Resident Duty Hours Enhancing Sleep, Supervision, and Safety (2009) / Chapter Skim
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Appendix C International Experiences Limiting Resident Duty Hours
Appendix C International Experiences Limiting Resident Duty Hours
Pages 339-362
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From page 339... ...
Each country has experienced difficulties implementing its intended reductions due to workforce shortages and some have faced strains on educational training, including reduced clinical contact and procedural experience. The committee reviewed the strategies used by these countries to overcome the challenges encountered from reducing resident duty hours and identified educational redesign, scheduling flexibility, and a period of phase-in to adjust to changes as relevant lessons for the U.S.
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From page 340... ...
Consequences of reduced duty hours on the resident workforce labor supply, and the impacts of hour reductions on resident education and training are also examined, with a final look at efforts to overcome these challenges through program redesign. General Overview of Country Experiences The rationale for regulations to reduce duty hours in New Zealand and Europe and for duty hour reform in Australia has been primarily from the perspective of worker safety, more so than patient safety, as it has been in the United States or Canada.
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From page 341... ...
TABLE C-1 Resident Duty Hour Regulations in Various Countries, 2008 Maximum Maximum Minimum How Hours Hours Consecutive Hours of Are Averaged Hours per Rest Between Country Regulated per Week Shift Shifts Europea European 48 13 11 Comission and collective agreements Franceb Government 52.5 10 -- United Kingdomc Ministerial 56-64 14-24 8-12 agreements Denmarkd Legislation and 37 13-16 11 collective agreements New Zealande Collective 72 16 8 agreements (not averaged) Australiaf Collective Unrestricted NA NA agreements Canadag Provincial Unrestricted Varies by Varies by collective nationally province province agreements Manitoba -- 89 24 + 2 NA British Columbia -- NA 24 8 Ontario -- 60 (ICU, ED)
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From page 342... ...
differences in acuity of patient populations IOM staff searched Medline and Embase databases using a combination of the following terms: junior doctors, doctors in training, residency, resident work, workload, patient outcomes, adverse medical events, mortality, morbidity, medical education, medical training, Europe, United Kingdom, France, Denmark, Germany, Australia, New Zealand, and Canada. Websites of national medical and resident organizations were also searched.
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From page 343... ...
20 3,745 Same as New Zealand Adverse Events Study 7.5 36.9 United States New Yorkf (1984) 51 30,195 Unintended injury caused by medical management 3.7 that resulted in disability 27.6 Utah and 28 14,700 Injury caused by medical management that resulted 3.2 NA Coloradod,g in prolonged hospital stay or disability at discharge (1992)
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From page 344... ...
Current Resident Duty Hour Regulations Europe The main objective of the European Working Time Directive (EWTD) , issued by the European Council, "is to promote health and safety at work, given the clear evidence that people who work long hours run higher risks of illness and accidents" (European Trade Union Confederation, 2006)
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From page 345... ...
per week, • A maximum of 8 hours of night work on average per 24 hours, and • A right to 4 weeks of paid annual leave. Prior to the establishment of the EWTD, each European country had different duty hour regulations for its medical residents, ranging from a 65hour-per-week maximum in Ireland, to 56 hours averaged over 24 weeks in Germany, to no hour restrictions at all in Denmark and France (Australian Medical Association, 1998)
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From page 346... ...
. Canada In Canada, individual provinces establish duty hour regulations through collective agreements negotiated by resident associations with hospitals, resulting in variations in these regulations across the country.
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From page 347... ...
. However, an article reporting, in part, on France, whose national government is the regulatory force for duty hour limits, mentioned that it has not assigned an organization the responsibility for enforcing the established limits, nor does it currently monitor compliance rates itself (Woodrow et al., 2006)
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From page 348... ...
Resident duty hour guidelines are advisory, as opposed to being binding rules, and there is no designated enforcement body. The guidelines of the code imply that working more than 50 hours per week puts a resident at "significant risk" of fatigue and associated negative consequences, while working 70 hours or more is considered to put residents at "higher risk" (Australian Medical Association, 2005; Scallan, 2003)
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From page 349... ...
The following section discusses some reasons why countries may encounter difficulties achieving compliance with their own regulations along with other challenges that medical training has faced because of reducing duty hours. Consequences and Barriers Reducing resident duty hours abroad has led to several changes in health systems that have pushed countries to create new ways to provide continuous services to patients and maintain educational opportunities for residents.
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From page 350... ...
Labor Supply Shortages Employing shift systems, with explicit or implicit reductions in total duty hours, requires more doctors to provide 24-hour coverage. The implementation of more shift-based schedules to comply with the duty hour regulations and recommendations in Europe, New Zealand, and Australia has thus created or exacerbated workforce shortages and strained financial resources.
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From page 351... ...
, and its importance receives attention in Chapter 4 of this report. Surgeons particularly express significant concern about the potential effects of hour limits on resident performance because of reduced operative experience (Royal College of Surgeons of England, 2007b, 2008; Thorne et al., 2006)
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From page 352... ...
. In response to these issues, the Royal College of Surgeons has developed its own set of rotation guidelines in compliance with the EWTD for surgeons in training to follow, hoping to maximize patient safety and resident surgeon learning (Royal College of Surgeons of England, 2007a)
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From page 353... ...
and required hours to achieve safe patient care and quality resident education. Similar to the medical education system in the United Kingdom, different types of residency programs in the United States have national requirements to fulfill regarding educational content within the duty hour restrictions.
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From page 354... ...
Changes specifically related to resident duty hours and schedules might require some time for planning to accommodate constraints in workforce and other resources. Chapter 7 contains the committee's recommendations for adjusting duty hours, and Chapter 9 includes macro-level estimates of the potential costs, as well as the type and number of clinical personnel that would be needed to replace existing residents under further adjusted duty hours.
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From page 355... ...
. Similarly, although restrictions on hours vary by province in Canada, many medical training programs throughout the country have been focused on improving patient outcomes through improved resident training strategies for several years.
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From page 356... ...
Based on the above review of educational changes, it is evident that some countries have begun to redesign their educational system, focusing changes in both curriculum and competency-based aspects, and that these changes have been in response to decreased duty hours and some negative impacts on resident training. Conclusion When considering the experiences of the countries examined in this chapter with duty hour regulations, it is important to remember that most of these countries have lower duty hour limits than the United States (e.g., Europe, 48; New Zealand, 72)
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From page 357... ...
However, the committee concluded that no single system is directly applicable to that of the United States given the different construct and culture of our healthcare system. Although the committee lacks systematic multinational evidence on resident education and patient outcomes as a result of implementing duty hour regulations, from the evidence gathered it appears that any changes in duty hour limits would necessitate modifications to redesign and enhance the medical training system, to have an available workforce to substitute for hours that residents are not available to staff, and to create substantial financial resources.
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From page 358... ...
2007. Prevocational medical training and the Australian curriculum framework for junior doctors: A junior doctor perspective.
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From page 359... ...
2004. Regulation of junior doctors' work hours: An analysis of British and American doctors' experiences and attitudes.
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From page 360... ...
2008. Collective agreement: Article 14 -- duty hours.
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From page 361... ...
2006. Duty hours reforms in the United States, France, and Canada: Is it time to refocus our attention on education?
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