Dec. 9, 2008 A new report from the Institute of Medicine proposes revisions to medical residents' duty hours and workloads to decrease the chances of fatigue-related medical errors and to enhance the learning environment for these doctors in training.
The report does not recommend further reducing residents' work hours from the maximum average of 80 per week set by the Accreditation Council for Graduate Medical Education (ACGME) in 2003, but rather reduces the maximum number of hours that residents can work without time for sleep to 16, increases the number of days residents must have off, and restricts moonlighting during residents' off-hours, among other changes.
Altering residents' work hours alone, however, is not a silver bullet for ensuring patient safety, stressed the committee of medical and scientific experts that wrote the report. The committee also called for greater supervision of residents by experienced physicians, limits on patient caseloads based on residents' levels of experience and specialty, and overlap in schedules during shift changes to reduce the chances for error during the handover of patients from one doctor to another.
Financial costs and an insufficient health care work force are the biggest barriers to further revising resident hours, the report notes. It calls for additional funding for teaching hospitals, estimating that the additional costs associated with shifting some work from current residents to other health care personnel or additional residents could be in the ballpark of $1.7 billion per year.
"Fatigue, spotty supervision, and excessive workloads all create conditions that can put patients' safety at risk and undermine residents' ability to learn," said committee chair Michael M.E. Johns, chancellor, Emory University, Atlanta. "Health care facilties can create safer conditions within the existing 80-hour limit by providing residents regular opportunities for sleep and limiting extended periods of work without rest. But these steps should be supplemented by additional efforts to improve patient safety and ensure residents get the full experience they need to safely and competently practice medicine at the end of their training."
Studies showing the detrimental effects of fatigue on human performance underlie the committee's recommendations to reduce maximum shift lengths and to increase opportunities for residents to catch up on sleep. Because no single model of scheduling fits all training facilities or medical specialties, the committee offered two options for dealing with extended shifts. Residents either could work a maximum shift of 16 continuous hours or they could work a 30-hour shift provided that they get an uninterrupted five-hour break for sleep after working 16 hours. Sleep breaks during shifts should count toward the 80-hour limit. In addition, the committee recommended:
- There should be defined off-duty periods between shifts based on the timing and duration of shifts.
- The number of mandatory days off should increase.
- Medical moonlighting by residents during their off-hours should be restricted.
Violations of the current limits on duty hours occur frequently and are underreported, the committee found. ACGME's monitoring of training hospitals' compliance with the limits should be strengthened by having more frequent visits and making them unannounced.
Residency Review Committees need to establish standards of supervision for residents. The committee found that closer resident supervision leads to fewer errors, lower patient mortality, and improved quality of care. First-year residents, in particular, benefit from careful oversight and should not be on duty without immediate access to a supervisor on the premises, the report says.
Each medical specialty needs to set specific guidelines for the number of patients that residents in different years of post-graduate training should be permitted to treat during a shift, the report adds. Only the Internal Medicine Residency Review Committee has set such guidelines. They are necessary because heavy workloads and the compression of work into fewer hours contribute to safety risks for both patients and residents.
Health care facilities should schedule an overlap of residents' schedules during shift changes to enable optimal transitions of patients' care from one team to another, the report adds. Patient handovers have been identified as among the likeliest times for errors to occur, often because of poor communication among care providers.
A major concern stemming from the 2003 duty hour regulations is the effect they have had on the availability of staff to handle teaching hospitals' caseloads and provide quality care while also providing residents with adequate supervision and training, as workloads have shifted among staffers or been compressed into shorter working hours. The committee acknowledged its recommendations will increase the number of residents, midlevel providers, and trained physicians needed to provide 24-hour coverage in training hospitals and clinics.
To implement the report's recommendations, some of the work currently performed by residents would have to be done by others. The committee estimated that the cost for additional personnel to handle reduced resident work could be roughly $1.7 billion annually. This is less than half of 1 percent of what Medicare spends on care for older Americans annually. As another IOM report on medication errors noted, the extra medical costs of treating drug-related injuries occurring in hospitals conservatively amount to $3.5 billion a year.
The study was sponsored by the U.S. Agency for Healthcare Research and Quality. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.
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