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Regulating Shorter Shifts For Medical Interns May Not Reduce Errors

Shorter shifts for medical staff

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) mandated shorter shifts for first-year medical interns during their residency. They went from grueling through nearly 30 brutal hours straight to 16 per shift.

The policy was implemented in hopes of reducing fatigue and depression. It was intended to allow for more sleep and curb slip-ups made by trainees.

A recent pair of studies published in the Journal of the American Medical Association of Internal Medicine suggested this move has had the opposite influence in eliminating or reducing learning hospital errors. Instead, the regulated shifts increased the occurrence of preventable mistakes.

University of Michigan Medical School researchers analyzed surveys from 2,300 first-year residents in 51 programs in more than 12 hospital systems. Surveys were sent out in 2009, 2010, and 2011 every three months.

The questionnaire inquired to the overall well-being, mental health, sleep habits, work hours, and job performance of the first year students.

Results were compared between the interns working after the 2011 ACGME guidelines of 16-hour shifts and prior to the restriction when students labored 30 hours a shift within an 80 hour week.

None of the students reported attaining additional sleep or an improvement in overall well-being, but they did incur a slight rise in serious errors from 20 to 23 percent. In 2010, 19.9 percent of interns admitted to committing an error that ultimately harmed a patient. After the new rules took effect in 2011, limiting hours, the number increased to 23.3 percent.

Half of the mistakes reported were medication errors, 20 percent misdiagnosed ailments, another 20 percent executed the incorrect treatment, and 10 percent were surgical or procedural mistakes.

A similar investigation performed by researchers at Michigan State University suggested interruptions nearly doubled the odds of errors among hospital staff.

Dr. Srijan Sen, a University of Michigan Medical School psychiatrist and lead author the survey study, was not surprised by the results – as interns did not perform optimally after 24 straight hours nor did they execute tasks mistake-free when pressured to accomplish the same workload in less time.

The expectation of having the interns complete the same amount of work in fewer hours contributed to the blunders. Fewer errors were attributed to exhaustion and more to hurried practices. In addition, students were inadvertently limited on their educational and training opportunities with senior staff.

In another study, Dr. Sanjay V. Desai – an assistant professor of medicine at the Johns Hopkins University School of Medicine, director of the internal medicine residency program at Johns Hopkins Hospital in Baltimore, and lead author – addressed how even with a shortened number of hours per shift interns still did not attain the benefit of additional sleep. However, they did encounter a reduced number of hours in learning time. Overall patient welfare and training suffered.

Desai’s team observed different work schedules among 43 interns at Johns Hopkins Hospital. Medical interns worked either under the ACGME 2003 model of being on call every fourth night with a 30-hour shift limit, being on call every fifth night and working for 16 hours straight, or working a regular week on the night shift not exceeding 16 hours a time.

Each group maintained their respective schedule for three months and were instructed to wear a special wristwatch used to measure sleep patterns.

Desai found medical errors rose from 130 percent to 200 percent during patient hand-offs (moving from caregiver to caregiver), when using the 16-hour shift model. Overall care was so poorly executed, as a result of the shorter schedule, the controlled trial had to be terminated early.

Interns working a 30-hour shift typically had three patient hand-offs, where as those working in a 16-hour shift had an average of nine. The more hand-offs increased the odds of a possible error.

Associated hospital staff reported a better quality of patient care executed in part of the 30-hour shift group.

The 16-hour shift hindered rounds, the period during the shift where a senior physician tests trainees about their medical knowledge regarding a diagnosis and potential treatment options for patients.

The shorter shift cut the number of educational rounds, plus students were unable to follow the patients throughout the first day of hospital admission – a key time for initial tests and diagnosis.

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