It is common for medical interns to work beyond the recently implemented work-hour limits and be at increased risk for job-related injuries such as needlesticks and cuts, which were associated with longer hours and fatigue, according to two studies in the September 6 issue of JAMA, a theme issue on medical education.
Exposures to contaminated fluids from percutaneous (through the skin) needlesticks and lacerations are serious hazards associated with postgraduate medical training. These injuries may result in the transmission of blood-borne pathogens, including hepatitis and human immunodeficiency viruses, and thus have significant occupational health implications, according to background information in the article. Factors contributing to the occurrence of these percutaneous injuries (PIs) in physicians have not been well studied.
Najib T. Ayas, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues examined the contributing factors for PIs in interns and assessed their relationship to extended-duration work. The study included Web-based surveys of self-reported percutaneous exposures from 2,737 of the estimated 18,447 interns in U.S. postgraduate residency programs from 2002 to 2003. Each month, comprehensive Web-based surveys asked about work schedules and the occurrence of PIs in the previous month.
From a total of 17,003 monthly surveys, 498 PIs were reported. Of these, 294 were due to lacerations from a sharp instrument (such as a scalpel), and 204 were due to a needlestick. Rates of injuries varied significantly, depending on type of residency. Interns in surgery and obstetrics/gynecology residency programs had the greatest risk, presumably because they perform more invasive procedures than other specialties.
In 90 percent of the 498 injuries, 1 or more factors contributing to the incident were reported. The most commonly reported contributing factor was a lapse in concentration (63.8 percent of the incidents), followed by fatigue (31.0 percent of the incidents). Percutaneous injuries were more frequent during extended work compared with nonextended work. Extended work injuries occurred after an average of 29.1 consecutive work hours; nonextended work injuries occurred after an average of 6.1 consecutive work hours. The rate of PI was twice as high during the nighttime than during the daytime.
"The association of these injuries with extended work duration is likely due to the adverse cognitive effects of the sleep deprivation associated with such extended work, consistent with experimental data," the authors write.
"Given the potentially serious consequences of such injuries, implementation of safety measures designed to reduce the risk of these occupational injuries should be undertaken. The impact of comprehensive fatigue management programs on the risk of these occupational exposures should be evaluated," the researchers conclude.
Most Medical Interns Report Non-Compliance With Work-Hour Limits
More than 80 percent of medical interns surveyed in 2003-2004 indicated they were working hours in excess of what is currently mandated, according to a study in the September 6 issue of JAMA.
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented work hour limits for all physicians-in-training (residents) in the United States, according to background information in the article. Each trainee is limited to a maximum of 30 consecutive work hours, a maximum of 80 weekly work hours, averaged over 4 weeks, and 1 day in 7 (averaged over 4 weeks) must be free of all duties. These limits were developed in response to national concern with the long work hours of residents.
Christopher P. Landrigan, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues conducted a study to estimate the frequency with which interns (first-year residents) were compliant with the ACGME duty hour standards in the first year following implementation. The study consisted of monthly Web-based surveys to assess the work hours and sleep of 4,015 interns, conducted pre-implementation of ACGME standards (July 2002 through May 2003) and post-implementation (July 2003 through May 2004). Participants completed 29,477 reports of their work and sleep hours.
In the year following implementation of ACGME standards, 83.6 percent of participating interns reported work hours that were noncompliant during at least 1 month. Hours in violation of the duty hour standards were reported during 44.0 percent of the monthly reports received postimplementation; 61.5 percent of the months during which interns' worked exclusively in hospital settings contained reported hours in violation of the standards. Over the year, monthly rates of noncompliance decreased from 48.8 percent to 38.0 percent. Comparing postimplementation to preimplementation, average weekly work hours decreased 5.8 percent, from 70.7 hours to 66.6 hours.
Working shifts greater than 30 consecutive hours was reported by 67.4 percent of interns. Averaged over 4 weeks, 43.0 percent reported working more than 80 hours weekly, and 43.7 percent reported not having 1 day in 7 off work duties. Postimplementation, average sleep duration increased 6.1 percent (22 minutes), however, reported average sleep during extended shifts decreased 4.5 percent.
The researchers write that there are several reasons why rates of noncompliance may have remained high. "First, the ACGME duty hour standards were unaccompanied by financial and technical support. Programs may not have the resources or expertise to redesign their schedules to the extent required. In addition, house officers are typically unwilling to depart precipitously at the scheduled change of shift when an emergent patient care situation demands their continued presence. Such situations are common in high intensity settings, yet most scheduling systems do not account for these commonplace emergencies."
Commentary: High-Quality Learning for High-Quality Health Care
In an accompanying commentary, David C. Leach, M.D., and Ingrid Philibert, M.H.A., M.B.A., of the Accreditation Council for Graduate Medical Education, Chicago, discuss the larger issues of medical residents' learning environment.
"The academic community continues to contribute to the debate about resident duty hours and the broader elements of the learning environment to work toward ensuring high-quality learning for high-quality health care. Accreditation is not static; examples of programs and institutions that have successfully modified their patient care and learning environments inform the development of standards and enable the dissemination of new approaches to the problem of delivering safe and effective care in an environment that fosters good learning."
"Professional standards suited to multidisciplinary teams, handoffs, and shift-based approaches to care are emerging and need further refinement; some of this is occurring already," the authors write. "High-quality learning is impossible in the absence of high-quality patient care; likewise, high-quality patient care is impossible without high-quality learning. Attention to both is needed."
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