New Rules for Resident Hours Called Inadequate

June 29, 2011

June 29, 2011 — First-year residents must pull shifts no longer than 16 hours straight, thanks to new work standards that take effect on July 1, but a group of patient safety advocates says more must be done to protect all residents from sleep deprivation, fatigue, and the medical errors that often follow.

In an article published last week in the online journal Nature and Science of Sleep, these patient safety advocates write that the new standards issued by the Accreditation Council for Graduate Medical Education (ACGME) "stop considerably short" of guidelines issued by the Institute of Medicine (IOM), which they endorse. An IOM report published online in 2008, titled "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety," recommended that the maximum shift for any resident be 12 to 16 hours.

As it stands, beyond their first year, residents can be scheduled for up to 24 straight hours, and they can stay on an additional 4 hours for the sake of a proper patient hand-off, according to the ACGME standards taking effect July 1. Under the previous ACGME standards, 24 hours was the maximum shift for all residents, and 6 hours was the most they could tack on.

The authors of the article in Nature and Science of Sleep wanted more change than that.

"The current system amounts to an abuse of patient trust," said coauthor Lucian Leape, MD, an adjunct professor of health policy at the Harvard School of Public Health in Boston, Massachusetts, in a press release accompanying the article. "Few people enter a hospital expecting that their care and safety are in the hands of someone who has been working a double-shift or more with no sleep. If they knew, and had a choice, the overwhelming majority would demand another doctor or leave."

Dr. Leape helped convene a group of 26 "stakeholders" in the issue of patient-safety, including medical educators, hospital administrators, and sleep scientists, for a 2-day conference last year on how to implement the 2008 IOM report on resident hours. The article in Nature and Science of Sleep presents their final recommendations.

Experience "Does Not Overcome the Need for Sleep"

The ACGME and IOM appear to disagree on the connection between fatigue and medical errors committed by residents. The ACGME has stated that there are "limited data" on the subject, whereas the IOM asserts that there is enough evidence to justify its more stringent reforms.

According to the ACGME, shorter shifts are warranted for first-year residents, whom it calls the least experienced and most vulnerable physicians in training. In their case, "fatigue has an influence on the frequency of errors," the accrediting organization once stated. However, beyond year 1, longer shifts are appropriate because residents must be prepared to "practice medicine outside the learning environment where they will be unsupervised, must think independently, and often must function at their top abilities when fatigued."

Charles Czeisler, MD, PhD, another coauthor of the Nature and Science of Sleep article, counters that a resident's experience "does not overcome the need for sleep."

"There is no justification for maintaining unsafe work hours, other than that they're a good deal for hospitals," said Dr. Czeisler, chief of the Division of Sleep Medicine at Brigham and Women's Hospital in Boston, in the press release. "But they endanger patients, and they even endanger residents."

Other recommendations from Dr. Czeisler and his fellow patient safety advocates include:

  • requiring attending physicians to supervise all hospital admissions,

  • requiring in-house supervision of all critical care services performed by residents,

  • eliminating noneducational and nonessential work from resident duties,

  • making adherence to IOM recommendations on work hours a condition of receiving Medicare funds for residency training,

  • providing transportation for any resident who says he or she is too tired to drive home safely, and

  • training residents and attending physicians on standardized ways to effectively hand-off patients.

Shortening shifts, providing more supervision, and reforming residency training in other ways will require hospitals to hire more personnel. However, the quality improvement that ensues (eg, fewer preventable errors, shorter hospital stays, smarter discharges) will yield savings that help offset higher staffing costs, according to the authors.

Nat Sci Sleep. 2011;3:47-85. Full text

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