Hospitals alerted to fatigue's dangers

The Joint Commission advises hospitals to reduce the risk of drowsy doctoring and nursing. A study says work-hour rules have increased neurosurgery complications.

By Kevin B. O’Reilly — Posted Jan. 9, 2012

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The Joint Commission has issued a sentinel-event alert saying drowsy health professionals are likelier to be involved in adverse events than their well-rested counterparts. The commission advised the more than 6,500 hospitals and other health care organizations it accredits to take steps to mitigate the risks of such fatigue.

The December 2011 action comes amid more pushback against the Accreditation Council for Graduate Medical Education's resident work-hour restrictions, with research published in December 2011 linking the limitations with more complications among neurosurgery patients.

No single incident precipitated the commission's alert, said Ana Pujols-McKee, MD, the organization's chief medical officer.

"Fatigue has been recognized as an underlying, contributing factor to many events," Dr. McKee said. "We receive and review about 900 events every year that are sentinel in nature, and we recognize this is an important problem that organizations need to begin to take a closer look at."

The organization defines a sentinel event as "any process variation for which a recurrence would carry a significant chance of a serious adverse outcome." Although the alert applies to any health professional whose fatigue could harm patients, the commission highlighted research showing that nurses who work shifts longer than 12.5 hours are three times likelier to make patient care mistakes than other nurses.

"An overwhelming number of studies keep saying the same thing -- once you pass a certain point, the risk of mistakes increases significantly," said Ann Rogers, PhD, RN, a sleep-medicine expert at Emory University in Atlanta who is quoted in the alert. "We have been slow to accept that we have physical limits and biologically we are not built to do the things we are trying to do."

The commission says hospitals should make sure physicians, nurses and other health professionals do not work too many extended, consecutive shifts and give workers a chance to offer feedback on scheduling. Health care organizations also should make sure their patient hand-off procedures are safe, the alert says. When they must work long hours, doctors and nurses ought to heed fatigue-fighting tips such as engaging in active conversations with other people and what the commission calls "strategic caffeine consumption."

Many people "misuse coffee and do not understand how to use coffee," Dr. McKee said, noting that consuming caffeine while alert is ineffective. "If you drink it when you're not tired, you're going to miss out on the caffeine effect later on."

Though sentinel event alerts can sometimes serve as precedents for Joint Commission mandates, Dr. McKee said the organization wants to avoid telling hospitals exactly how to handle the problem.

"We respect the fact that the issue of fatigue is variable depending on what type of organization you're in and what type of discipline you're dealing with, whether it's a nurse or a physician or a respiratory therapist," she said. "We see this as an opportunity for us not to be prescriptive, but to engage with the organizations to come up with solutions that work for them."

Fatigue's effects disputed

The ACGME, to the consternation of some physician organizations and residency program directors, opted for a mandatory approach to the fatigue problem when it limited residents to an 80-hour workweek in 2003. Further restrictions that took effect in July 2011 limited first-year residents to 16-hour shifts.

The work-hour restrictions aimed at protecting patients may be leading to more complications, said a study in the Dec. 2, 2011, Journal of Neurosurgery. The review of morbidity and mortality rates at the University of Vermont College of Medicine neurosurgery service from 2000 to 2006 found that death rates did not change after the work-hour restrictions took effect but that complications rose, from 70 per 1,000 patients to 89 per 1,000.

"For neurosurgery, the one-size-fits-all rules don't apply," said Travis M. Dumont, MD, lead author of the study and a neuroendovascular fellow at Millard Fillmore Gates Hospital in Buffalo, N.Y. "We're delivering some data suggesting that the 80-hour workweek for our specialty is not necessarily improving care."

Dr. Dumont said neurosurgery training is impeded by work-hour limits.

"Neurosurgery requires making tough, life-or-death decisions every day, in the middle of the night at times," he said. "My fear is that you'll see 10 years from now a group of neurosurgeons who are getting this kind of training on the job, out in practice, rather than getting it during residency."

Residents today seem less committed to patient care, said Eric M. Deshaies, MD, coordinator of the neurosurgery residency program at State University of New York Upstate Medical University in Syracuse.

"I've had to strictly enforce those work-hour rules, and I've seen many changes in residents' feelings of dedication toward patients," he said. "They feel that they are shift workers now."

The rules also require increased use of hand-offs, which can endanger patients, Dr. Deshaies said.

"No matter how much you try with the use of computerized systems, you almost always have something that gets missed or is not conveyed to the incoming resident," he said.

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9 ways to give rest to the weary health care worker

In a December 2011 sentinel-event alert, the Joint Commission offered advice to help health care organizations prevent fatigue-related adverse events:

  • Review policies to ensure that they address extended work shifts and hours.
  • Assess hand-off procedures to ensure that they protect patients adequately.
  • Invite staff to take part in designing work schedules to minimize potential for fatigue.
  • Offer tips to fight fatigue, such as doing things that involve physical action, talking with other people, taking short naps and drinking coffee only when tired.
  • Educate staff about sleep hygiene and the effects of fatigue on patient safety.
  • Offer opportunities for staff to express concerns about fatigue.
  • Use a system of independent second checks for critical tasks and complex patients.
  • Consider fatigue as a potential contributing factor when reviewing all adverse events.
  • Ensure that the nap room is cool, dark, quiet and comfortable; provide eye masks and ear plugs; and let workers turn off pagers between shifts.

Source: "Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety," The Joint Commission, Dec. 14, 2011 (link)

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External links

"Sentinel Event Alert Issue 48: Health care worker fatigue and patient safety," The Joint Commission, Dec. 14, 2011 (link)

"Increased rate of complications on a neurological surgery service after implementation of the Accreditation Council for Graduate Medical Education work-hour restriction," Journal of Neurosurgery, Dec. 2, 2011 (link)

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