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Work-hour limits found to create little respite for residents

Researchers saw no changes in total hours of work and sleep among housestaff studied.

By Kathleen Phalen Tomaselli amednews correspondent — Posted Sept. 1, 2008

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Imposed work-hour limits offer little relief for residents contending with around-the-clock patient care, early-morning rounds and time-devouring handoffs, according to a study published in the August Pediatrics.

The study of 220 residents at three pediatric hospitals found that total hours of work and sleep did not change after application of work-hour limits by the Accreditation Council for Graduate Medical Education. In 2003, the ACGME set limits at 24 to 30 hours per shift and 80 hours per week.

Rates of medication errors and resident depression and injuries did not change from 2003 to 2004, according to the study of daily reports of resident work and sleep hours, and a review of medication errors.

"The ACGME continues to allow 24 to 30 continuous hours, and shaving a bit off a shift has no effect," said study lead author Christopher P. Landrigan, MD, MPH, of Children's Hospital in Boston.

Citing previous research, Dr. Landrigan pointed to an increased risk for patients and residents as work hours surpass 16 hours. There is an increased risk of medical errors, serious diagnostic errors and needlestick injuries, he said.

"The U.S. lags behind other countries. In New Zealand, physicians are limited to 16 hours, and in Europe, 13," he said.

ACGME officials said the study was well-designed but they raised concerns that the data used from 2003-04 were old. An ACGME 2006-07 survey indicates that work hours have been reduced: 94% of the 58,602 residents surveyed said they always or usually meet the ACGME's requirements for duty hour limits.

In addition, the ACGME has issued more citations for noncomplicance of hour limits since the study ended. For example, there were 101 citations in 2003-04; in 2006-07, there were 227.

"If there is an indication of noncompliance we send a letter and follow with a site visit," said Ingrid Philibert, PhD, senior vice president of field activities for the ACGME. "If there is an egregious violation it could mean the loss of accreditation."

While extended shifts for residents have routinely been the norm, "Some of our research suggests that extended work hours may contribute to a significant increase in fatigue-related preventable adverse events," said William B. Munier, MD, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. "We need to focus on optimizing work schedules to create a care environment that is safe for patients, residents and other health workers."

Nonetheless, a study in the July 23, 2007, Archives of Internal Medicine showed that 87% of clinical faculty thought the new 80-hour work week compromised continuity of care.

"It's more complex than duty hours," said Theodore C. Sectish, MD, a site director for the Pediatrics study and program director of the pediatric residency program at Children's Hospital in Boston. "We need to look at [patient] handoffs. These are difficult, given the complexity of patients. We've got to be more creative."

According to Dr. Sectish, some programs at Children's Hospital are trying to change. Critical care fellows are limited to shorter shifts (12 to 14 hours), and the clinical oncology rotation is trying to reduce the number of extended shifts.

During the American Medical Association's June meeting, delegates voiced concerns about duty-hour restrictions. The AMA supports the 80-hour limit. AMA policy says resident duty hours must not be excessive and the structuring of duty hours and on-call schedules must focus on the needs of patients, continuity of care and residents' educational needs.

This fall, the Institute of Medicine will release a report with tactics for resident work schedules.

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