The August issue of “The Hospitalist” has some good resources about scheduling hospitalists’ workshifts. Of course, the advice probably applies equally well to scheduling shift work of any healthcare worker.
An audio interview (Henkel 2011a) with Christopher P. Landrigan, director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital has some really good points about the effects of shiftwork on mistakes and patient safety. He stresses that you don’t want to schedule someone to work too many nights in a row, citing literature from multiple industries that shows error rates go up with consecutive nights worked. Our November 9, 2010 Patient Safety Tip of the Week “study on shift workers in fields other than healthcare ( ”cited a Folkard 2003) which showed that the risk of incidents increased each consecutive day worked. For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%).
So Landrigan says that it is probably better to schedule hospitalists for only 3-4 days of night shifts rather than the more popular 7days on/7 days off pattern.
He also discusses the biology of circadian rhythms and notes the importance of taking a 1.5-2.0 hour nap on the afternoon prior to working the first night shift and that working a day shift immediately after a night shift is not a good idea. He discusses how working consecutive night shifts adds to the burden of sleep deprivation, which ultimately has a role in the occurrence of mistakes and errors. When asked about “nocturnists”, he does note that some people have been able to alter their circadian rhythms to accommodate chronic night shift work. But he cautions that when such people take vacations their bodies return to a “day” circadian rhythm and there may be problems when they return to the night shift pattern.
Not only are too many consecutive night shifts potentially dangerous to patients, they are dangerous to the healthcare workers themselves. In the second article (Henkel 2011b) Landrigan notes “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”
The latter article also has good advice from John Krisa, medical director of an Albany, NY-based hospitalist group. He avoids 50-50 parceling out of night and day shifts for his hospitalists and uses per diem hospitalists and moonlighters to cover some of the night shifts. That leaves a core of regular hospitalists to provide continuity during the day shifts. Such continuity is likely to garner increased scrutiny after the recent publication of an article (Kuo 2011) showing that patients cared for by hospitalists have shorter lengths of stay but more readmissions and, ultimately, higher overall costs than patients followed in hospital by their primary care physician.
These are some good bits of wisdom. The whole field of managing the biology of shiftwork is just beginning to focus on healthcare.
Henkel G. ONLINE EXCLUSIVE: How to minimize the adverse affects of working night shifts. The Hospitalist. August 2011
Henkel G. ONLINE EXCLUSIVE: Scheduling Rules of Thumb. Safety, equality should factor into HM groups’ coverage plans. The Hospitalist. August 2011
Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101
Kuo Y-F, Goodwin JS. Association of Hospitalist Care With Medical Utilization After Discharge: Evidence of Cost Shift From a Cohort Study. Ann Intern Med 2011; 155: 152-159