New resident duty-hour limits not enough: Fatigue, errors still rampant

As new duty-hour rules go into effect next week, academic hospitals may be scrambling to figure out whether updated limits on resident work hours will improve patient care. New research indicates that more sleep for residents doesn't necessarily mean better error prevention, according to an article published today in the Nature & Science of Sleep journal.

The duty-hour limits, which go into effect on July 1, fall short of creating better patient safety, according to the article authors and participants of a June 2010 conference at Harvard Medical School.

"What started as a good system has evolved into a system where the residents are extremely sleep deprived, caring for some of the sickest patients in the country, and that's a set-up for disaster," Dr. Christopher Landrigan, one of the report's authors told Reuters.

As many as 180,000 patients each year die due to harm resulting from their medical care, according to a press release.

Duty-hour limits were created, in part, based on the recommendations of the often cited 2009 Institute of Medicine report, which called for significant changes in residency training programs, particularly with shifts that last more than 16 hours without sleep.

As a result, the Accreditation Council for Graduate Medical Education (ACGME) passed rules to limit shifts of first-year residents to no more than 16 hours without sleep. However, the authors argue that the rules do not go far enough because they do not prohibit senior residents from working 28 hours consecutively.

In addition to patient safety concerns surrounding handoffs, duty-hour limits also have financial implications for teaching hospitals. Reduced resident schedules often means using other physicians to fill in, which have associated costs.

"Extensive research has shown that experience does not overcome the need for sleep," said report co-author Charles Czeisler, PhD, MD, chief of the division of sleep medicine at Brigham and Women's Hospital in Boston, in the press release. "There is no justification for maintaining unsafe work hours, other than that they're a good deal for hospitals. But they endanger patients, and they even endanger residents."

The authors recommend that resident workload requirements be redesigned so that residents spend more time on particular parts of education so other hospital professionals can handle drawing blood, maintaining paperwork, and starting IV lines. In addition, the authors recommend providing resident transportation when they are too tired to go home and include moonlighting in the work-hour limits.

For more:
- read the press release
- here's the Reuters article
- read the ACGME Common Program Requirements (.pdf)
- check out the ACGME specialty-specific duty hour definitions (.pdf)

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