Resident Duty Hours

Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue.

Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning.

All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.

Contents

• THE NATIONAL ACADEMIES
• COMMITTEE ON OPTIMIZING GRADUATE MEDICAL TRAINEE (RESIDENT) HOURS AND WORK SCHEDULES TO IMPROVE PATIENT SAFETY
• Reviewers
• Foreword
• Preface
• Acknowledgments
• Abstract
• Summary
  • STUDY SCOPE AND OVERVIEW
  • BACKGROUND
  • THE HISTORY OF RESIDENT DUTY HOUR REGULATION
  • IMPLEMENTATION OF 2003 DUTY HOUR RULES
  • THE NEXT ERA OF REFORM FOR BETTER EDUCATION AND PATIENT SAFETY
  • COMMITTEE FINDINGS AND RECOMMENDATIONS
  • CONCLUSION
  • REFERENCES
• 1. Background and Overview
  • CHARGE TO COMMITTEE
  • GRADUATE MEDICAL TRAINING
  • DUTY HOUR DEMANDS IN THE MEDICAL PROFESSION
  • SCOPE AND ORGANIZATION OF REPORT
  • REFERENCES
• 2. Current Duty Hours and Monitoring Adherence
  • SETTING DUTY HOUR LIMITS
  • ADAPTING TO 2003 DUTY HOURS
  • DUTY HOURS IN SELECTED INDUSTRIES
  • MONITORING DUTY HOURS
  • REFERENCES
• 3. Adapting the Resident Educational and Work Environment to Duty Hour Limits
  • RESIDENT EDUCATIONAL AND WORK SYSTEMS
  • REDESIGNING RESIDENT WORK AND WORKLOAD
  • CHANGES IN RESPONSE TO DUTY HOUR LIMITS
  • COSTS OF ADAPTING TO THE 2003 DUTY HOUR LIMITS
  • REFERENCES
• 4. Improving the Resident Learning Environment
  • EDUCATIONAL PRINCIPLES
  • IMPACT OF 2003 LIMITS ON EDUCATIONAL OUTCOMES
  • REDESIGNING EDUCATION AND EDUCATIONAL INNOVATIONS
  • CONCLUSION
  • REFERENCES
• 5. Impact of Duty Hours on Resident Well-Being
  • RESIDENT SAFETY
  • RESIDENT WELL-BEING AND QUALITY OF LIFE
  • CONCLUSION
  • REFERENCES
• 6. Contributors to Error in the Training Environment
  • MEASURING HOSPITAL-BASED ERROR RATES AND RESIDENT INVOLVEMENT
  • FATIGUE AS A CONTRIBUTOR TO ERROR
  • IMPACT OF REDUCED DUTY HOURS ON ERROR RATES AND PATIENT SAFETY
  • OTHER CONTRIBUTORS TO ERROR
  • SUMMARY
  • REFERENCES
• 7. Strategies to Reduce Fatigue Risk in Resident Work Schedules
  • FATIGUE, WORK HOURS, AND SLEEP LOSS
  • NEED FOR SLEEP
  • EFFECTS OF ACUTE SLEEP DEPRIVATION ON HUMAN PERFORMANCE
  • ACUTE SLEEP DEPRIVATION AND RESIDENT PERFORMANCE
  • ACUTE SLEEP LOSS PLUS INEXPERIENCE IN FIRST-YEAR RESIDENTS
  • WORK DURATION AND RISK
  • PREVENTION OF ACUTE SLEEP DEPRIVATION
  • IMPROVING ADHERENCE TO USE OF PROTECTED SLEEP PERIODS
  • PREVENTION OF CHRONIC SLEEP DEPRIVATION
  • APPROACHES TO PREVENT CHRONIC SLEEP LOSS
  • RECOVERY SLEEP
  • ADJUSTMENTS TO THE 2003 RESIDENT DUTY HOUR LIMITS
  • ADDITIONAL CONSIDERATIONS UNDERPINNING RECOMMENDATION 7-1
  • RESIDENT MOONLIGHTING
  • REFERENCES
• 8. System Strategies to Improve Patient Safety and Error Prevention
  • LEARNING IN A CULTURE OF SAFETY
  • REDUCING ERRORS BY IMPROVING HANDOVERS
  • HANDOVER INTERVENTIONS
  • TRAINING DOCTORS AND ERROR REPORTING
  • DEVELOPING A TEAM CULTURE
  • CONCLUSION
  • REFERENCES
• 9. Resources to Implement Improvements for Patient Safety and Resident Training
  • Preamble to Recommendations
  • COST IMPLICATIONS OF CHANGES TO DUTY HOURS
  • FUNDING THE COMMITTEE’S RECOMMENDATIONS
  • WORKFORCE IMPLICATIONS
  • A PHASED IMPLEMENTATION OF DUTY HOURS, ITS EVALUATION, AND FURTHER RESEARCH
  • REFERENCES
• Appendix A Statement of Task
• Appendix B Comparison of Select Scheduling Possibilities Under Committee Recommendations and Under 2003 ACGME Duty Hour Rules
• Appendix C International Experiences Limiting Resident Duty Hours
• Appendix D Glossary, Acronyms, and Abbreviations
• Appendix E Committee Member Biographies
• Appendix F Public Meeting Agendas

This study was supported by Contract No. HHSP233200700003T between the National Academy of Sciences and the Agency for Healthcare Research and Quality. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

Suggested citation:

IOM (Institute of Medicine). 2009. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: The National Academies Press.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.