Resident Duty Hours Enhancing Sleep, Supervision, and Safety (2009) / Chapter Skim
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From page 385... ...
See also Committee on Innovation, 79, 146 Compliance with current duty hours; complaint procedures, 18, 82 Schedules and scheduling core competencies, 149, 277 caseload caps, 9, 94-97, 100, 101-104 Educational Innovations Project, 148 costs, 113, 114-115 government oversight option, 78-80 electronic health records and Joint Commission oversight option, 17, information systems, 100-101 80-83 funding for, 98 monitoring adherence to duty hours, 15, learning and work environment, 98-99 16-18, 36, 37, 69-70, 73-83 mean duty-hour changes, 55-57 monitoring implementation of number of residency or fellowship recommendations, 295, 322, 324-325 positions, 105, 108, 113-114 new-organization oversight option, organizational and management factors, 77-78 100-101 recommendations to, 11, 16-18, 23 patient characteristics, 91-93 regulation of residency programs, 32 schedule changes, 8, 99, 105, 106-108 strategies, 105-114 385
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From page 386... ...
See Workload/caseload 144, 149 Center for Epidemiological StudiesAmerican Board of Medical Specialties, 73, Depression Scale, 168-169 145 Centers for Medicare and Medicaid Services American Board of Surgery In-Training (CMS) , 75 Examination, 145, 199 GME funding, 22, 41, 42, 79, 113, 114, American Medical Association, 64-65, 73, 298, 299, 300, 319-320 145 Office of Clinical Standards and Quality, Anesthesiology, 19, 33, 56, 63, 129, 147, 78 161, 208, 270, 341 oversight of ACGME monitoring, 17, APACHE IV database, 197 47, 78-83 Association of American Medical Colleges, quality and safety assessments, 75, 185 73, 125, 319 186, 187 Association of Program Directors in Internal reimbursement policies, 92 Medicine, 103 Charge to committee, 29-30, 217-218, Attending physicians.
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From page 387... ...
See also Compliance handovers and, xii, 6, 21, 38, 40, 107, with current duty hours; Limits on 193, 266, 268-269, 270, 274, 275, duty hours 277 and admission of patients, 249 limits on work hours and, 9, 38, 125, changes in mean duty hours, 55-57 194 and chronic sleep deprivation, 235 long-block practice and, 148-149 committee recommendations compared patient characteristics and, 9, 92-93, 140 to, 245 patient concerns, 39-40 suggested refinements, 54-55 protected sleep time and, 217, 230, 231, 241, 247, 268-269
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From page 388... ...
See also Supervision Health; U.S. Public Health Service of residents Department of Veterans Affairs, 113, 325 continuity of care, 126, 140-141 electronic medical records system, 197, graded responsibility model, 126, 272 127-136 error reports, 189, 191 professionalism, 126, 128, 135 GME funding, 22, 32, 298, 299, 318 reflective learning, 126, 138-139 National Surgical Quality Improvement workload-learning balance, 127, Program, 199 136-140 oversight of resident hours, 79 Educational redesign interventions patient outcomes after 2003 rules competency-based, 146-147, 355-356 implementation, 196-197 international experience, 354-356 recommendations to, 22, 23, 32, 318, long-block design, 148-149 325 long-term effectiveness, 203 Depression, 10, 30, 109, 159, 160, 165, quality improvement techniques, 149, 166, 167, 168-169, 171, 173, 174, 356 207, 211 simulation-based training, 19, 147-148 defined, 168 surgery program, 199 Dermatology, 33, 49, 56, 62 team training, 131, 133, 135-136, Diabetes, 171 285-286 Duke University LIFE Curriculum, 248 Electronic medical records systems, 100, Duty hours.
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From page 389... ...
