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7
Strategies to Reduce Fatigue Risk
in Resident Work Schedules
The scientific literature makes clear that risks of fatigue-related errors and
accidents derive from multiple interacting variables of work and sleep.
This chapter discusses the literature on sleep and human performance and
recommends specific adjustments to the current Accreditation Council for
Graduate Medical Education (ACGME) resident duty hours to enhance
the prevention and mitigation of resident fatigue as an unsafe condition,
thereby improving performance and the safety of both patients and resi-
dents. The major rationales for the recommendations are the following:
() work duration should be limited because human performance degrades
after hours of wakefulness whether one is working or not; () suffi-
cient time for sleep needs to be incorporated into daily and weekly work
schedules to prevent acute and chronic sleep deprivation, respectively, and
to allow recovery from accumulated sleep debt; and () when extended
duty periods are considered an essential aspect of resident training and
continuity of care, a protected sleep period should be provided during that
period to reduce the effects of acute sleep loss and to enhance performance.
Because of the diversity of specialty and hospital needs, the committee
leaves some flexibility for programs, but urges that adequate protected
sleep periods be maintained, and that fatigue prevention and mitigation be
a matter of professionalism that requires attention by residents, attending
physicians and all those charged with maintaining patient safety.
The consensus committee was charged by the Agency for Healthcare
Research and Quality (AHRQ) to “1) synthesize current evidence on medi-
cal resident schedules and healthcare safety and 2) develop strategies to
enable optimization of work schedules to improve safety in the healthcare
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RESIDENT DUTY HOURS
work environment.” This chapter deals with scientific evidence that fatigue
is an unsafe condition that can occur relative to the timing and duration
of work and sleep opportunities, which are fundamental components of
residents’ schedules. The chapter reviews scientific literature on fatigue, its
consequences, and its prevention, and provides recommendations and evi-
denced-based justifications for ways to reduce fatigue as a safety risk while
residents are training intensively by working long hours.
Many of the recommendations focus on ensuring residents obtain ad-
equate sleep, which research has shown is among the most fundamental
biological needs, to counter fatigue and promote learning and memory. The
focus on resident fatigue prevention in the recommendations for duty hour
adjustments in the latter sections of this chapter is a response to AHRQ’s
charge that the committee develop strategies to enable optimization of work
schedules to improve safety in the healthcare work environment. Other
chapters in this report recommend additional ways in which safety can be
enhanced through supervision, appropriate workload, teamwork, and sys-
tem changes. This chapter takes an evidenced-based approach to developing
recommended changes in only those aspects of resident duty hours that are
most likely to result in fatigue as an unsafe condition that can pose risks
to both patients and residents. Thus, to retain the training value and flex-
ibility in scheduling required by different specialties and rotations within
specialties, while preventing and mitigating sleep loss that contributes to
fatigue-related errors and accidents, the recommendations derived from
this chapter relative to duty hours are focused more on providing predict-
able and protected time for sleep and recovery sleep than on limiting total
work hours.
FATIGUE, WORK HOURS, AND SLEEP LOSS
In healthy individuals, fatigue is a general term used to describe feelings
of tiredness, reduced energy, and the increased effort needed to perform
tasks effectively and avoid errors. It occurs as performance demands in-
crease because of work intensity and work duration, but it is also a prod-
uct of the quantity and quality of sleep and the time of day work occurs
(Dinges, 2001). All of these factors are relevant aspects of residency train-
ing duty hours (Buysse et al., 2003). Some current aspects of resident duty
hours can interfere with normal sleep patterns and lead to sleep depriva-
tion, with the extent of this deprivation differing according to the workload
demands and schedule of each residency specialty.
