Resident Work Hours

The traditional 24-30 hour work shifts of physicians-in-training greatly increases the risk of injury both to physicians themselves and their patients. In a series of studies published since 2004, schedules built on a foundation of 24-hour shifts have been found to increase the risk of provider occupational injuries as well as serious medical errors and patient injuries. As medical errors cause between 44,000 and 98,000 deaths each year in the U.S. (Institute of Medicine, 1999), implementation of systems that reduce the risk of errors is a major public health concern.

Physicians-in-training working traditional schedules with recurrent 24-hour shifts:

• Make 36% more serious medical errors than those whose scheduled work is limited to 16 consecutive hours;(Landrigan et al, NEJM 2004)
• Make five times as many serious diagnostic errors;(Landrigan et al, NEJM 2004)
• Have twice as many on-the-job attentional failures at night;(Lockley et al, NEJM 2004)
• Suffer 61% more needlestick and other sharp injuries after their 20th consecutive hour of work, exposing them to an increased risk of acquiring hepatitis, HIV, and other blood-borne illnesses;(Ayas et al, JAMA 2006)
• Double their risk of a motor vehicle crash when driving home after 24 hours of work;(Barger et al, NEJM 2005)
• Experience a 1.5 to two standard deviation deterioration in performance relative to baseline rested performance on both clinical and non-clinical tasks; (Philibert, Sleep 2006)
• Suffer decrements in performance commensurate with those induced by a blood alcohol level of 0.05 to 0.10% (Dawson and Reid, Nature 1997; Arnedt et al., JAMA 2005)
• Report making four times as many fatigue-related medical errors that lead to a patient’s death (Barger et al., PLoS Medicine, 2006).

Professional regulations implemented to date have been inadequate to address this problem. 84% of interns nationwide are non-compliant with the work hour limits of the Accreditation Council of Graduate Medical Education (ACGME) (Landrigan et al, JAMA 2006), which allow regular shifts of up to 30 hours in a row (including time for transitions of care), and 80 hours of work per week (averaged over each 4-week period). Even were compliance perfect, however, these limits would be insufficient.

Work shifts of 30 consecutive hours unquestionably lead to profound performance decrements, and greatly exceed U.S. hours of service regulations in the airline industry and trucking, as well as work hour limits for physicians in Europe, where work of more than 13 hours in a row or 48-56 hours per week is prohibited by law. In light of the evolution of data regarding the dangers of residents’ ubiquitous sleep deprivation, an evidence-based redesign of current resident work schedules is needed urgently. Such a redesign must incorporate infrastructural improvements to minimize errors due to care discontinuities and optimize medical education. An essential first step, however, is the implementation of safe work limits.

In 2004, the Sleep Research Society assembled the SRS Presidential Task Force on Sleep and Public Policy to develop model legislation regarding physician-in-training work hours. The central provisions of the Task Force’s recommendations are:

• Weekly work hours of physicians-in-training should be limited to an optimal maximum of 60 hours of work per week, and a fixed maximum limit of 80 hours of work in any week;
• Consecutive work should be limited to an optimal limit of 12 hours of consecutive work, with a maximum limit of 18 consecutive hours of work in any setting, including time for the transition of patient care information.
• Physicians-in-training should have 16 hours free of all duties following a shift of >18 consecutive hours, and at least 10 hours free of all duties after work shifts of shorter than 18 consecutive hours.
• Physicians-in-training should have at least 36 consecutive hours free of work including two consecutive nocturnal periods once every seven days, and a 60-hour consecutive period free of work once every four weeks. 
• Physicians-in-training who are assigned to patient care responsibilities in an emergency department or other high-intensity setting where the probability and/or potential consequence of a medical error is high should work no more than 12 continuous hours in that setting.
• Physicians-in-training should not be scheduled to work an 18-hour shift more often than every third night.

The taskforce also recommended that the following issues be considered in development of Safe Work Hours Legislation:

1. The optimal way to provide education to hospital leaders and resident physicians and other trainees in clinical training programs to increase awareness of the risks of sleep deprivation;
2. The potential role of annual sleep disorders screening for all physicians to reduce the risk of sleep disorder-related errors and accidents;
3. The use of fatigue counter-measures to mitigate the effects of sleep deprivation, including, but not limited to the use of naps before and during work shifts, rest breaks, and caffeine;
4. The responsibility of health care employers to provide safe transport home for any resident physicians and other trainees in clinical training programs impaired by sleepiness; and
5. A requirement for physicians who have been awake for more than 22 of the prior 24 hours to inform their patients of the extent and potential safety impact of their sleep deprivation and to obtain consent from such patients prior to providing clinical care or performing any medical or surgical procedures.

Evidence-based limitation of resident-physicians’ work hours has been endorsed by the National Sleep Foundation and the Sleep Research Society. Given the scope of the patient safety epidemic in the United States, and the extremely high number of errors attributable to traditional 24-hour work shifts, reduction of providers’ consecutive work hours represents a major opportunity for the sleep medicine and science community to effect public health improvements.

To translate the above findings into effective health policy, the recommendations outlined above must be taken up by policymakers as well as the scientific community. In Massachusetts , Senator Richard Moore has introduced legislation to develop a committee that would formally consider introducing work hour limits for residents. At the federal level, Congressman John Conyers has repeatedly introduced legislation to reduce resident work hours. Further State and Federal efforts incorporating up-to-date evidence and the recommendation of the SRS Presidential Taskforce will be needed, however, to advance legislation promoting safe work hours for physicians-in-training.

The Sleep Research Society supports passage of Safe Resident Work Hours Legislation across the United States. We invite the participation of SRS members interested in championing this crucial issue. If you are interested in joining this initiative and/or working on Safe Resident Work Hours Legislation, please send your contact information to Nick Cekosh, SRS Coordinator.