See also Sleep loss and deprivation work environment and adverse events, 189-191 apprenticeship approach, 7, 29 caseload and, 68, 218 costs, 7 evidence-based management of, 68-69 deficiencies, 69-70 extended duty hours and performance, didactic sessions and study, 51, 96, 98, 12, 40, 106, 163, 190, 191-193, 218- 106, 109, 126, 132, 141, 143-144, 219, 220 223, 232, 252, 364 injuries to residents related to, 18, 39, funding, 22-23, 28, 32, 41, 42, 79, 113, 160-162, 164, 224, 225-226, 365 114, 298, 299, 300, 319-320 history, 28 learning objectives, 125-126 needs, 37-38
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From page 390... ...
390 INDEX number of residents and programs, 30- Health Insurance Portability and 32, 33, 189 Accountability Act, 77 overview, 27, 30-34, 47-48, 90 Health Resources and Services principles, 126-141 Administration, 22, 32, 298, 299, regulation of programs, 32 300, 318 specialty programs, 32, 35 Healthcare Cost and Utilization Project, stipends for residents, 29 195, 196 subspecialty (fellowship) programs, 32, Heavy call, 163 42, 51 Home-call, 105 Hospital at Night program, 356 Hospitalists, 8, 54, 98, 113, 198, 249, 285 H Handovers or handoffs I caseload and, 94-95, 102, 141 and cognitive functioning, 269, 276 Inpatient wards, 61, 91 communication issues, 40, 102, 107, Institute for Healthcare Improvement, 274 204, 207, 267-268, 271-272 100,000 Lives and 5 Million Lives and continuity of care, xii, 6, 21, 38, 40, campaigns, 194 107, 193, 266, 268-269, 270, 274, Intensive care rotations, 61 275, 277 compliance with duty-hour limits, 61, 71 defined, 21, 364 extended-duty hours, 224 designing interventions, 269-277 handover practices, 108, 132, 204, 271 frequency under 2003 rules, 21 impact of duty-hour reforms, 179, 190, general guidance for improving, 271-276 195-196, 197, 198, 200-204, 210, information transfer, 266-267, 272-273 222, 224, 235, 237, 314 innovative strategies, 273-275 international duty-hour limits, 341, 346 international experience, 269 intervention study, 190, 200-204 Joint Commission Patient Safety Goal, learning environment, 34, 190 269-271 medical errors and PAEs, 179, 183, 186 and learning, 193, 271 187, 190, 192, 195, 203, 210, 222, limits on duty hours and, 40, 54-55, 235, 314 268-269 neonatal, 30, 100 and medical errors, 21, 107, 179, 189, pediatric, 112 194, 202, 204, 206, 209, 266-269, substitution strategies, 112 274-275, 277, 323 supervision, 130, 132 and patient safety, 21, 40, 107, 193, Internal medicine 267-268 caseload, 19, 95, 103 recommendations, 21-22, 277 combined specialties, 32, 56 scheduling for, 13, 21, 51, 52, 53, 106- compliance with duty-hour limits, 55, 107, 108, 202, 223, 245, 273 56, 63, 65, 96, 108 supervision, 132 duty-hour demands, 35 teaching the process, 6, 275, 276-277 duty-hour limits, 49 team approach, 274, 283, 286 handovers, 268, 271 variability of, 268 impacts of duty-hour limits, 69, 91, 132, Harvard National Depression Screening Day 142, 144, 167-168, 169, 172, 174, Scale, 169 196 Harvard Work Hours, Health and Safety long-block training design, 148 Group, 225 medical errors, 206, 207 Health information systems, 100-101, noneducational activities, 93, 111 280-282 number of residents and programs, 33
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From page 391... ...