Risks of fatigue-related errors and accidents in relation to work sched-
ules derive not from the single factor of the total hours of work in a week,
but from multiple interrelated and interacting aspects of work, rest, and
sleep. These include but are not limited to (1) the duration of work peri-
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STRATEGIES TO REDUCE FATIGUE RISK
ods within a single day and over time, (2) the time of day at which work
occurs, (3) variation in the timing of work within and between weeks, (4)
the duration of sleep obtained on work days and on non-work days, (5)
the frequency and duration of days off from work, (6) the different vulner-
abilities of workers to fatigue from these factors, and (7) the volume and
intensity of work (Dinges, 1995; Drake et al., 2004; Folkard et al., 2005;
Rosa, 2001; Van Dongen, 2006). It is not surprising that concern about
the negative effects of sleep deprivation on residents is one of the primary
reasons duty hour restrictions have been implemented by the Accreditation
Council for Graduate Medical Education (ACGME, 2003).
This chapter contains a synthesis of the current evidence about fatigue,
performance, and safety risks posed by different work-rest-sleep factors
applicable to current ACGME duty hour rules and possible adjustments to
those rules. First, the chapter focuses on acute sleep deprivation and ways
to prevent the development of acute sleep loss (e.g., shorter duty periods)
or ways to mitigate the effects of acute sleep loss by use of sleep during
extended duty periods that may be required for patient care and education.
The chapter then examines ways to prevent and address the accumulation
of chronic partial sleep loss in residents. After reviewing this evidence, the
committee proposes strategies to enable optimization of resident work
schedules to improve safety in the healthcare work environment while tak-
ing into account the learning and experience that residents must achieve
during their training.
NEED FOR SLEEP
A sizeable scientific literature exists on the extent to which preventing
fatigue, and its associated cognitive performance deficits, depends heavily
upon the extent to which acute (daily) and chronic (weekly) sleep needs
are met. Moreover, reviews of the risks posed by residency duty hours
have emphasized that prevention of sleep deprivation in residents is the
most important way to reduce fatigue risks to patient and resident safety
(Baldwin and Daugherty, 2004; Buysse et al., 2003; Cavallo and Mallory,
2004; Gaba and Howard, 2002; Howard et al., 2002; Landrigan et al.,
2007; Lockley et al., 2006; Parshuram, 2006; Veasey et al., 2002; Weinger
and Ancoli-Israil, 2002). Below the committee reviews evidence concerning
the benefits to human performance, and potentially to patient safety, from
increased sleep time.
Before the 2003 duty hour reforms, first-year residents reported sleep-
ing an average of 5.7 (standard deviation [SD] .90) hours per night and
second-year residents reported an average of 5.98 (SD .98) hours (Baldwin
and Daugherty, 2004). However, self-reported sleep times tend to over-
estimate actual physiological sleep obtained (Jean-Louis et al., 2000). No
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0 RESIDENT DUTY HOURS
national study of resident sleep hours is available post duty hour reform
in 2003. Furthermore, the average number of hours reported by residents
may mask the actual degree of sleep deprivation because the schedule of
work (e.g., night work, extended duty shifts) may significantly influence the
amount of uninterrupted sleep possible.
Reducing work hours does not necessarily result in a corresponding
increase in sleep hours. An examination of work hours and the amount of
sleep obtained by residents shows that there is a statistically significant but
only moderate correlation between residents’ work hours and their sleep
hours, with approximately 15 percent (Baldwin and Daugherty, 2004;
Baldwin et al., 2003) to 33 percent (Lockley et al., 2004) of common vari-
ance between work time and sleep time (see Figure 7-1).
The varied elements influencing fatigue interact in complex ways that
make it difficult to attribute risk of reduced resident performance to re-
duced hours of work. For example, the study by Landrigan and colleagues
(2004) restricted the work of interns to approximately 16 hours at a time
and eliminated extended duty periods (24 hours or more), which resulted in
an average of 19.5 hours less work per week than the traditional schedule,
but it also resulted in 5.8 hours more sleep per week. A survey conducted
by Baldwin and Daugherty (2004) of residents prior to the 2003 duty hour
limits also revealed an inverse relationship between average weekly work
hours reported by residents and average weekly sleep time (Figure 7-1A).
