long hours and medical risks

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freelancewriter

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On the wire today (Reuters):
"Long Nursing Shifts Raise Error Risk, U.S. Study Finds"
http://www.reuters.com/newsArticle.jhtml?type=healthNews&storyID=5602962

There has been lots of discussion on this forum and elsewhere about the long hours that residents work, and the correlation with medical mistakes. (There's also the issue of being able to learn when you're so tired.)

Perhaps the AMSA and others should stand up for other health professionals, such as nurses, who put in shifts that are too long in terms of alertness and patient safety. Good or bad idea for AMSA, residents, etc., to adopt the issue of nurses hours? Worth discussing, I think...
 
What constitutes a shift that is too long? Most of the RNs I know work 12s and if your tried to take that away they'd hurt you. It's seen as a perk to work 3 or 4 days per week. The docs in my group work between 8.5 and 11 hour shifts. Many like the long shifts for the same reasons. The longest I ever worked as a resident without a break and without sleep was 46 hours. I don't recommend that.
 
I'd like to know more about the scientific method used to get these results b/c I really don't beleive them. At all the hospitals I've worked in the standard nursing shift is 12 hours for ICU or floor, they have to call us with medication errors to notify us, and I've recieved only about 5 calls for that all year long - always minor errors that didn't affect patient outcome anyway. I can't beleive that switching shifts more frequently would help - there's something to be said for better continuity of care when a patient has only 2 nurses per 24 hour period vs 3 on an 8 hour shift system.

12 hours is a pretty standard shift for many jobs in many industries, and it's really not that long of a day.

The point made above is important too - many nurses LIKE have long shifts b/c it means a full-time week in just 3 shifts, making being home with kids or going back for further schooling much more managable than if they had to work 5 8-hour shifts a week. Take away this advantage from the profession of nursing and you'll have even a worse shortage of nurses.
 
There's another factor here too. More frequent shift changes means more patient handoffs. In EM signout is one of our riskiest things for med mal. If you work shorter hours there are necessarily more signouts. This applies to nurses too.
 
I'm with these guys above. The longest nursing shift I've seen in the hospitals I've worked in was 12 hours. Next to the 30 hour maximum for resident shifts, 12 hours seems pretty reasonable. I'd probably be a little irritated if AMSA or whoever took up the nurses' cause before addressing any resident grievances over working conditions.
 
Raise your hand if you feel as sharp during the last 2 hours of your 12 hour shift as you do at the first. The study is sound. It's not a hard study to do if all the nursing shifts are 12 hours long. You just track when mistakes are made and plot them according to time of day. I'm currently working only 12 hour shifts, and I don't particularly like it. I'm clearly more likely to make mistakes at the end of the shift, and I have to slow down and double check things more often when I'm tired. Plus, another fairly recent study found that emergency physicians' productivity fell off pretty badly during the end of a 12 hour shift.
 
Should the AMSA comment on the nursing hours issue? Whether or not you think they should have, they did:

Medical students react to study findings that link nursing errors to long hours
http://www.medicalnewstoday.com/medicalnews.php?newsid=10461

Here's a quote:
"If it has been proven that nurses should not work over forty hours per week, then how is it safe for a doctor to work over eighty?" says Brian Palmer, M.D., M.S., M.P.H., AMSA national president. "The current regulations placed upon medical residents have undoubtedly improved working conditions for many; however, this new information proves that patients are unsafe when hospital staff works extended shifts."

Rather than a hypothetical on whether or not AMSA should have taken a position, we can comment on an actual article...

(And, if you're wondering, I don't write or work for AMSA.)
 
So, if we limit nurse work hours, and we limit resident work hours, and there's a shortage of nurses... who is going to do the work? At some point, someone has to get the job done. This sort of "we're going to make it illegal to work more than X hours" mentality is going to undermine patient care. If there is no one else available, physicians (including residents) should work more than 80 hours per week. The second line of defense are the nurses.

Anka
 
freelancewriter said:
Should the AMSA comment on the nursing hours issue? Whether or not you think they should have, they did:

Medical students react to study findings that link nursing errors to long hours
http://www.medicalnewstoday.com/medicalnews.php?newsid=10461

Here's a quote:
"If it has been proven that nurses should not work over forty hours per week, then how is it safe for a doctor to work over eighty?" says Brian Palmer, M.D., M.S., M.P.H., AMSA national president. "The current regulations placed upon medical residents have undoubtedly improved working conditions for many; however, this new information proves that patients are unsafe when hospital staff works extended shifts."

Rather than a hypothetical on whether or not AMSA should have taken a position, we can comment on an actual article...

(And, if you're wondering, I don't write or work for AMSA.)
Click to expand...