See also Canada, 11, 346, 348-349 Adaptation to duty hour limits; competency-based training, 355-356 Educational principles; Educational consequences and barriers, 11, 54, redesign interventions; Supervision of 349-353 residents Denmark, 345 case mix and, 91-92, 142-143 enforcement methods, 346-349 caseload/workload, 18-19, 38, 94-97, Europe, 11, 37, 344-345, 347 136-140 general overview, 340-344 continuity of care and, 126, 140-141, handovers, 269, 350 148-149, 351 Ireland, 345 culture of safety, 6, 21-22, 133, 264-266 labor supply shortages, 342, 350-351 design of, 138-139 lessons for U.S. programs, 353-356 educational and work systems, 90-101 New Zealand, 11, 345, 347-348 human factors and system engineering overview of medical education, 340-341 approaches, 99 PAEs, 342-344 noneducational activities, 19-20, 72-73, phase-in time, 354 93-94, 96, 140 quality improvement practices, 356 overview, 32-34 redesign of education and training patient characteristics, 19, 91-93 systems, 354-356 recommendations, 18-22 regulations, 341, 344-346 reflective learning, 6, 19, 20, 38, 102, training and education opportunities, 104, 125, 126, 130, 134, 136-140, 351-353 149, 150 transition period, 354 service-education balance, 9, 98-99, 102 United Kingdom, 54, 269, 339, 341, team dynamics, 6 342, 343, 345, 347, 350, 351, 352, workflow fragmentation, 19, 99 355 Length of stay work schedules, 11, 110, 353 and educational opportunities, 91, 92, IPRO, 57, 58, 59, 60, 61, 62, 63, 70, 71, 95, 136 74, 75, 78 impact of duty-hour limits, 198 Ireland, 345 and medical errors, 181, 182, 195, 198 workload management and, 96, 285, 306 J Limits on duty hours.
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From page 392... ...
392 INDEX adjustments to, 6, 11, 12, 13, 241-243 diagnostic, 2, 94, 181, 188, 194, 201, and burnout, 167-168 207, 209 changes in response to, 105-114 fatigue and, 6, 10, 38, 179, 188-193, committee recommendations, 6, 11, 12, 202-203, 204, 205, 209, 217, 218, 13, 241-243 224, 225, 228, 237, 296, 320, 321 comparison of provisions, 52-53 frequency, 180-188 and continuity of care, 38, 125, 194 handovers and, 21, 107, 179, 189, 194, data on impacts, 30 202, 204, 206, 209, 266-269, 274 economic issues, 7-8, 28, 41 275, 277, 323 and education quality, 7-8, 10, 11, 14, in ICUs, 179, 183, 186-187, 190, 191, 28, 29, 38, 98-99, 126, 141-145 192, 195-197, 200-204, 207, 210, emergency room, 13, 14 222, 235, 266-269, 314 evolution of, 48-55 IT support systems and, 281 exemptions/exceptions, 12, 13, 15-16, learning from, 207-208, 264, 280 35, 63, 74, 78 limits on duty hours and, 10, 193-205, in-hospital on-call frequency, 13, 51, 59 209-210, 235, 321 and medical errors, 10, 193-205, 209- malpractice claims, 186, 187-188, 189, 210, 235, 321 191, 268, 282, 283 off-duty time, 13, 15, 51, 247 measuring hospital-based rates, 180-188 and patient outcomes, 9, 10, 193-205 medication, 21, 99, 132, 170, 181, 192, shift-related, 13, 68, 226-227, 244-246 198, 201, 205, 207, 208, 209, 265, transportation industries compared, 37, 268, 272, 281 65-69 organizational contribution, 205-209, and well-being of residents, 10, 39, 137, 210-211, 265-266 167-168, 169, 171-172, 173-174 perspectives of residents on, 205-206 and workload and learning, 38, 136-137 procedural, 181, 201, 206, 207, 208 workweek, 65-68, 244 randomized controlled trials, 10, 179, Long-block practice, 148-149 186, 200, 209 recommendations, 21-22, 280 reduction of, 9, 100, 101, 179, 180, M 186, 188, 190-191, 193-205, 208, 209-210, 211, 220, 222, 226, 235, Malpractice claims, 186, 187-188, 189, 266-269, 272, 274, 280, 281, 282, 191, 268, 282, 283 284, 314-315 Maslach Burnout Inventory, 166, 167, 168, reporting, 21-22, 182, 183-184, 185 169 186, 189, 208, 264, 265, 266, 277Medical Advantage Program, 299 280, 286, 322 Medical errors. See also Adverse events; research needs, 211, 250-251 Culture of safety; Patient outcomes; resident involvement, 8, 184, 186-188, Patient safety; Preventable adverse 200, 201, 205, 209 events root-cause analyses, 189 administrative, 206, 207 schedule and, 186, 187, 189, 190, 191 caseload and, 10, 38, 179, 189, 201- 193, 198, 200-201, 206, 208, 218 202, 206, 208, 209, 210, 314 219, 222, 224, 226, 238, 246-247 in communication, 204, 207, 211, self-reported exposure to, 207-208 267-268 sleep time and, 220, 246-247 cross-coverage and, 189, 194, 207 specialty and, 208 data sources and collection, 181-183, supervision and, 38, 129, 179, 188, 189, 186 192-193, 203-204, 207, 208, 209, defining, 181, 182 210, 225, 283 system strategies for reducing, 266-269
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From page 393... ...
