Examining self-reported and biological stress and near misses among Emergency Medicine residents: a single-centre cross-sectional assessment in the USA

• Published in: BMJ open Vol. 7; no. 8; p. e016479
• Main Authors: Arnetz, Bengt B, Lewalski, Philip, Arnetz, Judy, Breejen, Karen, Przyklenk, Karin
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 01.08.2017; BMJ Publishing Group
• Subjects: Adult; C-Reactive Protein - analysis; Clinical Competence - standards; Cross-Sectional Studies; Decision Making - physiology; Educational Measurement; Emergency medical care; Emergency Medicine; Female; Humans; Hydrocortisone - analysis; Interleukin-6 - blood; Internship and Residency; Male; Near Miss, Healthcare - statistics & numerical data; Patient safety; Physicians; Self Report; Stress, Physiological - physiology; Tumor Necrosis Factor-alpha - blood; United States; Work Schedule Tolerance - physiology; Work Schedule Tolerance - psychology; Workload; United States > US; Detroit Michigan; Michigan; professionalism; near misses; psychophysiology
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2017-016479

ObjectivesTo examine the relationship between perceived and biological stress and near misses among Emergency Medicine residents.DesignSelf-rated stress and stress biomarkers were assessed in residents in Emergency Medicine before and after a day shift. The supervising physicians and residents reported numbers of near misses.SettingThe study took place in the Emergency Department of a large trauma 1 centre, located in Detroit, USA.ParticipantsResidents in Emergency Medicine volunteered to participate. The sample consisted of 32 residents, with complete data on 28 subjects. Residents’ supervising physicians assessed the clinical performance of each resident.Primary and secondary outcome measuresParticipants’ preshift and postshift stress, biological stress (salivary cortisol, plasma interleukin-6, tumour necrosis factor-alpha (TNF-α) and high-sensitivity C-reactive protein), residents’ and supervisors’ reports of near misses, number of critically ill and patients with trauma seen during the shift.ResultsResidents’ self-reported stress increased from an average preshift level of 2.79 of 10 (SD 1.81) to a postshift level of 5.82 (2.13) (p<0.001). Residents cared for an average of 2.32 (1.52) critically ill patients and 0.68 (1.06) patients with trauma. Residents reported a total of 7 near misses, compared with 11 reported by the supervising physicians. After controlling for baseline work-related exhaustion, residents that cared for more patients with trauma and had higher levels of TNF-α reported a higher frequency of near misses (R2=0.72; p=0.001). Residents’ preshift ratings of how stressful they expected the shift to be were related to the supervising physicians’ ratings of residents’ near misses during the shift.ConclusionResidents’ own ratings of near misses were associated with residents’ TNF-α, a biomarker of systemic inflammation and the number of patients with trauma seen during the shift. In contrast, supervisor reports on residents’ near misses were related only to the residents’ preshift expectations of how stressful the shift would be.