I disagree that the new regulations have inproved working conditions. I know many residents who are miserable under the 80 hour cap. Many surgeons now do all scut and 0 OR time for more years because the scut has to get done (the attendings won't do it) and the OR was the reward. Many EM residents now have to work shorter but more numerous shifts. The problem with this, just like other unfunded mandates, is that there is an existing amount of work which used to be done by a given number of residents working whatever hours they worked. How can this be done by the same number of residents working fewer hours?
 
docB said:
The problem with this, just like other unfunded mandates, is that there is an existing amount of work which used to be done by a given number of residents working whatever hours they worked. How can this be done by the same number of residents working fewer hours?
Click to expand...

It can't. Increase the number of residents, or hire assistants to do the scut. If residents are being trained, then they shouldn't be doing so much scut that it interferes with their training (that is what medicare is paying for!). I'm sorry that the ED staff can't have it so they only work three days a week instead of 5. If a business didn't have enough employees to do all the work, they would have to hire more. Same thing applies here. Why is this such a hard concept for everyone?
 
Annette said:
It can't. Increase the number of residents, or hire assistants to do the scut. If residents are being trained, then they shouldn't be doing so much scut that it interferes with their training (that is what medicare is paying for!). I'm sorry that the ED staff can't have it so they only work three days a week instead of 5. If a business didn't have enough employees to do all the work, they would have to hire more. Same thing applies here. Why is this such a hard concept for everyone?
Click to expand...

It's a hard concept because none of the solutions are viable. The reason that the academics are against it is that many of them went into academics to have residents working as their slaves. Trying to take this away is tough. If you cut academic salaries (they're already low as it is) or make thier working conditions worse they'll bail. The nexus of most of these problems is not the ED BTW it's the inpt services. When it comes down to a question of trying to find money in the budget for midlevels, extra staff or whoever will be doing the extra work or screwing the resident most departments will be screwing the residents very quickly.
 
Sessamoid said:
Raise your hand if you feel as sharp during the last 2 hours of your 12 hour shift as you do at the first. The study is sound. It's not a hard study to do if all the nursing shifts are 12 hours long. You just track when mistakes are made and plot them according to time of day. I'm currently working only 12 hour shifts, and I don't particularly like it. I'm clearly more likely to make mistakes at the end of the shift, and I have to slow down and double check things more often when I'm tired. Plus, another fairly recent study found that emergency physicians' productivity fell off pretty badly during the end of a 12 hour shift.
Click to expand...


Actually, I feel just as sharpe at hour 18-20 as I do at hour 2-4. After 20, I start feeling a little sluggish, but I would have to agree with others that 80 hours is a little too strict for the surgical education. When I am forced to leave at 10 AM (even if I got some sleep) I am missing cases and education time. In my opinion, 95-100 would be a better number without the strict 30 hour rule. Only on weeks that I hit the high 90's or low 100's did I really feel beat down and unable to go on last year.
 
Thank you to all who have posted so far. The discussion is helping me, an interested outsider, learn more about the various sides of the issue through the lens of insiders experiencing duty hours (limits) firsthand.

The nurses hours study was picked up and rewritten by another site. It talks about the nursing hours and again mentions duty hours limits for residents. It is covered this time by "Ergonomic News" (Before seeing this, I had only thought of ergonomics as physical space issues, though I can see how fatigue is definitely a working condition.)
http://www.ergoweb.com/news/detail.cfm?id=959
 
Another problem with the whole idea of limited hours is that the hours are not as important as the workload. At one of our hospitals the shifts are 24 hrs but it's not a busy place and you get to sleep at night and have a fairly slow paced day. At our busy houses I feel dead after 9 hours.
 
As a nurse, I work 12 hour shifts in a CCU...I can't complain with having six days off in a row 🙂 At this point, I will not work a 8 hour shift unless it is an extra day...I really enjoy the 12 hour shift...I also agree that it allows for a better continum of care for the patients. Not to mention that many hosptials also do have 8 hour shifts available for those that can't do the 12 hours for whatever reason, you just have to find a unit that is willing to work with your needs... I think that one of the problems is the mandatory overtimes and 16 hour shifts. I have offered to stay OT for 16 hour shifts and yes, at the end, I am pretty tired...Thankfully, in the ICU setting, we usually have pretty good patient/nurse ratios, but I feel that the poor patient/nurse ratios on other units in the bigger issue (though both are important!)....these poor ratios are made worse when there is not enough staff on the oncoming shift-nurses are mandated to stay overtime (or choose to stay overtime) and things get missed...
 
At some point the lack of sleep becomes dangerous to the patient. Probably this is not at 12 hours but certainly after 24 hours without sleep there is some impairment.

I am glad they did away with thirty six hour shifts for residents.

🙂
 
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