Residents doubt work-hour limits benefit patient safety

Two new studies say limits placed on resident work hours in 2011 may need to be tweaked to foster the safer learning and patient care environments these rules set to create.

Limits on resident work hours — particularly a 2011 rule that allows first-year interns to work only 16 consecutive hours instead of the previous 30 hours — resulted in more self-reported medical errors, according to a University of Michigan Medical School study published online March 25 in JAMA Internal Medicine, formerly Archives of Internal Medicine.

The limits also resulted in a perception that the quality of care deteriorated and documentation that more patient handoffs occurred, something shown to increase errors, said a study by the Johns Hopkins University School of Medicine that also was published online March 25 in JAMA Internal Medicine.

The studies found that the extra sleep residents got as a result of working fewer hours did not seem to be significant, depression rates were not significantly reduced and time for learning was less under the new rules. Authors of both studies say further research is needed.

“Ultimately, we need to create a safe environment,” said Sanjay V. Desai, MD, lead author of the Johns Hopkins study. He is assistant professor of medicine at the Johns Hopkins University School of Medicine in Baltimore, and director of the internal medicine residency program at Johns Hopkins Hospital.

The Accreditation Council for Graduate Medical Education said it will incorporate the findings into an ongoing review of its standards.

“These results must be melded with results from other studies that examine other dimensions of the question, or which demonstrate differing results,” said Thomas Nasca, MD, CEO of the ACGME. “They provide valuable insight into certain dimensions of the ongoing discussion within and outside the profession related to resident education, sleep, well-being and patient care delivery.”

However, Dr. Nasca said the studies do not “address other relevant questions, such as supervision by faculty and senior residents, actual clinical outcomes, preparedness of entering interns for the duties assigned, and other dimensions of the learning environment that are relevant to the complex interactions inherent in the teaching and learning environment.”

Shifting the workload

Researchers found that the percentage of residents reporting an error that harmed a patient increased to 23.3% after the new rules took effect, up from 19.9% who reported an error the year before the rules took effect.

The University of Michigan study looked at more than 2,300 first-year residents at more than a dozen hospital systems nationwide.

“I was surprised. Going into it, I would have expected a reduction in errors,” said Srijan Sen, MD, PhD, study lead author and a psychiatrist at the University of Michigan Medical School.

He said “work compression” may be to blame. “Most hospitals didn't have additional funds or resources to cover the work interns do. They were asked to do the same amount of work in shorter hours,” Dr. Sen said.

Authors of a commentary accompanying the JAMA Internal Medicine studies agreed.

“Residents still perform most of the work but are now racing the clock. … In focusing on work hours rather than workload, the ACGME — under intense pressure from many groups, both within and outside medicine — treated the symptom, not the disease,” Lara Goitein, MD, a Santa Fe, N.M., diagnostic radiologist and Kenneth M. Ludmerer, MD, an internist in St. Louis, wrote in their commentary.

The authors, acknowledging that changes would be costly and face substantial hurdles, said training programs need to address residents' workloads directly.

“First, resident positions should be increased to reduce resident work intensity, which would simultaneously address the perceived national shortage of physicians,” the authors said. “Second, administrators of teaching hospitals should shift service burden from residents to nonresident providers in settings of high work intensity.”

Trouble with patient handoffs

The Johns Hopkins study found that patient handoffs among residents increased to as many as nine handoffs for those working 16-hour shifts, up from three handoffs for those working 30 hours straight.

“The more handoffs that occur, the greater the chance for errors,” said Dr. Desai, who trained 15 years ago, before any resident work hour rules were adopted.

In the months before the new 2011 rules took effect, Dr. Desai and his colleagues compared three work schedules. Some residents worked a pre-2011 schedule, on call every fourth night with a 30-hour limit on consecutive hours. Two other groups worked under the new rules: one group was on call every fifth night but worked only 16 hours straight; a second group worked a night float schedule that required working a regular week on the night shift, not more than 16 hours per shift.

Under the 30-hour limit, there were fewer handoffs. Dr. Desai said interns and nurses perceived a higher quality of care. The night float model was eliminated before the study was over because there was such a large number of people who believed the quality of care had declined.

Dr. Desai worries about the impact a 16-hour limit could have on the training of future physicians.

“The first 24 hours after someone is admitted to the hospital is important to training,” he said. “It is difficult to see how a patient gets better if you are not there to see the process of how they get better.”

He said residency programs need flexibility to design schedules that work best for training and patient safety at their institution.

The commentary authors agreed. They said the ACGME could immediately remove absolute restrictions on shift length and instead limit the weekly average hours and call frequency: “Although some longer shifts would be permitted, in our view the restoration of continuity of care would be worth it.”