Brigham and Women’s Hospital (BWH), in two of the nation’s first comprehensive studies of sleep and medical intern performance, has found evidence that indicates eliminating extended work shifts of 24 hours or more, implementing shift limits of 16 hours or less and reducing work weeks to less than 80-hours, decreases the number of medical errors performed by this group of physicians.
In the two studies, senior researcher Charles A. Czeisler, PhD, MD, chief of BWH’s Sleep Medicine Division and colleagues, gathered evidence evaluating the effect of eliminating extended works shifts. BWH is unveiling its plan to enhance patient safety through regulating shifts for its post-graduate year-one (PGY-1) interns, including:
- Restricting first year intern hours to 80 hours a week or less;
- Mandating first year interns do not work more than 24 hours consecutively; and,
- Mandating by July 2005 that first year interns cannot write orders for patient care activities after 18 consecutive hours on a shift.
According to BWH’s Chief Medical Officer Andy Whittemore, MD, the hospital’s preliminary plan could serve as a model for other medical institutions around the country. “BWH began implementing these guidelines in the summer of 2004. We believe they will be helpful to similar institutions in their efforts to increase patient safety and enhance the quality of interns’ lives – goals of our nationwide medical system. While reducing first year intern work hours requires a very significant hospital-wide effort, we have had support from the entire community as everyone recognizes that this is an important step in addressing patient safety. BWH, along with the other hospitals which comprise Partners HealthCare System, is proud to lead the nation in these efforts and will continue to do so by supporting the necessary research and policies to institute change.”
According to Czeisler, “While sleep experts advocate eight hours of sleep per 24 hour period, it has historically been difficult to achieve in medicine as patient care is an around the clock effort. These are the first studies to demonstrate clinically that reducing work shifts and tackling sleep deprivation will help increase attentiveness and reduce medical errors.”
Brigham and Women’s Hospital Leads Nation in Sleep Research and Patient Safety
To better understand the impact sleep has on medical intern performance, researchers at BWH pioneered two studies both designed to underscore and support efforts hospitals can take to improve patient safety.
The impact extended work shifts – 24 hours or more – has on the alertness and performance of PGY-1 medical interns is not well understood. In the first study in the NEJM, lead researcher Steven W. Lockley, PhD, Czeisler and colleagues studied 20 interns during two three-week rotations in both a medical intensive care unit (MICU) and a coronary care unit (CCU). Each intern participated in a traditional schedule – more than 80 hours per week with some shifts of 24 hours or more – and an intervention schedule – less than 80 hours per week with shifts not exceeding 16 hours.
Through daily sleep and work logs and continuous eye movement monitoring through electrooculography (EOG), researchers found that interns on the intervention schedule worked 19.5 hours per week less, slept 5.8 hours per week more and slept more in the 24 hours preceding each working hour. In addition, these interns had less than half the rate of attentional failures – as defined by slow rolling eye movements – while working during on-call nights.
According to Lockley, “This evidence reveals that the long-standing medical tradition of scheduling physicians to work 24 or more hours in a row adversely impacts their ability to remain awake and sustain attention while caring for patients.”