To address the abundant medical errors that result from the mandatory work schedule that prohibits medical residents from sleeping for 30 hours or more straight, earlier this week the Institute of Medicine (IOM) strongly recommended rule changes which would require residents to reduce their duty hours, increase their sleep hours, and have caps placed on the number of hours per week they can work.
The IOM’s report, "Resident Duty Hours: Enhancing Sleep, Supervision and Safety," was funded by the Agency for Healthcare Research and Quality (AHRQ), a division of the US Department of Health and Human Services.
Currently, the Accreditation Council for Graduate Medical Education (ACGME) allows an outrageous maximum shift length of 30 hours, which includes 24 hours of direct patient care and 6 hours of training or transition activities. Eighty hours is the maximum work week allowed.
"The impact of resident fatigue caused by long work hours is still a major concern," Joanne Conroy, MD, chief health care officer, Association of American Medical Colleges, told Medscape Medical News when asked for independent review of the IOM report. "We believe that improved management of the resident work day may lead to a safer clinical environment, although the data has not yet demonstrated this statistically."
Dr. Conroy noted that studies published more than a decade ago first demonstrated the effect of fatigue on performance levels.
"When Dawson and Reid first published the effect of fatigue on performance and equated it with alcohol impairment, the medical community took notice," Dr. Conroy said. "Anecdotally, we also recognize the tremendous variation among physicians in terms of their ability to recognize and manage their own fatigue." -Laurie Barclay, MD, Medscape Medical News
The IOM’s 15 month study examined relationships between residents’ work schedules, performance, and quality of care provided. Not too shockingly, it found that residents suffering from acute and/or chronic fatigue are more likely to make errors.
For years, various hospitals around the country have been providing transportation home for residents to keep them from getting into car accidents due to fatigue. It only makes sense that if you’re too tired to safely drive a car, you’re too tired to safely participate in surgery or even thoughtfully diagnose an atypical patient.
Accordingly, the IOM committee has recommended several major changes to the existing ACGMA rules. These include:
Residents who complete a 30-hour shift may treat patients for only up to 16 hours, followed by a 5-hour protected sleep period between 10 PM and 8 AM, during which time patient care would be managed by other nonsleeping residents or additional staff members.
Supervision of work hours should be increased because of frequent, often underreported lack of compliance with ACGME limits. The IOM committee recommends periodic independent reviews of hours worked by residents, as well as increased protections for those who report failure to comply with current work hour restrictions.
Moonlighting restrictions should be increased so that both internal and external moonlighting count against the ACGME 80-hour weekly limit. Only internal moonlighting, defined as additional paid healthcare work at the same healthcare facility, is currently considered to be part of the 80-hour weekly limit. Because moonlighting outside residency training affects strategically designed periods for rest and sleep and may hinder residents’ abilities to complete their primary duties, the IOM recommends that both internal and external moonlighting be counted toward the total work week hourly limit.
To facilitate recovery after working long shifts, the IOM report recommends guaranteed 5 days off per month, with 24 hours off each week and one 48-hour period off each month.
Hospital on-call periods for residents should be limited to no more than every third night.
Because the risk for motor vehicle accidents more than doubles when residents drive home after working extended shifts, hospitals should provide safe transportation to residents who are too fatigued to drive home.
Residents should receive more training on better communication, using a structured team approach, during change-of-shift handovers. These handovers will increase as resident shift duration decreases, possibly increasing the risk for adverse events unless training and team communication improve.
Residents should be more involved in patient safety activities and in adverse event reporting not only to improve quality of care but also to enhance their educational experience.
Changes like these make sense, not only in terms of improving the rate of medical mistakes, but in contributing to the physical and psychological wellbeing of medical residents themselves. If this in turn can bring our medical costs down in the long run, so much the better.