This month’s What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety” highlights the serious impact of provider fatigue on patient safety. We’ve done numerous columns focusing on the impact of fatigue in both nurses and physicians, not only on patient care but on their personal health. (See our Patient Safety Tips of the Week for November 9, 2010 “Sleeping Air Traffic Controllers: What About Healthcare?” and our What’s New in the Patient Safety World columns for February 2011 “ ”, April 26, 2011 “Update on 12-hour Nursing Shifts”, September 2011 “Shiftwork and Patient Safety, and November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”.)
There is absolutely no doubt about the negative impact that fatigue has on patient safety and quality outcomes. However, equally disturbing is the fact that some of our interventions to minimize fatigue in healthcare workers may introduce unintended consequences that do not remedy the underlying threats to patient safety.
In our November 2011 What’s New in the Patient Safety World column “Restricted Housestaff Work Hours and Patient Handoffs” we discussed the mixed results of studies looking at the impact on patients of restrictions on housestaff work hours. And we’ve discussed the fact that our efforts to minimize errors due to fatigue of long working hours (for not only physicians but also nurses and others) must always be balanced against the errors that occur due to fumbled handoffs that increase when work hours are restricted.
In response to the ACGME duty-hour restrictions for housestaff a variety of schedules have been tried. At Children’s Hospital in Boston they moved from a “night float” system to one in which housestaff worked one straight week of nights during their 28-day rotations (compared to previously working every fourth night). Christopher Landrigan, director of the Sleep and Patient Safety Program at Harvard, and colleagues (Chua 2011) looked at the impact of this change and found some surprising results. Though mean shift length was reduced by almost 2 ½ hours, the residents’ nightly sleep actually was reduced from 6.72 to 4.77 hours and total sleep reduced from 7.50 to 5.47 hours! The study did not assess impact on patient care.
Children’s Hospital of Boston subsequently reverted temporarily to a more traditional overnight call schedule and now has redesigned a night team schedule taking into account the results of this study. The article is a stark reminder that sometimes in our haste to correct one problem we inadvertently develop a solution that aggravates the original problem or creates new problems. And unless you actually measure the outcomes of the changes you make you may incorrectly assume that your changes created a desirable effect.
We had previously discussed some of Landrigan’s work in our September 2011 What’s New in the Patient Safety World column “Shiftwork and Patient Safety”. An audio interview (Henkel 2011a) with him in the August issue of “The Hospitalist” had some really good points about the effects of shiftwork on mistakes and patient safety. He stresses that you don’t want to schedule someone to work too many nights in a row, citing literature from multiple industries that shows error rates go up with consecutive nights worked. Our November 9, 2010 Patient Safety Tip of the Week “study on shift workers in fields other than healthcare ( ” cited a Folkard 2003) which showed that the risk of incidents increased each consecutive day worked. For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%). So Landrigan says that it is probably better to schedule hospitalists for only 3-4 days of night shifts rather than the more popular 7days on/7 days off pattern.
In the above interview Landrigan also discusses the biology of circadian rhythms and notes the importance of taking a 1.5-2.0 hour nap on the afternoon prior to working the first night shift and that working a day shift immediately after a night shift is not a good idea. He discusses how working consecutive night shifts adds to the burden of sleep deprivation, which ultimately has a role in the occurrence of mistakes and errors. When asked about “nocturnists”, he does note that some people have been able to alter their circadian rhythms to accommodate chronic night shift work. But he cautions that when such people take vacations their bodies return to a “day” circadian rhythm and there may be problems when they return to the night shift pattern.
Not only are too many consecutive night shifts potentially dangerous to patients, they are dangerous to the healthcare workers themselves. In the second article (Henkel 2011b) Landrigan notes “We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that they’re at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.”
And the Journal of Neurosurgery has a series of articles on the impact of duty-hour restrictions on neurosurgery residents. Neurosurgery has been one discipline in which sentiment against the work hour restrictions has run heavy, both from attendings, educators and residents. One study (Dumont 2011) demonstrated an increase in complication rates for neurosurgical procedures after implementation of restricted work-hour rules. They postulate that the increased number of handoffs required probably plays a major role in the increase in morbidity and complications.
Another study (Ganju 2011) performed pre- and post-call simulation tests on neurosurgical residents and concluded there was a marginal decline in proficiency post-call. However, they noted that the decline was much less significant than the decline seen in general surgery residents post-call. That article and the accompanying editorial (Dacey 2011) seem to be touting “neurosurgery residents are different – we’re tougher” and make a case that the same ACGME duty-hours restrictions should not apply equally to all specialties.
We don’t buy that. That’s the same sort of “Top Gun” attitude that got many early fighter pilots killed. Fatigue is real and impairs our ability to respond no matter what professional or lifestyle activity we are engaged in. What we need to do is develop better ways to recognize when fatigue is occurring (because we ourselves are not good judges of our abilities when fatigued) and develop better systems to care for our patients when we need to excuse ourselves from patient care because we are fatigued.
But Landrigan’s message is clear - be careful that the solution you try is not worse than the problem itself!
Chua K-P, Gordon MB, Sectish T, Landrigan CP. Effects of a Night-Team System on Resident Sleep and Work Hours. Pediatrics 2011; 128:6 1142-1147
Henkel G. ONLINE EXCLUSIVE: How to minimize the adverse affects of working night shifts. The Hospitalist. August 2011
Henkel G. ONLINE EXCLUSIVE: Scheduling Rules of Thumb. Safety, equality should factor into HM groups’ coverage plans. The Hospitalist. August 2011
Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101
Dumont TM, Rughani AI, Penar PL, Horgan MA, Tranmer BI, Jewell RP. Increased rate of complications on a neurological surgery service after implementation of the Accreditation Council for Graduate Medical Education work-hour restriction: Clinical article. Journal of Neurosurgery, epub ahead of print, December 2, 2011; DOI: 10.3171/2011.9.JNS116
Ganju A, Kahol K, Lee P, Simonian N, Quinn SJ, Ferrara JJ, Batjer HH. The effect of call on neurosurgery resident’s skills: implication for policy regarding resident call periods. Clinical article. Journal of Neurosurgery, epub ahead of print, December 2, 2011; DOI: 10.3171/2011.9.JNS101406
Dacey RG. Resident Work Hours (editorial). Journal of Neurosurgery, epub ahead of print, December 2, 2011
Responses Batjer HH, Ganju A. and Dumont TM, Rughani AI.