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A Bridge too Far: A Critique of the New ACGME Duty Hour Requirements

2011; Elsevier BV; Volume: 125; Issue: 1 Linguagem: Inglês

10.1016/j.amjmed.2011.10.002

1555-7162

Joseph S. Alpert, William H. Frishman,

Healthcare Policy and Management

SEE RELATED ARTICLE p. 104 SEE RELATED ARTICLE p. 104 The issue of resident work hours has been discussed extensively for more than 25 years.1Asken M.J. Raham D.C. Resident performance and sleep deprivation: A review.J Med Ed. 1983; 58: 382-388PubMed Google Scholar, 2Friedman R.C. Bigger J.T. Kornfeld D.S. The intern and sleep loss.N Engl J Med. 1971; 285: 201-203Crossref PubMed Scopus (255) Google Scholar, 3American College of Physicians: Working conditions and supervision for residents in internal medicine programs: Recommendations.Ann Int Med. 1989; 110: 657-663Crossref PubMed Scopus (34) Google Scholar, 4Asch D.A. Parker R.M. The Libby Zion Case—One step forward and two steps backward?.N Engl J Med. 1988; 318: 771-775Crossref PubMed Scopus (364) Google Scholar, 5McCall T. The impact of long working hours on resident physicians.N Engl J Med. 1988; 318: 775-778Crossref PubMed Scopus (109) Google Scholar, 6Levinsky N.G. Compounding the error.N Engl J Med. 1988; 318: 778-780Crossref PubMed Scopus (25) Google Scholar, 7Glickman R.M. House staff training—The need for careful reform.N Engl J Med. 1988; 318: 780-782Crossref PubMed Scopus (38) Google Scholar, 8Lockley S.W. Cronin J.W. Evans E.E. Cade B.E. Lee C.J. Landrigan C.P. et al.Effect of reducing interns' weekly work hours on sleep and attentional failures.N Engl J Med. 2004; 351: 1829-1837Crossref PubMed Scopus (748) Google Scholar, 9Landrigan C.P. Rothschild J.M. Cronin J.W. Kaushal R. Burdick E. Katz J.T. et al.Effect of reducing intern's work hours on serious medical errors in intensive care units.N Engl J Med. 2004; 351: 1838-1848Crossref PubMed Scopus (1409) Google Scholar, 10Mukherjee S. A precarious exchange.N Engl J Med. 2004; 351: 1822-1824Crossref PubMed Scopus (65) Google Scholar, 11Schuberth J.L. Elasy T.A. Butler J. Greevy R. Speroff T. Dittus R.S. et al.Effect of short call admissions on length of stay and quality of care for acute decompensated heart failure.Circulation. 2008; 117: 2637-2644Crossref PubMed Scopus (23) Google Scholar Errors and signs of sleep deprivation in residents have been catalogued in a few single institution studies with a limited number of residents and a modest number of observations.5McCall T. The impact of long working hours on resident physicians.N Engl J Med. 1988; 318: 775-778Crossref PubMed Scopus (109) Google Scholar, 8Lockley S.W. Cronin J.W. Evans E.E. Cade B.E. Lee C.J. Landrigan C.P. et al.Effect of reducing interns' weekly work hours on sleep and attentional failures.N Engl J Med. 2004; 351: 1829-1837Crossref PubMed Scopus (748) Google Scholar, 9Landrigan C.P. Rothschild J.M. Cronin J.W. Kaushal R. Burdick E. Katz J.T. et al.Effect of reducing intern's work hours on serious medical errors in intensive care units.N Engl J Med. 2004; 351: 1838-1848Crossref PubMed Scopus (1409) Google Scholar, 11Schuberth J.L. Elasy T.A. Butler J. Greevy R. Speroff T. Dittus R.S. et al.Effect of short call admissions on length of stay and quality of care for acute decompensated heart failure.Circulation. 2008; 117: 2637-2644Crossref PubMed Scopus (23) Google Scholar The results have been contradictory with some studies showing fewer errors with more mandated sleep time and one recent study showing increased length of stay and lower quality of care for patients with shorter duty shifts.8Lockley S.W. Cronin J.W. Evans E.E. Cade B.E. Lee C.J. Landrigan C.P. et al.Effect of reducing interns' weekly work hours on sleep and attentional failures.N Engl J Med. 2004; 351: 1829-1837Crossref PubMed Scopus (748) Google Scholar, 9Landrigan C.P. Rothschild J.M. Cronin J.W. Kaushal R. Burdick E. Katz J.T. et al.Effect of reducing intern's work hours on serious medical errors in intensive care units.N Engl J Med. 2004; 351: 1838-1848Crossref PubMed Scopus (1409) Google Scholar, 11Schuberth J.L. Elasy T.A. Butler J. Greevy R. Speroff T. Dittus R.S. et al.Effect of short call admissions on length of stay and quality of care for acute decompensated heart failure.Circulation. 2008; 117: 2637-2644Crossref PubMed Scopus (23) Google Scholar Over recent years, resident on-call duty hours spent in the hospital have been progressively reduced in response to requirements imposed by the Accreditation Council for Graduate Medical Education (ACGME), a non-governmental regulatory agency. These mandated changes in residency hours are being strictly enforced even though there is a remarkable paucity of outcomes data supporting these new rules. This year, the rules have become so stringent that they have forced training programs into what we and many others think may be a detrimental and dangerous situation for our patients. The number of consecutive hours and the number of patients that can be seen in a 24-hour period have been so restricted that many, if not most, patients admitted by residents are subjected to multiple physician changes during their first 24 hours in the hospital. This process of multiple patient hand-offs reminds me (JA) of what an old friend who was a high school football coach once told me: "The more hand-offs that are called for in a single play, the more likely there will be fumbles." We are convinced that this is now the situation on the in-patient services of all US post-graduate hospital training programs. We have yet to speak with anyone involved in resident training in any specialty that supports the new highly restrictive on-call hour requirements. Surgical faculty are particularly disturbed by shift work in the operating room. These colleagues and professional acquaintances are convinced that the new system will inevitably lead to many "fumbles" with increased likelihood of patient harm. Like many of the current readers of The American Journal of Medicine, we trained in a very different era when residents spent 36 out of every 48 hours in the hospital taking care of in-patients. Please do not misunderstand us: we are not calling for the return of this form of cruel and unusual punishment in our training programs. What we are calling