Giving Medical Residents More Work Flexibility Did Not Decrease Patient Safety Outcomes: Studies

Allowing medical residents to work more hours, with less structured breaks, does not appear to pose any risk to patient safety or increase death rates, according to the findings of two new studies.

Researchers concluded that flexible time off with no mandatory time off between shifts did not negatively impact patient safety. Similarly, marginal differences in sleep time on shift did not affect patient safety either.

The first study was published March 7, in The New England Journal of Medicine, focusing on extended shifts in medical residency programs. It examined data of 63 internal medicine residency programs during the 2015-2016 academic year. The programs were randomized into a group with standard duty hours or a group with more flexible duty hour rules that didn’t specify limits on shift length or mandatory time off between shifts.

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Between the two groups there was little difference in 30-day death rates.  The rates were 12.5% among the flexible program in the trial year and 12.2% in the standard program in the trial year. There were no major differences in seven-day readmission rates, patient safety indicators, 30-day readmission rates, or prolonged length of hospital stay.

The second study, also published in the New England Journal of Medicine, studied the same 63 internal medicine residency programs in the U.S. This time, the focus was on reduced sleep and sleep deprivation among medical trainees who used flexible hours or standard hour regulations.

The flexible group had 80-hour work weeks without limits, including shift length limits or mandatory time off between shifts. During the 14-day study period, 205 interns at six flexible programs and 193 interns at six standard programs were studied. Interns in the standard group averaged 7.03 hours of sleep per 24 hour shift while the flexible shift intern group averaged 6.85 hours of sleep.

There was largely no difference in the total sleep time between the two groups. More so, the reported sleepiness on shift between the groups also did not differ significantly.

In 2003, resident work hour limits were implemented to prevent doctor fatigue and reduce medical errors, as well as improve patient safety and outcomes. In 2011, the Accreditation Council for Graduate Medical Education (ACGME) adopted standard duty hours as the norm for doctor shifts to help prevent errors and unnecessary deaths. ACGME calls for 16-consecutive hour limits on first year resident shifts, 28-hour caps on all other residents, and a minimum eight-hour time off between work shifts.

Critics warned reduced work hours creates a new kind of risk when more patient handoffs occur. Increased patient handoffs may lead to increased errors because multiple medical professionals are now treating one patient, allowing more opportunities for missed medication, inaccurate dosing, and less familiarity with the patient’s diagnosis.

In fact, one study published in 2016 indicated patients face an increased risk of death when hospitals undergo staff changes at the end of shifts, causing more patient handoffs. More handoffs occur when doctors follow standard hour regulations and don’t have flexible shifts.

The findings of the new studies indicate flexible hours with fewer regulations may not pose as serious a threat to patients as researchers once believed.


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