The key to solving an emerging patient-safety concern could be to have doctors act more like nurses.
New restrictions on first-year resident work hours is leading to shorter shifts, which lead to more instances of physicians in training handing off a patient's care to a colleague, according to two studies posted last week on the JAMA Internal Medicine website.
There is general consensus that the greater the number of patient handoffs, the greater the risk for medical error. But some patient-safety experts are saying this risk can be managed by structuring a process—best done at the bedside—where the departing doctor can pass along pertinent information to the physician just starting his shift. Dr. Kedar Mate, vice president of the Institute for Healthcare Improvement, said this is what nurses have been doing effectively for years.
Mate said first-year residents (also known as interns) should meet at the patient's bedside, ideally with a family member or caregiver present, and recite this general script that summarizes a patient's status and treatment goals: This is patient so and so, he is facing these problems, this is the status of his treatment, this is what should happen during the next 24 hours, and these are the challenges he's facing in getting to that point.
Nurses working in shifts adopted this transition process a long time ago, and so now are hospitalist physicians and interns as they adopt the same work patterns. “This is all symbolic in a way,” Mate said. While new doctors in training might not find this means of communication unusual, “the old guard might be threatened and feel this is a waste of time or not part of what it means to be a doctor.”
The Accreditation Council for Graduate Medical Education imposed an 80-hour workweek (averaged over four weeks) in 2003. Additional restrictions rolled out in 2011 included counting any outside work, or “moonlighting,” by residents as part of their 80 hours and limiting interns to 16-hour shifts.
Those new limits went into effect on the traditional start date of new residency programs: July 1. Earlier that year, researchers at Johns Hopkins University in Baltimore randomly assigned 43 interns into three groups: One following the 2003 rules and two groups following 16-hour work schedules. While the 2011 compliant groups did get more sleep, the new regulations “decreased continuity of care and educational opportunities from teaching and patient care,” researchers wrote in one of last week's JAMA Internal Medicine studies.
The minimal number of patient handoffs increased from three under the 30-hour shift limit to as many as nine in 16-hour shifts. Also, the minimal number of interns seeing a patient during a three-day stay went from three to as high as five. “Increased supervision and training in handoffs may mitigate some of the threat,” researchers concluded. “Our results suggest an urgent need to study, standardize, teach and improve this critical component of care.”
Researchers at the universities of Michigan and Pennsylvania, meanwhile, found that more residents who began their training under the 2011 rules (22.3%) reported committing serious errors than their peers who started in 2009 and 2010 (19.1%). “The increase in handoffs may be a contributing factor to the increase in self-reported medical errors with the implementation of the new duty hour,” researchers wrote.
Mate concluded his residency training in 2003, the year the 80-hour workweek limit was first imposed. “I don't think we were paying as much attention to handoffs and now we have to,” he said. While handoffs were fewer then, he said they were largely chaotic and characterized the process as “50 people in a room all yelling at each other.”
But handoffs are in fact a process, and processes can be improved, said Alex Vandiver, executive director of the Joint Commission Center for Transforming Healthcare. The organization focuses on transfers between settings—such as from the emergency department to the inpatient floor and hospital to nursing home. But the principles, Vandiver said, are the same: communication, teamwork and measurement that the “people involved understand and have bought into.” If an organization takes the time to do that, he said, “they can reduce the risk that something bad might happen.”
The ACGME's 2011 rules followed several recommendations included in a December 2008 Institute of Medicine report on the subject of resident work hours. The committee that wrote that report was chaired by Dr. Michael M.E. Johns, then the chancellor at Emory University in Atlanta.
Johns, noting that the IOM report did not recommend the 16-hour work-shift limit, said in an interview last week that the emphasis should be on managing fatigue, not managing work hours. “This is a multifactoral issue—it's not just work hours,” Johns said. A fatigued resident is a potentially cognitively impaired resident, he said. “For the good of the resident, as well as the good of the patient, not being fatigued is important.”
Yet healthcare is a 24/7 industry, and workplaces are regulated because time off is not, observed one of Johns' colleagues on the IOM committee, David Dinges, chief of the sleep and chronobiology division at the University of Pennsylvania, Philadelphia.
People have to be professional and self-manage their fatigue, he said, and this involves showing up fit for work as well as taking a break when fatigued or asking others to check over your work. “This is really about fatigue management and system management.”
The keys, Dinges said, could be different rules for different specialties and more study on the issue. “This is not 16-hour vs. no 16-hour limit for me. It's about trials that seek to find the way that's optimum,” Dinges said. “It's hard to stop at one point and say, 'This is all the evidence we'll ever need.' ”