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Revised Hours and Workloads for Medical Residents Needed to Prevent
Fatigue-Related Mistakes, But Altering Hours Alone No Guarantee of Patient Safety
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,
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
Additional information on Resident Duty Hours: Enhancing Sleep, Supervision, and Safety can be found at http://www.iom.edu/residenthours. Copies of the report are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.nap.edu. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above). In addition, a podcast of the public briefing held to release this report is available at http://national-academies.org/podcast.
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[ This news release and report are available at http://national-academies.org ]
Board on Health Care Services
Committee on optimizing graduate medical trainee (resident) Hours
and work schedules to improve patient safety
Michael M.E. Johns, M.D. (chair)
James P. Bagian, M.D.
Chief Patient Safety Officer and Director
Jayanta Bhattacharya, M.D., Ph.D.
Assistant Professor of Medicine
Center for Primary Care Outcomes Research
Maureen Bisognano, M.S., R.N.
Executive Vice President and Chief Operating Officer
Institute for Healthcare Improvement
Pascale Carayon, Ph.D.
Procter & Gamble Bascom Professor in Total Quality
Department of Industrial and Systems Engineering, and
Center for Quality and Productivity Improvement
Jordan J. Cohen, M.D.
Professor of Medicine and Public Health
David F. Dinges, Ph.D.
Professor and Chief
Division of Sleep and Chronobiology
Department of Psychiatry
Javier A. Gonzalez
Professor of Pediatrics and Director
Pediatric Residency Programs
Peter J. Kolesar, Ph.D.
Professor Emeritus and Research Director
Brian W. Lindberg, M.A.
Consumer Coalition for Quality Health Care
Kenneth Ludmerer, M.D., M.A.
Professor of Medicine and History
Daniel Munoz, M.D., M.P.A.
Division of Cardiology
Christopher Parshuram, M.B.Ch.B., D.Phil.
Center for Safety Research; and
Department of Critical Care Medicine
Hospital for Sick Children, and
Departmemts of Pediatrics, Health Policy Managementl, and Evaluation
Ann E. Rogers, Ph.D.
Denise M. Rousseau, Ph.D.
H. J. Heinz II Professor of Organizational Behavior and Public Policy, and
Project of Evidence-Based Organizational Practices
Eduardo Salas, Ph.D.
Pegasus Professor of Psychology and University Trustee Chair
Institute for Simulation and Training
Bruce Siegel, M.D., M.P.H.
Center for Health Care Quality
Cheryl Ulmer, M.S.
Dianne Wolman, M.G.A.