"The problem with being on call every other night is that you miss half the cases!"
Excessive resident fatigue was just par for training in the old days of Medicine before duty hours came into effect, thanks to the ACGME. In 2008, the Institute of Medicine (IOM) provided more restrictive duty-hour recommendations. Key leaders in Emergency Medicine convened to develop a consensus response to these IOM recommendations. The following is a summary of the response, published in Journal of Emergency Medicine.
Here are the key 2008 duty-hour recommendations, borrowed from the IOM website:
(click to enlarge)
In general, the EM consensus responses to these recommendations took into account a need for "a balance between patient safety, resident wellness, and training." I'm listing some of the more interesting responses:
IOM Recommendation:
"Programs should design resident schedules using the following parameters: Scheduled continuous duty periods must not exceed 16 h unless a 5-h uninterrupted continuous sleep period is provided between 10:00 p.m. and 8:00 a.m. This period must be free from all work and call, and used by the resident for sleep in a safe and sleep-conducive environment. The 5-h period for sleep must count toward total weekly duty hour limits. After the protected sleep period, a resident may continue the extended duty period up to a total of 30 h, including any previous work time and the sleep period. Residents should not admit new patients after 16 h during an extended duty period."
EM Response:
"If the current system for resident overnight coverage of inpatient services is maintained, the recommendations of a 5-h ‘‘nap gap’’ may lead to a backlog of patients waiting to be admitted and hence increased patient crowding in the emergency department (ED). Increased patient boarding has been shown to decrease patient safety. Requiring a 5-h sleep period would necessitate additional patient care handovers, which has patient safety issues. Finally, implementation of a nap policy would be contrary to the recommendations from another IOM report on emergency care in America."
My reading between the lines:
The "nap gap" concept will NOT work. Inpatient services should get rid of call and convert to a shift-based system, similar to the ED.
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IOM Recommendation:
"Programs should design resident schedules using the following parameters: Night float or night-shift duty must not exceed four consecutive nights and must be followed by a minimum of 48 continuous hours off duty after three or four consecutive nights."
EM Response:
"Studies from EM and sleep experts show that limiting the number of night shifts to a maximum of three to four may not provide the most beneficial sleep schedule. Flexibility is the most important consideration for program directors and resident sleep schedules."
My reading between the lines:
Bad idea. There isn't any literature stating that 4 nights, followed by 2 days off is better than, for instance, 5 nights and 3 days off. As someone who used to make the resident and faculty schedules, I can state for a fact -- flexibility is key. The more rules and restrictions you put on making the shift schedule, the more disruption you put on everyone's schedule. And I mean -- everyone. For instance, which is worse on an individual?
- Option #1: Work 4 nights in a row, 2 days off, 1 night, 24 hours off, and then followed by 4 days shifts
- Option #2: Work 5 nights in a row, 3 days off, then followed by 4 day shifts
What HAS been proven in the literature is that longer blocks of night shifts, followed by longer blocks of day shifts, is better tolerated in EM.
Take a look at this article. There are more excellent points made by my friend Dr. Mary Jo Wagner (first author) and her colleagues. A controversial question that arises from these duty hour restrictions are that with fewer actual clinical hours worked, should residents be extending their training by another year? If so, who pays for this?
Wagner MJ, et al (2010). Duty hours in emergency medicine: balancing patient safety, resident wellness, and the resident training experience: a consensus response to the 2008 institute of medicine resident duty hours recommendations. The Journal of emergency medicine, 39 (3), 348-55 PMID: 20634017