Thus, it is not possible to isolate the distinct effects of shift length, total
work hour limitation, increased sleep time, and/or other consequences of
adjusting the duty hour limits (e.g., increased staffing) on the reduction of
medical errors found by Landrigan and colleagues (2004). Although the
separate contribution of increased sleep time to error reduction cannot be
measured, there is ample reason (reviewed below) that sleep could be the
primary way in which fatigue and its risks were mitigated in the residents
studied by Landrigan and colleagues.
Circadian Influence
Acute sleep loss begins when an individual remains awake beyond 16
to 18 hours or into the habitual nocturnal period for sleep (Van Dongen
and Dinges, 2005). Extensive research has shown the brain’s circadian sys-
tem ceases to oppose the physiologic pressure for sleep after 16-18 hours
of being awake. This results in steady increases between midnight and 6-
10 a.m. (when the body is biologically programmed to sleep) in sleepiness
and sleep propensity, lapses of attention and memory, and a wide range of
other cognitive performance deficits (Van Dongen and Dinges, 2005). This
natural pressure for sleep occurs when someone is awake at night, whether
or not the person is working. Morning hours (4-10 a.m.) are a peak time
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STRATEGIES TO REDUCE FATIGUE RISK
A
B
7-1a
FIGURE 7-1 Relationship of residents’ average weekly sleep to average weekly
hours of work.
NOTE: Figure A is survey data from n = 3,406 residents. Scatterplot of reported
average weekly work hours of sleep with reported average weekly work hours,
PGY (postgraduate year) 1 and PGY2 combined (regression line plotted, r = –.39).
Figure B is sleep log data in n = 20 interns. Relationship between the duration of
work and the duration of sleep for 20 interns during the traditional schedule and
the intervention schedule. The duration of work and the duration of sleep were
inversely correlated (r = –0.57, p < 0.001) during the traditional intervention sched-
ules, with the best-fit regression predicting a 19.2-minute loss of sleep per week for
every additional hour of work per week.
(A) Reprinted, with permission, from Baldwin and Daugherty, 2004. Copyright
2004 by the American Academy of Sleep Medicine.
(B) Reprinted, with permission, from Lockley et al., 2004. Copyright © 2004 Mas-
sachusetts Medical Society. All rights reserved.
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RESIDENT DUTY HOURS
for drowsy driving accidents (Pack et al., 1995) and other industrial catas-
trophes (Dinges, 1995; Mitler et al., 1988). However, our innate circadian
biology begins promoting wakefulness during the day. Performance impair-
ments from a night without sleep actually decline somewhat by 6-10 p.m.
(i.e., at 36-40 hours of being awake) relative to the peak for poor perfor-
mance earlier in the day between 6 and 10 a.m. (i.e., 24-28 hours awake)
(Van Dongen and Dinges, 2005). This circadian modulation of sleepiness
and alertness was part of the justification for ACGME’s settling on a 30-
hour rather than a 24-hour extended duty period (ACGME, 2003, 2004),
although some programs scheduled these extended duty periods in a non-
circadian fashion (e.g., starting the 30 hours at noon).
