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Clinical question: Does a resident’s ability to make decisions in the management of critically ill patients deteriorate with longer periods of wakefulness?

Background: Residents work long shifts, particularly in the ICU. Their cognitive performance on standardized tests and clinical performance in surgical simulators deteriorates with sleep deprivation. The effect of prolonged wakefulness on resident management of critically ill patients is not known.

Study design: Experimental within-subjects comparison.

Setting: Simulator at the Centre of Excellence for Surgical Education and Innovation, Vancouver General Hospital, Canada.

Synopsis: Twelve internal medicine residents at various levels of training from the University of British Columbia were studied. The residents provided simulated care for critically ill patients at four time points over 26 hours of wakefulness. At each time point, the residents first managed a cardiac dysrhythmia, then a complex patient scenario that would require ICU-level care. They were then scored for errors and given a global score by two of the investigators.

Resident errors in the management of dysrhythmias decreased at the first time point, and remained stable through the next two time points. The mean error rate for the complex patient scenarios increased from 0.92, with a steady rate of rise to 1.58 at the last session. The mean global score for the complex patient scenario showed a trend toward decline as well. Despite this being a small study with relatively subjective outcomes, the results are consistent with previous studies and raise concern for increasing the risk for error in the care of highly vulnerable critically ill patients by residents working long hours.

Bottom line: There is a progressive decrement in resident performance with increasing periods of wakefulness when delivering ICU-level patient-management decisions in a simulator environment.

Citation: Sharpe R, Koval V, Ronco JJ, et al. The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: A patient simulator study. Crit Care Med. 2010;38:766-770.

Reviewed for TH eWire by Dimitriy Levin, MD, Jeffrey Carter, MD, Erin Egan, MD, JD, Jonathan Pell, MD, Laura Rosenthal, MSN, ACNP, Nichole Zehnder, MD, Hospital Medicine Group, University of Colorado Denver

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