Reduction in Residents' Hours Linked to Uptick in Surgical Complications

June 30, 2012

"PATIENT HANDOFFS!!! The hidden unregulated danger for patients."

The following article which appeared in newspapers recently reports that a new study concerning patient complications indicated that there were actually more complications when the work hours for residents were reduced. This reduction in work hours for residents was a common sense solution to a dangerous tradition of routinely requiring residents to work 20 hour shifts and even longer in many situations. The article says that actually tired residents taking care of patients had less complications reported than the residents who now work less hours and are less tired? The findings in this report appear to be illogical and I would have to know the details of the study in order to determine if in fact it was a worthwhile and valid study.

However, the article does indirectly refer to a rather secretive procedure in many hospitals in that there are no firmly established rules or guidelines that are executed in a regular basis concerning PATIENT HANDOFFS regarding the outgoing physician and the incoming physician as well as the nurses going off duty and coming on duty. PATIENT HANDOFFS refers to the responsibility of a physician or nurse going off duty to personally meet with the physician or nurse coming on duty so that a well-informed and comprehensive review of the patients being treated at that time is appropriately made to the oncoming physician or nurse. This process, to be done properly, may sometimes require an in depth review of the patients chart and actually a bedside visit with the patient. Any serious problems need to be addressed in depth at that time.

PATIENT HANDOFFS that occur when nurses are passing in the hallway and trade a few sentences is usually nowhere near adequate nor are a couple of words jotted on a slip of paper and left for the oncoming nurse is adequate. In my experience, I have found that many instance of neglectful care is directly related to the lack of any warning or communication during the PATIENT HANDOFF. The following article does not address this situation at all but I can state with certainty that improving the practice of PATIENT HANDOFFS would result in significantly less neglect and injury to patients which sometimes result in DEATH. Anyway, for what it's worth, here is the published article."

All doctors in the United States must go through a minimum of three years of on-the-job residency training. While residents do have patient care responsibilities, they should always be under the supervision of an experienced attending physician.

There is no doubt that residency can be a rigorous and challenging experience for doctors in training. Cognizant of research that links physician fatigue and hospital negligence, the Accreditation Council for Graduate Medical Education acted in 2003 to limit the number of hours that residents could work. However, the rigid limitations they imposed seemed to create their own set of problems, as outlined in a new study introduced at the 2012 meeting of the American Association of Neurological Surgeons.

Passing Patients Between Care Providers Potentially More Dangerous Than Fatigue

When the duty-hour restrictions were introduced in 2003, they limited residents to a maximum of 24 continuous hours on duty, a maximum of 80 hours per week and required at least one 24-hour day off each week. Residents were also encouraged to have at least 10 hours off between each work period. Fully licensed practicing physicians, on the other hand, are only limited in their work hours by their own sense of responsibility and best practices.

On the surface, these limits for residents seem like good policy. Nobody wants to be seen by a tired doctor; 80 percent of respondents in a 2009 poll of 1,200 Americans said they would want a different physician if they knew their doctor had been on duty for more than 24 hours. Yet, while everyone can agree that more rest for doctors is a good thing, rigid duty-hour limits do not always fit in to the realities of medical practice.

In the new study, data was collected for neurosurgical trauma patients admitted to teaching hospitals in the years 1999-2002 (before the restrictions were put in place) and compared to information for the years 2005-2008 (after the restrictions had become established). Researchers found a 23 percent greater rate of reported patient complications during the later years.

"[D]uty hour restrictions have resulted in increased transfers of care, and these transfers of care are the strongest predictor for potentially preventable adverse patient events," Dr. Brian Hoh said as he presented the new study to the American Association of Neurological Surgeons, according to Medscape Medical News. "Duty-hour restrictions have also resulted in reduced resident experience," Dr. Hoh added.

In other words, the main problem posed by shift limits is that they can lead to patient handoffs. Patients' care does not always fit into neat episodes -- for instance, a difficult labor and delivery could last longer than 24 hours. The new research seems to back up previous studies that indicate patients are better off with a tired doctor who knows them than a well-rested doctor who is new to the case.

Balance Between Rest, Continuity in Care Necessary to Prevent Medical Errors

Hardly anyone accepts that doctors, residents or otherwise, should be working excessive hours that put patient safety at risk. On the other hand, duty-hour restrictions should be nuanced enough to take into account the nature of medical work that does not always fit into clearly defined shifts.

Whatever the status of duty-hour guidelines, the primary focus in any medical setting should be patient safety. If a medical procedure has caused harm to you or a loved one, you may be entitled to monetary damages. Contact a medical malpractice attorney today to learn more.

Article provided by Vincent Morgera
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