EFFECTS OF ACUTE SLEEP DEPRIVATION
ON HUMAN PERFORMANCE
Findings on the effects of 30-hour extended duty periods on the perfor-
mance of physicians (Philibert, 2005) and the reduction in adult intensive
care unit (ICU) medical errors when intern duty periods were limited to
approximately 16 hours (Landrigan et al., 2004) received much attention
in the medical community. These results, however, were not surprising
given data that have accumulated over the past 100 years about the effects
of sleep deprivation on attention, memory, and a range of cognitive func-
tions (Dinges and Kribbs, 1991; Durmer and Dinges, 2005; Harrison and
Horne, 2000; Kleitman, 1963; Patrick and Gilbert, 1896). There is a sub-
stantial scientific literature on the cognitive and functional deficits induced
when healthy (non-physician) adult volunteers remain awake for 24 to 40
hours (Durmer and Dinges, 2005; Harrison and Horne, 2000; IOM, 2006;
Philibert, 2005). In addition, neuroimaging studies have confirmed that a
night without sleep results in changes in brain functions that are associated
with unstable and inaccurate performance on a wide range of cognitive
tasks including attention, working memory, and executive functions such
as problem solving and decision making (Bell-McGinty et al., 2004; Chee
and Choo, 2004; Chee et al., 2006, 2008; Chuah et al., 2006; Drummond
et al., 1999, 2000, 2005; Habeck et al., 2004; Lim et al., 2007; Portas et
al., 1998; Thomas et al., 2000; Wu et al., 2006).
Although the majority of healthy adults exposed to wakefulness ex-
tended from 16-18 hours to 24-30 hours experience performance-impairing
fatigue, there are substantial differences among individuals in the onset and
magnitude of cognitive changes induced by a night without sleep (Doran et
al., 2001; Leproult et al., 2003; Van Dongen et al., 2004). There is as yet
no reliable objective biomarker for differential vulnerability to the effects of
sleep loss, although a recent study suggests one possible genetic candidate
(Groeger et al., 2008; Viola et al., 2007). Approaches designed to help in-
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STRATEGIES TO REDUCE FATIGUE RISK
dividuals become aware of their own personal vulnerability to the cognitive
effects of sleep loss, combined with information on how to prevent these
effects, could form the basis of a more personalized fatigue management
system (Dinges, 2004; Van Dongen et al., 2007). ACGME is encouraged to
look into developing these systems based on the approaches developed in
regulated transportation industries for their applicability to residency.
ACUTE SLEEP DEPRIVATION AND RESIDENT PERFORMANCE
Current ACGME duty hours set an upper limit on duty hours of 24
hours with an additional 6 hours to allow adequate time for patient fol-
low-up, didactic learning, and patient handovers (ACGME, 2003, 2004).
ACGME proposed this 30-hour work limit (also referred to as a “long call”
schedule or an extended duty period [Knauth, 2007]) in order “to address
the effects of acute sleep loss” (ACGME, 2003). However, this limit does
not adequately protect against acute sleep loss (Dinges, 2005; Philibert,
2005). An ACGME meta-analysis of 60 studies on the effects of sleep
deprivation in 959 physicians found that “Sleep loss of less than 30 hours
reduced physicians’ overall performance by nearly 1 standard deviation
and clinical performance by more than 1.5 standard deviations” (Philibert,
2005, p. 1392). These very large effect sizes on a large sample of resident
physicians leave little doubt that acute total sleep loss of 30 hours dimin-
ishes resident performance. Thus, it was concluded that allowing residents
to stay awake for 30 hours on duty “may not completely guard against
the negative effect of sleep loss on cognitive and clinical performance”
(Philibert, 2005, p. 1392).
Both realistic patient simulator studies (Howard et al., 2003) and field
studies of residents working extended duty periods (24 or more hours) have
often found performance deficits post-call relative to pre-call (Eastridge et
al., 2003; Friedman et al., 1971; Kahol et al., 2008; Leonard et al., 1998).
However, some studies have not found such deficits (e.g., Jakubowicz et al.,
2005; Jensen et al., 2004; Uchal et al., 2005). It is not possible to determine
whether the latter studies had inadequate power to detect statistically sig-
nificant differences as a function of work time. Since all of these field studies
vary greatly in the rigor of their study designs and methods, what factors
specifically contributed to the different outcomes cannot be determined.
