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Original Contribution
December 5, 2012

Effect of a Protected Sleep Period on Hours Slept During Extended Overnight In-hospital Duty Hours Among Medical Interns: A Randomized Trial

Author Affiliations

Author Affiliations: Center for Health Equity Research & Promotion, Philadelphia Veterans Affairs Medical Center (Drs Volpp and Shea and Mss Norton and Novak); Department of Medicine (Drs Volpp, Shea, Bellini, and Dine, Mss Norton and Novak, and Mr Zhu), Division of Sleep and Chronobiology, Department of Psychiatry (Drs Basner and Dinges and Mr Ecker), Perelman School of Medicine, Departments of Health Care Management (Dr Volpp) and Statistics (Dr Small), the Wharton School, and the Leonard Davis Institute Center for Health Incentives and Behavioral Economics (Drs Volpp, Shea, and Small, Mss Norton and Novak, and Mr Zhu), University of Pennsylvania; and Pulsar Informatics Inc, Philadelphia (Dr Mollicone).

JAMA. 2012;308(21):2208-2217. doi:10.1001/jama.2012.34490
Abstract

Context A 2009 Institute of Medicine report recommended protected sleep periods for medicine trainees on extended overnight shifts, a position reinforced by new Accreditation Council for Graduate Medical Education requirements.

Objective To evaluate the feasibility and consequences of protected sleep periods during extended duty.

Design, Setting, and Participants Randomized controlled trial conducted at the Philadelphia VA Medical Center medical service and Oncology Unit of the Hospital of the University of Pennsylvania (2009-2010). Of the 106 interns and senior medical students who consented, 3 were not scheduled on any study rotations. Among the others, 44 worked at the VA center, 16 at the university hospital, and 43 at both.

Intervention Twelve 4-week blocks were randomly assigned to either a standard intern schedule (extended duty overnight shifts of up to 30 hours; equivalent to 1200 overnight intern shifts at each site), or a protected sleep period (protected time from 12:30 AM to 5:30 AM with handover of work cell phone; equivalent to 1200 overnight intern shifts at each site). Participants were asked to wear wrist actigraphs and complete sleep diaries.

Main Outcome Measures Primary outcome was hours slept during the protected period on extended duty overnight shifts. Secondary outcome measures included hours slept during a 24-hour period (noon to noon) by day of call cycle and Karolinska sleepiness scale.

Results For 98.3% of on-call nights, cell phones were signed out as designed. At the VA center, participants with protected sleep had a mean 2.86 hours (95% CI, 2.57-3.10 hours) of sleep vs 1.98 hours (95% CI, 1.68-2.28 hours) among those who did not have protected hours of sleep (P < .001). At the university hospital, participants with protected sleep had a mean 3.04 hours (95% CI, 2.77-3.45 hours) of sleep vs 2.04 hours (95% CI, 1.79-2.24) among those who did not have protected sleep (P < .001). Participants with protected sleep were significantly less likely to have call nights with no sleep: 5.8% (95% CI, 3.0%-8.5%) vs 18.6% (95% CI, 13.9%-23.2%) at the VA center (P < .001) and 5.9% (95% CI, 3.1%-8.7%) vs 14.2% (95% CI, 9.9%-18.4%) at the university hospital (P = .001). Participants felt less sleepy after on-call nights in the intervention group, with Karolinska sleepiness scale scores of 6.65 (95% CI, 6.35-6.97) vs 7.10 (95% CI, 6.85-7.33; P = .01) at the VA center and 5.91 (95% CI, 5.64-6.16) vs 6.79 (95% CI, 6.57-7.04; P < .001) at the university hospital.

Conclusions For internal medicine services at 2 hospitals, implementation of a protected sleep period while on call resulted in an increase in overnight sleep duration and improved alertness the next morning.

Trial Registration clinicaltrials.gov Identifier: NCT00874510.

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