Sleep standard compliance low, new study shows
Sleep standard compliance low, new study shows
Lack of sleep may endanger patients, providers
Standards put in place in 2003 to ensure ample sleep for interns are not being complied with, according to a new study published in the Journal of the American Medical Association1. The standards, implemented by the Accreditation Council for Graduate Medical Education (ACGME), seek to limit interns to no more than 80 hours a week, averaged over a four-week period. ACGME also limits the number of consecutive hours an intern can work to no more than 30.
A national web-based survey, completed in May 2004, yielded 4,015 participants out of the 37,000 or so interns in U.S. residency programs; they completed 29,477 reports of their work and sleep hours. Here are some of the key findings:
- 83.6% of the respondents reported work hours in violation of the standards during one or more months.
- Working shifts greater than 30 consecutive hours was reported by 67.4% of the respondents.
- Averaged over four weeks, 43% reported working more than 80 hours weekly.
- 43.7% reported not having one day in seven off work duties.
Ineffective penalties?
Lead author Christopher P. Landrigan, MD, MPH, Assistant Professor of Pediatrics and Medicine, Harvard Medical School, and Associate Physician, Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, says he was surprised by the findings. "We certainly expected there was going to be some degree of non-compliance and guessed it would be higher than was reported to ACGME, but we never imagined there would be 84% violation," he says.
One of the reasons behind the non-compliance, Landrigan posits, is the way the penalties are structured.
"The main penalty is that potentially they could come in and shut the program down; it's almost an all-or-nothing situation," he explains. "You can either provide a citation or suspension from accreditation. One of the concerns we had had with the standard was that because there were such harsh penalties, it was potentially a real disincentive for a program to report noncompliance, or for residents or interns to report it."
The other problem, he continues, involves the standards themselves. "The way they are set up, the interns can work up to 30 hours in a row, and no more than 80 hours in a week averaged over four weeks. In practice, that means you could be working three 100-hour weeks and then a 20-hour week."
In addition, he says, the 30-hour maximum shift length "is far beyond what is allowed in other industries. Pilots, for example, cannot be on for more than eight consecutive hours, and truckers are limited to 11 hours." In Europe, he notes, interns cannot work more than 13 hours in a row.
"There is a growing body of evidence that this many hours is unsafe, and a revision is necessary," Landrigan asserts.
Initiate a policy
The other problem, he says, is enforcement. "ACGME is both the data collector and the enforcer — and the two can't exist in tandem," Landrigan insists. "For example, when there is a problem involving airline safety risk, it is reported anonymously to the NTSB [National Transportation Safety Board], but the rules are enforced by the FAA [Federal Aviation Agency]. This helps you get good data and promote safety."
There is nothing stopping individual facilities from instituting policies that restrict interns to fewer hours than the ACGME allows, says Landrigan. "In fact," he adds, "quality managers absolutely should advocate that within their hospitals. They are in one of the best positions in the country to try and make an impact on this issue."
What should such a policy look like? "What's required to achieve gains in safety is not to think in terms of the current standard but to aim for something much more substantial," Landrigan advises. "I recommend, based on other industries, that ideally shifts should be limited to 10-13 hours, and a maximum of 18 — for any healthcare worker."
There is no longer any doubt about how serious a safety issue sleep deprivation is, says Landrigan. "Over the past five years, a wealth of data has been gathered on sleep deprivation," he observes. "There is no doubt that efforts made at hospitals to improve working schedules could be one of the most powerful interventions to improve safety of patients and workers."
Reference
1. Landrigan CP, Barger LK, Cade BE, Ayas NT, Czeisler CA. Interns' Compliance With Accreditation Council for Graduate Medical Education Work-Hour Limits. JAMA. 2006;296:1063-1070.
For more information, contact:
Christopher P. Landrigan, MD, MPH, Assistant Professor of Pediatrics and Medicine, Harvard Medical School, Associate Physician, Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA. Phone: (617) 525-7310. E-mail: [email protected].
Standards put in place in 2003 to ensure ample sleep for interns are not being complied with, according to a new study published in the Journal of the American Medical Association.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.