Asleep at the bedside? IOM says feds should issue tough work hour limits
Asleep at the bedside? IOM says feds should issue tough work hour limits
Medical resident fatigue poses patient safety risk
Hospitals need federal oversight to ensure that their medical residents are not working excessive hours that could lead to hazardous levels of fatigue, an Institute of Medicine (IOM) panel has concluded.
Two accrediting bodies the Accreditation Council for Graduate Medical Education (ACGME) and the Joint Commission also should monitor compliance with limits on work hours, the IOM said, and the new limits on work hours and tougher enforcement should occur "with all deliberate speed." Although some measures would require a phase-in, the IOM suggested its recommendations should be put into place within 24 months.
While the connection between fatigue and medical errors has received attention during the last 10 years, this report garnered immediate national attention. The New York Times editorialized that the IOM report did not go far enough to protect medical residents and their patients from the consequences of fatigue.
In its report, Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, released in December, the IOM recommended shifts of no more than 16 hours, but it sanctioned shifts of up to 30 hours if the residents had five hours of "protected" sleep after 16 hours of work. "A ban on shifts longer than 16 hours seems preferable," the Times said. ACGME currently allows shifts of 30 hours, with no more than 24 hours involved in admitting patients and six hours for transitional and educational time.
The Times also urged stronger oversight. "The accrediting organization (ACGME) can't be counted on to get tough," the editorial stated. "If violations continue to occur, Congress may want to put federal regulators in charge of monitoring residents' hours."
In fact, organizations supporting medical residents may turn to Congress for legislative action that goes beyond the IOM recommendations. "They've effectively bent over backwards to find a way to address the problem that does not require residency programs to fundamentally reorganize themselves," says Peter Lurie, MD, MPH, deputy director of the Health Research Group at Public Citizen, a Washington, DC-based consumer advocacy organization. Public Citizen, along with the Committee of Interns and Residents and the American Medical Student Association unsuccessfully petitioned the U.S. Occupational Safety and Health Administration to address the issue and has pressed for federal legislation.
The IOM noted that implementing its recommendations would require hospitals to change health care delivery to make up for fewer medical resident hours. The IOM estimated the cost at $1.7 billion which it said would require an additional commitment by "all funders of graduate medical education." Medicare is the single largest funder of graduate medical education.
ACGME, which in 2003 set a limit of 80-hour work weeks averaged over four weeks, issued a statement saying it has "aggressively enforced" the work hours standards. The accrediting body plans to convene a conference in March to "carefully review the IOM report as part of discussions on possible refinements to the duty hour standards."
Despite concerns about the specific limits, sleep experts and worker advocates lauded the IOM report as a milestone and possible catalyst for change. "For the first time, the medical profession has acknowledged that working for more than 16 consecutive hours without sleep is hazardous for patients as well as the physicians themselves," says Charles Czeisler, MD, PhD, FRCP, a professor and director of sleep medicine at Harvard Medical School and chief of the Division of Sleep Medicine at Brigham and Women's Hospital in Boston.
Czeisler notes that other safety-oriented industries, including trucking, rail, nuclear power, and air transportation, have work limits to prevent fatigue. Europe also is moving to a 48-hour limit on physicians in training.
The IOM reviewed studies by Czeisler and other sleep researchers, including one that found that 43% of interns reported exceeding the ACGME limit of 80 hours per week, averaged over four weeks.1
Czeisler and colleagues also compared the patient safety impact of fatigue and the reduced continuity of care as a result of more patient hand-offs to other physicians. The medical residents in the ICU working a traditional schedule made 36% more errors than those who worked shorter shifts.2
"The errors that were being made were not knowledge-based errors, but they were slips and lapses: Forgetting to check a lab that had come back. Using an X-ray from three days ago instead of a current X-ray. Trying to do a procedure on the wrong side of the chest. These are the kinds of serious medical mistakes that the exhausted physician is making and that's why it's hazardous," he says.
Five hours of protected sleep will not reduce the risks associated with fatigue, says Lurie. "When I was a resident, I had occasional nights when I had eight hours of uninterrupted sleep and I was still exhausted the next day. It's not the same as being at home [asleep]," says Lurie.
Working while fatigued also can be hazardous to the medical residents themselves, putting them at greater risk for injury and for driving accidents on their way home.
Neurosurgeons decry rigid limits
Some medical specialties have argued that rigid work hour limits would be detrimental to resident education and even to patient safety by removing the physician who had admitted a patient and is most knowledgeable about the case.
In neurosurgery, for example, a single operation could last four to 18 hours not including the preoperative and postoperative work, notes Katie Orrico, JD, director of the Washington, DC, office of the American Association of Neurological Surgeons. Practicing neurosurgeons also cope with sleep challenges, particularly if they are called into a trauma case at night after working all day. They are not governed by a 16-hour rule, she says.
"If [neurosurgery residents] are reduced to this shiftwork mentality or find themselves coming in and out of cases depending on what hour on the clock it is, that's going to be significantly detrimental to their overall training," Orrico says. "They're certainly going to have reduced surgical experience and expertise because they're not going to be exposed to the full panoply of activities that go into taking care of a neurosurgical patient."
In fact, the IOM panel said they chose not to reduce the 80-hour workweek limit to allow flexibility to specialties "to have what they determine to be sufficient hours to achieve their learning goals." Some specialties should be able to reduce their residents' workweeks, the IOM said.
"Although the scientific evidence base establishes that human performance begins to deteriorate after 16 hours of wakefulness, the committee does not believe that limiting all shifts to a maximum of 16 hours would address the educational needs of all specialties," the IOM stated.
Long shifts and little sleep have become a rite of passage for young doctors. But tradition is not a reason to maintain the status quo, says Czeisler.
"Many people want to prove themselves, prove they have the right stuff and the stamina to get through it," he says. "But the proving ground unfortunately is not a boot camp. The proving ground is working with very ill patients so that when they slip up as a consequence of sleep deprivation, people are harmed."
The IOM panel emphasized the need for better monitoring, including unannounced visits and a system that would make it easier for residents to file complaints without concern for repercussions. The IOM panel also recommended that:
Moonlighting both at the hospital and at other facilities should be included in the residents' 80-hour workweek limits. Residents should be required to receive written permission for moonlighting, and the moonlighting hours should be monitored.
Residents should immediately begin to receive safe transportation options, such as vouchers for taxis or public transportation, if they can't safely drive home after an extended shift due to fatigue.
Hospitals should restructure health care delivery or provide additional support services to "minimize ... work that is of limited or no educational value."
Hospitals should have adequate, on-site supervision of residents.
Programs should create "structured handover procedures to ensure continuity of care and patient safety."
Safety reporting and quality improvement should be a part of residents' education.
(Editor's note: A copy of the IOM report, Resident Duty Hours: Enhancing Sleep, Supervision and Safety, is available at www.nap.edu/catalog.php?record_id=12508.)
References
1. Landrigan CP, Barger LK, Cade BE, et al. Interns' compliance with Accreditation Council for Graduate Medical Education work-hour limits. JAMA 2006; 296:1,063-1,070.
2. Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351:1,838-1,848.
Hospitals need federal oversight to ensure that their medical residents are not working excessive hours that could lead to hazardous levels of fatigue, an Institute of Medicine (IOM) panel has concluded.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.