Mohapatra A, Bandari J, Orikogbo O et al: Resident duty hour compliance and sleep after transitioning to a night float system: a prospective observational study in an academic urology program. Urol Pract 2021; 8: 409.

In 2003 the Accreditation Council for Graduate Medical Education (ACGME) established the 80-hour workweek for resident physicians, and in 2011 limited shifts to 24 contiguous hours.^1-3 These policy changes were motivated by research demonstrating that residents working extended shifts were more likely to make medical errors and experience deteriorations in surgical ability. To comply with duty hour limitations, residency programs have implemented different call systems. One system is night float, wherein 1 or more residents work at night and are off during the day. Alternatively, some programs have residents take home call. During home call the on-call residents field all pages from home but go into the hospital to see patients as needed. In this system residents are expected to work the day preceding and following the overnight call.

The first multi-institutional, randomized, controlled trial to study the effects of duty hour restrictions on surgical residents and outcomes was the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial. The FIRST trial found similar rates of surgical complications, patient mortality, and resident satisfaction with or without hour restrictions.⁴ Studies examining the impact of night float on resident wellness, resident education, and patient safety have had mixed results, with some studies reporting improved perceptions of wellness among residents and others reporting no change.⁵

The applicability of these findings to urology residents is unclear. In contrast to larger general surgery and internal medicine programs, urology residencies have just 1 to 5 trainees a year, and residents often take home call while covering multiple hospitals. We recently transitioned from home call to a night float system, and have reported the results of a prospective observational study comparing patient care, communication, quality of life, resident education, duty hour violations, sleep, and interaction with nurses before and after this transition.⁶

For our study, residents and attending physicians were asked to complete surveys about patient care, education, quality of life, and communication with members of the health care team. Nursing staff were also asked to evaluate resident promptness, availability, knowledge of the patients’ treatment plans, respectfulness, communication, and ease of identifying the on-call resident. All surveys used a 5-point Likert scale and were administered to physicians and nurses 2 months before and 4 months after the transition, which was on June 23, 2019. In addition, we obtained actigraphy data from junior residents to assess sleep duration for each of the following sleep periods: night of home call (on-duty sleep period), daytime on night float (off-duty sleep period), and night while off from work (control). These sleep periods were selected at random prior to starting the sleep or work period.

Responses were compared separately for junior residents, senior residents, and attendings. Response rates were 100% (11/11), 80% (8/10), and 95% (19/20), respectively. According to all 3 groups, quality of life and research improved significantly after night float, without a significant negative impact on the other education domains, including case volume. Junior residents rated night float as superior in all respects, including patient care, education, and communication (with the day team, nurses, other services, and handoffs), and night float was associated with significantly fewer duty hour violations. Senior residents reported significant improvements in patient care and more time spent reading urology texts. Attendings noted that day team efficiency and the quality of handoffs improved after the transition without any significant negative changes related to the switch. Nurses reported that on-call resident availability, knowledge of plan, respectfulness, and communication significantly improved, as well as ease of identifying the on-call resident (p < 0.05 for all). Finally, residents slept significantly more than during home call (mean 7.1 vs 2.5 hours, p < 0.001) as well as on their nights off (7.1 vs 6.8 hours, p = 0.4) while on night float.

Overall, the institution of a night float system has led to favorable results, particularly among junior residents, who take the majority of primary calls. Both faculty and residents also noted improvements in quality of life, research, and efficiency of the day team. No domains were worse with night float. Junior residents also reported fewer ACGME duty hour violations and slept approximately 5 hours more per night compared to home call. Although our findings may not be applicable to all residency programs, we believe that night float is the preferable option when feasible.