CIR Pushes for Patient and Resident Safety as Challenges Mount to Institute of Medicine Report on Resident Work Hours

Universally viewed as ”the gold standard” of academic research,an Institute of Medicine report is usually accorded great respect and legitimacy — but not this one!

The IOM’s “Resident Duty Hours: Enhancing Sleep, Supervision and Safety” was produced over 12 months by a panel of experts and vetted in the most rigorous of peer review processes. CIR praised the groundbreaking report and its core recommendations for improving the safety of patients and physicians. Nevertheless, the reaction from organized medicine since its release in December 2008 has been decidedly negative.

In June, the ACGME held a 2009Duty Hours Congress in Chicago. The newly formed Duty Hours Task Force spent two days listening to testimony from 44 of the 120+ medical organizations submitting position papers on the subject. Of those presentations, only CIR and the American Medical Student Association (AMSA) urged the ACGME to seriously consider the recommendations of the IOM report.

“I was stunned that the IOM’s findings were so easily dismissed by these physicians,” said CIR National Vice-President Dr.Nailah Thompson,who represented CIR at the meeting.

“They ignored the decades of research on sleep deprivation and human performance, and rejected the studies that have been done on resident physicians, fatigue and patient safety,” said Dr. Thompson. “Many fixated on the fact that fewer hours worked meant more handovers,which could lead to more medical errors. Why can’t that be solved by improving our handover training—which we need to do in any case?”

Dr. Thompson also heard many speakers complain openly about today’s residents being poorly trained.“There were countless references to ‘the good old days’ when there were no hours limits. They painted a picture of today’s residents as unprofessional shift workers, so uncommitted that if hours were further reduced, we would surely walkout on our patients when the bell rang. That is not a picture of the residents I know,” she said.

“We are taught, above-all, to practice evidence-based medicine,” said Dr. Thompson. “Yet here are our medical educators ignoring the evidence and recommendations for change! It was quite an eye-opener.”

CIR urged the ACGME to embrace the IOM report, champion those medical innovators who are already successfully making change,and aggressively lobby for the additional federal funds needed for implementation.

The IOM report states that although the additional funding required may be significant — at least $1.7 billion — that figure is actually only 0.4% of the entire Medicare budget. Should preventable adverse events drop by just 7% as a result of reducing resident work hours to safer limits, the IOM suggests the savings to the system would offset the costs.

CIR also reminded the ACGME Task Force that patients and the general public are deeply concerned about the relationship between fatigue and errors. They are aware that other industries entrusted with the public’s safety—like aviation,trucking and nuclear power—have had regulation in place for decades to limit work hours to safe levels.

That common sense notion that staying up for 24 hours impairs performance holds for medicine as well.In a 2004 Kaiser Family Foundation survey of public opinion on the causes of medical errors, 74% of respondents listed overwork, stress or fatigue of health professionals as a“very important cause of medical errors” and 66% felt “reducing the work hours of doctors in training to avoid fatigue” would be very effective in reducing preventable errors.

ACGME Director Tom Nasca, MD, sent out a letter later in June, reporting“The ACGME has commissioned three comprehensive reviews of the literature on related topics to provide the intellectual basis for any new standards recommended.”

Dr. Nasca said it will take 10months to consider any hours changes it will recommend and that the ACGME will also “initiate a separate,annual “Patient Safety and the Learning Environment” evaluation of each ACGME-accredited sponsor coincident with the implementation of new duty hour standards.”

Clearly, this issue is far from being resolved.



Where CIR Departs from the IOM Recommendations
CIR testimony made clear that some alterations to the IOM recommendations were necessary:

1. A 30-hour shift with a mandatory five hour nap is unworkable and unenforceable, and should be abandoned in favor of the IOM’s recommended maximum shift of no more than 16 hours.

2. The IOM’s limit of 4 consecutive night shifts should be extended to 5 nights, as is currently the casein many programs that have successfully reduced hours.

3. Hand-overs: in addition to a greater emphasis on standardized, state of the art hand-overs to address continuity of care concerns, resident scheduling should also allow for sufficient overlap to allow the necessary time for quality hand-overs.

4. Home Call limitations should be included for those rotations when the number of phone calls results in frequent night-time disruptions, even in those cases in which the resident is not required to come into the hospital.(Note: the IOM report is silent on the subject of home call.)

Read CIR’s complete testimony at the June 2009 ACGME Duty Hours Congress:
 CIR ACGME Testimony 2009