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Boston, MA
Drs. Lilly and Landrigan are affiliated with Brigham and Women’s Hospital.
Correspondence to: Craig M. Lilly, MD, Brigham and Women’s Hospital, Boston, MA 02215; e-mail: clilly{at}partners.org
One of the most pressing questions facing the critical care community is how best to staff our ICUs. Adequate staffing is associated with reduced mortality (relative risk for ICU mortality, 0.61; 95% confidence interval, 0.50 to 0.75) and shorter length of critical illness,1 yet it has been clear for some time that we are facing a growing shortage of physicians to staff our units.2 Unlike specialties such as emergency medicine, which have adopted work duration limits and consequent transferral of patient management among rested physicians, the approach in most ICUs is either not to provide continuous on-site physician care or to have physicians-in-training work frequent extended-duration shifts (> 24 h).
A recent study3 has called into question the safety of such prolonged shifts. An increasing body of knowledge indicates that physicians working shifts in excess of 16 to 18 consecutive hours are a risk to their patients, themselves, and the general public. The Intern Sleep and Patient Safety Study4 found that interns working traditional extended shifts of 24 to 30 h had twice as many on-the-job attention failures at night, made 36% more serious medical errors overall, and made five times more serious diagnostic errors than interns whose scheduled work was limited to 16 consecutive hours. Similarly, a recent study by Arnedt and colleagues4 found that pediatric residents working extended-duration shifts had decrements in sustained attention, vigilance, and simulated driving performance similar to those induced by a blood alcohol level of 0.04 to 0.05%. While there has been a legitimate concern that poorly implemented scheduling interventions could lead to increased error rates due to discontinuities in care,5 it is increasingly clear that the traditional work shifts of physicians-in-training (24 to 30 h) lead to far more neurobiological impairment than the medical community has heretofore appreciated. Studies of interventions to effectively reduce consecutive work hours are needed.
This issue of CHEST (see page 3910) contains an original contribution by Afessa and colleagues6 from the Mayo Clinic College of Medicine that describes the effects of a scheduling intervention to eliminate all extended-duration housestaff shifts from a 24-bed, tertiary-care, academic medical center, adult medical ICU. The observations made by the authors are important because they demonstrate that with committed local leadership, it is possible to eliminate extended-duration shifts from ICUs without compromising the benefits of on-site physician management. These authors found that eliminating extended-duration shifts using teams committed to the effective transfer of patient information can lead to better outcomes, consistent with the findings of the Intern Sleep and Patient Study.3 Moreover, this study allows us to estimate the trial size required to comprehensively study a scheduling intervention in tertiary, academic medical center ICUs. For key outcomes such as mortality and length of stay, it appears that a multicenter trial would be required to garner an adequate number of observations.
As a society, we have little tolerance for drivers or professionals under the influence of alcohol. However, we have not fully assimilated the problem of physicians operating at a comparable level of impairment due to sleep deprivation. Beyond the effects on critically ill patients, the effects of extended-duration shifts on the physician and society can be judged from the Harvard Work Hours, Health and Safety Study.7 This validated national Web-based survey of 2,737 interns reported that the odds of having a motor vehicle crash was 2.3 (95% confidence interval, 1.6 to 3.3) times higher after an extended-duration shift than after a nonextended-duration work shift. A prospective analysis calculated that each extended-duration shift increased the monthly risk of any motor vehicle crash by 9.1% and the risk of a post-extended duration shift crash by 16.2%; in other words, interns working 10 extended calls in a month (a traditional "q3" schedule) had a 162% increased risk of a post-call motor vehicle crash. These findings come on the heels of a host of prior studies reporting analogous increases in motor vehicle crashes and industrial accidents among truck drivers, pilots, and industrial workers working prolonged shifts. Advances in our understanding of the neurobiology that underlies the association of sleep deprivation and impaired performance long ago led to the elimination of extended-duration work shifts in the airline and long-distance trucking industries. Eliminating these shifts from our hospitals is long overdue.
To bring about these changes, we need further studies of scheduling interventions, and we need to improve procedures for transferring care between providers working shorter shifts. The questions being asked by Afessa and colleagues6 are important because they highlight significant gaps in our understanding of the effects of work schedule on these outcomes. ICUs are especially important venues for studying transfer of care because of the high acuity of illness, the high risk, and consequences of errors.89 The urgency imposed by the physiologic instability common in ICUs demands rapid responses by fully informed physicians. We need to develop and validate not only improved procedures and tools for the transfer of patient information but also methods for effective communication.
It is the role of the American College of Chest Physicians along with other professional societies that promote outstanding critical care to provide leadership to meet the needs of our critically ill patients. In addition, it is essential that we design a positive intensive care training experience for our residents and fellows so that we can attract enough qualified physicians to meet our expanding workforce needs. Crafting work schedules that eliminate extended-duration shifts may not only improve provider and patient safety but will also help to attract the best professionals to critical care. Meeting the needs of an older, sicker, growing patient population, addressing the data on the dangers of extended work shifts, and filling the all-too-acute need for effective staffing and communication solutions requires fundamental reconsideration of our systems for delivering critical care. The American College of Chest Physicians, the American Thoracic Society, the Society of Critical Care Medicine, and other societies that support critical care professionals are in a unique position to advocate for the resources to address our knowledge gaps, develop solutions, and drive needed improvements in quality. Changing care for the better requires leadership and teamwork. All of the societies that support critical care professionals should be involved in coordinating these efforts through active dialogue, coordinated advocacy, and task forces.
References
This article has been cited by other articles:
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  M. Wise and P. Frost Shift work in intensive care. Chest, August 1, 2006; 130(2): 624 - 625. [Full Text] [PDF]
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