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University Hospital of Wales Cardiff, UK
Correspondence to: Matt Wise, DPhil, University Hospital of Wales, Cardiff, UK CF14 4XW; e-mail: mattwise{at}doctors.org.uk
To the Editor:
We read with great interest the study of Afessa et al (December 2005),1 which piloted a shift system for housestaff in a medical ICU. Although this represents a novel pattern of working among doctors in US training programs, this has become the accepted standard in the United Kingdom. The authors concluded that their study was insufficiently powered to detect significant differences in mortality, length of stay, or educational outcomes, and that a larger multicenter study may be required to address these issues.2 However, a possible confounding factor in this study was that the length and pattern of shifts may not have been optimal for reducing fatigue. While reduction to a 14-h shift represents a significant decrease both in the length of the duty period and the number of hours worked per week over the nonpilot period, in the United Kingdom this would, by current standards, be regarded as excessive. Although a decade or so ago the 100-h week was commonplace, national and European working-time legislation now limits doctors to working no > 56 h a week, with defined rest periods between shifts and days off between consecutive shifts.
The optimal shift pattern for medical housestaff may be informed by data from the aviation industry, where safety is of paramount concern. Aviation accidents have a huge impact not only in financial cost but also in adverse public perception. This has focused the attention of aviation authorities on working patterns, fatigue, and error. The shift patterns of aircrew now consider circadian rhythms, quantity of sleep, and periods of wakefulness prior to duty periods in addition to length of shift.3 As a consequence, nighttime shifts are shorter than those during the day, and the number of consecutive night duty periods are restricted, with specific rest requirements before and after the shift in order to reduce the accumulated sleep deficit.4 In the study by Afessa et al,1 the shift pattern, and in particular working four consecutive 14-h night shifts, may abrogate the potential benefits of a shift system on patient outcome.
Another possible reason why there was no demonstrable improvement in mortality or length of stay may have been the population of staff chosen for the implementation of a shift system. It seems more probable that the work patterns of senior doctors would be expected to have greater influence on patient outcomes than those of trainees. It is well-recognized that staffing ICUs with intensivists reduces morbidity, mortality, and costs.567 Unfortunately, in the United States a shortage of intensivists precludes the widespread adoption of this model of care.8 One solution, which increases senior input, is the development of telemedicine7; but this is unlikely to ever be the equivalent of the "hands-on" presence of an intensivist at the patient’s bedside. In the United Kingdom, intensivist staffing of the ICU is the norm, although these doctors operate an on-call system out of hours rather than being a permanent resident in the ICU. Since September 2004, intensivists here in Cardiff have abandoned the traditional on-call system in favor of providing a continuous resident service by working shifts.9 We believe that this change is more likely to benefit patients than altering the work patterns of our trainees, and as such is truly "a shift for the better."2
Footnotes
The authors have no conflict of interests.
References
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