Report links safety to physicians' sleep

More rest lowers accidents among doctors in study

It's not just the marathon hours that doctors-in-training work but the lack of sleep they get between shifts that can impair their performance and potentially harm patients, says a national report recommending broad changes by hospitals.

The Institute of Medicine, commissioned by Congress to study residents' hours five years after the first voluntary limits were put in place, suggested in a report released yesterday that residents get protected sleep periods during lengthy shifts and closer supervision by senior physicians, and that there be more extensive communication during handovers of patients from one resident to another.

"Our overarching conclusion is that the science clearly shows that fatigue increases the chances of errors, and residents often work long hours without rest and regular time off," said Dr. Michael M.E Johns, chancellor of Emory University and chairman of the committee that prepared the report, in a conference call with reporters.

But the changes would be expensive, costing an estimated $1.7 billion to pay for relief to fill in for residents who are off duty. Boston teaching hospitals said it was too soon to say whether they would adopt any of the proposed changes.

Current guidelines, set by the Accreditation Council for Graduate Medical Education, say residents can work an average of 80 hours per week over four weeks and no more than 30 consecutive hours at a time.

The new recommendations call for a maximum shift of 16 continuous hours, or a 30-hour shift that includes five hours of sleep. The sleep time would be included in the weekly 80 hours.

The accrediting group said it is reviewing the report before deciding whether to adjust its rules.

The recommendations are grounded in a growing body of research showing that not only can patients suffer, but residents can, too, when they are deprived of sleep.

Residents greatly increased their risk of motor vehicle crashes and accidents with needles, called needlesticks, after working more than 24 hours straight, Dr. Christopher Landrigan, director of the sleep and patient safety program at Brigham and Women's Hospital, said in an interview.

He presented his research on sleep and safety to the Institute of Medicine committee, including a study at the Brigham that compared residents who worked 16-hour shifts to their peers on duty for 30 hours. The frequency of medical errors was dramatically lower in the 16-hour-shift group.

"There are extremely clear data now that [among] doctors who work more than 16 hours without a break, the risk of making a mistake to themselves and others goes up," Landrigan said. "There's no clear data on what the perfect solution to the problem is."

At Beth Israel Deaconess Medical Center, Dr. Richard Schwartzstein, vice president for education, said "the present system is actually working quite well," and added that he is concerned about an increase of handoffs of responsibility for patients with more shift changes, which can lead to errors.

Dr. Debra Weinstein, vice president for medical education at Partners Health Care, the parent organization of Massachusetts General Hospital, and Brigham and Women's Hospital, said of the IOM report: "We need to make sure we have adequate time to adapt and adequate funding to insure that patients get the care and attention they need."