Resident Duty Hours: Enhancing Sleep, Supervision, and Safety (2009)

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Abstract The Institute of Medicine’s Committee on Optimizing Graduate Medi- cal Trainee (Resident) Hours and Work Schedules to Improve Patient Safety evaluated the literature concerning (1) the impact of current residents’ duty hours on patient safety and (2) the relationship of hours of work and sleep to performance. The principal aim of residency training in the United States is to prepare young doctors for the safe, independent practice of medicine once they are on their own. While they are in training, residents are often required to be on duty for long hours. Many medical educators believe that extensive duty hours during training are essential to provide residents with the rich educational experience necessary to achieve professional compe- tence in the complexities of diagnosis and treatment of patients. In 2003 the Accreditation Council for Graduate Medical Education (ACGME) adopted common program requirements to restrict resident workweeks to an aver- age of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours, as well as other limits. Based on its review of the scientific evidence, the committee recognized that it should focus on increasing opportunities for sleep during resident training to prevent acute and chronic sleep deprivation and to minimize fatigue-related errors, rather than on simply reducing total duty hours. It recommends a protected sleep period of 5 hours during any work shift beyond 16 hours duration. This on-duty sleep period should be counted toward the weekly maximum of 80 hours averaged over 4 weeks. The A ­ CGME and residency programs should also • increase the opportunity for sleep each day by having defined peri- ods off between shifts,  

 RESIDENT DUTY HOURS • increase the number and regularity of days free from work for “catch-up sleep” and recovery to minimize cumulative sleep loss, • limit any additional paid healthcare work (moonlighting) that resi- dents undertake, and • provide safe transportation to any resident too fatigued to drive home safely. The committee sees benefits in continuing ACGME monitoring of recommended duty hours because of the relationship of duty hours to edu- cation. However stronger enforcement and whistle-blower processes need to be adopted by ACGME and supported by outside oversight to promote adherence and to protect residents who report pressure to violate rules. Duty hour limits should be accompanied by specialty-specific workload reductions and additional funding to avoid unintended consequences on patient safety and residents’ safety and education. The committee recom- mends improvements in the content of residents’ work, a patient workload appropriate to learning and observation of duty hours, and better supervi- sion with more frequent consultations between residents and their super- visory attending physicians. Greater supervision, especially of first-year residents, could intercept errors before they harm patients (e.g., having to spend more days in a hospital because a resident did not order a diagnostic test). Such “near-miss” experiences then become opportunities for learning. In addition, residents should be trained in systems for quality improvement and error reporting. A handover, the transfer of patient information and responsibility for patient care from one healthcare provider or team of caregivers to another, is identified as a time when lack of clear communication can contribute to error, but it can also be a time for learning and the interception of er- rors. The committee recognizes that it is vital for residents to learn how to perform handovers most effectively because handover frequency increased after the 2003 duty hour limits and may increase further with new duty hour parameters. Shift changeovers should be scheduled so that there is adequate overlap time to conduct effective handovers. To meet the committee’s recommendations, additional financial and human resources will have to be obtained and existing ones applied dif- ferently. Some resident work could be transferred to other clinicians, ad- ditional residents, and support staff. According to an economic estimate of select scenarios commissioned by the committee, the annual national costs of personnel substitution could be around $1.7 billion. This represents ap- proximately 0.4 percent of Medicare outlays. Additional funds for graduate medical education (GME) would be needed to support recommendations not contained in the economic model. The committee strongly urges Con- gress and all potential GME and research funding sources to support the 

abstract  recommendations and the evaluations necessary to monitor and assess their full effect. More knowledge of the details of implementation will help avoid unintended consequences and refine duty hour and educational require- ments over time. Educating resident physicians is an exceedingly critical function of the health system to ensure safe, high-quality health care to patients in the fu- ture. A fundamental requirement of resident education is in-depth, firsthand experience caring for actual patients. Ensuring the safety and well-being of patients who participate in the education of residents is of utmost impor- tance. One must look beyond hours of work alone as a risk factor and put in place practices (e.g., time for sufficient sleep, enhanced supervision, ap- propriate workload, unambiguous handovers) to minimize other contribu- tors to errors so that the patient care environment can be made safer.