As in the more well-designed study by Landrigan and colleagues (2004),
factors other than work duration per se (e.g., differences in degree of sleep
deprivation) may have contributed to those findings in which extended duty
hours reduced resident performance. The prospective controlled study of
Landrigan and colleagues suggests that performance deficits associated with
extended duty periods (24 + 6 hours) could adversely affect patient safety
(Landrigan et al., 2004), and that the increased sleep time resulting from
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4 RESIDENT DUTY HOURS
elimination of these long on-call duty periods might have helped to decrease
attentional failures stemming from sleep loss during overnight work hours
(Lockley et al., 2004). In contrast, retrospective studies, such as one by
Ellman (2005), have not shown differences in patient outcomes.
The findings of the meta-analysis conducted by ACGME on the ef-
fects of sleep deprivation on physicians (Philibert, 2005) are consistent
with previous reviews of the adverse effects of work periods beyond 24
hours on resident performance (Asken and Raham, 1983; Veasey et al.,
2002), and with the report on the beneficial effects of limiting ICU interns’
continuous work periods to “approximately 16 hours” (Landrigan et al.,
2004, p. 1839). Furthermore, a nationwide web-based survey of 2,737 in-
terns found that extended work duration was associated with an increased
risk of percutaneous injuries to interns (Ayas et al., 2006), and the more
frequently interns experienced an extended work period of 24-30 hours,
the more fatigue-related errors they reported (Barger et al., 2006b; see also
Gander et al., 2000). Thus, considerable evidence as reviewed in this chap-
ter now exists to suggest that the 2003 ACGME extended duty hour limit
for residents of 24 + 6 continuous hours (ACGME, 2003) is likely to result
in increased risks (via performance errors) to both patients and residents
than shorter-duration work periods.
The same 2,737 interns queried for information on fatigue-related er-
rors (Barger et al., 2006b) and percutaneous injuries (Ayas et al., 2006)
during extended duty periods were also asked about motor vehicle inci-
dents and crashes. Sleep deprivation from extended shifts contributed to
significantly elevated risks of motor vehicle crashes, near-miss incidents,
and incidents involving involuntary sleep while driving home from the
hospital after an extended duty period (post-call) compared to drives home
after non-extended work periods. The odds ratio for sleep-deprived drivers
was 2.3 for crashes and 5.9 for near-miss incidents (Barger et al., 2005).
An earlier smaller survey of residents found comparable results (Marcus
and Loughlin, 1996). The willingness of residents to drive when they are
drowsy may be, in part, associated with the effects of sleep deprivation on
judgment. Recent studies have found that sleep loss can result in greater
risk taking (Killgore et al., 2006; McKenna et al., 2007; Roehrs et al., 2004;
Venkatraman et al., 2007).
Collectively, the research on resident physicians indicates that sleep
loss associated with having to stay awake for an extended period (up to 30
hours or more)—rather than the performance of work per se—is likely the
primary reason that neurobehavioral and cognitive performance degrades
during residents’ extended duty periods. This conclusion is consistent with
findings from laboratory studies of healthy adults showing that the adverse
effects on cognitive performance of remaining awake 24 or more hours are
found even when people are awake without working (Dinges and Kribbs,
1991; Harrison and Horne, 1999, 2000).
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STRATEGIES TO REDUCE FATIGUE RISK
ACUTE SLEEP LOSS PLUS INExPERIENCE
IN FIRST-YEAR RESIDENTS
The seminal studies by the Harvard Work Hours, Health and Safety
Group on resident duty hours in relation to both patient safety (Barger et
al., 2006b; Landrigan et al., 2004) and resident safety (Ayas et al., 2006;
Barger et al., 2005) focused on interns (first-year resident physicians) who
are the least experienced and work more hours, and therefore are more
prone to errors if not properly supervised. Interns are also more sleep
deprived than other resident physicians. A national random sample survey
that obtained data on sleep from 3,604 first-year (interns) and second-year
residents during 1998-1999 found that interns reported obtaining signifi-
cantly less sleep than second-year residents (Baldwin and Daugherty, 2004).
