship between resident sleep deprivation and performance,1,2,10 but the intent of these prior reviews was to not to assess the effects of specific interventions, or to rate the evidentiary strength of the studies conducted. We therefore conducted a systematic review with the specific aim of determining whether safety, education, and quality of life have improved or deteriorated in programs that have reduced or eliminated shifts > 16 h, and to assess the quality of included studies using the U.S. Preventive Services Task Force methodology.