Medical Error Risk Rises Under Shorter Medical Intern Shifts

The 2011 decision to limit from 30 to 16 hours the time hospital internal medicine trainees can continuously work may be making patients less safe, because it leads to far more hand-offs and perceptions by nurses and residents that quality of care suffers.

The new rules also didn't do what they were intended to accomplish, which was to significantly increase the amount of time trainees would sleep each week. Instead, only three of 14 hours in amount of time gained from work shifts is used for sleep, researchers say.

Those were among several findings of a Johns Hopkins University experiment that enrolled 43 house staff interns to various models of consecutive hourly duty limits during the early months of 2011. It is published in Monday's online edition of JAMA Internal Medicine.

"Handoffs, a known risk factor for medical errors, increased 130% to 200% in the experimental" groups, compared with the control group, although increased supervision and training of handoffs "may mitigate some of the threat," wrote Sanjay V. Desai, MD, assistant professor of medicine and lead author of the paper.

In a news release, he said "the consequences of these sweeping regulations are potentially very serious.

"Despite the best of intentions, the reduced work hours are handcuffing training programs, and benefits to patient safety and trainee well-being have not been systematically demonstrated," he said.

Desai drew these conclusions after setting up a three-month experiment that compared three work schedules for trainees, two of which used a 16-hour limit and one which used a 30-hour limit. They were:

• On call every fourth night with a 30-hour duty limit, OR
• On call every fifth night with a 16-hour continuous duty limit, OR
• On a night float schedule with a 16-hour continuous duty limit

When Desai and colleagues analyzed the results, they realized that the lowest number of interns who cared for one patient during a three-day stay went from three to as high as five.

Additionally, educational opportunities suffered under the 16-hour limits. For starters, interns had fewer admissions in the two 16-hour schedules than in the 30 hour schedule, and more patients were cared for by each intern in the 30-hour schedule.

Other lost opportunities came from the reduced amount of time 16-hour-scheduled interns spent attending a daily noon conference, and reduced amount of time they spent attending and teaching rounds, compared with interns on a 30-hour schedule.

And even though trainees in the 16-hour limited work schedule were not supposed to exceed that, they did. Violations of the 16-hour rule occurred in 36% of one 16-hour group of trainees, and 16% of the other 16-hour group.

"Implementing the 2011 Accreditation Council for Graduate Medical Education duty hour regulations may present challenges and could have unintended consequences," the authors wrote. Although sleep duration did increase during the on-call period, the regulations did not lead to an increase in average sleep per day.

Additionally, the 2011 rules resulted in a decrease in "continuity of patient care, intern and nurse perceptions of quality of care, and educational opportunities from teaching and patient care," Desai wrote.

In an accompanying invited commentary, Lara Goitein, MD, and Kenneth M. Ludmerer, MD, of Christus St. Vincent Regional Medical Center in Santa Fe, NM, said the current limitations are "too inflexible."

Not only has the policy change created a situation that leads to increased medical errors, they wrote, but "limiting work hours without commensurately decreasing workload exacerbates the already extreme work compression for residents." In other words, these trainees have to do more in less time.

"Residents still perform most of the work, but are now racing the clock."

Teaching hospitals have focused on work hours, rather than on workload because they "are heavily dependent on the work provided by residents" and reassigning patients to non-resident services "is more expensive than implementing work hour limitations, at least in direct costs.

Goitein and Ludmerer say the situation can be repaired in two ways. First, teaching hospitals can increase resident training positions to reduce work intensity, and they can shift some patients to non-resident providers.

"Of course these measures are costly and will face substantial hurdles," they wrote, but there is some evidence that making adjustments can pay off, and even pay for itself through reduced 30-day readmissions, shorter lengths-of-stay, and reduced need for intensive care unit admission.

In sum, they argue: "Residents should no longer be asked to do an increasing amount of work in less time and with less flexibility."