JAMA: Day or night surgeons provide tip-top transplants

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More than 98,000 deaths annually are attributed to medical errors and some say medical staff fatigue and nighttime hours may affect outcomes. However, as far as thoracic organ transplants go, a new study has found that operative time of day had no significant impact on one-year survival, according to results published in the June 1 issue of the Journal of the American Medical Association.

Using United Network for Organ Sharing (UNOS) data, Timothy J. George, MD, of John Hopkins Medical institutions in Baltimore, and colleagues examined 27,118 patients to assess whether performing orthotropic heart transplants or lung transplants at night led to more adverse outcomes.

The researchers defined daytime as 7 a.m. to 7 p.m. and nighttime as 7 p.m. to 7 a.m. Of the 27,118 patients, 16,573 patients underwent heart transplant; 8,346 patients underwent transplant procedures during the day and 8,227 patients underwent transplants at night. Meanwhile, 10,545 patients underwent a lung transplant. Of those patients, 5,179 patients underwent transplants during the day and 5,366 underwent transplants at night.

During a mean 32.2-month follow-up, 8,061 patients died. However, survival was similar for transplants performed during the day or night. The 30-day survival rate for heart transplants that took place during the day was 95 percent compared to 95.2 percent for procedures that took place during the night.

The researchers reported the 90-day survival rate for heart transplants to be 92.6 percent during the day versus 92.7 percent during the night. The rate at one-year was 88 percent for procedures that took place during the day versus 87.7 percent that took place at night.

“Nighttime heart transplants were not associated with an increased risk of 30-day, 90-day, or one-year mortality on multivariable analysis,” the authors noted. Factors linked to increased mortality at 90 days for heart transplant patients included increased age, creatinine level, mean pulmonary artery pressure, preoperative need for ventilation, ICU care, extracorporeal membrane oxygenation, ventricular assist devices support and ischemic time.

“[W]e conclude that operative time of day is not associated with short-term survival after thoracic organ transplant procedures,” the authors noted. “Diligent postoperative care may ameliorate the potential detrimental effects of nighttime surgery on survival; however, postoperative complications are measures not so readily offset by meticulous postoperative care.”

The researchers noted that surgical fatigue can lead to careless surgical techniques that can increase bleeds. However, the current study showed that fatigue was not linked to poor surgical techniques during nighttime procedures.

Nighttime operations are common and healthcare personnel should have systems and protocols in place to help prevent error, the authors wrote. These strategies could include instating transplant teams that include surgeons, anesthesiologists, perfusionsists and operating room staff, who can work together to mobilize for rapid transplant operations.

“Such routine camaraderie and familiarity likely diminishes the novelty of the operation, lessening the burden and strain of the nighttime environment,” the authors concluded.