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Patient Safety Tip of the Week
May 2, 2023
ACGME Work Hour Guidelines
Not Good Enough
When this author was a medical resident at Johns Hopkins
Hospital, we worked roughly 120 hours per week. So, the ACGME move to restrict
resident work hours to 80 hours per week looked like a good improvement. But
think about that thats still double the typical work week for anybody else!
Is that really safe for our patients? Or for the health of our residents? Multiple
studies on fatigue in nurses have demonstrated that extended work hours are
associated with not only more errors in patient care, but also with detrimental
effects on the personal health of nurses.
Barger and colleagues (Barger 2023) conducted
a nationwide prospective cohort study of resident-physicians in the US in their
second year or beyond. They found that working more than 48 hours per week was
associated with an increased risk of self-reported medical errors, preventable
adverse events, and fatal preventable adverse events as well as near miss
crashes, occupational exposures, percutaneous injuries, and attentional
failures (all P<0.001).
Working between 60 and 70 hours per week was associated with
more than twice the risk of a medical error (odds ratio 2.36) and almost three
times the risk of preventable adverse events (OR 2.93) and fatal preventable
adverse events (OR 2.75).
Also, working one or more shifts of extended duration in a
month while averaging no more than 80 weekly work hours was associated with an
84% increased risk of medical errors, a 51% increased risk of preventable
adverse events, and an 85% increased risk of fatal preventable adverse events.
Regarding resident personal safety, working one or more
shifts of extended duration in a month while averaging no more than 80 weekly
work hours also increased the risk of near miss crashes and occupational
exposures. Working one or more shifts of extended duration while averaging no
more than 80 hours per week in a month significantly increased the near miss
crash risk (incidence rate ratio 1.47). And the combination of more weekly work
hours (>80) and shifts of extended duration further increased the risk of a
near miss crash (incidence rate ratio 2.54).
The authors conclude that exceeding 48 weekly work hours or
working shifts of extended duration endangers even experienced (ie, PGY2+) resident physicians and their patients. They
suggest that regulatory bodies in the US and elsewhere should consider lowering
weekly work hour limits and eliminating shifts of extended duration to protect physicians
training and their patients.
When designing resident work schedules, we are always balancing
several factors patient safety, personal safety, educational needs, and (the
elephant in the room) workforce needs. Lets face it even having more
hospitalists and using nurse practitioners and physicians assistants, most
hospitals still rely substantially on residents for providing 24-hour coverage
of hospitalized patients.
Of course, what is still not known is what impact a
reduction in resident work hours to 48 hours per week would actually have on
patient safety outcomes. The other serious consideration in reducing resident
work hours is that the number of handoffs will increase and we know that
handoffs introduce new vulnerabilities in patient safety. A small study (Cappuccio
2009) involving 19 residents examined the impact of the European
Working Time Directive (EWTD) that limited the maximum required working hours
to 48 per week. Review of medical records of those residents who worked fewer
than 48 hours per week showed a third fewer medical errors than those who
worked a 56 work hour limit per week. Thats
reassuring.
Most previous studies looking at resident work hours have
focused on those residents during their first postgraduate year (PGY1). The
current study was on residents during more advanced years, but the findings are
very similar to those seen in PGY1 residents.
Studies now in both nursing and physicians-in-training show
a detrimental effect of long hours for both patients and the individuals personally.
It will be interesting to see how the AGCME responds to the challenge raised by
this study by Barger et al.
Some of our other columns on housestaff
workhour restrictions:
December 2008 IOM Report on Resident Work Hours
February 26, 2008 Nightmares: The Hospital at Night
January 2010 Joint Commission Sentinel Event Alert:
Healthcare Worker Fatigue and Patient Safety
January 2011 No Improvement in Patient Safety: Why Not?
