Residents make more errors when they work shorter shifts
More handoffs are one reason
While many believe that legal risks would be reduced as a result of the Accreditation Council for Graduate Medical Education's reduction in resident shift lengths from 30 to 16 hours, two recent studies suggest that the opposite is true.1,2
In one study, 2,323 medical interns serving before and after the new duty hour requirements were surveyed, and the percentage who reported concern about making a serious medical error increased from 19.9% to 23.3%.1 Srijan Sen, MD PhD, the study's lead author and assistant professor of psychiatry at University of Michigan Health System in Ann Arbor, says he was surprised at the study's findings.
"Going into the 2011 duty hour reforms, it was clear that interns do not function optimally after working 24 hours in a row," he says. "So I was hopeful that that reducing the maximum shift length would lessen the number of hours worked by fatigued physicians and ultimately help both interns and patients."
One important implication is to be as vigilant as possible during patient handoffs, says Sen. "There is good evidence that handoffs have increased substantially with the new duty hour rules," he underscores. "These are high-risk time periods for poor communication and errors."
Handoffs are concern
Another study found that patient handoffs among residents increased from three for those working 30 hours straight, to as many as nine handoffs for those working 16-hour shifts.
Researchers compared three work schedules. Some residents worked a pre-2011 schedule (on call every fourth night with a 30-hour limit on consecutive hours). Two other groups worked under the new rules. One group was on call every fifth night but worked only 16 hours straight, and a second group worked a night float schedule that required working a regular week on the night shift and not more than 16 hours per shift.
Interns and nurses perceived a higher quality of care under the 30-hour limit. The night float model was eliminated before the study was over because there were such a large number of people who believed the quality of care had declined.
The original premise of the 2011 rules was that shorter shifts leads to residents sleeping more, resulting in less fatigue and fewer errors, says Sanjay Desai, MS, the study's lead author and director of the residency program for internal medicine at Johns Hopkins Hospital in Baltimore. "While [the premise] seems logical, it breaks down fairly fast," says Desai. "We have learned that patient safety is an exceptionally complex science. Manipulating any one variable necessarily affects many other relevant variables. The net effect is unpredictable."
To reduce risks, Sen advises improving handoff training and aligning schedules better with residents' natural circadian rhythms. "Ultimately though, I think we will have to take steps to actually reduce the amount of work asked of residents rather than just reducing the hours," he says. Currently, residents are being asked to do the same amount of work as prior residents, but in less overall time.
"In the cases where additional resources, such as nurse practitioners and physician assistants, have been brought online to reduce the non-educational work burden of residents, the quality of care appears to have been maintained or even improved," says Sen.
References
1. Sen S, Kranzler HR, Didwania AK, et al. Effects of the 2011 duty hour reforms on interns and their patients: A prospective longitudinal cohort study. JAMA Intern Med 2013; 173(8):657-662.
2. Desai SV, Feldman L, Brown L, et al. Effect of the 2011 vs 2003 duty hour regulationcompliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: A randomized trial. JAMA Intern Med 2013; 173(8):649-655.
SOURCES
- Sanjay Virenda Desai, MD, Program Director, Osler Medical Residency, Johns Hopkins Hospital, Baltimore. Phone: (410) 955-3467. Email: [email protected].
- Srijan Sen, MD, Assistant Professor, Psychiatry, University of Michigan Health System, Ann Arbor. Phone: (734) 764-6443. Fax: (734) 763-5580. Email: [email protected].
