Dead on Their Feet: Healthcare Worker Fatigue and Patient Safety Grena Porto Sr. Vice President Marsh USA, Inc.

2. Key Points Fatigue degrades performance. Healthcare workers regularly work long hours and are sleep deprived. Healthcare workers perform duties that require skills that are known to degrade with fatigue. The healthcare industry has taken little meaningful action to address the issue of fatigue in the workforce. Consumers are becoming concerned. There is a need for a comprehensive approach that goes well beyond duty limits.

3. 3 24 hours without sleep has the same impact on performance as a blood alcohol level of 0.10. Performance parameters that are particularly vulnerable: Tracking Communication Mood Hand-eye coordination Impact of Fatigue on Performance

4. 4 "The human brain simply does not perform reliably for 24 consecutive hours without sleep." Charles Czeisler, Baldino Professor of Sleep Medicine, Harvard University Impact of Fatigue on Performance

5. Back in 1984,�..

6. 6 Libby Zion, age 18, died in a New York City hospital from a series of lapses in her care, including prescription of Demerol, which reacted dangerously with the Nardil she was taking. Her father, Sidney Zion, a New York Times reporter, agitated for and got official attention and investigation. Bell Commission appointed by governor to investigate the case found, among other things: Poor supervision of residents Lack of coordination of care Fatigued residents made errors As a result, NY adopted mandatory duty limits for residents. Libby Zion

7. Duty Limits: The New York Experience

8. New York Times Article � 12/14/97 The stories told by weary residents and interns are of a hospital culture that either overtly or subtly forces them to work more than the legal 80 hours a week: In no case was a schedule ever posted officially listing them as working more than 80 hours a week. In some cases, they said, separate schedules were drawn up for clinic and in-patient duties and the two lists were not reconciled. Residents and interns said that although a schedule may list them, for example, as working from 7:30 in the evening until 7:30 the next morning, it was made clear to them that they should actually arrive an hour or two before the starting time and that they were expected to stay late, too.

9. New York Times Article (con�t) In addition to their long hours working with patients, residents are expected to attend conferences that are technically optional, but at which attendance is taken and expected. Such educational meetings are supposed to be part of the 80-hour-a-week limit. Most residents described working an average of 95 to 110 hours a week. One first-year internal medicine resident at a Manhattan hospital logged his schedule for last week, tallying 118.5 hours, which he described as a heavy but typical load: On Saturday and Sunday, he worked 36 straight hours Monday, from 6 A.M. to 9 P.M. Tuesday, 6 A.M. to midnight Wednesday, 6 A.M. to 3:30 A.M. the next day Thursday's shift was from 6 A.M. to 9 P.M. Friday, from 6:30 A.M. to 7:30 P.M.

10. New York Times (con�t) ''It's totally unreasonable,'' the resident said of his schedule. He said he doubted that major mistakes were made because of fatigue. Rather, he said: ''You tend to miss things. You let things fall through the cracks that can come back to bite you.'' ''The way it hurts most,'' he added, ''is that you end up making decisions factoring in what's easiest for you, what won't bog you down and keep you there longer.''

11. Duty Limits: ACGME

12. ACGME Duty Limits 80 hours per week, including in-house call, averaged over 4 weeks �Under certain circumstances, residency programs may be allowed to increase the duty hours by 10% if doing so is optimal for resident education and patient care.� Residents must be given one day out of seven free of all clinical and educational duties, averaged over 4 weeks. Residents cannot be scheduled for in-house call more than once every three nights, averaged over 4 weeks. Residents may not be on duty more than 24 hours, although residents may remain on duty for up to an additional 6 hours to hand off patients to new teams, maintain continuity of care or participate in educational activities. Adequate time for rest and personal activities must be provided. This should consist of a minimum of a 10-hour period between daily duty periods and after in-house call.

