24+ hour shifts for hospital interns: good idea or bad?

My last 14 months in the army was spent in Germany working 24 on / 24 off. We might, and I emphasize "might," get 2-3 hours sleep on that shift. No worries though, I was only providing security for nuclear missiles.

InTheShop said...
I can't find any evidence to back up your statement. Therefore I reject it.

Just Google it.

https://www.nejm.org/doi/full/10.1056/nejmoa041406

Here's just one article I found on this topic....there are many more from the NIH, NTSB, OSHA, etc.

Jack,

The point is, that you are missing, is that circadian disruption IS A PROBLEM, and it causes (or leads to) errors of judgment, accidents, etc. Are you saying that is not a true statement?

[URL]https://psnet.ahrq.gov/primers/primer/37/Fatigue-Sleep-Deprivation-and-Patient-Safety[*URL]

Here's one from January of this year. Check out side bar references on the above article.

Jack,

Your first comment in this thread is below.....

Blackjack said...
There are more errors from the increased number of case "handoffs" from shorter shifts than there are from extended shift fatigue.

Interesting, what is the source of this statement? Don't accuse me of being lazy--back when I was a student (and even today as well) students who do not cite sources for claims get automatic "F" grades. It's not the reader's job to track down the source, it is the writer's job to cite them properly.

I can give my own perspective on the issue of overworked interns since I was one from July 1, 1974, to June 30, 1975. The bad old days some would say. I'd be one who said that. I was an Internal Medicine intern at a large prestigious university. We routinely worked 90 hour weeks but often 100 or 110 hour weeks. Sometimes we could catch a little nap in the middle of the night while we waited for something to happen but it was not unusual to start work at 7 am one day and work without sleep until we could get out of the hospital at 9 or 10 pm the next day. I often forgot to eat I was so busy. I lost 15 lbs in the first three months. Internship lasts a year and not every rotation was 110 hour weeks.

Yes, it was like a boot camp and taught me things I never would have known otherwise but I know I made mistakes I don't think I would have made if I wasn't so tired. I remember two vividly. One was an old man (actually, he was younger than I am now but hey, I was 26 at the time and he seemed really old) who had borderline kidney failure. His potassium was dangerously high and we were treating him for it so I was responsible for checking his level twice a day and ordering treatment (repeat enemas). This meant I had to draw his blood myself and take it to the lab myself, which I did over and over. One evening I drew the blood and took it to the lab but forgot to call to check the result. Later that evening I was called to his bed for a code blue. He died. I remembered his potassium level then. It was very high again and that is why he died. I just forgot to check it.
The other case was a young woman with leukemia. My job was to give her a chemotherapy drug (methotrexate) into her spinal fluid. I made a mistake and gave her 10 times the proper dose. The good news in her case was she got a complete remission so maybe my mistake helped her. But there had been a case at that hospital sometime before where a patient got the wrong drug into the spinal fluid and was permanently paralyzed.

So probably the long hours are useful training but I'd say the patient costs are too high. Costs to the interns are pretty high, too. One of my fellow interns tried suicide because he just could not take the pressure. I myself became very bitter but eventually got over it.

Argent -

I hardly think we could have read a grittier, more incisive -- or more shocking -- account of just how problematic this marathon hospital stay-awake practice can be.

It took great courage for you to share your gripping story with us. Thank you for that.

I hope your experience was something that you were able to come to grips with, preferably long ago.

And if you did feel guilt about it, I know you must have run through the events of that day in your mind a thousand times. What if I had remembered to check? What if I had done this, or done that?

Well, what if you hadn't been so fatigued? In which case it's the system's fault, not yours.

Or what if the patient would have died anyway?

I hope you at some point made peace with what happened that day and moved on.

But if sharing your story with us now, even now, has somehow proved to be cathartic for you, then all to the good.

But again, thank you for sharing this extraordinary story with us. It could not be more informative.

Thanks for your interesting anecdote, Argent; you aren’t alone, as you now know more clearly than when you were 26. Glad to have your inputs here at HW/PC.

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Flight takeoffs and landings are an interesting parallel to the subtopic being discussed here. The majority of student flight accidents occur during these transition phases (look it up). Planes don’t generally just fall out of the air mid-flight; the majority fatal “crashes” commonly occur when the “handoffs” take place between earth and sky.

