Interns, residents exceeding work limits; injuries resulting

One study indicates many are overworked

Medical residents are continuing to put themselves at risk of job-related injuries like needlesticks and cuts by working beyond work-hour limits set out three years ago by the Accreditation Council for Graduate Medical Education (ACGME).

The working hours of medical interns (or first-year residents) — many of whom put in more than 100 hours in some weeks — came under scrutiny by the Occupational Safety and Health Administration (OSHA) and ACGME when studies indicated that injuries and illnesses to residents, and increased errors on the job, were associated with the extended work hours.

In response, ACGME in 2003 implemented work hour limits for all physicians-in-training in the United States. Each trainee is limited to a maximum of 30 consecutive work hours, a maximum of 80 weekly work hours, averaged over four weeks, and one day in seven (averaged over four weeks) must be free of all duties.

But studies done by ACGME and researchers at Boston's Brigham and Women's Hospital and Harvard Medical School indicate that to varying degrees, the work hour limits continue to be exceeded.

Cuts, needlesticks associated with long hours

Exposures to contaminated fluids from percutaneous needlesticks and lacerations are known serious hazards associated with postgraduate medical training. These injuries may result in the transmission of blood-borne pathogens, including hepatitis and human immunodeficiency viruses and, thus, have significant occupational health implications.

Researchers at Brigham and Women's Hospital and Harvard Medical School examined the contributing factors for needlesticks and cuts in interns and assessed their relationship to extended-duration work. The study1 included Web-based surveys of self-reported percutaneous exposures from 2737 of the estimated 18,447 interns in postgraduate residency programs from 2002 to 2003. Each month, comprehensive Web-based surveys asked about work schedules and the occurrence of injuries in the previous month.

From a total of 17,003 monthly surveys, 498 needlesticks and cuts were reported. Of these, 294 were due to lacerations from sharp instruments (such as a scalpel), and 204 were due to needlesticks. Rates of injuries varied significantly, depending on type of residency. Interns in surgery and obstetrics/gynecology residency programs had the greatest risk, presumably because they perform more invasive procedures than other specialties.

In 90% of the 498 injuries, one or more factors contributing to the incident were reported. The most commonly reported contributing factor was a lapse in concentration (63.8% of incidents), followed by fatigue (31% of the incidents). Percutaneous injuries were more frequent during extended work compared with nonextended work. Extended work injuries occurred after an average of 29.1 consecutive work hours; nonextended work injuries occurred after an average of 6.1 consecutive work hours. The rate of injury was twice as high during night hours than during the daytime.

"The association of these injuries with extended work duration is likely due to the adverse cognitive effects of the sleep deprivation associated with such extended work, consistent with experimental data," the authors write. "Given the potentially serious consequences of such injuries, implementation of safety measures designed to reduce the risk of these occupational injuries should be undertaken. The impact of comprehensive fatigue management programs on the risk of these occupational exposures should be evaluated."

Some disagreement on noncompliance rate

Another group of Brigham and Women's/ Harvard researchers studied how many first-year residents (interns) were complying with the ACGME duty hour standards in 2003-2004, the first year following implementation of the rules. According to Christopher Landrigan, MD, MPH, lead author of the study,2 more than 80% of the first-year residents reported they were exceeding the mandated hours.

The study consisted of monthly Web-based surveys to assess the work hours and sleep of 4015 interns, conducted one year before the ACGME standards were adopted and one year after implementation.

In the year following implementation of ACGME standards, 83.6% of participating interns reported work hours that were noncompliant during at least one month.

On a positive note, over the course of the year following implementation of ACGME mandates, monthly rates of noncompliance decreased from 48.8% to 38%. Comparing postimplementation to preimplementation, average weekly work hours decreased 5.8%, from 70.7 hours to 66.6 hours.

After the work-hours standard was imposed, residents reported their average sleep duration increased by 22 minutes; however, reported average sleep during extended shifts decreased 4.5%.

The researchers conclude that one reason the rate of noncompliance remained high could be that the duty hour standards amounted to unfunded mandates for some institutions.

"Programs may not have the resources or expertise to redesign their schedules to the extent required," according to the authors. And residents are typically unwilling to leave their shift when working on an emergent patient care situation, common in the high-intensity setting of hospitals, they add.

But ACGME's data on the three years since the implementation of duty hour standards indicate that survey responses from 101,250 residents reflects that most programs "are in substantial compliance" with the standard, the association announced in a press release in September 2006.

For academic year 2004-2005, the ASGME cited just over 7% of programs reviewed that year for duty hour violations, and 3% of residents reported working more than 80 hours per week in the previous four weeks.

ACGME takes issue with the Landrigan study, saying those results were based on a small sample spread out over many hospitals, and does not give a full picture of the compliance rate.

Reference

1. Ayas NT, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA. 2006;296:1055-1062.

2. Landrigan CP, et al. Interns' compliance with Accreditation Council for Graduate Medical Education work-hour limits. JAMA. 2006;296:1063-1070.

Source

Accreditation Council for Graduate Medical Education requirements for resident duty hours available at www.acgme.org.