13. So, according to ACGME, residents can still work up to nine (9) 30-hour shifts every month.

14. �What is more, most of the interns (83.6 percent) reported that, even in the year after the standards were introduced, they worked more hours than allowed. And the Harvard study shows that things have not gotten any better.� (Cromie, 2006, reporting on Czeisler study) Compliance with the ACGME Mandate

15. 15 Impact of ACGME Duty Limits Czeisler and his colleagues conducted a national survey of serious medical errors and their consequences as described by 2,737 interns in all medical specialties: Those who worked more than five marathon shifts in a month were seven times more likely to report significant medical errors than those who worked no extended shifts. Interns who put in between one and four extended shifts reported that potentially harmful errors were three times more likely than when they were well rested. Interns who put in more than five 24- to 30-hour shifts in a month were involved in 300 percent more fatal errors than when they did not work extended shifts. They were also more likely to fall asleep during surgery, while examining patients, during hospital rounds, and during lectures or seminars. Even interns who worked less than the current limits, but who continued to work five to nine extended-duration shifts per month, had eight times greater odds of reporting preventable medical errors that harmed patients. These errors included more than four times [4.6] more fatalities than those committed by interns who did not work extended shifts." Past studies show that, after long shifts, interns get into more traffic accidents than nine-to-five workers. They also stick themselves with needles, and lacerate themselves with scalpels and broken glass at increased rates (see Sept. 14-20, 2006, Harvard Gazette).

16. So, what is a reasonable schedule?

17. The ACGME Schedule vs the �Modified Schedule� Study compared traditional (ACGME) schedule vs modified scheduled consisting of 60-63 hours, with no more than 16 hours consecutive duty The ACGME schedule was associated with: 35.9% more serious errors, including 56.6% more non-intercepted serious errors 20.8% more serious medication errors. 5.6 times more serious diagnostic errors. (Landrigan, Rothschild, et. al., 2004)

18. The unanswered question is, what rate of medical errors are we willing to tolerate?

19. 19 Until recently, very little data about impact on safety and errors. No consensus or evidence on solutions. The necessity of long work hours and continuity of care. Long hours prepare novices for the rigors of practice. Impact on staffing. Costs. Why Don�t We Do Something?

20. Costs Cost of replacing one medical resident with a �physician extender� - $215k-$315k Hospitals in NY spent $220M in 1993 complying with 405 regs. LA County hospital system spends $7M per year UPenn spends $6.5M per year (Note: all data reported in 2003) (Klingensmith, 2006)

21. Napping Short naps are effective to relieve fatigue during long shifts. Interns who took advantage of naps reported less fatigue on the post-call day. Interns who took naps had greater sleep efficiency. However, compliance was only 22! Continuity of care cited as a concern. (Arora, Dunphy et. al., 2006)

22. 22 Fatigue among nurses, pharmacists, CNAs, techs, others. The quest for overtime pay. The 24/7 society. Growing incidence of sleep disorders. Variability in sleep requirements. The mismatch between the 24 hour day and the almost 25-hour circadian rhythm. The inability to enforce sleep � the internet, video games, etc. Other Issues

23. ''We wanted these laws to change the culture. They didn't.� Bertrand M. Bell, MD Chairman, Bell Commission

24. �Culture eats strategy�s lunch seven days a week.�

25. 25 Questions?

26. 26 Resources ACGME resident duty standards, available at www.acgme.com. Accessed 10/15/07. Arora V, Dunphy C, Chang VY, Ahmad F, et. al. Effects of on-duty napping on intern sleep time and fatigue. Annals of Internal Medicine, 2006; 144:792-98. Cromie WJ. Doctor fatigue hurting patients. Harvard Gazette, 12/10/06. Available at www.hno.harvard.edu/gazette. Accessed 10/12/07. Fein EB. Flouting law, hospitals overwork novice doctors. New York Times, 12/14/97. Available at www.nytimes.com. Accessed 10/18/07. Gaba DM, Howard SK. Fatigue among clinicians and the safety of patients. New England Journal of Medicine, 2002; 347(16):1249-55. Klingensmith ME. Current data on impact of duty hours on hospitals, patients, faculty and residents. (Power Point presentation). Accessed on-line on 12/13/07. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, et. al. Effect of reducing interns� work hours on serious medical errors in intensive care units. New England Journal of Medicine, 2004; 351:1838-48.

27. 27 Grena Porto, RN, ARM, CPHRM Sr. Vice President Marsh USA, Inc. Two Logan Square Philadelphia, PA 19103 (215) 246-1144 (215) 246-1399 - fax grena.porto@marsh.com