See also Centers for Medicare Administration, 251 and Medicaid Services National Association of Inpatient Provider Analysis and Treatment File, Physicians, 103 196 National Healthcare Quality Report, 186 reimbursement policies, 129, 300 National Institute for Occupational Safety Teaching Physician Presence Rules, 130 and Health, 226, 235 title XVIII, 50 National Institutes of Health, 23, 251, 325 Medicare Trust Fund, 78 National Sleep Foundation, 39, 56 MetroHealth, 101 National Surgical Quality Improvement Midlevel providers, 105, 112. See also Program, 199 Nurse practitioners; Physician National Transportation Safety Board, 68 assistants Needlesticks.
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From page 394... ...
See also Patient impacts of nonfatal events, 265 safety incidence, 186-187, 194, 201 Patient outcomes international experience, 342-344 institution-specific studies, 9, 197-200 malpractice claims, 182, 187-188 interventional study in ICUs, 200-204 reducing duty hours and, 214 nationwide studies, 9, 195-197 scheduling effects, 190, 200-201, 204, natural experiments, 193-199 205, 209, 210, 323 New York State studies, 194-195 Preventive medicine, 33, 49, 56, 62, 149 schedule changes and, 108 Professionalism, 31, 65, 126 sleep deprivation and, 192, 224 fatigue and, 173-174, 175, 217 supervision and, 129 impact of duty-hour limits, 173-174 Patient safety, 39-41. See also Adverse perceptions of long hours as, 82, events; Medical errors; Preventable 248-249 adverse events team aspects of, 286 caseload and, 10, 94-95, 102, 137 Protected sleep data sources for assessing quality and, adherence to, 230-232 185-186 benefits, 229 fatigue prevention and mitigation and, and continuity of care, 21, 217, 230, 190-191 231, 241, 247, 268-269 handovers and, 21, 40, 107, 193, as fatigue countermeasure, 12, 18, 228 267-268 recommendation, 12, 16, 18, 245, indicators of, 186, 195 247-248 limits on duty hours and, 29, 193-205 residents' use of, 229-231 measuring, 181-184 supplementary night float for, 229, 306 recommendations, 18-20 Psychiatry, 32, 33, 55, 56, 62, 63, 142 research needs, 7 Public Citizen, 8, 49, 50, 53, 54-55, 75 Puerto Rico, 50, 75
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From page 395... ...
See also Fatigue; Sleep loss moonlighting, 2, 13, 16, 252, 322 and deprivation oversight of ACGME, 17-18, 47, 77, 80, driving incidents, 18, 39, 51, 162-164, 81, 82 165, 222, 224, 225, 236 phased implementation, 11, 24, 320- extended duty hours and, 160, 161, 162, 322, 354 163, 164, 165, 225-226, 235, 237 protected sleep period, 12, 16, 18, 245, improving, 18, 164-165 247-248 night shifts and, 160-161, 162, 239 research and evaluation, 23, 24, 250, physical injuries, 18, 39, 160-162, 164, 322-325 224, 225-226, 365 resource allocations, 11, 22-23, 318 recommendations, 18, 164 safety improvements, 18-20, 164, 321, sleeping arrangements onsite, 165 322 specialty differences, 161 supervision of residents, 20, 133, 322 transportation services, 164, 165 transportation for residents, 2, 18, 164, workweek and, 161 165 year of residency and, 161
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From page 396... ...
