Commentary: Improving Patient Safety in Teaching Hospitals by Modifying Residents’ Work Hours
This work was partly supported by HSR&D. Drs. Volpp and Landrigan are part of HSR&D’s Center for Health Equity Research and Promotion.
At the request of Congress, an Institute of Medicine committee is reviewing the evidence on the relationship between residents’ work hours and patient safety, and will develop recommendations for improvement. This is the result of increasing evidence that indicates residents’ sleep deprivation endangers patients and residents. Moreover, studies have not shown consistent benefit from the implementation of current reduced duty-hour standards, though some reductions in mortality were observed at VA hospitals. This Commentary proposes priorities that can guide the medical community in developing specific alternatives for regulating physician work hours that could maximize patient and physician safety while preserving the best possible training for physicians.
- The authors propose 8 guiding principles and note that work schedule reform should use the best scientific evidence to devise an optimal system.
- Rigorously study alternatives for work hour reduction: Randomized trials comparing the effectiveness and cost-effectiveness of approaches to work hour reduction versus the status quo (e.g., 16- to 18-hr shift limits vs. 24-hr shifts) would be of particular value.
- Measure outcomes related to resident education: The effects of different work hour reduction strategies on long-term educational outcomes need to be assessed.
- Improve “sign-out” procedures: This could substantially improve the safety of the health care system, regardless of the approach to duty hour reform.
- Eliminate or minimize situations in which residents work continuously for 24-30 hours: After 24 hours of being awake, impairments in performance are similar to having a blood alcohol level of 0.10%.
- Improve monitoring of standards: Monitoring and enforcing duty hour standards through a third-party mechanism would greatly enhance the ability to ascertain compliance and effectiveness.
- Increase flexibility for implementation and enforcement: The flexibility of enforcement methods (e.g., rewards vs. penalties) are important and should be accelerated.
- Recognize the importance of supervision and work intensity: With inadequate supervision or insufficient support staff, residents may try to fit more work into less time.
- Align incentives for payment with desired objectives: An incentive-based approach would encourage programs to be innovative rather than simply meeting current standards.
Volpp K, Landrigan C. Building Physician Work Hour Regulations from First Principles and Best Evidence. JAMA September 10, 2008;300(10):1197-99.