Field studies in many domains have found evidence of decision fatigue, a phenomenon describing how decision quality can be impaired by the act of making previous decisions. Debate remains, however, over posited psychological mechanisms underlying decision fatigue, and the size of effects in high-stakes settings. We examine an extensive set of pretrial arraignments in a large, urban court system to investigate how judicial release and bail decisions are influenced by the time an arraignment occurs. We find that release rates decline modestly in the hours before lunch and before dinner, and these declines persist after statistically adjusting for an extensive set of observed covariates. However, we find no evidence that arraignment time affects pretrial release rates in the remainder of each decision-making session. Moreover, we find that release rates remain unchanged after a meal break even though judges have the opportunity to replenish their mental and physical resources by resting and eating. In a complementary analysis, we find that the rate at which judges concur with prosecutorial bail requests does not appear to be influenced by either arraignment time or a meal break. Taken together, our results imply that to the extent that decision fatigue plays a role in pretrial release judgments, effects are small and inconsistent with previous explanations implicating psychological depletion processes.

Introduction: Decision fatigue is a well-characterized phenomenon that has rarely been studied in the medical field. Emergency department (ED) physicians make many clinical decisions every shift. In this study, we examined ED physician decisions in computed tomography (CT) ordering, consultations, and discharges over time in an eight-hour shift. Methods: We performed a cohort study of adult patients presenting to two EDs of an academic, tertiary care hospital over a two-year period using the hospital administrative database. Patients triaged to the Urgent Care (minor acuity) area of the ED were excluded. Patients were analyzed based on the hour of the shift that they were initially assessed by an ED physician. For each hour, we evaluated the proportion of patients who had CTs, consultations, discharges, consultations not resulting in admission, returns within 72 hours of discharge, and median ED length of stay (LOS). Patients under the care of more than one ED physician (i.e. handovers) were analyzed as the time seen by the initial physician. Statistical significance of outcomes over time was assessed using random effects logistic regression. Results: 87,752 patients were included in the study period. 42,146 patients (48.0%) received consultations, of which, 29,347 (69.6%) were admitted. 45,470 patients (51.8%) were discharged without consultation, of which, 4102 (9.0%) returned within 72 hours. The median ED LOS for all non-consulted discharged patients was 4.9 hours. There was a statistically significant decline in the hourly rates of CT head and CT abdomen ordering as the shift progressed. CT head ordering declined significantly from 15.8% in the first hour to 12.2% in the last hour (p<0.0001) while CT abdomen declined significantly from 9.6% to 7.6% (p<0.0001). There were no significant differences in the hourly rates of consultations, consultations not resulting in admission, discharges, discharges returning within 72 hours, or ED LOS. Conclusion: ED physician decisions about patient disposition did not change in relation to hours into the shift. Interestingly, the rates of CT head and CT abdomen declined as the shift progressed. The lower CT ordering rates do not seem to be associated with any differences in patient disposition or ED LOS. In this large patient sample, we did not find evidence of decision fatigue among ED physicians.