November 2011 Restricted Housestaff
Work Hours and Patient Handoffs
January 3, 2012 Unintended Consequences of Restricted Housestaff Hours
June 2012 Surgeon Fatigue
November 2012 The Mid-Day Nap
December 10, 2013 Better
Handoffs, Better Results
April 22, 2014 Impact of Resident Workhour Restrictions
January 2015 More Data on Effect of Resident Workhour
Restrictions
August 2015 Surgical Resident Duty Reform and
Postoperative Outcomes
September 2015 Surgery Previous Night Does Not Impact
Attending Surgeon Next Day
March 2016 Does
the Surgical Resident Hours Study Answer Anything?
April 2019 iCOMPARE
Study on Resident Work Hour Rules
August 2020 New
Twist on Resident Work Hours and Patient Safety
Some of our other columns on the role of fatigue in
Patient Safety:
November 9, 2010 12-Hour Nursing Shifts and Patient Safety
April 26, 2011 Sleeping Air Traffic Controllers: What About
Healthcare?
February 2011 Update
on 12-hour Nursing Shifts
September 2011 Shiftwork and Patient Safety
November 2011 Restricted Housestaff
Work Hours and Patient Handoffs
January 2012 Joint Commission Sentinel Event Alert:
Healthcare Worker Fatigue and Patient Safety
January 3, 2012 Unintended Consequences of Restricted Housestaff Hours
June 2012 June 2012 Surgeon Fatigue
November 2012 The Mid-Day Nap
November 13, 2012 The 12-Hour Nursing Shift: More Downsides
July 29, 2014 The 12-Hour Nursing Shift: Debate Continues
October 2014 Another Rap on the 12-Hour Nursing Shift
December 2, 2014 ANA Position Statement on Nurse Fatigue
August 2015 Surgical Resident Duty Reform and
Postoperative Outcomes
September 2015 Surgery Previous Night Does Not Impact
Attending Surgeon Next Day
September 29, 2015 More on the 12-Hour Nursing Shift
September 6, 2016 Napping
Debate Rekindled
April 18, 2017 Alarm
Response and Nurse Shift Duration
July 11, 2017 The
12-Hour Shift Takes More Hits
February 13, 2018 Interruptions
in the ED
April 2018 Radiologists
Get Fatigued, Too
August 2018 Burnout
and Medical Errors
September 4, 2018 The
12-Hour Nursing Shift: Another Nail in the Coffin
August 2020 New
Twist on Resident Work Hours and Patient Safety
August 25, 2020 The Off-Hours Effect in
Radiology
September 2020 Daylight
Savings Time Impacts Patient Safety?
January 19, 2021 Technology to Identify
Fatigue?
October 12, 2021 FDA Approval of Concussion
Tool Why Not a Fatigue Detection Tool?
February 2022 Does
Time of Day Matter?
Our previous columns
on the 12-hour nursing shift:
November 9, 2010 12-Hour
Nursing Shifts and Patient Safety
February 2011 Update
on 12-hour Nursing Shifts
November 13, 2012 The 12-Hour Nursing Shift: More Downsides
July 29, 2014 The 12-Hour Nursing Shift: Debate Continues
October 2014 Another Rap on the 12-Hour Nursing Shift
December 2, 2014 ANA Position Statement on Nurse Fatigue
September 29, 2015 More on the 12-Hour Nursing Shift
July 11, 2017 The
12-Hour Shift Takes More Hits
May 29, 2018 More
on Nursing Workload and Patient Safety
September 4, 2018 The
12-Hour Nursing Shift: Another Nail in the Coffin
February 9, 2021 Nursing Burnout
References:
Barger LK, Weaver MD, Sullivan JP, et al. Impact of work
schedules of senior resident physicians on patient and resident physician
safety: nationwide, prospective cohort study. BMJ Medicine 2023; 2: e000320
https://bmjmedicine.bmj.com/content/2/1/e000320
Cappuccio FP, Bakewell A, Taggart FM,
et al. Implementing a 48 H EWTD-compliant rota for
junior doctors in the UK does not compromise patients safety: assessor-blind
pilot comparison. QJM 2009; 102: 271-282
https://academic.oup.com/qjmed/article/102/4/271/1550702
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