Interns also had significantly more prolonged sleep deprivation and longer
single periods without sleep than second-year residents. Additionally, this
study found that residents averaging 5 or fewer hours of sleep per night
were more likely to report serious accidents or injuries, conflict with other
professional staff, use of alcohol, use of medications to stay awake, notice-
able weight change, working in an impaired condition, and having made
significant medical errors. Residents reporting more instances of inadequate
supervision and occasions of working while impaired, as well as those who
believed that they should have taken time off for illness but did not, also re-
ported less sleep time and more sleep deprivation (Baldwin and Daugherty,
2004). While these results pre-date the current ACGME resident duty
hour limits and consequently may not generalize to residents today, they
are consistent with the more recent studies by the Harvard Work Hours,
Health and Safety Group indicating that sleep deprivation in interns (the
least experienced residents) poses an unsafe condition.
WORK DURATION AND RISK
Continuous time spent performing work (referred to as time on task)
may also increase the risk of accidents, but this is less clearly understood
and documented than the contribution of acute sleep deprivation to the
risk of accidents. Reviews across industries of the relative risk of accidents
as a function of work hour duration (with attempts to adjust for exposure)
generally conclude that the risk of accidents can begin to increase as time
working exceeds 8 hours, and especially when it exceeds 12 hours, although
the increases in risk after 12 hours of work are not always consistent or
large (Caruso et al., 2004; Knauth, 2007; Nachreiner, 2001).
There are very few data, however, to inform work-hour guidelines in
health care. A retrospective analysis of 411 recorded medical staff expo-
sures to biological fluid at a university hospital with an emergency medicine
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RESIDENT DUTY HOURS
residency program found a statistically significant increase (after adjusting
for the number of workers per exposure) in exposures during 9-12 hours
on duty (Macias et al., 1996). Two studies involving a total of 895 U.S.
hospital staff nurses found an increase in self-reported errors and near-
errors when work shifts were extended to 12.5 hours or longer (Rogers et
al., 2004; Scott et al., 2006), although a smaller (and likely underpowered)
study of nurses in Japan who were allowed to nap while working reported
that 16-hour night shifts did not result in greater fatigue or difficulties con-
centrating than 8-hour night shifts (Takahashi et al., 1999).
A report by the National Institute of Occupational Safety and Health
on overtime and extended work shifts has concluded that factors other than
simply work duration per se contribute to the relationship between work
duration and risk (Caruso et al., 2004). These factors are similar to the list
at the beginning of this chapter and include shift start time, total hours
worked in a week, rotation of work shifts between day and night work, and
workload (e.g., Macdonald and Bendak, 2000). Moreover, there is much
less information on the effects of work durations beyond 12 hours (Caruso
et al., 2004), prompting the National Occupational Research Agenda Long
Work Hours Team to propose a framework for future studies of long work
hours, “including determinants, outcomes, and moderating factors of long
work hours, suggesting that studies need to include more clear and com-
plete descriptions of work schedules, worker characteristics, and the work
environment, and need to consider a wider range of possible health, safety,
social and economic outcomes for workers, families, employers, and the
community. Additional studies are needed on vulnerable employee groups
and those critical to public safety. More studies are also needed to develop
interventions and test their effectiveness” (Caruso et al., 2006, p. 930).
Maximal Hour Limits per Shift
The evidence reviewed above supports the conclusion that performance
is compromised by remaining awake beyond 16 hours (i.e., acute sleep
deprivation). Therefore the extended duty shifts (24 + 6 hours) permitted
in the current ACGME resident duty hour limits (ACGME, 2003) promote
conditions for fatigue-related errors that pose risks to both patients and
residents (Ayas et al., 2006; Barger et al., 2006a; Landrigan et al., 2004;
Lockley et al., 2007). Limiting continuous work time to 16 hours would
reduce these risks. A 16-hour continuous work limit is also reasonable in
light of studies that equate the effects on performance from being awake
more than 16 hours to the effects of 0.05 to 0.10 percent blood alcohol
concentration (Arnedt et al., 2005; Dawson and Reid, 1997; Lamond and
Dawson, 1999; Williamson and Feyer, 2000). While 16 hours of continuous
work reflects a clear limit relative to safety, there is no compelling evidence
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STRATEGIES TO REDUCE FATIGUE RISK
that risks to patient safety increase from 8 to 12 hours of work, but some
data from nurses suggest that risk may increase after 12 hours of work,
although the work-related factors that contribute to this risk are unknown
(Bollschweiler et al., 2001; Rogers et al., 2004).