See Patient safety; Resident safety 273 Safety net teaching hospitals, 23, 98, 300- and safety and well-being of residents, 302, 318, 364 107, 108, 109, 160-161, 162, 163, Schedules and scheduling. See also Extended 164, 165, 169 duty hours; Shifts separation between, 59-60, 61, 62, 66 admissions flow, 99 67, 245, 246-247, 250 comparison of extended duty periods, transportation industry, 66-67, 68 332-333 Sleep Alertness, and Fatigue Education in and continuity of care, 21, 108, 109, Residency, 248 110, 174, 349 Sleep education, 16, 18, 165, 190, 227, and education opportunities, 14, 28, 241, 248-249 105, 106, 108, 109 Duke University LIFE Curriculum, 248 examples, 105, 107-108, 198, 331-337 Sleep efficiency, 229 frequency of changes, 40, 105 Sleep inertia, 227, 232 and handovers, 13, 21, 51, 52, 53, 106- Sleep loss and deprivation.
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From page 397... ...
See also Workforce implications and well-being of residents, 174-175 and continuity of care, 113, 197
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From page 398... ...
See Graduate medical training handovers, 266-277 Transforming Care at the Bedside program, quality improvement practices, 100, 274 277-282 Transitional year programs, 56, 63, 274 team culture, 100, 282-286 Transportation industry compared, 65-68, workflow and caseload management, 99 100-104 Trauma and Emergency Medicine Information System, 199 T U Teaching hospitals, See Council of Teaching Hospitals and Health Systems; United Kingdom, 54, 269, 339, 341, 342, Education 343, 345, 347, 350, 351, 352, 355 Team and teamwork, 34 U.S. Bureau of Labor Statistics, 35, 307 adaptation to new rules, 97-98, 105 U.S.
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From page 399... ...
See also Current duty hours; and medical errors, 179 Limits on duty hours noneducational work and, 38, 101-102 comparison of provisions, 52-53, 65-69 number of residents and, 354-355 compliance with 80-hour rule, 9, 56, 57, and professionalism, 176 59-61 and safety and well-being of residents, exemptions, 63 10, 166, 167, 168 first-year residents (interns) , 9, 34, 35 Workflow fragmentation, 19, 99 historical, 34 Workforce implications and injuries to residents, 161 of committee recommendations, 11, maximum hours, 12, 13, 14, 28, 49, 50, 318-320 51, 66-67, 244, 305, 341, 344-345, continuity of care, 113, 197 346, 347, 348, 356 reducing noneducational tasks, 102 and medical errors, 189 staff shortages, 22, 29, 41, 319 and safety and well-being of residents, Workload/caseload 161, 166 adaptation to duty-hour limits, 9, 94-97, by specialty, 35 100, 101-104 transportation industry, 65-68 and adherence to duty-hour limits, 9, 38, 96, 102 admissions, 15, 51, 91, 95, 96, 103, Y 104, 136, 248, 249, 305 and cognitive function, 19, 96, 97-98, Year of residency 137-139, 140 and caseload, 103 data sources and collection, 103 and compliance with duty-hour limits, and education outcomes, 102 64, 208 and fatigue, 68 and medical errors, 179, 187-188, 207, for fully trained physicians, 103 208, 209, 225 and handovers, 94-95, 102 PGY-1 (first-year/intern)
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From page 400... ...
, 93, 142-143, 172, 286 PGY-6 (sixth-year) , 172 and safety and well-being of residents, 161, 166-167, 172-173 and sleep deprivation, 219-220, 225 and workweek, 9, 34, 35 Z Zion, Libby, 8, 20, 28, 48-49, 128-129
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