July 28, 2011

When Interns Snooze, Do Patients Lose?

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For the second time in eight years, the organization that regulates graduate medical education has limited the number of hours interns and residents may work at a time.

The move, enacted by the Accreditation Council for Graduate Medical Education (ACGME), is intended to prevent medical errors resulting from sleep deprivation, but critics say it will drive up health care costs and lead to more handoffs of care, which can also put patients at risk.

The new rules, which went into effect in June, limit first year residents, also called interns, to 16-hour shifts. Second and third-year residents may still work 28 hours at a time but are prohibited from taking on new patients in the last four hours.

Administrators who run the graduate medical training programs at the Yale School of Medicine and the University Of Connecticut School Of Medicine say they knew the changes were coming and have been preparing for more than a year.

“We can have a philosophical discussion about whether shorter hours improve patient safety, but the bottom line it that it’s a done deal; the new rules are here to stay. The culture is changing and we have to embrace those changes,” said Dr. Kiki Nissen, UConn’s associate dean for graduate medical education.

Nissen said UConn mainly is relying on “physician extenders” – nurse practitioners and physician assistants – to help care for patients. “It’s an ongoing process. Most of our programs have already implemented the changes,” she said.

At Yale, Dr. Stephen Huot, director of the Residency Training Program for Internal Medicine, said new providers have been hired, including non-resident physicians and non-physician extenders, to provide coverage. Noting that the new staffing changes were phased in at Yale throughout the past year, Huot said, “The changes will be monitored not only for adherence to the duty hour rules, but for the impact on patients as well as the education of trainees.”

One byproduct of shorter shifts is increased handoffs, in which one doctor transfers information about a patient to the next physician on duty. Huot says this can also increase sources of error. In an effort to minimize that risk, Nissen said every program at UConn must now develop a handover curriculum.

The ACGME last changed the duty hours for residents in 2003. At that time, residents were limited to 80 hours a week, but were permitted to work 30 hours at a stretch. The cost of implementing these new rules nationwide will reach nearly $381 million annually, according to the ACGME.

 

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