for are studies to examine the impact of the currently mandated system in comparison to what was required just 1 year ago. At that time residents were allowed to work only 80 hours per week, spending every 5th night in the hospital. In addition, residents were allowed to remain in the hospital, taking continuous on-call, for a maximum of 30 hours. In my opinion, this system allowed ample time off from call to recover from the 30-hour stint in the hospital. Why have we seen this continuing pressure from the ACGME to restrict resident on-call time in the hospital? What data or studies support this curtailment of duty hours? Primarily, the information supporting duty hour restrictions comes from a limited number of studies of residents on call taken together with an extensive literature resulting from studies of airline pilots and long-haul truck drivers who work long and continuous hours at night. Sleep deprivation in these individuals was shown to impair their judgment and their performance. It is alleged that residents performing long on-call shifts in the hospital are subject to the same sleep deprivation with resultant error-prone performances. The small number of studies in residents mentioned earlier were all unblinded, performed in single institutions, and involved a limited number of observations of patient outcomes. In this issue of the Journal, Mueller et al report multi-center survey data provided by 169 hospitals that have internal medicine residency training programs. They found that "variations in resident workload are not associated with differences in quality of care, readmission, or mortality rates for common inpatient diagnoses."12Mueller S.K. Call S.A. McDonald F.S. Halvorsen A.J. Schnipper J.L. Hicks L.S. Impact of resident workload and handoff training on patient outcomes.Am J Med. 2012; 125: 104-110Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar In the current era of evidence-based medicine, in order to make major policy decisions, more studies are needed. 8Lockley S.W. Cronin J.W. Evans E.E. Cade B.E. Lee C.J. Landrigan C.P. et al.Effect of reducing interns' weekly work hours on sleep and attentional failures.N Engl J Med. 2004; 351: 1829-1837Crossref PubMed Scopus (748) Google Scholar, 9Landrigan C.P. Rothschild J.M. Cronin J.W. Kaushal R. Burdick E. Katz J.T. et al.Effect of reducing intern's work hours on serious medical errors in intensive care units.N Engl J Med. 2004; 351: 1838-1848Crossref PubMed Scopus (1409) Google Scholar, 11Schuberth J.L. Elasy T.A. Butler J. Greevy R. Speroff T. Dittus R.S. et al.Effect of short call admissions on length of stay and quality of care for acute decompensated heart failure.Circulation. 2008; 117: 2637-2644Crossref PubMed Scopus (23) Google Scholar In addition, we reject the analogy of observations made on airline pilots and truck drivers as models for medical residency duty hour modeling. There is a huge difference between sitting in a small, darkened enclosure surrounding by continuously droning noise and long stretches of monotony. The situation for the resident on-call is the opposite of the situation for the pilot or truck driver: the hospital is fully lighted, there is constant stimulation and interaction with patients, nurses, pharmacists, and technicians, and there is continuous demand for intellectual decision-making. All of these factors contribute to a state of wakefulness that makes sleepiness and incorrect judgment much less likely compared with the aviation and highway situation. Unfortunately, as already noted, there is a paucity of scientifically rigorous, controlled study of sleep deprivation in residents who are on-call in the hospital. What is clearly required are a number of carefully controlled, randomized, long-term studies of different resident on-call schedules with errors committed as the primary outcome being evaluated. We would like to suggest the following multicenter trial to produce the information we need in order to set requirements for the number of hours that residents spend in the hospital on-call. Large numbers of US training hospitals would participate in this study and would be randomly assigned to 1 of 2 duty hour protocols. This experiment would last for 2 years and would monitor the number and the seriousness of any medical errors committed when residents were assigned to one of these 2 duty hour regimens: A. The currently mandated duty hour schedule and, B. The formerly employed, every 5th night on-call schedule. In this protocol, half the hospitals would use program A the first year followed by program B in the second year while the other half of the hospitals would start with program B during the first year and then switch to program A during the second year. An independent events committee would monitor patient charts for error events and would be blinded as to which program was being employed at the time of a patient's admission to the hospital. At the end of 2 years, it would be possible to compare the total number of medical errors that had occurred with the 2 systems as well as the severity of the errors with any potential harm to patients. At that point, it would be possible to select the duty hour training schedule that led to the least number of errors. Such studies also could be repeated in the future using other novel and innovative resident duty call schedules in an attempt to arrive at the best solution to this vexing issue in resident training. In current medical training and practice, we always attempt to make medical care as evidenced-based as possible. Why are we not doing the same thing with respect to resident duty hours? We look forward to responses to this editorial on our blog at http://amjmed.blogspot.com. Damage and Duty Hours? A Proposal for Further StudyThe American Journal of MedicineVol. 125Issue 10PreviewThe editorial "A Bridge Too Far: A Critique of the New ACGME Duty Hour Requirements"1 addressed recent changes in duty hour requirements. As a second-year medical resident in a system with q3 and q4 call on wards and intensive care units, I understand your concern that duty hour reduction leads to multiple handoffs and increased chance of errors. I share your concern that changes may mean reduced exposure to a broad range of medical and surgical conditions. Full-Text PDF