Fatigue: It’s a fickle member of the obstetrical team
Extended on-call shifts might take a toll on OBs’ performance and judgment. Is a change in order?
A nap can improve function
For centuries, OBs have taken a nap to reduce the adverse impact of an extended period of wakefulness. Does this practice work?
Yes, it appears. In a randomized trial, physicians and nurses who worked consecutive 12-hour night shifts in an emergency department were randomized to take a nap or to not nap during their shift. Those in the nap group were able to sleep, on average, 25 minutes.
At the end of the 12-hour shift, clinicians who took a nap demonstrated, overall, 25% fewer lapses in performance than controls did as measured by a standardized test of psychomotor task vigilance and recall memory tasks. Clinicians who took a nap were also capable of completing more quickly simulated intravenous line insertion.5
But beware of sleep inertia! Decision-making is significantly impaired in the 30 minutes immediately after awakening from a nap or sleep, research shows.11 A nap improves productivity over an extended period of wakefulness, but be aware that you may be at increased risk of making a medical error immediately after you awake from a nap.
Often, an OB who is on-call is awakened from a nap and required to make important clinical decisions or perform surgical interventions. Consequently, an earlier nap may improve performance later, during the last hours of an extended shift, but a nap may diminish performance in the 30 minutes right after awakening.
Contingency planning—more a good idea than a practice
Sometimes, an extended-duty shift is marked by few complex cases—and the clinician can sleep for a significant period. Occasionally, however, several high-acuity cases transpire in rapid sequence during an extended-duty shift—and the OB must stay awake for an extended period. OB groups that schedule extended on-call shifts of 24 to 60 hours should consider contingency planning for the occasional interval of exceptionally busy patient care activity. Such a plan might include having a backup call physician to take over cases when the primary on-call physician has been awake continuously for 24 hours or longer.
Yet such planning remains more a good idea than a practice: In one recent survey, approximately 75% of OB care groups reported that they did not have a contingency plan.2
Shrinking the shift
An alternative to formal contingency planning is to adopt call schedules that strictly limit shifts to 12 to 14 hours. The work shifts of airline pilots and interstate truck drivers, for example, are strictly limited. That policy is based on a belief that a long interval of wakefulness increases the risk of commercial airline and motor vehicle accidents.
Other developed countries are shortening call schedules. In the United Kingdom, maximum duty hours for a resident are 56 a week, 13 consecutively. Compare the United States, where they are 80 hours a week, 30 consecutively.
Some investigators claim that heavy call shifts (90 hours a week) erode physician performance on attention, vigilance, and task testing more than moderate alcohol consumption does (blood alcohol level, 0.05). 12 That research has serious limitations, but some pundits may conclude that physicians who undergo an extended period of wakefulness are “impaired” just as if they drank alcohol on the job….
Stay tuned, and stay awake!
Maximum work hours per week and consecutive hours of wakefulness are likely to remain priority issues in obstetrics. We can lead the charge to reengineer OB call schedules by adopting formal contingency plans, with backup call coverage or strict limitations on work hours, and by identifying other innovative methods to reduce fatigue.
In the absence of continuing physician leadership, however, the federal and state governments will likely become actively engaged on the matter of extended-duty fatigue—and may consider legislating work rules similar to those that have been placed on airline pilots.
