Thursday, October 28, 2004

From the October 28th edition of The New England Journal of Medicine comes two papers and two editorials concerning the 80-hour workweek. The authors created what they called an "intervention schedule" where the interns worked no more than 16 hours at a time. The effects on the intern's fatigue and the effect it has on errors. The first: Effect of Reducing Interns' Weekly Work Hours on Sleep and Attentional Failures:
Background Knowledge of the physiological effects of extended (24 hours or more) work shifts in postgraduate medical training is limited. We aimed to quantify work hours, sleep, and attentional failures among first-year residents (postgraduate year 1) during a traditional rotation schedule that included extended work shifts and during an intervention schedule that limited scheduled work hours to 16 or fewer consecutive hours.

Methods Twenty interns were studied during two three-week rotations in intensive care units, each during both the traditional and the intervention schedule. Subjects completed daily sleep logs that were validated with regular weekly episodes (72 to 96 hours) of continuous polysomnography (r=0.94) and work logs that were validated by means of direct observation by study staff (r=0.98).

Results Seventeen of 20 interns worked more than 80 hours per week during the traditional schedule (mean, 84.9; range, 74.2 to 92.1). All interns worked less than 80 hours per week during the intervention schedule (mean, 65.4; range, 57.6 to 76.3). On average, interns worked 19.5 hours per week less (P<0.001), slept 5.8 hours per week more (P<0.001), slept more in the 24 hours preceding each working hour (P<0.001), and had less than half the rate of attentional failures while working during on-call nights (P=0.02) on the intervention schedule as compared with the traditional schedule.

Conclusions Eliminating interns' extended work shifts in an intensive care unit significantly increased sleep and decreased attentional failures during night work hours.
Would this translate into reduced errors? The paper :Effect of Reducing Interns' Work Hours on Serious Medical Errors in Intensive Care Units attempts to answer the question:
Background Although sleep deprivation has been shown to impair neurobehavioral performance, few studies have measured its effects on medical errors.

Methods We conducted a prospective, randomized study comparing the rates of serious medical errors made by interns while they were working according to a traditional schedule with extended (24 hours or more) work shifts every other shift (an "every third night" call schedule) and while they were working according to an intervention schedule that eliminated extended work shifts and reduced the number of hours worked per week. Incidents were identified by means of a multidisciplinary, four-pronged approach that included direct, continuous observation. Two physicians who were unaware of the interns' schedule assignments independently rated each incident.

Results During a total of 2203 patient-days involving 634 admissions, interns made 35.9 percent more serious medical errors during the traditional schedule than during the intervention schedule (136.0 vs. 100.1 per 1000 patient-days, P<0.001), including 56.6 percent more nonintercepted serious errors (P<0.001). The total rate of serious errors on the critical care units was 22.0 percent higher during the traditional schedule than during the intervention schedule (193.2 vs. 158.4 per 1000 patient-days, P<0.001). Interns made 20.8 percent more serious medication errors during the traditional schedule than during the intervention schedule (99.7 vs. 82.5 per 1000 patient-days, P=0.03). Interns also made 5.6 times as many serious diagnostic errors during the traditional schedule as during the intervention schedule (18.6 vs. 3.3 per 1000 patient-days, P<0.001).

Conclusions Interns made substantially more serious medical errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. Eliminating extended work shifts and reducing the number of hours interns work per week can reduce serious medical errors in the intensive care unit.
This paper describes some of the "serious medical errors" and "nonpreventable adverse events" that range from the tragic to the inane:
As intern is preparing to perform a thoracentesis on the left side of the patient’s chest, the senior resident enters the room and informs the intern that the pleural effusion is on right side of the patient’s chest.
Now JACHO recommends a "time out" for invasive procedures that prevents such things from happening.
Patient with defibrillator implanted on left side urgently needs central access for ionotropic support. Intern inserts a central venous catheter in the left subclavian vein. Not recognizing that the vein contains the wire from the defibrillator, the intern is having repeated difficulty advancing the introducer. In the middle of the placement, the cardiology fellow enters and asks the intern to abort the procedure immediately. The catheter is removed before it can interfere with or dislodge the defibrillator wire.
I'm sure the cardiology fellow did more than "ask" the intern to abort the procedure. The phrase "chewed his ass so hard that he needed a colostomy" comes to mind.
A right-sided tension pneumothorax develops after a technical error during placement of a subclavian venous catheter leads to pleural-space puncture.
It happens.
The attending physician devised a plan to transfuse a patient for a hematocrit of <30. Despite these instructions, the intern fails to check laboratory results for 36 hours. When the laboratory results are finally checked, hematocrit is found to have been 26 in the interim. The patient has tachycardia for a protracted time as a consequence.
Sounds like laziness to me. Kevin does a good job of discussing one of the editorials concerning a weak link in this process, the "check out". From the other editorial:Residency Regulations — Resisting Our Reflexes. Sounds like those in academic medicine need a playbill to keep up:
The "bad" weekend is coming up: the pre-call resident is off today, because she is on long call on Saturday and will have to come in post-call on Sunday. She also happens to be post–short call from yesterday, and her absence today means she won't be part of attending rounds when her new cases are presented. Her interns, on the other hand, are here today but will not come in post-call on Sunday; only the resident will come in, and she will round only on the new admissions from Saturday, not the rest of her service. The long-call team must cease taking admissions at 6 p.m. and leave the hospital by 9:30. Night float picks up the admissions from 6 p.m., with a second shift of night float starting at midnight. Thus, there are many more night admissions handed off to the day team on short-call days, which are beginning to resemble long-call days in heft and complexity. The short-call team that is accepting admissions today needs to present its cases to me today instead of tomorrow (in addition to the cases being presented by the resident-less team that is post–short call from yesterday), because they need to be off tomorrow because they are on long call on Sunday.
Makes my head hurt. These studies provide short-term results, but the long-range effects of the limits will take years to examine. How will residents that have worked in the "bubble" of workhour limits respond to the "real world" when such limits do not apply? Time will tell.
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