Restoration of resident sleep and wellness with block scheduling

Abstract

Introduction Block scheduling during residency is an innovative model separating inpatient and ambulatory rotations. We hypothesized this format may have a positive impact on resident sleep and wellness as compared to a traditional format. Methods We performed a single-center, cross-sectional, observational study of residents rotating in the medical intensive care unit (MICU). Residents were observed for 4 weeks at a time: Internal Medicine (IM) residents for 3 MICU weeks followed by one ambulatory week, and non-IM residents for 4 weeks in the MICU. We monitored daily total sleep time (TST) utilizing actigraphy, and wellness measures with weekly Epworth Sleepiness Scale (ESS) and Perceived Stress Scale (PSS) questionnaires. Results 64 of 110 (58%) eligible residents participated, 49 (45%) were included in the final analysis. Mean daily TST for the entire cohort was 6.53h (± 0.78h). Residents slept significantly longer during the ambulatory block compared to the MICU block (mean TST 6.97h ±1.00h vs 6.43h ± .78h; p < .0005). Sleep duration during night call was significantly shorter than day shift (mean TST 6.07h ±1.16h vs 6.50h ± .73h; p = <.0005). 390 of 490 (80%) of ESS and PSS questionnaires were completed, scores significantly declined while in the MICU. IM residents had significant improvement in TST, ESS and PSS scores (p < .05) at the end of the ambulatory week. Non-IM residents, who remained in the MICU for a fourth week, continued a trend of decline in perceived wellness. Conclusion Despite duty hour restrictions, residents are getting inadequate sleep. As MICU days accumulate, measures of resident wellness decline. Residents in a block schedule experienced improvement in all measured parameters during the ambulatory week, while residents in a traditional schedule continued a downward trend. Block scheduling may have the previously unrecognized benefit of repaying sleep debt, correcting circadian misalignment and improving wellness.

Sleep is just part of the picture

“…Many studies have now examined work‐hour restrictions. As Bordley et al note in their article in this journal, the results have been mixed, and not always positive for residents . One previous commentary hypothesised that a possible reason is that residents are still required to do the same amount of work compressed into shorter hours …”

“…The intervention described by Bordley et al in this issue circumvented the compression of work by separating the in‐patient from the out‐patient service, and protecting the out‐patient service from weekend and overnight coverage . They found that increased opportunity to sleep results in more sleep and increased subjective wellness, although interestingly, residents slept less than expected on their MICU (medical intensive care unit) rotation, perhaps in part because they employed the night‐shift system, which has been shown to have the worst effect on residents' hours of sleep .…”

“…Sleep is only one factor, and perhaps it is time to study these complex systems as a whole. As an example, in this study, one could wonder who was taking care of the MICU patients for the week that the residents were at their ambulatory clinic. Was it the attending physicians?…”

“…In addition, the residents in this study spent a shorter period of time (3 weeks versus 4 weeks) in the MICU . What are the effects of this?…”

“…The bigger take‐home message from the article by Bordley et al may be that more residency education needs to take place in the ambulatory setting. From a resident perspective, this may be a good option.…”