Instead of Duty-Hour Restrictions, Try Bedside Sign Out

As it turns out, reducing the number of hours that residents are allowed to work without taking a break – from 30 down to 16 – actually makes them more stressed out and depressed, results in more clinical errors, and doesn’t lead to their getting any more sleep than they did before.

That’s according to two recent studies in the Journal of the American Medical Association which looked at the effects of duty-hour restrictions, which were instituted in 2011 as part of an effort to “protect patients from errors made by sleepy doctors.” Oops. 

I must say, having trained in both the pre and post duty-hour restriction eras (I had four years of military service sandwiched in between), I’m not surprised by the findings.

I’ll give you the Cliff Notes here:

1. Adding duty-hour restrictions did not increase the amount of sleep residents get overall per week. This is not surprising. Sleep is a commodity, but so is free time. And given the choice, most twenty to thirty year olds would gladly trade sleep for some extra free time. Especially those with young children and family obligations.
2. Twenty percent of the residents surveyed for the study screened positive for depression. Again, not surprising given what we know about the inherent stressors of residency training, the high incidence of mood disorders in health-care workers in general, and the aforementioned sleep problem. And while many residency programs (including my alma mater George Washington) have formally adopted resident wellness as part of their curriculum, I think the ACGME will have a difficult time putting a dent in this number by duty hour restriction alone. Residency is a bear.
3. Medical errors harming patients increased 15% to 20% among residents with duty-hour restrictions compared with residents who worked longer shifts.

To me, this last finding is the most interesting one of the study. Herein lies the obvious unintended consequence of duty-hour restriction – the discontinuity of care and opportunity for the introduction of hand-off errors.

Don’t get me wrong – I happen to be in favor of some duty-hour restrictions on residency trainees. Having fallen asleep holding a surgical hook as an intern myself, I can attest to the absurdity of 30 hours straight of anything, especially patient care.

I think the takeaway from this study, however, is that teaching and rehearsing effective hand-off procedures is more important than ever. At MEP, universal bedside sign outs are a fundamental part of our practice model. If you haven’t tried them in awhile, you really should.

Bedside sign outs provide tremendous piece of mind for the departing physician, the assurance that what you are handing off to your colleague is not in fact a complete and utter mess. They put the receiving physician in a much better position to respond to events that will inevitably occur just moments after the departing physician has made it to the parking lot. And besides the obvious benefits of improving communication and patient safety, they are a HUGE satisfier for the patient and their family, allowing the opportunity for clarifying questions on treatment plans and disposition.

It’s what you would expect from your mother’s doctors, right?