In hospitals, ineffective handoffs of information, responsibility and accountability similarly are a key source of patient safety “crashes.” Accordingly, each and every hospital has developed their own unique internal procedures—systems engineering methods—to help minimize handoff problems. Dr Atul Gawande (some of you may be familiar with him as author of “Being Mortal”) wrote two acclaimed, best-selling books related to this topic: “Complications: A Surgeon's Notes on an Imperfect Science” and “Better: A Surgeon's Notes on Performance” which emphasizes the systems approach to hospital error reduction without wiping out individual conscientiousness.

In flight, just about everyone uses essentially the same checklist prior to takeoffs and landings…but each flight has exactly one takeoff and one landing. A flight from Chicago to Cleveland has one of each, and so does the flight from Chicago to Tokyo. In hospitals, just about every individual hospital has their own, unique (different) handoff procedure. Quite naturally there is variation and some hospitals are better than others at handoffs. HERE’S A KEY POINT: when there are shorter duty cycles/shifts of workers, patients experience more handoffs (more takeoffs & landings), and (therefore) more problems occur.

Sleep deprivation is also source of hospital errors; there is no dispute about this fact, and I think several members posted links (I didn't read them; no need) which are probably informative about the existence of cognitive performance impairment from lack of sleep. Probably some of those studies were used a decade ago when the maximum duty of residents was reduced from 24- to 16-hours, believing that with more sleep fewer mistakes would be made.

Does the reduction in duty cycle/sleep deprivation improve patient mortality outcomes? It turns out “no.” Following the recent increase back to 24-hours max duty cycle, sixty-three internal medicine residency programs participated (coordinated out of UPenn) in a study published in March 2019 in the NEJM (look it up)—half of first-year residents were restricted to 16-hours shifts, the other half had no limit on how long residents could work. Results: the number of patients who died within 30 days was statistically the same, and although medical errors were not directly examined, the implication is that the rate of medical error was also similar.

So, bottom line: the shorter duty cycles don’t reduce mortality/errors in terms of sleep deprivation, but shorter duty cycles create more risky “handoffs.”

In the OP, this was posted:

81GyGuy said...
Let's hear it if you have an opinion on this practice [24-hour resident duty], agreeing or disagreeing with it.

My opinion--counter-intuitive as it may be to some of you--is based on these data.

Post Edited (Blackjack) : 6/12/2019 11:06:34 AM (GMT-6)

Thanks, Jack, that is an interesting take---but might I suggest you're mixing apples and oranges. Sleep deprivation creates cognitive errors/errors in judgment, as Argent poignantly shared with us. In short, sleep deprivation leads the physician to make errors based on incorrect interpretation or use of information that he/she has in front of them. (Misreading a syringe and administering 10X the correct dose of a medication).

Handoff issues are about properly organizing and sharing information between the outgoing and incoming person. It's about communication: if the person going home fails to clearly share (or properly chart) important information about patient X, then the errors that might happen are not cognitive or judgment errors, but are errors due to lack of appropriate information.

I agree that the outcome might be the same or similar--but the root cause is very, very different. And conflating them (the root causes) leads us no further to a resolution. I've worked shift work. I've trained people in how to do effective handoffs at shift change. Not in medicine--which I'm sure has a high order of complexity--but the principles of how to do it are well understood. It begins with written notes, and taking written notes. Verbal handoffs are (almost) worthless.

It's interesting that in virtually every other field of endeavor where this has been studied, longer hours leads to more errors---except in medicine. Why is that? Is it about what the researchers are trying to prove?

The OP, as I read it, poses the question: are 24 hour shifts a good or bad idea? With links to articles pro and con. I take the con position, largely by my past experience (9 years of it) of working rotating and midnight shifts, and periodically working up to 16 hours in a row. I know about the failures of judgment and inability to be attentive to complex issues after having been nominally awake for extended hours.

We had a truism as well: anyone who works or has worked the midnight shift and claims they have never fallen asleep is a liar. We had a guy who literally fell asleep standing up in the elevator--and nobody knew where he was for a while.

The issues that stem from shift change handovers are different issues--and I would suggest could be dealt with by having better, more formal hand off processes.

Can we agree to disagree?