In conclusion, the reviews of safe work hour limits and sleep depri-
vation indicate that either extended duty periods must be eliminated to
improve patient safety relative to resident performance (Landrigan et al.,
2004, 2007), or if extended duty periods of 24 + 6 hours are to remain an
essential feature of resident training, provision for sleep following 16 hours
of work will be needed, before the extended work period continues to 30
hours. The mitigating effects of sleep are discussed below.
PREVENTION OF ACUTE SLEEP DEPRIVATION
This section reviews what is known about sleep obtained by residents
during extended duty periods. As a fundamental biological function, sleep
both stabilizes waking performance and enhances the ability to learn and
remember (Huber et al., 2004; Lim and Dinges, 2008; Stickgold, 2005;
Stickgold et al., 2000; Walker and Stickgold, 2006). Continued advances in
neurobiology have identified circadian timing and homeostatic mechanisms
in the brain (Fuller et al., 2006) that require sleep to be obtained daily in
adequate quantity and quality to prevent the physiological and behavioral
effects of sleep deprivation. Prevention of sleep deprivation in residents is
regarded as among the most essential ways to manage fatigue and its risks
(Buysse et al., 2003; Dawson and McCulloch, 2005; Gaba and Howard,
2002; Gabow et al., 2006; Horrocks et al., 2006; Landrigan et al., 2007;
Parshuram, 2006; Veasey et al., 2002).
The committee observed that ensuring residents obtain adequate sleep
during their scheduled workweeks is a feature currently missing in the
ACGME duty hours and resident training culture. Reduced sleep periods are
common in many residency programs (Baldwin and Daugherty, 2004). Since
current efforts to educate residents about sleep and fatigue management are
by themselves not sufficient to increase sleep durations (Arora et al., 2007),
requirements for protected sleep periods should be a priority in any new
ACGME duty hour limits. Residents should practice good sleep hygiene and
learn the importance of avoiding fatigue-related errors by obtaining essential
sleep both daily and weekly as a matter of professional responsibility.
Although reduction of resident duty hours alone is one way to achieve
more sleep (Lockley et al., 2004, 2006, 2007), it is an indirect and ineffi-
cient way to increase sleep given the moderate correlation between resident
work hours and sleep time (see Figure 7-1) (Baldwin and Daugherty, 2004;
Lockley et al., 2004). Reducing work hours could limit the time available
for educational training experiences of residents (Ludmerer and Johns,
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RESIDENT DUTY HOURS
Additionally, sponsoring institutions must not require that residents and fel-
lows engage in moonlighting to cover cutbacks in hours on other services.
So that moonlighting does not undermine the intent of limiting duty hours,
the committee recommends the following.
Recommendation 7-2: The ACGME should immediately amend its
current requirements on moonlighting by
• Requiring that any internal and external moonlighting for pa-
tient care adhere to the duty hour limits listed above (e.g., 80
hours and all other limits), even if the program has received an
exception to schedule longer hours, and
• Requiring that sponsoring institutions, if they choose to permit
moonlighting, include provisions in resident contracts that (1)
a resident must request prospective, written permission from
the program director for moonlighting; and (2) resident perfor-
mance will be monitored to ensure that there is no adverse effect
of moonlighting on resident performance.
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———. 2007b. ACGME program requirements for graduate medical education in emergency
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