Thomas J. Nasca, M.D., M.A.C.P.
Chief Executive Officer
Accreditation Council for Graduate Medical Education
515 North State Street, Suite 2000
Chicago, IL 60654
Re: The Accreditation Council for Graduate Medical Education’s (ACGME’s) Common Program Requirements for Resident Duty Hours in the Learning and Working Environment
Dear Dr. Nasca:
The National Center for Health Research strongly supports maintaining the cap of 16 consecutive hours for shift work for first-year residents. The data on the negative impact of sleep deprivation makes it very clear that the 16-hour cap should be expanded to all medical residents. The caps will help to minimize errors in patient care due to fatigue and compromised concentration and judgment, and will improve the quality of residents’ learning experience. As you know, resident duty hours (RDH) became an issue in 1984 when a college student (Libby Zion) in New York died from a medical error that was determined “to be related to resident fatigue and poor resident supervision.” [1] The current RDH requirements are based on the findings of the 2010 ACGME Task Force on Quality Care and Professionalism. In September 2015, ACGME established a task force to develop recommendations for revising the RDH requirements. We understand that ACGME will publicly release a draft proposal for revision of its resident duty-hour limits and solicit comments from stakeholders in the coming months. However, we are commenting now because we are concerned that numerous physician organizations have advocated lifting the 16-hour cap to allow interns to work for 24 or more hours in a row without sleep.
Previous studies found residents scheduled for 24-hour shifts suffer 61% more needlestick and other sharp injuries after 20 hours on duty, and their risk of automobile accidents doubles when driving home after 24 consecutive hours of work [2]. Studies also indicate these excessive consecutive work hours are harmful to patients, with a “greater than 2-fold increase in preventable adverse events.” [3] In addition, a recent study found that “patients taken care of by housestaff working more than 80 hours per week had increased length of stay and number of ICU transfers.” [4]
Most healthy adults require a minimum of 5 hours of sleep per 24 hours and ideally 7.5-8.5 hours. When working 24-hour shifts, acute and chronic fatigue impairs residents’ executive and cognitive functions including response time, mood, motivation and initiative [5].
Respondents to an orthopaedic patients’ survey stated that they “felt that resident fatigue was harmful to patient care and that DHRs [duty-hour requirements] were beneficial for both residents and patients.” [6] Although there are conflicting studies on whether DHRs have accomplished their goal of improving patient safety [6], this is more likely to be because 16 consecutive hours are still too long, not because 24 consecutive hours are not a problem. We therefore urge the ACGME to make patients’ lives a priority by keeping the first-year residents’ hours capped at 16 hours of continuous duty and to also apply the cap to all other residents.
We are aware that concerns have been raised about “decreased [resident] experience in patient care, and inexperience in handoffs leading to errors in patient care.” [4] Many newly trained general surgeons are perceived to be underprepared to independently practice general surgery [3]. However, there is no scientific evidence that removing the 16-hour cap will improve that situation.
Sincerely,
Diana Zuckerman, PhD
President
National Center for Health Research
- Mirmehdi I, O’Neal C-M, Moon D, MacNew H, and Senkowski C, (2016). The Interventional Arm of the Flexibility In Duty-Hour Requirements for Surgical Trainees Trial: First-Year Data Show Superior Quality In-Training Initiative Outcomes, Journal of Surgical Education. https://www.ncbi.nlm.nih.gov/pubmed/27651054
- Lockley SW, Barger LK, Ayas NT, et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(11 Suppl):7-18.
- Elmariah H, Thomas S, Boggan JC, Zaas A, and Bae J (2016). The Burden of Burnout: An Assessment of Burnout Among Internal Medicine Residents After the 2011 Duty Hour Changes, American Journal of Medical Quality. https://www.ncbi.nlm.nih.gov/pubmed/26917807
- Ouyang D, Chen JH, Krishnan G, Hom J, Witteles R, and Chi J (2016). Patient Outcomes when Housestaff Exceed 80 Hours per Week, The American Journal of Medicine. https://www.ncbi.nlm.nih.gov/pubmed/27103047
- Agency for Healthcare Research and Quality (September 2016). Department of Health and Human Services. Fatigue, Sleep Deprivation, and Patient Safety. https://psnet.ahrq.gov/primers/primer/37/fatigue-sleep-deprivation-and-patient-safety?utm_source=AHRQ&utm_medium=EN-3&utm_term=&utm_content=3&utm_campaign=AHRQ_EN10_11_2016
- Mercuri JJ, Okey NE, Karia RJ, Gross RH, and Zuckerman (2016). Resident Physician Duty-hour Requirements: What Does the Public Think?Journal of the American Academy of Orthopaedic Surgeons. https://www.ncbi.nlm.nih.gov/pubmed/27661392