Shorter Intern Shifts Mean Fewer Medical Errors

Harvard moves to limit hours at its teaching hospital

WEDNESDAY, Oct. 27 , 2004 (HealthDayNews) -- Harvard University's teaching hospital is introducing what would seem to be a common-sense move but is really a revolution in medical education: a 16-hour limit on the time doctors-in-training can work on a given shift.

The decision was bolstered by two in-house studies showing that shorter work shifts for interns reduce treatment errors.

Internship is an important step in medical education that gives young doctors the experience to go out on their own. Decades ago, interns literally lived at the hospital, on call at any time and for any length of time.

"When I was in training, we worked 120 hours a week," said Dr. Andy Whittemore, chief medical officer at Brigham and Women's Hospital, where Harvard Medical School graduates train and practice.

"But we usually could get some sleep during that time. Now that the [patient] length of stays has come down and therapeutic options have exploded, the pace of life in the institution precludes the ability to get sleep on a shift," he said.

The need to limit the workload of interns has been recognized by the Accreditation Council for Graduate Medical Education, whose regulations now say a work week can be no longer than 80 hours. But the two Brigham and Women's studies and the measures they have spurred don't deal with the total number of work hours in a week but the length of individual shifts.

The studies appear in the Oct. 28 issue of the New England Journal of Medicine.

One study, led by Dr. Charles A. Czeisler, chief of the hospital's sleep medicine division, studied 20 interns during two three-week stays in an intensive-care unit and a coronary-care unit. Each intern worked both a traditional schedule of more than 80 hours a week with some shifts longer than 24 hours, and a less intensive schedule of less than 80 hours a week, with no shifts longer than 16 hours.

Studies showed that on the shorter schedule, the interns had less than half the rate of failure to pay proper attention, as measured by slow rolling eye movements that indicate sleepiness.

The second study, led by Dr. Christopher P. Landigran, a professor of pediatrics at Harvard, focused on medical errors. It found that during 2,203 patient-days, interns on the traditional longer schedule made 35.9 percent more errors than those on the shorter schedule.

"To the best of our knowledge, this is the most comprehensive study which looked at outcome in terms of patient safety," Landigran said in a statement.

But moving from those findings to an actual change of schedule for all interns at the hospital is a complicated process, Whittemore said.

To start with, the hospital works on a July-to-July schedule, pegged to the school year, so the changes can't be made until next July. And when those changes are made, extra personnel will be needed to do what the interns don't have time to do. And those staffers -- such as nurse practitioners and physicians assistants -- are in short supply, Whittemore said.

Then there's the question of money. Shorter schedules for interns will cost the hospital $3 million to $4 million, Whittemore said, and it is not at all certain that improvements in treatment will pay for that.

"Although there clearly was a difference in respect to medical errors, there was no difference in mortality and no difference in length of stay, and therefore no difference in cost," he said of Czeisler's study.

Still, Whittemore said, "Chuck's study introduced sound science to guide us in making changes." Brigham and Women's is "shooting for July 05" to institute the new schedules, he said, and other medical centers will be watching.

"We clearly are in the vanguard, but other institutions clearly are wrestling with this problem," Whittemore said.

More information

For more on medical training programs for interns, visit the Accreditation Council for Graduate Medical Education.

SOURCES: Andy Whittmore, M.D., chief medical officer, Brigham and Women's Hospital, Boston; Charles A. Czeisler, M.D., Ph.D, chief, sleep medicine division, Brigham and Women's Hospital, Boston; Oct. 28, 2004, New England Journal of medicine
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